Controversies in Pediatric Refractive Development Timothy Hug, OD, FAAO

Transcription

1 Controversies in Pediatric Refractive Development Timothy Hug, OD, FAAO Please silence all mobile devices and remove items from chairs so others can sit. Unauthorized recording of this session is prohibited

2 Disclosure Statement: Nothing to disclose (but probably shouldn't have used "controversies")

3 Refractive Error Discussion Topics Infants and the Emmetropization Process (birth 12/18 months) Toddlers and Hyperopia Regression (18-36 months) School age Children and Myopia Development / Progression (4 years 12 years ) (3 13years) (7 17 years)

4 My Clinical Considerations / Conundrums/ Controversy? Questions or additions Jennifer Qayum and Moderated Q&A

5 Refractive Error Development Infants and the Emmetropization Process

6 Myopia at 1 4 months may become low hyperopia by 12 months Hyperopia at 1 4 months also becomes low hyperopia by 12 months At end of 12 months should be +200 to +300 (I consider up to 18 months)

7 Courtesy of Don Mutti OD

8 Accommodation is a possible visual signal for emmetropization Is a rapid process occurring in the first year of life Dr Don Mutti

9 Accommodation may trigger the emmetropization process High hyperopia requires "extra" accommodation, triggering a response to elongate the eye Myopia requires no accommodation which triggers a "stop" to the axial elongation component Mild hyperopia - "just right" Mutti, Mitchell; Accommodation, Acuity, and their Relationship to Emmetropization; optvissci 2009

10 Courtesy of Don Mutti OD

11 If refracting 3 month old...is it safe to let them go until pre school? Plano Do all three have a chance to be at months?

12 Would we prescribe at three months of age or would that interfere with emmetropization?

13 What does interference with this process look like? Animal models of inducing a refractive error vs correcting a refractive error Prescribing may interfere? - not quite

14 "Give me a monkey and I can make him whatever refractive error you want... Dr Earl Smith

15 NLDO and the tear lake Patients up to 14 months of age 8 % of unilateral NLDO had anisometropia > 1.0 D More hyperopic eye on side of NLDO? Did this eye get the wrong signal about emmetropizaton from the tear lens? Kipp, et al, Anisometropia and amblyopia in nasolacrimal duct obstruction; Journal AAPOS, June 2013

16 Prematurity

17 Prematurity 31 weeks / < 1500 grams Retinopathy of Prematurity Spontaneous regression Laser treatment Avastin treatment

18 No periphery! Does peripheral defocus apply?

19 I don t know WHATS going on with the premature myopia Dr Earl Smith

20 Lens thickness is responsible for myopia in laser treated ROP Is this evidence of feedback loop? Could ciliary process stretching from laser lead to lens thickness increases to myopia land

21 Approximately 2/3 of eyes with high risk pre-threshold ROP are likely to be myopic in the preschool years Myopia is associated with shallowing of AC and steepening of the cornea, and increased lens thickness 1.Quinn, et al; Progression of myopia and high myopia in the Early Treatment for Retinopathy of Prematurity Study, Journal AAPOS April McLoone, et al; Long term refractive and biometric outcomes following diode laser therapy for retinopathy of prematurity; J AAPOS,Octo 2006

22 Avastin use / studies Less myopia and less astigmatism than laser treated cohorts Early evidence that high myopia is not developing with Avastin use Is it the intensity of the disease or the Avastin itself? Intraviteral bevacizumab for retinopathy of prematurity: refractive error results; Harder, et al; AJO; June 2013

23 Intervene when visual system / process is in trouble eg: I had this patient this one time who s mother once said.(poor way to teach but ) 7 mos old with searching type nystagmus given rx, nystagmus went away Accommodative et p cortical development of binocular wiring which is worse glasses for life or binocular decay?

24 Dr Qayum 4 / 7 mo old accomm ET

25 Infant Summary Slide Controversy? Prescribing in this age group may alter process but save vision and binocularity at all costs Aphakia always needs help When can we predict future refractions? How frequently should refraction occur in this group?

