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Step 1: Prescribing Doctor Selection:
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Step 2: Patient Progression Assessment
Current age of patient:
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6 years old 7 years old 8 years old 9 years old 10 years old 11 years old 12 years old 13 years old 14 years old
Ethnicity:
Undefined
Undefined Asian European
Current SE Refractive Error:
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-0.25 -0.50 -0.75 -1.00 -1.25 -1.50 -1.75 -2.00 -2.25 -2.50 -2.75 -3.00 -3.25 -3.50 -3.75 -4.00 -4.25 -4.50 -4.75 -5.00 -5.25 -5.50 -5.75 -6.00
Myopia Management Intervention:
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MiSight Orthokeratology 0.01% Atropine 0.025% Atropine 0.05% Atropine 0.1% Atropine 0.5% Atropine 0.01% Atropine + Orthokeratology
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Historical

at years old
using intervention
Estimated Progression [Refractive (D)]
Without Treatment:
Initial
3 years after
Age 17
With treatment:
3 years after
Age 17
Estimated Progression [Axial Length (mm)]
Without Treatment:
Initial
3 years after
Age 17
With treatment:
3 years after
Age 17
Evidence Based Estimation
Based on your Assessment
at years old
using intervention
Ethnicity
Progression without treatment
Refractive (D)
Axial Length (mm)
Expected amount of myopia after 3 years:
Expected amount of myopia by age 17:
Expected progression with recommended treatment
Expected amount of myopia after 3 years:
Expected amount of myopia by age 17:
The study evaluating this specific intervention did not assess refractive error progression.
The study evaluating this specific intervention did not assess axial progression.
Myopia Progression Evidence Based Estimation
*The initial 3 years of data are derived from the MiSight progression data, beyond 3 years we utilize the average of this 3-year data to project subsequent progression.
**If multiple inputs exist for same age the most recent will be display.
The study evaluating this specific intervention did not assess refractive error progression.
*Normal axial progression is based on the following study: Zadnik K, Mutti DO, Mitchell GL, Jones LA, Burr D, Moeschberger ML. Normal eye growth in emmetropic schoolchildren. Optom Vis Sci. Nov 2004;81(11):819-28. doi:10.1097/01.opx.0000145028.53923.67
The study evaluating this specific intervention did not assess axial progression.
Learn More
Corneal reshaping contact lenses
They are worn during sleep and removed in the morning. They temporarily change the shape of the cornea (the clear window on the front of the eye), so that the child can see clearly all day long without glasses or contact lenses. During the first two weeks of wear, your child will experience changing vision. When the vision gets worse, s/he may put on glasses to provide clear vision. Although the chance of an eye infection is still very low (about one case per 719 years of wear), it is greater for corneal reshaping contact lenses than usual daytime contact lens wear because the contact lens is worn overnight.

Soft dual focus contact lenses
It is similar to lenses routinely worn to help people over 40 years of age read clearly as well as see far away. Children may not see quite as clearly with these contact lenses as other types of contact lenses, but there are not additional risks compared to regular daily contact lens wear.
Atropine
It is an eye drop that typically makes light seem bright because it makes the pupil (black hole in the middle of the eye) bigger, and it blurs near vision because it reduces the ability to focus the eyes while looking at near. Low concentration (0.01% - 0.05%) atropine has been shown to slow the progression of nearsightedness without increasing pupil size or decreasing near vision dramatically. Only 8% of children complained of problems with low concentration atropine and glasses can reduce symptoms if your child notices poor reading vision or lights seem too bright.

