Lecture: Current Understanding of Myopia Among Pediatric Populations: Treatment Options in 2023

Hi, good morning, everyone. We have a very exciting program for everyone, and let me share my slides first so that we could get it … Can you see my slides OK, guys? OK, perfect, perfect. Thank you very much. Our topic of today’s webinar is current understanding of myopia among pediatric populations, an update treatment options in 2023. So first I’m truly excited to present to you our excellent speakers from different parts. First I have Dr. Rupa Wong, from Honolulu eye clinic, USA. She is a very well known person on social media and even though we only met her once, I feel like I actually know her, because I see her on social media quite a bit. And then Jason Yam, of course he does not need any introduction, he’s from the Chinese University of Hong Kong and he spearheads many of the myopic treatment studies in Asia. He was actually ranked one of the most influential ophthalmologists in Asia Pacific region this year. So I’m very proud to have Dr. Yam with you. And Dr. Ken Nischal, again does not need any introduction. He’s from the University of Pittsburgh, US A. I’m just so excited and hopefully he could share with us the myopic myopia statement that he helped to develop for the pediatric ophthalmologists all over the world. And I’m from universities of California at Irvine and without further ado, I would like to ask a few questions so that we have some idea who we’re talking to. We had 2200 had participants registered today, so we have people from all over the world. So first question, I’m going to give you five seconds. If you could just choose one of the following: Are you a pediatric ophthalmologist, general ophthalmologist or just nonpediatric ophthalmologist, pediatric optometrist, general optometrist, nurse or technician or other, please. The response … Lawrence, we don’t have the response. Am I not seeing it? OK, thank you. So we have we have about 40% general ophthalmologists, 14% pediatric ophthalmologists and 5% pediatric optometrists, and a significant portion of general optometrist. Thank you very much, and we have nurses, technicians and other. OK. Next question: Is in the last four years, have you seen a significant increase in myopia in children? And if you feel that it was more than 15%, choose the first. Second is moderately increased, approximately 10%, and third is mild increase, 1 to 5%, and 4 is now change. I’m going to give you 5 seconds. OK, I’m going to say about significant portion of the participants about 86% of the participants have noticed a moderate to significantly increased incidence of myopia. Thank you. Next, last question: How do you treat myopia? Behavior modifications? Pharmacologic therapy, multifocal contact lenses, or ortho K, bifocal, progressive spectacles, or red light or others. If it’s others, please type in how you treat myopia. I’m going to give you 7 seconds. By the way this webinar is going to be only an hour today, and I know you have busy schedules, so we’ve got lots to cover. So it’s all over the place. OK, great. Thank you we’re going to cover all that today. So for the next 10 to 15 minutes, I would like to talk about the current state on myopia, and what are some of the medical reasons for myopic progression? What are some of the things that we can be causing ourselves iatrogenically? So how big is this problem? And as we all know, this is a graph that we are painfully aware. The studies back in 2016 have shown speculated that there’s going to be approximately 50% or 52% of the prevalence of myopia among children globally, but of course, when the data came out, they didn’t expect Covid, so there’s a significant environmental risk factors that may have exacerbated this. Covid 19, and during this time, there was a significant limited there was an the outdoor time that children have spent has decreased significantly and there was an increased time indoor. Recently the studies have shown there’s a significant increase in the incidence of juvenile diabetes in pediatric population, and this is actually one of the big concerns among pediatricians, and also, the obesity. The body mass index has almost doubled during this Covid time in the last three years, according to the CDC. So and not to mention the high educational pressure in certain parts of the world. I think this pressure is actually pretty much all over the world, and so myopia is not just a is not just an eye this situation is just not it’s not on an eye problem, but it’s really the whole body, and I think what we do for the eyes, I think has an impact for the wellness and health of the children. So with that, the current state in 2023, East Asia recently studies have shown that 80% of the latest cohorts of high school graduates are myopic. That is significant. So how do you define 20/20? When you say 20/20, that’s based on average population and maybe we need to change the way that we define 20/20, normal vision And 10% of the children are highly myopic, meaning 6 or more. And how are we doing in the US? Unfortunately we’re not doing much better. In urban areas, it’s 41%, and that number I expect to increase significantly. So why does this matter? The our research from Orbis have shown, very nicely, with the lead author of Nathan Condon, looked at the impact of vision impairment and ocular morbidity on their treatment of depression and anxiety, and there were various causes that were causing anxiety and depression among children, but myopia was one of the biggest factors that kids were scared of. So this is not something that we should take lightly. The axial length is the most important determinant of the refractive error, there’s a strong correlation between the two. And typically at birth the axial lengths is about 17 millimeters and grows into about 23.6mm in adulthood but every millimeter change causes about 2.5 diopters of myopia, and when these eyeballs continue to elongate beyond 26mm, then it is considered pathologic and that’s a refractive error of about 