Myopia management by Optom Ankit Varshney

Optom. Ankit S. Varshney
B.Optom, M.Optom, Ph.D. in Optometry(pursuing) Fellowof IACLE(Aus.), Fellowof ASCO(Mum.)
Prof. at (ShreeBharatimaiyaCollege of Optometry & Physiotherapy, Surat)
Life Member of Indian Optometric Association (IOA)
Associate Member of Association of Schools and Colleges of Optometry(ASCO)
Member of Optometry Council of India(OCI)
Educator Member of International Association of Contact lense Educators (Australia)(IACLE)
Mail id: ankitsvarshney@yahoo.com
Whatsapp no. +918155955820
Prevention& SlowingtheProgressionMyopia

“We are so busy stuck deep in myopic world (Home Lockdown),
that we don’t get opportunities to look out (Broad)”.
14 July 2020 Optom. Ankit Varshney 2

Myopia Control or Not……That
is the Question?

Orthokeratolo
gy
Soft Multifocals
Atropine

Myopia
Management
what we know is changing at a
Rapid pace
Optometrist—
Having Trouble Keeping Up-to-
Date?

Why
Should
You Care?
Myopia is reaching epidemic levels
around the globe like COVID’ 19
In the India, rates of myopia have
almost doubled in 30 years
50% of the world population will
be myopic by 2050
AHuge Myopic Population Exist
2.5 billion 2020 ~5 Billion 2050

Myopia canresult in
visual MORBIDITY
1. Greater risk of RD, macula
degeneration, glaucoma, early
onset cataracts,peripheral
retinal degeneration,
chorioretinal deg.
2. Irrespectiveofhyperopia &
Astigmatism, myopic
progression & prevalence
increase with passage of time.
3. Myopia is influenced by
environmental condition in
school age.
Why
Myopia
Managemen
t?

Why Myopia
Management?
Impaired Quality Of Life
People with a high myopia experience impaired quality
of life similar to that of people with keratoconus

Myopia Management…….
Prevention
Control
Success
Tips for practitioners
What Are the
Latest
Developments in
Myopia
Management
Today’s
Goal
You will be updated with the latest evidence-based strategies &
recommendations to have successful outcomes with your patients

• Environmental
• Pharmaceutical
•Optical
Myopia Control: Approaches

1. Prevention
What Are the
Latest
Developments
in Myopia
Management ?

MYOPIA
Management
What’s the
Goal?
1. Prevention of myopia onset
2. Slowing myopia progression

PREVENTION of myopia onset
Strongest predictors of myopia development
1. Number of parents with myopia
2. Amount of time spent playing outdoors

Risk Factors
1. Genetics
2. Near work
3. Outdoor play time
4. Night lights
5. Accommodative dysfunction

1. Genetics
There is a strong association between number of myopic
parents and the risk of childhood myopia development.

Zero Parent
withMyopia
10%
• Zero parents with myopia = 10% risk

One Parent
withMyopia
20%-25%
• One parent with myopia = 20-25% risk

TwoParents
withMyopia
40%-50%
• Two parents with myopia = 40-50% risk

2. Near Work
NO LINK found between myopia development and amount of
near work. (Jones-Jordan et al. 2011)
NO LINK found between rate of progression and amount of
near work. (Jones-Jordan et al. 2012)

3. Outdoor Play Time
Amount of time spent outdoors protective against the onset of
myopia. (Jones et al. 2007)
Effect on rate of progression? (Jones-Jordon et al. 2012, Xiong 2017)
Outdoor vs Indoor Vision
1. Light level
2. Spectral composition of light
3. Dioptric topographies

Outdoor vs. Indoor Vision
1. Ambient Light Level

Outdoor vs. IndoorLight Levels
OUTDOOR LIGHTING
INDOOR LIGHTING

High Ambient LightTreatment??

2. Spectral Composition

*

3. Dioptric Topography

4. Night time lighting
•Parental myopia
◦ Families with 2 myopic parents reported using night-lights
significantly more than families with zero or 1 myopic parent.

5. Accommodation
Accommodative patterns associated with myopia
Increased AC/A ratio is early sign of becoming myopic (Mutti et al. 2017)
Increased accommodative lag occurs AFTER myopia onset (Mutti et
al. 2006)

2.Control
What Are the
Latest
Developments
in Myopia
Management?

