Myopia: Applying Research to Practice

Transcription

1 Myopia: Applying Research to Practice Daniel J. Press, OD, FCOVD Director, Pediatrics and Binocular Vision North Suburban Vision Consultants Park Ridge and Deerfield, IL 1 I have no financial interests in any products mentioned Speakers Bureau-VTI Shadowed Dr. Stu Grant 2007-Joined private practice Dr. Leonard Press 2008-Vision By Design Dr. Earl Smith-Peripheral defocus 2009-COVD Meeting Dr. Nick Despoditis-Supercharge 2011-COVD Lecture Dr. Jeff Cooper-Atropine 2012-Moved to Chicago Dr. Barry Eiden 3 (C) Copyright Dr. Daniel Press

2 Consider progressive myopia as a health concern Motivated to slow the progression of childhood myopia Goals: Pick up pearls to apply to practice tomorrow 4 CONTACT LENSES We want everyone to try contact lenses and don t want cost to get in the way. We don t charge fitting fees and have partnered with the largest contact lens company to keep the most popular lenses in stock 5 most leaders work hard to make their teams and organizations better but many are so focused on the short-term, day-to-day routines, and on fighting fires that they neglect to work on long term priorities. If the internal rate of change doesn t exceed the external rate of change, you will lose the race. You can t be all things to all people. Work to prioritize the opportunities you see and pursue them in an intelligent way. 6 (C) Copyright Dr. Daniel Press

3 people don t buy What you do, they buy Why you do it... 7 To protect your child s vision 8 To protect your child s vision CRT Atropine MF CL s Myopia Management 9 (C) Copyright Dr. Daniel Press

4 Myopia is increasing 40-50% prevalence in US and Europe 1 Almost 80% prevalence in some Asian countries 2 5 billion affected people by Earlier onset means higher myopia 4 1,2 3 1 Vitale, S., Sperduto, R., & Ferris, F. (2009). Increased Prevalence of Myopia in the United States Between and Archives of Ophthalmology. 127(12): Dolgin, E. (2015). The myopia boom. Nature. 519(7543): Holden, B. A., et al. (2016). Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through Ophthalmology. 123(5): Flitcroft, D. (2012). The complex interactions of retinal, optical and environmental factors in myopia aetiology. Progress in Retinal and Eye Research. 31(6): Br J Ophthalmol Jul;102(7): In 2000, MMD VI was estimated to affect 4.2 million people, increasing to 55.7 million in MMD blindness in 2000 was estimated to affect 1.3 million people, increasing to 18.5 million in 2050, 11 Odds Ratios of Ocular Disease 2 to Myopia References 1 Flitcroft, D. I. (2012). The complex interactions of retinal, optical and environmental factors in myopia aetiology. Progress in retinal and eye research, 31(6), Mitchell, P., Hourihan, F., Sandbach, J., & Wang, J. J. (1999). The relationship between glaucoma and myopia: the Blue Mountains Eye Study. Ophthalmology, 106(10), Vongphanit, J., Mitchell, P., & Wang, J. J. (2002). Prevalence and progression of myopic retinopathy in an older population. Ophthalmology, 109(4), Ogawa, A., & Tanaka, M. (1988). The relationship between refractive errors and retinal detachment--analysis of 1,166 retinal detachment cases. Japanese journal of ophthalmology, 32(3), (C) Copyright Dr. Daniel Press

5 3.5 %Incidence of RD <4.74D >5-6D >6D 0.015% 0.07% 3.2% A Review of Current Concepts of the Etiology and Treatment of Myopia. Cooper J, Tkatchenko AV Eye&Contact Lens Vol 44;4; Reducing Myopia progression by 33% would result in 73% reduction of Myopia>5D Reducing Myopia progression by 50% would result in 90% reduction of Myopia>5D Brennan NA. Predicted reduction in high myopia for various degrees of myopia control. Cont Lens Anterior Eye 2012;35(Suppl 1):e14-e15 14 (C) Copyright Dr. Daniel Press

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7 Can myopia exist without nearsightedness? Axial length of the eye is excessively long (>23mm) Talk about Myopia not nearsightedness 19 Femtosecond laser crosslinking of the cornea for noninvasive vision correction 20 Family History of eye disease? Both of us wear glasses Myopic Parents Parental myopia > Offspring myopia Myopia is caused by both genetic and environmental factors- 3.6% of the variance of the refractive-error trait is explained by genetic variants 1 1. Verhoeven, V. J. et al. Genome wide meta analyses of multi ancestry cohorts identify multiple new susceptibility loci for refractive error and myopia. Nat. Genet. 45, (2013). 21 (C) Copyright Dr. Daniel Press

