Practical Myopia Management for the Busy Optometrist
Maria K. Walker, OD, MS, FAAO
1
United States: ~45% prevalence
2
Theophanous C, et al. Myopia Prevalence and risk factors in children. Clin Ophthalmol. 2018;12:1581-1587.2Vitale S, et al. Prevalence of refractive error in the United States, 1999-2004. Arch Ophthalmol. 2008;126(8):1111–9. Holden BA et al. Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050. Ophthalmology. 2016;123(5):1036–42.
96.5% myopia at age 19
>80% myopia at age 18
Current worldwide prevalence:22%
Est. prevalence in 2050:44%
2050 Projection:
5 Billion people with myopia
1 Billion people with PATHOLOGIC myopia
Pathologic or Degenerative Myopia
Axial length >26.5 (26) mm or myopia >6 DAssociated with several pathologies
Glaucoma, cataracts, retinal tears/detachments, CNV, macular atrophy, choroidal degeneration, and more
2% worldwide currentlyest. to be 10% worldwide in 2050 (~1 billion people)
Glaucoma
http://www.aao.org/eyenet/article/myopia-glaucoma-sorting-out-diagnosis
http://www.retinalphysician.com/articleviewer.aspx?articleID=105386
Choroidal Neovascularization
6
Retinal Detachment
Glaucoma
Myopic Retinal Degeneration
https://www.specsavers-spectrum.com/profile-journal/drp-myopic-degeneration/
7
Hayashi, K. et al. (2010) ‘Long-term Pattern of Progression of Myopic Maculopathy A Natural History Study’, Ophthalmology, 117, pp. 1595–1611. Ikuno, Y. Overview of the complications of high myopia. Retina, 37(12), pp. 2347–2351. 2010.Linsenmeier, R. A. and Padnick-Silver, L. Metabolic dependence of photoreceptors on the choroid in the normal and detached retina’, IOVS, 41(10), pp. 3117–3123. 2000. Pierro, L. et al. Peripheral retinal changes and axial myopia. Retina, 12(1), pp. 7–12. 1992.
Choroidal Neovascularization
Cataract
Myopic CNV
http://www.retinalphysician.com/articleviewer.aspx?articleID=105386
http://www.eyeworld.org/article-honing-in-on-refractive-error-and-long-term-incidence-of-cataract
Dr. Alex P Hunyor, MD. http://imagebank.asrs.org/file/3094/myopic-cnv
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Avila, M. et al. (1984) ‘Natural history of choroidal neovascularization in degenerative myopia.’, Ophthalmology, 91(12), pp. 1573–1581.Cohen, S. Y. et al. (1996) Etiology of Choroidal Neovascularization in Young Patients, Ophthalmology.Neuhann, I. M. et al. (2008) ‘Retinal detachment after phacoemulsification in high myopia: Analysis of 2356 cases’, J Cataract Refract Surg, 34, pp. 1644–1657. Yoshida, T. et al. (2003) ‘Myopic Choroidal Neovascularization A 10-year Follow-up’, Ophthalmology, 110, pp. 1297–1305. Pan, C.-W. et al. ‘Myopia and Age-Related Cataract: A Systematic Review and Meta-analysis’.
Theories of Myopic
Progression
- 5x increased risk with myopic parents- Over 20 genes identified
- Near work- Lack of ”horizon” viewing- Light levels
- Undercorrection- Lag of accom.
- Near work- Image shell in specs
Protective Hormones?- Dopamine- Vitamin D
9FlitcroftDI. The complex interactions of retinal, optical and environmental factors in myopia aetiology. Prog Retin Eye Res. 2012; 31(6):622-60.
Full Circle Myopia Management
• Treatment• Sibling risks• Risks/Protective
factors
• Monitor tx efficacy• Modify and add
treatments
• Contact Lenses• Spectacles• Therapeutics
• Refraction (wet)• Axial Length• Progression risks
Detect Treat
EducateManage
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Full Circle Myopia Management
• Ref raction (wet)
• Axial Length
• Progression risks
Detect
11
Normative Data
Pediatric Norms:
Infants: approx +2.00D
3-5 yo: emmetropization
May have +1D at 5yo
6-16 yo: slight myopic shift
12Mayer et al. Cycloplegic refractions in healthy children aged 1 through 48 months. Arch Ophthalmol. 119. Nov 2001. 1625-1628.
Normative DataPediatric Norms:
Infants: 19-21 mm
3-5 yo: 21-22 mm
6 yo: 22 – 22.75 mm
13
Bach A et al. Axial length development in children. Int J Ophthalmol. 12(5): 815-819
What about light levels?