MYOPIA
Management
What’s the
Goal?
1. Prevention of myopia onset
2. Slowing myopia progression

Controlling Myopia
INEFFECTIVE STRATEGIES
1. Undercorrection (Spectacles)
2. SV Gas Permeable Contact Lenses
3. Segment Bifocal or Progressive Addition Lenses(Spects.)
PROMISING TREATMENTS
4. Topical Pharmaceuticals
5. Executive BF and Prisms
6. Ortho K and Soft BF Contact Lenses

1. Undercorrection of Myopia
 Hyperopic defocus promotes eye growth and myopia development.
 Myopic defocus limits eye growth and promotes formation of hyperopia.
Question:
◦ Does undercorrection (myopic defocus) slow myopia progression?
Answer:
◦ NO. Opposite effect observed. Fully corrected myopic eyes
progressed slower than under-corrected eyes (Chung et al. 2002)
◦ Under-correction may promote growth similar to mechanism in
deprivation myopia that outweigh effects of myopic defocus.
Peripheral hyperopic defocusacceleratesaxial growth
Peripheral myopic defocus canreduceaxial growth*

2. Gas Permeable Contact Lenses
 Rigid, gas permeable lenses can mold cornea.
Question:
◦ Does RGP lenses slow myopia progression?
Answer:
◦ Some reduction in myopia progression but NO change in reducing
axial length (Walline et al. 2004)
◦ Since treatment effects are only corneal, effect only temporary,
therefore GPCs should not be fit solely for myopia control purposes.

3. Segment BF and PALs
 Myopes tend to under-accommodate at near (OA)(Gwiazda et al. 1993)
 This results in HYPEROPIC blur at near. Hyperopic blur drives myopia.
Question:
◦ Does reducing accommodative lag with near add reduce progression?
Answer:
◦ No impact of bifocals on slowing myopic progression (Grosvenor et al. 1987)
◦ Statistically significant, but clinically insignificant reduction in progression
(Gwiazda et al. 2003) -0.20 over 3 years

Controlling Myopia
1. Undercorrection
2. SV Gas Permeable Contact Lenses
3. Segment Bifocal or Progressive Addition Lenses
PROMISING TREATMENTS
4. Topical Pharmaceuticals
5. Executive BF and Prisms
6. Ortho K and Soft BF Contact Lenses

PROMISING STRATEGIES
4. Topical Pharmaceuticals – Antimuscarinicagents
Topical Pirenzepine was found to slow myopia progression but
Topical pirenzepine not commercially available
Topical Atropine (0.01%) is most effective, but have side
effects of blur and photophobia
 Slows progression of myopia (Chua et al. 2006, Wu et al. 2011)

5. Executive Bifocals with Prism
Some effect in slowing progression of myopia found with
+1.50 Executive BF and 3BI Prism (Cheng et al. 2010 and 2014)
• Lag ofAccommodation
• Near Phoria Status
(Reduced Amount of progression & Axial length)
Executive bifocals with a larger inferior zone might possibly be
acting in a similar fashion

6. Multifocal Contact
Lenses and
Orthokeratology

Contact
Lenses
OROrthokeratology
Soft Multifocals

Slowing the Progression of Myopia
with CLs
Ortho-k andsoft multifocals inhibit myopiaprogression by inducing peripheral retinal myopic defocus*.
Peripheral hyperopic defocusacceleratesaxial growth Peripheral myopic defocus canreduceaxial growth*
Ortho-K
Near
Center-Distance*
Relative +Plus (Myopic Defocus) Soft Multifocal

Is Ortho-K
OK?
Ideal Candidates for myopia control

Orthokeratology
Ideal Candidates
Treatment zone
AreaofPeripheral Myopic Defocus
• Larger pupils facilitate the myopia control
outcome
• The peripheral myopic defocus will lie in the pupil
• The peripheral myopic defocus will lie outside
of the pupil for small pupils &will limit
the efficacy of myopia control
The average treatment zone for OK is 3.5 mmwith 1.5
to 2.0mmzone of peripheral myopic defocus so a
5mmpupil (3.5 + 1.5 mm)is ideal Above pupil is too
small
1. Large pupils

Orthokeratology
IDEAL CANDIDATES
Sphericalcorneal GP onhigh toric cornea
High Cyl >1.75 D is not idealunlessyouhaveatoric ortho-K option
Myopes with up to 6.00D of sphere*
The FDA approval for ortho-k:
Temporary reduction of myopia up to –6D of sphere with
up to 1.75 D of WTR, 0.75 ATR astigmatism *
Attempting to correct greater than 4.00D
increases the risk of central staining (Liu 2016)
High levels of correction (> 4.00D) also increases
the risk of a decentered lens and treatment zone.
*Ortho-K is Approved for all ages not myopia
control
2. Myopes <6D of sphere
3. Children unable to wear softs CLs due to allergies

