Myopia Management: Transformations Over the Past Decade Part 2
Jennifer Galvin, MD:
The other thing that I wanted to bring up, we had talked about the pharmacological treatment, but also there’s contact lenses that cancel the progression. I don’t know if that’s something that you incorporate in your practice. Certainly is something that I do. Cooper Vision’s my site. Contact lens is something that we’ve used in the last three year, as you know it came on the market really in 2020 and the right in the spring of 2020, right before the pandemic. But I’ve seen excellent results is with the MiSight contact lens as well. Just to enlighten our listeners, as they may know, it’s the first FDA approved soft contact lens. It’s a daily for children, eight to 12 year olds.
Leanne Liddicoat, OD:
I use that as well. It is really nice to have something FDA approved. I think it gives another level of comfort for parents who haven’t heard much about myopia management up to this point. I especially enjoy using that in patients that already require corrections. So part of my job is twofold, correcting the central blur for my patients that have already converted to myopia, and then of course mitigating the damage that comes from the overly elongated eye in a progressive myope. So the MiSight contact lenses have worked beautifully for that. I do not have … initially I thought I might have some difficulty with my patients sitting in a classroom looking in the far distance. So I have occasionally gone ahead and given them an extra quarter diopter of minus in their contact lens prescription when I order the MiSight contacts. And just that little bump, I have not had any patients complaining about the quality of their distance vision in that particular lens design. And it works extremely well.
Jennifer Galvin, MD:
Yeah. No, I agree. I’ve had, and I work with optometrists at our firm as well, so we have a collaborative team, but the MiSight contact lens, even with the dilute atropine as a kind of complimentary treatment is often needed, not for every patient, but it’s talked about with the parents and if there’s a need for that, but certainly either standalone MiSight contact lenses as well as dilute atropine has been an excellent way to mitigate the myopia progression, and the amblyopia for sure in terms of the potential severe effect on the vision. And especially when we know we have a very strong family history that we can’t predict the future, but we know that … one of my patients that has the most severe family history is an uncle that has a -18. So he first came to me when he was three years old. He was already a -6, but of course he wasn’t going to be able to wear that or tolerate that as glasses. So having the dilute atropine treatment at night, and then when he’s now closer to age eight, with the MiSight contact lens. So having both of those treatments really compliment the management of the myopia mitigation.
Leanne Liddicoat, OD:
I agree. I agree. And when I have a young patient with one or two myopic parents, I just go ahead and get an axial link baseline pretty much as soon as they can sit still in the instrument. And it’s not invasive, as you know. It’s certainly better than when we just had the ultrasound AScan option. So I have a handful of three and four year olds that we have reliable axial length data for, and then we watch those –
Jennifer Galvin, MD:
That’s outstanding. I think that’s outstanding. You need to publish that data for sure. No, go ahead. You were saying … so by having that, the baseline …
Leanne Liddicoat, OD:
So if those children progress in axial length over 12 months more than 0.2 millimeter, I initiate treatment. If any of those children increase in their refractive data more than 0.5 in the direction of myopia, so if they’re six and they have less than +0.75 diopter of hyperopia, I am very likely to begin treatment, but then again, if they progress towards myopia, more than a half diopter in a year, I’m starting treatment. And again, going back to axial length, if they grow more than 0.2 millimeters over 12 months, although I’m checking them every six months if they have the family history, and especially honestly if they are of Asian ethnicity. We have several studies that have shown that those children are particularly progressive with their myopia. So I’ll, I’ll probably start those patients in treatment a little sooner as well.
Jennifer Galvin, MD:
Yes. Yeah. No, I agree. Those are great points. I don’t check axial length every six months, but I think that’s something that I need to revisit, especially based on the cohorts that are more inclined to be at risk, like you mentioning based on the strong family history, the ethnicity, your race, and also the level of compliance that’s going to be kind of reinforced with different cohorts and subpopulations as well. So those are really great points. And then having that data set, as you already mentioned, to be able to have that conversation with a parent or caregiver to say, “This is … just making that great analogy that we could to a growth curve of our height, weight, or head circumference. Likewise, our axial length very much represents that based on age and of gender, ethnicity and race.” And we’re building that database, which is very, very valuable for this generation and the next generation, for sure.
Leanne Liddicoat, OD:
Especially given the fact that the majority of the elongation, the growth, the stretching of the retina happens in the first decade of life. So both of us are so well positioned to address this because there’s a good percentage of our practice that falls in that age demographic.
Jennifer Galvin, MD:
That’s right. Absolutely. And then to the audience as well, we’re very passionate about myopia progression, but the underlying issue is also not only the secondary effects when they’re a little older, but amblyopia. This amblyopia is a real thing, and being able for them to reach that correct visual acuity for their vision being right at the place where we want it to be has to do a lot with what that axial length is and what it potentially could become in a problematic way, as well as this change in refractive error. So it’s very much tied to the medical diagnosis for the wellbeing of this child and preteen. And then we certainly follow them in their teens, as you do.
Also, I have a conversation with parents, I’m sure, as you do as well, about how there’s even a myopia progression in our twenties more often in males than females, but certainly depending on family history, could be for both. Or even if there isn’t a family history, that’s something that we’re looking for stability. So we can’t say, “Okay, you’re 18 or 16, see you later,” that we’re definitely going to have this ongoing relationship to make sure stability in their myopia and axial length measurement is truly there.
Leanne Liddicoat, OD:
I agree, and that’s critical. And I can’t help but wonder how much of the recent changes in our culture and society relative to how our teenagers spend time, relative to looking up close. I can’t tell you how many patients in their teens honestly share with me that they watch everything on their phone. They don’t watch TV
Jennifer Galvin, MD:
TV isn’t a thing.
