PREVENTING MYOPIA PROGRESSION
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Transcript of PREVENTING MYOPIA PROGRESSION
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PREVENTING MYOPIA PREVENTING MYOPIA PROGRESSION PROGRESSION
DR PRASHANT SAHAREDR LIONEL KOWAL
OMC RVEEH & CERAMELBOURNE AUSTRALIA
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MECHANISMMECHANISM
Many Interesting Innovative and Credible Theories – no proof1. disruption of emmetropisation2. form deprivation3. optical defocus4. excessive accommodation5. incremental retinal defocus theory Hung & Ciuffreda ARVO 01
6. abnormal scleral collagen
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MECHANISMMECHANISMGenetic aspects Many different genes : ? phenotype / genotype correlation. ? Each genetic type of myopia has a UNIQUE MECHANISM / ROMP / RESPONSE TO DIFFT TREATMENTSHong Kong? 90% incidence of myopiaGenetic influences less credible
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TREATMENTS TO ARREST TREATMENTS TO ARREST MYOPIA MYOPIA
OPTICAL1.↓duration of spectacle wear2. planned under correction2. Bifocals / PALs3. contact lenses / orthoKPHARMACOLOGICAL4. atropine / pirenzipine5. ocular hypotensives
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IDEAL STUDYIDEAL STUDY
Prospective Randomised Double blind? Monocular control [systemic absorption]
*Determine optimal timing & duration of Rx
**Detect catch-up after stopping Rx
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APPARENTLY EXCELLENT APPARENTLY EXCELLENT RESULTRESULT
MyopiaDS
AGE
CONTROL
TREATMENT
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EXCELLENTEXCELLENTRESULTRESULT
MyopiaDS
AGE
CONTROL
NEW RATE
TREATMENT STOPPED
AFTER STOPPING Rx, ROMP @ ‘NEW’ [LOWER] RATE
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SIMULATED EXCELLENT SIMULATED EXCELLENT RESULT-1RESULT-1
MyopiaDS
AGE
CONTROL
CATCH UP ON STOPPING Rx
STOP TREATMENT
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MyopiaDS
AGE
CONTROL
AFTER STOPPING Rx, ROMP @ ‘OLD’ [control] RATE
TREATMENT STOPPED
OLD RATE
SIMULATED EXCELLENT SIMULATED EXCELLENT RESULT- 2RESULT- 2
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SIMULATED EXCELLENT SIMULATED EXCELLENT RESULT-3RESULT-3
MyopiaDS
AGE
CONTROL
CATCH UP
SLOWS MYOPIC PROGRESSION
Rx SLOWS ROMP. MYOPIA CATCHES UP DESPITE CONTINUING / AFTER STOPPING Rx
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APPARENTLY EXCELLENT APPARENTLY EXCELLENT RESULT : EASILY RESULT : EASILY
SIMULATEDSIMULATED
MyopiaDS
AGE
CONTROL
TREATMENT
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STUDY QUESTIONSSTUDY QUESTIONS 1. CONTROL GROUP 2. DURATION OF
TREATMENT 3. DURATION OF
FOLLOW UP4. DATA AFTER
TREATMENT STOPPED
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TREATMENTS TO ARREST TREATMENTS TO ARREST MYOPIA MYOPIA
OPTICAL1.↓duration of spectacle wear2. planned under correction2. Bifocals / PALs3. contact lenses / orthoKPHARMACOLOGICAL4. atropine / pirenzipine5. ocular hypotensives
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OPTICAL RxsOPTICAL Rxs
Saw BJO 2002Saw BJO 2002
1. < full time wear of full Rx2. Under correction3. B-F & PALs
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< FULL TIME WEAR #1< FULL TIME WEAR #1Saw, BJO 2002Saw, BJO 2002
NRCT N= 43 3ya. full time specs wearb. wear for distance full timec. wear for distance d. non wearRESULT: NS
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< Full time wear #2< Full time wear #2
NMRCT Finland n= 240 9-11y f/u: 3ya. SV, full correc, cont useb. SV, full correc, distance onlyc. BifocalsRESULT: ROMP: NS
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Planned undercorrection / 1Planned undercorrection / 1
Straub: Fully correc / Under correcROMP: NS
Tokoro and Kabe:Fully corrected –0.83D/y Under corrected –0.47D/y
p< 0.01
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Planned undercorrrection /2Planned undercorrrection /2
CHUNG VIS RES 2002 CHILDREN UNDERCORRECTED BY -0.75
SMALL [STATS SIGN] INCREASE ROMP OVER 2 YRS
0.25D GREATER THAN FULLY CORRECTED
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BIFOCALS / PALsBIFOCALS / PALs Saw BJO 2002Saw BJO 2002
3 well designed RCTUSA, DENMARK, FINLANDBifocals +1 to +2 addsSample sizes 32-240Result : NS
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PALsPALsLeung and Brown Hong Kong 36: +1.5 - +2 add. ROMP -3.67 to -3.73D. 32: SV. ROMP -3.67D. NS.
Shih and colleagues Taiwan 227 6-12yPALs -1.19D/y. SV -1.40D/y. NS
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CORRECTION OF MYOPIA CORRECTION OF MYOPIA EVALUATION TRIAL EVALUATION TRIAL
(COMET) PALs vs. SV (COMET) PALs vs. SV
IOVS 20033 y. N= 469. age 6-11y MULTICENTRE USA RANDOMISEDDOUBLE MASKED. SE –1.25 to –4.50
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COMET #2COMET #2
PALsSlight ↓ ROMP, AL, # of Rx changes
RECOMMENDATIONS Effects too small to change your current routine
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ATROPINEATROPINEEASILY UNDERSTOOD Fx:Muscarinic antagonist → blocks accommodationIf Xs accom → ↑axial length, At may block thisNon – Accomm Fx [McBrien]:* Affects dopamine release ?influence retinal signals ?control eye growth* Suppresses GH
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ATROPINE STUDIESATROPINE STUDIESBEDROSSIAN
Ophthalmology 1979 n = 62 1% At hs ONE eye for 12 mo.
