Practical Myopia Management for the Busy Optometrist

Maria K. Walker, OD, MS, FAAO

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United States: ~45% prevalence

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Theophanous C, et al. Myopia Prevalence and risk factors in children. Clin Ophthalmol. 2018;12:1581-1587.2Vitale S, et al. Prevalence of refractive error in the United States, 1999-2004. Arch Ophthalmol. 2008;126(8):1111–9. Holden BA et al. Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050. Ophthalmology. 2016;123(5):1036–42.

96.5% myopia at age 19

>80% myopia at age 18

Current worldwide prevalence:22%

Est. prevalence in 2050:44%

2050 Projection:

5 Billion people with myopia

1 Billion people with PATHOLOGIC myopia

Pathologic or Degenerative Myopia

Axial length >26.5 (26) mm or myopia >6 DAssociated with several pathologies

Glaucoma, cataracts, retinal tears/detachments, CNV, macular atrophy, choroidal degeneration, and more

2% worldwide currentlyest. to be 10% worldwide in 2050 (~1 billion people)

Glaucoma

http://www.aao.org/eyenet/article/myopia-glaucoma-sorting-out-diagnosis

http://www.retinalphysician.com/articleviewer.aspx?articleID=105386

Choroidal Neovascularization

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Retinal Detachment

Glaucoma

Myopic Retinal Degeneration

https://www.specsavers-spectrum.com/profile-journal/drp-myopic-degeneration/

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Hayashi, K. et al. (2010) ‘Long-term Pattern of Progression of Myopic Maculopathy A Natural History Study’, Ophthalmology, 117, pp. 1595–1611. Ikuno, Y. Overview of the complications of high myopia. Retina, 37(12), pp. 2347–2351. 2010.Linsenmeier, R. A. and Padnick-Silver, L. Metabolic dependence of photoreceptors on the choroid in the normal and detached retina’, IOVS, 41(10), pp. 3117–3123. 2000. Pierro, L. et al. Peripheral retinal changes and axial myopia. Retina, 12(1), pp. 7–12. 1992.

Choroidal Neovascularization

Cataract

Myopic CNV

http://www.retinalphysician.com/articleviewer.aspx?articleID=105386

http://www.eyeworld.org/article-honing-in-on-refractive-error-and-long-term-incidence-of-cataract

Dr. Alex P Hunyor, MD. http://imagebank.asrs.org/file/3094/myopic-cnv

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Avila, M. et al. (1984) ‘Natural history of choroidal neovascularization in degenerative myopia.’, Ophthalmology, 91(12), pp. 1573–1581.Cohen, S. Y. et al. (1996) Etiology of Choroidal Neovascularization in Young Patients, Ophthalmology.Neuhann, I. M. et al. (2008) ‘Retinal detachment after phacoemulsification in high myopia: Analysis of 2356 cases’, J Cataract Refract Surg, 34, pp. 1644–1657. Yoshida, T. et al. (2003) ‘Myopic Choroidal Neovascularization A 10-year Follow-up’, Ophthalmology, 110, pp. 1297–1305. Pan, C.-W. et al. ‘Myopia and Age-Related Cataract: A Systematic Review and Meta-analysis’.

Theories of Myopic

Progression

- 5x increased risk with myopic parents- Over 20 genes identified

- Near work- Lack of ”horizon” viewing- Light levels

- Undercorrection- Lag of accom.

- Near work- Image shell in specs

Protective Hormones?- Dopamine- Vitamin D

9FlitcroftDI. The complex interactions of retinal, optical and environmental factors in myopia aetiology. Prog Retin Eye Res. 2012; 31(6):622-60.

Full Circle Myopia Management

• Treatment• Sibling risks• Risks/Protective

factors

• Monitor tx efficacy• Modify and add

treatments

• Contact Lenses• Spectacles• Therapeutics

• Refraction (wet)• Axial Length• Progression risks

Detect Treat

EducateManage

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Full Circle Myopia Management

• Ref raction (wet)

• Axial Length

• Progression risks

Detect

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Normative Data

Pediatric Norms:

Infants: approx +2.00D

3-5 yo: emmetropization

May have +1D at 5yo

6-16 yo: slight myopic shift

12Mayer et al. Cycloplegic refractions in healthy children aged 1 through 48 months. Arch Ophthalmol. 119. Nov 2001. 1625-1628.

Normative DataPediatric Norms:

Infants: 19-21 mm

3-5 yo: 21-22 mm

6 yo: 22 – 22.75 mm

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Bach A et al. Axial length development in children. Int J Ophthalmol. 12(5): 815-819

What about light levels?