Orthokeratolo
gy
Ideal Candidates
especially swimmers
4. Athletes

Orthokeratology
Options
Many more……….
Wave

Soft
Multifocals
Ideal Candidates
oResponsible enough to wear lenses during the day
oLow and high myopes
Ortho-K canbemorechallenging to fit(>5D)
oLow astigmats
Very limited reusablesoft multifocal toric options
No daily disposablemultifocal toric option

Soft Multifocal
Options
CooperVision
“D” Lens OU
J&JVision
Currently recommendation is *Center-Distance for effective myopia control

Newer Daily Disposable Multifocal
Options
Visioneering Technologies
CooperVision (Not availablein U.S.)
Marketed specifically formyopiamanagement
LaunchedinCanada 2018
Both Center-Distance designs

Coming
Soon
SYNERGEYES
EXTENDED
DEPT H OF FOCUS
(EDOF) LENS

Which is the most effective
option?
70-80%
Side effects:
Blurred vision
Photosensitivity*
Orth-K and soft multifocals have similar efficacy *
Slightly better efficacy with concentric
ring design than aspheric design
Ortho-K
45%
Soft Multifocal
38%

Which soft design?
Concentric Ring
MiSight 1 Day
Aspheric design
Image Credit Dinardo A, Rosen C . CLS
2017

Concentric Ring
Treatment zones create myopic defocus.
Two correction zones that helps correct myopia in all gaze positions.
Children can see clearly while slowing their myopia progression
Imagecredit CooperVision MiSight 1 Day
3 year findings ~60% less myopia progression
MiSignt 1Day

Which contact lens
myopia control
option is the
safest?
The risk of MK....
Overnight Ortho-K = daily wear of reusable soft
*Daily disposable wear < soft reusable
Children (aged 8-12) have a lower rate of infectionthan
teens & adults
Attributed to better compliance & closerparental
supervision
Safer Than YouThink
Low Risk of CL-related
inflammatory events
Bullimore MA 2017 ; Wagner H et al 2014

Which
Option is
preferred by
parents?
Eye
drops
Bifocal
glasses
Ortho-K Soft MF
N=196, 3 University
Sites
(0
)

Management
Options

3. Measuring Success
What Are the
Latest
Development
s in Myopia
Management?

Clinically meaningful myopia control
1. Refractive error
◦ 0.50 D per year
2. Axial length
◦ 0.1mm to 0.2mm per year

MYOPIA
CONTROL
Tools of the Trade

Tools
1. Axial length measures
◦ Contact biometry
◦ Non-contact biometry

Tools
2. Refractive Error
◦ Cycloplegic autorefraction
◦ Open field autorefractor
◦ Measures both eyes at the same time
◦ Open view window allows you to choose target
◦ Can measure peripheral refraction

Suggested to continue myopia control at least through the age during
which their myopia is expected to progress (age 15 or 16)
Little evidence on when it is appropriate to stop myopia control
When should
We Stop?

Optoms:
What Are
You
Waiting
For?
High
Myopia
preventi
on
Safe
Increased
Revenue
Parents Are
Interested
Control of myopia may become the standard of care

Parents Are Interested: so
educate them
70% of parents
wanted to pursue
myopia control
were unaware of
myopia control &
complications of high
myopia

4. Tips for
Practitioners

Points to
Consider
Myopia control is not FDAApproved*
Myopia control is off-label
Ortho-K is FDA approvedformyopiareduction, NOT
myopia control
Potential Complications
Abrasions,infections etc.
Potential Complications-What to Do
Return to Eye Doctor ASAP
Care
Avoiding water, etc.
Financial policy
Fitting andfeesare non-refundable
Side effects (Atropine)
Avoidance of other anti-cholinergics
CreateAConsentForm

Choose a myopia control option that best fits the patient’s
and parent’s lifestyle
Myopia Control
Selection

Monitor Closely
Cyclo
Refraction
BV &
Accommodative
testing
Axial
length

Myopia
Management
THE

thinkabout
reducingmyopia
Sight is a gift

Success
Tips for practitioners
Myopia Management….
Prevention
Control
What Are the
Latest
Developments in
Myopia
Management?

Its okay to be myopic
But make sure
You don’t give frames to your foresight.
“Let your mind go out of Boundaries”
Ankit VArshney

Myopia management by Optom Ankit Varshney

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