September 2021
Column
A Myopic Profession
Myopia management keeps intriguing - but it also keeps surprising me, I have to say. We mentioned scleral schism in previous publications - to the point of an apparent divide between research in that field versus the practical implementation of the modality. But nothing compares to myopia management in that regard! It’s more like the Grand Canyon. I had the good fortune of visiting Kevin Chan at the Treehouse Eyes practice in the Washington, DC area (US) this summer. It’s an example of one of the few practices in the world that exclusively focuses on myopia management. The practice is not in a shopping center or a hospital, but in an office building. They only have kids as patients. And they have organized the practice in such a way that kids actually look forward to coming into the office for regular checkups of their axial length. Pretty cool. As you might expect from any myopia center, interventions offered are diverse, including contact lenses - both soft and ortho-k - but also atropine in different concentrations and outdoor strategies. Sometimes we may be a tad myopic in our profession, in which the starting point and sometimes the prime focus is contact lenses. Well - myopia management is about much more than just contact lenses. Let’s start with the myopic child and then see what strategies are desired and optimal. Circling back to the 'scleral lens schism' mention: in that publication it was literally stated: "Scleral lens fitting does not treat a condition, it treats the entire person - and even entire families." Boy, is that true for myopia management or what?
The International Myopia Institute (IMI) has developed a Facts and Findings Infographic for practitioners based on the IMI White Papers. It looks at the impact of myopia, risk factors and different management options. Click image to the left for a free PDF download of the infographic.  
GMS
Erasmus MC
Desiderius Erasmus Roterodamus (1466–1536) was a Dutch philosopher and one of Europe's most famous and influential scholars. He embraced the humanistic belief in an individual's capacity for self-improvement and the fundamental role of education. Today, the Erasumus University in Rotterdam is a leading center for myopia research and is home to the 2022 International Myopia Conference.
Digital Devices
Two Dutch optometrists/orthoptists at the Erasmus University defend their respective PhD theses on various myopia matters this month. First is Clair Enthoven: she looked at lifestyle factors in myopia development. A couple of statements from her thesis: not just high myopia, but also low and intermediate myopia are associated with pathologies in adulthood, illustrating the need to prevent as many myopic diopters in childhood as possible. Also: more hours of digital near work increase the risk of myopia; this association can be moderated by outdoor exposure. She also stated that COVID-19 measures such as social isolation and home confinement may be effective to prevent COVID-19 infections, but they also facilitate myopia development and progression. A special smartphone Myopia App was developed by Clair and her team. Dutch teenagers spent almost 4 hours per day on their smartphones. Episodes of 20 minutes of continuous use were associated with more myopic refractive errors. This suggests that frequent breaks should become a recommendation for smartphone use in teenagers.
High-dose Atropine Treatment
Jan-Roelof Polling’s thesis, titled Development and management of refractive error in childhood, states that the myopia prevalence in Rotterdam children increased from 1 in 10 in 9 year olds to 1 in 5 in 13 year olds. Children who have 3D of myopia at the age of 10 will virtually all have high myopia in adulthood. He investigated the use of high-dose atropine for progressive myopia and found it a feasible treatment for all children despite the side effects. In his prospective study, children with progressive myopia over 1D/year or myopia of less than 2.5D were prescribed atropine 0.5% as a starting point. At baseline, median spherical refraction of the children was −5.03D with an axial length (AXL) of 25.14mm. Median annual progression was −0.25D or 0.11mmin AXL. In conclusion; in these European children with or at risk of developing high myopia, a starting dose of atropine 0.5% was associated with decreased progression during a 3-year treatment regimen. The study supports high-dose atropine use as a treatment option for children at risk of developing high myopia in adulthood.
