Building a Myopia Control Practice. Andrew D. Pucker, OD, PhD, FAAO Assistant Professor

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1 Building a Myopia Control Practice Andrew D. Pucker, OD, PhD, FAAO Assistant Professor

2 Disclosures My research has been supported by the following organizations over the past three years: National Eye Institute American Academy of Optometry Optikal Company Alcon I have written newsletters for the following organizations: Contact Lens Spectrum Contact Lenses Today Oculus, Inc. TearLab Corporation Bausch + Lomb Contamac Euclid Systems Contact Lens Update Optometry Times None of these entities have directly affected the content of this presentation

Why Should You Open a Myopia Control Clinic? 1. 2. 3. 4. 5.

3 Why Should You Open a Myopia Control Clinic? Myopia control options likely work A huge myopic population exists We should inform our patients We should inform our students Myopia control can generate revenue

4 Prevalence of Myopia United States 33% (Vitale 2008) Western Europe 27% (Kempen 2004) China 39% (Wong 2000) Taiwan 85% (Lin 2004) Australia 16% (Kempen 2004)

5 Myopia Can Result in Visual Devastation High myopia (-9.00D >) is associated with a 50% risk of developing myopic retinopathies (Vongphanit 2002) Lacquer Cracks

6 Myopia Can Result in Visual Devastation Posterior subcapsular cataracts (PSC) (Lim 1999) Associated with Low myopia Primary open angle glaucoma (POAG) (Marcus 2011) 2.0x to 2.5x greater chance Retinal detachments (RD) (Ogawa 1988) 2.4x to 24x greater chance

7 Building a Myopia Control Practice

8 Planning Committee Clinic structure (contact lens clinic-based) Clinic added to special rotations schedule Materials development (consent, marketing, didactic) Fees and scheduling system created Staff awareness meeting

9 Implementation

10 Patient Education is Everything

11 Nearsightedness can be best defined as A. B. C. A decreased ability to see distance objects A decreased ability to see near objects A decreased ability to see distance and near objects

12 Myopia can be best defined as A. B. C. A decreased ability to see distance objects A decreased ability to see near objects A decreased ability to see distance and near objects

13 Subjects Understanding of the Terms Myopia and Nearsightedness Subjects Definition of Myopia A decreased ability to see distance objects A decreased ability to see near objects A decreased ability to see distance and near objects A decreased ability to see distance objects Subjects Definition of Nearsightedness A decreased ability to A decreased ability see distance and near to see near objects objects Total Subjects Total Subjects Survey found that only 66% of subjects were able to correctly define both myopia and nearsightedness (Pucker & Cox, AAO 2017)

14 Definitions Questions Based on Education Category 120" 100" Number'of'Subjects' 80" 60" 40" 20" 0" Did"not"graduate"High" High"School"Graduate" Some"College" Completed"a" School" Bachelor's"Degree" Highest'Level'of'Educa9on' Completed"a"Master's" Completed"a"Doctoral" Degree" Degree" Myopia"and"Nearsightedness"correct" Myopia"incorrect,"Nearsightedness"correct" Myopia"correct,"Nearsightedness"incorrect" Myopia"and"Nearsightedness"incorrect"

15 Intended to educate patient and parent Intended to get patient and parent buy-in Helps provide legal coverage Write it at a 4 th grade reading level (Williams 1995)

17 Myopia Education Topics Define myopia, its potential causes, and who gets it

18 What Causes Myopia?

19 Heritability of Myopia Children with myopic parents have greater risk for becoming myopic (United States) (Jones 2007) 10% if 0 parents myopic 20-25% if 1 myopic parent (2.08 greater odds) 40-50% if 2 parents myopic (5.07 greater odds)

20 Heritability of Myopia Twin studies indicate the genetics account for about 90% of myopia variability (Lyhne 2001; Dirani 2006; Hammond 2001)

21 Myopia Genetics Juvenile-onset myopia likely has a complex inheritance pattern No single gene has been found that causes myopia (Hysi et al., 2014)

22 Near Work May or May Not Be Associated with Myopia Early work found a link between near work and myopia (e.g., Orthodox Jews) Large cross-sectional and longitudinal studies have not found a link between myopia development and near work (e.g., CLEERE Study)

Accommodative System is Still Linked to Myopia Development Myopic children have increased accommodative lag (Mutti DO 2006; Gwiazda J 2005) Myopic

23 Accommodative System is Still Linked to Myopia Development Myopic children have increased accommodative lag (Mutti DO 2006; Gwiazda J 2005) Myopic children have higher response AC/A ratios (Mutti DO 2000; Gwiazda J 2005) The CM is thicker in myopic children and adults (Oliveira C 2005; Pucker AD 2013)

Education Prevalence of myopia dramatically increased among Inuit after the introduction of Western education (Young 1969; Morgan 1975) Severity of

24 Education Prevalence of myopia dramatically increased among Inuit after the introduction of Western education (Young 1969; Morgan 1975) Severity of myopia increases with years of education (Tay 1992) Subjects with higher IQ scores were more likely to be myopic (surrogate for near work?) (Saw 2004)

cities than outer suburban environments (Ip 2008) Myopic

25 Urbanization Myopic subjects are more likely to live in an urban environment (Paritsis 1983) Myopia is more common in inner cities than outer suburban environments (Ip 2008) Myopic subjects are more likely to live in an apartment than a large home (Ip 2008)

26 Time Outdoors Subjects spending more time on sports and outdoor activities each week were less likely to be myopic (Jones 2007)

