be in charge of your myopia control strategy · binocular vision environment three pillars of...
TRANSCRIPT
15032018
1
Be in charge of your myopia control strategy
Dr Kate Gifford OD PhDBAppSc(Optom)Hons GCOT FBCLA FIACLE FCCLSA FAAO
Dr Langis Michaud OD MSc ndash Professor FAAO (Dipl) FSLS FBCLA FEAOO
DISCLOSURE
bull Dr Gifford
Honorarium received from
bull Alcon
bull Coopervision
bull Menicon
bull Visioneering Technologies
Dr Michaud
Honorarium Received from
bull Cooper
bull Johnson Johnson
bull Blanchard Labs
Co-owner USPTO 62590388 Medical device for axial length and myopia management
15032018
2
FIRST LECTURE Kate Gifford
It was never easy to look
into the future but it is
possible and we should
not miss our chance
-Andrei Linde
15032018
3
There is no lsquosafersquo level of myopia
Cataract (PSCC)
Retinal detachment
MyopicMaculopathy
-100 to -300 21 31 22
-300 to -600 31 90 97
-600 to -800 55 215 406
Increased risk
Younan et al 2002 Ogawa amp Tanaka 1988 Vongphanit et al 2002 in Flitcroft 2012
15032018
4
Myopia management
The next steps
First corrections
The full picture
Myopia management
First corrections
15032018
5
The myopia-suspect
Less time spent outdoors (lt60-90 min day)
One or two myopic parents
Binocular vision disorders
(Esophoria Accom lag High ACA)
Jones et al 2007 Read et al 2014 Xiong et al 2017 Gwiazda et al 2005
The myopia-suspect
Jones-Jordan et al 2010 Mutti et al 2007
Less hyperopia than age normal
Pre-myopes have less hyperopic refractions for up to 4 years before onset
Fastest change in refraction is in the year before onset
15032018
6
RampL +025Two myopic parents
RampL -025Two myopic parents
At least 90 min day of outdoor time can help prevent onset12 and progression34 of myopia
Wearing a hat sunglasses and playing in shade still gives gt1000 lux compared to 50-400 lux indoors5
Playing near a window doesnrsquot count5
Itrsquos not about physical activity ndash itrsquos about light exposure4
Outdoor time doesnrsquot directly trade for near work time4
Outdoor time
1Rose et al 2008 2Wu et al 2013 3Lin et al 2014 4Read et al 2015 5Saw et al IMC 2017
15032018
7
The sooner you start the better
Donovan et al 2012Bullimore et al 2002 McBrien et al 1997
Goss et al 1985 Bullimore et al 2002
le025D per year
18+
Specs - uncorrection amp undercorrection
Chung et al 2002
Under correction to 612
Sun et al 2017
Full correction
Uncorrection may work in early myopes lt075DFull distance correction in myopes 075D+
Full correction
Uncorrected
15032018
8
RampL -050Unaided vision RampL 66-OU 66
Binocular vision normal at near (unaided)
RampL -050Unaided vision RampL 612+OU 69
Esophoria andor accommodative lag at near (aided)
Myopia management across the world
971 practitioners 12 countries 6 languages
15032018
9
Use UnderCorrection for Myopia Control
Approach
No Sometimes Always
Eye
care
Pra
ctiti
oners
(
)
0
20
40
60
80
100UK+EIRE
Europe
Asia
Australasia
N America
S America
Wolffsohn et al 2016
Myopia management
The next steps
First corrections
The full picture
15032018
10
Myopia management
The next steps
EFFICACY
Contact lens myopia control - meta-analysis papers
OrthoKSun et al 2015 Si et al 2015
(both open access)
Bifocal and multifocal SCLsLi et al 2017
~ 50
~ 50
15032018
11
Describing efficacy
Atropine 01-1
Atropine 001OK MFSCL
Until further noticehellip
~ 50
15032018
12
Myopia = inaccurate BV behaviour
Near esophoria
Accommodative lag
Higher ACA ratios
Greater variability in accommodative responses
Bennett et al 1989 Bullimore et al 1992 Rosenfield et al 1994 Drobe et al 1995 Gwiazda et al 1995Abbott et al 1998 Gwiazda et al 1999 Mutti et al 2000 Rosenfield et al 2002 Vera-Diaz et al 2002 Chen et al 2003 Wolffsohn et al 2003 Nakatsuka et al 2005 Allen et al 2006 Pandian et al 2006 Harb et al 2006 Mutti et al 2006 Ciuffreda et al 2008 Vasudevan et al 2008 Lin et al 2012
Binocular vision amp myopia control
1Edwards et al 2002 2Gwiazda et al 2003 3Yang et al 2009 4Cheng et al 2010
Progressive spectacles applied to all myopes1-3 helliphelliphelliphelliphelliphellip12-17Progressive spectacles for binocular vision problemshelliphelliphelliphellip37Bifocal spectacles for progressing myopes4helliphelliphelliphelliphelliphelliphelliphelliphellip37-55
15032018
13
Binocular vision amp myopia control
5Aller et al 2016 6Zhu et al 2014 7-9Gifford et al 2017 abc 10Tarrant et al 2008
Bifocal SCL fit to esophores5helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip70OrthoK gives a 56 better myopia control effect in lsquobelow averagersquo accommodators6
OrthoK reduces near esophoria and accommodative lag7-9
Multifocal SCL reduce accommodative lag10
Spectacles are sometimes better than CLs
Stronger corrections (prism add) may be needed for severe BV issues
Multifocal SCL and OK will also have some effect but less predictable
If BV is normal helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOrthoK or MF SCLLarge ESOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOKMFSCLspecsLarge EXOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipSpecs may be best
Changing from specs to CLrsquos in myopes gives an exophoric shift
ESOPHORIA ACCOMMODATIVE LAG
Jalie 1973 Bennett et al 1989 Evans 2007 Grosvenor 2007 Jiminez et al 2011 Snir et al 2003
15032018
14
R -200 -075 x 90L -250 -125 x 90
Age 10
R -275 -075 x 90 L -500 -150x 90
L almost constant exotropia NgtD
Age 11
R -325 -075x 90L -550 -175 x 90
Age 12
Myopia control = spectacles and
BV management
Some progression is
normal
YouTube Myopia Profile
15032018
15
Myopia management made simple
SAFETY
The next steps
Safety ndash microbial keratitis Stapleton et al 2008 Sankaridurg et al 2013 Bullimore et al 2013 Bullimore 2017
0
5
10
15
20
25
DWRGP
DW soft DW DD DW SiH DW SiH(kids)
EW soft EWSiHy
OK (all) OK(kids)
12 2 2
12
0
20
25
7
13
0 04 01
0
425
0 0
Any MK
MK with2 lines ofVA loss
Per 10000 wearers per year
15032018
16
Open access paper
Similar rates of corneal infiltrative events and microbial keratitis compared to adults
May be a lower risk in children aged 8-12 years (likely due to compliance)
Kids and contact lenses - safety
Reinforce care and maintenance instructions ndash children (8-12 years) recall less after 3 months than teens (Walline et al 2010)
Kids are NOT more risky CL wearers than adults ndash no difference in adverse events after 10 years of wear (Walline et al 2011)
Most common complication ndash CLPC 4 infiltrative keratitis 1 (Sankaridurg et al 2013 Bullimore et al 2013)
Safety of a D centred reusable multifocal and OrthoK is similar (Stapleton et al 2008 Bullimore et al 2013)
15032018
17
Myopia management
The next steps
First corrections
The full picture
Myopia management
The full picture
15032018
18
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment1 2 hours outdoor time per day2 Limit near work to 2 hours per day
(after school) 3 2020 rule ndash regular breaks
Rose et al 2008 Wu et al 2013 Lin et al 2014 Read et al 2015 Woodman et al 2011 Aldossari et al 2017
15032018
19
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Prescribe spectacles (progressive bifocals) if the child is not suitable
for contact lenses
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Consider adding low dose atropine if optical correction (CLrsquos or
spectacles) does not provide sufficient myopia control
15032018
20
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Managing esophoria and accommodative lag may provide
additional benefit for myopia control
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia Mythbusting
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
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25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
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26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
2
FIRST LECTURE Kate Gifford
It was never easy to look
into the future but it is
possible and we should
not miss our chance
-Andrei Linde
15032018
3
There is no lsquosafersquo level of myopia
Cataract (PSCC)
Retinal detachment
MyopicMaculopathy
-100 to -300 21 31 22
-300 to -600 31 90 97
-600 to -800 55 215 406
Increased risk
Younan et al 2002 Ogawa amp Tanaka 1988 Vongphanit et al 2002 in Flitcroft 2012
15032018
4
Myopia management
The next steps
First corrections
The full picture
Myopia management
First corrections
15032018
5
The myopia-suspect
Less time spent outdoors (lt60-90 min day)
One or two myopic parents
Binocular vision disorders
(Esophoria Accom lag High ACA)
Jones et al 2007 Read et al 2014 Xiong et al 2017 Gwiazda et al 2005
The myopia-suspect
Jones-Jordan et al 2010 Mutti et al 2007
Less hyperopia than age normal
Pre-myopes have less hyperopic refractions for up to 4 years before onset
Fastest change in refraction is in the year before onset
15032018
6
RampL +025Two myopic parents
RampL -025Two myopic parents
At least 90 min day of outdoor time can help prevent onset12 and progression34 of myopia
Wearing a hat sunglasses and playing in shade still gives gt1000 lux compared to 50-400 lux indoors5
Playing near a window doesnrsquot count5
Itrsquos not about physical activity ndash itrsquos about light exposure4
Outdoor time doesnrsquot directly trade for near work time4
Outdoor time
1Rose et al 2008 2Wu et al 2013 3Lin et al 2014 4Read et al 2015 5Saw et al IMC 2017
15032018
7
The sooner you start the better
Donovan et al 2012Bullimore et al 2002 McBrien et al 1997
Goss et al 1985 Bullimore et al 2002
le025D per year
18+
Specs - uncorrection amp undercorrection
Chung et al 2002
Under correction to 612
Sun et al 2017
Full correction
Uncorrection may work in early myopes lt075DFull distance correction in myopes 075D+
Full correction
Uncorrected
15032018
8
RampL -050Unaided vision RampL 66-OU 66
Binocular vision normal at near (unaided)
RampL -050Unaided vision RampL 612+OU 69
Esophoria andor accommodative lag at near (aided)
Myopia management across the world
971 practitioners 12 countries 6 languages
15032018
9
Use UnderCorrection for Myopia Control
Approach
No Sometimes Always
Eye
care
Pra
ctiti
oners
(
)
0
20
40
60
80
100UK+EIRE
Europe
Asia
Australasia
N America
S America
Wolffsohn et al 2016
Myopia management
The next steps
First corrections
The full picture
15032018
10
Myopia management
The next steps
EFFICACY
Contact lens myopia control - meta-analysis papers
OrthoKSun et al 2015 Si et al 2015
(both open access)
Bifocal and multifocal SCLsLi et al 2017
~ 50
~ 50
15032018
11
Describing efficacy
Atropine 01-1
Atropine 001OK MFSCL
Until further noticehellip
~ 50
15032018
12
Myopia = inaccurate BV behaviour
Near esophoria
Accommodative lag
Higher ACA ratios
Greater variability in accommodative responses
Bennett et al 1989 Bullimore et al 1992 Rosenfield et al 1994 Drobe et al 1995 Gwiazda et al 1995Abbott et al 1998 Gwiazda et al 1999 Mutti et al 2000 Rosenfield et al 2002 Vera-Diaz et al 2002 Chen et al 2003 Wolffsohn et al 2003 Nakatsuka et al 2005 Allen et al 2006 Pandian et al 2006 Harb et al 2006 Mutti et al 2006 Ciuffreda et al 2008 Vasudevan et al 2008 Lin et al 2012
Binocular vision amp myopia control
1Edwards et al 2002 2Gwiazda et al 2003 3Yang et al 2009 4Cheng et al 2010
Progressive spectacles applied to all myopes1-3 helliphelliphelliphelliphelliphellip12-17Progressive spectacles for binocular vision problemshelliphelliphelliphellip37Bifocal spectacles for progressing myopes4helliphelliphelliphelliphelliphelliphelliphelliphellip37-55
15032018
13
Binocular vision amp myopia control
