Round table: Pediatric ophthalmologists address ‘hot topic’ of stemming myopia progression

While studies are promising, availability, stability and duration of treatment still need to be addressed.

Issue: October 10, 2016

Robert S. Gold, MD: Our first topic is an extremely hot topic in pediatric ophthalmology today, and that is myopia: the disease process of myopia, the prevention of progression of myopia, and what treatment modalities we are willing to implement to address the issue. So this topic is pertinent. The first question is, are you currently treating in your practice with low-dose 0.1% atropine eye drops for select patients for myopic progression?

M. Edward Wilson, MD: I am currently not treating patients with it. At least one of my partners in practice is doing it through a compounding pharmacy. I am at the stage at which I have been discussing the current state of the art and all of the options and all of the evidence with the families who need to know this. I have not gotten to the point yet where I am prescribing it.

Rudolph S. Wagner, MD: No, I have not started to treat patients with it yet, although this year a lot of new information has come out and I will certainly start thinking about it. One thing that would make me hesitate is the availability of the medication. The atropine has to be prepared. You cannot get it from a local pharmacy. There is a mail-in pharmacy that provides it to 49 states, including New Jersey, where I am from. So if I wanted to get it, I could, but if it were more readily available and easier for the patients to get, I would certainly consider using it, especially the low dose.

Gold: One of my major concerns is cost. To my knowledge, atropine drops are not covered by insurance, they have to be compounded, and they are needed long term, even up to 2 years or more. So that is a concern of mine.

Scott E. Olitsky, MD: About 2 years ago we assigned one of our doctors to the role for exactly this purpose. If any one of us has a parent who is interested in atropine, the doctor meets with that parent and discusses the literature with them. To date, very few parents have opted to have their child treated, but at least we feel like they are getting all of the information.

Erin D. Stahl, MD: One of the things that is going to be a real challenge to pediatric ophthalmologists is the amount of chair time that it takes to talk about the studies, to talk about the long-term effects, to talk about what we know and what we don’t know. I feel like this model is helpful, that one person takes on the task and has longer appointments to do this. So you can bring up the topic and then refer them on, and have it taken care of outside of your busy clinic.

Gold: The message is that while studies are promising, availability, stability and the duration of treatment still need to be addressed.

Wilson: We would like to see testing done in a diverse population. We would really like to see a U.S. study. The studies have been in an Asian population, for the most part, Singapore and Taiwan.

Kenneth P. Cheng, MD: We just don’t know enough about the pathogenesis of myopia at this point. With all the use in Asia of atropine, especially low-dose atropine, it seems to be a safe enough treatment, and I have no problems starting to talk about it with patients. But there is so much that we don’t know about the genetics and the environmental factors that are in play. There was one study about sunlight exposure in children whose families had emigrated from Singapore to New Zealand. The children who adopted an Australian lifestyle of playing outside had less progression of myopia than the children who kept Asian tradition and Chinese school and long, long periods of reading.

On top of that, we don’t really know about the changing environment here in the United States. People are using more and more computer time and time in front of phones. The newest video displays put out significant amounts of blue wavelight energy, and that has potentially an effect on circadian rhythm. Whether that has some effect on growth of the eye, just like sunlight exposure, who knows? And, we are changing the kind of lightbulbs that we use in our houses that put out different light spectrums, so there is a huge difference in environment here.

It may be that some of these things explain some of this global explosion, or maybe the prevalence of myopia and the amount of myopia that people are developing may have nothing to do with it at all. There is so much we don’t know, and I agree that we really need to have good, controlled long-term studies and then look at effects and duration of treatment. We have no idea how long to treat these children.

Wilson: One more comment. The topic is timely. There is a lot of discussion about it; for example, the FDA requested a public workshop on the device side to educate themselves about whether they should be approving devices, contact lenses and such, specifically for the treatment of myopia. American Association for Pediatric Ophthalmology and Strabismus, Contact Lens Association of Ophthalmologists, American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery and two optometric groups, the American Optometric Association and the American Academy of Optometry, are all involved. It just shows you that this discussion is very timely.

Gold: So the question is, are you comfortable at the moment starting select patients on low-dose atropine for myopia?

Wagner: I would like to see more data, perhaps in diverse populations, before I proceed. For me, a lot rests on availability and cost. I would be much more willing to try it if it was more readily available and the cost was lower.