MiSight contact lenses
MiSight contact lenses are a type of dual focus contact lens that has been specifically FDA approved approved treatment to reduce axial elongation and myopia progression in children 8 to 12 with myopia of -0.75 to -4.00 diopters of myopia and less than -1.00 diopters of astigmatism.
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{{OfficeName}}
{{date}}
at {{age}} years old
using {{intervention}} intervention
Estimated Reduction in Progression: {{difference}} [Refractive (D)]
Current:
{{current}}
Predicted by age {{age}}
Without Treatment:
{{predictedUntreated}}
With Treatment:
{{predicted}}
Estimated Reduction in Progression: [Axial Length (mm)]
Current:
{{currentAxial}}
Predicted by age {{age}}
Without Treatment:
{{predictedUntreatedAxial}}
With Treatment:
{{predictedAxial}}
{{date}}
at {{age}} years old
using {{intervention}} intervention
Estimated Reduction in Progression:
After {{years}} years of intervention:
{{current}}
{{currentAxial}}
Myopia Eye Examination Report
Patient
Name:
DOB:
/
/
Address:
Phone:
Family / General Practice Physician
Name:
Address:
Phone:
Fax:
Other Coordinating Physician
Name:
Address:
Phone:
Fax:
I recently had the pleasure of evaluating the ocular and visual health of our mutual patient. We had a long discussion about the treatment options related managing the progression of myopia and the associated ocular diseases. Based on the current evidence and progression data we have decided to proceed with the below treatment. I have also provided you with an evidence-based estimation of untreated and treated estimations.
Based on your Assessment
at years old
using intervention
Ethnicity
Progression without treatment
Refractive (D)
Axial Length (mm)
Expected amount of myopia after 3 years:
Expected amount of myopia by age 17:
Expected progression with recommended treatment
Expected amount of myopia after 3 years:
Expected amount of myopia by age 17:
Based upon your clinical situation, your doctors recommendation is:
Next Steps
Comments:
Next appt date (if avail):
/
/
Signature:
/
/
Citation:
  • P. Chamberlain, S. C. Peixoto-de-Matos, N. S. Logan and C. Ngo, "A 3-year Randomized Clinical Trial of MiSight Lenses for Myopia Control," Optom Vis Sci ., vol. 96, no. 8, pp. 556-567, 2019.
  • C. S. Cho P, "Retardation of myopia in Orthokeratology (ROMIO) study: a 2-year randomized clinical trial," Invest Ophthalmol Vis Sci, vol. 53, no. 11, pp. 7077-7085, 2012.
  • E. A. Chua WH, "Atropine for the treatment of childhood myopia. (ATOM1)," Ophthalmology, vol. 113, pp. 2285-2291, 2006.
  • A. Chia, W. H. Chua, Y. B. Cheung and et al, "Atropine for the treatment of childhood Myopia: Safety and efficacy of 0.5%, 0.1%, and 0.01% doses (Atropine for the Treatment of Myopia 2)," Ophthalmology, vol. 119, pp. 347-354, 2012.
  • J. C. Yam, F. L. MMed, X. Zhang, S. M. Tang and et al, "Two-Year Clinical Trial of the Low-Concentration Atropine for Myopia Progression (LAMP) Study: Phase 2 Report," Ophtalmology, vol. 127, no. 7, pp. 910-919 , 2020.
Note - If faxed, this report must include the HIPPA Privacy Rule fax cover sheet
© 2021 Vision Source ® L.P. All rights reserved.
Based on your current risk factors, myopia amount and evidence based progression models, and visual requirements, we recommend the following treatment for slowing your progression of myopia.
Based on your Assessment
at years old
using intervention
Ethnicity
Progression without treatment
Refractive (D)
Axial Length (mm)
Expected amount of myopia after 3 years:
Expected amount of myopia by age 17:
Expected progression with recommended treatment
Expected amount of myopia after 3 years:
Expected amount of myopia by age 17:
The study evaluating this specific intervention did not assess refractive error progression.
*The initial 3 years of data are derived from the MiSight progression data, beyond 3 years we utilize the average of this 3-year data to project subsequent progression.
**If multiple inputs exist for same age the most recent will be display.
The study evaluating this specific intervention did not assess axial progression.
*Normal axial progression is based on the following study: Zadnik K, Mutti DO, Mitchell GL, Jones LA, Burr D, Moeschberger ML. Normal eye growth in emmetropic schoolchildren. Optom Vis Sci. Nov 2004;81(11):819-28. doi:10.1097/01.opx.0000145028.53923.67
Learn More
Corneal reshaping contact lenses
They are worn during sleep and removed in the morning. They temporarily change the shape of the cornea (the clear window on the front of the eye), so that the child can see clearly all day long without glasses or contact lenses. During the first two weeks of wear, your child will experience changing vision. When the vision gets worse, s/he may put on glasses to provide clear vision. Although the chance of an eye infection is still very low (about one case per 719 years of wear), it is greater for corneal reshaping contact lenses than usual daytime contact lens wear because the contact lens is worn overnight.

Soft dual focus contact lenses
It is similar to lenses routinely worn to help people over 40 years of age read clearly as well as see far away. Children may not see quite as clearly with these contact lenses as other types of contact lenses, but there are not additional risks compared to regular daily contact lens wear.
Atropine
It is an eye drop that typically makes light seem bright because it makes the pupil (black hole in the middle of the eye) bigger, and it blurs near vision because it reduces the ability to focus the eyes while looking at near. Low concentration (0.01% - 0.05%) atropine has been shown to slow the progression of nearsightedness without increasing pupil size or decreasing near vision dramatically. Only 8% of children complained of problems with low concentration atropine and glasses can reduce symptoms if your child notices poor reading vision or lights seem too bright.

MiSight contact lenses
MiSight contact lenses are a type of dual focus contact lens that has been specifically FDA approved approved treatment to reduce axial elongation and myopia progression in children 8 to 12 with myopia of -0.75 to -4.00 diopters of myopia and less than -1.00 diopters of astigmatism.
Based upon your clinical situation, your doctors recommendation is:
The United States Food and Drug Administration (FDA) has approved the MiSight contact lenses for the purpose of slowing the progression of myopia in children. Additional studies also show us that other contact lenses and prescription eye drops can slow the progression of nearsightedness in children as well.
All contact lenses and eye drops used at have been approved by the FDA, but some may not have been approved yet to specifically to slow the progression of nearsightedness.
I understand the risks as indicated above, and I understand that while these treatments are approved by the FDA, they are not approved to slow the progression of nearsightedness. I further understand that there ls no guarantee or assurance of any treatment outcome for my child and that these treatments may not slow the progression of nearsightedness.
Citation:
  • P. Chamberlain, S. C. Peixoto-de-Matos, N. S. Logan and C. Ngo, "A 3-year Randomized Clinical Trial of MiSight Lenses for Myopia Control," Optom Vis Sci ., vol. 96, no. 8, pp. 556-567, 2019.
  • C. S. Cho P, "Retardation of myopia in Orthokeratology (ROMIO) study: a 2-year randomized clinical trial," Invest Ophthalmol Vis Sci, vol. 53, no. 11, pp. 7077-7085, 2012.
  • E. A. Chua WH, "Atropine for the treatment of childhood myopia. (ATOM1)," Ophthalmology, vol. 113, pp. 2285-2291, 2006.
  • A. Chia, W. H. Chua, Y. B. Cheung and et al, "Atropine for the treatment of childhood Myopia: Safety and efficacy of 0.5%, 0.1%, and 0.01% doses (Atropine for the Treatment of Myopia 2)," Ophthalmology, vol. 119, pp. 347-354, 2012.
  • J. C. Yam, F. L. MMed, X. Zhang, S. M. Tang and et al, "Two-Year Clinical Trial of the Low-Concentration Atropine for Myopia Progression (LAMP) Study: Phase 2 Report," Ophtalmology, vol. 127, no. 7, pp. 910-919 , 2020.
Signature: