1. Fusion 2012 LVPEI Lionel Kowal Melbourne

2. Number & complexity of proposed explanations for myopia genesis & progression relates to the imagination of the investigators Number of trials to try decrease the Rate Of Myopia Progression* has been exceeded only by their ingenuity * ROMP = Rate Of Myopia Progression

4. Why I have trouble assessing the literature 1: measuring myopia When I refract a patient before or after cyclopentolate I often have trouble determining the endpoint precisely either with retinoscope or subjectively I think that ±0.25 DS is ambitious for some patients & Drs, & ± 0.5 DS is more realistic This potential error rate not considered by most authors I always do an autorefractor measurment – it is sometimes not reliable in my office yet is often relied on in published studies!

5. Myopia DS AGE CONTROL TREATMENT Why I have trouble assessing the literature 2: WHAT IS A GOOD RESULT?

6. Myopia DS AGE CONTROL NEW RATE TREATMENT STOPPED AFTER STOPPING Rx, ROMP* @ ‘NEW’ [LOWER] RATE * ROMP = Rate Of Myopia Progression

7. Myopia DS AGE CONTROL CATCH UP ON STOPPING Rx STOP TREATMENT

8. Myopia DS AGE CONTROL AFTER STOPPING Rx, ROMP @ ‘OLD’ [control] RATE TREATMENT STOPPED OLD RATE SIMULATED EXCELLENT RESULT- 2 MUST HAVE FOLLOW UP

9. Myopia DS AGE CONTROL CATCH UP SLOWS MYOPIC PROGRESSION Rx SLOWS ROMP. MYOPIA CATCHES UP DESPITE CONTINUING / AFTER STOPPING Rx

10. WHAT WE NEED TO KNOW IN A TRIAL TO REDUCE ROMP 1. CONTROL GROUP 2. DURATION OF TREATMENT 3. DURATION OF FOLLOW UP 4. DATA AFTER TREATMENT STOPPED

11. What works to reduce the rate of myopia progression Atropine 1% ~30 papers since 1973 show efficacy ≥2 have long term follow up after cessation of drops Catch up is small, still < untreated group > 100 years of atropine use in ophthalmology NO reported cases of UV toxicity etc

12. Atropine 1% In Singapore it's too hot to spend much time outdoors in the sunshine. In Sydney I offer the drops to those Asian Aussies who spend most of their time indoors studying. These kids tolerate it very well. I've had only one kid out of hundreds who stopped the drops because of glare. I don't offer it to the "bronze" Anglo-Aussies who spend a lot of time outdoors and don't overdo the close work. Stephen Hing | Ophthalmologist

13. What probably works to reduce ROMP Atropine 0.01% In Press in ‘Ophthalmology’ from Singapore 2y result ≈ 1% AtropineNO side effects If long term follow up is +ve, this will probably become routine treatment

14. 0.01% Atropine ATOM2 study 1 Atropine for the Treatment of Myopia 1 (ATOM1): 1% effective in controlling ROMP but side effects from cycloplegia & mydriasis. ATOM2 : compare efficacy / side effects of 0.5%, 0.1%, & 0.01%. 400 children aged 6 –12, myopia ≥ -2.0D & astigmatism ≤-1.5D ….randomly assigned to 0.5%, 0.1%, and 0.01%, once nightly R&L for 2y. Cycloplegic refraction, axial length, accommodation amplitude, pupil diameter, and acuity at baseline, 2w, then every 4 mo for 2y.

15. 0.01% Atropine ATOM2 study 2 Main Outcome: Myopia & axial length progression at 2y ROMP at 2y was -0.30±0.60, -0.38±0.60, and -0.49±0.63 D in the 0.5%, 0.1%, & 0.01% groups, respectively ROMP in ATOM1: placebo: -1.20±0.69 D; 1% : -0.28±0.92 D.

16. 0.01% Atropine ATOM2 study 3 Axial Length increase 0.27 ±0.25, 0.28 ±0.28, and 0.41 ±0.32 mm in the 0.5%, 0.1%, and 0.01% groups..differences in myopia progression (0.19 D) and axial length change (0.14 mm) between groups were clinically insignificant 0.01% : negligible effect on accommodation, pupil size, and no effect on near visual acuity. 0.01% has minimal side effects c.f. 0.1% and 0.5%, and is nearly as effective in controlling myopia progression.

17. 1. ↓ duration of spectacle wear 2. planned under correction 2. Bifocals / PALs 3. contact lenses / orthoK …NO repeatable positive clinically significant effect

18. NEW 1: Relatively hyperopic PERIPHERAL REFRACTION may stimulate myopia and myopic progression PubMed: Myopia Peripheral Refraction 181 references NEW 2: Bifocals with prisms NEW 3: Spectacle Monovision

19. Eye Shape and Refraction Model Myope. More Prolate shape Relatively hyperopic periphery Simple minus lens correction can trigger further axial elongation Emmetrope. Oblate shape Relatively myopic in the periphery Appears to have a stable refraction Wallman & Winawer 2004Slide from Prof E Howell

20. Zeiss Myovision lenses

21. Myovision ‘....I assume you are referring to the published paper in September [2010] Optometry & Vision Science. You are reading it correctly, in that the data does not support any significant effect in reducing myopia progression.......’

22. Peripheral Correction Hypothesis The relatively hyperopic trend in the periphery would require over-plus ‘correction’ to stabilise the refraction while a minus correction is required for the central myopia Multi-focal glasses? Only plus in the lower field Leung & Brown 1999, Gwiazda et al 2005 Multi-focal contact lenses? Aller 2004, 2006 Australia: Cooper Proclear ‘D’ soft disposable daily wear contact lenses Minus centre / Plus surround +1.50 D add Slide from Prof E Howell

23. IOVSDec 2011 Decrease in rate of myopia progression with a contact lens designed to reduce relative peripheral hyperopia: one-year results. Sankaridurg P, Holden B, Smith E 3rd, Naduvilath T, Chen X, de la Jara PL, Martinez A, Kwan J, Ho A, Frick K, Ge J. Brien Holden Vision Institute, Sydney, Australia. ROMP -0.57 D/y in treatment group = placebo group in ATOM1.

24. NEW 2: bifocals with BO prisms Arch Ophthalmol. 2010 Jan;128(1):12-9. Randomized trial of effect of bifocal and prismatic bifocal spectacles on myopic progression: two-year results. Randomized trial of effect of bifocal and prismatic bifocal spectacles on myopic progression: two-year results. Cheng D, Schmid KL, Woo GC, Drobe B Cheng D, Schmid KL, Woo GC, Drobe B

27. Been and gone Pirenzepine Novartis didn’t proceed Ocular hypotensives Some papers in 70’s-80’s

28. MYOPIA 1. Major personal / societal problem

29. MYOPIA 2. Convincing EARLY data on ↓ ROMP with Atropine 0.01%. I now offer it to all myopes who fit the ATOM2 criteria

30. MYOPIA 3. ? Genetic segregation first & repeat optical and drug studies