Be in charge of your myopia control strategy

Transcription

1 Be in charge of your myopia control strategy Dr Kate Gifford O.D. Ph.D. BAppSc(Optom)Hons, GCOT, FBCLA, FIACLE, FCCLSA, FAAO Dr Langis Michaud O.D. M.Sc. Professor FAAO (Dipl), FSLS, FBCLA, FEAOO DISCLOSURE Dr Gifford Honorarium received from Alcon Coopervision Menicon Visioneering Technologies Dr Michaud Honorarium Received from Cooper Johnson * Johnson Blanchard Labs Co-owner USPTO 62/590,388 Medical device for axial length and myopia management 1

2 FIRST LECTURE Kate Gifford It was never easy to look into the future, but it is possible and we should not miss our chance. -Andrei Linde 2

3 There is no safe level of myopia Increased risk Cataract (PSCC) Retinal detachment Myopic Maculopathy to to to Younan et al 2002, Ogawa & Tanaka 1988, Vongphanit et al 2002 in Flitcroft

4 Myopia management First corrections The next steps The full picture First corrections Myopia management 4

5 The myopia-suspect One or two myopic parents Less time spent outdoors (<60-90 min / day) Binocular vision disorders (Esophoria, Accom lag, High AC/A) Jones et al 2007, Read et al 2014, Xiong et al 2017, Gwiazda et al The myopia-suspect Pre-myopes have less hyperopic refractions for up to 4 years before onset Fastest change in refraction is in the year before onset Less hyperopia than age normal Jones-Jordan et al 2010, Mutti et al

6 R&L Two myopic parents R&L Two myopic parents Outdoor time At least 90 min / day of outdoor time can help prevent onset 1,2 and progression 3,4 of myopia Wearing a hat, sunglasses and playing in shade still gives >1000 lux compared to lux indoors 5 Playing near a window doesn t count! 5 It s not about physical activity it s about light exposure 4 Outdoor time doesn t directly trade for near work time 4 1 Rose et al 2008, 2 Wu et al 2013, 3 Lin et al 2014, 4 Read et al 2015, 5 Saw et al IMC

7 The sooner you start, the better 0.25D per year 18+ Donovan et al 2012 Bullimore et al 2002, McBrien et al 1997, Goss et al 1985, Bullimore et al Specs - uncorrection & undercorrection Uncorrected Full correction Full correction Under correction to 6/12 Sun et al 2017 Uncorrection may work in early myopes <0.75D Full distance correction in myopes 0.75D+ Chung et al

8 R&L Unaided vision R&L 6/6- OU 6/6 Binocular vision normal at near (unaided) R&L Unaided vision R&L 6/12+ OU 6/9 Esophoria and/or accommodative lag at near (aided) Myopia management across the world 971 practitioners, 12 countries, 6 languages 8

9 Use UnderCorrection for Myopia Control Eye care Practitioners (%) UK+EIRE Europe Asia Australasia N America S America 0 No Sometimes Always Approach Wolffsohn et al, 2016 Myopia management First corrections The next steps The full picture 9

10 Myopia management The next steps EFFICACY Contact lens myopia control - meta-analysis papers OrthoK Sun et al 2015; Si et al 2015 (both open access) Bifocal and multifocal SCLs Li et al 2017 ~ 50% ~ 50% 10

11 Describing efficacy Atropine 0.1-1% Atropine 0.01% OK, MFSCL Until further notice ~ 50% 11

12 Myopia = inaccurate BV behaviour Near esophoria Accommodative lag Higher AC/A ratios Greater variability in accommodative responses Bennett et al 1989, Bullimore et al 1992, Rosenfield et al 1994, Drobe et al 1995, Gwiazda et al 1995,Abbott et al 1998, Gwiazda et al 1999, Mutti et al 2000, Rosenfield et al 2002, Vera-Diaz et al 2002, Chen et al 2003, Wolffsohn et al 2003, Nakatsuka et al 2005, Allen et al 2006, Pandian et al 2006, Harb et al 2006, Mutti et al 2006, Ciuffreda et al 2008, Vasudevan et al 2008, Lin et al 2012 Binocular vision & myopia control Progressive spectacles applied to all myopes % Progressive spectacles for binocular vision problems...37% Bifocal spectacles for progressing myopes % 1 Edwards et al 2002, 2 Gwiazda et al 2003, 3 Yang et al 2009, 4 Cheng et al

