1
Myopia Control
Jeffrey J. Walline, OD PhDThe Ohio State University College of Optometry
Disclosures
• Bausch + Lomb: research materials
Myopia Control
http://www.nature.com/news/the-myopia-boom-1.17120
From: nature.com
Prevalence Prevalence
From: visionimpactinstitute.org/research/direct-costs-of-myopia-in-singapore
Cost
More Myopia = More Vision Loss
Flitcroft DI. Prog Retin Eye Res 2012;31:622-60
1 10 100
1.00 to 2.99
3.00 to 4.99
5.00 to 6.99
7.00 to 8.99
≥ 9.00
Odd Ratio
Myo
pia
(D
)
End of Lecture, You Will Be Able To…
• Talk to parents about myopia control options
• Understand how myopia progression slowed
• Understand how to maximize myopia control
What is Clinically Meaningful?
• Assume
• ‐0.50 D per year progression
• From 8 to 16 years
• Begin as ‐1.00 D, end as ‐5.00 D
% Reduction Final Refractive Error
25 ‐4.00
50 ‐3.00
75 ‐2.00
100 ‐1.00
2
Myopia Control Summary
Soft Bifocal-19 -7 21 40 43 76393036
AtropineOrthokeratologyMultifocal Specs
Undercorrection
Adler D, Millodot M. Clin Exp Optom 2006;89:315‐21
Chung K, et al. Vision Res 2002;42:2555‐9
ChungAdler
Gas Permeable CL
Walline JJ, et al. Arch Ophthalmol 2004;122:1760‐6Katz J, et al. AJO 2003;136:82‐90
Bifocal/Multifocal Spectacles
PALSV
•Gwiazda J, et al. IOVS 2003;44:1492-500.•COMET2 Study Group IOVS 2011;52:2749-57.
Bifocal/Multifocal Spectacles
Cheng D, et al. JAMA Ophthalmol 2014;132:258‐64
Special Spectacles
Sankaridurg P, et al. OVS 2010;87:631‐41
Is It Commercially Available? Myopia Control‐Pirenzepine
Siatkowski RM, et al. J Aapos 2008;12:332-9Tan DT, et al. Ophthalmol 2005;112:84-91
Myopia Control Summary
Soft Bifocal-19 -7 22 40 43 764630 36
AtropineOrthokeratologyMultifocal Specs
3
Soft Bifocal Myopia Control
Anstice N, Phillips J. Ophthalmol 2011;118:1152‐61
Soft Bifocal Myopia Control
Sankaridurg P, et al. IOVS 2011;52:9362-7.
Soft Bifocal Myopia Control
Walline JJ, et al. OVS 2013;90:1207-14
Soft Bifocal Myopia Control
Lam CS, et al., BJO 2014;98:40-5
Orthokeratology Myopia Control
Cho P & Cheung SW. IOVS, 2012;53:7077‐85.
Orthokeratology Myopia Control
Charm J and Cho P. OVS 2013;90:530-9
High Myopes
Orthokeratology Myopia Control
Chen C, et al. IOVS 2013;54:6510-7
Toric
How Do OK and SBCL Slow Myopia?
• Smith EL, et al. IOVS 2005;46:3965‐72.
• Smith EL, et al. Vis Res 2009;49:2386‐92
The Periphery Matters
4
• Smith EL, et al. IOVS 2005;46:3965‐72.
• Smith EL, et al. IOVS 2007;48:3914‐22.
• Smith EL, et al. Vis Res 2009;49:2386‐92
Eye Growth Animal Models Eye Growth Humans
Queiros A, et al. OVS 2010;87:323‐9
Peripheral Optical Profile
Myope corrected with specs, CL
Myope corrected with corneal reshaping or soft bifocal
Eye Growth Humans
Mutti DO, et al. IOVS 2011;52:199‐205
Myopia Control‐Soft Bifocal
Sankaridurg P, et al. IOVS 2011;52:9362-7.
1% Atropine Myopia Control
1% Atropine Myopia Control
Treatment Author (year) Duration Completion (%)
1% atropine Chua (06) 2 years 87
0.1‐0.5% atropine Shih (99) 2 years 93
0.5% atropine Shih (01) 18 months 87
GP Walline (04) 3 years 100
GP Katz (04) 2 years 37
GP Khoo (99) 3 years 53
GP Perrigin (90) 3 years 56
GP Baldwin (69) 1 year 70
0.01% Atropine Myopia Control
Chia A, et al. Ophthalmol 2012;119:347-54
0.01% Atropine Myopia Control
0.01% 0.1% 0.5%
Accommo (D) ‐4.6 ‐10.1 ‐11.8
Pupil (meso, mm) 1.15 2.71 3.56
Pupil (photo, mm) 0.75 2.24 3.11
Dist VA (logMAR) ‐0.02 +0.01 ‐0.01
Near VA (logMAR) ‐0.02 +0.06 +0.25
Reading specs (% yes) 6 61 70
Chia A, et al. Ophthalmol 2012;119:347-54
5
0.01% Atropine Myopia Control
Chia A, et al. AJO 2014;157:451-7
0.01% Atropine Myopia Control
Chia A, et al. AJO 2014;157:451-7
Outdoor Time Myopia Control
Jones LA, et al. IOVS 2007;48:3524-32
Outdoor Time Myopia Control
Wu PC, et al. Ophthalmol 2013;120:1080-5
Outdoor Time Myopia Control
Not Myopic Myopic
Wu PC, et al. Ophthalmol 2013;120:1080-5
Outdoor Time Myopia Control
• What does this mean?
