Have you ever had a moment that changed the course of your professional life? Maybe it was a particular patient outcome, an article you read or a conference you attended? For me that moment occurred in Chicago at Vision by Design, the annual conference of the Orthokeratology Academy of America (OAA), in April 2014, when I was fortunate to hear Dr. Ian Flitcroft (ophthalmologist) present ‘The Myopic Epidemic – The Real Costs to Society and Healthcare’. That career changing moment has been reinforced every year since, at various meetings on myopia around the world.
In Chicago, Dr. Flitcroft provided his perspective of where we are in terms of considering myopia – not just as a treatable condition, but as a preventable one. He also shared the benefits to public health of doing so. He made the point that myopia is second only to age as a risk factor for a wide range of ocular disease, including glaucoma and retinal detachment. Also, he stated that myopia was a more significant risk factor for ocular pathology than poorly controlled hypertension and smoking was for cardiovascular disease. This lecture left delegates with no doubt. They had a responsibility to provide some form of myopia control to all children and young adults with progressive myopia.
Myopia is a Privilege of Human Beings
This statement might sound strange. However, at Vision by Design 2015 in Houston, USA, Associate Professor Pat Caroline explained that emmetropisation happens in all species, including humans. The two eyes grow in a rather co-ordinated way, with each species finding their version of 20/20 by visual feedback. The eye grows to a specific length that will guarantee the survival of the species on this planet. It is a very Darwinian effect present in all species including humans. While this visual feedback mechanism is so intact in animals, it has gone awry in humans. That is why we are the only species on this planet that has a refractive error. It is a luxury we enjoy as humans. Our survival on this planet is not predicated on emmetropisation.
Myopia control will certainly become more topical. We are moving into an era where I believe providing some form of myopia control will become our duty of care. Lack of knowledge will not be an excuse
Power of Prediction
How do you know who is at greatest risk? At EurOK 2015 in Budapest, Hungary, two speakers, Professor Mark Bullimore and Dr. Jacinto Santodomingo, shared research identifying two very strong predictors:
- Refraction less than +075D at age six, and
- Both parents being myopic.
A cycloplegic refraction was recommended for any young child who is less than +1.00D. The child should then be reviewed every six months for at least 12–18 months to see if there is any change.
Is it Really a Big Deal?
Had I not already been convinced, the inaugural Vision by Design Asia in Singapore during October 2015 would have left me with no doubt. Professor Brien Holden had been scheduled to present, however due to his untimely passing, the ‘Brien A. Holden Memorial Lecture: Myopia – A Global Epidemic’, was presented by Dr. Fabian Conrad.
Dr. Marino Formenti (EurOK President), Amanda Rungis (OSO Board Member) and Dr. Cary Herzberg (IAO President) at EurOK 2015
OSO Board Members with IAO President at OSO 2014; from left: Kathleen Watt, Jagrut Lallu, Amanda Rungis, Dr. Cary Herzberg (IAO President), Dr. Gavin Boneham (OSO President), Celia Bloxsom, and Oliver Woo.
Dr. Gavin Boneham (OSO President) with Dr. Fabian Conrad (Brien Holden Vision Institute) at Vision by Design Asia, 2015]
In 2010, 1.9 billion people worldwide were myopic and 205 million had high myopia. Assuming current rates of increase, Dr. Conrad shared these Brien Holden Vision Institute worldwide estimates:
- Presently there are about 2–2.5 billion people with myopia,
- By 2050, five billion people will be myopic, which will be half the world’s population,
- By 2050 there will be almost one billion high myopes, 10 per cent of the world’s population.
What Works?
Clearly, the need for myopia control exists because of the massive global increase in myopia and high myopia. Therefore, it is imperative to control the rate of progression or delay the age of onset.
