Myopia Management. Michael J. Lipson OD FAAO FSLS

Transcription

1 Myopia Management Michael J. Lipson OD FAAO FSLS

2 Disclosure I am a consultant to Bausch and Lomb - Specialty Lens Products Division I am on the advisory board of the GPLI I have received research funding from: Bausch and Lomb Paragon Vision Sciences

3 Why Myopia Management? Myopia is a DISEASE!! Myopia creates risk of vision-threatening eye disease Glaucoma Cataract Myopic Macular Degeneration Peripheral Retinal Degeneration Retinal Tears/Retinal Detachment

4 Increased Risk Cataract Glaucoma 5.5x 4x greater 6.00D of myopia Myopic Macular Degeneration 40.6 x greater 6.00D Peripheral Retinal Degeneration 21 x greater 6.00D Retinal Tears/Retinal Detachment 21.5x greater 6.00D Source: Flitcroft 2012

5 Myopia Management Methods Courtesy JJ Walline 2016

6 Current Evidence-Based Treatments OrthoK Soft Multifocals Other Multifocals Atropine Drops (1% vs. Low Dose) Huang J, Wen D, Wang Q, et al. Efficacy comparison of 16 interventions for myopia control in children: A network meta-analysis. Ophthalmol 2016;123: DOI /j.ophtha

7 Mechanism of OrthoK Fluid forces Squeeze film forces Inward push force where lens curve is flatter than cornea Outward pull force where lens curve is steeper than cornea

8 Mechanism of OrthoK epithelium Mid-peripheral central mid-peripheral Epithelial compression Epithelial migration epithelium stroma

9 How OrthoK slows myopic progression Optical effect Creates relative peripheral myopia Myopic defocus Signals the eye to stop growing longer Change in peripheral refraction from hyperopic to myopic Not due to accommodation or change in central refraction

10 OrthoK Numerous studies show significant slowing of rate of myopia progression 40-60% less progression 75% show little or no progression Numerous designs of lenses Most designed to correct refractive error Designs fairly similar (reverse geometry) Worn only while sleeping Slowing of Myopia progression is wonderful SIDE EFFECT!! Si J-k, et al. Orthokeratology for Myopia Control: A Meta-Analysis.Optom Vis Sci. 2015;92: Lipson MJ, Harris JK, Lather HD, Niziol LM, Musch DC. Axial Length in Overnight Corneal Reshaping Patients: Large Case Series. Advances Ophthal Vis Sci 2016

11 Customizing OrthoK for Even Better Slowing of Myopic Progression Smaller treatment zone more peripheral myopia within the pupil Aspheric Base Curve creation of more peripheral myopia Wider/Steeper Reverse Curve Larger/Steeper ring of corneal steepening Testing of peripheral refraction pre and post treatment Challenging!!! Kang P, Gifford P and Swarbrick H. Can Manipulation of Orthokeratology Lens Parameters Modify Peripheral Refraction? Optom Vis Sci. 2013;90;

12 OrthoK for Refractive correction Vision is good 92% - 20/25 (6/7.5) or better Comparable to va with scl Good vision all day Increased Spherical Aberration Before More night glare (adults) not much with children After Lipson MJ. Long-term clinical outcomes for overnight corneal reshaping in children and adults. Eye Contact Lens 2008;34: Berntsen DA, Barr JT, Mitchell GL. The Effect of Overnight Contact Lens Corneal Reshaping on Higher-Order Aberrations and Best-Corrected Visual Acuity. Optom Vis Sci 2005;82:

13 Summary Studies Demonstrate OrthoK is an effective refractive option OrthoK is safe OrthoK slows myopic progression OrthoK is a viable alternative to: glasses daytime contacts LASIK.

14 OrthoK Advantages Disadvantages No correction needed during waking Must be worn regularly 6-7 hours nights/wk Optical effect always in effect Minimum wearing time of 7 hrs/night Significant slowing of myopia progression Careful lens care is essential Good record of safety Minor risk of serious complications Can start early age 7-8 Patients like it! Good Compliance

15 Patients Prefer OrthoK In a crossover study pts wore OrthoK and SCL (2 mo each) At study conclusion 69% chose OrthoK (90% for or less) 31% chose SCL (50% for m0re than -3.00) Lipson MJ, Sugar A, Musch DC. Overnight corneal reshaping versus soft disposable contact lenses: vision-related quality-of-life differences from a randomized clinical trial. Optom Vis Sci 2005;82:

16 Compliance with OrthoK Wear and Care Careful lens care with PRESCRIBED regimen is essential Compliance with PRESCRIBED follow-up is essential Must be worn regularly 6-7 nights/wk Minimum wearing time of 7 hrs/night Minor risk of serious complications

17 Quality of Life Studies Crossover study-orthok and SCL (n=65) 2 mo each mode OrthoK wearers report (compared to SCL wear) Less activity restrictions More night glare More self-confidence Less Worry Less dependence on correction Lipson MJ, Sugar A, Musch DC. Overnight corneal reshaping versus soft disposable contact lenses: visionrelated quality-of-life differences from a randomized clinical trial. Optom Vis Sci 2005;82:

18 Quality of Life with OrthoK high level of patient satisfaction following overnight orthokeratology. Hiraoka, T, et al. Patient Satisfaction and Clinical Outcomes After Overnight Orthokeratology. Optom Vis Sci 2009;86:

19 Prescribing OrthoK Myopia Control effect is in force 100% of waking hours Can start young Age 7-8 (earlier is better) Compliance is good Lenses never leave home Parents and children LOVE IT!!

20 Same Optical theory as OrthoK Peripheral Myopic Defocus Soft Multifocal Lenses Distance-Center Multifocal Worn during waking hours Less than 1.00 cyl

21 Soft Multifocal Lenses Center Distance Variable size of center-distance zone Daily Disposable or Monthly Disposable

22 Soft Multifocal Lenses Center Near Reports of myopia control

23 Soft Multifocal Lenses Multiple Zones Still reports good myopia control Currently, not available

24 Myopia Control with Soft MF Anstice N, Phillips J. Ophthalmol 2011;118:

25 Myopia Control with SCL MF Table 4. Myopia progression and axial elongation of included studies during different periods of follow-up Concentric ring bifocal SCLs Study (Author, Year) Follow up (mo) Myopia progression (D) Axial elongation (mm) Experimental Control % slowing Experimental Control Rate Aller et al. (2016) % % Anstice et al. (2011) % % Lam et al. (2014) % % % % % % % Peripheral add multifocal SCLs Range 19-72% 7-79% Mean 43% 38% Fujikado et al. (2014) % % Walline et al. (2013) % % % % Sankaridurg et al. (2011) % % % % Paune et al. (2015) % % % % % % % % Cheng et al. (2016) % % % % Li S-M, et al. Studies using concentric ring bifocal and peripheral add multifocal contact lenses to slow myopia progression in school-aged children: a meta-analysis. Ophthalmic Physiol Opt doi: /opo.12332

26 Soft Multifocal Lenses New Designs Highly aspheric, center-near multifocal NaturalVue (VTI), MISight Excellent myopia control reported Majority showed > 75% reduction in MP Short-term study Pre-existing MC treatments Older Age Mean =11 Cooper J, et al. Case Series Analysis of Myopic Progression Control With a Unique Extended Depth of Focus Multifocal Contact Lens. Eye and Cont Lens.2017;Published Ahead-of-Print. October 19,2017. doi: /ICL

27 Prescribing Soft MF Prescribe highest ADD tolerable for good distance vision Lenses should be worn most of waking hours Can be Daily or Monthly disposable Generally in older children 10 yrs old and older

28 Other Lens Options GP Multifocals Can be prescribed for children with astigmatism Various designs available center-near Aspheric or concentric Custom zone sizes Daytime wear

29 Other Lens Options Hybrid Multifocals Center Near and Center- Distance available Custom Zone sizes Daytime wear

30 Other Lens Options Scleral Multifocals Great comfort Custom designs/custom Optics Variable zone size Center- Distance

31 Pharmaceutical Myopia Control Atropine 1% Atropine Diluted (0.5%, 0.1%, 0.02%, 0.01%) Custom compounding Pirenzepine not available in US Photo from Singapore

32 Atropine 1% non-specific muscarinic receptor antagonist anti-myopia effect is based in the retina/choroid. Exact mechanism unknown Studies show 90% reduction in myopia progression Significant side effects Near Blur and Photophobia Concern for rebound effects upon discontinuation Gong Q, et al. Efficacy and Adverse Effects of Atropine in Childhood Myopia: A Meta-analysis. JAMA Ophthalmol. doi: /jamaophthalmol Published online May 11, Pineles SL, et al. Atropine for the Prevention of Myopia Progression in Children. Ophthalmology. 2017;124:

33 Myopia Control with Atropine Results: 60-90% slowing of myopic progression with Atropine

34 Low-Dose Atropine (0.02% and 0.01%) Same mechanism of action Good control of myopia progression - refraction and AL 59% less myopic progression * Better long-term (5yr) MC than 1% + Max dosage without clinical symptoms 0.02% # * Chia A. Atropine for the Treatment of Childhood Myopia: Safety and Efficacy of 0.5%, 0.1%, and 0.01% Doses (Atropine for the Treatment of Myopia 2). Ophthalmology 2012;119: Chia A, et al. Five-Year Clinical Trial on Atropine for the Treatment of Myopia 2. Ophthalmology 2016;123: # Cooper J, et al. Maximum Atropine Dose Without Clinical Signs or Symptoms. Optom Vis Sci 2013;90:

35 ATOM 2 Atropine of various dosage ATOM 2 study 2 yr changes 0.5% 0.1% 0.01% Refractive change(d) -0.30± ± ±.63 Axial length change(mm) 0.27± ± ±.32 N=400, age 6-12, 2yrs with 0.5%, 0.1% and 0.01% Atropine Atropine 0.01% has minimal side effects compared with Atropine at 0.1% and 0.5%, and retains comparable efficacy in controlling myopia progression.

36 Myopia Control with Low-Dose Atropine Mean Age = 9.5yrs Mean baseline rx = Atropine 0.01% only -0.42D more myopia in 2 yrs Chia et al Placebo -1.25D more myopia in 2 yrs

37 Myopia Control with Low-Dose Atropine Over 5 yrs less myopic progression with 0.01% Atropine Chia et al. 2016

38 Prescribing Low-Dose Atropine Any age 3 and older Any amount of myopia or more Well-tolerated, very rare side-effects Patients not ready for OrthoK or soft MF Patients who do not want OrthoK or soft MF Can be combined with OrthoK or Soft MF Talking to patient and parents

39 Prescribing Low-Dose Atropine Prescribe 1 drop in each eye before bedtime Contact high-quality custom compounding pharmacy Send rx to pharmacy (Fax, or online) Pharmacy contacts parents for delivery and payment info Sterile formulation, delivered to patient Can be preserved or preservative-free (kept in refrig) Monitor rx and axial length every 6 months

40 Atropine Clinical Issues Low Dose Well-tolerated, very rare side effects Tapering If stopping, 1-2 month taper is recommended Every other night x 1 wk, every 3rd night x 1wk Question???? Can Atropine PREVENT myopia?

41 Atropine Rebound Rebound effect has been observed More rebound with 1.0% Tapering reduces rebound effect Minimal rebound with 0.01% AND tapering

42 Other Factors for Myopia Control Time Outdoors Increasing Outdoor Time Delays Onset of Myopia Once Myopia is present Increased Outdoor Time May Not Slow Progression Read SA, Collins MJ and Vincent SJ. Light Exposure and Physical Activity in Myopic and Emmetropic Children. Optom Vis Sci 2014;91: Shah RL, Huang Y, Guggenheim JA, et al. Time Outdoors at Specific Ages During Early Childhood and the Risk of Incident Myopia. Invest Ophthalmol Vis Sci. 2017;58: Xiong S, Sankarigurg P, Naduvilath, et al. Time Spent In Outdoor Activities In Relation To Myopia Prevention And Control: A Meta-analysis And Systematic Review. Acta Ophthalmol. 2017;95:

43 Myopia Control Summary Meta-Analysis-Efficacy of 16 methods Effective. Refraction Atropine, OrthoK Axial Length Atropine, OrthoK, Soft MF Optical Interventions all show individual variation Not Effective RGPs, Conventional SCL, Under-Correction, VT Huang, J, et al. Efficacy Comparison of 16 Interventions for Myopia Control in Children: A Network Meta-analysis. Ophthalmology 2016;123:

44 Summary Orthok Is Effective In Slowing Myopic Progression % Soft MF Lenses Slow Myopic Progression 30-70% Atropine Slows Myopic Progression 60-70% Increased Outdoor Time delays Onset of Myopia 1-2 hours/day

45 What to Do on Monday Talk To Your Patients/Parents About Myopia Prescribe OrthoK No Daytime Correction AND Myopia Management Prescribe Soft Multifocal Highest Add Tolerated Prescribe Low-Dose Atropine Any Age Until Ready For Orthok Or SCL MF Get Kids Outside!!

46 Grazie Merci -Thank You Gracias CnacЍϭo Dank Je Hvala Vam - Хвала вам -mulțumesc Michael J. Lipson OD FAAO FSLS University of Michigan Department of Ophthalmology and Visual Science Northville, MI, USA mjlipson@med.umich.edu