Lecture: Confidence in Practice – Myopia Management in Clinical Practice

>> SOOJIN NAM: Hello, good morning, good afternoon, and good evening to everyone joining us today. I’m very excited to be here to share with you some of the case studies that were presented at the very recent international MiYOSMART case study contest that was held at the IMC last year. Today you have presenting Dr. Tang Yan, who is a pediatric ophthalmologist from China, Martelie Burger, who is an optometrist based in South Africa with a special interest in pediatric eye care, and myself, I’m an optometrist and I’m based in Sydney, and right now it is midnight, so I must really love myopia a lot if I would rather talk about myopia at midnight than go to sleep. So I should tell you that, you know, just to retread, Dr. Tang Yan, Dr. Martelie Burger and myself, we were all finalists at the case study contest. And Dr. Tang took the crown as the winner for her very comprehensive and educational case study on early onset myopia. Now, look, I know I’m very much looking forward to learning from the two ladies tonight, and just before we start, I would just like to take the time to thank Hoya for the very unique and innovative opportunity to share our case studies on a global stage. The program was obviously held in beautiful Sanya in China, generously hosted by Hoya. I would love to see more people become involved in the future. Really, this is how we all grow potentially, by sharing and collaborating so that ultimately we can have the best outcome for our patients. So if we can just start with a poll, and just answer some questions so you can let me know what type of myopia control interventions you prescribe the most. So which myopia control intervention do you prescribe the most? Do you prescribe myopia control spectacle lenses, myopia control contact lenses, orthokeratology, low dose atropine, low level red light therapy? The one you prescribe most often outside of combination therapy. And the results are MiYOSMART lenses. Considering that particular lens has always been available in the last few years, it is quite interesting how myopia-specific spectacle lenses have become such a popular intervention across the board. So let me introduce tonight’s first speaker, Dr. Tang Yan. I had the pleasure of sharing the same stage with her in China, and it is now my great pleasure today to share the same screen for tonight’s webinar. As I mentioned, Dr. Tang is a doctor from China, and specifically, tell me if I didn’t pronounce this correctly, she is an expert in the study of myopia and will illustrate different cases and emphasize the importance of combination therapy for effective myopia control. Please welcome Dr. Tang Yan. Are you ready to share your screen? You’re still muted. Tang, you’re still muted. Andy, are you able to unmute Dr. Tang? >> TANG YAN: Can you hear me? Hello. Thank you for the introduction. I can’t share my screen because another is sharing it. >> SOOJIN NAM: Okay, I’ll stop sharing my screen so you can share yours. >> TANG YAN: Let me try again. Okay. Is that okay? >> SOOJIN NAM: Fabulous. Looks good. >> TANG YAN: Oh, yes. Thank you very much. So I’m very lucky to see you again, thank you for our conference. Today I will start my cases. Because English is my second language, please forgive me. First, I want to a polling question. Could you please share the polling question here. Today I will share three cases, one by one. The first — oh, it’s come to the polling question. You can begin. The polling question is about when you see a child that was 4.8 years old, who has myopia, very low myopia, what treatment you will choose. In a few seconds we will see the results. And today I will share about very young children, 4.8, and another is two years old. At the end of the cases is one years old. So let’s see. Okay. I think most of you will feel you can follow up. He was a young boy, 4.8 years old, a Chinese boy. His father had myopia. He did not have enough auto activities. Here we go. We can see the eyes change. At first, his parents did not choose to wear glasses, but the eyeballs change very fast. At the first two months, it had changed about 01 millimeters. So the parents have chosen the MiYOSMART glasses to help him. You can see in a long period of time, it was amazing, the eyeballs are controlled very good, almost stable. For about one year and a half, something changed. The children had gone to school, about six-year-old boy, it changed very, very fast. So the parents want their children to not always wear glasses. So they choose to wear ortho-K contact lenses. The ortho-K contact lenses, it changed very fast, at about two months, it changed very fast in two months, it has changed almost 0.1 millimeters. It came with 0.0 atropine, still very quick. So we use atropine about two times a day. So at the conclusion, you see at four and five years old, it’s very stable. At six years old, in the primary school, it’s not very stable. If you change the ortho-K contact lenses, the speed is more of a factor. These are very difficult cases for us to control the myopia. Wearing the MiYOSMART, it is a bad effect of the eye’s function, you see both the NRA and PRA, both eyes’ function are not very bad. The second two cases was two years ago. And you see she was a Chinese girl. Her mother had RP disease. The father is very healthy, has very healthy eyes. The left eye is 0.27 myopia. The right eye, very low myopia. The levels are very short and not very long. But we see the fundus. It has a lot of change. So we can see, OCT, you see 1.55 micrometers. You see, single vision lenses just to make sure it’s not amblyopia. You see it changed very fast in the left eye, 0.8 millimeters in one year. The parents change to glasses, in the peripheral is blurry, and in the center, very small area is clear. But it did not work. The eyeballs still grow very fast, 0.51, in one year. So this time, the parents have chosen the MiYOSMART. Oh, you can see the surprise after wearing the MiYOSMART, about one year, it growth was very stable, it’s about 0.14, and 0.22 per year. And you see this is the refraction change. You can see after wearing the MiYOSMART, it’s very stable. So you can see the MiYOSMART works better than the single VIX lenses and the peripheral blurry lenses. And she was a very, very young girl. So if you wear the MiYOSMART, we make amblyopia. Is that true? I think not. It’s the same age as average young person. And the second, the third, is more younger boy. He was one years old. And what we have done for him, when he first comes to our clinic hospital, he was just one years old and nine months. Both his father and mother have almost minor 6 myopia. His parents were very, very nervous about him, because