13 Binocular vision & myopia control Bifocal SCL fit to esophores % OrthoK gives a 56% better myopia control effect in below average accommodators 6 OrthoK reduces near esophoria and accommodative lag 7-9 Multifocal SCL reduce accommodative lag 10 5 Aller et al 2016, 6 Zhu et al 2014, 7-9 Gifford et al 2017 a,b,c, 10 Tarrant et al 2008 Spectacles are sometimes better than CLs ESOPHORIA ACCOMMODATIVE LAG Stronger corrections (prism, add) may be needed for severe BV issues Multifocal SCL and OK will also have some effect, but less predictable If BV is normal. OrthoK or MF SCL Large ESO.....OK/MFSCL/specs Large EXO Specs may be best Changing from specs to CL s in myopes gives an exophoric shift Jalie 1973, Bennett et al 1989, Evans 2007, Grosvenor 2007, Jiminez et al 2011, Snir et al

14 Age 10 R / x 90 L / x 90 Age 11 Age 12 R / x 90 L / -1.50x 90 L almost constant exotropia N>D R / -0.75x 90 L / x 90 Myopia control = spectacles and BV management Some progression is normal YouTube / Myopia Profile 14

15 Myopia management made simple The next steps SAFETY Safety microbial keratitis Stapleton et al 2008, Sankaridurg et al 2013, Bullimore et al 2013, Bullimore Per 10,000 wearers, per year Any MK ,2 DW RGP ,4 0 DW soft DW DD DW SiH DW SiH (kids) EW soft EW SiHy 2,5 7 OK (all) 0 0 OK (kids) MK with 2 lines of VA loss 15

16 Open access paper Similar rates of corneal infiltrative events and microbial keratitis compared to adults May be a lower risk in children aged 8-12 years (likely due to compliance) Kids and contact lenses - safety Reinforce care and maintenance instructions children (8-12 years) recall less after 3 months than teens (Walline et al 2010) Kids are NOT more risky CL wearers than adults no difference in adverse events after 10 years of wear (Walline et al 2011) Most common complication CLPC 4%, infiltrative keratitis 1% (Sankaridurg et al 2013, Bullimore et al 2013) Safety of a D centred reusable multifocal and OrthoK is similar (Stapleton et al 2008, Bullimore et al 2013) 16

17 Myopia management First corrections The next steps The full picture Myopia management The full picture 17

18 Three pillars of clinical myopia control Environment Contact Lenses Binocular vision Three pillars of clinical myopia control Environment 1. 2 hours outdoor time per day 2. Limit near work to 2 hours per day (after school) 3. 20/20 rule regular breaks Contact Lenses Binocular vision Rose et al 2008, Wu et al 2013, Lin et al 2014, Read et al 2015, Woodman et al 2011, Aldossari et al

19 Three pillars of clinical myopia control Environment Contact Lenses Binocular vision Prescribe spectacles (progressive / bifocals) if the child is not suitable for contact lenses. Three pillars of clinical myopia control Environment Contact Lenses Binocular vision Consider adding low dose atropine if optical correction (CL s or spectacles) does not provide sufficient myopia control 19

20 Three pillars of clinical myopia control Environment Contact Lenses Binocular vision Managing esophoria and accommodative lag may provide additional benefit for myopia control Myopia Mythbusting They re myopic anyway there s no big difference between being and It s best to wait for progression before commencing myopia management. If I don t fit OrthoK, I can t do myopia control. Kids and contact lenses ooooh that s a bit risky. 20