6, and why does that matter? Because this can increase the risk of glaucoma. It doesn’t just increase the risk of glaucoma due to the stretching of the sclera, but it makes it difficult for us to diagnose and there’s a 16% increase in cataract formation and of course with the stretching there’s a choroidal thinning and that leads to choroidal neovascularization, and staphyloma. We may see aftermath in years down the road. So this is important, we need to prevent these children from developing these potential complications, and also, the tear in the Bruch membrane can lead to lacquer plaques which you can see here. And then retinal detachment. So what are the risk factors of myopia in development? Genetic factors which we really don’t have a lot of control over, but there are things that we can do in terms of environmental factors. And Ken’s going to talk about that in detail. And I want to focus on what are some of the medical reasons, what are some of the things that can be potentially iatrogenic and what are some of the medical conditions that we need to be aware of that can lead to myopia. So I will discuss the 6 main mechanisms of myopia first. First, eyelids. This is not something that we think about. There’s a significant increase in incidence of dry eyes, but blepharitis in Down syndrome patients with chronic rubbing can result in atypical presentation of myopia and irregular astigmatisms, eczema, this is a big topic. Vernal choroidal conjunctivitis. And these are developing in patients due to chronic rubbing. And second, change in power of the lenses, especially in diabetes. As I’ve mentioned, that juvenile diabetes is on the rise due to inactivity and people are becoming sedentary, we’re not moving, and glucose resulting in sorbitol resulting in osmotic changes and osmolarity of the lens resulting in significant myopia, which can also be a result of galactosemia, uremia, and sulfonamides. Many medications can cause it, as well. Changes in the lens. Cataract formations as these lenses are developing worsening of cataracts, especially in anterior lenticonus, they can develop a significant myopia, so making sure that we do a good slit lamp examination is important. Change in the lens position, especially with miotics with the interior lens movement, or even dislocation, or excessive accommodations can result in the myopia. Typically with Marfans or homocystinuria. Changes in the cornea, with the keratoconus that we talked about. With the change in axial lengths with the connective tissue disorders, retinopathy of prematurity. Children are more than born premature and especially those have have had treatment and glaucoma. So what is some of the systemic disease that’s associated with myopia, especially in patients who have central and peripheral visual loss, with color vision defects and nyctalopia. These are various genetic disorders that can result in a it IRDs, but as you can see here, the different genetic mutations can present with various and overlapping phenotypic presentations. So getting these histories of peripheral vision, nyctalopias, visual field deficits, is extremely important. What are the other conditions? Congenital stationary night blindness, especially photophobias with the nyctalopia and nystagmus. Albinism. With the X linked recessive traits and looking for any chorio retinal atrophies in the periphery is important. And then pseudomyopia, so the patients may present with a significant myopia one day with an intermittent isotropa, so these are things that you have to think about. And then multisystem disease, in patients with connective tissue disorder, such as sticklers syndrome, Marfan syndrome, etc. And medications. I had a couple of patients who were on Topamax for a poorly controlled seizures and these patients can develop ciliochoroidal effusions with the forward displacement of the lens Iris diaphragm and they can present in addition to the myopia, they can present with angle closure glaucoma. And these various sulfa medications, sulfonamides, acetazolamide, spironolactone, Bactrim etc. are some of the medications that can result in these sort of myopic spasms. So no everything is what it seems and you need to rule out these potential medical reasons before considering this is a most likely environmental or genetic related progression of myopia. We’re going to answer many er other questions, so please feel free to type in your questions and we’re going to address the questions as much as we can, and thank you very much, and then I would like to introduce Rupa, who’s our next speaker from Honolulu Eye Clinic. Thank you very much. Rupa? Dr. Wong: Will thanks, Donny, I’m going to share my screen now. >> Dr. Suh: Yeah, sure. >> Dr. Wong: So as Donny mentioned, I am over in Hawai’i, in Honolulu, and this is why I’m very passionate about myopia management. As you can tell, my husband is of East Asian descent, we’re in Hawai’i, that bridge between main land America and Asia, and my husband is very high myope with a lot of history of I wanted to make sure that my three children did not end up with the high myopia that the rest of his family have, so that’s where I became personally interested and I see a large Asian population, of course, in Hawai’i. And so it’s very important. As Donny mentioned, I am very active on social media. If any of you are on TikTok, might remember this. My daughter told me at 6 years old that I didn’t know anything about math, despite taking multivariable calculus and algebra, I don’t know math, but as we saw in the studies, after that 2020 school year of Covid confinement, 6 year olds had a 3X increase of myopia, 8 year olds a 1.4X increase and the benefits of myopia control have been shown, especially when they looked at it just countered with the effects of contact lens treatment and that’s always the concern, so even it assuming an incidence of microbial keratitis between 1 and 25 per 10,000 patient years, that requires about 38 to 956 patients to be exposed to five years of wear to produce five years of vision loss, so