9/25/2017. Walid H Attia MD Cairo University

Transcription

1 Walid H Attia MD Cairo University 1

2 2 D of anisomyopia, 1 D of anisohyperopia, and 1.5 D of anisoastigmatism are known to lead to amblyopia. Is this amount anisometropia enough to offer refractive surgery? >6 D of anisometropia, only 25% had a successful outcome 3 to 6 D of anisometropia, only 67% had a successful outcome <3 D anisometropia typically achieve good success rates From this data, consider refractive surgery when at least 3 to 4 D of anisometropia is present 2

3 Determining when a patient has failed traditional therapy, "This has certainly not been answered by any of the studies. For example, if a 5-year-old child has anisometropia and is -5 D in one eye and plano in the other eye and fails to improve with traditional treatments, when do you draw the line? How strongly do you reinforce? How many cycles do they have to fail? The window for treating amblyopia starts to close around age 7, so if you wait too long, you've lost your window to regain significant vision in those kids," Quoted from Dr. Erin Stahl, MD, a pediatric ophthalmologist in Kansas City, Mo. Refractive procedures that may be applicable are: PRK, LASIK, LASEK, clear lens extraction, phakic intraocular lenses, and intrastromal corneal ring (MyoRing implantation) Refractive procedures that have undergone significant investigation in children are PRK, LASIK, and LASEK 3

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5 Decentration Central island Predictability Induced astigmatism Back in 1998, I was not thrilled about treating astigmatism because children are treated under general anesthesia, and it's hard to ensure that you are treating right on axis Now the situation is different, platforms with innovative technology: faster spot scanning laser pulse, reduced eye-tracking latency time, mechanisms to compensate for pupillary cyclotorsion and pupillary centroid shifts and wavefront-guided technology for customised ablation will result in significantly improving our visual outcome 5

6 NOT A BIG ISSUE OUR MAIN CONCERN We are significantly weakening the child cornea 6

7 HAZE IS OUR MAIN CONCERN Age High errors (I only treat 4-5D) Mitomycin Iced water Prolonged steroid therapy Choose the right time to draw the line Choose the right procedure (pre-op examination) PRK up to 4-5 D LASIK up to 8 D Consider CXL with LASIK Close follow up for changes in corneal biomechanics (change? go for CXL) Full circle intracorneal ring (MyoRing implantation) still studying 7

8 Imagine, the presence of preventive measures to reduce the rate of myopic and hyperopic progression This will definitely take the centre stage from therapeutic intervention, thus significantly lowering the overall incidence of high anisometropia and thus the potential consideration for any surgical correction Articles were reporting that there is no true treatment for controlling the progression of myopia. A number of recent clinical trials, however, is giving us the hope in arresting myopic progression: -Various doses of topical atropine -Multifocal contact lenses -Progressive added lenses -Orthokeratology therapy These articles are discussing the possibility of controlling myopic progression thus, reducing the incidence of high anisometropia These methods if succeded will certainly lead to a new pathway in significantly decreasing the need for laser refractive surgery or IOL implantation in children 8

9 1. Grzybowski A, Armesto A, Szwajkowska M, The role of atropine eye drops in myopia control, Curr Pharm Des, 2015;21: Shih KC, Chan TC, Ng AL, et al., Use of atropine for prevention of childhood myopia progression in clinical practice, Eye Contact Lens, 2015 [Epub ahead of print]. 3. Smith MJ, Walline JJ, Controlling myopia progression in children and adolescents, Adolesc Health Med Ther, 2015;13: Kumaran A, Htoon HM, Tan D, et al., Analysis of changes in refraction and biometry of atropine and placebo treated eyes, Invest Ophthalmol Vis Sci, 2015;56: Santodomingo-Rubido J, Villa-Collar C, Gilmartin B, et al., The effects of entrance pupil centration and coma aberration on myopic progression following orthokeratologyo, Clin Exp Optomo, 2015 [Epub ahead of print]. 6. Chia A, Lu QS, Tan D, Five year clinical trial on atropine for the treatment of myopia 2: myopia control with atropine 0.01% eye drops, Ophthalmology, 2015 [Epub ahead of print]. 7. Yi S, Huang Y, Yu SZ, et al., Therapeutic effect of atropine 1 % in children with low myopia, J AAPOS, 2015; in press. 8. Clark TY, Clark RA, Atropine 0.01 % eye drops significantly reduce the progression of childhood myopia, J Ocul Pharmacol Ther, 2015; in press. 9. Sun Y, Xu F, Zhang T, et al., Orthokeratology to control myopia progress: a meta-analysis, PLoS One, 2015;10:e Li J, Jian D, Xia X, et al., Evaluation of 12 myopia-associated genes in Chinese patients with high myopia, Invest Ophthalmol Vis Sci, 2015;13;56: Zhang Q, Genetics of refraction and myopia, Prog Mol Biol Transl Sci, 2015;134: Smith MJ, Walling JJ, Orthokeratology Adolesc Health Med Ther, 2015;13: Fu AC, Chen XL, Lv Y, et al., Higher spherical equivalent refractive errors is associated with slower axial elongation, Cont Lens Anterior Eye, 2015 [Epub ahead of print]. 14. Li SM, Kang MT, Wu SS, et al., Efficacy, safety, acceptability of orthokeratology on slowing axial elongation in myopic children by meta-analysis, Curr Eye Res, 2015;3: González-Méijome JM, Carracedo G, Lopes-Ferreira D, et al., Stabilization in early adult-onset myopia with corneal refractive therapy, Cont Lens Anterior Eye, 2015 [Epub ahead of print]. 16. Sun Y, Xu F, Zhang T, et al., Correction: orthokeratology to control myopia progression: A meta-analsysis, PLoS One, 2015;11;10:e Si JK, Tang K, Bi HS, et al., Orthokeratolgoy for myopia control: a meta-analysis, Optom Vis Sci, 2015;92: Felipe-Marquez G, Nombela-Palomo M, Cacho I, et al., Accommodative changes produced in response to overnight orthokeratology, Graefes Arch Clin Exp Ophthalmol, 2015;253: Swarbrick HA, Alharbi A, Watt K, et al., Myopia control during orthokeratology lens wear in children using a novel study design, Ophthalmology, 2015;122: Zhu MJ, Feng HY, He XG, et al., The control effect of orthokeratology on axial length elongation in Chinese children with myopia, BMC Ophthalmol, 2014;14: Zhong Y, Chen Z, Xue F, et al., Corneal power change is predictive of myopia progression in orthokeratology, Optom Vis Sci, 2014;91: Hiraoka T, Kakita T, Okamoto F, Oshika T, Influence of ocular wavefront aberrations on axial length elongation in myopic children treated with overnight orthokeratology, Ophthalmology, 2015;122: Aller TA, Clinical management of progressive myopia, Eye (Lond), 2014;28:

