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Currently, one-third of children and adolescents worldwide have myopia, with the prevalence expected to dramatically increase by the year 2050.

 Although our profession has made significant strides in progressing myopia management toward standard of care, optometrists still face challenges implementing myopia management into everyday clinical practice. Parents are often skeptical about what they may perceive as a novel approach to myopia, may have cost concerns, or even be fearful of potential adverse effects that contact lenses or eye drops may have on their child. To make the most impact on our concerted fight against myopia, we need a plethora of options to accommodate each type of patient, refractive error, and budget. This article will highlight the future of myopia management and what options are on the horizon.

Currently, the most widely accepted eye drop for myopia management is atropine, a nonselective muscarinic antagonist. Although the exact mechanism of action is unknown, the leading hypothesis is that atropine targets muscarinic and nonmuscarinic receptors in the retina and sclera, limiting their thinning and ultimately retarding axial elongation.

 Clinically, atropine is being used off label, but findings from the LAMP trial have shown 0.05% atropine to be more effective than 0.025% and 0.01% when controlling myopia progression. In addition, all concentrations resulted in minimal adverse effects.

 Despite findings from clinical trials supporting safety and efficacy of atropine, many parents are still leery of using a non–FDA-approved pharmaceutical agent for their child. Thus, there have been significant efforts in our industry to get an FDA-approved formulation to market.

Sydnexis’ SYD-101 is a patented atropine formulation containing a unique ingredient that stabilizes atropine to near physiologic pH. To prevent rapid degradation of atropine, most water-based formulations are dropped below pH 5, which is very acidic and consequently uncomfortable for the user and decreases bioavailability. On the contrary, SYD-101 is specially designed to maximize comfort, stability, and efficacy.

 Currently, SYD-101 (0.01% and 0.03% atropine) is in an ongoing phase 3 clinical trial (STAR; NCT03918915) with more than 850 participants enrolled, with an expected completion date in 2025.

Vyluma’s Childhood Atropine for Myopia Progression (CHAMP; NCT03350620) trial tested the efficacy of NVK002, their preservative-free, low-dose atropine formulation (0.01% and 0.02%). CHAMP was a multicenter, international trial that enrolled 576 children with myopia over a 4-year period. Results showed 0.01% atropine was associated with slower myopic progression and axial elongation when compared with placebo. In addition, it exhibited a strong safety profile and no significant rebound effect, proving NVK002 as a potential treatment for childhood myopia.

 Currently, Vyluma is in discussion with the FDA to address their questions about Vyluma’s trial and their atropine formulation in hopes of forging a path forward.

Eyenovia’s phase 3 CHAPERONE trial (NCT03942419) tested MicroPine low-dose atropine (0.1% and 0.01%) with their proprietary Optejet dispensing platform. This was a US-based, multicenter trial that evaluated 252 children with myopia over 4 years. The drug was well tolerated by the participants; however, the rate of myopic progression was unfortunately not significantly different between the 2 treatment arms and the placebo arm. Because the study did not meet its primary end point of less than 0.5 D of progression over 3 years, Eyenovia decided to terminate the trial as of November 2024.

 However, the company is now more thoroughly reviewing the data and evaluating next possible steps.

iVeena’s IVMED-85 is an experimental topical eye drop containing copper used twice daily to slow myopia progression. Copper is a cofactor for lysyl oxidase (LOX). The proposed mechanism of action is to increase LOX, which is the enzyme that mediates collagen cross-linking in both the sclera and cornea. IVMED-85, theoretically, should increase LOX activity and result in corneal flattening, scleral stiffening, and axial elongation reduction.

 In October 2023, iVeena Delivery Systems was awarded a National Eye Institute Phase 1 Small Business Research Grant for IVMED-85. For now, we are currently awaiting further information on their first human clinical trials.

Likely the most anticipated addition to comprehensive myopia management is an FDA-approved spectacle option. Although several lenses are in the pipeline, none are currently available in the US market.

Essilor’s Stellest lenses employ highly aspherical lenslet target (HALT) technology. The lens consists of 1021 invisible lenslets strategically arranged on 11 rings. This design creates a volume of myopic defocus in the peripheral retina. The clinical trial results reveal the Stellest lenses save 1.75 D of myopia over a 5-year period, providing conclusive evidence in its ability to slow myopia progression.

