Roundtable tackles pediatric myopia management, dichoptic treatments

Roundtable Participants

The question I have not learned to answer yet is, if a patient comes for their first visit with a diagnosis of myopia and they are –1 D, do we start treatment right away? First, it takes a lot of time to discuss. Second, if the parents have high myopia, it might be a good idea to start treatment right away. However, if the parents do not have any significant myopia, I am unsure if those patients need to be started on treatment right away. I don’t have that answer. I don’t think anybody does, and that is one of the things we want to learn. If the parents insist on treatment, I will do it. I think it is safe.

In my experience, MiSight works just as well as atropine, which initially surprised me. MiSight works great in Hispanic patients, which we did not know, and I am getting good results easily in the 85% range. What I don’t know is if I am having an effect on 2- and 3-year-olds who I have placed on atropine because they already have –4 D or –5 D. I am not harming the patient, but I don’t know if I am going to get results.

Gold: A quick comment on the –4 D cases. I think that is a different disease.

Warman: Yes, I agree.

Gold: I don’t know if the atropine is going to work in those particular cases, to tell you the truth.

Warman: It probably will not, but I am putting the kids on it because I want to learn and know.

Rudolph S. Wagner, MD: I am skewed toward the population that Dr. Warman described — kids coming in who are recent-onset myopes and have parents who are both high myopes. When I see those cases, I am more likely to offer atropine as a possibility for treatment. I think that is where you can do the most good, by preventing them from progressing like their parents. You don’t always know that, of course, but if you have two parents who are high myopes, you have a pretty good idea this is going to happen.

I have MiSight available as well, and I think it can be useful. MiSight takes a lot of explanation, and it is a little bit more expensive than the contact lenses that would be routinely used. If you explain why you want to use MiSight, they are more likely to use it. There are people who come in and will bring it up, so you don’t always have to. The ones who are aware of this treatment typically are concerned about progressive myopia in their family, and they are easily convinced to use something that makes sense scientifically like those lenses.

Gold: I am in a private practice. Sometimes in a private practice, these patients come in and they have seen an optometrist already, but they want another opinion. They may have been offered MiSight or orthokeratology. These discussions, wherever you are in practice, are lengthy. You cannot go in there and say, “Hi, I’m going to give your child atropine. It’s going to decrease myopia. Here is the prescription.” It does not work that way, at least in my practice.

I have an information sheet on myopia that includes the disease process and treatments. I will discuss with the parents whatever the refractive error is, give them a prescription for their glasses and say, “Here are your choices. Instead of making a decision right now, go home and talk about it, and then give us a call.” I give them a different line to call. I ask if they are interested in doing one of these treatments, whether it is atropine or MiSight, if they are a candidate. That gives parents an opportunity to think about it and not have to make a decision on the spot.

If it is a very mild myope, I will not necessarily start them on anything at first. I say, “Let’s watch this. I’ll see you back in 6 months, and if it gets worse, I will start treatment.” There are a lot of people who do not like that. They will say, “They are nearsighted. You have to treat them right away.” That is another opinion that is a little more aggressive, but there are many ways to do this, and I don’t think any of the ways are wrong.

M. Edward Wilson, MD: For those of us who are in large departments, patient discussions are a big deal, and so we have people who are willing to spend the time with these patients. When I see a myope who, for example, I saw last year and their glasses have increased, I talk about the 20-20-20 rule. Every 20 minutes, look at a target at least 20 feet away for 20 seconds. Spend time outdoors. Then I say, “I’m sure you’ve heard about other treatments. If you’d like to learn more, there are folks in our department who will spend as much time as necessary to make sure you make the right choice for your child.” Then, fortunately, I can move them onto someone who is dedicated and can spend the time to give the parents what they need.

Gold: Good point. I think that is the difference with academia. You have people on your staff who can do that. If you are in a private practice situation, you have to adapt accordingly when you receive those phone calls from the parents or you have that discussion in the room. But I have found that these discussions are longer than strabismus surgery consent. This has become such a prevalent topic. These discussions can take 20 to 30 minutes of your time. I have tried to make it as palatable and positive as possible for the parents.

Wagner: Be prepared for the onslaught of patients because the CHAMP study is in phase 3 and had its data submitted for FDA approval. If the approval of NVK002 (Vyluma) goes through, it is going to bring more media attention to myopia, and there will be more patients than ever having an interest in it.

Douglas R. Fredrick, MD, FAAP: We made a video on the terms and conditions that we play while patients are dilating, and it answers a lot of questions. It kills time, and they get to learn about the American Association for Pediatric Ophthalmology and Strabismus. It is a little more in depth than the American Academy of Ophthalmology’s video but not too much for them to digest.