8 Researchers identified 161 genetic factors for myopia. This quadruples the number of known genetic risk factors playing a role in all retinal cell types. Our results support the notion that refractive errors are caused by a light-dependent retina-to-sclera signaling cascade and delineate potential pathobiological molecular drivers. Genome-wide association meta-analysis highlights light-induced signaling as a driver for refractive error, Nature Genetics (2018). 22 Choroidal thickness reduced during accommodation 1 1. Regional changes in choroidal thickness associated with accommodation Woodman- Pieterse et al. Investigative Ophthalmology & Visual Science, vol. 56, no. 11, pp , Axial Length N= hours/week outdoors 1 year Intervention Control 24 (C) Copyright Dr. Daniel Press

9 Increased eye disease with increasing myopia Retinal detachment, Glaucoma, earlier cataract, maculopathies Higher likelihood of myopia if or less at 6 years old Zadnick K et al. JAMA Ophthalmol Jun;133(6):683-9 Kids who spend more time outdoors when they are younger (Pre-myopic) are less likely to develop myopia when they are older Significant increase in prevalence in one generation From the 70 s to 90 s over 65% increase /01/2016 Clara, 8 years old Referred by her Ped OMD for myopia treatment Standard eye exam Refraction: OD: x103 OS: x035 Discussed myopia and its implications Informed of procedures for comprehensive myopia evaluation 27 (C) Copyright Dr. Daniel Press

10 Nothing Is More Valuable Than Your Time finite asset and, once spent, cannot be replenished (C) Copyright Dr. Daniel Press

11 Diagnostic Evaluation beyond routine Binocular Testing Stereopsis, vergence ranges, vergence facility, NPC Accommodative Testing Accommodative lag, NRA/PRA, Pull Away [ (age)], Minus lens to blur, Accommodative Facility (Binocular/Monocular) Pupil diameter in bright and dim lighting conditions Corneal Topography/Tomography Non-contact axial length measurements (IOL-Master) Specular Microscopy Education 31 Pros/Cons of different options Efficacy of different options? To date the 3 options all have close to 50% reduction in myopia progression What would you do? I treat every child that I see as if they were my own. I would not recommend anything for your child that I would not do to my own children How long will they be treated for? Technology s influence on their condition (C) Copyright Dr. Daniel Press

12 34 Vision Therapy Alignment Fit GP Lenses Under-corrected Spectacle Rx Bifocal/Multifocal Spectacle Rx Atropine Therapy Soft Multifocal Contact Lenses Corneal Refractive Therapy (CRT) 35 VISION THERAPY Theory based in near-point stress model for myopia Can improve accommodation/vergence, oculomotor, visual perceptual skills Potential to improve blur interpretation which may lead to better visual acuity but not myopia as defined today 36 (C) Copyright Dr. Daniel Press

13 Bifocal Spectacle Rx Studies have mixed results Flat top/executive bifocal > PAL s More effective in Asian population Convergence Excess/Accommodative Dysfunction 37 peripheral refractive errors can have a substantial impact on central refractive development in primates. Earl Smith, et. al short-term exposure to myopic defocus induced relative choroidal thickening while hyperopic defocus led to choroidal thinning in children Optical Defocus Rapidly Changes Choroidal Thickness in Schoolchildren. Wang et.al. PLoS One. 2016; 11(8) (C) Copyright Dr. Daniel Press

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15 Local influence not dependent of CNS feedback When conflicting signals exist between the central and peripheral retina, peripheral visual signals dominate central refractive development Traditional spectacle lenses increase peripheral hyperopic defocus 43 Ortho-k treatment induced significant choroidal thickening and a slowing of eye growth Choroidal thickness and axial length changes in myopic children treated with orthokeratology. Li et.al. Cont Lens Anterior Eye Dec;40(6): Jun-Kang, et al. Orthokeratology for Myopia Control: A Meta-analysis. Optometry & Vision Science: March Volume 92 - Issue 3 - p Included 7 studies, 435 subjects, 218 OK and 217 Control, 2 year follow up. Axial Length was the outcome measure At 2 years follow-up, the AL elongation of the orthokeratology group was significantly slower than that of the control group (C) Copyright Dr. Daniel Press