 Recently, they became available in several sun tints, with expanded parameters on the horizon for non-US markets.

HOYA’s MiYOSMART lenses use “defocus incorporated multiple segments” technology. The lens consists of a clear 9-mm central optic zone surrounded by several segments of +3.50 D arranged in a honeycomb-like pattern, creating peripheral blur. Findings from the 2-year clinical trial concluded that children wearing the MiYOSMART lenses had 60% less myopia progression when compared with children wearing single-vision lenses.

 This study is ongoing and is the longest running myopia control spectacle lens study to date. MiYOSMART lenses are also available in photochromics and polarized sun tints in 30 countries but are not yet available in the US.

SightGlass Vision lenses use the Diffusion Optics Technology (DOT) design, which consists of a clear, central optic zone surrounded by thousands of light-scattering microdots, which mimic natural light settings. These lenses slow myopia progression by scattering the light before it reaches the retina, which, in turn, interrupts the signal for axial elongation. The 2-year pivotal CYPRESS trial (NCT04947735) results showed 59% reduction in myopia progression for participants wearing the DOT lenses full-time vs those wearing single-vision lenses.

 In addition, the 4-year data echoed the 2-year data, showing statistically significant slowing of axial elongation and cycloplegic spherical equivalent refraction.

 In February 2024, SightGlass received Breakthrough Device designation from the FDA, which is reserved for “highly innovative devices that provide more effective treatment or diagnosis of life-threatening or irreversibly debilitating human disease or conditions.”

 This allows for more frequent FDA feedback during the premarket review phase along with prioritized submission review.

Currently, CooperVision’s MiSight 1 Day is the only FDA-approved myopia control option. MiSight is a dual-focus lens consisting of 2 correction zones for the correction of the patient’s refractive error and 2 treatment zones consisting of 2 D of defocus. In findings from their landmark 7-year clinical trial, MiSight slowed myopia progression and axial elongation by an average of 59% and 57%, respectively, in children aged 8 to 12 years at the initiation of treatment. After 6 years, approximately 25% of patients showed minimal to no progression, and after 7 years, there was no rebound effect after lens cessation.

Visioneering Technologies has an ongoing clinical trial, Progressive Myopia Treatment Evaluation for NaturalVue Multifocal Contact Lens Trial (PROTECT; NCT05159765), evaluating the effectiveness of NaturalVue Multifocal in managing myopia progression in children. NaturalVue Multifocal is a daily, disposable, center-distance, extended depth-of-focus design. The 1-year results are promising, with adjusted outcomes of 89% reduction in myopia progression and 58% reduction in axial elongation when compared with single-vision lens wearers. Further insights into the long-term impacts of this lens design will be revealed in the 2- and 3-year data.

Johnson & Johnson Vision’s Abiliti 1-Day Soft Therapeutic Lenses for Myopia Management are silicone hydrogel lenses designed with RingBoost technology. These lenses create a ring of focus that is formed in front of the retina and around the visual axis, theoretically allowing more treatment power to be engineered into the lens design. Their 6-month pilot study comparing ACUVUE OASYS, a dual-focus design on OASYS material, with Abiliti 1-Day resulted in Abiliti 1-Day providing the least amount of axial elongation. More studies are underway as we anticipate more long-term data findings.

Repeated low-level red light (RLRL) therapy has recently gained attention as a potential treatment for myopia progression. The exact mechanism of action is not yet well understood, but the leading hypothesis is that red light can prevent structural changes in both the retina and choroid and reduce scleral hypoxia seen in patients with myopia, both of which could prevent myopia onset and reduce progression.

 RLRL therapy consists of foveal exposure to long-wavelength red light (635-650 nm) for 3 minutes twice daily. Although RLRL appears to be an attractive, simple option for myopia management, serious safety concerns have been raised, including the long-term impacts of red-light exposure. Findings from a recent study found that during the 3-minute sessions, 2 different RLRL devices approached or surpassed their thermal and photochemical maximum permissible exposure, putting the retina at significant risk for irreversible damage.