21 Myopia Mythbusting Myopia Management They re Keeping myopic myopia anyway below -3.00D there s and no axial big difference length below 26mm between significantly being reduces and lifelong risk of pathology and vision loss It s Intervention best to wait before progression age 12 will before have the commencing biggest impact myopia on management. reducing progression (including visual environment advice) Until further notice atropine, OrthoK and MFSCL are all If similar. I don t Specs fit OrthoK, are valid I can t too do pick myopia the optical control. correction first and add atropine second SCL safety in younger children appears to be better than Kids and contact lenses ooooh that s a bit risky. teens, and the risk of future myopic pathology is certain. Clinical resources 21

22 Clinical resources for myopia management Facebook / Myopia Profile YouTube / Myopia Profile 22

23 SECOND LECTURE Langis Michaud Myopia /AL management clinical testing 1. Oriented case history (risk factors) Family/patient background Ethnical origins Environmental conditions Past evolution 2. Refractive and binocular vision assessment BV assessment: phoria at near, AC/A, accommodative lag Cycloplegic refraction 3. Ocular parameters Topography Pupils Axial Length 4. Ocular health Slit lamp DFE 23

24 Set-up a myopia assessment (2) 4. Corneal Topography May impact contact lens selection Look at both sides! 5. Axial Length The true gold-standard assessment for evolution 6. Aberrometry TOPO back and front corneal floats.. OD OS 24

25 Association of Axial Length With Risk of Uncorrectable Visual Impairment for Europeans With Myopia J. Willem L. Tideman, MD; Margaretha C. C. Snabel, MD; Milly S. Tedja, MD; Gwyneth A. van Rijn, MD; King T.Wong, MD; RobertW. A.M. Kuijpers, MD, PhD; Johannes R. Vingerling, MD, PhD; Albert Hofman, MD, PhD ; Gabriëlle H. S. Buitendijk, MD; Jan E. E. Keunen, MD, PhD; Camiel J. F. Boon, MD, PhD; Annette J.M. Geerards, MD; Gregorius P. M. Luyten, MD, PhD; Virginie J. M. Verhoeven, MD, PhD; Caroline C.W. Klaver, MD, PhD JAMA Ophthalmol. doi: /jamaophthalmol Published online October 20, Mode of correction : HOA High-Order Aberrations theory A greater increase in coma-like aberrations = less axial elongation (Hiraoka, Ophthalmology, 2015; 122; ) Spherical aberrations are linked to the LAG There is a significant negative correlation between SA and CSF Degradation of the image (lower sensitivity) may impact the progression of myopia (like deprivation) We should control spherical aberrations in myopes 25

26 ACCOMMODATION AND ABERRATIONS Although central optical blur is the primary stimulus required to drive the accommodative system,(kruger 1986) insufficient accommodation, i.e., an increased lag of accommodation, has previously been linked to axial elongation.(mutti 2006; Gwiadza 2004) Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004) Further, multifocal contact lens designs induce higher order aberrations, which may affect the peripheral refraction profiles as well as accommodative responses (Ruiz-Alcocer, 2012) Myopic defocus with CD Increased lag with CN Influenced also by SA Optom Vis Sci Feb;94(2): doi: /OPX Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance. Fedtke C 1, Sha J, Thomas V, Ehrmann K, Bakaraju RC. Primary SA = negative with Centered-Near Designs In agreement with previous studies distance measurements of the current study showed that when using commercially available center distance lenses, it was possible to reduce relative hyperopia or induce relative myopia in the peripheral visual field and that this myopic shift was more pronounced in the nasal visual field. The opposite effect, i.e., an increase in relative hyperopia, has been observed for the center-near lenses tested in this and previous studies CONCLUSION Based on the hypothesis that myopic retinal defocus counters eye growth, all center-near multifocal lenses exhibited the preferred features of on-axis at near, i.e., producing a central myopic shift compared to the control. The center-distance lens showed the preferred off axis features by producing significant relative peripheral myopic shift, which in the periphery increased further during accommodation. When accounting for primary spherical aberration, these on and off-axis features, i.e., the reduction of hyperopic retinal defocus, were more pronounced, 26