when you balance that with how each additional diopter of myopia increases the risk of myopic maculopathy by 58%, primary opening angle glaucoma by 20%, and even RDs by 30%, then they’ve shown that the risks and benefits of myopia control are real. So I’m going to focus first on contact lenses. The first that I do in my practice is the dual focus daily disposable soft contact lenses. These are here marketed in the US as the MiSight contact lens by Cooper vision and they have to you treatment zones and two corrective zones. For them it’s not specifically about the add power. They’re not taking a presbyopic corrective lens, it’s a different type of design and mechanism. With the two correction zones, the myopia is controlled so that the children have clear distance vision, and then the two treatment zones rely on two diopters of myopic defocus to place the treatment image in front of the retina. And all of this goes back to the theory of hyperopic defocus as being the driver of axial elongation. And by placing the two diopters of myopic defocus in the treatment zone for those contact lenses in front of the retina, then they are no longer having that as a driving force of increased myopia. The initial three year myopia study done by MiSight showed that the group only progressed .9 diopters through the course of 6 years. It was an FDA approved trial. 148 eyes with 109 subjects. They looked at the MiSight versus the pro clear. They examined kids 8 to 12 years of age and they had to wear for them for ten hours a day. So that’s really important when discussing with patients, as well. Shown to reduce myopia progression by 59% and the contact lens is available in . 5. Daily disposable. They had an extended study. Half received 3 years of treatment, half received full 6 years of treatment and did a washout the final year and they showed that there was no rebound effect. And that was really important, because many people were concerned as soon as they stopped the contact lens Another contact lens of course is ortho Kerratology. I saw that many of you do orthokeratology, I actually do not do orthokeratology in my practice, although the a report by the American Academy of Ophthalmology has shown that it has a potentially greater effect when used in older children, ages 6 to 8. Safety is a concern, but there are ways to combat toes safety issues. It’s a rigid gas permeable lens. Flattens the central cornea. It was FAD approved in 2002, but originally prescribed as a Lasik alternative as a way to get out of glasses or daytime contacts. But they noticed over time that myopic children weren’t progressing as fast as other kids. So it reduced myopia progression by 50% in groups with successful fit. Most studies were in Asian populations. So many fact seem to be affected whether the age of onset, the higher baseline myopia, the pupil size and the treatment zone and there has been shown a little bit of rebound in some of the clinical studies. The ortho K lenses just can the exam if you yourself do not fit it, a quick review. Some optometrists or ophthalmologists will have an in office and they reevaluate the fit and vision. And it may take up as many as 3 ortho K temporary lenses to achieve the final result. Things that influence patient selection, the amount of astigmatism and the axis, the corneal toxicity, that should say toricity, not toxicity. Microbial keratitis is a real concern, so Pseudomonas and acath amoeba were the most serious. Estimated anywhere from 4.9 to 13.9 per 10,000 patient years, but this risk can be significantly reduced when there’s good fit and adherence to proper eye lens and care and proper training of the patients and the parents. The corneal changes that some of us have seen, which is why I don’t tern personally do this in my practice, since I’m married to a cornea surgeon is stable endothelial cell density, increased polymeg thism, the increased anterior stromal Kerr at sites and even fibrillary lines. So just to review a little bit of my experience with the MiSight contact lens I was the first in the state to fit the MiSight, I offer it to ages 8 and above who do not have a significant amount of astigmatism. So less than 7 diopters of astigmatism. Because currently it is not available in a TORO lens. I do refractions and axial length every 6 months and I use buyometry for the axial length. I use the Lenstar so I can chart. This is helpful to give to patients and parents. I educate the parents patients, I’ve made a little video with my daughter. it’s not something that’s going to invade your eye or anything like that, OK? Just a picture and what it’s doing is it’s measuring how long your eyeball is. Not to move around. >> So I send this video, I have it up on YouTube, but I also send it to all of my patients and they like to watch it, the kids like to watch it, they like to see my daughter. If you’ve seen my daughter, she loves to be the star of the show, but also kids with relate to her, so that makes it easy for them that they’re not anxious when they come in. I also send a contact lens tutorial before the contact lens fitting appointment. 3 to 4 minute video that I created in my office with my staff and we have what we call contact lens homework so that we teach them how to open the eyelid, how to touch their eye so they’re not rolling their eye back and getting a Bells reflex. All of these steps help decrease the chair time and the amount of time the patient is in the office so it’s not sucking up a lot of your time to be able to offer this to patients. So just a couple cases: I have a patient who was. 2 The parents wanted to do MiSight. They had learned about it. And I fit each patient or my optometrist does. So sometimes they ask how did you come up with that number? We will do a fitting in the office and do an overrefraction. And you can see from the initial visit, the one year and then even now the 18 month visit that the refraction has stabilized as has the axial length elongation. And this is where it’s nice to chart this for parents. Second case, 15 