February 2023 Virtual event Presentation

Child Patient Story with Focus on Early Mitigation

Play Video about Child Patient Story
Foo Li Lian

By Dr. Foo Li Lian, Clinical Assistant Professor, Duke-NUS Graduate Medical School; Consultant Ophthalmologist, Singapore National Eye Centre; MD, MMed (Ophth), FRCOphth, BEng (1st class honors)

About the presentation

With ever increasing prevalence of high myopia amongst the young, it is now a global concern due to the latent risk of sight-threatening complications such as retinal detachment, open-angle glaucoma, myopic macular degeneration and choroidal neovascularization (CNV). Learn about the journey of a patient at the Singapore National Eye Centre (Myopia Centre) re-told by Li Lian Foo, a consultant ophthalmologist with the Myopia Service and Refractive Department, Singapore National Eye Centre and Myopia Centre of Excellence, and gain insights into the progression and challenges faced by patients during their preschool and early childhood years.

FAQ from the event

How does atropine slow myopia progression

Frankly speaking, nobody know today what the exact mechanism is that enables atropine to slow myopia progression, all we know after the 10-20 years of usage and radomized controlled trials is that it works.

Of course, nothing is perfect in this world and the drawback is the side effects; patients can get glare and so forth. At the end of the day, it is a trade-off.

What is the best measure of myopia progression? Diopter change or axial length?

Axial length is definitely the best way to measure progression of myopia. In an ideal world, I would like to have both. If I have the choice between axial length and spherical equivalent, definitely axial length, however, acknowledging that not everyone has access to axial length measurement equipment, I would say that having some sort of progression tracking, such as spherical equivalent, is better than nothing.

Do you think starting with 0.05% atropine is the best concentration?

Until only a few years ago, I used to start all patients on 0.01% atropine eye drops; but now, I access the patient and the dosage depends on their profile e.g. if the patient is a 10 year-old hyperope or a very low myope or so, I might very well start them on 0.01%, however, if that same patient profile is already at -3.00 diopter, the question is: can we really afford to start with 0.01% and wait and see what happens? In such a case, I would say that the benefits of a higher dosage outweigh any risks.

How long will you continuously utilise atropine drops on a patient, considering the adverse effects?

In the past, we used to think that there is a time limit on how long you can use atropine drops in children, however, in my opinion there really isn’t any time limit and as long as their myopia is progressing, I would continue; it is not until the progress halts or minimises that I would consider tapering them off atropine. I would caution against suddenly stopping treatment because you risk a sudden rebound and all the years of treatment are then wasted.

How do you taper off atropine treatment on a patient?

First of all, I would caution against suddenly stopping treatment because you risk a sudden rebound and all the years of treatment are then wasted. I would taper the patient off instead and how this is done depends very much on whether the patient is on a high or lower dosage of atropine.

For high dosage patients, it will take longer becuase the risk of a rebound is higher.

For a patient on 0.01% how uses atropine everyone night, you could for example reduce it to six days per week for three months; then 5 days per week for three months and so on.

What factors will make you consider stopping atropine treatment?

If the child’s myopia has stablised for one to one and a half year; but it also really depends on age, the older the child is, the more likely we are to stop treatment, whereas with a young child, we are more likely to taper off the treatment more slowly, for example, with atropine drops, we may reduce the treatment every six months as opposed to every three months for an older child.

References

Jones L et al IMI – Industry Guidelines and Ethical Considerations for Myopia Control Report. Invest Ophthalmol Vis Sci. 2019 Feb 28;60(3):M161-M183.
https://myopiainstitute.org/imi-whitepaper/industry-guidelines-and-ethical-considerations-for-myopia-control/

International Myopia Institute White Papers & Clinical Summaries
https://myopiainstitute.org/imi-white-papers/

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Mitigation
Measurement
Management

Prepared by the World Council of Optometry Myopia Management Resource Committee 2023.
The World Council of Optometry Myopia Management Standard of Care initiative is a collaborative partnership between World Council of Optometry and CooperVision.

Soft Dual Focus or Multifocal Contact Lenses

Spectacle Lenses for Myopia Control

Orthokeratology

Atropine

When to wear it

Children who are physically active
Ideal for very young wearers
Children disliking glasses and/or inclined to not wearing them full-time

Considerations

Shown to improve confidence and ability to participate in activities.

Typically more availability for astigmats.

No wearing time during waking hours.

Optical correction is still needed.

* Excluding children frequently engaged in water sports.