after the cycloplegia, the atropine, he had minus 3.5/2.5. You also see the fundus is really something where you can see the my myopia change. You can see the OCT-choroidal thickness, it’s about 169, 167. What should we do? We have done the gene test. Fortunately, we haven’t found any of the high myopia single gene changes. So we haven’t found the gene. Eyeballs changed very, very fast. We first just used the single region glasses, used 0.01 atropine. It did not work. About the first six months, the eyeballs would change about 0.13 micrometers. And we changed another way, we used also the MiYOSMART glasses with 0.05 atropine QN in Beijing. It a little bit worked, it had been more slower, but the parents were also very nervous, is that enough amount? At the end we went to — in China it was very warm and always a lot of sunshine in the front of the beach, outdoor activities about five hours a day and more walks. You see half a year has changed, 0.18 millimeters. And you see this is the refraction time to what is changed, it was more stable than using normal glasses. And the MiYOSMART is more better than the normal glasses also. And the conclusion of visual activity, it was better and better. So let’s have another polling question for you. Please, Andy. So I will ask you the polling question. When you find children have these high myopia, do you think 0.22 millimeters half a year change is okay? Or we should choose another way to help him to control the myopia? Could you please give me the polling and give me the answer. How do you feel we can help them? I think about the most doctors will choose to change to another kind of glasses. And the other most chose is to make the atropine the more concentration and the more times. Let me give my result. We have many times talked with their parents how we can help these children. But at that time, you know, in China, we have a kind of rapid low level red light therapy in China. But for these very, very young people, we do not have many choices, but we have to try because the parents are wondering if the children need surgery, clearly more stronger, but they tend to choose the LL red light therapy. You can see that here. At first, we haven’t used it, the change is 0.6 millimeters, 0.12 millimeter in five months. But after we use the therapy, the eyeballs will be shorter, about 0.22, it is amazing. For very young people, it was a challenge for us, we Ned to help them to control the myopia, to help them to avoid retina disease, cataract, glaucoma. But we do not have many ways, MiYOSMART or contact lenses or atropine, something like that. And firstly I want to discuss, does MiYOSMART have a negative impact on vision development. I think the answer is no, because we have tried many very young children, in the peripheral, it cannot focus but it doesn’t stop visual development. Will MiYOSMART lenses have a negative impact on visual function? I have found that it did not affect the visual function. After we have tried on the first cases, we also find the same result. And the discussion 4 is, will something like the glasses, like MiYOSMART, have more effect and be safer for very young children? I think the answer is yes. It’s very difficult for us to choose the Ortho-K contact lenses. It’s very difficult for us, we do not let them wear any glasses for visual activity. I think it might be a very good way for them to choose MiYOSMART, because sometimes I think the DOT glasses, the visual function a little bit weaker than the MiYOSMART glasses, in my opinion. I’m not sure. So after the last discussion, what should we do if the MiYOSMART is not effective enough in controlling myopia? We try to find many ways to make it balance. If we just use one glasses, it’s safe and effective, we can use it. But sometimes it was very difficult for us, we just need to try eye surgery, we use the red light, atropine, something like that, we just need to make a balance. I think the key is to improve, hyperopia can be key to controlling myopia. After using the red light, MiYOSMART is a good choice for kids with myopia, even for children under the age of five. It’s more difficult to control congenital myopia progression, meaning occasionally, individually, and comprehensive solutions are also needed. Thank you. This is the end of the slides. Thank you. >> SOOJIN NAM: Thank you so much for that presentation. Let me just get my slides up. That was excellent, it was very insightful and interesting for you to be presenting case studies on a four-year-old, a two-year-old, and a one-year-old. I actually found it quite interesting when you said that the Ortho-K, when they wore the Ortho-K, the progression was faster than MiYOSMART lenses, that was an interesting observation to see. You mentioned the use of repeated low level red light on a three-year-old. I’m actually quite amazed you can get a three-year-old to sit down to look at the red light twice a day. So if you can maybe give us some hints and strategies on how you can encourage kids to sit and do anything [laughs], because I can’t get them to sit down and do much for very long. What I actually wanted you to do, Tang, if you don’t mind, maybe for those who don’t have access to the low level red light instrument, to just maybe talk about what it is briefly, to explain to them what this treatment is, because they may not have it available in their country. >> TANG YAN: It’s a kind of light that just has one light, about 530 zero, the power. And you use it about 0.2 mico-V, three minutes a day, two times. And when they use it, they listen to the stories or something like that. After they use it, sometimes they will feel they see something more clear and more lighter. So the children can follow the therapy very easily than others. He was a very young child but he can follow it and he likes it. >> SOOJIN NAM: I’m amazed you were able to get him to sit down three minutes twice a day. Do you believe that combination therapy is going to become more important as time goes on, as an intervention strategy? >> TANG YAN: Yes, I do think so. Because I think just one therapy is not enough for these very young children. I think comprehensive, we really need, yes. >> SOOJIN NAM: Yes. I have to say, Tang, I always learn a lot. Even though I’ve already heard your presentation before, I learned more things again. You explained some concepts in a very clear and engaging way. I want to thank you for being such a great leader in the field of myopia management. Congrats again. >> TANG YAN: Thank you very much. >> SOOJIN NAM: Congratulations for winning the inaugural MiYOSMART case study contest. I’m sure there will be lots of questions that will come from your presentation. So what I would like to do now is share my screen again. And what I