5Aller et al 2016 6Zhu et al 2014 7-9Gifford et al 2017 abc 10Tarrant et al 2008
Bifocal SCL fit to esophores5helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip70OrthoK gives a 56 better myopia control effect in lsquobelow averagersquo accommodators6
OrthoK reduces near esophoria and accommodative lag7-9
Multifocal SCL reduce accommodative lag10
Spectacles are sometimes better than CLs
Stronger corrections (prism add) may be needed for severe BV issues
Multifocal SCL and OK will also have some effect but less predictable
If BV is normal helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOrthoK or MF SCLLarge ESOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOKMFSCLspecsLarge EXOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipSpecs may be best
Changing from specs to CLrsquos in myopes gives an exophoric shift
ESOPHORIA ACCOMMODATIVE LAG
Jalie 1973 Bennett et al 1989 Evans 2007 Grosvenor 2007 Jiminez et al 2011 Snir et al 2003
15032018
14
R -200 -075 x 90L -250 -125 x 90
Age 10
R -275 -075 x 90 L -500 -150x 90
L almost constant exotropia NgtD
Age 11
R -325 -075x 90L -550 -175 x 90
Age 12
Myopia control = spectacles and
BV management
Some progression is
normal
YouTube Myopia Profile
15032018
15
Myopia management made simple
SAFETY
The next steps
Safety ndash microbial keratitis Stapleton et al 2008 Sankaridurg et al 2013 Bullimore et al 2013 Bullimore 2017
0
5
10
15
20
25
DWRGP
DW soft DW DD DW SiH DW SiH(kids)
EW soft EWSiHy
OK (all) OK(kids)
12 2 2
12
0
20
25
7
13
0 04 01
0
425
0 0
Any MK
MK with2 lines ofVA loss
Per 10000 wearers per year
15032018
16
Open access paper
Similar rates of corneal infiltrative events and microbial keratitis compared to adults
May be a lower risk in children aged 8-12 years (likely due to compliance)
Kids and contact lenses - safety
Reinforce care and maintenance instructions ndash children (8-12 years) recall less after 3 months than teens (Walline et al 2010)
Kids are NOT more risky CL wearers than adults ndash no difference in adverse events after 10 years of wear (Walline et al 2011)
Most common complication ndash CLPC 4 infiltrative keratitis 1 (Sankaridurg et al 2013 Bullimore et al 2013)
Safety of a D centred reusable multifocal and OrthoK is similar (Stapleton et al 2008 Bullimore et al 2013)
15032018
17
Myopia management
The next steps
First corrections
The full picture
Myopia management
The full picture
15032018
18
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment1 2 hours outdoor time per day2 Limit near work to 2 hours per day
(after school) 3 2020 rule ndash regular breaks
Rose et al 2008 Wu et al 2013 Lin et al 2014 Read et al 2015 Woodman et al 2011 Aldossari et al 2017
15032018
19
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Prescribe spectacles (progressive bifocals) if the child is not suitable
for contact lenses
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Consider adding low dose atropine if optical correction (CLrsquos or
spectacles) does not provide sufficient myopia control
15032018
20
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Managing esophoria and accommodative lag may provide
additional benefit for myopia control
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia Mythbusting
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
3
There is no lsquosafersquo level of myopia
Cataract (PSCC)
Retinal detachment
MyopicMaculopathy
-100 to -300 21 31 22
-300 to -600 31 90 97
-600 to -800 55 215 406
Increased risk
Younan et al 2002 Ogawa amp Tanaka 1988 Vongphanit et al 2002 in Flitcroft 2012
15032018
4
Myopia management
The next steps
First corrections
The full picture
Myopia management
First corrections
15032018
5
The myopia-suspect
Less time spent outdoors (lt60-90 min day)
One or two myopic parents
Binocular vision disorders
(Esophoria Accom lag High ACA)
Jones et al 2007 Read et al 2014 Xiong et al 2017 Gwiazda et al 2005
The myopia-suspect
Jones-Jordan et al 2010 Mutti et al 2007
Less hyperopia than age normal
Pre-myopes have less hyperopic refractions for up to 4 years before onset
Fastest change in refraction is in the year before onset
15032018
6
RampL +025Two myopic parents
RampL -025Two myopic parents
At least 90 min day of outdoor time can help prevent onset12 and progression34 of myopia
Wearing a hat sunglasses and playing in shade still gives gt1000 lux compared to 50-400 lux indoors5
Playing near a window doesnrsquot count5
Itrsquos not about physical activity ndash itrsquos about light exposure4
Outdoor time doesnrsquot directly trade for near work time4
Outdoor time
1Rose et al 2008 2Wu et al 2013 3Lin et al 2014 4Read et al 2015 5Saw et al IMC 2017
15032018
7
The sooner you start the better
Donovan et al 2012Bullimore et al 2002 McBrien et al 1997
Goss et al 1985 Bullimore et al 2002
le025D per year
18+
Specs - uncorrection amp undercorrection
Chung et al 2002
Under correction to 612
Sun et al 2017
Full correction
Uncorrection may work in early myopes lt075DFull distance correction in myopes 075D+
Full correction
Uncorrected
15032018
8
RampL -050Unaided vision RampL 66-OU 66
Binocular vision normal at near (unaided)
RampL -050Unaided vision RampL 612+OU 69
Esophoria andor accommodative lag at near (aided)
Myopia management across the world
971 practitioners 12 countries 6 languages
15032018
9
Use UnderCorrection for Myopia Control
Approach
No Sometimes Always
Eye
care
Pra
ctiti
oners
(
)
0
20
40
60
80
100UK+EIRE
Europe
Asia
Australasia
N America
S America
Wolffsohn et al 2016
Myopia management
The next steps
First corrections
The full picture
15032018
10
Myopia management
The next steps
EFFICACY
Contact lens myopia control - meta-analysis papers
OrthoKSun et al 2015 Si et al 2015
(both open access)
Bifocal and multifocal SCLsLi et al 2017
~ 50
~ 50
15032018
11
Describing efficacy
Atropine 01-1
Atropine 001OK MFSCL
Until further noticehellip
~ 50
15032018
12
Myopia = inaccurate BV behaviour
Near esophoria
Accommodative lag
Higher ACA ratios
Greater variability in accommodative responses
Bennett et al 1989 Bullimore et al 1992 Rosenfield et al 1994 Drobe et al 1995 Gwiazda et al 1995Abbott et al 1998 Gwiazda et al 1999 Mutti et al 2000 Rosenfield et al 2002 Vera-Diaz et al 2002 Chen et al 2003 Wolffsohn et al 2003 Nakatsuka et al 2005 Allen et al 2006 Pandian et al 2006 Harb et al 2006 Mutti et al 2006 Ciuffreda et al 2008 Vasudevan et al 2008 Lin et al 2012
Binocular vision amp myopia control
1Edwards et al 2002 2Gwiazda et al 2003 3Yang et al 2009 4Cheng et al 2010
Progressive spectacles applied to all myopes1-3 helliphelliphelliphelliphelliphellip12-17Progressive spectacles for binocular vision problemshelliphelliphelliphellip37Bifocal spectacles for progressing myopes4helliphelliphelliphelliphelliphelliphelliphelliphellip37-55
15032018
13
Binocular vision amp myopia control
5Aller et al 2016 6Zhu et al 2014 7-9Gifford et al 2017 abc 10Tarrant et al 2008
Bifocal SCL fit to esophores5helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip70OrthoK gives a 56 better myopia control effect in lsquobelow averagersquo accommodators6
OrthoK reduces near esophoria and accommodative lag7-9
Multifocal SCL reduce accommodative lag10
Spectacles are sometimes better than CLs
Stronger corrections (prism add) may be needed for severe BV issues
Multifocal SCL and OK will also have some effect but less predictable
If BV is normal helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOrthoK or MF SCLLarge ESOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOKMFSCLspecsLarge EXOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipSpecs may be best
Changing from specs to CLrsquos in myopes gives an exophoric shift
ESOPHORIA ACCOMMODATIVE LAG
Jalie 1973 Bennett et al 1989 Evans 2007 Grosvenor 2007 Jiminez et al 2011 Snir et al 2003
15032018
14
R -200 -075 x 90L -250 -125 x 90
Age 10
R -275 -075 x 90 L -500 -150x 90
L almost constant exotropia NgtD
Age 11
R -325 -075x 90L -550 -175 x 90
Age 12
Myopia control = spectacles and
BV management
Some progression is
normal
YouTube Myopia Profile
15032018
15
Myopia management made simple
SAFETY
The next steps
Safety ndash microbial keratitis Stapleton et al 2008 Sankaridurg et al 2013 Bullimore et al 2013 Bullimore 2017
0
5
10
15
20
25
DWRGP
DW soft DW DD DW SiH DW SiH(kids)
EW soft EWSiHy
OK (all) OK(kids)
12 2 2
12
0
20
25
7
13
0 04 01
0
425
0 0
Any MK
MK with2 lines ofVA loss
Per 10000 wearers per year
15032018
16
Open access paper
Similar rates of corneal infiltrative events and microbial keratitis compared to adults
May be a lower risk in children aged 8-12 years (likely due to compliance)
Kids and contact lenses - safety
Reinforce care and maintenance instructions ndash children (8-12 years) recall less after 3 months than teens (Walline et al 2010)
Kids are NOT more risky CL wearers than adults ndash no difference in adverse events after 10 years of wear (Walline et al 2011)
Most common complication ndash CLPC 4 infiltrative keratitis 1 (Sankaridurg et al 2013 Bullimore et al 2013)
Safety of a D centred reusable multifocal and OrthoK is similar (Stapleton et al 2008 Bullimore et al 2013)
15032018
17
Myopia management
The next steps
First corrections
The full picture
Myopia management
The full picture
15032018
18
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment1 2 hours outdoor time per day2 Limit near work to 2 hours per day
(after school) 3 2020 rule ndash regular breaks
Rose et al 2008 Wu et al 2013 Lin et al 2014 Read et al 2015 Woodman et al 2011 Aldossari et al 2017
15032018
19
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Prescribe spectacles (progressive bifocals) if the child is not suitable
for contact lenses
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Consider adding low dose atropine if optical correction (CLrsquos or
spectacles) does not provide sufficient myopia control
15032018
20
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Managing esophoria and accommodative lag may provide
additional benefit for myopia control
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia Mythbusting
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
4
Myopia management
The next steps
First corrections
The full picture
Myopia management
First corrections
15032018
5
The myopia-suspect
Less time spent outdoors (lt60-90 min day)
One or two myopic parents
Binocular vision disorders
(Esophoria Accom lag High ACA)
Jones et al 2007 Read et al 2014 Xiong et al 2017 Gwiazda et al 2005
The myopia-suspect
Jones-Jordan et al 2010 Mutti et al 2007
Less hyperopia than age normal
Pre-myopes have less hyperopic refractions for up to 4 years before onset
Fastest change in refraction is in the year before onset
15032018
6
RampL +025Two myopic parents
RampL -025Two myopic parents
At least 90 min day of outdoor time can help prevent onset12 and progression34 of myopia
Wearing a hat sunglasses and playing in shade still gives gt1000 lux compared to 50-400 lux indoors5
Playing near a window doesnrsquot count5
Itrsquos not about physical activity ndash itrsquos about light exposure4
Outdoor time doesnrsquot directly trade for near work time4
Outdoor time
1Rose et al 2008 2Wu et al 2013 3Lin et al 2014 4Read et al 2015 5Saw et al IMC 2017
15032018
7
The sooner you start the better
Donovan et al 2012Bullimore et al 2002 McBrien et al 1997
Goss et al 1985 Bullimore et al 2002
le025D per year
18+
Specs - uncorrection amp undercorrection
Chung et al 2002
Under correction to 612
Sun et al 2017
Full correction
Uncorrection may work in early myopes lt075DFull distance correction in myopes 075D+
Full correction
Uncorrected
15032018
8
RampL -050Unaided vision RampL 66-OU 66
Binocular vision normal at near (unaided)
RampL -050Unaided vision RampL 612+OU 69
Esophoria andor accommodative lag at near (aided)
Myopia management across the world
971 practitioners 12 countries 6 languages
15032018
9
Use UnderCorrection for Myopia Control
Approach
No Sometimes Always
Eye
care
Pra
ctiti
oners
(
)
0
20
40
60
80
100UK+EIRE
Europe
Asia
Australasia
N America
S America
Wolffsohn et al 2016
Myopia management
The next steps
First corrections
The full picture
15032018
10
Myopia management
The next steps
EFFICACY
Contact lens myopia control - meta-analysis papers
OrthoKSun et al 2015 Si et al 2015
(both open access)
Bifocal and multifocal SCLsLi et al 2017
~ 50
~ 50
15032018
11
Describing efficacy
Atropine 01-1
Atropine 001OK MFSCL
Until further noticehellip
~ 50
15032018
12
Myopia = inaccurate BV behaviour
Near esophoria
Accommodative lag
Higher ACA ratios
Greater variability in accommodative responses
Bennett et al 1989 Bullimore et al 1992 Rosenfield et al 1994 Drobe et al 1995 Gwiazda et al 1995Abbott et al 1998 Gwiazda et al 1999 Mutti et al 2000 Rosenfield et al 2002 Vera-Diaz et al 2002 Chen et al 2003 Wolffsohn et al 2003 Nakatsuka et al 2005 Allen et al 2006 Pandian et al 2006 Harb et al 2006 Mutti et al 2006 Ciuffreda et al 2008 Vasudevan et al 2008 Lin et al 2012
Binocular vision amp myopia control
1Edwards et al 2002 2Gwiazda et al 2003 3Yang et al 2009 4Cheng et al 2010
Progressive spectacles applied to all myopes1-3 helliphelliphelliphelliphelliphellip12-17Progressive spectacles for binocular vision problemshelliphelliphelliphellip37Bifocal spectacles for progressing myopes4helliphelliphelliphelliphelliphelliphelliphelliphellip37-55
15032018
13
Binocular vision amp myopia control
5Aller et al 2016 6Zhu et al 2014 7-9Gifford et al 2017 abc 10Tarrant et al 2008
Bifocal SCL fit to esophores5helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip70OrthoK gives a 56 better myopia control effect in lsquobelow averagersquo accommodators6
OrthoK reduces near esophoria and accommodative lag7-9
Multifocal SCL reduce accommodative lag10
Spectacles are sometimes better than CLs
Stronger corrections (prism add) may be needed for severe BV issues
Multifocal SCL and OK will also have some effect but less predictable
If BV is normal helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOrthoK or MF SCLLarge ESOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOKMFSCLspecsLarge EXOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipSpecs may be best
Changing from specs to CLrsquos in myopes gives an exophoric shift
ESOPHORIA ACCOMMODATIVE LAG
Jalie 1973 Bennett et al 1989 Evans 2007 Grosvenor 2007 Jiminez et al 2011 Snir et al 2003
15032018
14
R -200 -075 x 90L -250 -125 x 90
Age 10
R -275 -075 x 90 L -500 -150x 90
L almost constant exotropia NgtD
Age 11
R -325 -075x 90L -550 -175 x 90
Age 12
Myopia control = spectacles and
BV management
Some progression is
normal
YouTube Myopia Profile
15032018
15
Myopia management made simple
SAFETY
The next steps
Safety ndash microbial keratitis Stapleton et al 2008 Sankaridurg et al 2013 Bullimore et al 2013 Bullimore 2017
0
5
10
15
20
25
DWRGP
DW soft DW DD DW SiH DW SiH(kids)
EW soft EWSiHy
OK (all) OK(kids)
12 2 2
12
0
20
25
7
13
0 04 01
0
425
0 0
Any MK
MK with2 lines ofVA loss
Per 10000 wearers per year
15032018
16
Open access paper
Similar rates of corneal infiltrative events and microbial keratitis compared to adults
May be a lower risk in children aged 8-12 years (likely due to compliance)
Kids and contact lenses - safety
Reinforce care and maintenance instructions ndash children (8-12 years) recall less after 3 months than teens (Walline et al 2010)
Kids are NOT more risky CL wearers than adults ndash no difference in adverse events after 10 years of wear (Walline et al 2011)
Most common complication ndash CLPC 4 infiltrative keratitis 1 (Sankaridurg et al 2013 Bullimore et al 2013)
Safety of a D centred reusable multifocal and OrthoK is similar (Stapleton et al 2008 Bullimore et al 2013)
15032018
17
Myopia management
The next steps
First corrections
The full picture
Myopia management
The full picture
15032018
18
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment1 2 hours outdoor time per day2 Limit near work to 2 hours per day
(after school) 3 2020 rule ndash regular breaks
Rose et al 2008 Wu et al 2013 Lin et al 2014 Read et al 2015 Woodman et al 2011 Aldossari et al 2017
15032018
19
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Prescribe spectacles (progressive bifocals) if the child is not suitable
for contact lenses
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Consider adding low dose atropine if optical correction (CLrsquos or
spectacles) does not provide sufficient myopia control
15032018
20
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Managing esophoria and accommodative lag may provide
additional benefit for myopia control
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia Mythbusting
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
5
The myopia-suspect
Less time spent outdoors (lt60-90 min day)
One or two myopic parents
Binocular vision disorders
(Esophoria Accom lag High ACA)
Jones et al 2007 Read et al 2014 Xiong et al 2017 Gwiazda et al 2005
The myopia-suspect
Jones-Jordan et al 2010 Mutti et al 2007
Less hyperopia than age normal
Pre-myopes have less hyperopic refractions for up to 4 years before onset
Fastest change in refraction is in the year before onset
15032018
6
RampL +025Two myopic parents
RampL -025Two myopic parents
At least 90 min day of outdoor time can help prevent onset12 and progression34 of myopia
Wearing a hat sunglasses and playing in shade still gives gt1000 lux compared to 50-400 lux indoors5
Playing near a window doesnrsquot count5
Itrsquos not about physical activity ndash itrsquos about light exposure4
Outdoor time doesnrsquot directly trade for near work time4
Outdoor time
1Rose et al 2008 2Wu et al 2013 3Lin et al 2014 4Read et al 2015 5Saw et al IMC 2017
15032018
7
The sooner you start the better
Donovan et al 2012Bullimore et al 2002 McBrien et al 1997
Goss et al 1985 Bullimore et al 2002
le025D per year
18+
Specs - uncorrection amp undercorrection
Chung et al 2002
Under correction to 612
Sun et al 2017
Full correction
Uncorrection may work in early myopes lt075DFull distance correction in myopes 075D+
Full correction
Uncorrected
15032018
8
RampL -050Unaided vision RampL 66-OU 66
Binocular vision normal at near (unaided)
RampL -050Unaided vision RampL 612+OU 69
Esophoria andor accommodative lag at near (aided)
Myopia management across the world
971 practitioners 12 countries 6 languages
15032018
9
Use UnderCorrection for Myopia Control
Approach
No Sometimes Always
Eye
care
Pra
ctiti
oners
(
)
0
20
40
60
80
100UK+EIRE
Europe
Asia
Australasia
N America
S America
Wolffsohn et al 2016
Myopia management
The next steps
First corrections
The full picture
15032018
10
Myopia management
The next steps
EFFICACY
Contact lens myopia control - meta-analysis papers
OrthoKSun et al 2015 Si et al 2015
(both open access)
Bifocal and multifocal SCLsLi et al 2017
~ 50
~ 50
15032018
11
Describing efficacy
Atropine 01-1
Atropine 001OK MFSCL
Until further noticehellip
~ 50
15032018
12
Myopia = inaccurate BV behaviour
Near esophoria
Accommodative lag
Higher ACA ratios
Greater variability in accommodative responses
Bennett et al 1989 Bullimore et al 1992 Rosenfield et al 1994 Drobe et al 1995 Gwiazda et al 1995Abbott et al 1998 Gwiazda et al 1999 Mutti et al 2000 Rosenfield et al 2002 Vera-Diaz et al 2002 Chen et al 2003 Wolffsohn et al 2003 Nakatsuka et al 2005 Allen et al 2006 Pandian et al 2006 Harb et al 2006 Mutti et al 2006 Ciuffreda et al 2008 Vasudevan et al 2008 Lin et al 2012
Binocular vision amp myopia control
1Edwards et al 2002 2Gwiazda et al 2003 3Yang et al 2009 4Cheng et al 2010
Progressive spectacles applied to all myopes1-3 helliphelliphelliphelliphelliphellip12-17Progressive spectacles for binocular vision problemshelliphelliphelliphellip37Bifocal spectacles for progressing myopes4helliphelliphelliphelliphelliphelliphelliphelliphellip37-55
15032018
13
Binocular vision amp myopia control
5Aller et al 2016 6Zhu et al 2014 7-9Gifford et al 2017 abc 10Tarrant et al 2008
Bifocal SCL fit to esophores5helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip70OrthoK gives a 56 better myopia control effect in lsquobelow averagersquo accommodators6
OrthoK reduces near esophoria and accommodative lag7-9
Multifocal SCL reduce accommodative lag10
Spectacles are sometimes better than CLs
Stronger corrections (prism add) may be needed for severe BV issues
Multifocal SCL and OK will also have some effect but less predictable
If BV is normal helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOrthoK or MF SCLLarge ESOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOKMFSCLspecsLarge EXOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipSpecs may be best
Changing from specs to CLrsquos in myopes gives an exophoric shift
ESOPHORIA ACCOMMODATIVE LAG
Jalie 1973 Bennett et al 1989 Evans 2007 Grosvenor 2007 Jiminez et al 2011 Snir et al 2003
15032018
14
R -200 -075 x 90L -250 -125 x 90
Age 10
R -275 -075 x 90 L -500 -150x 90
L almost constant exotropia NgtD
Age 11
R -325 -075x 90L -550 -175 x 90
Age 12
Myopia control = spectacles and
BV management
Some progression is
normal
YouTube Myopia Profile
15032018
15
Myopia management made simple
SAFETY
The next steps
Safety ndash microbial keratitis Stapleton et al 2008 Sankaridurg et al 2013 Bullimore et al 2013 Bullimore 2017
0
5
10
15
20
25
DWRGP
DW soft DW DD DW SiH DW SiH(kids)
EW soft EWSiHy
OK (all) OK(kids)
12 2 2
12
0
20
25
7
13
0 04 01
0
425
0 0
Any MK
MK with2 lines ofVA loss
Per 10000 wearers per year
15032018
16
Open access paper
Similar rates of corneal infiltrative events and microbial keratitis compared to adults
May be a lower risk in children aged 8-12 years (likely due to compliance)
Kids and contact lenses - safety
Reinforce care and maintenance instructions ndash children (8-12 years) recall less after 3 months than teens (Walline et al 2010)
Kids are NOT more risky CL wearers than adults ndash no difference in adverse events after 10 years of wear (Walline et al 2011)
Most common complication ndash CLPC 4 infiltrative keratitis 1 (Sankaridurg et al 2013 Bullimore et al 2013)
Safety of a D centred reusable multifocal and OrthoK is similar (Stapleton et al 2008 Bullimore et al 2013)
15032018
17
Myopia management
The next steps
First corrections
The full picture
Myopia management
The full picture
15032018
18
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment1 2 hours outdoor time per day2 Limit near work to 2 hours per day
(after school) 3 2020 rule ndash regular breaks
Rose et al 2008 Wu et al 2013 Lin et al 2014 Read et al 2015 Woodman et al 2011 Aldossari et al 2017
15032018
19
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Prescribe spectacles (progressive bifocals) if the child is not suitable
for contact lenses
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Consider adding low dose atropine if optical correction (CLrsquos or
spectacles) does not provide sufficient myopia control
15032018
20
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Managing esophoria and accommodative lag may provide
additional benefit for myopia control
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia Mythbusting
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
6
RampL +025Two myopic parents
RampL -025Two myopic parents
At least 90 min day of outdoor time can help prevent onset12 and progression34 of myopia
Wearing a hat sunglasses and playing in shade still gives gt1000 lux compared to 50-400 lux indoors5
Playing near a window doesnrsquot count5
Itrsquos not about physical activity ndash itrsquos about light exposure4
Outdoor time doesnrsquot directly trade for near work time4
Outdoor time
1Rose et al 2008 2Wu et al 2013 3Lin et al 2014 4Read et al 2015 5Saw et al IMC 2017
15032018
7
The sooner you start the better
Donovan et al 2012Bullimore et al 2002 McBrien et al 1997
Goss et al 1985 Bullimore et al 2002
le025D per year
18+
Specs - uncorrection amp undercorrection
Chung et al 2002
Under correction to 612
Sun et al 2017
Full correction
Uncorrection may work in early myopes lt075DFull distance correction in myopes 075D+
Full correction
Uncorrected
15032018
8
RampL -050Unaided vision RampL 66-OU 66
Binocular vision normal at near (unaided)
RampL -050Unaided vision RampL 612+OU 69
Esophoria andor accommodative lag at near (aided)
Myopia management across the world
971 practitioners 12 countries 6 languages
15032018
9
Use UnderCorrection for Myopia Control
Approach
No Sometimes Always
Eye
care
Pra
ctiti
oners
(
)
0
20
40
60
80
100UK+EIRE
Europe
Asia
Australasia
N America
S America
Wolffsohn et al 2016
Myopia management
The next steps
First corrections
The full picture
15032018
10
Myopia management
The next steps
EFFICACY
Contact lens myopia control - meta-analysis papers
OrthoKSun et al 2015 Si et al 2015
(both open access)
Bifocal and multifocal SCLsLi et al 2017
~ 50
~ 50
15032018
11
Describing efficacy
Atropine 01-1
Atropine 001OK MFSCL
Until further noticehellip
~ 50
15032018
12
Myopia = inaccurate BV behaviour
Near esophoria
Accommodative lag
Higher ACA ratios
Greater variability in accommodative responses
Bennett et al 1989 Bullimore et al 1992 Rosenfield et al 1994 Drobe et al 1995 Gwiazda et al 1995Abbott et al 1998 Gwiazda et al 1999 Mutti et al 2000 Rosenfield et al 2002 Vera-Diaz et al 2002 Chen et al 2003 Wolffsohn et al 2003 Nakatsuka et al 2005 Allen et al 2006 Pandian et al 2006 Harb et al 2006 Mutti et al 2006 Ciuffreda et al 2008 Vasudevan et al 2008 Lin et al 2012
Binocular vision amp myopia control
1Edwards et al 2002 2Gwiazda et al 2003 3Yang et al 2009 4Cheng et al 2010
Progressive spectacles applied to all myopes1-3 helliphelliphelliphelliphelliphellip12-17Progressive spectacles for binocular vision problemshelliphelliphelliphellip37Bifocal spectacles for progressing myopes4helliphelliphelliphelliphelliphelliphelliphelliphellip37-55
15032018
13
Binocular vision amp myopia control
5Aller et al 2016 6Zhu et al 2014 7-9Gifford et al 2017 abc 10Tarrant et al 2008
Bifocal SCL fit to esophores5helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip70OrthoK gives a 56 better myopia control effect in lsquobelow averagersquo accommodators6
OrthoK reduces near esophoria and accommodative lag7-9
Multifocal SCL reduce accommodative lag10
Spectacles are sometimes better than CLs
Stronger corrections (prism add) may be needed for severe BV issues
Multifocal SCL and OK will also have some effect but less predictable
If BV is normal helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOrthoK or MF SCLLarge ESOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOKMFSCLspecsLarge EXOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipSpecs may be best
Changing from specs to CLrsquos in myopes gives an exophoric shift
ESOPHORIA ACCOMMODATIVE LAG
Jalie 1973 Bennett et al 1989 Evans 2007 Grosvenor 2007 Jiminez et al 2011 Snir et al 2003
15032018
14
R -200 -075 x 90L -250 -125 x 90
Age 10
R -275 -075 x 90 L -500 -150x 90
L almost constant exotropia NgtD
Age 11
R -325 -075x 90L -550 -175 x 90
Age 12
Myopia control = spectacles and
BV management
Some progression is
normal
YouTube Myopia Profile
15032018
15
Myopia management made simple
SAFETY
The next steps
Safety ndash microbial keratitis Stapleton et al 2008 Sankaridurg et al 2013 Bullimore et al 2013 Bullimore 2017
0
5
10
15
20
25
DWRGP
DW soft DW DD DW SiH DW SiH(kids)
EW soft EWSiHy
OK (all) OK(kids)
12 2 2
12
0
20
25
7
13
0 04 01
0
425
0 0
Any MK
MK with2 lines ofVA loss
Per 10000 wearers per year
15032018
16
Open access paper
Similar rates of corneal infiltrative events and microbial keratitis compared to adults
May be a lower risk in children aged 8-12 years (likely due to compliance)
Kids and contact lenses - safety
Reinforce care and maintenance instructions ndash children (8-12 years) recall less after 3 months than teens (Walline et al 2010)
Kids are NOT more risky CL wearers than adults ndash no difference in adverse events after 10 years of wear (Walline et al 2011)
Most common complication ndash CLPC 4 infiltrative keratitis 1 (Sankaridurg et al 2013 Bullimore et al 2013)
Safety of a D centred reusable multifocal and OrthoK is similar (Stapleton et al 2008 Bullimore et al 2013)
15032018
17
Myopia management
The next steps
First corrections
The full picture
Myopia management
The full picture
15032018
18
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment1 2 hours outdoor time per day2 Limit near work to 2 hours per day
(after school) 3 2020 rule ndash regular breaks
Rose et al 2008 Wu et al 2013 Lin et al 2014 Read et al 2015 Woodman et al 2011 Aldossari et al 2017
15032018
19
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Prescribe spectacles (progressive bifocals) if the child is not suitable
for contact lenses
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Consider adding low dose atropine if optical correction (CLrsquos or
spectacles) does not provide sufficient myopia control
15032018
20
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Managing esophoria and accommodative lag may provide
additional benefit for myopia control
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia Mythbusting
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
7
The sooner you start the better
Donovan et al 2012Bullimore et al 2002 McBrien et al 1997
Goss et al 1985 Bullimore et al 2002
le025D per year
18+
Specs - uncorrection amp undercorrection
Chung et al 2002
Under correction to 612
Sun et al 2017
Full correction
Uncorrection may work in early myopes lt075DFull distance correction in myopes 075D+
Full correction
Uncorrected
15032018
8
RampL -050Unaided vision RampL 66-OU 66
Binocular vision normal at near (unaided)
RampL -050Unaided vision RampL 612+OU 69
Esophoria andor accommodative lag at near (aided)
Myopia management across the world
971 practitioners 12 countries 6 languages
15032018
9
Use UnderCorrection for Myopia Control
Approach
No Sometimes Always
Eye
care
Pra
ctiti
oners
(
)
0
20
40
60
80
100UK+EIRE
Europe
Asia
Australasia
N America
S America
Wolffsohn et al 2016
Myopia management
The next steps
First corrections
The full picture
15032018
10
Myopia management
The next steps
EFFICACY
Contact lens myopia control - meta-analysis papers
OrthoKSun et al 2015 Si et al 2015
(both open access)
Bifocal and multifocal SCLsLi et al 2017
~ 50
~ 50
15032018
11
Describing efficacy
Atropine 01-1
Atropine 001OK MFSCL
Until further noticehellip
~ 50
15032018
12
Myopia = inaccurate BV behaviour
Near esophoria
Accommodative lag
Higher ACA ratios
Greater variability in accommodative responses
Bennett et al 1989 Bullimore et al 1992 Rosenfield et al 1994 Drobe et al 1995 Gwiazda et al 1995Abbott et al 1998 Gwiazda et al 1999 Mutti et al 2000 Rosenfield et al 2002 Vera-Diaz et al 2002 Chen et al 2003 Wolffsohn et al 2003 Nakatsuka et al 2005 Allen et al 2006 Pandian et al 2006 Harb et al 2006 Mutti et al 2006 Ciuffreda et al 2008 Vasudevan et al 2008 Lin et al 2012
Binocular vision amp myopia control
1Edwards et al 2002 2Gwiazda et al 2003 3Yang et al 2009 4Cheng et al 2010
Progressive spectacles applied to all myopes1-3 helliphelliphelliphelliphelliphellip12-17Progressive spectacles for binocular vision problemshelliphelliphelliphellip37Bifocal spectacles for progressing myopes4helliphelliphelliphelliphelliphelliphelliphelliphellip37-55
15032018
13
Binocular vision amp myopia control
5Aller et al 2016 6Zhu et al 2014 7-9Gifford et al 2017 abc 10Tarrant et al 2008
Bifocal SCL fit to esophores5helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip70OrthoK gives a 56 better myopia control effect in lsquobelow averagersquo accommodators6
OrthoK reduces near esophoria and accommodative lag7-9
Multifocal SCL reduce accommodative lag10
Spectacles are sometimes better than CLs
Stronger corrections (prism add) may be needed for severe BV issues
Multifocal SCL and OK will also have some effect but less predictable
If BV is normal helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOrthoK or MF SCLLarge ESOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOKMFSCLspecsLarge EXOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipSpecs may be best
Changing from specs to CLrsquos in myopes gives an exophoric shift
ESOPHORIA ACCOMMODATIVE LAG
Jalie 1973 Bennett et al 1989 Evans 2007 Grosvenor 2007 Jiminez et al 2011 Snir et al 2003
15032018
14
R -200 -075 x 90L -250 -125 x 90
Age 10
R -275 -075 x 90 L -500 -150x 90
L almost constant exotropia NgtD
Age 11
R -325 -075x 90L -550 -175 x 90
Age 12
Myopia control = spectacles and
BV management
Some progression is
normal
YouTube Myopia Profile
15032018
15
Myopia management made simple
SAFETY
The next steps
Safety ndash microbial keratitis Stapleton et al 2008 Sankaridurg et al 2013 Bullimore et al 2013 Bullimore 2017
0
5
10
15
20
25
DWRGP
DW soft DW DD DW SiH DW SiH(kids)
EW soft EWSiHy
OK (all) OK(kids)
12 2 2
12
0
20
25
7
13
0 04 01
0
425
0 0
Any MK
MK with2 lines ofVA loss
Per 10000 wearers per year
15032018
16
Open access paper
Similar rates of corneal infiltrative events and microbial keratitis compared to adults
May be a lower risk in children aged 8-12 years (likely due to compliance)
Kids and contact lenses - safety
Reinforce care and maintenance instructions ndash children (8-12 years) recall less after 3 months than teens (Walline et al 2010)
Kids are NOT more risky CL wearers than adults ndash no difference in adverse events after 10 years of wear (Walline et al 2011)
Most common complication ndash CLPC 4 infiltrative keratitis 1 (Sankaridurg et al 2013 Bullimore et al 2013)
Safety of a D centred reusable multifocal and OrthoK is similar (Stapleton et al 2008 Bullimore et al 2013)
15032018
17
Myopia management
The next steps
First corrections
The full picture
Myopia management
The full picture
15032018
18
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment1 2 hours outdoor time per day2 Limit near work to 2 hours per day
(after school) 3 2020 rule ndash regular breaks
Rose et al 2008 Wu et al 2013 Lin et al 2014 Read et al 2015 Woodman et al 2011 Aldossari et al 2017
15032018
19
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Prescribe spectacles (progressive bifocals) if the child is not suitable
for contact lenses
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Consider adding low dose atropine if optical correction (CLrsquos or
spectacles) does not provide sufficient myopia control
15032018
20
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Managing esophoria and accommodative lag may provide
additional benefit for myopia control
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia Mythbusting
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
8
RampL -050Unaided vision RampL 66-OU 66
Binocular vision normal at near (unaided)
RampL -050Unaided vision RampL 612+OU 69
Esophoria andor accommodative lag at near (aided)
Myopia management across the world
971 practitioners 12 countries 6 languages
15032018
9
Use UnderCorrection for Myopia Control
Approach
No Sometimes Always
Eye
care
Pra
ctiti
oners
(
)
0
20
40
60
80
100UK+EIRE
Europe
Asia
Australasia
N America
S America
Wolffsohn et al 2016
Myopia management
The next steps
First corrections
The full picture
15032018
10
Myopia management
The next steps
EFFICACY
Contact lens myopia control - meta-analysis papers
OrthoKSun et al 2015 Si et al 2015
(both open access)
Bifocal and multifocal SCLsLi et al 2017
~ 50
~ 50
15032018
11
Describing efficacy
Atropine 01-1
Atropine 001OK MFSCL
Until further noticehellip
~ 50
15032018
12
Myopia = inaccurate BV behaviour
Near esophoria
Accommodative lag
Higher ACA ratios
Greater variability in accommodative responses
Bennett et al 1989 Bullimore et al 1992 Rosenfield et al 1994 Drobe et al 1995 Gwiazda et al 1995Abbott et al 1998 Gwiazda et al 1999 Mutti et al 2000 Rosenfield et al 2002 Vera-Diaz et al 2002 Chen et al 2003 Wolffsohn et al 2003 Nakatsuka et al 2005 Allen et al 2006 Pandian et al 2006 Harb et al 2006 Mutti et al 2006 Ciuffreda et al 2008 Vasudevan et al 2008 Lin et al 2012
Binocular vision amp myopia control
1Edwards et al 2002 2Gwiazda et al 2003 3Yang et al 2009 4Cheng et al 2010
Progressive spectacles applied to all myopes1-3 helliphelliphelliphelliphelliphellip12-17Progressive spectacles for binocular vision problemshelliphelliphelliphellip37Bifocal spectacles for progressing myopes4helliphelliphelliphelliphelliphelliphelliphelliphellip37-55
15032018
13
Binocular vision amp myopia control
5Aller et al 2016 6Zhu et al 2014 7-9Gifford et al 2017 abc 10Tarrant et al 2008
Bifocal SCL fit to esophores5helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip70OrthoK gives a 56 better myopia control effect in lsquobelow averagersquo accommodators6
OrthoK reduces near esophoria and accommodative lag7-9
Multifocal SCL reduce accommodative lag10
Spectacles are sometimes better than CLs
Stronger corrections (prism add) may be needed for severe BV issues
Multifocal SCL and OK will also have some effect but less predictable
If BV is normal helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOrthoK or MF SCLLarge ESOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOKMFSCLspecsLarge EXOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipSpecs may be best
Changing from specs to CLrsquos in myopes gives an exophoric shift
ESOPHORIA ACCOMMODATIVE LAG
Jalie 1973 Bennett et al 1989 Evans 2007 Grosvenor 2007 Jiminez et al 2011 Snir et al 2003
15032018
14
R -200 -075 x 90L -250 -125 x 90
Age 10
R -275 -075 x 90 L -500 -150x 90
L almost constant exotropia NgtD
Age 11
R -325 -075x 90L -550 -175 x 90
Age 12
Myopia control = spectacles and
BV management
Some progression is
normal
YouTube Myopia Profile
15032018
15
Myopia management made simple
SAFETY
The next steps
Safety ndash microbial keratitis Stapleton et al 2008 Sankaridurg et al 2013 Bullimore et al 2013 Bullimore 2017
0
5
10
15
20
25
DWRGP
DW soft DW DD DW SiH DW SiH(kids)
EW soft EWSiHy
OK (all) OK(kids)
12 2 2
12
0
20
25
7
13
0 04 01
0
425
0 0
Any MK
MK with2 lines ofVA loss
Per 10000 wearers per year
15032018
16
Open access paper
Similar rates of corneal infiltrative events and microbial keratitis compared to adults
May be a lower risk in children aged 8-12 years (likely due to compliance)
Kids and contact lenses - safety
Reinforce care and maintenance instructions ndash children (8-12 years) recall less after 3 months than teens (Walline et al 2010)
Kids are NOT more risky CL wearers than adults ndash no difference in adverse events after 10 years of wear (Walline et al 2011)
Most common complication ndash CLPC 4 infiltrative keratitis 1 (Sankaridurg et al 2013 Bullimore et al 2013)
Safety of a D centred reusable multifocal and OrthoK is similar (Stapleton et al 2008 Bullimore et al 2013)
15032018
17
Myopia management
The next steps
First corrections
The full picture
Myopia management
The full picture
15032018
18
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment1 2 hours outdoor time per day2 Limit near work to 2 hours per day
(after school) 3 2020 rule ndash regular breaks
Rose et al 2008 Wu et al 2013 Lin et al 2014 Read et al 2015 Woodman et al 2011 Aldossari et al 2017
15032018
19
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Prescribe spectacles (progressive bifocals) if the child is not suitable
for contact lenses
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Consider adding low dose atropine if optical correction (CLrsquos or
spectacles) does not provide sufficient myopia control
15032018
20
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Managing esophoria and accommodative lag may provide
additional benefit for myopia control
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia Mythbusting
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
9
Use UnderCorrection for Myopia Control
Approach
No Sometimes Always
Eye
care
Pra
ctiti
oners
(
)
0
20
40
60
80
100UK+EIRE
Europe
Asia
Australasia
N America
S America
Wolffsohn et al 2016
Myopia management
The next steps
First corrections
The full picture
15032018
10
Myopia management
The next steps
EFFICACY
Contact lens myopia control - meta-analysis papers
OrthoKSun et al 2015 Si et al 2015
(both open access)
Bifocal and multifocal SCLsLi et al 2017
~ 50
~ 50
15032018
11
Describing efficacy
Atropine 01-1
Atropine 001OK MFSCL
Until further noticehellip
~ 50
15032018
12
Myopia = inaccurate BV behaviour
Near esophoria
Accommodative lag
Higher ACA ratios
Greater variability in accommodative responses
Bennett et al 1989 Bullimore et al 1992 Rosenfield et al 1994 Drobe et al 1995 Gwiazda et al 1995Abbott et al 1998 Gwiazda et al 1999 Mutti et al 2000 Rosenfield et al 2002 Vera-Diaz et al 2002 Chen et al 2003 Wolffsohn et al 2003 Nakatsuka et al 2005 Allen et al 2006 Pandian et al 2006 Harb et al 2006 Mutti et al 2006 Ciuffreda et al 2008 Vasudevan et al 2008 Lin et al 2012
Binocular vision amp myopia control
1Edwards et al 2002 2Gwiazda et al 2003 3Yang et al 2009 4Cheng et al 2010
Progressive spectacles applied to all myopes1-3 helliphelliphelliphelliphelliphellip12-17Progressive spectacles for binocular vision problemshelliphelliphelliphellip37Bifocal spectacles for progressing myopes4helliphelliphelliphelliphelliphelliphelliphelliphellip37-55
15032018
13
Binocular vision amp myopia control
5Aller et al 2016 6Zhu et al 2014 7-9Gifford et al 2017 abc 10Tarrant et al 2008
Bifocal SCL fit to esophores5helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip70OrthoK gives a 56 better myopia control effect in lsquobelow averagersquo accommodators6
OrthoK reduces near esophoria and accommodative lag7-9
Multifocal SCL reduce accommodative lag10
Spectacles are sometimes better than CLs
Stronger corrections (prism add) may be needed for severe BV issues
Multifocal SCL and OK will also have some effect but less predictable
If BV is normal helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOrthoK or MF SCLLarge ESOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOKMFSCLspecsLarge EXOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipSpecs may be best
Changing from specs to CLrsquos in myopes gives an exophoric shift
ESOPHORIA ACCOMMODATIVE LAG
Jalie 1973 Bennett et al 1989 Evans 2007 Grosvenor 2007 Jiminez et al 2011 Snir et al 2003
15032018
14
R -200 -075 x 90L -250 -125 x 90
Age 10
R -275 -075 x 90 L -500 -150x 90
L almost constant exotropia NgtD
Age 11
R -325 -075x 90L -550 -175 x 90
Age 12
Myopia control = spectacles and
BV management
Some progression is
normal
YouTube Myopia Profile
15032018
15
Myopia management made simple
SAFETY
The next steps
Safety ndash microbial keratitis Stapleton et al 2008 Sankaridurg et al 2013 Bullimore et al 2013 Bullimore 2017
0
5
10
15
20
25
DWRGP
DW soft DW DD DW SiH DW SiH(kids)
EW soft EWSiHy
OK (all) OK(kids)
12 2 2
12
0
20
25
7
13
0 04 01
0
425
0 0
Any MK
MK with2 lines ofVA loss
Per 10000 wearers per year
15032018
16
Open access paper
Similar rates of corneal infiltrative events and microbial keratitis compared to adults
May be a lower risk in children aged 8-12 years (likely due to compliance)
Kids and contact lenses - safety
Reinforce care and maintenance instructions ndash children (8-12 years) recall less after 3 months than teens (Walline et al 2010)
Kids are NOT more risky CL wearers than adults ndash no difference in adverse events after 10 years of wear (Walline et al 2011)
Most common complication ndash CLPC 4 infiltrative keratitis 1 (Sankaridurg et al 2013 Bullimore et al 2013)
Safety of a D centred reusable multifocal and OrthoK is similar (Stapleton et al 2008 Bullimore et al 2013)
15032018
17
Myopia management
The next steps
First corrections
The full picture
Myopia management
The full picture
15032018
18
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment1 2 hours outdoor time per day2 Limit near work to 2 hours per day
(after school) 3 2020 rule ndash regular breaks
Rose et al 2008 Wu et al 2013 Lin et al 2014 Read et al 2015 Woodman et al 2011 Aldossari et al 2017
15032018
19
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Prescribe spectacles (progressive bifocals) if the child is not suitable
for contact lenses
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Consider adding low dose atropine if optical correction (CLrsquos or
spectacles) does not provide sufficient myopia control
15032018
20
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Managing esophoria and accommodative lag may provide
additional benefit for myopia control
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia Mythbusting
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
10
Myopia management
The next steps
EFFICACY
Contact lens myopia control - meta-analysis papers
OrthoKSun et al 2015 Si et al 2015
(both open access)
Bifocal and multifocal SCLsLi et al 2017
~ 50
~ 50
15032018
11
Describing efficacy
Atropine 01-1
Atropine 001OK MFSCL
Until further noticehellip
~ 50
15032018
12
Myopia = inaccurate BV behaviour
Near esophoria
Accommodative lag
Higher ACA ratios
Greater variability in accommodative responses
Bennett et al 1989 Bullimore et al 1992 Rosenfield et al 1994 Drobe et al 1995 Gwiazda et al 1995Abbott et al 1998 Gwiazda et al 1999 Mutti et al 2000 Rosenfield et al 2002 Vera-Diaz et al 2002 Chen et al 2003 Wolffsohn et al 2003 Nakatsuka et al 2005 Allen et al 2006 Pandian et al 2006 Harb et al 2006 Mutti et al 2006 Ciuffreda et al 2008 Vasudevan et al 2008 Lin et al 2012
Binocular vision amp myopia control
1Edwards et al 2002 2Gwiazda et al 2003 3Yang et al 2009 4Cheng et al 2010
Progressive spectacles applied to all myopes1-3 helliphelliphelliphelliphelliphellip12-17Progressive spectacles for binocular vision problemshelliphelliphelliphellip37Bifocal spectacles for progressing myopes4helliphelliphelliphelliphelliphelliphelliphelliphellip37-55
15032018
13
Binocular vision amp myopia control
5Aller et al 2016 6Zhu et al 2014 7-9Gifford et al 2017 abc 10Tarrant et al 2008
Bifocal SCL fit to esophores5helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip70OrthoK gives a 56 better myopia control effect in lsquobelow averagersquo accommodators6
OrthoK reduces near esophoria and accommodative lag7-9
Multifocal SCL reduce accommodative lag10
Spectacles are sometimes better than CLs
Stronger corrections (prism add) may be needed for severe BV issues
Multifocal SCL and OK will also have some effect but less predictable
If BV is normal helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOrthoK or MF SCLLarge ESOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOKMFSCLspecsLarge EXOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipSpecs may be best
Changing from specs to CLrsquos in myopes gives an exophoric shift
ESOPHORIA ACCOMMODATIVE LAG
Jalie 1973 Bennett et al 1989 Evans 2007 Grosvenor 2007 Jiminez et al 2011 Snir et al 2003
15032018
14
R -200 -075 x 90L -250 -125 x 90
Age 10
R -275 -075 x 90 L -500 -150x 90
L almost constant exotropia NgtD
Age 11
R -325 -075x 90L -550 -175 x 90
Age 12
Myopia control = spectacles and
BV management
Some progression is
normal
YouTube Myopia Profile
15032018
15
Myopia management made simple
SAFETY
The next steps
Safety ndash microbial keratitis Stapleton et al 2008 Sankaridurg et al 2013 Bullimore et al 2013 Bullimore 2017
0
5
10
15
20
25
DWRGP
DW soft DW DD DW SiH DW SiH(kids)
EW soft EWSiHy
OK (all) OK(kids)
12 2 2
12
0
20
25
7
13
0 04 01
0
425
0 0
Any MK
MK with2 lines ofVA loss
Per 10000 wearers per year
15032018
16
Open access paper
Similar rates of corneal infiltrative events and microbial keratitis compared to adults
May be a lower risk in children aged 8-12 years (likely due to compliance)
Kids and contact lenses - safety
Reinforce care and maintenance instructions ndash children (8-12 years) recall less after 3 months than teens (Walline et al 2010)
Kids are NOT more risky CL wearers than adults ndash no difference in adverse events after 10 years of wear (Walline et al 2011)
Most common complication ndash CLPC 4 infiltrative keratitis 1 (Sankaridurg et al 2013 Bullimore et al 2013)
Safety of a D centred reusable multifocal and OrthoK is similar (Stapleton et al 2008 Bullimore et al 2013)
15032018
17
Myopia management
The next steps
First corrections
The full picture
Myopia management
The full picture
15032018
18
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment1 2 hours outdoor time per day2 Limit near work to 2 hours per day
(after school) 3 2020 rule ndash regular breaks
Rose et al 2008 Wu et al 2013 Lin et al 2014 Read et al 2015 Woodman et al 2011 Aldossari et al 2017
15032018
19
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Prescribe spectacles (progressive bifocals) if the child is not suitable
for contact lenses
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Consider adding low dose atropine if optical correction (CLrsquos or
spectacles) does not provide sufficient myopia control
15032018
20
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Managing esophoria and accommodative lag may provide
additional benefit for myopia control
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia Mythbusting
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
11
Describing efficacy
Atropine 01-1
Atropine 001OK MFSCL
Until further noticehellip
~ 50
15032018
12
Myopia = inaccurate BV behaviour
Near esophoria
Accommodative lag
Higher ACA ratios
Greater variability in accommodative responses
Bennett et al 1989 Bullimore et al 1992 Rosenfield et al 1994 Drobe et al 1995 Gwiazda et al 1995Abbott et al 1998 Gwiazda et al 1999 Mutti et al 2000 Rosenfield et al 2002 Vera-Diaz et al 2002 Chen et al 2003 Wolffsohn et al 2003 Nakatsuka et al 2005 Allen et al 2006 Pandian et al 2006 Harb et al 2006 Mutti et al 2006 Ciuffreda et al 2008 Vasudevan et al 2008 Lin et al 2012
Binocular vision amp myopia control
1Edwards et al 2002 2Gwiazda et al 2003 3Yang et al 2009 4Cheng et al 2010
Progressive spectacles applied to all myopes1-3 helliphelliphelliphelliphelliphellip12-17Progressive spectacles for binocular vision problemshelliphelliphelliphellip37Bifocal spectacles for progressing myopes4helliphelliphelliphelliphelliphelliphelliphelliphellip37-55
15032018
13
Binocular vision amp myopia control
5Aller et al 2016 6Zhu et al 2014 7-9Gifford et al 2017 abc 10Tarrant et al 2008
Bifocal SCL fit to esophores5helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip70OrthoK gives a 56 better myopia control effect in lsquobelow averagersquo accommodators6
OrthoK reduces near esophoria and accommodative lag7-9
Multifocal SCL reduce accommodative lag10
Spectacles are sometimes better than CLs
Stronger corrections (prism add) may be needed for severe BV issues
Multifocal SCL and OK will also have some effect but less predictable
If BV is normal helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOrthoK or MF SCLLarge ESOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOKMFSCLspecsLarge EXOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipSpecs may be best
Changing from specs to CLrsquos in myopes gives an exophoric shift
ESOPHORIA ACCOMMODATIVE LAG
Jalie 1973 Bennett et al 1989 Evans 2007 Grosvenor 2007 Jiminez et al 2011 Snir et al 2003
15032018
14
R -200 -075 x 90L -250 -125 x 90
Age 10
R -275 -075 x 90 L -500 -150x 90
L almost constant exotropia NgtD
Age 11
R -325 -075x 90L -550 -175 x 90
Age 12
Myopia control = spectacles and
BV management
Some progression is
normal
YouTube Myopia Profile
15032018
15
Myopia management made simple
SAFETY
The next steps
Safety ndash microbial keratitis Stapleton et al 2008 Sankaridurg et al 2013 Bullimore et al 2013 Bullimore 2017
0
5
10
15
20
25
DWRGP
DW soft DW DD DW SiH DW SiH(kids)
EW soft EWSiHy
OK (all) OK(kids)
12 2 2
12
0
20
25
7
13
0 04 01
0
425
0 0
Any MK
MK with2 lines ofVA loss
Per 10000 wearers per year
15032018
16
Open access paper
Similar rates of corneal infiltrative events and microbial keratitis compared to adults
May be a lower risk in children aged 8-12 years (likely due to compliance)
Kids and contact lenses - safety
Reinforce care and maintenance instructions ndash children (8-12 years) recall less after 3 months than teens (Walline et al 2010)
Kids are NOT more risky CL wearers than adults ndash no difference in adverse events after 10 years of wear (Walline et al 2011)
Most common complication ndash CLPC 4 infiltrative keratitis 1 (Sankaridurg et al 2013 Bullimore et al 2013)
Safety of a D centred reusable multifocal and OrthoK is similar (Stapleton et al 2008 Bullimore et al 2013)
15032018
17
Myopia management
The next steps
First corrections
The full picture
Myopia management
The full picture
15032018
18
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment1 2 hours outdoor time per day2 Limit near work to 2 hours per day
(after school) 3 2020 rule ndash regular breaks
Rose et al 2008 Wu et al 2013 Lin et al 2014 Read et al 2015 Woodman et al 2011 Aldossari et al 2017
15032018
19
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Prescribe spectacles (progressive bifocals) if the child is not suitable
for contact lenses
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Consider adding low dose atropine if optical correction (CLrsquos or
spectacles) does not provide sufficient myopia control
15032018
20
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Managing esophoria and accommodative lag may provide
additional benefit for myopia control
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia Mythbusting
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
12
Myopia = inaccurate BV behaviour
Near esophoria
Accommodative lag
Higher ACA ratios
Greater variability in accommodative responses
Bennett et al 1989 Bullimore et al 1992 Rosenfield et al 1994 Drobe et al 1995 Gwiazda et al 1995Abbott et al 1998 Gwiazda et al 1999 Mutti et al 2000 Rosenfield et al 2002 Vera-Diaz et al 2002 Chen et al 2003 Wolffsohn et al 2003 Nakatsuka et al 2005 Allen et al 2006 Pandian et al 2006 Harb et al 2006 Mutti et al 2006 Ciuffreda et al 2008 Vasudevan et al 2008 Lin et al 2012
Binocular vision amp myopia control
1Edwards et al 2002 2Gwiazda et al 2003 3Yang et al 2009 4Cheng et al 2010
Progressive spectacles applied to all myopes1-3 helliphelliphelliphelliphelliphellip12-17Progressive spectacles for binocular vision problemshelliphelliphelliphellip37Bifocal spectacles for progressing myopes4helliphelliphelliphelliphelliphelliphelliphelliphellip37-55
15032018
13
Binocular vision amp myopia control
5Aller et al 2016 6Zhu et al 2014 7-9Gifford et al 2017 abc 10Tarrant et al 2008
Bifocal SCL fit to esophores5helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip70OrthoK gives a 56 better myopia control effect in lsquobelow averagersquo accommodators6
OrthoK reduces near esophoria and accommodative lag7-9
Multifocal SCL reduce accommodative lag10
Spectacles are sometimes better than CLs
Stronger corrections (prism add) may be needed for severe BV issues
Multifocal SCL and OK will also have some effect but less predictable
If BV is normal helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOrthoK or MF SCLLarge ESOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOKMFSCLspecsLarge EXOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipSpecs may be best
Changing from specs to CLrsquos in myopes gives an exophoric shift
ESOPHORIA ACCOMMODATIVE LAG
Jalie 1973 Bennett et al 1989 Evans 2007 Grosvenor 2007 Jiminez et al 2011 Snir et al 2003
15032018
14
R -200 -075 x 90L -250 -125 x 90
Age 10
R -275 -075 x 90 L -500 -150x 90
L almost constant exotropia NgtD
Age 11
R -325 -075x 90L -550 -175 x 90
Age 12
Myopia control = spectacles and
BV management
Some progression is
normal
YouTube Myopia Profile
15032018
15
Myopia management made simple
SAFETY
The next steps
Safety ndash microbial keratitis Stapleton et al 2008 Sankaridurg et al 2013 Bullimore et al 2013 Bullimore 2017
0
5
10
15
20
25
DWRGP
DW soft DW DD DW SiH DW SiH(kids)
EW soft EWSiHy
OK (all) OK(kids)
12 2 2
12
0
20
25
7
13
0 04 01
0
425
0 0
Any MK
MK with2 lines ofVA loss
Per 10000 wearers per year
15032018
16
Open access paper
Similar rates of corneal infiltrative events and microbial keratitis compared to adults
May be a lower risk in children aged 8-12 years (likely due to compliance)
Kids and contact lenses - safety
Reinforce care and maintenance instructions ndash children (8-12 years) recall less after 3 months than teens (Walline et al 2010)
Kids are NOT more risky CL wearers than adults ndash no difference in adverse events after 10 years of wear (Walline et al 2011)
Most common complication ndash CLPC 4 infiltrative keratitis 1 (Sankaridurg et al 2013 Bullimore et al 2013)
Safety of a D centred reusable multifocal and OrthoK is similar (Stapleton et al 2008 Bullimore et al 2013)
15032018
17
Myopia management
The next steps
First corrections
The full picture
Myopia management
The full picture
15032018
18
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment1 2 hours outdoor time per day2 Limit near work to 2 hours per day
(after school) 3 2020 rule ndash regular breaks
Rose et al 2008 Wu et al 2013 Lin et al 2014 Read et al 2015 Woodman et al 2011 Aldossari et al 2017
15032018
19
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Prescribe spectacles (progressive bifocals) if the child is not suitable
for contact lenses
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Consider adding low dose atropine if optical correction (CLrsquos or
spectacles) does not provide sufficient myopia control
15032018
20
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Managing esophoria and accommodative lag may provide