26 So, if emmetropization process works well Child should be at months of age

27 +2.00

28 What if it didn t - Accommodative ET Intervention stay the course Don t cut plus on accommodative esotropia all you're doing is increasing divergence amplitudes...not influencing the refractive outcome (I think) Park, et al report increase incidence of decompensation with reduced plus

29 What happens to the hyperopic refractive error in accommodative ET? Treatment outcomes in refractive accommodative esotropia (Berk, et al, Journal of AAPOS, August 2004) Hyperopia regressed 0.16 D / year for 80.5 % The effect of optical correction on refractive development in children with accommodative esotropia (Biler, et al, Journal of AAPOSAugust 2010) Hyperopia regressed 0.10 D / year Long term changes in refractive error in patients with accommodative esotropia (Park et al, Ophthalmology, Novemeber 2010) Noted no difference between full correction or reduced correction in magnitude of hyperopic regression (0.25 D yr)

30 What if it didn t - High Myopia associated with ROP Progressive Don t think myopia progression treatment will work on ROP based myopia

31 Toddlers Hyperopic regression Ages 3-6 years Reasoning? Axial length increase Prescribing glasses? Animal models were inducing a refractive error NOT correcting one What interferes with this?

32 Do we interfere with any refractive process in this age group by prescribing glasses? Limited evidence that the emmetropization process is active, rather a trend for slow hyperopic regression

33 Prescribing Amblyopia prevention / treatment Daily living needs Learning Cutting plus... Why does hyperopia when associated with accommodative ET not regress the same? Can this be a clue early hyperopic prescribing may halt regression/progression

34 Uncorrected hyperopia and preschool early literacy VIP, Ophthalmology 2016 Conclusion Uncorrected hyperopia >4.0 D, or >3.0 D to <6.0 D with reduced binocular near VA in 4 5 year old children is associated with worse performance on early literacy testing

35 Amblyopic refractive risks Hyperopia Myopia > Anisometropia > 1.5

36 If amblyopia present in this age group...save the vision...unchartered waters in regard to "emmetropizaton/hyperopic regression/myopic progression"

37 Toddler summary slide Intervention for amblyopia treatment / protections Intervention for strabismus / binocular disorders Intervention for learning in moderate hyperopes When can we predict future refractions?

38 What about over minus for IXT Closest thing to the animal models in which we are inducing a refractive error and not treating a refractive error

39 School aged 4-14 yr 3 13 yr 7 12 yr (myopia progression studies)

40 Ages 7 12 Hyperopia regression Myopia progression Same thing? Axial length increase 3 D shift over 5 years 3/5 D per year?

41 Myopia Land Hyperopia Land

42 Myopic Progression Who progresses Myopes Myopia associated with systemic co-morbidities Why treat the progression Are we preventing myopia? Are we preventing progression of myopia? Early atropine studies the treated eye caught up with the untreated eye after stopping atropine Add Singapore atropine article references

43 Previous thoughts on myopia progression Relative peripheral hyperopia does not predict development and progression of myopia in children article Atchison et al

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45 Should clinical myopia progression treatment decision be based only on studies ie ages refractive errors Pre-treatment? Need for "algorithim"? How long do we treat? When can we find evidence of treatment benfits? Still wearing glasses

46 Should we be informing parents of outcomes of myopia progression treatments ie myopia still progresses?

47 What other tricks does mother nature have in store? Effect of ocular alignment in emmetropization in children < 10 years with amblyopia article hey we are passed emmetropization age, pal!

48 School aged summary slide Intervene for - Daily living Amblyopia? Is that a consideration for prevention or treatment When can we predict future refractions?

49 Summary Slide 0-18 months Active Emmetropization process Multiple refractions to monitor changes Final refraction at mos to ensure "gradutation" Intervention for visual distress Accommodative ET Myopia associated with ROP

50 Summary Slide 3 6 years old Hyperopia regresses Prescribe for visual distress Amblyopia Daily Living

51 Summary Slide 7-12 years old Hyperopia regresses Myopia progresses

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