will do is introduce our next speaker. Our next talk will be given by Martelie Burger. Martelie, as I mentioned, is an optometrist based in South Africa with a special interest in pediatric eye care. She runs a pediatric practice and holds a degree from England. She’ll talk about how to manage high astigmatism and whether or not full correction should be applied in very young children. This is certainly a challenging cohort of patients, and I look forward to hearing your recommendations, Martelie. If you’re ready to share your slide. >> MARTELIE BURGER: Thank you, SooJin. If you could just stop sharing your slide. >> SOOJIN NAM: Yes, here we go. >> MARTELIE BURGER: Okay. Thank you so much for the introduction, SooJin, I appreciate that. So today I want to just talk a little more about correcting myopia astigmatism in very young children. So I took this case because this case is very close to my heart. I wanted to take this child from the genetic consequences that his family has faced over the years, and how exciting for optometry worldwide that we can alter a genetic pathway. Focusing on his family tree of severe myopic complications, he will likely encounter the same results if his myopia is left untreated. All males on the maternal side over the age of 50 have or had visual loss that could not be corrected due to the complications of myopia. My greatest wish is to manipulate his genetics and change his genetic destiny for good. And to provide him with an opportunity in life free from the bleak possibility of permanent, uncorrectable vision loss. One of the most difficult decisions I had to make with this case was to fully prescribe for astigmatism at the age of three or to prescribe as we do with our regulations, because we know astigmatism can still very much change, we like to underprescribe. My other concerns with the patient was will the patient be compliant and will the glasses survive a three-year-old boy. So now, looking at the case history, the patient is a Caucasian male. His current age is four years, five months. The age of onset for the myopia was three years, one month. Like I said with his family history, myopic astigmatism for males on the maternal side ending in high myopia. The mother has low myopia. His grandfather had normal glaucoma and macula hole from the age of 45. So he had never had optical correction previous to the three years one month. And because we live in South Africa, outdoor exposure, I said two to three hours but it can be much more than that. His close work is limited to one to two hours a day. So the pregnancy was uncomplicated. The mother had an elective C-section at 38 weeks, five days, with no complications. He had already had quite a few hospitalizations in his first two years of life. At three months he was in NICU for seven days with viral pneumonia. He was hospitalized with RSV virus for one day. He had grommets at 12 months. He had a Cox saki virus and tonsillitis at 18 months for four days, and he had a second grommet at 19 months following tonsillitis. He sat at six months, crawled at 11 months, walked at 16 months. His language development is at the lower range of normal currently. Abnormal gait until three years seven months. So currently he’s slightly delayed in his gross motor development. However he outgrew a lot of his arguing he had that caused all these ear infections. He’s currently taking no medication and is a healthy young boy. So I’m going to take you through my test results. Like I said, the first evaluation was at three years, one month. So obtaining an unaided VA for a three-year-old can be quite tricky, because often you don’t know if they just don’t know what you’re showing them or if they’re just shy or just uncertain. So to make sure that he did have visual acuities, I do it twice, once with a pediatric with a spectrum and then repeat it to confirm what I did was accurate. Then I relied greatly on Mohindra ret. As you can see, Mohindra is one of the techniques that is close to the refraction results. So we got a slightly reduced calculation or findings with the cycloplegic refraction. Often I will do, on the followup evaluations, I won’t always do a cycloplegic refraction because if the Mohindra rate was below a certain amount, I won’t need to do the cycloplegic refraction again. It is the golden standard. The K readings, the astigmatism that we see there. The axial lengths was quite within the normal. If I can give tips for the current equipment measuring lengths, it makes it easy to use on a three-year-old. Multiple measurements, bribery, corruption, just to get him to comply, to get actual measurements from him. But then we went to look at the spherical equivalent. On the right, we have minus 1.5 on the right and minus 1 on the left. Spherical acuity was fine, contrast sensitivity test hiding Heidi was normal, binocularly, nothing worth mentioning. We ended up with 6/6 in both eyes. We got these results, I really had to decide, are we going to prescribe fully, are we going to do a partial prescription. But I end up prescribing the full cycloplegic refraction and when I take them again in six months time, everything stayed very similar except that we had slight reduction in astigmatism on the right eye even though we gave the full prescription. That was a great relief, when I saw that. Everything else stayed quite the same. What was also encouraging was with the high MEM rate at six months compared to the month before, six months before, even though it was over a lower minus prescription. Again, six months later, we repeated the exam again, and everything stayed almost exactly the same over the next six months. And the only other thing that was worth mentioning is that I did find a small esophoria movement. Andy, if you can put up the poll. In practice, do you find that myopia progresses more with a patient with esophoria or exophoria? You guys can take your time and answer that. So what I saw with the research was that studies have showed that with esophoria, we often see there’s a slow progress in myopia. They say that it might be because of the increased convergence. But I have to say for myself, in practice, it is often — sometimes it goes that way, sometimes it doesn’t. So I will be really monitoring this patient closely with emerging esophoria. So I’ll move on. So after my initial tests, I sat with a — sorry, guys. I sat with a differential diagnosis in my head. One would be myopic astigmatism. The other would be accommodation excess. Not doing the cycloplegic refraction, you always at this age group can have overaccommodation, excess, increased astigmatism due to the overaccommodation. So very important that the cycloplegic was done to rule out accommodative excess. With the corneal astigmatism, we’ll always be on the lookout for possible emerging keratoconus. My final diagnosis was myopic astigmatism. I prescribed MNRI therapy for treatment. With the research available on myopia management for this age group, we need to start myopia management. We know from birth, if there’s esophoria, you apply full plus, overplusing him at this stage to get everything straight. There’s no confusion for us. But with myopia it’s a little more daunting. I believe we should value the quality of clear, comfortable vision. Even more so, it is critical for early development in life. If we know what we know about myopia and myopia progression, should we not look at the spherical equivalent and not at the astigmatism. I think if there is one thing that is engraved in my mind, after my studies, the VHR counts, giving full prescription for beta acuity as well as myopia management was the right thing for me to do. Because I believe to start myopia management as soon as possible with this case gave me great comfort that we saw the reduction in astigmatism even though the patient received the full prescription and no myopia progression took place for this period. Another thing that I feel very passionate about is in also the dispensing. With this young boy, it took regular frame adjustments, intense parent education, and frame hooks to keep the frame in place. The parents could then adjust the frame at home with the frame hooks to make sure that the child is looking through the optical zone for the majority of the time. I feel passionate about the reflex coating. As we know, with development delays, introduced VAs, that it is based to prescribe a good quality antireflex coating to ensure optical polarity. These lenses also needed to be replaced at the six-month followup evaluation because it was scratched badly. I’m not talking about normal wear and tear. He explored by scraping his glasses on a brick. So one research question, is underprescribing of astigmatism still the golden standard if the spherical equivalent is myopic? Or does it contribute to myopic regression? Then how do I get a child to wear glasses? This is possibly the most asked question in my practice. With this young child, it took four weeks for him to get comfortable in his glasses. In the beginning, he will take them off, compare vision with and without. So all the caregivers were advised this would be normal and they should just put the glasses back on as often as possible without making a fuss. After four weeks of seeing it gradually change, he did not want to take the glasses on anymore, as you can see, he literally goes to sleep with his glasses on and it’s the first thing he looks for in the morning when he wakes up. In a very short time, he had no problems to adapt. Dispensing is often overlooked. I believe with accurate dispensing, there will be even better results. Finding a frame that was durable and active for this exploring toddler was essential. As you can see from the bottom picture of him peeping over the glasses, that it’s an ongoing challenge, and that’s why the whole parental system and care giving system needs to be advised on how his glasses should fit for him to have active treatment zone a majority of the time. So my treatment strategy for this patient was technically those lenses with full prescription, focusing on the spherical equivalent in the astigmatism, by saying that it means I rather fully prescribe this astigmatism prescription and not reduce his astigmatism prescription. I took care, I did a dispensing check at two weeks. It’s often very important, make sure that parents still understand that the glasses need to still correctly, you double-check that they actually are. For the remainder of his childhood we will do six-month followup evaluations. When it comes to the compliance of the treatment, we need the parents to understand the need for the glasses. And with the need of the glasses also we need to explain to them that they need to limit screen time, they need to play outside, they need too wear the glasses for it to work. I find explaining myopia to the patient in a scientific way works well. If they get the “why,” they always comply. We should also remember it is equally important to reiterate visual hygiene. Screen time, outdoor time, you know, so important in the treatment of myopia that it cannot be left behind. What I find with the toddler and screen time, the answer is no screen time on a tablet or a cellphone more than 20 minutes. Picking a fight with a three or four-year-old is not my favorite time. I would rather say no, you fight for two weeks, and after that that becomes the new rule. So my takeaway for you today is, every letter on the chart counts. It is never, ever too early to start myopia control. Adaptation is better than you would expect. And dispensing is a key to the success. Damaging the lenses is going to be a reality. And concentrate on the spherical equivalent with myopia control when deciding when to prescribe. In the last year, we compared this child that was not able to draw himself at the age of three to a child that is now self-assured, bursting with confidence, participating in sports, and improved beyond expectations in hill overall development. There is the portrait to prove it. We see in practice the success rate is far higher than the 60% reduction rate that the research is showing for MiYOSMART lenses. That is when the patient is compliant. I thank you. >> SOOJIN NAM: Thank you, Martelie, that was excellent. Always better the second time around and your first time around was excellent. I’m really impressed how comprehensive your review points are, Martelie, you actually do so much every time they see you every six months. Is that your routine for all your patients? >> MARTELIE BURGER: I take great care with myopia, because one slip, you miss a year or six months visit, and you get a 50% reduction. My followup, if they’re that young, I do two appointments, if the concentration does not last. But yes, that’s what I do with every six-month followup. >> SOOJIN NAM: That’s very impressive. And I notice you take keratology readings as well. Is that something you do routinely for patients with astigmatism or is that something you do for all of them? >> MARTELIE BURGER: It’s something I do for all of them. The equipment I’ve got, it’s a mobile unit, and I just do it in any way. So it did make a big difference in my clinical outlook. Maybe when they’re eight, nine years old, I won’t be so comprehensive. But at this young, delicate age, we really took our time, yes. >> SOOJIN NAM: And you’re right when you said that it’s really exciting to think that we are here today as eye care practitioners, providing treatments that can actually change the projection of