Associated with reducing myopia incidence (even those with high amount of near work)
Physical activity not necessary
Directsunlight also not necessary
Recommend 8-15 hours of outdoor activity per week
Does notprotect against progression
14
What about near work?
greater near work may influence development and progression of myopia (36,37,39 in IMI)
Close reading (less than 20cm)
Continuous reading (greater than 45 min)
Note: great amount of outdoor activity and high levels of near work reduced incidence
15
Clinical Guidelines
16
Standard Procedure for Myopia Exam
HistoryAge, sex, ocular health, surgery, general health and FHx
Onset of myopia, history of myopic progression, prev. treatments
RefractionCycloplegic – recommended dosage is two drops 1% tropicamide or cyclopentolate, 5 minutes apart. Perform refraction after 30 mins.
Anterior ocular health evaluationFundus examination
Appearance of chorioretinal atrophy, staphyloma, PPA, tilted discs
1. Gifford KL, Richdale K, Kang P et al. IMI – Clinical Management Guidelines Report. IOVS (2019) 60(3): M184-M203 17
Standard Procedure for Myopia Exam
Specialized refractionBinocular vision testingCorneal topographyAxial length
1. Gifford KL, Richdale K, Kang P et al. IMI – Clinical Management Guidelines Report. IOVS (2019) 60(3): M184-M203 18
Refraction
• Wet vs. dry• Wet refraction = Rx?• Be careful: do not solely rely on refraction!
19Gaurisankar ZS et al. Correlations between ocular biometrics and refractive error: A systematic review and meta-analysis. Acta Ophthalmol. 2019;97(8):735–43.
Axial Length MeasurementsWhat are we actually measuring?
How accurate is it?
20
The “true” Axial Length
Don’t fall subject to the ASSUMPTIONS of sound and light
MRIEnucleation
Clearly not practical techniques (nor necessary)
21
Precision and Accuracy
• Precision (repeatability): How close is measurement “a” to measurement “b”?• Accuracy / Validity: Is the device giving an accurate (correct, true) measurement?
• Correlation: How well can we predict the measurement of one instrument by knowing another?
A precise and repeatable instrument is needed for myopia
management
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R.E. change Predicted AL Change Actual AL Change
-1.50 -0.37 x 005 0.45 mm 0.22 mm
-3.25 - 0.62 x 165 1.15 mm .12 mm
Patient 1
Patient 2
Patient 3
R.E. change Predicted AL Change Actual AL Change
+0.37 -0.87 x 180 0 mm 0.18 mm
+0.25 -0.62 x 005 0 mm 0.18 mm
R.E. change Predicted AL Change Actual AL Change
-0.50 -1.50 x 013 0.37 mm 0.85 mm
-0.50 -1.00 x 170 0.30 mm 0.91 mm
Axial Length: Primary Outcome for monitoring myopic progression
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Ultrasound
Highly repeatable & precise
Somewhat dependent on eye position
Longer acquisition time
Practicality not always best for kids
Contact
Longer acquisition time
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Interferometry
Lenstar (Haag-Streit)
IOL Master 500 & 700 (Zeiss)
Pentacam AXL (Oculus)
OA-2000 (Tomey)
AL-Scan (Nidek)
OCT-B
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Interferometry vs. Ultrasound
Wang X, et al. Comparison axial length measurements from three biometric instruments in high myopia. Int J Ophthalmol. 9(6). 2016.
Ultrasound consistently measures shorter than interferometry
No change in MAGNITUDE of difference in normal eyes or high myopia
0.24mm shorter
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IOL Master 700
Axial length
Keratometry
Refraction calculations
Designed for cataract surgery
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Technology Alert: Tomey OA 2000
PupillometerKeratometerBiometer (axial length)Pachymeter
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Technology Alert:
PentacamAXL
• Tomography & all features of Pentacam• Axial length
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Technology Alert:
Myopia Master
Axial lengthRefraction (pupil diameter)Corneal CurvatureCalculates risk of myopia & has customizable “take home” report
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Comparing New Technology with Established Technology
• IOL Master 500 vs. 700: mean difference of 0.008 mm
• IOL Master 500 vs. Pentacam AXL: difference of 0.026 mm
• Similar repeatability between all of them
• Take home: compare instrument to standard instruments prior to purchase
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More…
Take home: use the methodology that best fits your practice, and use it consistently
Lipson MJ. Axial length measurement: PalmScan versus IOLMaster. ECL 2015 May; 42(3).Yeu E. Agreement of ocular biometry measurements between 2 biometers. J Cataract Refract Surg. 2019 Aug;45(8): 1130-1134.Guler E, et al. Comparison of a new optical biometry with an optical low-coherence reflectometry for ocular biometry. CLAE 2016 Oct;39(5):336-41
PalmScan portable ultrasound - good correlation to IOLMaster1
Aladdin biometer (interferometry) - good correlation to Lenstar2
OCT biometry (B-OCT) - good correlation to Lenstar3
Several other customized systems (research)
Is that it? Do we need to consider anything else?