year old girl. So outside of that window, that’s FDA approved in this country, but I still offer if parents are interested in it. Sometimes the child wants it versus they’re already in contact lenses as this girl was, so it’s easy to switch into the due al focus contact lens. Prescription had increased despite being on atropine.01%. But she admitted she was not very compliant. And over 6 months, a little bit of an increase and you see it looks like it decreased her axial length from 6 months to a year and that’s because we changed software, so I think there was a little bit of recalibration that was necessary. and you can see plateau there. The other thing is I try to give a folder to the patients and the parent so they don’t need to make all the decisions there in the office, they can take all the information home and use it, they can then text or email my myopia coordinator so they can decide at home and not feel pressured. Because a lot of these treatments are not covered with insurance, at least in this country, which means they’re a little bit more expensive. I also send a text after the appointments with the patients making sure they are had having a good fit and they aren’t having a. So I’m on social, please feel free to follow along, message me if you have any questions about my presentation, and thank you so much. > Dr. Suh: Thank you, Rupa. That was excellent. I’m sure there will be lots of questions. Dr. Yam from Hong Kong will be presenting the next talk on atropine. There is a lot of questions about the atropine, pharmacologic therapy which has been around for about 30 years now.Ites the myopic treatment that we have studied the most. So please, Dr. Yam, tell us about your studies and what your recommendations are for us. Dr. Yam: Thank you, Donny, and hello, everyone, it’s my great honor to be in this webinar and to share with you some of my understanding about atropine and what concentrations and how you gets it. I would like to share mostly based on some of the findings from our LAMP 1 and LAMP 2 studies. So a lot of atropine work is learned from our dear colleagues in Taiwan which has been using atropine drops for 20 or 30 years already. Here the graph shows you that had in the whole region using atropine from 1% to .1% vary widely. And also two important studies that we all learned a lot the Singapore ATOM study, the ATOM 1 study using 1% atropine, and the ATOM 2 study using .5%, .1%, and .01% atropine. And some remaining questions that our work has been doing is to answer the following questions: What are is the efficacy compared with the placebo? Are there any concentration dependent response in what’s the optimal concentration? Any effect on the cornea or the lens power? Any factors associated with the treatment response? Any biomarker, continue treatment after how many or to recontinue after 2 years and any longer term efficacy, and can atropine delay or continue onset. >> So I would like to share with you one study which we started in 2017. It is a RTC of 438 children, and using mainly .05%, .025% and placebo group. And so far we have reported our two year. Our five year results is coming. Here are the report today, I would like to highlight some of the findings. In fact, in LAMP 1 study, the graph shows a clear concentration dependent response. And compared with the placebo group, we can see that also along a concentration dependent pons, .05% roughly is 67%. .0025% is roughly 43 percent and .01% is roughly 23% in our study. .05 roughly, the pupil size were increased by 1mm: And accommodation loss, in .05%, you would lose about 2 diopter. What does it mean? Means that if a child having a accommodation diopter at 12 and then reduce to 10, they have increased their reading distance by roughly 8cm to 11cm, so they so it doesn’t happen too much, because usually is about 30cm, and we also document the use of photo chromic glasses, progressive glasses, photophobia. Photophobia at 2 weeks is quite significant. And after a longer time, usually the photophobia will be got used to. And across the full group is not significantly different, and also that results that we have documented, including the other kinds of parameter is also not significant across all the groups. And therefore, our LAMP 1 first year results demonstration that low concentration atropine is working comparing to the placebo group and the concentration related response is also happening among these low concentration and also .05% is considered as an optimal concentration, and in the second year, we probably also follow the case together, in the two years, but in the placebo group, we have to switch over to the .05% because of the ethical concern after 1 year placebo. So you see that the concentration dependent response remains, .0, .1, and .025 group. In .01% it’s 1.12. So rough. Another concern is we can see that the SE progression, efficacy seems to be better than the axial eelongation in the LAMP 1 and also the other studies reported. There is some discussion whether atropine the effect of the atropine is due to the change in the corneal power and curvature, but it is important that were the anti myopic effect is reducing axial elongation or other associated biometric changes is better. Therefore, we look into the study and then we look into the other parameters, including the SE change, axial length changes, and also the corneal power, lens power and we found that SE and axial length are longer in concentration dependent response, but the corneal power, lens power and also the anterior change about er are the same. Therefore there is some differences and also, low concentration atropine has no significant effect on the corneal power and lens power. In fact, anti myopic effects may be reducing axial elongation and therefore it can reduce future myopic concentration. And we look into this is a graph to show you that it is a different age group and also the SE progression. In fact, you can see older age, in fact, we have a better response, at SE we have a poorer response. The reason is