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Combatting Myopia proves to be a strong drawcard

02/05/2019By Lewis Williams PhD
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To coincide with the Australian launch of the MiSight 1 day anti-myopia contact lens, CooperVision presented a lecture series on myopia. LEWIS WILLIAMS details the knowledge shared at the Sydney event.

CooperVision conducted a well-attended eastern seaboard lecture circuit featuring local myopia experts, company professional services staff, and Professor Ian Flitcroft, one of the most experienced myopia campaigners in the world.

The events were central to the Australian launch of CooperVision’s MiSight 1 day anti-myopia contact lens (CL), following its selective release several years earlier. The CL has been available in some Asia-Pacific markets since about 2011.

Mr Joe Tanner, CooperVision Australia and New Zealand professional services manager, moderated the Sydney program. CooperVision’s recent acquisitions, such as of Paragon Vision Sciences and Blanchard Contact lenses, have led to the formation of a specialty eyecare division within the parent company. Those acquisitions also mean that CooperVision now has the potential to offer a broader range of CLs including orthokeratolgy and mini-scleral CLs, as well as the MiSight product.

That range of specialty CLs differs in one other important aspect; they are true prescribed products, some with therapeutic indications. This means they are not commodity items, and professional involvement is required at all stages of their prescribing and use.



"In cases in which pre-myopia is detected, the known subsequent risks justify early intervention."
Ian Flitcroft, ophthalmologist at Dublin’s Children’s University Hospital

Tanner gave some results from surveys of the Australian market conducted by CooperVision. It revealed that until recently, progressive powered spectacle lenses (PPLs) were the most common form of myopia-control treatment prescribed in Australia. The most common myopia corrections given in Australia took the form of spectacles and orthokeratology, in that order.

Interestingly, most practitioners were only seeing 1 to 4 young myopes a month, and most practitioners only had between 1 and 10 young myopes undergoing some form of myopia treatment. A lack of specialist equipment was given as a barrier to greater involvement, but exactly what equipment needs are being unmet was not revealed. Importantly, 99.5% of all those surveyed felt they should discuss myopia with the parents of young or incipient myopes.

The myopia problem

Tanner gave a brief presentation on myopia in Australia, a condition currently afflicting about a third of the population. By 2020, that figure is expected to rise to 36%. Of the country’s 8.2 million myopes, he estimated that around 3.2 million are between 6 and 16 years of age.

While axial length (AL) changes are often used as a proxy for changes in myopia, the reality is not quite as straightforward. That is especially true when pharmacological interventions, such as atropine, are involved. Regardless, there is ample data to show that ALs >26 mm are undesirable as vision impairment occurs in 25% of those who exceed that AL. The impairment rate rises to 90% once an AL of 30 mm is reached.

Tanner revealed that some Australian children actually experience less time outdoors, a known myopia issue, than high-security prisoners. Changes in our society are partly to blame for this situation. For example, in the 1970s, around 80% of children walked to school. That figures now hovers around the 10% mark, in part due to parental fear related to child security.

Tanner reported that the MiSight 1 day CL is currently in a 10-year international clinical field trial, and that the study has almost reached the 5-year stage.

In a 3-year European trial of the CL, 144 children took part aged between 8 and 12 with no previous clinical experience, with spherical equivalent refractive errors (SEREs) between –0.75 and –4 DSph and no more than a 0.75 Cyl. The CooperVision Proclear CL, which is made of the same material as MiSight and has a similar overall design, was used as a control CL in the contralateral eye.

At the 1-year stage, the MiSight CLs had achieved a reduction of 69% in SERE versus baseline data. That result had decreased to 59% by the 2-year stage, which was retained at the 3-year mark. AL figures approximated those results as shorter: 63%, 54%, and 52% for the respective years. For ethical reasons, treatment CLs were swapped to the other eye at 3 years to prevent an unbalanced outcome in the longer-term.

KEYNOTE SPEAKERS

Joe Tanner

Ian Flitcroft

Oliver Woo

Myopia in optometrical practice

Experienced Eastwood optometrist, orthokeratologist, and anti-myopia practitioner Dr Oliver Woo gave a brief address relaying his experiences with MiSight, Ortho-K, and myopia control in general. He described myopia as a great practice builder with patient retention rates approaching 99%. He recommended starting on young patients before 12 years of age, and described the Chinese social media app WeChat as a great source of referrals.

He has a particular interest in the 8 to 10 year age group of early myopes or those exhibiting little or no hyperopia versus the expected age norms. However, he did admit that myopia management required commitment and dedication, as it involves more that just a prescription and talking. Rather, it requires ‘doing’ and long-term attention to both lifestyle and retinal health. He also suggested that practitioners should be proud of what they are doing and what they are achieving.

Unlike some CL pursuits, he described MiSight as an on-label use product backed by good evidence based on 4 or more years of clinical experience. He estimated that AL changes amounted to 0.11 mm per annum versus 0.4 mm per annum if no steps are taken to combat myopia progression. He also alluded to the possibility of combination therapy, such as MiSight and low-dose atropine.

He will start therapy at 6 years of age if the case warrants intervention, provided the child’s parents are involved and capable of CL management. Finally, he described myopia management as a treatment plan, not a ‘product’. Safety has to remain foremost under all circumstances to avoid poor outcomes or reputational damage. Woo summarised the two possible attitudes to myopia management as: “Do it one day, or do it from day one!”.