Associated with reducing myopia incidence (even those with high amount of near work)

Physical activity not necessary

Directsunlight also not necessary

Recommend 8-15 hours of outdoor activity per week

Does notprotect against progression

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What about near work?

greater near work may influence development and progression of myopia (36,37,39 in IMI)

Close reading (less than 20cm)

Continuous reading (greater than 45 min)

Note: great amount of outdoor activity and high levels of near work reduced incidence

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Clinical Guidelines

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Standard Procedure for Myopia Exam

HistoryAge, sex, ocular health, surgery, general health and FHx

Onset of myopia, history of myopic progression, prev. treatments

RefractionCycloplegic – recommended dosage is two drops 1% tropicamide or cyclopentolate, 5 minutes apart. Perform refraction after 30 mins.

Anterior ocular health evaluationFundus examination

Appearance of chorioretinal atrophy, staphyloma, PPA, tilted discs

1. Gifford KL, Richdale K, Kang P et al. IMI – Clinical Management Guidelines Report. IOVS (2019) 60(3): M184-M203 17

Standard Procedure for Myopia Exam

Specialized refractionBinocular vision testingCorneal topographyAxial length

1. Gifford KL, Richdale K, Kang P et al. IMI – Clinical Management Guidelines Report. IOVS (2019) 60(3): M184-M203 18

Refraction

• Wet vs. dry• Wet refraction = Rx?• Be careful: do not solely rely on refraction!

19Gaurisankar ZS et al. Correlations between ocular biometrics and refractive error: A systematic review and meta-analysis. Acta Ophthalmol. 2019;97(8):735–43.

Axial Length MeasurementsWhat are we actually measuring?

How accurate is it?

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The “true” Axial Length

Don’t fall subject to the ASSUMPTIONS of sound and light

MRIEnucleation

Clearly not practical techniques (nor necessary)

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Precision and Accuracy

• Precision (repeatability): How close is measurement “a” to measurement “b”?• Accuracy / Validity: Is the device giving an accurate (correct, true) measurement?

• Correlation: How well can we predict the measurement of one instrument by knowing another?

A precise and repeatable instrument is needed for myopia

management

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R.E. change Predicted AL Change Actual AL Change

-1.50 -0.37 x 005 0.45 mm 0.22 mm

-3.25 - 0.62 x 165 1.15 mm .12 mm

Patient 1

Patient 2

Patient 3

R.E. change Predicted AL Change Actual AL Change

+0.37 -0.87 x 180 0 mm 0.18 mm

+0.25 -0.62 x 005 0 mm 0.18 mm

R.E. change Predicted AL Change Actual AL Change

-0.50 -1.50 x 013 0.37 mm 0.85 mm

-0.50 -1.00 x 170 0.30 mm 0.91 mm

Axial Length: Primary Outcome for monitoring myopic progression

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Ultrasound

Highly repeatable & precise

Somewhat dependent on eye position

Longer acquisition time

Practicality not always best for kids

Contact

Longer acquisition time

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Interferometry

Lenstar (Haag-Streit)

IOL Master 500 & 700 (Zeiss)

Pentacam AXL (Oculus)

OA-2000 (Tomey)

AL-Scan (Nidek)

OCT-B

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Interferometry vs. Ultrasound

Wang X, et al. Comparison axial length measurements from three biometric instruments in high myopia. Int J Ophthalmol. 9(6). 2016.

Ultrasound consistently measures shorter than interferometry

No change in MAGNITUDE of difference in normal eyes or high myopia

0.24mm shorter

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IOL Master 700

Axial length

Keratometry

Refraction calculations

Designed for cataract surgery

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Technology Alert: Tomey OA 2000

PupillometerKeratometerBiometer (axial length)Pachymeter

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Technology Alert:

PentacamAXL

• Tomography & all features of Pentacam• Axial length

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Technology Alert:

Myopia Master

Axial lengthRefraction (pupil diameter)Corneal CurvatureCalculates risk of myopia & has customizable “take home” report

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Comparing New Technology with Established Technology

• IOL Master 500 vs. 700: mean difference of 0.008 mm

• IOL Master 500 vs. Pentacam AXL: difference of 0.026 mm

• Similar repeatability between all of them

• Take home: compare instrument to standard instruments prior to purchase

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More…

Take home: use the methodology that best fits your practice, and use it consistently

Lipson MJ. Axial length measurement: PalmScan versus IOLMaster. ECL 2015 May; 42(3).Yeu E. Agreement of ocular biometry measurements between 2 biometers. J Cataract Refract Surg. 2019 Aug;45(8): 1130-1134.Guler E, et al. Comparison of a new optical biometry with an optical low-coherence reflectometry for ocular biometry. CLAE 2016 Oct;39(5):336-41

PalmScan portable ultrasound - good correlation to IOLMaster1

Aladdin biometer (interferometry) - good correlation to Lenstar2

OCT biometry (B-OCT) - good correlation to Lenstar3

Several other customized systems (research)

Is that it? Do we need to consider anything else?

