視光師在如何防治視光師在如何防治

及控制近視中及控制近視中

所需要擔任的角色所需要擔任的角色

樊志誠博士

2009 年12月18日

Why patient visits the optometrist?Why patient visits the optometrist?

• Vision problems

– Blur, double vision, squint, tired eye, ocular

discomfort, eye pain…

• Regular check up

• Contact lens fitting and after care

• Screening of eye diseases

• Others…

What do they expect from the optometrist?What do they expect from the optometrist?

• Refraction?

• Ocular examination?

• Have a new pair of spectacles / sunglasses / contact lenses?

Solve their problems

LetLet’’s check if we are s check if we are

doing a good jobdoing a good job

Case OneCase One

• Boy, age 8

• For regular eye check

• Plano o.u., 6/6 o.u.

• Normal binocular vision

• Healthy eye

• Mother once mentioned her brother always mixed up some colors

What would you do?

Case TwoCase Two

• Female, age 30+

• Complaint vision blur, want contact lens

• RE -3.50 6/6

• LE -4.75 -1.75x120 6/9

• Previous Rx

• RE -3.25 6/6

• LE -4.00 -1.25x40 6/7.5

• Otherwise normal

What would you do?

Case ThreeCase Three

• Male, age ~38

• Heavy computer user

• Complaint tired eye when reading user manual

• RE -0.25 6/6

• LE +0.75 -0.50x180 6/6

What would you do?

What you need to answer What you need to answer

these questions isthese questions is

KNOWLEDGEKNOWLEDGE

FAQ after an eye examinationFAQ after an eye examination

• 我幾多度?

• 我有無加深?

• 我加深得多唔多?

• 我係唔係加深得好快?

• 我D近視算唔算深?

• 我D近視係唔係好深?

• 我D近視有無得醫?

• …

家長會問

• 有無辦法可以唔會加深?

• …

視光師的角色視光師的角色

1. To Understand1. To Understand

Why myopia need to be managed?Why myopia need to be managed?

MYOPIAMYOPIA

= =

A MAJOR PUBLIC HEALTH A MAJOR PUBLIC HEALTH

ISSUE!!!ISSUE!!!

The prevalence of myopia varies with age, countrycountrycountrycountry, gender, race, ethnicity, occupation, environment, and other factors

USA 36%

Europe 22%Urban China 73%

Singapore 87%

Taiwan 85%

MYOPIA: A MAJOR PUBLIC HEALTH ISSUE

The prevalence of myopia varies with age, country, gender, race, ethnicity, occupation, environment, and other factors

MYOPIA: A MAJOR PUBLIC HEALTH ISSUE

Increasing Myopia Prevalence in Young Adults

0

20

40

60

80

100

1965 1970 1975 1980 1985 1990 1995 2000 2005

% M

yo

pic

Singapore USA Taiwan

Wu HM et al,. 2001 Optomtry and Vision Science. 78(4):234-239.

Sperduto et al. Arch Ophthalmol. 1983 Mar;101(3):405-7.

Vitale S, Ellwein L, et al. 1999-2004

Lin LLK et al. Annals Academy of Medicine 2004, 33(1)27:33.

• Myopia on-set starts younger

– The earlier the onset of myopia, the higher the level at which it stabilizes

– The earlier the onset of myopia, the higher myopia progression rate

• Myopia severity is increasing

– Average myopia for 18-year-olds in Taiwan:

1983: -2.55 (±2.55)

2000: -3.64 (±2.41) (p<0.05)

Committee on Vision, National Research Council. Myopia The National Academies Press. 1989.

Gwiazda J, Hyman L et al. Ophthalmic Epidemiology 2007; 14(4)230-37.

Goss DA, Cox VD. J Am Optom Assoc. 1985, 56(8):608-13.

Lin LLK, Shih YF,et al. Annals Academy of Medicine. 2004 33(1)27-33.

MYOPIA: A MAJOR PUBLIC HEALTH ISSUEThe prevalence of myopia varies with age, country, gender, race, ethnicity, occupation, environment, and other factors

Myopia Progression

-9

-8

-7

-6

-5

-4

-3

-2

-1

0

0 2 4 6 8 10 12 14 16 18 20 22 24

Age (yr)

Sp

h E

qv (

D)

SE(D)

Controlled +0.30/yr

Myopia progression predictionMyopia progression prediction

Start Intervention

Model of myopia progression over time*, with or without myopic defocus

Modeling assumptions:

•Treatment intervention at age 8 with -1.25D myopia

•Treatment effect 0.30D/yr

*Myopia model from Thorn et al. OVS 2005

High

Myopia

Without Intervention

With Intervention

MYOPIA: A MAJOR PUBLIC HEALTH ISSUE

• Myopes of -6.00D or more are considered at

higher risk of retinal related complications

• The prevalence of high myopia (-6.00D or more)

in young adults is 22% in Hong Kong (Ho et al.,

1995) and 21% in Taiwan (Lin et al., 2004)

HIGH MYOPESHIGH MYOPES

Ho, Lo and Lau 1995. Proceedings of the 5th International Conference on Myopia.

