-19%-7% 18% 40% 42% 76%46% myopia control

1

Myopia Control

Jeffrey J. Walline, OD PhDThe Ohio State University College of Optometry

Myopia Control Myopia Control Summary

-19% -7% 18% 40% 42% 76%46%

Bifocal / PALUndercorrection

Atropine

Pirenzepine

GP OK

Soft Bifocal

Specs

What is Clinically Meaningful?

• Assume

• ‐0.50 D per year progression

• From 8 to 16 years

• Begin as ‐1.00 D, end as ‐5.00 D

% Reduction Final Refractive Error

25 ‐4.00

50 ‐3.00

75 ‐2.00

100 ‐1.00

Clinically MeaningfulMethod Average Reduction (min; max)

Undercorrection ‐19 (‐22; ‐16)

GP Contact Lenses ‐7 (‐8; ‐5)

Bifocal/Multifocal Spectacles 18 (3.1; 32)

Pirenzepine 35 (30; 39)

Corneal Reshaping Contact Lenses 51 (26; 79)

Soft Bifocal Contact Lenses 52 (44; 58)

Atropine 81 (76; 96)

Myopia Control Summary

-19% -7% 18% 40% 42% 76%46%


Atropine

Pirenzepine

GP OK

Soft Bifocal

Specs

Myopia Control‐Bifocal Specs

PALSV

•Gwiazda J, et al. IOVS 2003;44:1492-500.•COMET2 Study Group IOVS 2011;52:2749-57.

Spectacles

Sankaridurg P, et al. OVS 2010;87:631‐41

Is It Commercially Available?

2

Myopia Control‐Pirenzepine

Siatkowski RM, et al. J Aapos 2008;12:332-9.


-19% -7% 18% 40% 42% 76%46%


Atropine

Pirenzepine

GP OK

Soft Bifocal

Specs

Side Effects

Accrual and Post‐Cessation

• Tong L, et al. Ophthalmol 2009;116:572‐9.






-19% -7% 18% 40% 42% 76%46%


Atropine

Pirenzepine

GP OK

Soft Bifocal

Specs


42% 59%46%

AtropineOrthokeratology Soft Bifocal

Soft Bifocal Myopia Control

Anstice N, Phillips J. Ophthalmol 2011;118:1152‐61

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Sankaridurg P, et al. IOVS 2011;52:9362-7.


Walline JJ, et al. OVS 2013;90:1207-14


Lam CS, et al., BJO 2014;98:40-5

Orthokeratology Myopia Control

Cho P & Cheung SW. IOVS, 2012;53:7077‐85.


High Myopes

Charm J and Cho P. OVS 2013;90:530-9


Toric

Chen C, et al. IOVS 2013;54:6510-7

0.01% Atropine Myopia Control

Chia A, et al. Ophthalmol 2012;119:347-54


0.01% 0.1% 0.5%

Accommo (D) ‐4.6 ‐10.1 ‐11.8

Pupil (meso, mm) 1.15 2.71 3.56

Pupil (photo, mm) 0.75 2.24 3.11

Dist VA (logMAR) ‐0 02 +0 01 ‐0 01Dist VA (logMAR) ‐0.02 +0.01 ‐0.01

Near VA (logMAR) ‐0.02 +0.06 +0.25

Reading specs (% yes) 6 61 70

Chia A, et al. Ophthalmol 2012;119:347-54


Chia A, et al. AJO 2014;157:451-7

4


• Not commercially available

• Compounding pharmacy

• 1 gt OU QHS

• $38 for 3 month supply$38 for 3 month supply

• 10 mL X 20 drops per mL

• 200 drops or 100 drops per eye

• 90 days = 3 months

Outdoor Time Myopia Control

Jones LA, et al. IOVS 2007;48:3524-32


Wu PC, et al. Ophthalmol 2013;120:1080-5


Not Myopic Myopic

Wu PC, et al. Ophthalmol 2013;120:1080-5


• What does this mean?

• Outdoor time preventsmyopia, but does not slow progression

Accrual of Treatment Effect

Atropine

Tong L, et al. Ophthalmol 2009;116:572‐9


Multifocal Specs

Gwiazda J, et al. IOVS 2003;44:1492‐1500


Cho P & Cheung SW. IOVS, 2012;53:7077‐85


Hiraoka T, et al. IOVS 2012;53:3913‐9

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• Likely to be more effective because myopia control lasts for longer period of time

Pupil Size

OK SV

Chen Z, et al. OVS 2012;89:1636‐40

Pupil Size

Interaction, p < 0.001

Santodomingo J, et al. OVS 2013;90:1225-36

Pupil Size


• More retina with myopic blur = stronger myopia control

Peripheral Myopic Blur

Ortho-K

Specs

Cho 2005 Kakita 2011


Interaction, p = 0.007

Santodomingo J, et al. OVS 2013;90:1225-36

Peripheral Myopic BlurNasal Temporal

Inferior

Zhong Y, et al. OVS 2014;91:404-11

all p < 0.001


Sankaridurg P, et al. IOVS 2011;52:9362-7.