16 Averaging the mean of the 7 studies yields a 47% decrease in axial length over 2 years for OK wearers Jun-Kang, et al. Orthokeratology for Myopia Control: A Meta-analysis. Optometry & Vision Science: March Volume 92 - Issue 3 - p Cheung SW et al. Microbial Contamination of Periorbital Tissues and Accessories of Children. Optom Vis Sci Jun;93(6):612-8 Results: Ortho-k subjects had significantly less total isolates in the conjunctiva than controls Conclusion: physiologic effect of this treatment on the types of normal flora in children was minimal and should not increase the risk of microbial keratitis in children with good compliance Bullimore MA et al. The risk of microbial keratitis with overnight corneal reshaping lenses. Optom Vis Sic Sep;90(9): Results: Overall rate of MK is 7.7 per 10,000 patient years of wear. SiHy daily wear 11.9 per 10,000 patient years of wear (diff study) Liu YM et al. The Safety of Orthokeratology-A Systematic Review. Eye Contact Lens Jan;42(1):35-42 Conclusion: There is sufficient evidence to suggest that OrthoK is a safe option for myopia correction and retardation. 48 (C) Copyright Dr. Daniel Press

17 49 How much are the braces in Orthodontia? (C) Copyright Dr. Daniel Press

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20 58 October 2015 October 2016 June 2018 Refraction OD: x100 OD: x100 Signed up, OS: level x035 3 CRT OS: x035 Axial Length Last follow Unknown up was June 12, 2017 OD: mm OS: mm OD: plano OS: plano OD: mm OS: mm Plan Update Rx Design CRT lenses Return in 6 mos. Any further increase consider combined tx 59 How soon are the results and what to do in the mean time? Every night or every other night? Care system? Replacement schedule? 60 (C) Copyright Dr. Daniel Press

21 Our Routine: Order empirically based on K s, Refraction and HVID Patient returns for instructional class (dispensing visit) Returns for first morning follow up while wearing the lenses WOW the patient with the improvement in Unaided VA 1 week, 1 month, 3 month, 6 month follow up schedule USE CONSULTATION 61 Always use topical anesthetic Teach removal with DMV Consider diluted anesthetic for home Experimental use of anesthetic No safety data 62 First Morning: Evaluate lenses for binding Patient removal of lenses Topography Auto-Refraction/K s Slit lamp evaluation One Week, One Month, Three Month, Six Month: Afternoon/Evening appointment Unaided VA s Topography Auto-Refraction/K s Refraction Slit lamp evaluation 63 (C) Copyright Dr. Daniel Press

22 Do not state CRT stops the progression of myopia Advise parents that goal is limiting the progression of myopia and not to see 20/20 Take acuity binocular in free space and monocular behind phoropter If one design doesn t work, try another Confirming myopia control with CRT 1. Unaided refraction 2. Refraction over lenses 3. Washout period with topographic stability 64 1 st visit 12/29/2016-Prior rate of myopia progression: 2D/Year 12 years old 06/20/16 12/29/16 Refraction OD: OS: x162 OD: OS: x165 Axial Length Unknown OD: mm OS: mm Plan Update Rx Not CRT 65 Pharmacologic Therapy Atropine Ophthalmic Pirenzepine Ophthalmic Dopamine 66 (C) Copyright Dr. Daniel Press

23 Chia, et al. Five-Year Clinical Trial on Atropine for the Treatment of Myopia 2: Myopia Control with Atropine 0.01% Eyedrops. Ophthalmology Feb;123(2): Conclusion: The efficacy of atropine is dose independent, whereas the adverse effects are dose dependent. Limitations:.. not enough studies examined each atropine concentration, different types of studies were combined in this meta-analysis to investigate the overall effects of different doses, which might be a source of additional heterogeneity we did not evaluate the axial length across various doses of atropine (C) Copyright Dr. Daniel Press

24 A Randomized, Double-Blinded, Placebo-Controlled Trial of 0.05%, 0.025%, and 0.01% Atropine Eye Drops in Myopia Control Almost published Conclusions: The 0.05%, 0.025%, and 0.01% atropine eye drops reduced myopia progression along a concentrationdependent response. All concentrations were well tolerated without an adverse effect on vision-related quality of life. Of the 3 concentrations used, 0.05% atropine was most effective in controlling SE progression and AL elongation over a period of 1 year. Where do we start? 0.01%, 0.02%, 0.05%? 71 Accommodative? Atropine inhibits experimental myopia in the chick without causing cycloplegia. Chick eyes have striated ciliary muscle innervated by nicotinic receptors, not muscuranic receptors. Effective at lower doses that have little impact on accommodation Neurotransmitter mediated? Dopamine, Nitric Oxide Choroidal Thickening? atropine may act to block the myopiagenic effects of hyperopic retinal defocus 1 1. Effect of Atropine Eye Drops on Choroidal Thinning Induced by Hyperopic Retinal Defocus Chiang, Phillips. Journal of Ophthalmology January 2018, Article ID (C) Copyright Dr. Daniel Press