OSO 2016Gold Coast, Australia |
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Have I convinced you about the importance of myopia control? Would you like to know more? We invite you to attend the 12th Congress of the Orthokeratology Society of Oceania (OSO) from 23–25 September. This year, OSO will also host the fifth Congress of the International Academy of Orthokeratology (IAO) and, to allow for the greater number of overseas delegates anticipated, will be held at the Surfers Paradise Marriott Resort and Spa. The conference will be officially opened by OSO President Dr. Gavin Boneham and IAO President Dr. Cary Herzberg. OSO 2016 will feature many great local and international speakers presenting the most up-to-the-minute information about orthoK and myopia control. You will learn how to correct not just myopia, but hyperopia, presbyopia and astigmatism with orthoK. Other topics will include binocular vision and orthoK, preventing infections and problem solving. Sunday morning’s lecture about myopia control, co-presented by Dr. Herzberg and Dr. Marino Formenti (EurOK President), will definitely be a highlight. The congress is suitable for both beginners and experienced orthoK fitters. There will be plenty of time to socialise during the evenings and meet the speakers. This is a rare opportunity to network with the greatest orthokeratologists in the world. And if you think optometrists are boring, you’ve never partied with orthokeratologists. I have a suspicion that orthoK would never have been conceived without a great deal of red wine appreciation. Details Where: Surfers Paradise Marriott Resort & Spa, Gold Coast Queensland, Australia For further details and to register, visitoso.net.au/whats-on, or contact Celia Bloxsom: (AUS) 0421 633 792 or Amanda Rungis on (AUS) 0418 616 965. |
Spectacle Strategies
Progressive lenses have achieved statistically significant but clinically insignificant results (0.2D over three years), though some subgroups may be more successful. A recent study using executive bifocals with a +1.5D ADD identified a 42 per cent reduction over three years without prism and a 51 per cent reduction over three years with a 3D base in prism. However, because executive bifocals are not cosmetically ideal, they may not be an ideal solution, especially for teenagers due to peer pressure, self-esteem issues and bullying.
Peripheral defocus correction e.g. MyoVision has achieved statistically significant results (0.3D over three
years) but not as clinically significant as hoped, with limiting factors including eye movements behind the lens and compliance.
Contact Lens Strategies
Studies have shown that bifocal or multifocal contact lenses can achieve a 40–50 per cent reduction, and that commercially available lenses with a centre distance design slow progression by creating myopic defocus in the periphery.
Orthokeratology (orthoK) lenses correct central refractive error while leaving peripheral myopic blur uncorrected. All studies have found effective myopia control to varying degrees, as high as 60–70 per cent.
Dr. Cary Herzberg:A Special Mention |
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One of my favourite parts of any international orthoK conference is hearing Cary Herzberg speak. Cary is the president of the American Academy of Orthokeratology and Myopia Control (AAOMC) and the president of the International Academy of Orthokeratology (IAO). His knowledge and experience are remarkable. However, the thing I find most inspiring is his passion for myopia control. During his presentations, regardless of topic, you can witness a legendary man living a life of purpose. My favourite ‘Cary moments’ over the last three years:
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Other Strategies
Atropine works even in very low doses, 0.01 per cent dose had similar efficacy to the higher concentration but with fewer side effects, similar reduction in myopia progression to orthoK, again studies have shown 60–70 per cent, but the rebound effect has not been fully established.
Time outdoors has been repeatedly shown to lead to later onset of myopia. There are two theories why this is so:
- Light levels are higher outdoors
- Lower dioptric demand outdoors (nearly entire visual field is in focus).
Therefore, of all the methods currently available to slow the progression of myopia, orthoK, soft bifocal contact lenses and atropine, are the most effective. Furthermore, all patients should be encouraged to spend a minimum of two hours per day outdoors.
What to Avoid
- Spectacle under-correction has been shown to make myopia progress faster, and is therefore longer advised,
- Aspheric single vision spectacle lenses – create even more peripheral hyperopic defocus and are likely to progress myopia faster,
- Distance only SCLs with peripheral minus power profiles.
The Future
Myopia control will certainly become more topical. We are moving into an era where I believe providing some
form of myopia control will become our duty of care. Lack of knowledge will not be an excuse. The question is – are you ready?
Amanda Rungis, M. Optom., B. Optom. Hons, is an optometrist and orthokeratologist. She first developed an interest in orthoK and speciality contact lenses in 1997, while doing the course Advanced Contact Lens Studies presented by Helen Swarbrick, as part of her Master degree. She is a board member of the Orthokeratology Society of Oceania (OSO) and a board member of the International Academy of Orthokeratology (IAO). She is the owner of Sure Eye Care, a practice she founded in 2005 on the Central Coast of NSW. She is the president of the Central Coast Optometry Society and a national committee member of Optometry Giving Sight (OGS).
