Robert A. Clark

Purpose: The aim of this study was to determine whether routinely recorded baseline clinical factors, alone or combined with machine-learning predictive modeling, can provide individual risk stratification for myopia control by identifying children who will progress more than 0.25 diopters (D) during their first year of low-dose atropine treatment. Methods: From a 555-child source cohort treated initially with atropine 0.01% or 0.02%, 468 children had qualifying 9- to 15-month follow-up; 427 children started atropine monotherapy without a baseline optical adjunct. A child was classified as poorly responsive if either treated eye progressed more than 0.25 D of spherical equivalent refraction from baseline to the qualifying visit. This threshold was a practical clinical refraction boundary and was tested in sensitivity analyses using a 0.50-D threshold, annualized progression, and an annualized >0.50 D/year threshold. A prevalence reference, age-plus-refraction logistic regression, elastic-net regression, gradient boosting, and an exploratory multilayer-perceptron neural network were compared by repeated cross-validation. Results: Of 427 children, 159 (37%) were poorly responsive. Discrimination was poor and machine learning provided no improvement: the area under the curve (AUC) was 0.60 for logistic regression and 0.57 for gradient boosting [difference −0.03; 95% confidence interval (CI) −0.06 to 0.01]. Age alone performed similarly (AUC 0.60). No threshold was clinically useful; a high-sensitivity rule flagged 85% of children to identify 88% of poor responders, with positive predictive value 0.39. Conclusions: Routinely recorded baseline factors did not provide clinically useful individual-level prediction of the first-year progression category. With this predictor set, observing early on-treatment progression remains the practical way to identify children who may need escalation.

Background/Objectives. To estimate the cost-utility of atropine-based myopia control versus single-vision (SV) correction in US children, crediting both prevented myopia-associated complications and the ongoing refractive-functional burden of higher myopia as quality-adjusted life years (QALYs). Subjects/Methods. We analysed 553 children on atropine-based treatment at one US practice; atropine monotherapy (n = 443) was primary. Adult spherical equivalent refraction (SER) at age 30 was projected, and a two-segment logistic function mapped projected SER to lifetime risk of myopic maculopathy, retinal detachment, primary open-angle glaucoma and posterior subcapsular cataract. Onset-timed, survival-weighted prevention QALYs were combined with an ongoing refractive-functional decrement (δ = 0.002/dioptre/year). The two co-primary analyses were a Total-Value model and a Pathology-Only reference; incremental cost-effectiveness ratios (ICERs) versus SV used one-way, probabilistic and bootstrap analyses. Results. For atropine monotherapy, the modelled age-30 SER difference averaged 1.14 D. The payer ICER was US$13,671/QALY for Total-Value (bootstrap 95% CI 12,323–15,309) and $31,507 for Pathology-Only (26,910–37,461); the refractive-functional stream contributed the larger share, and myopic maculopathy about 72% of the pathology benefit. The probability of cost-effectiveness at $50,000/QALY was 1.00 (Total-Value) and 0.94 (Pathology-Only). The principal dependency was durability of the refractive separation (ICER $28,640 if functional accrual was truncated at observed follow-up; $78,257 if separation was lost by age 30). Conclusions. Atropine monotherapy was cost-effective versus SV. The Total-Value analysis, which recognises a modest ongoing burden of correction dependence, was more favourable, while the Pathology-Only result remained cost-effective. Estimates depend on persistence of the refractive separation and the discount rate.

Background/Aims: To determine whether first-year response to low-dose atropine predicts long-term myopia control and may guide treatment escalation in myopic children. Methods: A retrospective chart review (2012–2025) identified children treated with atropine 0.01%–0.05% at a single practice with ≥54 months of treatment. Children were excluded with insufficient follow-up (<54 months of treatment), comorbidities that might affect myopia progression or concurrent baseline optical myopia-control therapy. First-year response was modelled as the spherical equivalent refraction (SER) progression rate (diopters (D)/year, continuous, positive values indicating worsening myopia) and by responder status (defined as≤0.25D total progression at 12±3 months). The primary outcome was successful control maintaining≤0.25 D/year over follow-up. Key secondary outcomes were total SER progression and time-to-treatment escalation. Eye-level models accounted for correlation between fellow eyes and adjusted for baseline age and baseline SER. Results: 71 children (142 eyes) had a mean follow-up of 6.8±2.0 years. First-year responders included 101/142 eyes (71%) with higher odds of successful control (adjusted OR 2.66, 95% CI 1.11 to 6.35, p=0.028) and less total SER progression (adjusted difference 0.57D, 95% CI 0.28 to 0.86, p<0.001). Each additional 0.25 D/year of year-1 progression was associated with lower odds of successful control (OR 0.73, 95% CI 0.59 to 0.89, p=0.002) and greater total progression (0.22 D more, 95% CI 0.16 to 0.29, p<0.001). Dose escalation occurred earlier in nonresponders; responders had a lower hazard of escalation (HR 0.27, 95% CI 0.14 to 0.52). Conclusion: First-year SER change is strongly predictive of long-term outcomes; despite earlier treatment escalation in nonresponders, responders had a much higher likelihood of sustained long-term control. Early response assessment may help identify high-risk patients for closer monitoring and/or treatment intensification.