because when you are treating or when you are having younger children or children at a high risk of inherent progression, the treatment response will become worse, and in fact we noticed that if you are at age 4, using .05%, is similar to an age of 6 using .025%, is similar to the age of 8 using .01%, and also similar to age of .using placebo group. In fact, there’s an age dependent effect in each treatment group and also significant when we are coping with younger children with myopia, they must be inherently progressing faster, because young children of 4 years old with 1 diopter myopia, is completely different with a 8 year old with 1 diopter myopia. They’re completely different. Because in younger children they have a higher accommodation register, they can tolerate a higher concentration much better than a teenage, than an older kid, older child, because when the accommodation is less, they are tolerant not that good comparing to younger children. And also any biomarkers that we can see for we looked into the choroid, there is a changes of choroidal thickening of effects, in .01% .025%, and .05%. There is a choroidal thickening and that is also concentration dependent. The higher the concentration, the more thicker. And also this thickening can also contribute to the SE progression effect, and so therefore atropine can induce a choroidal thickening along a concentration dependent response. The choroidal thickening was associated with a slower SE progression and axial length progression. In the third year we want to answer a few questions, in the third year report. After two years, should we continue treatment, or can we stop the treatment? And what is the longer term efficacy, and if you started treatment are there any rebounds and what are the factors associated with the rebound? So in the third year, in each group we randomized each group into continue the treatment and stopping the treatment. And we see that in fact using had continuing the atropine in the third year, the concentration dependent response remains, .05 better, then .25 better, and .01. If you continue the treatment it’s better than if you stop the treatment. In all the concentrations, in all the treatment groups, if you continue the treatment in the third year, it is still better than than stopping the treatment. And then we can see that if you stop the treatment, there is two factors associated with a rebound. Number one is the age. Number two is the concentration. But you can see that if you are one year older before you stop the treatment, there is a .08 in the beta. That is roughly 10 .08 diopter increase that is than in the rebound. Then if you wait one year later to stop the cessation of treatment one year later, you can slow down the rebound to become less and the higher concentration, the more the rebound. Although in our third year report, the .01, .025, .01 percent, they’re fairly significant, so therefore we during the third year you continue treatment. .05% remains the optimal concentration over 3 years. Stopping treatment at an older age and a lower concentration is associated with a smaller rebound, the difference in rebound are clinically not significant across all three concentrations and all concentrations appear to be and we suggest using the treatment into the third year. So after the I would like to talk about whether we can use the atropine to reduce the incidence of the myopia in children. Not just for those children who are progressing, but to prevent those high risk children from developing. So these are the questions, and this is the LAMP2 study is on placebo controlled trial on delaying myopia onset with atropine 4 to 9 years of age. Why 4 to 9 years? Because these are particularly at higher risk. Of course we could start at older age and the risk would be less. And we give .0etc. There’s two primary outcomes that we are looking for. One is cumulative incidence of myopia. We define as any eye becoming.50 diopter in either eye is becoming myopia, and the other is myopic shift. Whenever one has an myopic shift over one eye, we count as a nast fast myopic shift. So we randomized the trial into two groups. One of the parents are myopic 3 diopter more. And so we can see that across each time point, .05, the research group is better than. .05% atropine over two years is 28.4%. .01 atropine is 45.9% placebo is 53%. And the myopic shift is significantly smaller in the atropine group. I have to define that during Covid, all of the progression get shifted up. 53% is quite high in the placebo group is quite high, but of course all the group in the Covid group is similar. So the comparison is very valid and the myopic shift is also happening to become slower in the myopic shift. That is the SE myopic shift. So LAMB2 study suggest that atropine drops can delay the onset of myopia compared with the .01% atropine or placebo group. And there is no significant report the a difference difference at first among all the three groups. So I think my time is up. But the LAMP studies, thank you very much for having me here to share with you some of the findings, and I would like to thank my team and also my department for all the work we do together. Thank you. Dr. Suh: Thank you, Jason, that was excellent, I really enjoyed it in so many ways and I love how you’re working on studies to be more proactive in treating these patients even before and I’m pretty sure people have many questions, but excellent, excellent, Jason, and thank you for being a great leader in this particular field of myopic progression. So next talk will be given by Dr. Nischal, who doesn’t need any introduction, and he’s going to be talking about what are the things that we can do that’s short of atropine or contact lenses? So please, Ken? Dr. Nischal: Hi, everybody, so I’m going to talk this back a little bit to some basic understanding of how the eye grows, so I’m talking about behavioral interventions and spectacle lens interventions. These are my disclosures, only two are relevant. I am a clinical trial participant, for both Essilor and NORO. So before I start, I want everybody to get their telephones out, get your smartphones out because I’m going to show you a QR code. This is going to be very helpful to your parents and to you. And here is the QR code. So the World Society of Pediatric Ophthalmology and Strabismus created a Myopia Consensus Statement in 2016. It was downloaded over 112,000 times over the world, because people find it useful to explain to their parents and some of their colleagues what myopia control was about. We’ve updated that and have just released it. This is the QR code for that Myopia Consensus Statement, and I think it’s important to know that this statement only takes into consideration data that has had two years’ follow up. So if there’s anything newer that’s only been one year follow up, we did not include it. And then what we did is this is the other QR code you want. This is a Myopia Consensus Statement that is really very simple with cartoon characters, and I’m going to go through this, and then go through what I’m going to cover, which is behavioral interventions, so here’s the burden that Dr. Suh so very nicely described, and I want everybody to remember something: while theoretically if we reduce the axial length, we should reduce the complications we’re talking about, right now there is no study that has shown because we haven’t been doing it long enough that reduction in axial length actually does stop all of these pathological events from happening. It should, but if a parent asks you, all you can say is that theoretically it should, but right now there is no study that shows that it does. However, there’s enough incidental evidence to suggest it might. So these are the interventions that don’t work, and this is important. Right? Undercorrection of a myopic prescription does not work. Pinhole glasses do not work, blue light blocking glasses did not work, bifocal glasses did not work, progressive additional spectacle lenses do not work, peripheral plus correcting lenses do not work, but they’re different than the lenses I’m going to be talking about. And daytime single vision soft contact lenses or rigid do not work. So those are the things we don’t know work. These are the things that appear to, would and I want to talk about the behavioral interventions and the optical treatment that is really the spectacle lenses. Rupa Wong talked about the prescription lenses and Jason talked about the atropine eyedrops. So that’s the conclusion. There is the QR code again. When you did a QR code on this particular last page, that takes you to the full statement if you want to read it in more detail. All right, let’s take it back to mothers. My mother, God bless her soul, said don’t read too much, your eyes will get weak, she said don’t wear your glasses all the time, your eyes will get weak and she said go play outside you’ll get strong. I ignored her and I ended up with had none of my children are myopic. We didn’t have all this amazing science that’s been done on humans. We only had animal work. And so here’s the mix of the magic and science, and understanding of myopia control, and it all boils down to emmetropization. Emmetropization is the active control of the growth of the eye that occurs within the eye and a lot of these pictures that I’m going to show you, if they have a gray background, they’ve been taken from this website. I encourage you to go and have a look at it. It’s a great website, www.opt.uh.edu And what they’ve done is in macaque monkeys if you rear them in light, they will emmetropize, but if you rear them in darkness, you lose that ability to emmetropize. That’s a very important finding, that light has an effect on how the eye grows. If you suture the eyelid of the monkey, you will get myopia. So it occurs not only in animals, it occur in human beings, so form deprivation causes the eyeball to grow longer. All right. What’s interesting is that form deprivation does not require a visual signal to leave the eye, right? It’s a vision dependent mechanism that the whole reflex is in the eye, and that’s crucial to our understanding of how we control the growth of the eye. If it’s something happening only in the eye, then maybe we can think about some of the drops that we’ve been talking about affecting the eye alone. So my mother used to say, don’t read too much, your eyes will get weak, don’t wear your glasses all the time, your eyes will get weak and go play outside, your eyes will get strong and let’s see if she’s right. Myopia has historically been associated with nearwork. We’ve known for years, 1882, Tschernig was quoted about I Duke Elder, that if you look at farm workers compared to the myopia is different. The odds of myopia increased by 2% for every one diopter hour of near work per week. So we can’t stop children from working hard. This is a really good paper. 2022, 1400 children in North India. If you look at the genetic makeup of the Northern Indian populace, there is so it means you’ve got a heterogenetic community where the findings are generalizable to most parts of the world. So you’ve got 1400 children of either sex and what they found was a highly statistically significant positive correlation when children are reading in dim light for the prevalence of myopia. And you know what, there was a study done in 1972, where they reared macaque monkeys in mono chromatic light, that’s black light, that’s the equivalent of reading in dim light and all of those monkeys got axial length increased. So I’ll explain what that means. Here’s a study that I think is really good. You should read this, and remember, it’s open access, so you should be able to get it. They concluded in this Meta analysis that the use of smart device exposure might be associated with increased risk of myopia. It is not so much the smart device, it is the change of behavior in the children not going out outside that probably has more of an effect. So my mother said don’t read too much, your eyes will get weak, she was right. Don’t read in the dark, your eyes will get