For the entire Kaiser system in northern and southern California, which is more than 4 million people, we have one compounding pharmacy, and everybody gets 0.05% atropine for a $5 copay. What we are a little bit worried about is what will happen when NVK002 gets approved. If something is FDA approved, I don’t know whether you can prescribe a compounded medicine with the inherent liabilities. That is going to be difficult for the institution because right now 20% of Kaiser patients are on Medicaid. They are under California Care, which I did not know previously. I thought Kaiser was all private insurance, as people work for companies such as Facebook and Google. However, there are a lot of people who take the government option, and we have a lot of kids on atropine. I think there will be interesting challenges coming.

Dichoptic treatments

Gold: There has been some discussion about performing amblyopia treatment with new dichoptic devices.

Warman: I have been exposed to both Luminopia (Luminopia) and CureSight (NovaSight). I was involved with Luminopia for one of the early pilot studies. However, one disadvantage was that I did not have the best virtual reality set at that time.

I also was one of the early adopters of CureSight. I have four patients using it right now, before it rolls out, and I am starting to get my early results back. I do limit it at the present time to patients who are noncompliant and frustrated with standard treatments.

When we offer CureSight, patients typically sound enthusiastic at first. However, for both Luminopia and CureSight, I found that neither option is a panacea. We have noncompliance for different reasons. One reason is that patients sometimes believe it is too long — 1.5 hours a day — to watch the videos. Or the child will look above the glasses because it is easier instead of looking through them. The parents cannot always be around to help because these are parents who also were not very good at compliance before.

It may be too soon for these dichoptic treatments. They are not the future of amblyopia treatment, at least not at the present time. I am not against these dichoptic treatments, but I am also not that impressed. If I have a patient who comes in with significant amblyopia and they are already 5 or 6 years old, I am not going to start with any of those treatments. I am going to go with my old-fashioned patching. I know patching works.

Fredrick: I have not yet used either dichoptic option. In the Kaiser system, we are debating how to integrate these treatments. Kaiser is protective of its electronic health record, so sharing information about the video with the patient through the EHR might be a nonstarter, at least with CureSight. Dr. Warman, shouldn’t it give you information through the EHR, or am I wrong about that?

Warman: Yes, they are monitoring everything.

Fredrick: I think all of us agree that people want technology. Personally, I don’t think I would use it as a first-line treatment. I would use it when our regular mousetrap, which we know works, fails. I am curious about how other academic institutions are going to use these treatments. Whether or not you have orthoptists who are going to manage this or if pediatric optometrists are going to be the ones managing it, it is going to be time intensive.

Wagner: I have not used these treatments personally, but I am aware of the studies. At the AAPOS meeting, one of the conclusions from one of the companies was that dichoptic treatment was the equivalent of occlusion therapy.

Gold: Our practice was one of the clinical sites for Luminopia. You have to pick the right patients. I think that is the key. It is not right for everyone. There are some kids who enjoy using both of them who have been more than likely noncompliant. You need to pick the right people and then see where it goes.

Wilson: Look at the progress they have made from the initial studies. It is up to the point where dichoptic treatments may work as well as patching. This shows us that, as these gaming experts get into this and make it better and better, these dichoptic treatments are probably going to be the future. It is going to take over patching eventually. Now, it does not necessarily have better outcomes. It will just be more fun for the kids, and we have been looking to have something to replace a patch for decades. We are not there yet, but we are making some strong progress in that direction.

• References:
• Holden BA, et al. Ophthalmology. 2016;doi:10.1016/j.ophtha.2016.01.006.
• Warman R, et al. Low-dose atropine vs peripheral defocus soft contact lenses for myopia control. Presented at: American Association for Pediatric Ophthalmology and Strabismus; March 29-April 2, 2023; New York.

• For more information:
• Douglas R. Fredrick, MD, of Kaiser Permanente South San Francisco, can be reached at douglas.r.fredrick@kp.org.
• Robert S. Gold, MD, of Eye Physicians of Central Florida, can be reached at rsgeye@gmail.com.
• Rudolph S. Wagner, MD, of Rutgers New Jersey Medical School, can be reached at r.s.wagner@rutgers.edu.
• Roberto Warman, MD, of Miami Children’s Hospital, can be reached at rwarman@eyes4kids.com.
• M. Edward Wilson, MD, of Storm Eye Institute, Medical University of South Carolina, can be reached at wilsonme@musc.edu.