Does pupil size matter when it comes to the efficacy of myopia spectacles?
Dr. Mai: I don't think there's any research that the clinical trials have delineated in terms of pupil size and effectiveness. In general, just prescribe it. And I would not worry about the minutiae of pupil size. I wouldn't let that to dissuade me from one treatment option that much than any others. And so yeah, not a lot of data, but certainly something that we can continue to look at.
If someone wants to discontinue atropine treatment, how are we tapering it? And if so, what's the proper protocol to discontinue?
Dr. Mai: In general, the recommendation is not to stop cold turkey. So let's say that on 0.05%, you wouldn’t just stop altogether, and you'd wait for the patient to be relatively stable. At least 6 to 12 months of stable axial length is a good metric, kind of a rule of thumb to make sure the patient's not still progressing. Once you taper, you probably want to go from 0.05% to 0.025%, and then do that for 3 to 6 months, check for stability, make sure the patient's doing well, then taper from 0.025% to 0.01%. Watch that for again, [for another] 3 to 6 months, make sure everything's good. And then from then on, you might be able to stop altogether. And so that process would take a little bit of time, six to 12 months at a minimum. So that's a good tapering sequence.
And can you talk about what are you doing if someone just decides randomly they don't want to do it anymore, and they're really young. And then let's also talk about what happens when maybe they're older, and things look a little bit more stable, and what that process looks like.
Dr. Mai: Let's say it's atropine and they want to stop altogether. We'll still try to taper them if the patient's willing to do that. We did a study about this with our other [] study. It showed that actually, when we looked at kids after multiple years, most kids that were in orthokaretology, about 80% of them still stayed with it. But in this study, only like 20 to 30% of the patients on atropine actually stayed with it after two or three years because they generally switched to soft multifocals, [or] orthokeratology, because they're just older and ready for it, and they didn't want to be on atropine anymore. And so we handle this all the time in clinic, where we transition from atropine to something else. In general, what we usually do is we would continue the atropine.
We might switch them to, let's say the patient wants to do contact lenses, and then so they wear contact lenses, or they do orthokeratology. We do that for a period of time where they're actually in a slight combo, and versus just stopping the atropine cold turkey, we would taper the atropine, like I mentioned before, just to make sure the axial lens control is still good. And ideally by the end of it, they can just stay on just Ortho-K, just Stellest or something like that, or a soft multifocal, and you can discontinue a combination. Or if you feel that patient needs combo because combo in general might be better, you just keep them on combo.
Do you have one that you are going toward more often than another combination, since there's so many different combinations that are out there? Do you have something that you're like, "Yes, this is kind of what I do for majority of my patients."
Dr. Mai: Probably about 15 to 20% of my patients are on combo. Again, we've done over a thousand cases, and I'd say the majority of that all in combo are right now on orthokertology and atropine. That's just my clinic, and there's a decent amount of studies that show that the efficacy of that is so good. So that's been my go-to.
I would love to hear your advice for how you are addressing people that are not responding to therapy.
Dr. Mai: So there are cases that we have that are probably pathological myopia in nature. It's another mechanism. They might have a disease process that leads to [it], let's say, it's Ehlers-Danlos syndrome. They might have something that causes their myopia to still progress despite all of our conventional treatments. We still try because the cost of wearing a soft contact lens that has a multifocal component in it, or just single vision [is the same]. If we have a multifocal component of the soft lens that the patient already needs to wear to see clearly, let's say there might be some effect in terms of myopic control with that. So we still go for it, even though the fact that we know that the train might be still going to just keep rolling despite our best efforts.
At what point with OrthoK are you troubleshooting the fit versus switching to something like a soft myopia management lens?
Dr. Mai: Vast majority of them stay, but we've had situations— anyone that does a lot of orthokeratology knows that sometimes you get some undercorrection, sometimes a kid has bad days. Sometimes you get that plus a quarter minus one axis 180 that you can never, ever rub out. You tried your best. You redesigned 10 times using the best consultants and whatever. And so sometimes you do switch out. Usually, it's lifestyle-based. Sometimes it's the kids having trouble with glare at nighttime with orthokeratology. I don't hide from the fact that orthokeratology can have issues at nighttime. And so those are the situations in which we do switch out, and we'll try soft lenses. Now we might even try to myopic control specs.
B free lenses for myopia management: I've heard they have toric parameters, but I don't see that anywhere. What are we doing for patients who want these soft lenses that are approved for myopia management, but they have maybe a large amount of astigmatism?
Dr. Mai: Yeah, got a lot of those or oblique axes and things like that. So what we've typically done in the office is you can actually make custom multifocal toric lenses. So let's say the patient's like a minus six with four diopters as a cylinder. We've done custom soft multifocal contact lenses that are toric in nature. In general, there are certain lenses, I'm not going to throw out the name of the product, but there's certain lenses that claim that they can mask up the two diopters that are daily disposable that we've done decently well with. But beyond that, yeah, I might look at other options, toric lenses, custom-made ones. And I know a lot of manufacturers are going to come up with more toric parameters soon. But until that happens, you do what you can with what you can.
Make sure to watch the full video to get further insights into the current state of myopia management in 2026!