weak. She was right. What about going outside? These are studies from 2007, all the way to 2011, and now I’m going to show more recent ones that show that there are protective effects not associated with exercise if you get children to go out at least two hours a day, or are daylight exposed. Here’s another metanalysis, overall findps indicate that increasing time spent outdoors may be a simple strategy to which reduce the risk of developing myopia. But here’s the problem: It’s not clear that the time outdoors slows the annual rate of myopia progression, once a child is myopic. So for all of those of you who in countries where it’s hard to get the special spectacles, it’s hard to get contact lenses, it’s hard to get atropine, if your parent if the parents of the child are myopic, and the child is not myopic, tell them: No reading in dim light. If you read, then try and read for about half an hour and then try and take a break. We don’t know if that’s protective, but definitely not reading in dim light, and get out two hours a day. Play outside. You can do that to try to arrest the progression of what we call pre myopes. And here’s a study showing that light levels affect axial growth. So it’s not just being outside. It’s the luminance, so if it’s very cold where you are in the world, stick the child by the window. In fact, there are countries like Singapore and Taiwan, where they are building schools with clear walls so that light can come into the classroom. I’m going to repeat: There are studies that show that if you have got myopia already, it doesn’t necessarily mean that outdoor exposure will slow that progression of myopia, but it’s still worth trying. So the recommendation is 2 hours of daylight exposure daily will help, definitely if you’re not a myope, might help if you’re early myopia. So she said go play outside, your eyes will get strong. She was right. What about the next one? Here’s a study that showed if that if you put myopic lenses in front of a normal macaque monkey, they become myopic. If you put convex lenses, they become myopic. We knew this information 50 years ago, in animal models that were non human primates. Why in because when you put a concave lens in front of an eye, you get a beautiful image on the fovea, but you get what we call a hyperopic defocus. In a growing eye, the eye thinks, ooh, I’ve got to catch those rays that are falling behind me, so I’ve got to grow faster and when they grow faster, bingo, they become more myopic. All right? And you know what? There is an animal, the eagle, the only April the eagle can catch its prey as it falls from the sky as the speed it does is because it has a differential axial length and it uses different images depending on how close it is, and so it’s the same thing. The peripheral retina in primates, nonhuman or human, can grow, it drives axial length. So that’s called hyperopic defocus, so the two lenses that deal with that, and you can look at this from this website, are the HAL lenses, that’s the highly aspherical lenslet spectacle lenses, and in this study they showed that compared to the my opa was slowed the most with HAL lenses. Then there’s the DIMS lenses, they do the same thing, what they do is they make the peripheral focus fall in front of the retina, so the eye stops growing or tries to slow growing, and there was a study here by Zhang et al which. Now, there’s a third type of lens but it works continual. This is called the dot lens. And again, the dot lens works on a particular way. This study tests the hypothesis that environmental factors which produce abnormal contrast between adjacent cones are a signal for axial elongation. And the development of myopia. And what they showed was by reducing that contrast with these DOT spectacle lenses, you could induce slow myopia progression. Now, I’m not going to go into the deI wills ta of this, but there are certain polymorphisms in these two genes, OPN1W and OPN1LW which increase the pigment and are associated with high myopia. So by reducing the contrast, that’s the less contrast on the left, they showed that you actually reduce the myopic progression. So my mother said, don’t wear your glasses all the time, your eyes will get weak and the traditional concave lenses do in fact do that. So here are the interventions that appear to work, and we’ve discussed all of them. And if you want to get the consensus statement, there it is. Thank you very much for listening to me. Remember, mothers are always right! Dr. Suh: [laughter] Ken, I cannot agree with you more. You know, I’m pretty sure that the audience understand why I picked these three amazing speakers and I thank you very much. There was just so much information, and I feel very honored to be part of this excellent speakers, so I’m going to just, you know the hour is up, so I’m going to just ask each one of you. I went through all the questions, and you know, there are a lot of great questions, but I’m going to ask just a one question for each one of you that would represent the meaning of these questions. So first, I’m going to go to Jason. For, you know, these young patients, especially, you know, in Asia, obviously most of the patients have brown eyes, but you know, when you visit Hong Kong and Singapore and Taiwan and you know, there are enough people with light eye colors, so do you use a different would you is your recommendation for atropine, would it change for lighter color eyes? Obviously here in the United States and in Europe, many of the patients have lighter eye colors, and these atropine do have a greater impact in terms of the dilation. I’m not sure about the reduction in the accommodative amplitudes, but I don’t know if you notice any changes, so what are your thoughts, Jason? Dr. Yam: Thank you, Donny. I think different color Iris in relationship to the atropine, there is more data now that’s coming up from various reports. So far I think the concentration dependent response still remains, and but I will say on on the other hand I would look into different ways. When we’re coping