someone’s refractive error, not just change their final prescription, but potentially give them a quality of life that is improved. We are definitely living in the golden age when we have all of these new research coming through. So well done, Martelie, that’s an excellent presentation. There are going to be lots of questions coming through. So maybe if you and Tang can just monitor the questions coming through and see if you want to answer them or any particular ones you would like to answer during the open session at the end. Now, I’m going to start my presentation. I’m sorry we are running a little bit late, so please be patient. I’ll do my best to get through it as quickly as I can. My presentation is — so this is me with two of my favorite myopic patients. It is my pleasure to present a case study on a young child with syndromic myopia. We will review the protocols outlined by the International Myopia Institute. Is it moving across? Let me have a look. Are the screens moving? Let me share my screen again, for some reason it is not going. There we go. And I will share my screen again. So here is just a little quick snapshot of some of the diagnostic tools we have available at our practice in Sydney. And here is a little snippet of what it looks like in Australia. There are about a thousand ophthalmologists and 6,000 open tomorrow terrorists providing eye care to a population of about 26 million people. So in Australia, you can have eye care done by the optometrist, and if you need tertiary care, you get referred. Here is the scope of optometry practice in Australia. We have about seven optometry schools, degrees are five to seven years. We have 60% that work in corporate optometry and 40% in private practice. I know that different countries have different ways of delivering and providing eye care to the community. I thought I would provide a little snapshot of what we do here in Australia. So let me introduce my case study to you. This is Kaichi, I first met Kaichi when he was four years old. His mother had been to the hospital with him and wanted a second opinion. He’s a little boy who is so bright and sunny and beautiful, he couldn’t sit still during the eye test, he was so interested in everything that’s around him. I really empathize with what Martelie was saying, because every visual acuity that you can get out of them does count. And I had to chase him to measure his visual acuity, which really turned out to be reduced. And, you know, myopia in young children is not very common. So this is a case study in how we manage those kids. If we look at the prevalence, myopia in children under the age of five and six is very rare. In China and Singapore, the reference rates, that’s worse than minus six diopters in children. In the U.S., the prevalence of myopia worse than minus 4 is really low, something like 6 to 8. We need to be mindful that children with high levels of myopia in early childhood do not progress at the same rate as school-age children who develop myopia later in life. And there are two main types of genetic etiology, where hopefully you’re collectively quite familiar with school age progressing myopia. Most of the intervention studies include subjects that fit into this profile. But when it comes to children with syndromic myopia, they’re excluded from studies. And so — and of course this is so that the results of the study are not confounded. However for people like us, and this is why so many case studies like Martelie’s and Dr. Tang, focus on young children with myopia, because it makes it hard for us to figure out how to manage this special group of patients, who really they need us more, not less, to manage their eye condition. So here are some syndromic myopic conditions that you may present with in your consulting room. And this particular diagram, which is a little difficult to see, demonstrates the genes which have been identified for both common refractive errors and syndromic myopia. And as you can see, there are a lot of them. And that’s pretty much all I have to say about this one. Now, for an infant or child with high myopia that warrants a closer assessment, the IMI provides a management pathway with clear instructions on what to look for in terms of relevant findings and the actions you can take. Obviously start by taking a detailed history to identify syndromic forms of myopia. You don’t want to miss that. Ask about birth history, developmental milestones, and any other signs of developmental delays or health issues. If you have the knowledge to do so, examine from nonocular findings, even observations to see if they need a further-on review by a pediatrician. Assess visual acuity. This is key, it’s important to what we do, assess visual function and color vision as it can help differentiate children with retinal dystrophy. After you’ve ticked off all those items from your eye test, here are the next steps in the flowchart. Take ROP and keratoconus measurements, eye movements, retinal examination, and you’ll miss clues if you don’t do a slitlamp even if it’s difficult to do on a young child. Ocular imaging if possible on younger children, I know it’s not easy. I also know that not everyone will have access to this information. But if you do, they will certainly help you with an earlier diagnosis. Now, electrophysiology, which has been mentioned by Dr. Tang, is not part of the battery of tests, but it is an important consideration for potential referrals, especially because they are central for detecting conditions such as retinal dystrophies. So let’s go back to Kaichi. Kaichi fortunately had a very normal developmental history with an uncomplicated full term birth. If we look closely at his risk factors associated with progressing myopia, whatever Kaichi’s mother is Asian, she’s Japanese, he was only three when diagnosed with myopia, his father is myopic, he was initially prescribed single vision lenses from the hospital, which as we all know, has no myopia control benefits. We’re very fortunate in Australia because like he loves spending time outdoors. I know for him, time outdoors was not a problem. Our story with Kaichi starts here. This is when we first met, with his myopia. And he looked like he may have had reduced visual acuity. At the first visit I tend not to worry too much because it might just have been the child not paying attention. But I wanted to look at how his prescription has changed over the last four years, and how his best corrected visual acuity has only ever been, if you have a look, 6/12. Note how the initial rate of progression was one diopter per year and now it’s slowed down to 0.375 since using combination treatment, in this case MiYOSMART lenses with low dose atropine. Now, this picture with his glasses dropping