Orbital pulleys act as functional origins of extraocular muscles (EOMs). We used multipositional magnetic resonance imaging (MRI) to provide evidence that gaze-related orbital pulley shift (GROPS) causes strabismus. We determined pulley positions in 9 patients with incomitant strabismus. GROPS was bilateral or unilateral. Most common was isolated inferior GROPS of the lateral rectus pulley; “V” exotropia resulted when this occurred in elevation, and when it occurred in adduction there was restrictive hypotropia (Brown’s syndrome). “V” pattern was also associated with excycio rotation of all rectus pulleys in elevation. Isolated GROPS of the medial rectus pulley occurred. GROPS causes sideslip of rectus EOMs, changing their pulling directions to cause incomitant strabismus. Diagnosis of GROPS requires multipositional EOM imaging.

The optic nerve (ON) becomes taut during adduction beyond ~26° in healthy people and patients with primary open angle glaucoma (POAG), but only retracts the globe in POAG. We used magnetic resonanc...

Purpose/Aim: We used magnetic resonance imaging (MRI) to investigate effects of intraocular pressure (IOP), race, and other factors on optic nerve (ON) traction in adduction, a phenomenon proposed as neuropathic in open angle glaucoma (OAG). Materials and Methods: Thirty-five patients with OAG (26 with maximal untreated IOP ≤21mmHg, 9 with IOP >21mmHg) and 48 controls underwent axial and quasi-coronal MRI in central gaze and large (27–33°) abduction and adduction. Some underwent MRI at smaller ductions (21–28°). Effects of presence vs. absence of OAG; within OAG whether maximum IOP level was ≤21mmHg vs. >21mmHg; adduction angle; race; age; and gender on ON path length and globe translation were analyzed using generalized estimating equations to account for possible intereye correlations of individual subjects. Results: Average visual field mean deviation (±standard error of mean, SEM) was -8.2±1.2 dB in OAG with normal IOP, and -6.1±1.4 in high IOP. In central gaze, ON path in OAG was significantly more redundant than in controls but in both groups the ON became significantly and almost equally straighter in small (~21°) or large (~27°) adduction than in central gaze. With progressive adduction only, globes retracted in OAG (PConclusions: Although ON tethering in adduction is normal, progressive adduction is associated with abnormal globe retraction, in OAG regardless of IOP level. This phenomenon is more prominent in Asians who have OAG. Traction in adduction may cause repetitive strain injury to the ON and peripapillary sclera, thus contributing to the optic neuropathy of glaucoma independent of IOP.

Introduction Topical atropine eye drops at low concentrations have been shown to slow myopia progression in East Asian studies. This study explored the effect of atropine 0.01% eye drops on controlling myopia progression in a multiethnic cohort of children in the USA. Methods A multicenter retrospective case–control study (n = 198) quantified the effect of adding nightly atropine 0.01% eye drops to treatment as usual on the progression of childhood (ages 6–15 years) myopia. Cases included all children treated with atropine for at least 1 year. Controls were matched to cases on both age (± 6 months) and baseline spherical equivalent refraction (SER) (± 0.50 diopters, D) at treatment initiation. The primary endpoint was the average SER myopia progression after 1, 1.5, and 2 years of therapy. A secondary outcome was the percentage of subjects with a clinically significant worsening of myopia, defined as a greater than − 0.75 D SER increase in myopia. Results The average baseline SERs for the atropine (n = 100) and control (n = 98) groups were similar (− 3.1 ± 1.9 D and − 2.8 ± 1.6 D, respectively) (p = 0.23). The average SER increase from baseline was significantly less for the atropine group than the control group at year 1 (− 0.2 ± 0.8 D compared with − 0.6 ± 0.4 D, p < 0.001) and at year 2 (− 0.3 ± 1.1 D compared with − 1.2 ± 0.7 D, p < 0.001). Secondary analysis at year 2 revealed that 80% of the control group vs. 37% of the atropine group experienced clinically significant worsening myopia of at least − 0.75 D (p < 0.001). There were no major safety issues reported in either group. Conclusion Similar to results reported in Asia, atropine 0.01% eye drops significantly reduced myopia progression in a cohort of US children over 2 years of treatment. Funding Nevakar, Inc. Plain Language Summary Plain language summary available for this article.