preventing myopia progression

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PREVENTING MYOPIA PREVENTING MYOPIA PROGRESSION PROGRESSION DR PRASHANT SAHARE DR LIONEL KOWAL OMC RVEEH & CERA MELBOURNE AUSTRALIA

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PREVENTING MYOPIA PROGRESSION . DR PRASHANT SAHARE DR LIONEL KOWAL OMC RVEEH & CERA MELBOURNE AUSTRALIA. MECHANISM. Many Interesting Innovative and Credible Theories – no proof 1. disruption of emmetropisation 2. form deprivation 3. optical defocus 4. excessive accommodation - PowerPoint PPT Presentation

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Page 1: PREVENTING   MYOPIA PROGRESSION

PREVENTING MYOPIA PREVENTING MYOPIA PROGRESSION PROGRESSION

DR PRASHANT SAHAREDR LIONEL KOWAL

OMC RVEEH & CERAMELBOURNE AUSTRALIA

Page 2: PREVENTING   MYOPIA PROGRESSION

MECHANISMMECHANISM

Many Interesting Innovative and Credible Theories – no proof1. disruption of emmetropisation2. form deprivation3. optical defocus4. excessive accommodation5. incremental retinal defocus theory Hung & Ciuffreda ARVO 01

6. abnormal scleral collagen

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MECHANISMMECHANISMGenetic aspects Many different genes : ? phenotype / genotype correlation. ? Each genetic type of myopia has a UNIQUE MECHANISM / ROMP / RESPONSE TO DIFFT TREATMENTSHong Kong? 90% incidence of myopiaGenetic influences less credible

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TREATMENTS TO ARREST TREATMENTS TO ARREST MYOPIA MYOPIA

OPTICAL1.↓duration of spectacle wear2. planned under correction2. Bifocals / PALs3. contact lenses / orthoKPHARMACOLOGICAL4. atropine / pirenzipine5. ocular hypotensives

Page 5: PREVENTING   MYOPIA PROGRESSION

IDEAL STUDYIDEAL STUDY

Prospective Randomised Double blind? Monocular control [systemic absorption]

*Determine optimal timing & duration of Rx

**Detect catch-up after stopping Rx

Page 6: PREVENTING   MYOPIA PROGRESSION

APPARENTLY EXCELLENT APPARENTLY EXCELLENT RESULTRESULT

MyopiaDS

AGE

CONTROL

TREATMENT

Page 7: PREVENTING   MYOPIA PROGRESSION

EXCELLENTEXCELLENTRESULTRESULT

MyopiaDS

AGE

CONTROL

NEW RATE

TREATMENT STOPPED

AFTER STOPPING Rx, ROMP @ ‘NEW’ [LOWER] RATE

Page 8: PREVENTING   MYOPIA PROGRESSION

SIMULATED EXCELLENT SIMULATED EXCELLENT RESULT-1RESULT-1

MyopiaDS

AGE

CONTROL

CATCH UP ON STOPPING Rx

STOP TREATMENT

Page 9: PREVENTING   MYOPIA PROGRESSION

MyopiaDS

AGE

CONTROL

AFTER STOPPING Rx, ROMP @ ‘OLD’ [control] RATE

TREATMENT STOPPED

OLD RATE

SIMULATED EXCELLENT SIMULATED EXCELLENT RESULT- 2RESULT- 2

Page 10: PREVENTING   MYOPIA PROGRESSION

SIMULATED EXCELLENT SIMULATED EXCELLENT RESULT-3RESULT-3

MyopiaDS

AGE

CONTROL

CATCH UP

SLOWS MYOPIC PROGRESSION

Rx SLOWS ROMP. MYOPIA CATCHES UP DESPITE CONTINUING / AFTER STOPPING Rx

Page 11: PREVENTING   MYOPIA PROGRESSION

APPARENTLY EXCELLENT APPARENTLY EXCELLENT RESULT : EASILY RESULT : EASILY

SIMULATEDSIMULATED

MyopiaDS

AGE

CONTROL

TREATMENT

Page 12: PREVENTING   MYOPIA PROGRESSION

STUDY QUESTIONSSTUDY QUESTIONS 1. CONTROL GROUP 2. DURATION OF

TREATMENT 3. DURATION OF

FOLLOW UP4. DATA AFTER

TREATMENT STOPPED

Page 13: PREVENTING   MYOPIA PROGRESSION

TREATMENTS TO ARREST TREATMENTS TO ARREST MYOPIA MYOPIA

OPTICAL1.↓duration of spectacle wear2. planned under correction2. Bifocals / PALs3. contact lenses / orthoKPHARMACOLOGICAL4. atropine / pirenzipine5. ocular hypotensives

Page 14: PREVENTING   MYOPIA PROGRESSION

OPTICAL RxsOPTICAL Rxs

Saw BJO 2002Saw BJO 2002

1. < full time wear of full Rx2. Under correction3. B-F & PALs

Page 15: PREVENTING   MYOPIA PROGRESSION

< FULL TIME WEAR #1< FULL TIME WEAR #1Saw, BJO 2002Saw, BJO 2002

NRCT N= 43 3ya. full time specs wearb. wear for distance full timec. wear for distance d. non wearRESULT: NS

Page 16: PREVENTING   MYOPIA PROGRESSION

< Full time wear #2< Full time wear #2

NMRCT Finland n= 240 9-11y f/u: 3ya. SV, full correc, cont useb. SV, full correc, distance onlyc. BifocalsRESULT: ROMP: NS

Page 17: PREVENTING   MYOPIA PROGRESSION

Planned undercorrection / 1Planned undercorrection / 1

Straub: Fully correc / Under correcROMP: NS

Tokoro and Kabe:Fully corrected –0.83D/y Under corrected –0.47D/y

p< 0.01

Page 18: PREVENTING   MYOPIA PROGRESSION

Planned undercorrrection /2Planned undercorrrection /2

CHUNG VIS RES 2002 CHILDREN UNDERCORRECTED BY -0.75

SMALL [STATS SIGN] INCREASE ROMP OVER 2 YRS

0.25D GREATER THAN FULLY CORRECTED

Page 19: PREVENTING   MYOPIA PROGRESSION

BIFOCALS / PALsBIFOCALS / PALs Saw BJO 2002Saw BJO 2002

3 well designed RCTUSA, DENMARK, FINLANDBifocals +1 to +2 addsSample sizes 32-240Result : NS

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PALsPALsLeung and Brown Hong Kong 36: +1.5 - +2 add. ROMP -3.67 to -3.73D. 32: SV. ROMP -3.67D. NS.

Shih and colleagues Taiwan 227 6-12yPALs -1.19D/y. SV -1.40D/y. NS

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CORRECTION OF MYOPIA CORRECTION OF MYOPIA EVALUATION TRIAL EVALUATION TRIAL

(COMET) PALs vs. SV (COMET) PALs vs. SV

IOVS 20033 y. N= 469. age 6-11y MULTICENTRE USA RANDOMISEDDOUBLE MASKED. SE –1.25 to –4.50

Page 22: PREVENTING   MYOPIA PROGRESSION

COMET #2COMET #2

PALsSlight ↓ ROMP, AL, # of Rx changes

RECOMMENDATIONS Effects too small to change your current routine

Page 23: PREVENTING   MYOPIA PROGRESSION

ATROPINEATROPINEEASILY UNDERSTOOD Fx:Muscarinic antagonist → blocks accommodationIf Xs accom → ↑axial length, At may block thisNon – Accomm Fx [McBrien]:* Affects dopamine release ?influence retinal signals ?control eye growth* Suppresses GH

Page 24: PREVENTING   MYOPIA PROGRESSION

ATROPINE STUDIESATROPINE STUDIESBEDROSSIAN

Ophthalmology 1979 n = 62 1% At hs ONE eye for 12 mo.

Fellow eye treated in Y2 [previously Rx’d eye now control].

At:↓ROMP Post At: ROMP @‘new’ [lesser]

rate

Page 25: PREVENTING   MYOPIA PROGRESSION

ATROPINE STUDIESATROPINE STUDIES

RCT X3 TAIWANAt 0.1 to 1%

Result: ROMP sign. ↓ Lower dose better tolerated

Page 26: PREVENTING   MYOPIA PROGRESSION

ATROPINE & B-F ATROPINE & B-F BRODSTEIN BRODSTEIN OPHTHALMOLOGY 1984OPHTHALMOLOGY 1984

n = 253. 1% At od. 9y f/up.↓ ROMP during Rx

ROMP after Rx = Control groupROMP fastest age 8 -12

Page 27: PREVENTING   MYOPIA PROGRESSION

ATROPINE & B-F UCLA ATROPINE & B-F UCLA

15 Myopes / 15 control At 1% OU mean 29m [3-96]

ROMP: At: 0.05D C : 0.84D p = 0.00021!!

Using same pair of glasses [months]:At: 25.1(+/-19.3)

C: 13.5(+/-10.3) p = 0.049

Page 28: PREVENTING   MYOPIA PROGRESSION

ATROPINE & B-F WILMER ATROPINE & B-F WILMER

CASE SERIES RETRO / INTER / NON COM

n = 706 age 6-16 yB-F : full cyclo / +2.25 addAt 1% 1/w. 3w - 10 yResult: 496 Fully Compliant. 210 Partly

ROMP: F/ Compliant 0.08D / y. Partly 0.23D / y

p < 0.001 !!

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ATOM STUDYATOM STUDY

ARVO 2003 CHUA [SINGAPORE]RANDOMIZED / DOUBLE MASKED / PLACEBO CONTROLLED

n=400 -1D to –6D 6-12 y1% At C: Isoptotears 1/dF/U: 4 monthly for 2 y. 90% @ 12mo, 80+% @ 2y

Cyclo ref / axial length CR / AL

Page 30: PREVENTING   MYOPIA PROGRESSION

ATOM STUDY #2: ATOM STUDY #2: RESULTSRESULTS

12 mo: CR C: – 0.76D. At : + 0.3D !!AL: C: +0.2 mm. At reduction 0.14 mm2yrs : CR / ALC: –1.20D / +0.38 mmAt -0.25D / AL unchanged from baselinep < 0.0001 @ 12 mo & 2 y

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PIRENZEPINEPIRENZEPINE

Selective M1subtype muscarinic antagonist

Animal studies: blocks ↑AL 2° to form deprivation

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PIRENZEPINE STUDY #1 PIRENZEPINE STUDY #1 /1/1

ARVO 2003 SIATKOWASKI MULTICENTRE RCT n=13 USA

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PIRENZEPINE #1 PIRENZEPINE #1 /2/2

N = 174 8-12 y Rx / C : 2:1 BD for 12 moENTRY : BCVA 20/25 or better REF ERROR –0.75 to –4.00D SECYL ≤1D

Page 34: PREVENTING   MYOPIA PROGRESSION

PIRENZEPINE #1 RESULTS PIRENZEPINE #1 RESULTS

OUTCOME : CYCLO A/REF @ 12 moEntry Ref Error: PIR -2.10; C -1.93ROMP: PIR –0.26D; C -0.53D p<0.0012% PIR >1D MP @ 12 mo20% C > 1D MP @ 12 mo p<0.001PIR 11% withdrew; C: 0%.

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PIRENZEPINE : STUDY #2PIRENZEPINE : STUDY #21yr Asian TrialMC / DM / PC /PARALLEL STUDY

353 children 6-12 ya. PIR bd b. Placebo morning+ PIR Evening c. Placebo bd

Ref error / AL

Page 36: PREVENTING   MYOPIA PROGRESSION

PIRENZEPINE – ASIA PIRENZEPINE – ASIA /2/2ROMP @ 12 mo a. -0.40D (PIR bd) b. -0.70D (PIR 1/d)c. -0. 80D (C)

a / b : p < 0.001 a / c : p < 0.001 b / c : NS

Page 37: PREVENTING   MYOPIA PROGRESSION

PIRENZEPINE – ASIA PIRENZEPINE – ASIA /3/3

AXIAL LENGTHa. +0.21mm (PIR bd)b. +0.30mm (PIR 1/d)c. +0.33mm (C)

All comparisons NS

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OCULAR HYPOTENSIVESOCULAR HYPOTENSIVES

↑ IOP → stretch sclera ↑axial length ↑myopiaLabetolol / TimololSeveral studies : no C, not randomisedDanish study 150 child. 0.25% timolol [2y]ROMP: Timolol -0.59D/y Single vision -0.57D/y

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SUMMARYSUMMARY

< Full time wear / undercorrection5 STUDIES

3 NS 2 SIGNIFICANT : 1 ROMP WORSE!

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SUMMARYSUMMARY

BIFOCALS & PALs7 studies : NS

One PAL study: Significant

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SUMMARYSUMMARY

PHARMACOLOGICAL STUDIES1. ATROPINE 8 studies SOne study : post Rx ROMP @ reduced ‘new’ rate

2. PIRENZEPINE 2% GEL 2 studies S

3. OCULAR HYPOTENSIVES NS

Page 42: PREVENTING   MYOPIA PROGRESSION

MYOPIAMYOPIA

1. Major personal / societal problem

2. Convincing data on ↓ ROMP with At / Pir. Need longer f/up.

3. ? Genetic segregation first & repeat optical and drug studies

Page 43: PREVENTING   MYOPIA PROGRESSION