Olitsky: The short answer to your question is, yes, we are comfortable. The long answer is we are comfortable discussing it and having somebody who really keeps up with everything to be able to discuss that with parents who can ultimately make that decision. Because maybe 10 years from now we will realize it was the right thing to do, and we want to have had that conversation and let the parents have a hand in that decision.

Cheng: I think the point that Erin brought up is true. The real discussion with a parent is tremendously complicated. A lot of parents may pick up on the lay press saying we are going to reduce the progression of myopia, but there has been no evidence whatsoever to suggest to anybody that this reverses myopia.

Then if you look at the typical population in the United States, whose mom and dad are moderate myopes or maybe only one parent is a moderate myope, the chances of that child progressing to high myopia with posterior segment problems and risk for retinal detachment, just by the genetics of it, is very, very small. So, the real number of patients who would truly benefit in a substantial way from this treatment is probably fairly limited in most practices.

Now, if you have parents who are –8 D to –9 D and are Asian, then it is a whole other situation. That is probably a very good patient to think about treating or to discuss treatment with. But for the average run-of-the-mill patient I don’t think it is going to make that much difference. Is it really so important instead of being –5 D even coming out –2.5 D or –3 D? Yes, I would much rather be a –2 D or –3 D than a –5 D, but is it so important to embark upon years of treatment that we just really aren’t 100% sure about and that has significant costs? I don’t know.

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Stahl: From the refractive surgery side you can certainly make the argument that refractive surgery options will be different with different levels of myopia. Say you are a –7 D and you have the option of laser surgery vs. if you were a –9 D and your best options were intraocular.

Cheng: The time to treat them to prevent their progression is when they are little, not when they are already 12 or 13. So I think that we are talking about what type of refractive technology is going to be available 10 or 15 years from now, and that may be a whole other situation entirely that we just don’t know about.

Gold: And other unknowns are other treatment modalities. Orthokeratology has come on the forefront again. Bifocal contact lenses, for the blur, do they have an effect? And we know bifocals really don’t seem to work.

Wagner: One of the things talked about here [at the AAPOS meeting] was myopia correction at the periphery. With glasses or contact lenses, myopia is corrected centrally but at the periphery there is a hypermetropic refractive error. The theory is that if you can balance the peripheral gradient, the refractive error is corrected uniformly to the periphery, then you might reduce the progression of the myopia and modify the emmetropization processes. So, it makes some sense. I always wondered how could orthokeratology reduce the axial length, which some studies say that it does. I just assumed it was maybe just by flattening the cornea and getting a shorter measurement, but this, I guess, theoretically could be a way.

Wilson: The optics are complicated. The concept of relative peripheral hyperopia and accommodation errors, and things that might lead to problems with emmetropization, we need to learn more about that. And on the pharma side, we don’t really even know how dilute atropine works. These things need to be worked out before we can decide what the appropriate treatment is.

Cheng: If anybody here had a child or a grandchild who was 5 years old and –1 D, what would you do?

Gold: I would not put them on atropine at this point.

Wilson: I would send them outdoors to play. Take away their iPad for a few hours a day.

Stahl: I would add that I would watch them closely, and if they were progressing at 0.5 D to 1 D a year, then I would consider starting treatment.

Gold: I watched my son progress myopically to a –6 D and then at age 23 years he had LASIK, and he is very happy. So that is the other way to go.

For more information:
Kenneth P. Cheng, MD, can be reached at 100 Bradford Road, Suite 320, Wexford, PA 15090; email: kpchengmd@me.com.
Robert S. Gold, MD, can be reached at 790 Concourse Parkway South, Suite 200, Maitland, FL 32751; email: rsgeye@gmail.com.
Scott E. Olitsky, MD, can be reached at Children’s Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64108; email: seolitsky@cmh.edu.
Erin D. Stahl, MD, can be reached at Children’s Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64108; email: edstahl@cmh.edu.
Rudolph S. Wagner, MD, can be reached at Doctors Office Center, Suite 6100, P.O. Box 1709, Newark, NJ 07101; email: wagdoc@comcast.net.
M. Edward Wilson, MD, can be reached at Albert Florens Storm Eye Institute, 167 Ashley Ave., Charleston, SC 29425; email: wilsonme@musc.edu.

Disclosures: Stahl reports a financial interest in Treehouse Health. The other round table participants report no relevant financial disclosures.