L-R: Dr Loren Rose, Dr Trent Sandercoe, Mariella Coluccio, Dr Shanel Sharma and Homma Ebrahimi.

WRITER Melanie Kell

Optometrists were urged to “do something” about progressing myopia – in children and also in adults – at the second annual Myopia Progression in Children (MPIC) conference in Sydney.

The 'noise’ around myopia management has been on the rise for some years now, but for ophthalmologist Dr Loren Rose, who completed a PhD on the disease, it’s still not loud enough.

To encourage evidence-based conversations, Dr Rose has now hosted two full-day myopia conferences for eye care professionals, where she and colleagues Drs Shanel Sharma and Trent Sandercoe have shared the latest research on diagnosis, management, and progression. Demonstrating the importance of collaborative care, this year Dr Rose also invited optometrists Mariella Coluccio and Homma Ebrahimi to present case studies from their own practices.

Dr Rose began the day by describing myopia in the Australian context, noting that the incidence is such that “we’re now lucky enough to have more research” to draw on.

While the incidence currently sits at 36%, she said the Australian population fits “into a higher trend of myopia… and into what will become an avalanche of myopia in our society”. The forecast is for high myopia to increase in Australia four-fold from 2020 to over four million in 2050 and a three-fold increase in New Zealand to over 600,000.

“We will have a lot of vision impairment – it’s going to affect everyone, not just the kids we talk about today,” she said. “We’re now realising there is a group of adults that are progressing… a group between 20 and 40 (years of age) who will continue to progress.”

Although adult progression will not be as rapid as we see in children, Dr Rose said it will be enough to cause a burden of higher myopia in our population.

In adults, the reasons for progression can be corneal, lenticular, or changes in axial length. There are currently no studies on adult myopia control intervention.

She said eye care professionals need to care about adult myopia because pathological myopia is related to high myopia.

“If you have a patient with more than –6D or 26mm in axial length, you’ve got (a risk of ) posterior staphylomas, myopic maculopathy, glaucoma, and retinal detachment.”

She said the risks increase when patients are high myopes, but also exist in moderate myopic patients. As we know, every dioptre matters. If a child or adult is progressing, we need to do something about it, she said.

An initial assessment for myopia should include the patient’s risk factors:

• Age and refraction, if known,

• Family history, and

• Exposure to natural light and near work.

A full assessment should include cycloplegic refraction and anterior and posterior examination with baseline interferometry.

Dr Rose reinforced the need to assess whether a patient’s myopia progression was due to axial change or corneal or lenticular change. Eye care professionals must remember that both connective tissue disease and retinal dystrophies are associated with progressive myopia in children. A young child with high myopia requires a referral for the investigation of connective tissue disease. A high myope with poor best-corrected vision may require electrophysiology for retinal disease.

Describing herself as being “big on axial length measurement”, Dr Rose said while the equipment to do so isn’t readily available in most optometry practices, this is the way to make myopia management easier and safer to practise.

OUTDOOR EFFECT

Dr Shanel Sharma spoke about importance of exposure to the outdoors to slow myopia progression. She said early Australian studies had proven that outdoor time was protective and resulted in a lower prevalence of myopia. This was tested in a Taiwanese study mandating two hours outdoors a day at school, which reduced the trend of increasing prevalence within a few years.

Dr Sharma explained that the effect is due to the lux (a unit of illuminance) and not UV exposure, as seen in both chick and monkey experiments. Animal experiments demonstrate that the intensity of light, which is significantly higher outside, even on a cloudy day, is the growth modulator.

She said near work has been more difficult to quantify but is an independent risk factor.

With this in mind, the recommendation is to increase outdoor activity to two hours per day to benefit myopia control. However, it is also important to protect children and adults from damaging exposure to UV light. Skin protection with hats, and appropriate frames with sun lenses are essential to protect the eyes and lids.

INTERVENTION

An overview of current refractive intervention by Dr Rose included an explanation of peripheral defocus lenses drawing on published research on D.I.M.S (Hoya) and HAL (Essilor) designs. Additionally, the recently released MyCon (Rodenstock), and soon-to-be-released MyoCare (Zeiss) lens designs were described. Early studies of DOT (SightGlass) technology were presented, and the audience also heard about the efficacy of CooperVision’s MiSight contact lenses as well as rigid gas-permeable contact lenses for orthokeratology.

An overview of current pharmacological intervention drew on the ATOM and LAMP studies,1,2 as well as Australian data on progression with low-dose atropine, which tells us that children can be fast progressors at any age and will respond to low-dose atropine. This has been demonstrated again in the recent CHAMP study overseas.3

Touching on other areas of research, the audience heard that choroidal thickness is now recognised as an early indicator of treatment effectiveness. Recent publications of repeat low-level red light may have a significant effect in retarding the elongation of the eye in myopia progression, which is being assessed for approval by the Therapeutic Goods Administration in Australia. Dr Rose said blue light technology is now being tested overseas.

MANAGEMENT OPTIONS

Ocular, genetic, and syndromic associations with myopia were discussed in a comprehensive presentation on myopia management. Recommending a holistic approach to myopia management, Dr Rose reviewed a “stepwise” process of risk assessment and examination. She said any child younger than 10 with high myopia should be investigated and reviewed, as should any young child whose myopic dioptres were greater than their age in years, or whose vision was suboptimal with accurate refraction.

Measurement of axial length prior to starting atropine was recommended and lifestyle modifiers should be part of the treatment discussion.

To highlight the various treatment needs and responses of different patients, Dr Rose presented multiple examples in a treatment algorithm.

CASE STUDIES

Dr Trent Sandercoe, Dr Rose, Dr Sharma, Ms Coluccio, and Ms Ebrahimi all presented case studies demonstrating the many presentations of myopia, paths of progression, and treatment options.

Dr Sandercoe demonstrated the effect of improved outdoor exposure in negating the need for other myopia intervention for some patients. Presenting a case study that showed how some patients seem more resistant to higher atropine doses than others, he reminded optometrists to always ask about compliance with drops.

Ms Coluccio presented a case study of a patient with progressive myopia that she treated with MiSight contact lenses. She said contact lenses can be an effective treatment motivator for children who are not keen on glasses, helping achieve compliance. Her message was that every dioptre matters and “just do something”.

Ms Ebrahimi also spoke about her experience of MiSight, as well as Bioinfinty multifocal off-label contact lenses for myopia control in children aged 11 to 16. She provided an overview of contact lens studies, the findings from which reflect tolerability and stability in her patients when used for myopia control.

Dr Sharma presented a case of low myopia in dioptres but long axial length, making the point that although myopia was low, the patient was at risk of pathological myopia due to the elongation. Her second case demonstrated that the combination of atropine and peripheral defocus lenses can better control axial growth in some patients.

Dr Rose presented a case of Stickler syndrome to demonstrate that systemic association can be detected in high myopes, even years after myopia diagnosis. Additionally, she recapped a case study from 2022 of spherophakia, and the case of a high myope with cone dystrophy, found on electrophysiology, who experienced a subsequent retinal detachment in one eye after mild trauma. Dr Rose said the lesson learnt from the latter case was that families and patients should be warned of the risk of retinal detachment and the need for prompt presentation and referral.

SPONSOR TALKS

Across the day, sponsors Hoya Vision, Aspen Pharmacare, Customised Compounding, EssilorLuxottica, EyeRising International, and Zeiss Myocare presented updates on their myopia technology/services. Additionally, a trade show enabled delegates to explore new technologies and talk to suppliers about the evidence behind their devices and treatments for myopia detection and management.

Dr Rose said the event, which was available to eye care professionals online and in person, was well received with the audience giving it a rating of 4.9/5.

“Audience members commented on the ‘concise, to the point presentations and interesting case studies’, the value of the discussion forum and presentation of difficult case studies, and the range of case studies presented,” she told mivision. “There was excellent interaction with industry and presenters, robust discussion, and excellent questions.”

Those with an interest in myopia can look forward to another MPIC conference in 2024.

References
1. Chua, W., Balakrishnan, V., Tan, D., Chan, Y., ATOM study group; efficacy results from the atropine in the treatment of myopia (ATOM) study. Invest. Ophthalmol. Vis. Sci. 2003;44(13):3119.
2. Yam, J.C., Li, F.F., Zhang, X., et al., Two-year clinical trial of the low concentration atropine for myopia progression (LAMP) study: Phase 2 report. Ophthalmology. 2020
Jul;127(7):910-919. doi: 10.1016/j.ophtha.2019.12.011. Epub 2019 Dec 21. PMID: 32019700.
3. Hershey, A.D., Powers, S.W., Coffey, C.S., et al., CHAMP study group. Childhood and adolescent migraine prevention (CHAMP) study: a double-blinded, placebo-controlled, comparative effectiveness study of amitriptyline, topiramate, and placebo in the prevention of childhood and adolescent migraine. Headache. 2013 May;53(5):799-816. doi: 10.1111/head.12105. Epub 2013 Apr 17. PMID: 23594025; PMCID: PMC3637406.