27 Soft MF: Design Ophthalmic Physiol Opt Jan;37(1): doi: /opo Epub 2016 Nov 23. Studies using concentric ring bifocal and peripheral add multifocal contact lenses to slow myopia progression in school-aged children: a meta-analysis. Li SM 1, Kang MT 1, Wu SS 2, Meng B 2, Sun YY 1, Wei SF 1, Liu L 3, Peng X 4, Chen Z 1,5, Zhang F 1, Wang N 1. CONCLUSIONS: Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically effective for controlling myopia in school-aged children, with an overall myopia control rates of 30~50% over 2 years. Concentric ring bifocal soft contact lenses seem to have greater effect than peripheral add multifocal soft contact lenses. Set-up a myopia assessment 6. Pupil size - The entrance door - Especially for OK - Drives distance blur 7. Slit lamp /DFE 27

28 Need to customize lens designs for every patient Myopia correction is not myopia control Clinical recommendations algorithm 28

29 Michaud, Simard - Cont Lens Spect, Sept 2017 (open access) Can we predict? 29

30 # GUIDE TO CLINICAL MANAGEM THE IDEAL MYOPIA CONTROL LENS Induce peripheral myopia without compromising vision Reduce lag of accommodation Reduce near esophoria Provide controlled release of antimuscarinic agents Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia 30

31 CALIBRATE INTERVENTIONS Mechanism How to fix it Options Binocular Vision issues Re-establish normal Accomodation -convergence balance Orthoptics /Vision Therapy Prismatic /bifocal glasses Higher add power- keep natural accomodation Optical Aberrations Calibrate blur in the optic zone Centred-distance MF Customizable OZ Generate Suppression Peripheral hyperopia Play with Net peripheral power Customizable OK Higher add power MF Depth of field vs depth of focus Depth of field: is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount Increases if pupil becomes smaller Depth of focus: is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount. Inversionnaly proportional to the pupil size 31

32 The future? Moving outward from the center of the lens, RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone. The blur zone is designed to be suppressed by the brain, effectively resulting in a virtual aperture created by the visual cortex, and therefore an extended depth of focus in which distance, intermediate, and near vision are all clear. Courtesy of Dr Benoit, Natural Vue Testing and outcome Schedule 1 week, 1 month, 3 months, 6 months What testing should we do? Oriented case history Refractive components BV if issues AL Ocular health 32

33 Potential modifications LZA: 1 angle change = 15 µm sag variation BC: 0.1 mm change = 7 µm sag variation 33

34 Follow-ups 34

35 Is this working? Diopters are not a valid reference to evaluate progression Mutti s theory: the first 0.1 AL increase Other treatment options to consider Environmental Ergonomical Lightning Outdoor Etc. DISCUSSION / PANEL 35

36 Myopia management puzzles Risks of long term atropine use Myopia management puzzles Risks of long term atropine use Customising treatments and off-label use 36

37 Myopia management puzzles Risks of long term atropine use Customising treatments and off-label use Measuring axial length in practice Myopia management puzzles Risks of long term atropine use Customising treatments and off-label use Measuring axial length in practice The challenge of high myopia 37

38 SUMMARY MC is easy to implement, patient by patient Strategy should be customized for every patient, as well as treatment options Importance of taking in account the big picture, including binocular vision Atropine plus optical corrections Hyperopic defocus = choroidal thinning Hyperopic defocus = no choroid change Myopic defocus = choroidal thickening Myopic defocus = choroidal thickening Phillips et al, IMC % 38

39 The digital world American Academy of Pediatrics ( and Australian Government Department of Health ( Under 2 years: no screen time 2-5 years: max 1 hour of screen time / day No more than 1 hour at a time sedentary/restrained/inactive when awake The digital world and virtual reality Ocular effects of virtual reality headset wear in young adults Turnbull P & Phillips J, Scientific Reports 2017 Mismatch between vergence and accommodation, but no change in BV status after indoor and outdoor simulations Choroidal thickening after VR trial Heat from headset, OR Beneficial effect on BV? (increased convergence and lead of accom for near objects) 39