32
The Choroid Effect
Temporal thickening of choroid: artificially “shorter” measurements
All myopia control methods can cause acute choroidal thickening
Choroid has diurnal variation in thickness
Burfield HJ, Patel NB, Ostrin, LA. Ocular biometric diurnal rhythms in emmetropic and myopic adults. IOVS 2018. 10:59(12:5176-5187
Tip: Take consistent time of day measurementsDevelop a consistent protocol for measuring AL
33
Accommodation Effect
Greater accommodation leads to greater AL measurement
Read SA, et al. Axial length changes during accommodation in myopes and emmetropes. OVS. 87 (9). Sept 2010.Drexler W, et al. Eye elongation during accommodation in humans: differences between emmetropes and myopes. IOVS. 1998;39:2140–7.
Cycloplegia matters with axial length measurement (not just refraction!)
34
Binocular Vision Assessment: Accommodation
35
Binocular Vision Assessment: Versions
36
Ancillary Technology for Myopia
ManagementPupillometry
Accommodative Testing
37
Ancillary Technology for Myopia Management
•Aberrometry• Role in myopia progression?• Role in CL management?
38
Calculating Risk • Age of onset
• Independent of sex, ethnicity, school, reading time, parents
• …so early myopes are high risk regardless
• Parents (3x w/2 parents)
• Outdoor time, close reading distance
• Ethnicity • Asians > European & African descent
39
Jiang X, Tarczy-HornochK, Cotter SA, et al. Association of Parental Myopia With Higher Risk of Myopia Among Multiethnic Children Before School Age. JAMA ophthalmology 2020. Liang CL, Yen E, Su JY, et al. Impact of family history of high myopia on level and onset of myopia. IOVS. 2004;45(10):3446-52. Zhang X, Qu X, Zhou X. Association between parental myopia and the risk of myopia in a child. Exp Ther Med. 2015;9(6):2420-28. MuttiDO, et al. Parental myopia, near work, school achievement, and children's refractive error. IOVS. 2002;43(12):3633-40.
PARENT EDUCATION: GLOBAL MYOPIA CENTER
https://globalmyopiacentre.org/
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PARENT EDUCATION: GLOBAL MYOPIA CENTER
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Full Circle Myopia Management
• Contact Lenses
• Spectacles
• Therapeutics
Treat
42
Contact LensesContact lens trends for MC in 2018
J. Nichols, CL Spectrum. Jan 201943
THE BIRTH OF THE MC THEORY
44Smith EL III. Prentice Award Lecture 2010: a case for peripheral optical treatment strategies for myopia. Optom Vis Sci. 2011;88:1029–44.
Single Vision specs/CL
45Image courtesy of Patrick Caroline
Peripheral refraction
The Journal of Optometry 2009
Ravi Bakaraju, Klaus Ehrmann, Eric Papas, Arthur Ho
Vision Cooperative Research Center, Sydney Australia 46
Image courtesy of Patrick Caroline47
Optical Designs of Myopia Management contact lenses
Concentric ring (bifocal) designs
Progressive power (peripheral add) designs
Orthokeratology designs
48
Soft CL for Myopia
49
Soft Contact Lenses:Myopia Management
Lens Brand Optical Design Replacement Disadvantages Advantages Highest ADD
available
Naturalvue(Visioneering)
Progressive power Daily Comfort/Vision Disposable
Specialeyes MF (Specialeyes)
Center distance
(Concentric ring)
Quarterly Replacement
Highly customizable
Not commercially available
Biofinity D MF(CooperVision) Monthly Replacement Availability
ProclearD MF(CooperVision) Monthly Replacement Availability
Toric Available
MiSight(CooperVision) Daily ?? FDA Approved
Disposable
Highest commercially available ADD: +4.00
CUSTOM SOFT MF
Optic Zone Size
Optic Zone Centration51
FITTING ORTHO-K
• Beware of asymmetric treatment zones due to toricity.
• May need toric / dual-axis ortho-k lenses for max treatment
• 20um difference (elevation) between major meridians: think dual axis!
52Jiang et al. Comparison of toric and spherical orthokeratology lenses in patients with astigmatism. J Ophthalmol. 2019 Feb 20;2019:4275269.
SPHERICAL VS. TORIC
Spherical Ortho-K Toric Ortho-K
53
Contact LensesContact lens trends for MC in 2018
J. Nichols, CL Spectrum. Jan 2019
Low to high myopes with
minimal astigmatism
Low/Moderate myopes with
minimal astigmatism
High myopes with high astigmatism
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Spectacles: MyoVision
• 203 Japanese children• 2 years
• -1.43D with MyoVision• -1.39 with SV control
Study could not verify treatment effect
Spectacles: DIMS lens(Defocus Incorporated Multiple Segments)
• 160 Chinese children• 2-years
• -0.41D in DIMS• -0.85 with SV
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AtropineAtropine 0.025 or 0.05%- minimal side effects compared with 1% atropine - dosed 1gtt OU at night before bed- minimal mydriasis and near complaints - LAMP study
Atropine 0.01%- Only if adjunctive therapy
Combined therapy?
