Welcome to Optometry Simplified.
In this weekly newsletter, I've curated the best resources to help you grow personally and professionally.
My mission is to find what's best for my patients and my practice.
Here's what I've found...
Links I Liked
Ordering labs for your patient can be intimidating.
Serology is one of those areas many ODs want to understand better, but often avoid because it feels risky or outside our lane. Mary Kate Walters, OD, FAAO, wrote a helpful resource, “The Optometrist’s Guide to Serology,” that cuts through that uncertainty with clear, practical guidance. Modern Optometry
What are the two sides of the horseshoe in the eye care industry?
Is optometry, potentially, just right in the center of being between the two extreme forms of medicine - between the wellness influencer-driven biohackers vs. the hospital system propelled by big pharma? Here is my favorite line: "Both ends curve toward the same mistake — toward an outsourcing of agency...and a hunger for certainty and control." Sensible Medicine
Research I'm Reading
What percentage of glaucoma patients are fast progressors?
Which stage of glaucoma, mild, moderate, or advanced, tends to have the fastest progression? How do we best detect fast progression? Global VF or central VF? These are all important questions for primary care optometrists managing glaucoma. This new paper attempts to answer each of them. American Journal of Ophthalmology
Deep Thoughts
The reaction to the FDA’s recent decision on low-dose atropine has been intense, and understandably so.
Many of the most thoughtful voices in myopia management have expressed frustration, disbelief, and concern for the long-term implications for our patients.
As I’ve been reading and listening, I’ve found myself wondering whether there may be more behind the FDA’s decision than what’s been discussed so far, which prompted me to take another look at the data.
Not to argue against myopia control. Not to minimize its importance. But to explore whether there is something structural or methodological we may be overlooking.
One lens that keeps pulling me back in is Number Needed to Treat (NNT).
NNT is not the only way to evaluate a therapy, and it certainly doesn’t capture everything that matters clinically.
But it does force a very specific question:
How many children need to be treated for one child to avoid clinically meaningful progression compared to control?
It strips away enthusiasm and asks us to look directly at effect size.
For some context, let's use commonly cited MiSight data:
- Treatment group: 18% progressed by 1.00D over 36 months
- Control group: 62% progressed by 1.00D over 36 months
That gives us:
- Absolute risk reduction: 62% - 18% = 44%
- NNT: 1 divided by 0.44 equals approximately 2.3, which we round up to 3
In practical terms:
Treat about three children with MiSight to prevent one child from progressing at least 1.00D over three years.
That is a very strong treatment signal, especially for a pediatric, long-term intervention.
Using publicly available topline data from the Sydnexis STAR trial, the treatment effect for 0.01% atropine is statistically significant, but smaller.
Here is the available data for 0.01% atropine from the STAR trial:
- Treatment group: 39.5% progressed by > -0.75D over 36 months
- Control group: 49.3% progressed by > -0.75D over 36 months
That gives us:
- Absolute risk reduction: 49.3% - 39.5% = 9.8%
- NNT: 1 divided by 0.098 equals approximately 10.2, which we round up to 11
In practical terms:
Treat about eleven children with 0.01% atropine to prevent one child from progressing at least 0.75D over three years.
That does not mean atropine does not work. It does mean the magnitude of benefit, particularly at 0.01%, is more modest.
And that difference in effect size may matter more than we would like to admit.
Also, I am still surprised that the pivotal trials focused on 0.01% and 0.03% rather than 0.05%.
I am not a myopia-only practitioner, but I manage enough myopia to know that once a relationship with a compounding pharmacy is established, 0.05 percent atropine is not especially difficult to prescribe from a practical standpoint.
Yes, there is a cost. Yes, it requires education and follow-through.
But clinically, many of us already believe the stronger signal lies there.
Which makes me wonder whether part of the hesitation we are seeing is less about atropine as a category and more about uncertainty around approving the weakest effective dose as the first and defining standard.
That is not a conclusion. Just a question.
I understand the appeal of an FDA-approved, shelf-stable, standardized drop. In theory, that solves many problems.
However, in practice, my experience managing dry eye has made me cautious. Regulatory approval does not always translate into easier access, better adherence, or smoother workflows. Sometimes it does. Sometimes it does not.
That reality makes me ask whether approval alone would meaningfully change care on the ground or merely change perceptions.
In the end, I do not have a clean takeaway here, and I am intentionally not trying to land one.
But when I look at:
- The very low NNT of MiSight myopia control
- The more modest effect size of 0.01% atropine
- The ongoing uncertainty around optimal dosing
- And the long-term nature of treating children for years
I can at least understand why regulators might pause, even if I do not fully agree with the outcome.
This is not a defense of the decision. It is an attempt to understand it.
And I think our profession is strongest when we are willing to examine data from multiple angles, even when that examination feels uncomfortable or out of step with the dominant narrative.
As always, I am still thinking this through, and I suspect many of us are.
Practice Performance Partners Pick
Hiring an associate in the new year? I am.
So I re-listened to this expert conversation between Aaron Werner, OD, and fellow private practice gurus, Laurie Sorrenson, OD, and Mick Kling, OD.
Listen and take notes to prepare for your future hires.
Can you do me a favor? If you found any of these resources helpful, share this newsletter with one of our colleagues!
See you next week!
--Kyle Klute, OD, FAAO