 Findings from this study highlight the urgent need for further research into the particular area of myopia management before implementing into clinical practice.

Dopavision’s MyopiaX is an innovative smartphone application that provides noninvasive, nonpharmaceutical treatment to the eye to slow myopia progression. Although children are engaging in fun virtual reality or educational content, the app administers patented blue light to the optic nerve head, activating a network of cells in the retina and increasing dopamine release. Dopamine is a neurotransmitter proven to inhibit axial elongation and myopia progression. Dopavision’s MyopiaX-1 randomized, controlled clinical trial (NCT04967287) is being conducted across 6 European countries with 124 children with myopia and is currently ongoing. The 6-month data released in October 2024 showed promising results of positive clinical effects on myopia progression and no ocular safety events.

 Completion of the MyopiaX-1 trial will provide further insights and allow for future clinical trials and further development of MyopiaX.

NovaSight’s TrackSight, an application capable of running on a laptop, tablet, or smartphone, uses the in-device camera to track eye movements. It is intended to be used by both children and young adults. Although the individual is using the app, reduction in myopia progression is achieved by real-time peripheral blur on their screen. Unlike spectacles, which offer static peripheral blur optics, this app tracks eye movements and creates custom-tailored contrast degradation depending on the location of the eyes. This allows for natural eye movements and uninterrupted on-axis acuity during the user’s experience. NovaSight is currently planning a feasibility trial to evaluate the immediate response on choroidal thickness, which would then be followed by a 12-month pilot study.

Because the number of patients with myopia will continue to increase, so should our number of options to help mitigate this worsening issue. As we await the exciting future of myopia management, be diligent about capitalizing on the options we currently have available, both on- and off-label.

Liang J, Pu Y, Chen J, et al. Global prevalence, trend and projection of myopia in children and adolescents from 1990 to 2050: a comprehensive systematic review and meta-analysis. 

. 2024;bjo-2024-325427. doi:10.1136/bjo-2024-325427

Upadhyay A, Beuerman RW. Biological mechanisms of atropine control of myopia. 

. 2020;46(3):129-135. doi:10.1097/ICL.0000000000000677

Yam JC, Zhang XJ, Zhang Y, et al. Three-year clinical trial of Low-Concentration Atropine for Myopia Progression (LAMP) study: continued versus washout: phase 3 report. 

. 2022;129(3):308-321. doi:10.1016/j.ophtha.2021.10.002

Safe and effective low-dose atropine can be stable and comfortable too. Review of Myopia Management

 August 15, 2023. Accessed January 8, 2025. https://reviewofmm.com/sydnexis-low-dose-atropine-formulation-can-be-stable-and-comfortable-too/

The safety and efficacy of SYD-101 in children with myopia (STAR). ClinicalTrials.gov. Updated February 15, 2024. Accessed January 8, 2025. https://clinicaltrials.gov/study/NCT03918915

Zadnik K, Schulman E, Flitcroft I, et al; CHAMP Trial Group Investigators. Efficacy and safety of 0.01% and 0.02% atropine for the treatment of pediatric myopia progression over 3 years: a randomized clinical trial. 

. 2023;141(10):990-999. doi:10.1001/jamaophthalmol.2023.2097

Eyenovia provides update on phase 3 CHAPERONE study. News release. Eyenovia. November 15, 2024. Accessed January 8, 2025. https://eyenoviabio.gcs-web.com/news-releases/news-release-details/eyenovia-provides-update-phase-3-chaperone-study

Ambati B, Molokhia S. Advancing myopia therapy with IVMED-85. Review of Myopia Management

October 15, 2021. Accessed January 8, 2025. https://reviewofmm.com/advancing-myopia-therapy-with-ivmed-85/

iVeena awarded NEI-SBIR grant for progressive myopia drug candidate IVMED-85. News release. iVeena. October 26, 2023. Accessed January 8, 2025. https://iveenamed.com/news/item/84-iveena-awarded-nei-sbir-grant-for-progressive-myopia-drug-candidate-ivmed-85

Li X, Huang Y, Liu C, et al. Myopia control efficacy of spectacle lenses with highly aspherical lenslets: results of a 5-year follow-up study. Presented at: Association for Research in Vision and Ophthalmology Annual Meeting; May 5-9, 2024; Seattle, WA.