57Yam JC et al. Two-year clinical trial of the low-concentration atropine for myopia progression (LAMP) Study: Phase 2 report. Ophthalmology. 2020 Jul;127(7):910-919.
“Contact lenses to slow progression of myopia”Padmaja Sankaridurg. Clin Exp Optom 2017. 100:432-437.
Several factors will affect treatment decision
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CHOOSING A MODALITYWhat would you choose?
Spectacle Rx Orthokeratology Soft Multifocal Daily wear GP
‐1.00DS
‐2.50‐1.00x180
‐9.00DS
‐4.00‐3.75x110
‐0.50‐2.00x180
‐3.00DS
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Full Circle Myopia Management
• Treatment
• Sibl ing risks
• Risks/ Protective factors
Educate
60
Eyeglasses
Nearsightedness
Vision
Contact Lenses
Bifocals
Myopia controlX61
Simplified Parent Education
Myopia is genetic• Risk increases with 1 or 2 myopic
parents• Darwinian theory
Environmental Risks• Less time outdoors• More near work demands• Refractive correction
Genetics
Environment
62
Parent & Patient EducationUse of Electronic Devices
63
PATIENT EDUCATION
• Starts in the waiting room• Videos• Literature (pamphlets)• Posters
• Identification of candidates and distribution of educational materials - by the doctor!
64
Kids Education
Design colorful, fun directional information
Educate children and parents differently
Make it FUN!65
Myopia Swag
Eyecare “Goody Bag”
CL/Glasses solutions & cases
Do’s and Don’t worksheet
Replacement schedule stickers
66
Contact Lens safety in children
Bottom line: minimal adverse events…But always use caution and provide
verbal and written instruction
67Chalmers RL, Wagner H, Mitchell GL, et al. Age and other risk factors for corneal infiltrative and inflammatory events in young soft contact lens wearers from the Contact Lens Assessment in Youth (CLAY) study. Invest Ophthalmol Vis Sci. 2011;52(9):6690-6696. Published 2011 Aug 24. doi:10.1167/iovs.10-7018
Dent Estet 4 KidsRomania
The Patient & Family Experience
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The Patient & Family Experience
Bayt Abdullah Children’sKuwait
69
Ramp up your webpage
http://videre-eyecare.com.sg/our-services/myopia-management/70
Patient Information ChecklistVideos, Posters, Interactive Models
Pamplets, Myopia education materials
Written instructions & contracts
Patient “goodie bags”
Parent resource sheet
71
Full Circle Myopia Management
• Monitor tx eff icacy
• Modify and add treatments
Manage
72
Meaningful Progression?
73
Meaningful Progression?
4/3/17: 24.18 ODand 24.29 OS3/12/18: 24.48 ODand 24.63 OS (approx 0.3mm oU)Factors: change in length AND total length (and age)
74
Full Circle Myopia Management
• Treatment• Sibling risks• Risks/Protective
factors
• Monitor tx efficacy• Modify and add
treatments
• Contact Lenses• Spectacles• Therapeutics
• Refraction (wet)• Axial Length• Progression risks
Detect Treat
EducateManage
75
Sequence of Exams
Comprehensive Exam: separate, (+)insurance
MC1: initial exam (private pay)Dry and wet AR & subjective refractionAxial lengthCorneal topographySelection of myopia control treatment (with follow-up exams as needed)
MC2: 6-month exam (private pay)Dry AR & subjective refractionAxial lengthCorneal topography (prn)*modification of treatment strategy as needed
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Materials
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Stay connected• Become a member of the International Myopia Institute
• Vision by Design (annual conference)
• Online resources
• www.myopiainstitute.ORG
• www.treehouseeyes.com
• www.calculator.brienholdenvision.org
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clinicaltrials.gov
10+ studies on Atropine
10+ studies on soft CL
10+ studies on Ortho-K
10+ studies on spectacles
Observational, environmental (lighting), genetic, surgical studies…
563 registered clinical trials on myopia
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Summary of Myopia Management
Know the science
Treat
Educate
Keep it simple & fun
80
The Future
COVID-19: where does the myopia management patient stand?
Telemedicine and myopia management?
Axial length measurements – at home?
Refractive telemedicine is already here
Activity monitoring
Risk assessment! https://www.bernell.com/product/BCPHSHIELD/Disinfection-Prevention
http://www.actigraphy.com/solutions/actiwatch/actiwatch2.html
thank you!82
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