Myopia Management in Practice
Treatment Algorithm
Langis Michaud and colleagues share their experience from the École d’optométrie, Université de Montréal on myopia management. The First Pillar is environmental control. While it is known that myopia can be explained in a small part (20–30%) by genetics, epigenetics ("epigenetic" describes factors beyond the genetic code) has more influence on progression and the level of final refractive error. It is therefore essential to consider elements from the environment influencing the onset and progression of myopia, according to the authors. There is consensus on the positive impact of exposure to daylight before the onset of myopia. Patients are advised to get a minimum of one hour, and preferably two hours, of outdoor activities each day. The pandemic brought greater attention to factors such as reading distance, screen time, and surrounding lighting during this type of work. The Second Pillar is binocular vision assessment. From the recent literature, it is possible to associate accommodation and convergence problems with progressive myopia. Accommodation modifies the quality of the optical signal received by the retina and can therefore influence the response to a given defocus. Normal accommodation is necessary for emmetropization as well as for effective control of its evolution, the authors state. The Third Pillar is Control of the Blur, peripherally, but also centrally. For the latter, this means the use of lenses that provide the highest convex power, within the pupil area, without inducing blur at distance. It also implies the full correction of any significant astigmatism (>0.75D). These goals are achieved most of the time with customization of ortho-k lenses. In the case of multifocal soft lens usage, the highest add possible should be selected, with full correction of astigmatism as part of the lens power or with glasses to be worn over the lenses. The fourth pillar involves selection of the right strategy, for which contact lenses as well as atropine and anti-myopia glasses are mentioned. A nice table provides available options in the market for ortho-k and soft-multifocal distance-centered lenses. Image: Unsplash Edi Libedinsky
Atropine & Ortho-k
Previous studies have found that both atropine and ortho-k each individually can slow axial elongation and can control the progression of myopia. This meta-analysis evaluated the combined effect of atropine with ortho-k. A total of five studies involving 341 participants younger than 18 years old met the inclusion criteria. The axial elongation was lower in the combination group (atropine and ortho-k) than that of the ortho-k-only group (0.25mm vs. 0.35mm). This meta-analysis demonstrated that atropine combined with orthokeratology may be superior to ortho-k alone. For more on combination therapy, see Cassandra Haines and Kate Gifford's online paper When More is More on the Myopia Profile platform. Image: Unsplash Towfiqu barbhuiya
Myopia Platforms
Myopia Profile Digest is a newsletter associated with the Myopia Profile platform, hosted by Kate and Paul Gifford as chief editors. It offers excellent scientific ánd clinical input. The August edition looks at combination therapy, as mentioned, but also offers case reports by Kimberley Ngu and Connie Gan.
Review of Myopia Management is a platform with Dwight Akerman as chief editor. It has continual updates on the latest developments. It separates out 'key issues', 'clinical' and 'practice management' as well as product updates. The August 16 contribution in the clinical arena comes from Noel Brennan: Why Am I Not Seeing More Myopia-Related Pathology in My Practice?
The Brien Holden Vision Institute does not need much introduction. In 1985, the late Professor Brien Holden established the Institute for Eye Research. In 2010, this became the “Brien Holden Vision Institute” or simply BHVI. It collaborates with Review of Myopia Management but also has its own designated newsletter. The August 19th edition of that looks at Axial Length Growth and the Risk of Developing Myopia in European Children by Erin Lam.
The newest newsletter is Mastering Myopia, which is hosted by Mark Bullimore and Shalu Pal. The August 2021 newsletter includes a column by Co-editor-in-chief Mark Bullimore titled A Worldwide Myopia Event and We’re All Invited, a contribution by Ariel Cerenzie My Child is Too Young for Contact Lenses and one by Kevin Chan on Decoding Lost Opportunities for Myopia Management.
To top it off: The Myopia Podcast by Optometric Insights Media. Dave Kading and Mile Brujic talk with experts in the field on everything related to orthokeratology and myopia managent, including but not limited to names like Maria Liu, Jeff Walline, Mark Bullimore, Randy Kojima and Patrick Caroline.
I-site is an educational newsletter that is distributed on a monthly basis and provides an update on rigid gas permeable-related topics (scientific research, case reports and other publications worldwide). I-site is objective and non-political. Disclosure: I-site's editor Eef van der Worp, optometrist PhD FAAO FBCLA FIACLE FSLS, receives educational grants from a number of industry partners but is not related to any specific company.