Lam CSY, Tang WC, Tse DYY, et al. Defocus incorporated multiple segments (DIMS) spectacle lenses slow myopia progression: a 2-year randomised clinical trial. 

. 2020;104(3):363-368. doi:10.1136/bjophthalmol-2018-313739

Rappon J, Neitz J, Neitz M, Chung C, Chalberg TW. Two-year effectiveness of a novel myopia management spectacle lens with full-time wearers. 

Chalberg T, Chung C, Young G, et al. Control of myopia using diffusion optics spectacle lenses: efficacy and safety study (CYPRESS) 42-month results. Presented at: Association for Research in Vision and Ophthalmology Annual Meeting; April 27, 2023; New Orleans, LA.

Kaiser Maharjan E. FDA grants SightGlass Vision Breakthrough Device designation for DOT spectacle lenses. 

February 15, 2024. Accessed January 8, 2025. https://www.optometrytimes.com/view/fda-grants-sightglass-vision-breakthrough-device-designation-for-dot-spectacle-lenses

Chamberlain P, Peixoto-de-Matos SC, Logan NS, Ngo C, Jones D, Young G. A 3-year randomized clinical trial of MiSight lenses for myopia control. 

. 2019;96(8):556-567. doi:10.1097/OPX.0000000000001410

Chamberlain P, Logan N, Jones D, Gonzalez-Meijome J, Saw SM, Young G. Clinical evaluation of a dual-focus myopia control 1 day soft contact lens: 6-year results. Presented at: 2020 American Academy of Optometry Annual Meeting; October 7-22, 2020.

Chamberlain P, Arumugam B, Arumugam B, et al. Myopia progression on cessation of dual-focus contact lens wear: MiSight 1 day 7-year findings. 

PROTECT RCT data update. Visioneering Technologies. Updated September 2024. Accessed January 8, 2025. https://global.vtivision.com/protect-study/

Johnson & Johnson Vision announces availability of ACUVUE Abiliti 1-day soft therapeutic lenses for myopia management in Singapore. News release. Johnson & Johnson Vision. December 8, 2022. Accessed January 8, 2025. https://www.jjvision.com/press-release/johnson-johnson-vision-announces-availability-acuvue-abiliti-1-day-soft-lenses

He X, Wang J, Zhu Z, et al. Effect of repeated low-level red light on myopia prevention among children in China with premyopia: a randomized clinical trial. 

. 2023;6(4):e239612. doi:10.1001/jamanetworkopen.2023.9612

Ostrin LA, Schill AW. Red light instruments for myopia exceed safety limits. 

. 2024;44(2):241-248. doi:10.1111/opo.13272

Joy J. Dopavision announces topline results for MyopiaX trial for slowing pediatric myopia progression. 

May 29, 2024. Accessed January 8, 2025. https://www.optometrytimes.com/view/dopavision-announces-topline-results-for-myopiax-trial-for-slowing-pediatric-myopia-progression

Eye-tracking software for myopia prevention. Review of Myopia Management. July 23, 2024. Accessed January 8, 2025. https://reviewofmm.com/eye-tracking-software-for-myopia-prevention/

From eye drops to novel treatments, it’s time to assess all options for improving patients’ visual acuity.

What’s on the horizon for myopia management?

“What is your job and where do you work?” has always been one of the first questions in my clinical history for new patients. Understanding the type of work and environment that patients spend a good part of their day in often offers some important clues to the reason for their visit.

Does the patient live or work in a “sick building”? Sick building syndrome (SBS) is a condition in which patients develop symptoms of illness or become infected with chronic disease from the building in which they work or reside.

 SBS is also known as building-related illness, building-related symptoms, or idiopathic environmental intolerance. Symptoms of SBS include but are not limited to headache, fatigue, dizziness, nausea, and nose, throat, and eye irritation.