with different progressive cohorts, we use different concentration. For fast progressive cohorts, I would say that in Asia, the cohort is faster than Caucasian, but it’s be it genetic, but it environmental, because the progressive rate is much slower for Caucasian from the West compared to the East, so far, those slower progressing children, either their’ Caucasian or they’re older age or they have less myopic parents, these are a less high risk group. Lower concentration, we have similar events comparing to those higher risk children using a higher concentration. So therefore, wheatear considering which concentrations we are using, number one we will discuss with the parents what’s their aim and we will review about their risk profile and then to see their response. That is my general response to these questions. >> Dr. Suh: Thank you, Jason. Just for the audience, we have a paper coming out from pedatic eye disease investigator group on low concentration of atropine, and our PEDI group is working very hard to write the manuscript and we’re very excited to present to you our results here from the United States, so Jason, thank you very much. And then Rupa, I’m going to one of the questions is again, you know, your interaction with your patients, I think truly is impressive and providing all the educational materials. How long, you know, one of the questions is how long do you continue typically once you start, like, and I think that’s the hard part, but another part that’s somewhat difficult to answer is how long do you continue these treatments with your had MiSight or any of the myopic progression treatment? >> Dr. Wong: I mean I think most of the studies have shown progression even until 17, 18 years of age, right, with myopia, so I will recommend if possible with the parents to continue until that age. I also look at that’s why I do like that printout that I get, it charts, you know, a rough estimate as to treatment versus untreatment, with the axial length elongation, they kind of do a trajectory and when I see those two lines starting to narrow that there’s not really going to be that much of improvement with myopia progression with the treatment. All right, they’re 17, let’s go ahead and terminate, it’s not really worth it, you can switch to a regular daily disposable or continue with the atropine drops. So I kind of use those two metrics to help decide. >> Dr. Suh: OK, thank you. And this question goes to Ken and I think you already answered it, and maybe you could just reiterate and what are some of the recommendations that you would have and summarize it? Many of the audience, they’re calling in from low income countries, and this question is, what treatment options can we offer in low income countries where we can’t access the atropine and MiSight contact lenses? And also here in the states, as well. We have many patients who cannot afford these the treatment options, so can you just, you know, a short sentence, what are some of the things that you could recommend to these providers and doctors where these treatment options are not available? >> Dr. Nischal: Yeah, so you look, the thing is that the environmental factors play a big role, even if you have a bit of myopia, I still ask parents not to let their children read in dim light. Not to let them use any smartphones in darkness, and I ask them remember that the DOT technology has shown that a high contrast has an effect on myopia. So if you’re in pitch black and you’ve got a smartphone light in your face, that’s high contrast. And so it’s really important, there’s lots of evidence that reading in dim light is not good, and it comes from animal studies, too. Like 50 years old animal studies. No. 2, two hours’ daylight exposure outside every day. Every day, and not sitting in the shade, you’ve got to be out in the sun or by a window. And the third thing is this: You cannot stop people wearing glasses, you’ve got to have clear visionings, but the concave glasses that you have, so there’s an argument that if you can take your glasses off and spend a little bit of time with them off all the time, there R. that may have an effect. But for low income countries, those are things you can do before we get a treatment out there. We do not know from the fact that some of what we’re saying, apart from the optical treatment, works in African eyes. We have evidence in East Asian, South Asian, European, but we do not evidence that at the moment in African eyes. So if you’re in Africa, and you’re listening to this, and you think that you feel a bit I don’t know, disconsolate, don’t. We don’t have the evidence, but you can do these simple environmental things to help your patients. >> Dr. Suh: That’s great. Thank you. And the last question is there are so many different causes from medical induced myopia, the general question is, how do you test for all those things? Well, I’m going to just tell you that the it’s actually not too difficult. You know, you should be doing a comprehensive eye exam before you initiate any type of myopic treatment. You have to obtain good history, make sure the patient is not on the medications that we just talked about. If they are, then check the anterior chamber and look for any kind of narrow angle or closed angle. Look for signs of nephritis, look for signs of lenses location, whether it’s anterior or different areas, and do a careful funduscopic examination, looking for signs of any that would suggest that the patient may have inherited retinal disease. I think those are just doing a general comprehensive eye examination, before we start these medications, or glasses or contact lenses, I think is critical. Well, thank you very much, Ken, Rupa, and Jason. I’ve actually personally learned a lot, and I look forward to seeing you guys again at future meetings and I’m so proud that we have such a strong community of immediate pediatric ophthalmologists supporting our pediatric ophthalmologists and optometrists over the world. Thank you so much for supporting Cybersight and Orbis. Thank you. .