Leanne Liddicoat, OD:
That’s us. That’s not them. They’ll watch an entire movie on a small screen 10 inches away from their face. So I’m constantly educating the patient themself in their teen years to help them understand, even though we may not have direct correlation yet in the research, it just stands to reason, because we’re seeing more progression in that age demographic just anecdotally, it could be the screens, it could be the fact that when we’re in our first decade of life, we spend a fair amount of time outside and it’s just a natural byproduct of playing in childhood. And then as we become teenagers and we become more dependent on our social media and our screens, those screens are generally viewed inside, not in front of a bright window. So it just makes me think that these are some environmental concerns that might show increased progression into the teens where maybe 20, 30 years ago, we may not have seen that based on the differences in our environment, in our culture.
Jennifer Galvin, MD:
Yeah, that’s absolutely correct. There was a study that was done in myopes already during the pandemic that did show because of, to no fault of anyone’s, that the children were using screens and Chromebooks and laptops, that there was a progression of already their myopia, but now that we’re out of the most critical time, at least by being here now at 2023 … but to your point, exactly, screens are a part of our life, and not only all of us to do our jobs, but it’s a conversation that I have with teenagers and young adults and children, about taking breaks if it’s possible, meaning that every 15-20 minutes, just looking away, to blink more, not only for their tear film and eye strain and headaches, but for their refractive air, and in particular if they’re myopes or at risk for being myopic.
And these are kind of social factors that we all can’t change because of how we learn. And a child doesn’t go to the library any longer, even to learn something, look up something in an encyclopedia. Now it’s you go right to your search engine electronically. You are able to do things much faster and much more complete, but it totally changes the dynamic for us as people that really care about the vision and the health of the eye, for sure.
Leanne Liddicoat, OD:
So when I follow up with patients, I see them … the patients that are under treatment, regardless of age, I see them every three months. And when I instruct them about taking breaks and then follow up with them three months later and ask how they’re doing with it, I always get this blank stare, which equates to basically, “Uh oh, I’m not doing that and now she’s going to admonish me again.” So I’ve started … what has worked fairly well, especially my teenage population, is asking them to literally set a timer. We have timers on everything, your Apple Watch, your phone, your home assistant, if you have a digital home assistant around, not to mention your Chromebook. I mean, it’s very easy to set a timer. And what I have found is when people are engaged looking at their screen, whether they’re doing it simply for entertainment or for education, they really don’t pay attention to the time. So I used to tell people when we were dealing with regular books, just move your bookmark ahead five pages and when you get to the bookmark, but now it’s a digital timer for sure.
Jennifer Galvin, MD:
Yeah. Yeah. No, that’s great advice. I agree with you in terms of even literally programming it in, because there’s so many different metrics that we have as part of our life anyway, and certainly children and preteens and teenagers and 20 year olds do as well. So this is something that can be kind of a double check to that, as well as making sure that their eye health is a priority and that we’re not also treating their dry eyes in addition to their myopia progression. So I think that’s great advice that we could give to other clinicians out there, is to tell them to use the devices that they already have to setting a timer. That’s really great advice, Dr. Liddicoat. That’s wonderful. So from our discussion today, what would you say is some of the take home messages for optometrists and eye doctors, ophthalmologists in regard to myopia and myopia management? And this has been a wonderful discussion with you today, Dr. Liddicoat.
Leanne Liddicoat, OD:
Sure, I appreciate that too. It’s fun to talk to someone from the other side of the country and know that I have colleagues that are equally concerned and aware and actively practicing myopia management. We should all be concerned. We know that this is a steadily growing problem. So we need to tap into our pediatrician colleagues, our ophthalmologist colleagues, our optometry colleagues, and we should all be either incorporating this into our practice, it might be management or referring those to other providers that do, because we know that there’s an increase in myopia. We know that myopia is starting even at younger and younger ages, which will likely result in more people becoming highly myopic.
And as you mentioned earlier, there are significant pathologies correlated with high myopia: myopic maculopathy for one, retinal detachments, glaucoma, cataracts. And those things have the capacity to cause permanent visual impairment. So as eye care professionals, that is our biggest aim and goal, is to protect our patients from visual impairment that could be permanent. So by doing myopia management and protecting our patients within the first two decades of life, we can make a significant change in the lifelong happiness and wellness of our patients.
Jennifer Galvin, MD:
No, I concur. Exactly. I think that if someone doesn’t feel comfortable or even is aware of what’s going on in terms of myopia management to please refer to an eye doctor that is, because there definitely are different cultural awareness and norms that people grew up with who are in their thirties, forties, and fifties, what they did, what they were taught and told to do, and to kind of take off that hat, so to speak, for them to be open to what is really the excellent research that’s been done there, as we’ve talked about today, whether it’s the CHAMP trial or the LAMP2 studies, or earlier the ADAM studies, and the fact that there are contact lenses that are FDA approved for children, that even though that wasn’t there for a lot of the adult population at all today, for them to be open and aware that this is something … it’s an important step to take for their children or children they know, or teenagers they know as well.
And that’s something that we’ll definitely have as a take home message as well, and that we all should be very concerned about it and not be worried how it was treated in the past because we have so much great treatment right now, and that having your child and teenager and 20 year olds in the right hands for an eye care professional is something that no one will regret at all.
Leanne Liddicoat, OD:
I agree. I agree. It’s been really fun talking with you about this.
Jennifer Galvin, MD:
Yeah, it’s been wonderful.