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The Choroid Effect

Temporal thickening of choroid: artificially “shorter” measurements

All myopia control methods can cause acute choroidal thickening

Choroid has diurnal variation in thickness

Burfield HJ, Patel NB, Ostrin, LA. Ocular biometric diurnal rhythms in emmetropic and myopic adults. IOVS 2018. 10:59(12:5176-5187

Tip: Take consistent time of day measurementsDevelop a consistent protocol for measuring AL

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Accommodation Effect

Greater accommodation leads to greater AL measurement

Read SA, et al. Axial length changes during accommodation in myopes and emmetropes. OVS. 87 (9). Sept 2010.Drexler W, et al. Eye elongation during accommodation in humans: differences between emmetropes and myopes. IOVS. 1998;39:2140–7.

Cycloplegia matters with axial length measurement (not just refraction!)

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Binocular Vision Assessment: Accommodation

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Binocular Vision Assessment: Versions

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Ancillary Technology for Myopia

ManagementPupillometry

Accommodative Testing

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Ancillary Technology for Myopia Management

•Aberrometry• Role in myopia progression?• Role in CL management?

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Calculating Risk • Age of onset

• Independent of sex, ethnicity, school, reading time, parents

• …so early myopes are high risk regardless

• Parents (3x w/2 parents)

• Outdoor time, close reading distance

• Ethnicity • Asians > European & African descent

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Jiang X, Tarczy-HornochK, Cotter SA, et al. Association of Parental Myopia With Higher Risk of Myopia Among Multiethnic Children Before School Age. JAMA ophthalmology 2020. Liang CL, Yen E, Su JY, et al. Impact of family history of high myopia on level and onset of myopia. IOVS. 2004;45(10):3446-52. Zhang X, Qu X, Zhou X. Association between parental myopia and the risk of myopia in a child. Exp Ther Med. 2015;9(6):2420-28. MuttiDO, et al. Parental myopia, near work, school achievement, and children's refractive error. IOVS. 2002;43(12):3633-40.

PARENT EDUCATION: GLOBAL MYOPIA CENTER

https://globalmyopiacentre.org/

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PARENT EDUCATION: GLOBAL MYOPIA CENTER

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Full Circle Myopia Management

• Contact Lenses

• Spectacles

• Therapeutics

Treat

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Contact LensesContact lens trends for MC in 2018

J. Nichols, CL Spectrum. Jan 201943

THE BIRTH OF THE MC THEORY

44Smith EL III. Prentice Award Lecture 2010: a case for peripheral optical treatment strategies for myopia. Optom Vis Sci. 2011;88:1029–44.

Single Vision specs/CL

45Image courtesy of Patrick Caroline

Peripheral refraction

The Journal of Optometry 2009

Ravi Bakaraju, Klaus Ehrmann, Eric Papas, Arthur Ho

Vision Cooperative Research Center, Sydney Australia 46

Image courtesy of Patrick Caroline47

Optical Designs of Myopia Management contact lenses

Concentric ring (bifocal) designs

Progressive power (peripheral add) designs

Orthokeratology designs

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Soft CL for Myopia

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Soft Contact Lenses:Myopia Management

Lens Brand Optical Design Replacement Disadvantages Advantages Highest ADD

available

Naturalvue(Visioneering)

Progressive power Daily Comfort/Vision Disposable

Specialeyes MF (Specialeyes)

Center distance

(Concentric ring)

Quarterly Replacement

Highly customizable

Not commercially available

Biofinity D MF(CooperVision) Monthly Replacement Availability

ProclearD MF(CooperVision) Monthly Replacement Availability

Toric Available

MiSight(CooperVision) Daily ?? FDA Approved

Disposable

Highest commercially available ADD: +4.00

CUSTOM SOFT MF

Optic Zone Size

Optic Zone Centration51

FITTING ORTHO-K

• Beware of asymmetric treatment zones due to toricity.

• May need toric / dual-axis ortho-k lenses for max treatment

• 20um difference (elevation) between major meridians: think dual axis!

52Jiang et al. Comparison of toric and spherical orthokeratology lenses in patients with astigmatism. J Ophthalmol. 2019 Feb 20;2019:4275269.

SPHERICAL VS. TORIC

Spherical Ortho-K Toric Ortho-K

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Contact LensesContact lens trends for MC in 2018

J. Nichols, CL Spectrum. Jan 2019

Low to high myopes with

minimal astigmatism

Low/Moderate myopes with

minimal astigmatism

High myopes with high astigmatism

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Spectacles: MyoVision

• 203 Japanese children• 2 years

• -1.43D with MyoVision• -1.39 with SV control

Study could not verify treatment effect

Spectacles: DIMS lens(Defocus Incorporated Multiple Segments)

• 160 Chinese children• 2-years

• -0.41D in DIMS• -0.85 with SV

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AtropineAtropine 0.025 or 0.05%- minimal side effects compared with 1% atropine - dosed 1gtt OU at night before bed- minimal mydriasis and near complaints - LAMP study

Atropine 0.01%- Only if adjunctive therapy

Combined therapy?

