視光師在如何防治 及控制近視中 所需要擔任的角色視光師在如何防治...
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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