Fellow eye treated in Y2 [previously Rx’d eye now control].
At:↓ROMP Post At: ROMP @‘new’ [lesser]
rate
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ATROPINE STUDIESATROPINE STUDIES
RCT X3 TAIWANAt 0.1 to 1%
Result: ROMP sign. ↓ Lower dose better tolerated
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ATROPINE & B-F ATROPINE & B-F BRODSTEIN BRODSTEIN OPHTHALMOLOGY 1984OPHTHALMOLOGY 1984
n = 253. 1% At od. 9y f/up.↓ ROMP during Rx
ROMP after Rx = Control groupROMP fastest age 8 -12
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ATROPINE & B-F UCLA ATROPINE & B-F UCLA
15 Myopes / 15 control At 1% OU mean 29m [3-96]
ROMP: At: 0.05D C : 0.84D p = 0.00021!!
Using same pair of glasses [months]:At: 25.1(+/-19.3)
C: 13.5(+/-10.3) p = 0.049
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ATROPINE & B-F WILMER ATROPINE & B-F WILMER
CASE SERIES RETRO / INTER / NON COM
n = 706 age 6-16 yB-F : full cyclo / +2.25 addAt 1% 1/w. 3w - 10 yResult: 496 Fully Compliant. 210 Partly
ROMP: F/ Compliant 0.08D / y. Partly 0.23D / y
p < 0.001 !!
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ATOM STUDYATOM STUDY
ARVO 2003 CHUA [SINGAPORE]RANDOMIZED / DOUBLE MASKED / PLACEBO CONTROLLED
n=400 -1D to –6D 6-12 y1% At C: Isoptotears 1/dF/U: 4 monthly for 2 y. 90% @ 12mo, 80+% @ 2y
Cyclo ref / axial length CR / AL
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ATOM STUDY #2: ATOM STUDY #2: RESULTSRESULTS
12 mo: CR C: – 0.76D. At : + 0.3D !!AL: C: +0.2 mm. At reduction 0.14 mm2yrs : CR / ALC: –1.20D / +0.38 mmAt -0.25D / AL unchanged from baselinep < 0.0001 @ 12 mo & 2 y
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PIRENZEPINEPIRENZEPINE
Selective M1subtype muscarinic antagonist
Animal studies: blocks ↑AL 2° to form deprivation
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PIRENZEPINE STUDY #1 PIRENZEPINE STUDY #1 /1/1
ARVO 2003 SIATKOWASKI MULTICENTRE RCT n=13 USA
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PIRENZEPINE #1 PIRENZEPINE #1 /2/2
N = 174 8-12 y Rx / C : 2:1 BD for 12 moENTRY : BCVA 20/25 or better REF ERROR –0.75 to –4.00D SECYL ≤1D
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PIRENZEPINE #1 RESULTS PIRENZEPINE #1 RESULTS
OUTCOME : CYCLO A/REF @ 12 moEntry Ref Error: PIR -2.10; C -1.93ROMP: PIR –0.26D; C -0.53D p<0.0012% PIR >1D MP @ 12 mo20% C > 1D MP @ 12 mo p<0.001PIR 11% withdrew; C: 0%.
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PIRENZEPINE : STUDY #2PIRENZEPINE : STUDY #21yr Asian TrialMC / DM / PC /PARALLEL STUDY
353 children 6-12 ya. PIR bd b. Placebo morning+ PIR Evening c. Placebo bd
Ref error / AL
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PIRENZEPINE – ASIA PIRENZEPINE – ASIA /2/2ROMP @ 12 mo a. -0.40D (PIR bd) b. -0.70D (PIR 1/d)c. -0. 80D (C)
a / b : p < 0.001 a / c : p < 0.001 b / c : NS
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PIRENZEPINE – ASIA PIRENZEPINE – ASIA /3/3
AXIAL LENGTHa. +0.21mm (PIR bd)b. +0.30mm (PIR 1/d)c. +0.33mm (C)
All comparisons NS
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OCULAR HYPOTENSIVESOCULAR HYPOTENSIVES
↑ IOP → stretch sclera ↑axial length ↑myopiaLabetolol / TimololSeveral studies : no C, not randomisedDanish study 150 child. 0.25% timolol [2y]ROMP: Timolol -0.59D/y Single vision -0.57D/y
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SUMMARYSUMMARY
< Full time wear / undercorrection5 STUDIES
3 NS 2 SIGNIFICANT : 1 ROMP WORSE!
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SUMMARYSUMMARY
BIFOCALS & PALs7 studies : NS
One PAL study: Significant
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SUMMARYSUMMARY
PHARMACOLOGICAL STUDIES1. ATROPINE 8 studies SOne study : post Rx ROMP @ reduced ‘new’ rate
2. PIRENZEPINE 2% GEL 2 studies S
3. OCULAR HYPOTENSIVES NS
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MYOPIAMYOPIA
1. Major personal / societal problem
2. Convincing data on ↓ ROMP with At / Pir. Need longer f/up.
3. ? Genetic segregation first & repeat optical and drug studies
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