57Yam JC et al. Two-year clinical trial of the low-concentration atropine for myopia progression (LAMP) Study: Phase 2 report. Ophthalmology. 2020 Jul;127(7):910-919.

“Contact lenses to slow progression of myopia”Padmaja Sankaridurg. Clin Exp Optom 2017. 100:432-437.

Several factors will affect treatment decision

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CHOOSING A MODALITYWhat would you choose?

Spectacle Rx Orthokeratology Soft Multifocal Daily wear GP

‐1.00DS

‐2.50‐1.00x180

‐9.00DS

‐4.00‐3.75x110

‐0.50‐2.00x180

‐3.00DS

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Full Circle Myopia Management

• Treatment

• Sibl ing risks

• Risks/ Protective factors

Educate

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Eyeglasses

Nearsightedness

Vision

Contact Lenses

Bifocals

Myopia controlX61

Simplified Parent Education

Myopia is genetic• Risk increases with 1 or 2 myopic

parents• Darwinian theory

Environmental Risks• Less time outdoors• More near work demands• Refractive correction

Genetics

Environment

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Parent & Patient EducationUse of Electronic Devices

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PATIENT EDUCATION

• Starts in the waiting room• Videos• Literature (pamphlets)• Posters

• Identification of candidates and distribution of educational materials - by the doctor!

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Kids Education

Design colorful, fun directional information

Educate children and parents differently

Make it FUN!65

Myopia Swag

Eyecare “Goody Bag”

CL/Glasses solutions & cases

Do’s and Don’t worksheet

Replacement schedule stickers

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Contact Lens safety in children

Bottom line: minimal adverse events…But always use caution and provide

verbal and written instruction

67Chalmers RL, Wagner H, Mitchell GL, et al. Age and other risk factors for corneal infiltrative and inflammatory events in young soft contact lens wearers from the Contact Lens Assessment in Youth (CLAY) study. Invest Ophthalmol Vis Sci. 2011;52(9):6690-6696. Published 2011 Aug 24. doi:10.1167/iovs.10-7018

Dent Estet 4 KidsRomania

The Patient & Family Experience

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The Patient & Family Experience

Bayt Abdullah Children’sKuwait

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Ramp up your webpage

http://videre-eyecare.com.sg/our-services/myopia-management/70

Patient Information ChecklistVideos, Posters, Interactive Models

Pamplets, Myopia education materials

Written instructions & contracts

Patient “goodie bags”

Parent resource sheet

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Full Circle Myopia Management

• Monitor tx eff icacy

• Modify and add treatments

Manage

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Meaningful Progression?

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Meaningful Progression?

4/3/17: 24.18 ODand 24.29 OS3/12/18: 24.48 ODand 24.63 OS (approx 0.3mm oU)Factors: change in length AND total length (and age)

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Full Circle Myopia Management

• Treatment• Sibling risks• Risks/Protective

factors

• Monitor tx efficacy• Modify and add

treatments

• Contact Lenses• Spectacles• Therapeutics

• Refraction (wet)• Axial Length• Progression risks

Detect Treat

EducateManage

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Sequence of Exams

Comprehensive Exam: separate, (+)insurance

MC1: initial exam (private pay)Dry and wet AR & subjective refractionAxial lengthCorneal topographySelection of myopia control treatment (with follow-up exams as needed)

MC2: 6-month exam (private pay)Dry AR & subjective refractionAxial lengthCorneal topography (prn)*modification of treatment strategy as needed

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Materials

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Stay connected• Become a member of the International Myopia Institute

• Vision by Design (annual conference)

• Online resources

• www.myopiainstitute.ORG

• www.treehouseeyes.com

• www.calculator.brienholdenvision.org

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clinicaltrials.gov

10+ studies on Atropine

10+ studies on soft CL

10+ studies on Ortho-K

10+ studies on spectacles

Observational, environmental (lighting), genetic, surgical studies…

563 registered clinical trials on myopia

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Summary of Myopia Management

Know the science

Treat

Educate

Keep it simple & fun

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The Future

COVID-19: where does the myopia management patient stand?

Telemedicine and myopia management?

Axial length measurements – at home?

Refractive telemedicine is already here

Activity monitoring

Risk assessment! https://www.bernell.com/product/BCPHSHIELD/Disinfection-Prevention

http://www.actigraphy.com/solutions/actiwatch/actiwatch2.html

thank you!82