Lin, Shih and Hsiao et al, 2004. Annals Academy of Medicine. Vol33 No.1, p27-33.

MYOPIA: A MAJOR PUBLIC HEALTH ISSUE

• Myopic macular degeneration is the seventh

greatest cause of registered blindness in adults

in Europe and in the United States

• Myopic macular degeneration is the leading

cause of blindness in Taiwan

Ho T.-C. et al., Longitudinal followup of lacquer cracks in myopic maculapathy using digitized indocyanine green

angiography and scanning laser ophthalmology in Myopia Updates II, Proceedings of the 7th International

Conference on Myopia, Springer, Tokyo 2000

HIGH MYOPESHIGH MYOPES

MYOPIA:A MAJOR PUBLIC HEALTH ISSUE

2. To Know More2. To Know More

How myopia can be How myopia can be

controlled?controlled?

LABORATORY STUDIESLABORATORY STUDIES• Location of point focus dictates direction of eye growth.

• Hyperopic defocus induces myopic growth

• Myopic defocus induces hyperopic growth

Hyperopic defocus(human: accommodative lag)

Myopic defocus

UNDERSTANDING HOW MYOPIA CAN

BE CONTROLLED

McBrien, N. A., A. Gentle, et al. (1999). Optometry and Vision Science 76(6): 419-427.

Schaeffel, F., A. Glasser, et al. (1988). Vision Research 28(5): 639-657.

Siegwart, J. T. and T. T. Norton (1993). Investigative Ophthalmology and Visual Science 34(ARVO Suppl): 1208.

UNDERSTANDING HOW MYOPIA CAN BE CONTROLLED

McBrien, N. A., A. Gentle, et al. (1999). Optometry and Vision Science 76(6): 419-427.

Schaeffel, F., A. Glasser, et al. (1988). Vision Research 28(5): 639-657.

Siegwart, J. T. and T. T. Norton (1993). Investigative Ophthalmology and Visual Science 34(ARVO Suppl): 1208.

When opposing defocus were presented simultaneously, the impact of

myopic defocus (+ power) dictates the eye growth

ANIMAL STUDIESANIMAL STUDIES

-15.00

-10.00

-5.00

0.00

5.00

10.00

15.00

0 3 6Time (day)

Refr

active e

rror

(TE

-CE

;

Mean +

/-S

EM

; dio

ptr

e)

-10D/+10 plus Tx optics

(+10D)n=5

(-11D)n=6

• 13 myopic children wore ‘monovision’ spectacles (monocular under-correction) for 18 months (Phillips, BJO, 2005)

• myopic retinal defocus slows axial elongation in human myopic eymyopic retinal defocus slows axial elongation in human myopic eymyopic retinal defocus slows axial elongation in human myopic eymyopic retinal defocus slows axial elongation in human myopic eyeseseses(as it does in animal eyes)

Change in SER

(D/yr)

Change in VCD

(mm/yr)

Dist----0.720.720.720.72

(± 0.32)

0.290.290.290.29

(± 0.11)

Tx

(Myopic

Defocus)

----0.320.320.320.32

(±0.30)

0.150.150.150.15

(± 0.12)

Inter-ocular difference:

Refractive error 0.40D/yr

Vitreous chamber depth 0.14 mm/yr

SPECTACLE MONOVISIONSPECTACLE MONOVISION

CONTROLS THE PROGRESSION OF MYOPIACONTROLS THE PROGRESSION OF MYOPIA

Monovision study clearly demonstrates effectiveness of

myopic defocus principle to control myopia however

monovision is not an effective solution – need to control

myopic progression in both eyes, not just one

• A contact lens that incorporates dual optical

properties

– an optic for vision correctionoptic for vision correctionoptic for vision correctionoptic for vision correction and an optic to optic to optic to optic to

counteract myopia progressioncounteract myopia progressioncounteract myopia progressioncounteract myopia progression

+

REQUIREMENTS

HOW TO CREATE MYOPIC DEFOCUS

= ActivControl™

Technology

MYOPIC DEFOCUS is comparable to

•Ortho-K and with tighter treatment effect distribution (±0.09 vs ± 0.38)