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Professor Ian Flitcroft

Professor Ian Flitcroft is an ophthalmologist at Dublin’s Children’s University Hospital with a myopia publishing record extending almost a quarter of a century; certainly more than many in the discipline. He also has other pursuits to his credit including published books on sci-fi, food and a web-based service promoting writing like his favourite author, Jane Austen.

Flitcroft’s presentation was titled Myopia Management - The time to act is now.

He stated that he has been advising ophthalmology for more than 20 years to treat myopia and its consequences, not just correct it. His advice has been heeded, but only after some delay. He described PPLs as a “poor choice” and said simple spectacles “don’t work”.

He believes that myopia has an image problem. Despite the general perception that it is a problem among people of Asian descent, it affects all races to varying extents. Quoting the Holden et al. (2016) paper on expected myopia prevalence figures for 2050, almost 50% of the world’s population are predicted to develop the condition.

Importantly, Tanner noted, and when questioned, Flitcroft agreed, that the rider that appears in Holden’s paper is often omitted: “We have not taken into account the effect of myopia control interventions that may take place between now and 2050”. Therefore, it is reasonable to assume that 50% of the population will not be myopic by 2050, because the relevant professions will not be sitting by idly.

According to Flitcroft, a significant problem with myopia is that patients do not understand it. They need to understand its potential to cause a visual disability, the fact that it is a disease, and what the risk factors are. For example, every dioptre of myopia increases the risk of glaucoma, myopic maculopathy, and retinal detachment. It remains the second biggest cause of vision impairment, and is a significant public health issue that benefits from every case prevented or reduced. The risks are cumulative, a fact that is often not apparent until patients are over 50 years of age.

Flitcroft offered an alternative definition of myopia: “The commonest ocular disease worldwide that results in a disability whenever an Rx is not worn, and when an Rx is worn there is an attendant risk (anti-myopia optics assumed not to be in use) along with an increased risk of a wide range of other ocular diseases”.

Importantly, the risks later in life are locked-in when the patient is young. Like smoking, or possibly excessive sun exposure before the age of 15, there is a significant lag between not introducing myopia prevention measures and the maximum manifestation of myopia’s problems.

He listed the treatments as being optical, pharmacological, environmental, and policy. When deciding on who to treat, he advised that those at higher risk of high myopia, the progressive myope, and the young showing signs of pre-myopia early, should be the focus of interventions. He suggested that the Brien Holden Vision Institute Myopia Calculator has utility in outcome prediction.

Flitcroft defined pre-myopia as manifest Rxs of between +0.75 D and –0.50 D when young. Importantly, it has to be realised that accelerated eye growth that can lead to the development of myopia happens well before the manifestation of myopia, up to 5 years before in his estimate.

He went as far as calling myopia a growth disorder. He too has an eye growth calculator that uses inputs of axial length and the patient’s sex. As a minimum standard of care, he offered an optical solution combined with a selected myopia progression intervention. He favours a comprehensive monitoring and intervention system so the problem is never left to ‘run away’. He takes a TEAM approach to myopia: Talk, Engage, Advocate, and Manage. Despite current plans, Flitcroft said he still has concerns for the next 20 years. He described the fovea-centric approach to myopia control featured in most spectacle and CL solutions as simply “wrong”, because it ignores the other 95% of the retina. His concept is to embrace the three relevant systems; the perceptual visual system, the luminance visual system, and the eye growth system. He advised researchers to think like an amicrine cell, one responsibility of which is to keep its part of the retina supplied with a clear image.

To better understand the effects of natural and added peripheral blur, such as myopic defocus, Flitcroft’s team has created a system of false-colour mapping of focused and blurred components in particular viewing circumstances. They can also identify high and low frequency objects present using Fourier analysis. Compared with nature, the manmade, urban environment robs the eye of details and randomness, replacing nature with smooth lines, regular shapes, vertical and horizontal straight lines. This makes an amicrine cell’s job difficult. As a result, he posed the question: What should be viewed when outdoor time is suggested or enforced? His parting comment was, “In cases in which pre-myopia is detected, the known subsequent risks justify early intervention”.

The MiSight product

The MiSight product is based on possibly the earliest patent relating to anti-myopia CLs (non-Ortho-K CLs) based on research by Dr John Phillips, Senior Lecturer, School of Optometry and Vision Science and the Auckland Myopia Laboratory, UAuckland, NZ. As a graduate student working with Phillips, Dr Nicola Anstice, now Optometry Head at the University of Canberra, co-authored a paper with Phillips on the effects of ‘Dual-Focus’ SCLs on axial myopia progression based on work probably performed in the late 1990s and the early 2000s.

The CooperVision MiSight 1 day product uses the company’s omafilcon A (phosphorylcholine) hydrogel material and comes as a universal fit CL (8.7/14.2 mm) CL in powers from –0.25 to –6.00 D in 0.25 D steps.

The product is not freely available to a practice until CooperVision has accredited it. That process involves participating in selected courses, webinars, a multiple-choice exam, and ancillary staff training. Those involved must also be prepared to deal with paediatric patients as young as 8 years of age. Once accredited, the practitioner and practice must be willing to be surveyed on their experiences with the product and their myopia management, in effect participating in a large field clinical trial.

Once accredited, trial CLs and support materials are supplied to the practice as appropriate. Importantly, accreditation is linked to a practice, not a particular practitioner. Locum optometrists, although they might be accredited, cannot prescribe the product in a non-accredited practice they might be working in. While that might seem odd at first glance, it has to be remembered that myopia management is a long-term process, and the required follow-up is not possible in a locum situation.

 

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