27 Meta Analysis of Time Outdoors Myopia Development Myopia Progression (Xiong 2017)

28 Define Myopia Control Myopia control is the reduction of myopia progression Myopia control is not the same as treating myopia

29 Describe the Control Options 0.01% Atropine Center-Distance Multifocal CLs Orthokeratology

30 How Effective is Myopia Control? (Smith and Walline 2015)

31 0.01% Atropine Considerations Less rebound and fewer side effects than 1.0% atropine (Chia 2014) Willingness to use use a drop with an unknown mechanism Increases pupil size (photophobia) and decreases accommodation (Chia 2012, 2014, 2016) 0.01% atropine acquisition Still need vision correction Subject age

32 Orthokeratology Considerations Contact lens parameters (sphere and cyl power) Must be mature (~8-years-old) Must be motivated Most expensive option

33 Multifocal CL Considerations Contact lens parameters (sphere and cyl power) Must be mature (~8-years-old) Must be motivated

34 Mechanism of Contact Lens-Based Myopia Control Smith et al. induced myopia with both minus and form deprivation lenses post foveal ablation (2007, 2009) Peripheral retina is important!

35 Myopic Eyes Have a Prolate Eye Shape (Berntsen & Kramer, 2013)

36 Myopia Control for Astigmatic Patients Center-distance, toric, multifocal custom soft lenses Bitoric gas permeable lenses Scleral lenses Pucker, August 2018

37 Combination Treatments OrthoK % atropine was 53% more effective than OrthoK OrthoK + atropine was more effective with lower amounts of myopia Bifocal & Atropine in Myopia (BAM) Study (NCT )

38 Myopia Control Education Topics Describe why myopia control is beneficial, who should undergo it, and its safety

39 Kids Can Safely Wear Contact Lenses Daily Wear Stapleton 2013 Overnight or Extended Wear Stapleton 2013 Non-CL wearers = ~1/ 10,000 people/year (Pepose 1992) 8- to 14-year-old subjects are less likely to develop a complication than 15- to 25-year-old subjects (Wagner 2014)

40 Contact Lens Safety Mean logmar acuity was 0.01 for each correction method

first line treatment for amblyopia Conventional occlusion and

41 Atropine [1%] is as effective as conventional occlusion for the treatment of amblyopia and therefore should be used as first line treatment for amblyopia Conventional occlusion and atropine penalization have similar reported rates of adverse event.

42 UAB s Myopia Control Clinic TO DO LIST PRELIMINARY DATA Reviewed and signed informed consent Quality of Life Survey Height measurement DIAGNOSTIC TESTINGS Visual Acuity at distance and near Cover Test at distance and near Accommodative Amplitudes Pupils (Obtain from LensStar) Anterior Slit Lamp Examination Topography and Keratometry with K5 PROGRESSION MANAGEMENT Dry Auto Refraction with Nidek ARK-1S Axial Length with LenStar

43 Treatment Myopia Control Fees Initial Consult Office Fees Orthokeratology Free Typical Cost + Myopia Control Fee + 6 Month Exam Multifocal Contact Lenses Atropine Eye Drops Free Typical Cost + Myopia Control Fee + 6 Month Exam Additional Costs Care System Contact Lenses Care System Free Cost of Two Exams Drops Glasses Fee is only charged after patient has selected a control method

called two weeks later Develop relationship with pharmacy

44 Patient Monitoring Contact lens patients are monitored per standard guidelines Atropine e-prescribed and patients are called two weeks later Develop relationship with pharmacy All patients are monitored at 6 months Develop a recall system

45 MYOPIA CONTROL CLINIC Atropine Guide How to use Atropine? Instill one drop in both eyes every night. What are the Side Effects? The most common potential side effects include blurry near vision and light sensitivity. If this occurs, please contact us immediately. Pharmacy: Solutions RX Phone: (205) Fax: (205) Address: th Avenue South Birmingham, AL Remedies Pharmacy Phone: (205) Fax: (205) Address: 4524 Southlake Pkwy, Suite 34 Hoover, AL Your next appointment is in 6 months:

46 Marketing a New Clinic is Difficult! We started with internal referrals until our systems were developed

47 External Marketing We have lectured to pediatric ophthalmologists, distributed newsletters, done a TV interview

48 URL: uab.edu/eyecare/myopiacontrol

Staff & Student Education Staff education meetings and emails

49 Staff & Student Education Staff education meetings and s Student education didactic and workshop training that includes homework

50 Current Status Systems are fully developed and are being refined Patient flow is steady and increasing Students consistently provide positive feedback

51 Building a Myopia Control Practice Andrew D. Pucker, OD, PhD March 2018

52 Myopia Control Summary General consensus is that it safe, so we should be prescribing myopia control Additional studies are currently underway to better understand myopia control Appropriate duration of treatment is unknown No treatment is FDA approved for myopia control

53 Myopia is Optometry It will take an entire generation to reverse the myopia boom! (Holden 2016)

54 Andrew D. Pucker:

55 Please remember to complete your session evaluations on the Academy.18 meeting app Tweet about this session using the official meeting hashtag #Academy18

Myopia Control. Financial Disclosures. Prevalence of Myopia 3/31/2019. Importance of Myopia Control. Myopia Control Treatment Options

Myopia Control. Financial Disclosures. Prevalence of Myopia 3/31/2019. Importance of Myopia Control. Myopia Control Treatment Options Financial Disclosures Myopia Control None Katherine Bickle, OD MS FAAO March 31, 2019 Prevalence of Myopia Importance of Myopia Control 42% of the United States population is myopic and 25% of children