• Greater myopic blur = greater myopia control

• Stronger add = better myopia control?

6

Can We Combine Treatments?

• Contact lens myopia control

• Optical effect

• Atropine

• Receptors at the retinal or scleral level

How Do CL Slow Myopia Progression? How Do CL Slow Myopia Progression?

• Smith EL, et al. IOVS 2005;46:3965‐72.

• Smith EL, et al. Vis Res 2009;49:2386‐92

How Do CL Slow Myopia Progression?



• Smith EL, et al. Vis Res 2009;49:2386‐92


H →M 4 (45) 2 (22)

In front of retina

behind retina

Hyper→Myo 4 (45) 2 (22)

Emm→Myo 13 (77) 1 (6)

Hyper→Emm 11 (40) 6 (22)

No shift 8 (5) 103 (65)

Hoogerheide J, et al. Ophthalmologica. 1971;163:209-15


Queiros A, et al. OVS 2010;87:323‐9


Myope corrected with specs, CL

Myope corrected with corneal reshaping or soft bifocal

Do So Contact Lenses ↑Myopia?

Myopic Creep


Liu Y, Wildsoet C. IOVS 2011;52:1078‐86

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Mutti DO, et al. IOVS 2011;52:199‐205


-5.25

-4.75

-4.25

-3.75

3 25

Spectacle

Contact Lens

-3.25

-2.75

-2.25

-1.75

-1.25Baseline 1 Year 2 Years 3 Years


25.0

25.5

26.0Spectacle

Contact Lens

23.5

24.0

24.5

Baseline 1 Year 2 Years 3 Years

Myopia Control Experience Treatment

Patients %

CRT 14 44

Daily disposable 8 25

Soft bifocal 7 22

Toric 2 6

Atropine 1 3

⅔ = myopia control

Race

Proportion by Race Asian (n = 14) White (n = 18)

CRT 64 28

Soft bifocal 14 28

Daily disposable 7 28

Toric 0 11

GP 0 6GP 0 6

Atropine 1 0

No FDA Approved Myopia Control

• Consent

Can Kids Safely Wear Orthokeratology? Orthokeratology Safety

• Watt and Swarbrick

• 123 cases reported in the literature

• 69% cases from China and Taiwan

• 55% 8 to 15 years old

65% d i 2001• 65% cases occurred in 2001

• 53% wore lenses for 1 year or less

• 61% 20/40 or better; 18% 20/200 or worse

• 40% Acanthamoeba

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Orthokeratology Safety

Age at Fit Patient‐years

Children 12.2 ± 2.5 1435

Adults 38.0 ± 11.1 1164


MK, >3 Months Wear Children Adults Overall

Cases 2 0 2

Incidence (per 10,000 pt‐yrs)13.9

1.7 to 50.40

0 to 31.77.7

0.9 to 27.8


Stapleton, et al. Ophthalmol 2008;115:1655-62

Can Kids Safely Wear Soft Bifocal? Soft Contact Lens Safety

Discontinue CL CIECLAY Study

Wagner H, et al. OVS 2011;88: 973-80 Chalmers RL, et al. IOVS 2011;52:6690-96

Soft Contact Lens Safety

Wagner H, et al. OVS 2011;88:973‐80

Long‐Term Safety

Child Teen p‐value

Eyes appeared more red with CL 36 36 1.00

Allergies worse with CL 22 17 0.45

E lid “ ff ” ith CLEyelids more “puffy” with CL 12 12 1.00

Painful red eye that required doctor visit 21 19 0.85

Walline JJ, et al. ECL 2013;39:283-9

Long‐Term Safety

Child Teen p‐valueVascularization 0.4 ± 0.5 0.2 ± 0.4 0.28Epithelial microcysts 0.2 ± 0.5 0.1 ± 0.4 0.53Mucin balls (#) 1.0 ± 3.5 0.6 ± 2.6 0.62( )Central corneal thickness (μm) 562 ± 39 554 ± 37 0.42Cell density (cells/mm2) 3016 ± 366 3073 ± 327 0.53Coefficient of variation 30.0 ± 4.9 29.9 ± 5.6 0.96

Walline JJ, et al. ECL 2013;39:283-9

Summary

• Contact lenses and low concentration provide the best myopia control without side effects

• Don’t know if we can combine to get stronger effect

• Use strongest tolerable add for soft bifocal

• Outdoor time may prevent myopia but not slow progression

• Contact lenses are safe for children

• If properly care

-19%-7% 18% 40% 42% 76%46% myopia control

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