down, and I love that Martelie also made a point about how important fitting is, and really as good as we are as eye care practitioners, we obviously focus on providing the most comprehensive eye test. Dispensing frames and lenses honestly are equally just as important. Here is a snapshot of Kaichi’s binocular vision, with a finding of reduced lag of accommodation. This is even with the use of atropine. Didn’t seem to be making much of a difference for him. Now, atropine also doesn’t appear to have caused any significant change in pupil size. Here is a little normative data, what you expect a child to have for the pupil size. And his was pretty much on average. There wasn’t really much to be concerned about there. And he wasn’t terribly concerned about any light sensitivity. That didn’t seem to be a big deal at all. Pretty average corneal curvatures, 42 to 43 diopters, small amount with astigmatism. If I go into this chart here, Kaichi was minus 4 in the right eye, minus 4.25 in the left eye at the age of six. If we plot these on the refractive growth chart it predicts his prescription to be at minus 13.5 in the right eye, minus 14 in the left by the time he’s 16. I know what you’re all thinking. To be fair, predicting the actual myopia progression in a really young myope is not very predictable, I know. But that’s not the point of a growth chart. For me, anyway, as a clinician, whenever we have a plan to manage a child, we want to have an end game. And if I’m explaining this to a parent and they look at this chart, you get a sense of potentially, you know, because it is relevant for a lot of kids, of how bad his prescription could become. And it creates a sense of urgency to do something today. One of the questions that was posted was how do you get the parents to engage with myopia management. Explaining to them why myopia management is important to do today because of what might happen together tomorrow to get buy-in from the parents. After all, when do we make the biggest impact? We make the biggest impact with myopia control when we start as early as possible, not later. If we have a look at the axial length growth chart, we notice Kaichi had really long axial growth from the age of six. It identifies those at risk of developing high myopia. We know that longer axial length is associated with pathological myopia. We all know this is the “why” of myopia management. An important clinical goal is to keep axial length at less than 26 millimeters. Now, here are some axial length measurements that I have for Kaichi from the age of six with progressive changes compared to baseline. And if you look, because I did put in the changes over time, they do actually appear to be slowing down. And I wanted to make a note here about refractive and axial growth charts for everyone, and that is that these charts may not be relevant for all children, especially those cases who have been excluded from studies due to confounding factors. So when I see a patient, and this is every person who walks in through the door, they are — Kaichi is not a cohort, not a statistic. Whilst all the tools and comparisons are useful, patients like Kaichi deserve individualized care and management, so understanding why he’s progressing myopia, and then providing a more tailored care for him, is really what we’re trying to do. Let’s look at some retinal pictures in the right eye. You can see obliquely inserted optic nerve heads with prominent temporary peripapillary atrophy. We can see retinal and choroidal thinning temporal to the disc, creating a tesselated appearance, associated with choroidal thickness. Just in case you were wondering. The neuroretinal rims are healthy. It is obviously clear that the discs are unusual. We have to remember there is no normative diameter among children anyway, we have to look at it case by case. When we zoom in closer, we see how crowded the optic nerve heads are. Just have a look at the macular region for the right eye. It appears a little thin but relatively unremarkable. The retinal scan doesn’t really explain Kaichi’s reduced visual acuity. However, if we zoom out of the OCT image of the macula, we find that Kaichi from the age of six already had signs of bilateral posterior staphyloma secondary to myopia. I don’t know about you, but I find it quite alarming to think that staphyloma can be present in such a young child. Staphyloma among young children is not actually that unusual. In fact around 13 % of Hoyle myopic children will have signs of posterior staphyloma. I wonder how many of us actively looking for it when they come in for an eye test. So diagnosis is really important. When things don’t quite make sense, we all need to remember to refer patients out for further diagnosis and management and do what we do best which is to provide the highest level of evidence in terms of myopia management. Obviously in Australia we’ve got optometrists providing primary eye care and then we have ophthalmologists who can take on the more complicated cases with tertiary care. Now, the IMI white paper has a flowchart on indications for referrals for infants and young children. I think it is reasonable that as primary eye care practitioners, we are able to recognize risk factors that indicates referrals. Some of these children will require a team of professionals to look after them. And this could include ophthalmologists, especially those who specialize in inherited disease, clinical geneticists, genetic counselors, pediatricians, as well as other allied health professionals. So going back to Kaichi again, after a few years of persistent reduced visual acuity, and we have been co-managing him with a local hospital all this time, I finally decided he was ready to go back and get a second referral to proffer the testing, because his visual acuity was just not getting better and it didn’t make sense. And fortunately, the hospital specifically noticed optometrists’ concerns of reduced best corrected visual acuity. And we finally had a reason for why Kaichi had congenital stationary night blindness of the incomplete type after he had electrophysiological testing. And appropriately, he was then referred for genetic testing. So what is congenital stationary night blindness? It is a condition where you have impaired rod photoreceptor function leading to poor vision in low light. And this is why a lot of them end up having poor visual acuity and a common symptom is poor vision at night. Congenital night blindness is also associated with myopia. And there’s no specific power that they relate it to. They can range anywhere from low all the way to high. And if we look at this particular study, you’ll find that it’s quite interesting, because not all patients with stationary night blindness