Speaker: Create a new protocol for myopia control

Pam Lowe

NEW YORK – Myopia is a disease, not a refractive error, and it is at epidemic proportions, Pam Lowe, OD, said here at Vision Expo East.

“Myopia is a new disease; we have to create a new protocol,” she said.

“By 2050 there will be almost 5 billion myopes, with 1 billion high myopes,” Lowe continued.

High myopes, which she defined as -5 D or higher, are at increased risk for conditions such as age-related macular degeneration, retinal detachment, glaucoma and cataract.

Lowe said risk factors include family history, ethnicity, age of onset, activities, gender and family history.

A child’s risk of high myopia often depends on age of myopia onset, she said.

In addition, “Once a child becomes myopic, that progression of 1 D or more a year puts them in a high-risk group,” she said.

Delaying the onset of myopia is a crucial approach, Lowe said.

“I have a patient who is -7.50 D, and now she has children; I’m going to start educating her on what she can do to prevent onset in her children,” she said. “You can’t fight genetics, but if you can reduce the amount of myopia that someone is destined to get, you can avoid the risks associated with high myopia.

“We know time spent outdoors is beneficial before you become myopic,” Lowe continued. However, what children do outside is important.

“They have to be doing something besides just sitting out there,” she said. “Basketball is a great activity. It’s a built-in peripheral defocus.”

Time spent performing close vision tasks is also a factor, Lowe said.

“It’s all about working distance, too,” she said. “Kids tend to bring things closer. If it’s less than 25 cm, the risk is greater even for under an hour.”

Lowe said she talks to parents who have myopia about these things if they have young children.

“If they’re esotropic or have a high lag of accommodation, those binocular vision disorders put kids at greater risk,” she added.

Lowe said the “jury is still out” on whether gender matters when it comes to myopia.

Treatments that have been proven to be ineffective for myopia control include single vision spectacles, single vision alignment gas-permeable lenses and multifocal spectacles.

However, “atropine definitely works,” she said.

A lose dose of atropine, 0.01%, instilled at bedtime, reduces refractive error, but axial length only slightly, she said. Orthokeratology (ortho-K) slows axial length, multifocal contact lenses slow axial length and refractive error about equally, and multifocal spectacles slow refractive error and axial length slightly.

Distance center multifocal soft contact lenses “take the strain off of anyone who has a lag of accommodation or vergence problem,” Lowe explained. “Ortho-K puts peripheral defocus on the retina and helps the eye be stimulated to not grow longer.”

Lowe said a new distance center hybrid lens is coming out for patients with a higher cylinder.

“It has a rigid center and distance center multifocal design with a soft skirt,” she said. “It’s another tool.”

The extended depth of focus (center distance) multifocal soft contact lens, NaturalVue Multifocal 1 Day Contact Lenses by Visioneering Technologies Inc., is available now, Lowe said.

CooperVision’s MiSight is not yet FDA-approved.

She noted that a risk of a distance center soft lens is possible aberrations from the multifocal design decreasing the distance visual acuity.

Lowe provided tips for fitting these lenses: “You go with your spherical equivalent at distance, start with the highest add, create peripheral defocus as much as you can. Then I see how they’re seeing. Overrefract to a comfortable distance visual acuity, but do not change the add; it helps with peripheral defocus.

“At the 1-week follow-up address any distance blur, especially in older children,” she continued. “Assess comfort and fit. Do not change the add unless you have to.”

Ortho-K is “more complicated,” Lowe said.

“In my office this is a higher fee; there are more visits, it’s more involved, the lenses cost more,” she said. “You have to have a topographer; you have to track the epithelium you’re moving.”

Patients must be followed at 1 day (“You must see them after they sleep in the lenses the first time,” she said.), 1 week, 1 month, 3 months and 6 months.

Lowe said good candidates for ortho-K are motivated patients and parents, astigmats and those who benefit from being spectacle- and contact lens-free throughout the day, such as athletes. Risks include overnight complications and improper care.

Lowe concluded: “Everything we’re talking about is not FDA approved. But as good doctors and clinicians, we know the studies are proving that we can slow this down. We’re not waiting for the FDA. We’re doing it off-label. You need to tell that to parents.

“If you’re not going to do myopia management, refer your patient to someone who does,” she added. “Please talk to your patients about it.” – by Nancy Hemphill, ELS, FAAO

Reference:

Lowe P. Myopia control in private practice. Presented at: Vision Expo East; New York; March 21-24, 2019.

Disclosure: Lowe reports she is on the speaker’s bureau or is a consultant for, but has no direct financial interest in: Alcon, Essilor, Luneau Technology, Maculogix and ZeaVision. She is on Essilor’s Myopia Taskforce.