Factors that precipitate patients’ symptoms can include:

- Chemical pollutants from indoor sources such as adhesives, carpeting, upholstery, manufactured wood products, paints, copy machines, pesticides, and cleaning agents that may emit volatile organic compounds (VOCs), including formaldehyde

- Ozone produced by printers and photocopiers

- Biological pollutants such as viruses, bacteria, dust mites, pollen, and toxic black mold

In the boroughs of New York, where I work and live, subway travel to and from work is a daily occurrence for many. It has come to light that fine iron particles from subway tracks, among a myriad of other pollutants, are released into the air of poorly ventilated subway tunnels.

 Additionally, a recent study in New York City draws a link between a fungus found on mice droppings in the city's homes and workspaces and asthma rates in exposed humans.

Furthermore, the exposed mucosal tissue of the ocular surface can come in contact with microplastic particles contained in toiletries, tap water, cosmetics, and air. Data from murine model experiments have demonstrated that microplastics can stimulate ocular surface inflammation and damage, induce apoptosis, and reduce corneal conjunctival and goblet cell epithelial cell viability.

Is it possible that some or all of these toxins/pollutants/micro-foreign bodies/microorganisms become trapped within Kessing’s Space (the narrow tear-filled separation of the tarsal conjunctiva from the eyeball that reduces friction during eye movements and blinking)? Especially when tear volume and exchange is reduced, can these toxins then perpetuate smoldering inflammation of the ocular surface? The palpebral conjunctiva and fornix house a unique microenvironment that is not subject to the mechanical forces of the blink that extrude harmful irritants to the cornea and interpalpebral bulbar conjunctiva.

There is evidence in the literature to support that lavage of Kessing’s Space effectively reduces MMP-9 expression on the ocular surface and improves the symptoms of dry eye disease.

 If you think about it, patients have been using eyewash cups made from a variety of materials including silver, glass, and aluminum for hundreds of years; silver eyecups were used as early as the 16th century. It was not until the 18th century when more common materials such as ceramics and glass made them popular and accessible to the general public. Do you remember the classic cobalt blue eyewash cup attached to the bottle of collyrium eyewash produced starting in 1911 (Wyeth Pharmaceuticals)?

 Patients have found relief from bulbar lavage for a very, very long time. Otherwise, Bausch + Lomb,

 are some of the many companies that currently provide eye washing irrigation solutions.

Should routine conjunctival irrigation be part of our treatment strategies in dry eye and ocular surface disease? What would be the protocol? What devices to potentiate conjunctival “wash” efforts should be employed? Is there a downside to “conjunctival wash” therapy? Of note, nonpreserved eyewash solution has no detrimental effects on the tear film and the ocular surface mucins.

 Additional data are required to answer these queries.

Until then, what are your thoughts? Contact me with your experience.

World Health Organization Regional Office for Europe. Sick building syndrome. Accessed December 17, 2024. 

https://www.wondermakers.com/Portals/0/docs/ 

Sick%20building%20syndrome%20by%20WHO.pdf

1997;349(9057):1013-1016. doi:10.1016/S0140-6736(96)07220-0

Azad S, Ferrer-Cid P, Ghandehari M. Exposure to fine particulate matter in the New York City subway system during home-work commute. 

 2024;19(8):e0307096.doi:10.1371/journal.pone.0307096

Liao Y, Gao IH, Kusakabe T, et al. Fungal symbiont transmitted by free-living mice promotes type 2 immunity. 

. Published online November 27, 2024. doi:10.1038/s41586-024-08213-2

Zhou X, Wang G, An X, et al. Polystyrene microplastic particles: in vivo and in vitro ocular surface toxicity assessment. 

. 2022;303:119126. doi:10.1016/j.envpol.2022.119126

de Paiva CS, St Leger AJ, Caspi RR. Mucosal immunology of the ocular surface. 

. 2022;15(6):1143-1157. doi:10.1038/s41385-022-00551-6

Mayer N, Kondapalli SSA, Venkateswaran N, Saeed HN. The efficacy of an irrigating eyelid retractor-facilitated ocular rinse on MMP-9 expression and dry eye disease. 

. 2024;4(3):142-146. doi:10.1016/j.aopr.2024.05.002

Li X, Kang B, Eom Y, et al. The protective effect of an eye wash solution on the ocular surface damage induced by airborne carbon black exposure. 