will present with the same symptoms. The most common ones are visual acuity at presentation, only half of them will complain about poor visual acuity, maybe that’s because they’re young when they’re first identified. By the end of followup, they realize they have it because they’re being tested after school years. Nystagmus, poor night vision and myopia. You can see the most common congenital stationary night blindness is the X-linked, accounting for 57% of all the cases. The X-linked form is often associated with both the complete and incomplete forms of congenital night blindness, which do differ in the extent of retinal dysfunction. If you remember, Kaichi was diagnosed with the incomplete form of stationary night blindness, and his specific genotype was CACNA1. The incomplete type is due to a dysfunction in both the on and off bipolar pathway. And it’s associated with a wider range of refractive errors. Some kids are manifest as hyperopes. The ON bipolar pathway is associated with a more severe myopia. You can see how the progression is slower. Most of the refractive changes happened in the early years rather than later years, which is in contradiction to kids who are school age kids where they progress faster as they go into school age years and then slow down as they grow older. So the expected rate of myopia progression is about half a diopter over two years. And, you know, should we be worried, especially if progression is slow, compared to, you know, school age kids who progress more than one diopter over a two-year period? And my conservative answer is yes, we should. They will still benefit from long term myopia management, because we know from research that every diopter counts. When you reduce it, you also reduce the risk of ocular pathology. Here is a little pretty picture of how light is transmitted through the retina and how we need all these cells to talk to each other in order to see what we see in our brain. Bear with me, I’ll go through some of these slides are actually quickly, but there’s a rhyme and reason for this. Now, congenital night blindness, as we mentioned earlier, is an inherited retinal disorder. And the defective visual signals are between photoreceptors and bipolar cells. This affects vision in dim light. This is why kids like Kaichi find it difficult to see at nighttime. The key areas are the retinoid recycling in the RPE layer, the photoreceptors, and the rod ON bipolar cell synapses. Most of the forms of stationary night blindness, retinoid recycling, are rarely dwell affected. Just as a reminder, I have to remind myself when I don’t see things for a long time, but I’m sure you all remember your Watson cones, special cells called photoreceptors that respond to light by generating electrical signals. Cones which respond to bright light and rods are sensitive to low light as well as peripheral. You might recall I mentioned electrophysiology was essential for diagnosing retinal dystrophy. This study, with those red ones moved out of the way, demonstrated that young children with high myopia had reduced responses to cones and rods compared to school age onset myopia. Findings like this can really help with early detection and provide better tailored interventions behind myopia. Now, when rods and cones detect light, either increasing or decreasing, they send signals through 2:00 main types of bipolar cells, the ON bipolar cells which activates when it becomes bright remember and the OFF bipolar cells which activates when it becomes darker. We get disrupted visual transmission in the rod ON bipolar, the green box. When they are weak, as is the case with incomplete congenital night blindness, or broken, as with the complete congenital stationary night blindness. And when the rod ON bipolar synapses don’t pass on light information effectively, the amacrine cells can’t do what they do best, which is release dopamine. The role of dopamine in myopia progression has been studied extensively. We need dopamine to support normal eye growth. When we don’t have enough to regulate growth, myopia develops. So the big question that was apparently asked by neuroscientists, because it wasn’t me, was whether rods or controls control the release of dopamine. A recent study found that only rods, not cones, were actually responsible for the release of dopamine in the retina. So they are super important for more than just seeing clearly in the dark. And in fact, patients like Kaichi help us to understand the pathogenesis of myopia. This paper hypothesized that exposure to insufficient light levels, we know we need about two hours every day in young children, can lead to a similar dysfunction of the ON pathway and hence why myopia develops. So studying patients with congenital night blindness could actually hopefully lead to therapies like gene editing to restore rod signaling, and maybe one day even help us prevent myopia. So when things don’t quite make sense, make sure you refer your patient out for further diagnosis and management. Make sure that you have a blood range of optical interventions and pharmaceutical interventions to manage myopic patients. And I think this is where my presentation ends, with some key takeaways when it comes to high and syndromic myopia patients, and that is that we really have to be mindful that the patterns for myopia onset and progression are different compared to typical myopia. Follow the IMI protocol. It’s very comprehensive, you can download it from online. Myopia control should be based on axial elongation. Even if they progress slowly, that’s still not a reason to not manage them. I did hear someone saying that if you have a young child, they don’t provide myopia management at all because they don’t progress. I don’t think that’s the case for everyone. High myopia patients are often excluded from myopia trials. And this limits evidence-based recommendations. So when making recommendations for these groups, make sure that you take it case by case and you try and tailorize it for them as much as possible. And when a referral is indicated, collaborate, collaborate, collaborate. Don’t leave them in your room. And that concludes my presentation. Thank you all for hanging in there to listen to our presentations tonight. Make sure you do get a stretch and get your circulation going. But I know that we now have some time to answer some questions. Tang, did you want to look at any of the questions that were sent through? Otherwise I’ve got some questions that were sent earlier that I can pop up. >> TANG YAN: We have tried our best to answer the questions. >> SOOJIN NAM: Oh, have you? Well done! I’ve got some here that I put on the slide, how about I share those ones. I just took a selection of questions. The first one was, and