• Outdoor time preventsmyopia, but does not slow progression
Accrual of Treatment Effect
Tong L, et al. Ophthalmol 2009;116:572‐9
Atropine
Accrual of Treatment Effect
Gwiazda J, et al. IOVS 2003;44:1492‐1500
Multifocal Specs
Accrual of Treatment Effect
Cho P & Cheung SW. IOVS, 2012;53:7077‐85
6
Accrual of Treatment Effect
Hiraoka T, et al. IOVS 2012;53:3913‐9
Soft Bifocal and Orthokeratology
0
10
20
30
40
50
60
70
80
90
100
Pau
ne
Fujikad
o
Walline
Lam
Sankaridurg
Cheng
Anstice
Aller
Hirao
ka
Santodomingo
Kakita
Cho
Pau
ne
Cho
Chen
Walline
Charm
Swarbrick
Slower Chan
ge Axial Len
gth (%)
Orthokeratology43%
Soft Multifocal CL38%
Accrual of Treatment Effect
• What does this mean?
• Likely to be more effective because myopia control lasts for longer period of time
Pupil Size
Chen Z, et al. OVS 2012;89:1636‐40
OK SV
Pupil Size
Interaction, p < 0.001
Santodomingo J, et al. OVS 2013;90:1225-36
Pupil Size
• What does this mean?
• More retina with myopic blur = stronger myopia control
Peripheral Myopic Blur
Ortho-K
Specs
Cho 2005 Kakita 2011
Peripheral Myopic Blur
Interaction, p = 0.007
Santodomingo J, et al. OVS 2013;90:1225-36
Peripheral Myopic BlurNasal Temporal
Inferior
Zhong Y, et al. OVS 2014;91:404-11
all p < 0.001
7
Peripheral Myopic Blur
Sankaridurg P, et al. IOVS 2011;52:9362-7.
Peripheral Myopic Blur
• What does this mean?
• Greater myopic blur = greater myopia control
• Stronger add = better myopia control?
Bifocal Lenses In Nearsighted Kids (BLINK)
• Purpose: to determine the strongest add power that could be tolerated by kids
Eligibility
• 8‐11 years old
• Spherical equivalent, non‐cycloplegic subjective refraction
• ‐1.00 D to ‐5.00 D
• ≤ 1.00 DC
• 20/25 or better BCVA OD, OS
• No gas permeable contact lenses
• Condition affects vision, CL wear
• Diabetes, Sjogrens, etc.
Randomization
• Proclear or Proclear Multifocal D OU
• Sphere
• +2.00 D add
• +3.00 D add
• +4.00 D add
• Random order
Protocol
• BLINK questionnaire
• Habitual visual acuity
• High contrast at distance OU
• Low contrast at distance OU
• High contrast at near OU
BLINK Questionnaire1. How clear was your vision when looking far away during the past week?1 2 3 4 5 6 7 8 9 10Good Perfect
SubjectsCompleted (n = 9)
Age (years) 10.2 ± 1.1
Gender (% Female) 77.8
Race (%)
Caucasian 66.7
Native American, Pacific Islander 22.2
More than one race 11.1
HCVA Distance(logMAR) ‐0.02 ± 0.09
HCVA Near (logMAR) ‐0.10 ± 0.07
LCVA Distance (logMAR) +0.18 ± 0.10
M (D) ‐2.04 ± 0.32
J0 (D) +0.04 ± 0.18
J45 (D) ‐0.01 ± 0.08
High Contrast Distance OU
p = 0.33
8
High Contrast Near OU
p = 0.27
Low Contrast Distance OU
p < 0.001
BLINK Questionnaire
• No differences
• Distance vision
• Near vision
• Ghost images
• Computer
• Strain or tiredness
• Contact lens comfort
• Sporting activities
Glare or Starbursts
p = 0.03
Changing Fixation Distance
p = 0.05
Overall
p = 0.05
BLINK Study Summary
• Objective vision
• +3.00 and +4.00 worse low contrast
• Subjective vision
• +3.00 and +4.00 worse
• Glare and starbursts (+4.00)
• Change fixation distance (+3.00 and +4.00)
• Overall (+3.00)
• Primarily due to add power
Can We Combine Treatments?
• Contact lens myopia control
• Optical effect
• Atropine
• Receptors at the retinal or scleral level
Myopia Control Experience
9
Treatment
Patients %
CRT 14 44
Daily disposable 8 25
Soft bifocal 7 22
Toric 2 6
Atropine 1 3
⅔ = myopia control
Race
Proportion by Race Asian (n = 14) White (n = 18)
CRT 64 28
Soft bifocal 14 28
Daily disposable 7 28
Toric 0 11
GP 0 6
Atropine 1 0
No FDA Approved Myopia Control
• Consent
Summary• Bifocal specs, GP CLs, undercorrection, special spectacles don’t work well enough
• Pirenzepine not available
• CLs provide best myopia control w/o side effects
• Low concentration atropine needs more evidence
• Don’t know if we can combine to get stronger effect
• Use strongest tolerable add for soft bifocal
• Outdoor prevents myopia, not slow progression
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