additional benefit for myopia control
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia Mythbusting
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
13
Binocular vision amp myopia control
5Aller et al 2016 6Zhu et al 2014 7-9Gifford et al 2017 abc 10Tarrant et al 2008
Bifocal SCL fit to esophores5helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip70OrthoK gives a 56 better myopia control effect in lsquobelow averagersquo accommodators6
OrthoK reduces near esophoria and accommodative lag7-9
Multifocal SCL reduce accommodative lag10
Spectacles are sometimes better than CLs
Stronger corrections (prism add) may be needed for severe BV issues
Multifocal SCL and OK will also have some effect but less predictable
If BV is normal helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOrthoK or MF SCLLarge ESOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipOKMFSCLspecsLarge EXOhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipSpecs may be best
Changing from specs to CLrsquos in myopes gives an exophoric shift
ESOPHORIA ACCOMMODATIVE LAG
Jalie 1973 Bennett et al 1989 Evans 2007 Grosvenor 2007 Jiminez et al 2011 Snir et al 2003
15032018
14
R -200 -075 x 90L -250 -125 x 90
Age 10
R -275 -075 x 90 L -500 -150x 90
L almost constant exotropia NgtD
Age 11
R -325 -075x 90L -550 -175 x 90
Age 12
Myopia control = spectacles and
BV management
Some progression is
normal
YouTube Myopia Profile
15032018
15
Myopia management made simple
SAFETY
The next steps
Safety ndash microbial keratitis Stapleton et al 2008 Sankaridurg et al 2013 Bullimore et al 2013 Bullimore 2017
0
5
10
15
20
25
DWRGP
DW soft DW DD DW SiH DW SiH(kids)
EW soft EWSiHy
OK (all) OK(kids)
12 2 2
12
0
20
25
7
13
0 04 01
0
425
0 0
Any MK
MK with2 lines ofVA loss
Per 10000 wearers per year
15032018
16
Open access paper
Similar rates of corneal infiltrative events and microbial keratitis compared to adults
May be a lower risk in children aged 8-12 years (likely due to compliance)
Kids and contact lenses - safety
Reinforce care and maintenance instructions ndash children (8-12 years) recall less after 3 months than teens (Walline et al 2010)
Kids are NOT more risky CL wearers than adults ndash no difference in adverse events after 10 years of wear (Walline et al 2011)
Most common complication ndash CLPC 4 infiltrative keratitis 1 (Sankaridurg et al 2013 Bullimore et al 2013)
Safety of a D centred reusable multifocal and OrthoK is similar (Stapleton et al 2008 Bullimore et al 2013)
15032018
17
Myopia management
The next steps
First corrections
The full picture
Myopia management
The full picture
15032018
18
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment1 2 hours outdoor time per day2 Limit near work to 2 hours per day
(after school) 3 2020 rule ndash regular breaks
Rose et al 2008 Wu et al 2013 Lin et al 2014 Read et al 2015 Woodman et al 2011 Aldossari et al 2017
15032018
19
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Prescribe spectacles (progressive bifocals) if the child is not suitable
for contact lenses
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Consider adding low dose atropine if optical correction (CLrsquos or
spectacles) does not provide sufficient myopia control
15032018
20
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Managing esophoria and accommodative lag may provide
additional benefit for myopia control
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia Mythbusting
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
14
R -200 -075 x 90L -250 -125 x 90
Age 10
R -275 -075 x 90 L -500 -150x 90
L almost constant exotropia NgtD
Age 11
R -325 -075x 90L -550 -175 x 90
Age 12
Myopia control = spectacles and
BV management
Some progression is
normal
YouTube Myopia Profile
15032018
15
Myopia management made simple
SAFETY
The next steps
Safety ndash microbial keratitis Stapleton et al 2008 Sankaridurg et al 2013 Bullimore et al 2013 Bullimore 2017
0
5
10
15
20
25
DWRGP
DW soft DW DD DW SiH DW SiH(kids)
EW soft EWSiHy
OK (all) OK(kids)
12 2 2
12
0
20
25
7
13
0 04 01
0
425
0 0
Any MK
MK with2 lines ofVA loss
Per 10000 wearers per year
15032018
16
Open access paper
Similar rates of corneal infiltrative events and microbial keratitis compared to adults
May be a lower risk in children aged 8-12 years (likely due to compliance)
Kids and contact lenses - safety
Reinforce care and maintenance instructions ndash children (8-12 years) recall less after 3 months than teens (Walline et al 2010)
Kids are NOT more risky CL wearers than adults ndash no difference in adverse events after 10 years of wear (Walline et al 2011)
Most common complication ndash CLPC 4 infiltrative keratitis 1 (Sankaridurg et al 2013 Bullimore et al 2013)
Safety of a D centred reusable multifocal and OrthoK is similar (Stapleton et al 2008 Bullimore et al 2013)
15032018
17
Myopia management
The next steps
First corrections
The full picture
Myopia management
The full picture
15032018
18
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment1 2 hours outdoor time per day2 Limit near work to 2 hours per day
(after school) 3 2020 rule ndash regular breaks
Rose et al 2008 Wu et al 2013 Lin et al 2014 Read et al 2015 Woodman et al 2011 Aldossari et al 2017
15032018
19
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Prescribe spectacles (progressive bifocals) if the child is not suitable
for contact lenses
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Consider adding low dose atropine if optical correction (CLrsquos or
spectacles) does not provide sufficient myopia control
15032018
20
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Managing esophoria and accommodative lag may provide
additional benefit for myopia control
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia Mythbusting
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
15
Myopia management made simple
SAFETY
The next steps
Safety ndash microbial keratitis Stapleton et al 2008 Sankaridurg et al 2013 Bullimore et al 2013 Bullimore 2017
0
5
10
15
20
25
DWRGP
DW soft DW DD DW SiH DW SiH(kids)
EW soft EWSiHy
OK (all) OK(kids)
12 2 2
12
0
20
25
7
13
0 04 01
0
425
0 0
Any MK
MK with2 lines ofVA loss
Per 10000 wearers per year
15032018
16
Open access paper
Similar rates of corneal infiltrative events and microbial keratitis compared to adults
May be a lower risk in children aged 8-12 years (likely due to compliance)
Kids and contact lenses - safety
Reinforce care and maintenance instructions ndash children (8-12 years) recall less after 3 months than teens (Walline et al 2010)
Kids are NOT more risky CL wearers than adults ndash no difference in adverse events after 10 years of wear (Walline et al 2011)
Most common complication ndash CLPC 4 infiltrative keratitis 1 (Sankaridurg et al 2013 Bullimore et al 2013)
Safety of a D centred reusable multifocal and OrthoK is similar (Stapleton et al 2008 Bullimore et al 2013)
15032018
17
Myopia management
The next steps
First corrections
The full picture
Myopia management
The full picture
15032018
18
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment1 2 hours outdoor time per day2 Limit near work to 2 hours per day
(after school) 3 2020 rule ndash regular breaks
Rose et al 2008 Wu et al 2013 Lin et al 2014 Read et al 2015 Woodman et al 2011 Aldossari et al 2017
15032018
19
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Prescribe spectacles (progressive bifocals) if the child is not suitable
for contact lenses
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Consider adding low dose atropine if optical correction (CLrsquos or
spectacles) does not provide sufficient myopia control
15032018
20
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Managing esophoria and accommodative lag may provide
additional benefit for myopia control
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia Mythbusting
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
16
Open access paper
Similar rates of corneal infiltrative events and microbial keratitis compared to adults
May be a lower risk in children aged 8-12 years (likely due to compliance)
Kids and contact lenses - safety
Reinforce care and maintenance instructions ndash children (8-12 years) recall less after 3 months than teens (Walline et al 2010)
Kids are NOT more risky CL wearers than adults ndash no difference in adverse events after 10 years of wear (Walline et al 2011)
Most common complication ndash CLPC 4 infiltrative keratitis 1 (Sankaridurg et al 2013 Bullimore et al 2013)
Safety of a D centred reusable multifocal and OrthoK is similar (Stapleton et al 2008 Bullimore et al 2013)
15032018
17
Myopia management
The next steps
First corrections
The full picture
Myopia management
The full picture
15032018
18
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment1 2 hours outdoor time per day2 Limit near work to 2 hours per day
(after school) 3 2020 rule ndash regular breaks
Rose et al 2008 Wu et al 2013 Lin et al 2014 Read et al 2015 Woodman et al 2011 Aldossari et al 2017
15032018
19
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Prescribe spectacles (progressive bifocals) if the child is not suitable
for contact lenses
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Consider adding low dose atropine if optical correction (CLrsquos or
spectacles) does not provide sufficient myopia control
15032018
20
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Managing esophoria and accommodative lag may provide
additional benefit for myopia control
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia Mythbusting
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
17
Myopia management
The next steps
First corrections
The full picture
Myopia management
The full picture
15032018
18
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment1 2 hours outdoor time per day2 Limit near work to 2 hours per day
(after school) 3 2020 rule ndash regular breaks
Rose et al 2008 Wu et al 2013 Lin et al 2014 Read et al 2015 Woodman et al 2011 Aldossari et al 2017
15032018
19
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Prescribe spectacles (progressive bifocals) if the child is not suitable
for contact lenses
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Consider adding low dose atropine if optical correction (CLrsquos or
spectacles) does not provide sufficient myopia control
15032018
20
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Managing esophoria and accommodative lag may provide
additional benefit for myopia control
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia Mythbusting
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
18
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment1 2 hours outdoor time per day2 Limit near work to 2 hours per day
(after school) 3 2020 rule ndash regular breaks
Rose et al 2008 Wu et al 2013 Lin et al 2014 Read et al 2015 Woodman et al 2011 Aldossari et al 2017
15032018
19
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Prescribe spectacles (progressive bifocals) if the child is not suitable
for contact lenses
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Consider adding low dose atropine if optical correction (CLrsquos or
spectacles) does not provide sufficient myopia control
15032018
20
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Managing esophoria and accommodative lag may provide
additional benefit for myopia control
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia Mythbusting