•the best outcomes from using spectacle BF/PALs

COMPARISON OF DIFFERENT METHODS OF CONTROLLING MYOPIA

2-year 0.13NAOrtho-KCho et al, 2005

10 months

0.130.30Soft myopic defocus contact lenses: MiSight™

ActivControl Technology™

2-year 0.16NAOrtho-KWalline et al, 2009

3-year 0.040.07PALGwiazda et al, 2003

2-year 0.170.28PALLeung & Brown, 1999

30 months

NA0.10Bifocal SpecFulk et al, 2000

3-year NA0.00Bifocal SpecGrosvenor et al, 1987

Study duration

Reduction inMyopic Progression. AXL/yr (mm)

Reduction in Myopic

Progression. SER/yr (D)

Treatment Authors

When to start?When to start?

AGE AT MAXIMUM RATE OF PROGRESSIONAGE AT MAXIMUM RATE OF PROGRESSION

Thorn, Gwiazda, Held, OVS 2005

Maximum

impact

3. Be Proactive3. Be Proactive

Why?Why?

Awareness of myopia Awareness of myopia

control methodcontrol methodss??

46%

54%

Yes

No

TotalBase Size:

All

Respondent

s

N=205

Child 6-8 yrs

49%51%

N=51 N=51

N=51 N=52

Child 9-10 yrs

39%

61%

Child 11-12 yrs

55%

45%

Child 13-15 yrs

42%

58%

AwareAwarenessness oof f eeyewear yewear wwhich hich sslows lows ddown own

mmyopic yopic pprogressionrogression

Less than 50% aware of eyewear which

slows down myopia progression

35%

65%

Yes

No

Awareness of OrthoAwareness of Ortho--KK

TotalBase Size:

All

Respondent

s

N=205

Child 6-8 yrs

33%

67%

N=51 N=51

N=51 N=52

Child 9-10 yrs

31%

69%

Child 11-12 yrs

47%53%

Child 13-15 yrs

29%

71%

Only one third aware of Ortho-K

Interest level in a Interest level in a

method of myopia method of myopia

controlcontrol

6%6%

8% 4%

27%18%

33%

50% 51%41%

55% 54%

15%22%

18%6% 13%

2%4%

2%2%6%

25%33%

73%

59% 61%67%65%

Total Child 6-8 yrs Child 9-10 yrs Child 11-12 yrs Child 13-15 yrs

Top-2-Boxes

Very Likely

Likely

Not likely nor unlikely

Unlikely

Very Unlikely

65%

Base Size: All

RespondentsN=205 N=51 N=51 N=51 N=52

Interest to Seek More InformationInterest to Seek More Information

Why unlikely50% Cannot afford the higher expense of contact lenses compared to eyeglasses

25% Eyeglasses can also slow down rate of myopia progression

14% Other reasons

13% Child is too young to be fitted with contact lenses right now

i.e. 9 out of 205

Parents with younger kid shows higher interested

A simple and systematic A simple and systematic

way to manage myopia way to manage myopia

MYOPIA MANAGEMENT

• Goal : To manage the onset and progression of

myopia

• Who benefit : Children with myopia or those at risk of

developing myopia.

• Consists of three basic steps:-

1. Identify high risk group

2. Counseling

3. Intervention

MYOPIA MANAGEMENT

Identify high risk group – essential elements

• Regular eye examinations

•Allow early detection, earlier intervention possible

• Proactive counseling

• Children with one or more myopic parents at higher

risk of developing myopia

• Both parents are myopic – 5X

• One parent is myopic – 2.5X

MYOPIA MANAGEMENT

Counseling - Lifestyle Changes

• Studies have shown children who spend more time on

outdoor activities are less susceptible to the on-set of

myopia

MYOPIA MANAGEMENT

Intervention

• Correction – Fully correct

•There is a believe that under correct -0.25D/-0.50D

may help to slow down myopia progression but

research result showed that this is not the case

• Myopia control

• Muscarinic antagonists - not available for

optometrist, obvious side effects

• Orthokeratology

• Spectacles: Mainly Progressive Addition Lenses

(PAL) – results vary

MYOPIA MANAGEMENTone or more

myopic parents?

child myopic?

counseling /

advice on outdoor

activities

Annual Eye

Examinations

Intervention –

prescribe myopia

control means

Annual Eye

Examinations

NO

NO

YES

YES YES

SUMMARYSUMMARY• Understand the prevalence and

severity of myopia is increasing

• Keep your knowledge update

• Utilizing a proactive, holistic

approach to manage myopia can

benefit children