. 2020;39(8):1040-1047. doi:10.1097/ico.0000000000002304

Kim A, Postnikoff CK, Nichols KK. Nonpharmaceutical eye wash may reduce matrix metalloprotease-9 (MMP-9) in dry eye. 

National Museum of American History. Eyecup. Accessed December 17, 2024. 

https://americanhistory.si.edu/collections/object/nmah_994422

Yazu H, Kozuki N, Dogru M, Shibasaki A, Fujishima H. The effect of long-term use of an eyewash solution on the ocular surface mucin layer. 

. 2019;20(20):5078. doi:10.3390/ijms20205078

From toxins to pollutants, the modern world contains harmful elements that impact the ocular surface.

What is hiding at Kessing's Space?

EnVision Summit Co-chairs Sherrol Reynolds, OD, FAAO; Katie Rachon, OD, FAAO, Dipl ABO; Jessica Steen, OD, FAAO, Dipl ABO; and Cecelia Koetting, OD, FAAO, Dipl ABO; express excitement for the upcoming conference and why optometrists should attend.

EnVision Summit 2025: Meet the chairs

As the optometry track of the EnVision Summit expands in 2025, so does attendee excitement for the conference, to be held from February 14-17 in Puerto Rico. Conference optometry faculty Sherrol Reynolds, OD, FAAO; Katie Rachon, OD, FAAO, Dipl ABO; Ashley Wallace-Tucker, OD, FAAO, FSLS, Dipl ABO; Jessica Steen, OD, FAAO, Dipl ABO; and Cecelia Koetting, OD, FAAO, Dipl ABO; share what they find makes EnVision special and what they plan to take part in during the conference.

Editor's note: The below transcript has been lightly edited for clarity.

Hello. My name is Dr Sherrol Reynolds, and I am a professor at Nova Southeastern University College of Optometry in Fort Lauderdale, Florida. I look forward to this year's EnVision Summit. It's going to be again in Puerto Rico. The dates are February 14 through the 17th, and it'll be in San Juan, Puerto Rico. And I have been invited again to present on the latest information when it comes to retina, new treatment when it comes to geographic atrophy, also talking about the latest research in retina, the latest update, the latest treatment modalities for our patients with retinal conditions, and to also be on panels with acclaimed experts and retinal specialists. I look forward to seeing you there.

Hi. I'm Katie Rachon. I'm an optometrist at Virginia Eye Consultants in Norfolk, Virginia. We are a tertiary care, OD/MD medical only center. I am currently the residency director there for 2 residents. And I'm excited to be a speaker at the EnVision conference and attending the conference this year, because last year we had an amazing time, and the optometry track, we learned from a wide variety of colleagues from different settings. We learned from a lot of ophthalmologists that joined us during our track, so we could hear a lot about comanagement. And of course, this is all in a beautiful setting in Puerto Rico over the weekend. So I'm really excited to join again as a speaker and as an attendee, and I hope to see you there.

Ashley Wallace-Tucker, OD, FAAO, FSLS, Dipl ABO:

I think it's incredible that ophthalmology and optometry are coming together in this conference. I don't think I've ever had a learning experience quite like this. It's just great to have a collaborative approach to eye care. You know, we have a lot to offer each other as two professions that are different but aligned in the mission for the best eye health and eye care for our patients.

I'm looking forward to EnVision in 2025 to connect with colleagues, with optometrists, with ophthalmologists, with high level education in a panel format, and to really engage our full community, our family members, our colleagues' children, in a really unique and special environment.

I'm excited that we are getting to do this again this year, and hopefully maybe some more of our optometry friends will learn about the conference and come join us, not just for the optometry track. I mean, it's really encouraged that we're all at the same meeting, and if you want to go sit in on a session that's going on over on the ophthalmology track that interests you go over there as well, and vice versa.

EnVision Summit optometry faculty Sherrol Reynolds, OD, FAAO; Katie Rachon, OD, FAAO, Dipl ABO; Ashley Wallace-Tucker, OD, FAAO, FSLS, Dipl ABO; Jessica Steen, OD, FAAO, Dipl ABO; and Cecelia Koetting, OD, FAAO, Dipl ABO; express excitement for the upcoming conference and why optometrists should attend.

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