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28 Li SM et al. Studies using concentric ring bifocal and peripheral add multifocal contact lenses to slow myopia progression in school-age children: a meta-analysis. Ophthalmic Physiol Opt Jan;37(1): Axial Length after 2 years 38% reduction with concentric ring MF CL s ex. Acuvue Bifocal 51% reduction with peripheral add MF CL s ex. Proclear/Biofinity MF In children who have worn NaturalVue Multifocal for 6-25 months: Annualized Refractive Error Change 1 (D) Prior Correction OD NaturalVue Multifocal OD -0.04* Prior NaturalVue Correction Multifocal OS OS -0.03* Prior NaturalVue Correction Multifocal Both Eyes Both Eyes Combined Combined -0.04* The decrease in the annualized refractive error change was 95.4% OD and 96.25% OS (96% for both eyes combined) with the most frequently observed decrease in refractive error change (mode) of 100% in each eye. 1 Cooper J, O Connor B, Watanabe R, Fuerst R, Berger S, Eisenberg N, Dillehay SM. Case series analysis of myopic progression control with a unique extended depth of focus multifocal contact lens. Eye & Contact Lens. 2017; (e-pub prior to 84 publication, Oct). MKT-NVB-SP1 r0 (C) Copyright Dr. Daniel Press

29 85 Kinoshita, N., Konno, Y., Hamada, N. et al. Jpn J Ophthalmol (2018) Additive effects of orthokeratology and atropine 0.01% ophthalmic solution in slowing axial elongation in children with myopia: first year results. A total of 40 consecutive subjects (20 subjects in the combination group and 20 in the monotherapy group) were followed for 1 year. The increase in axial length over 1 year was 0.09 ± 0.12 mm in the combination group and 0.19 ± 0.15 mm in the monotherapy group (P = , unpaired t test). Conclusion: During the 1-year follow-up, the combination of OK and atropine 0.01% ophthalmic solution was more effective in slowing axial elongation than OK monotherapy in children with myopia st visit 12/29/2016-Prior rate of myopia progression: 2D/Year 12 years old 06/20/16 12/29/16 12/07/17 Refraction OD: OS: x162 OD: OS: x165 Axial Length Unknown OD: mm OS: mm Plan Update Rx Refit into NV 1 day MF OD OS Start Atropine: 0.05% OD: OS: x165 OD: mm OS: mm No change in Tx 87 (C) Copyright Dr. Daniel Press

30 88 03/06/ years old Blurred distance x 2-3 weeks Atropine program Single Vision Glasses 89 (C) Copyright Dr. Daniel Press

31 92 Educate the staff Weekly office meetings Manage myopia of staff s children 93 (C) Copyright Dr. Daniel Press

32 Have dedicated information on your website: Read the available research The only true wisdom is in knowing you know nothing. Socrates Talk to colleagues-intra-optometric referrals Discuss myopia as a health concern Start where you are comfortable CRT: Myopia<3.00D and K s between Have a plan of action for different scenarios 96 (C) Copyright Dr. Daniel Press

33 Don t give away your services, your knowledge, your expertise Don t get caught up in materials-orthodontia Soft Multi-Focal CL s: Obtain fitting sets of designs showing promise of myopia stabilization Orthokeratology: Talk to your labs Atropine: Open a line of communication with a compounding pharmacy 97 Myopiaprofile.com Drs. Kate and Paul Gifford Myopia profile Facebook Set Google Alerts Myopia Orthokeratology Join the AAOMC Practice Update (C) Copyright Dr. Daniel Press

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35 103 Mom of Jeremy, Clara and Annabelle: As a parent of three kids who got such an unlucky genetic combination with their eyes, I am deeply grateful to be working with Dr. Press to give them a healthier future. I cannot adequately express in words what these treatment options mean for our family. Thank you. THANK YOU FOR YOUR ATTENTION! 105 (C) Copyright Dr. Daniel Press