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
19
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Prescribe spectacles (progressive bifocals) if the child is not suitable
for contact lenses
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Consider adding low dose atropine if optical correction (CLrsquos or
spectacles) does not provide sufficient myopia control
15032018
20
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Managing esophoria and accommodative lag may provide
additional benefit for myopia control
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia Mythbusting
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
20
Three pillars of clinical myopia control
Contact Lenses
Binocular vision
Environment
Managing esophoria and accommodative lag may provide
additional benefit for myopia control
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia Mythbusting
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
21
2
1
3
4
Theyrsquore myopic anyway ndash therersquos no big difference between being -200 and -300
Itrsquos best to wait for progression before commencing myopia management
Kids and contact lenses ndash ooooh thatrsquos a bit risky
If I donrsquot fit OrthoK I canrsquot do myopia control
Myopia MythbustingMyopia ManagementKeeping myopia below -300D and axial length below 26mm significantly reduces lifelong risk of pathology and vision loss
Intervention before age 12 will have the biggest impact on reducing progression (including visual environment advice)
Until further notice ndash atropine OrthoK and MFSCL are all similar Specs are valid too ndash pick the optical correction first and add atropine second
SCL safety in younger children appears to be better than teens and the risk of future myopic pathology is certain
Clinical resources
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
22
Clinical resources for myopia management
wwwmyopiaprofilecom
wwwmykidsvisionorg
Facebook Myopia Profile
YouTube Myopia Profile
httpwwwmyopiainstituteorgcommittees
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
23
SECOND LECTURE Langis Michaud
Myopia AL management ndash clinical testing
1 Oriented case history (risk factors)
bull Familypatient background
bull Ethnical origins
bull Environmental conditions
bull Past evolution
2 Refractive and binocular vision assessment
bull BV assessment phoria at near ACA accommodative lag
bull Cycloplegic refraction
3 Ocular parameters
bull Topography
bull Pupils
bull Axial Length
4 Ocular health
bull Slit lamp
bull DFE
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
24
Set-up a myopia assessment (2)
4 Corneal Topography
bull May impact contact lens selection
bull Look at both sides
5 Axial Length
bull The true gold-standard assessment for evolution
6 Aberrometry
TOPOhellip back and front corneal floatshellip
OD
OS
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
25
Association of Axial Length With Risk
of Uncorrectable Visual Impairment
for Europeans With MyopiaJ Willem L Tideman MD Margaretha C C Snabel MD Milly S Tedja MD Gwyneth A van Rijn MD
King TWong MD RobertW AM Kuijpers MD PhD Johannes R Vingerling MD PhD Albert Hofman MD PhD
Gabrieumllle H S Buitendijk MD Jan E E Keunen MD PhD Camiel J F Boon MD PhD Annette JM Geerards MD
Gregorius P M Luyten MD PhD Virginie J M Verhoeven MD PhD Caroline CW Klaver MD PhD
JAMA Ophthalmol doi101001jamaophthalmol20164009
Published online October 20 2016
Mode of correction HOA
bull High-Order Aberrations theory
bull A greater increase in coma-like aberrations = less axial elongation (Hiraoka Ophthalmology 2015 122 93-100)
bull Spherical aberrations are linked to the LAG
bull There is a significant negative correlation between SA and CSF
bull Degradation of the image (lower sensitivity) may impact the progression of myopia (likedeprivation)
bullWe should control spherical aberrations in myopes
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
26
ACCOMMODATION AND ABERRATIONS
Although central optical blur is the primary stimulus required to drive the accommodative system(Kruger 1986) insufficient
accommodation ie an increased lag of accommodation has previously been linked to axial elongation(Mutti 2006 Gwiadza 2004)
Children with higher myopia are reported to experience increased lags of accommodation (Gwiadza 2004)
Further multifocal contact lens designs induce higher order aberrations which may affect the peripheral refraction profiles as
well as accommodative responses (Ruiz-Alcocer 2012)
Increased lag with CN
Influenced also by SA
Myopic defocus with CD
Optom Vis Sci 2017 Feb94(2)197-207 doi 101097OPX0000000000001017
Impact of Spherical Aberration Terms on Multifocal Contact Lens Performance
Fedtke C1 Sha J Thomas V Ehrmann K Bakaraju RC
Primary SA = negative with Centered-Near Designs
In agreement with previous studies distance measurements of the current study showed
that when using commercially available center distance lenses it was possible to reduce
relative hyperopia or induce relative myopia in the peripheral visual field and that this
myopic shift was more pronounced in the nasal visual field The opposite effect ie an
increase in relative hyperopia has been observed for the center-near lenses tested in this
and previous studies
CONCLUSIONBased on the hypothesis that myopic retinal defocus counters eye growth all center-near multifocal
lenses exhibited the preferred features of on-axis at near ie producing a central myopic shift
compared to the control The center-distance lens showed the preferred off axis features by producing
significant relative peripheral myopic shift which in the periphery increased further during
accommodation When accounting for primary spherical aberration these on and off-axis features ie
the reduction of hyperopic retinal defocus were more pronounced
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
27
Soft MF Design
Ophthalmic Physiol Opt 2017 Jan37(1)51-59 doi 101111opo12332 Epub 2016 Nov 23
Studies using concentric ring bifocal and peripheral add multifocal
contact lenses to slow myopia progression in school-aged children a
meta-analysisLi SM1 Kang MT1 Wu SS2 Meng B2 Sun YY1 Wei SF1 Liu L3 Peng X4 Chen Z15 Zhang F1 Wang N1
CONCLUSIONS
Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically
effective for controlling myopia in school-aged children with an overall myopia control rates
of 30~50 over 2 years Concentric ring bifocal soft contact lenses seem to have greater
effect than peripheral add multifocal soft contact lenses
Set-up a myopia assessment
6 Pupil size
- The entrance door
- Especially for OK
- Drives distance blur
7 Slit lamp DFE
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
28
bull Need to customize lens designs for every patient
bull Myopia correction is not myopia control
Clinical recommendationsalgorithm
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
29
Can we predict
Michaud Simard - Cont Lens Spect Sept 2017 (open access)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
30
GUIDE TO CLINICAL MANAGEMENT
bull THE IDEAL MYOPIA CONTROL LENS
bull Induce peripheral myopia without compromising vision
bull Reduce lag of accommodation
bull Reduce near esophoria
bull Provide controlled release of antimuscarinic agents
bull Provide a beneficial shift in positive SA to improve near point depth of focus without compromising image quality
bull Measure ocular biometrics and analyze surroundings to provide real-time advice and training in avoiding stimulation increasing the risk of myopia
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
31
CALIBRATE INTERVENTIONS
Binocular
Vision issues
Mechanism
Optical
Aberrations
Peripheral
hyperopia
How to fix it
Re-establish
normal
Accomodation
-convergence
balance
Calibrate blur
in the optic
zone
Play with Net
peripheral
power
Options
Orthoptics Vision Therapy
Prismatic bifocal glasses
Higher add power- keep
natural accomodation
Centred-distance MF
Customizable OZ
Generate Suppression
Customizable OK
Higher add power MF
Depth of field vs depth of focus
Depth of field is the distance over which an object may be moved without causing a sharpness reduction beyond a certain tolerable amount
bull Increases if pupil becomes smaller
Depth of focus is the distance in front and behind the focal point (or retina) over which the image may be focused without causing a sharpness reduction beyond a certain tolerable amount
bull Inversionnaly proportional to the pupil size
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
32
The future
bull Moving outward from the center of the lens RELATIVE PLUS POWER rises dramatically in a smooth and continuous manner and creates a blur zone
bull The blur zone is designed to be suppressed by the brain effectively resulting in a virtual aperture created by the visual cortex and therefore an extended depth of focus in which distance intermediate and near vision are all clear
Courtesy of Dr Benoit Natural Vue
Testing and outcome
bull Schedule
bull 1 week 1 month 3 months 6 months
bull What testing should we do
bull Oriented case history
bull Refractive components
bull BV if issues
bull AL
bull Ocular health
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
33
Potential modifications
LZA 1 angle change = 15 microm sag variation
BC 01 mm change = 7 microm sag variation
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
34
Follow-ups
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
35
Is this working
bull Diopters are not a valid reference to evaluate progression
bull Muttirsquos theory the first 01 AL increase
bull Other treatment options to consider
bull Environmental
bull Ergonomical
bull Lightning
bull Outdoor
bull Etc
DISCUSSION PANEL
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
36
Myopia management puzzles
Risks of long term
atropine use
Myopia management puzzles
Risks of long term
atropine use
Customising treatments
and off-label use
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
37
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
Customising treatments
and off-label use
Myopia management puzzles
Measuring axial
length in practice
Risks of long term
atropine use
The challenge of
high myopia
Customising treatments
and off-label use
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
38
SUMMARY
bull MC is easy to implement patient by patient
bull Strategy should be customized for every patient as well as treatment options
bull Importance of taking in account the big picture including binocular vision
03
Atropine plus optical corrections
Phillips et al IMC 2017
Myopic defocus = choroidal thickening
Hyperopic defocus = choroidal thinning
Myopic defocus = choroidal thickening
Hyperopic defocus = no choroid change
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)
15032018
39
The digital worldhellip
American Academy of Pediatrics(wwwaaporg) and Australian Government Department of Health (wwwhealthgovau)
bull Under 2 years no screen time bull 2-5 years max 1 hour of screen
time day bull No more than 1 hour at a time
sedentaryrestrainedinactive when awake
The digital worldhellip and virtual reality Ocular effects of virtual reality headset wear in young adultsTurnbull P amp Phillips J Scientific Reports 2017
bull Mismatch between vergence and accommodation but no change in BV status after indoor and outdoor simulations
bull Choroidal thickening after VR trial ndashbull Heat from headset OR bull Beneficial effect on BV (increased
convergence and lead of accom for near objects)