10 Back in the day, it was believed that undercorrecting our patients would keep them from getting worse, says Dr. Lee. Studies, however, have found this not to be true. One study of 62 children ages 6-15 in Israel found that those who had been blurred by D experienced a slight increase in myopic progression of 0.17 D compared to those who had full correction. It s not preventing, it s actually enhancing myopia, says Dr. Lee. Similarly, a study of 106 Malay and Chinese children ages 9-14 years found that those who were blurred by D also experienced a slight increase in myopic progression of 0.23 D compared to full correction. A method that is slightly more effective is bifocals, says Dr. Nguyen. The presenters highlighted an 18-month study of 14 children in which the bifocal wearers with a D add progressed D per year vs D per year in the single-vision lens group. It sounds like it s a significant amount, but it s not a clinically significant amount because if you round the numbers to the nearest 0.25 D, it s about 0.50 very similar there, says Dr. Nguyen. 10

11 In the COMET 2 study, 8 to 11 year-old children used progressive addition lenses (PALs) with a D add. These children experienced D myopic progression vs D in the single-vision lens group. Dr. Lee says the difference was not very significant. In the ATOM1 study, half of the 346 Asian children ages 6-12 who participated received 1% atropine qhs for two years in either their right eye or their left eye. These children experienced a decrease in myopic progression of 1.10 D compared to the placebo treatment. The ATOM 2 study, which looked at varying doses of atropine 0.01%, 0.1%, and 0.5% found that the 0.01% dose had similar efficacy to the higher concentration but with fewer side effects. 11

12 7-methylxanthine (7-MX) is a metabolite of caffeine and theobromine that increases the thickness of posterior sclera. Researchers think that this helps to prevent myopia progression by preventing axial elongation, says Dr. Lee. 7-MX causes the posterior sclera collagen fibers to increase in diameter, and thus you re thickening that posterior sclera and preventing it from elongating. A Dutch study of 107 children ages 8-13 found that 400 mg tablets po qd of 7-MX decreased myopia progression by 66 percent and reduced axial length by 44 percent compared to the placebo group. A concern that we have with this study is there are no real studies on long-term side effects they just said it was safe and went with it, says Dr. Lee. Also, it7-mx is not commercially available, so it s not a treatment option. A study examined using multifocal contact lenses for myopia control in 40 children ages The children who were fit with CooperVision Proclear Multifocal D add experienced a 50 percent decrease in myopic progression and a 29 percent reduction in axial elongation. Another study featured 25 young adults ages Those who were fit in the CooperVision Biofinity Multifocal D add found that the lens design created a peripheral myopic defocus when looking at distance and near. 12

13 Orthokeratology came out of a lot of the research in the '80s looking at gas permeable lenses. We knew that the gas permeable intervention was workable in terms of slowing down rates of myopia, says Dr. Marsden. Orthokeratology allowed us to take a new philosophy in fitting and reshape the eye. In a three-year retrospective study that examined ortho-k vs. atropine 0.125%, every year, ortho-k edged out atropine in both myopia progression and axial length. Maybe ortho-k is more effective than atropine, says Dr. Nguyen. It would be interesting to see how ortho-k compares to atropine 0.01% because dosage was identified as beneficial without all of the side effects. The study also found that ortho-k was more effective in patients with higher amounts of myopia over those with lower amounts. 13