Myopia progression:can we prevent it?

Fusion 2012 LVPEILionel Kowal

Melbourne

MECHANISM OF MYOPIA PROGRESSION

Number & complexity of proposed explanations for myopia genesis &

progression relates to the imagination of the investigators

Number of trials to try decrease the Rate Of Myopia Progression* has been

exceeded only by their ingenuity

* ROMP = Rate Of Myopia Progression

Why I have trouble assessing the literature 1: measuring myopiaWhen I refract a patient before or after

cyclopentolate I often have trouble determining the endpoint precisely either with retinoscope or subjectively

I think that ±0.25 DS is ambitious for some patients & Drs, & ± 0.5 DS is more realistic

This potential error rate not considered by most authors

I always do an autorefractor measurment – it is sometimes not reliable in my office yet is often relied on in published studies!

APPARENTLY EXCELLENT RESULT

MyopiaDS

AGE

CONTROL

TREATMENT

Why I have trouble assessing the literature 2: WHAT IS A GOOD RESULT?

EXCELLENT RESULT MUST HAVE FOLLOW UP

MyopiaDS

AGE

CONTROL

NEW RATE

TREATMENT STOPPED

AFTER STOPPING Rx, ROMP* @ ‘NEW’ [LOWER] RATE

* ROMP = Rate Of Myopia Progression

SIMULATED EXCELLENT RESULT-1MUST HAVE FOLLOW UP

MyopiaDS

AGE

CONTROL

CATCH UP ON STOPPING Rx

STOP TREATMENT

MyopiaDS

AGE

CONTROL

AFTER STOPPING Rx, ROMP @ ‘OLD’ [control] RATE

TREATMENT STOPPED

OLD RATE

SIMULATED EXCELLENT RESULT- 2MUST HAVE FOLLOW UP

SIMULATED EXCELLENT RESULT-3

MyopiaDS

AGE

CONTROL

CATCH UP

SLOWS MYOPIC PROGRESSION

Rx SLOWS ROMP. MYOPIA CATCHES UP DESPITE CONTINUING / AFTER STOPPING Rx

WHAT WE NEED TO KNOW IN A TRIAL TO REDUCE ROMP

1. CONTROL GROUP2. DURATION OF TREATMENT

3. DURATION OF FOLLOW UP

4. DATA AFTER TREATMENT STOPPED

What works to reduce the rate of myopia progressionAtropine 1%

~30 papers since 1973 show efficacy≥2 have long term follow up after cessation

of dropsCatch up is small, still < untreated group> 100 years of atropine use in ophthalmologyNO reported cases of UV toxicity etc

Atropine 1%In Singapore it's too hot to spend much time outdoors

in the sunshine.  In Sydney I offer the drops to those Asian Aussies who

spend most of their time indoors studying.  These kids tolerate it very well.

 I've had only one kid out of hundreds who stopped the drops because of glare.   

I don't offer it to the "bronze" Anglo-Aussies who spend a lot of time outdoors and don't overdo the close work.  

Stephen Hing | Ophthalmologist Westmead Children’s hospital

What probably works to reduce ROMP

Atropine 0.01%In Press in ‘Ophthalmology’ from Singapore2y result ≈ 1% Atropine NO side

effectsIf long term follow up is +ve, this will

probably become routine treatment

0.01% Atropine ATOM2 study 1Atropine for the Treatment of Myopia 1 (ATOM1): 1% effective in controlling ROMP but side effects

from cycloplegia & mydriasis. ATOM2 : compare efficacy / side effects of 0.5%,

0.1%, & 0.01%.400 children aged 6 –12, myopia ≥ -2.0D &

astigmatism ≤-1.5D ….randomly assigned to 0.5%, 0.1%, and 0.01%, once nightly R&L for 2y.

Cycloplegic refraction, axial length, accommodation amplitude, pupil diameter, and acuity at baseline, 2w, then every 4 mo for 2y.

0.01% Atropine ATOM2 study 2

Main Outcome: Myopia & axial length progression at 2y ROMP at 2y was -0.30±0.60, -

0.38±0.60, and -0.49±0.63 D in the 0.5%, 0.1%, & 0.01% groups, respectively

ROMP in ATOM1: placebo: -1.20±0.69 D; 1% : -

0.28±0.92 D.

0.01% Atropine ATOM2 study 3 Axial Length increase 0.27±0.25, 0.28±0.28,

and 0.41±0.32 mm in the 0.5%, 0.1%, and 0.01% groups

..differences in myopia progression (0.19 D) and axial length change (0.14 mm) between groups were clinically insignificant

0.01% : negligible effect on accommodation, pupil size, and no effect on near visual acuity.

0.01% has minimal side effects c.f. 0.1% and 0.5%, and is nearly as effective in controlling myopia progression.

OLD OPTICAL TREATMENTS TO REDUCE ROMP

1.↓duration of spectacle wear2. planned under correction2. Bifocals / PALs3. contact lenses / orthoK

…NO repeatable positive clinically significant effect

NEW OPTICAL TREATMENTS TO REDUCE ROMP

NEW 1: Relatively hyperopic PERIPHERAL REFRACTION may stimulate myopia and myopic progressionPubMed: Myopia Peripheral Refraction 181 references

NEW 2: Bifocals with prisms

NEW 3: Spectacle Monovision

Eye Shape and Refraction Model

Myope.More Prolate shapeRelatively hyperopic peripherySimple minus lens correction can trigger further axial

elongation

Emmetrope.Oblate shapeRelatively myopic in the peripheryAppears to have a stable refraction

Wallman & Winawer 2004 Slide from Prof E Howell

Zeiss Myovision lenses

Myovision

‘ ....I assume you are referring to the published paper in September [2010]   Optometry & Vision Science.

You are reading it correctly, in  that the data does not support any significant effect in reducing  myopia progression. ......’

Peripheral Correction HypothesisThe relatively hyperopic trend in

the periphery would require over-plus ‘correction’ to stabilise the refraction while a minus correction is required for the central myopia

Multi-focal glasses? Only plus in the lower field Leung & Brown 1999, Gwiazda et al 2005

Multi-focal contact lenses? Aller 2004, 2006

Australia: Cooper Proclear ‘D’ soft disposable daily wear contact lenses

Minus centre / Plus surround +1.50 D add

Slide from Prof E Howell

CLs & Peripheral refraction IOVSDec 2011Decrease in rate of myopia progression with a contact lens designed to reduce relative peripheral hyperopia: one-year results.

Sankaridurg P, Holden B, Smith E 3rd, Naduvilath T, Chen X, de la Jara PL, Martinez A, Kwan J, Ho A, Frick K, Ge J.

Brien Holden Vision Institute, Sydney, Australia.

ROMP -0.57 D/y in treatment group = placebo group in ATOM1 .

NEW 2: bifocals with BO prismsArch Ophthalmol. 2010 Jan;128(1):12-9.

Randomized trial of effect of bifocal and prismatic bifocal spectacles on myopic progression: two-year results.

Cheng D, Schmid KL, Woo GC, Drobe B

Been and gonePirenzepine Novartis didn’t proceed

Ocular hypotensivesSome papers in 70’s-80’s

MYOPIA1. Major personal / societal problem

MYOPIA2. Convincing EARLY data on ↓ ROMP with Atropine 0.01% . I now offer it to all myopes who fit the ATOM2 criteria

MYOPIA3. ? Genetic segregation first & repeat optical and drug studies