this was from Malaysia, how do you make parents more confident with myopia control lenses? >> TANG YAN: Is that a question for me? >> SOOJIN NAM: Yes, you can answer that question. How do you make parents more confident about the myopia control lenses? >> TANG YAN: I think it’s a hard question, because if we have — firstly, as a doctor, we have the parents, we tell them we have some papers or we have evidence that control glasses can help the children. But sometimes it’s not effective on all the children. So we just tell them we are trying to find them a better way for them to control the myopia and give them the comfort that not just because of the lenses, it’s also because of the doctor, and we’re very confident to ourselves, we’ll be very patient to control the myopia in this area. So we just give them one kind of solution, but the doctor will follow you, something like, I think. >> SOOJIN NAM: I think you hit the nail on the head, Tang, if you’re confident, it will come through and parents are very good at picking up on it. So — and the other thing that I like to do is just to demonstrate all the efficacy. Second question, at what age should myopia management start? I put that in because there are a number of countries that ask that question. We’ve obviously all provided case studies on myopia management for very young children, and I don’t think that there is an age. I think if you see myopia, you have to really consider whether or not they need to start myopia management as soon as possible. What do you think, Martelie? >> MARTELIE BURGER: SooJin, I think you start myopia control and myopia starts. It should not be linked to an age, because we all know what myopia is going to do. We all know in which direction the actual length is going. So I don’t wait. And I don’t look at the age. I start myopia management when myopia starts. >> SOOJIN NAM: In fact, if anything, I actually saw a study of children wearing MiYOSMART lenses before they’re even myopic, and they found that the axial length progression in one year in five or six-year-olds was only .1 rather than other kids who were progressing a lot faster. So there’s even an argument being said now that maybe we should even look at myopia management before they even become myopic regardless of age, and it depends on their risk factors that they present with when they come in with their families. What about, what is needed to set up a myopia control clinic? That’s a very good question, because the equipment, the access to pharmaceutical interventions, there’s so much involved. What do you need to set up a myopia clinic? >> MARTELIE BURGER: If you look at each country’s minimum equipment list that’s necessary to practice your profession, basic equipment, that’s usually available, you should be able to manage myopia or set up a myopia clinic. Due to golden standards, you should not overestimate myopia or overdiagnose it. You’ve got a VA chart, an encyclopedia, you can have a myopia clinic. >> SOOJIN NAM: That’s right. To be honest with you, you don’t really need to have a lot of fancy equipment either. You just need to be able to be very good at observing. Even basic equipment can take you very far. In terms of monitoring for progression, it’s nice to have axial, but really, we know from research that a lot of the interventions, especially the evidence-based, they do work. So if you prescribe it, there is a good level of confidence that you are making a difference. How do you manage my myopia in children under the age of two? Dr. Tang, I think that’s your question. >> How to manage high — oh, first, most children in my hospital, two years old, myopia is not very common. I think if we see high myopia in under two years old, we also are very nervous about this kid, sometimes I think it’s because of the genes or sometimes because we have eye disease. So it’s not only we just control the myopia. We should find the eye problems such like the retina or such like the lenses. So the cases show children who are very lucky, they can find a way to control the myopia. But today I just want to show cases, but for all the doctors, I think I’m just a beginning learner, and I want to learn more knowledge from you all. >> SOOJIN NAM: Good point. So, you know, good recommending MiYOSMART as first option for a child’s first pay of glasses be good enough or should we wait to see progression? I think we all three of us would unanimously say, don’t wait to see progression. How a child progresses before, and even if they progress slowly, is really no indication of how they’re going to progress in the future. So just because they progress slowly previously does not mean they’ll continue to progress slowly in the future, is what I’m trying to say. And they have a high risk for myopia, I think you need to start at the very least, you know, encourage outdoor time, because if they’re premyope, even spending time outdoors will delay the onset by two years and that can be massive in terms of their endpoint prescription. So what is the right age to start MiYOSMART, to fit MiYOSMART lenses? I would probably say when you can find the right frame size that will fit their face, you can put MiYOSMART lenses on it. It really is more dependent on the frame than the actual age. Does binocular vision affect adaptation to MiYOSMART lenses? Martelie, you are the expert on this because you answered that question in your presentation. >> MARTELIE BURGER: Thank you, SooJin. So in practice, I have found a binocular case not being comfortable with the MiYOSMART lens. In the beginning when we started prescribing for myopia with MiYOSMART lenses that when we had a high lag of accommodation, we were cautious to prescribe. But a myopic child is a lazy focusing patient, because they don’t have to focus. The lag of accommodation is usually high when you put the script on. What I’ve done lately, for the last four years, is that I will initially ignore the lag of accommodation until they are on their six months visit. And I have to say I haven’t found one patient that hasn’t improved with their accommodation with the MiYOSMART lenses due to the fact that their accommodative system has to start focusing through the MiYOSMART lenses. So I have yet to find the patient that doesn’t accommodate with a high lag of accommodation. With the exophoria, if the exophoria is large, we do do convergence therapy. And if it’s larger that we can’t get any fusion, you know, then you do have to — when the fusion is low, before we get the — do full visual therapy capacity, we often prescribe prism with that. But it doesn’t affect the adaptation to the MiYOSMART. It’s just part of the binocular syndrome that they’ve got and they would have had those symptoms with or without other glasses. Thank you. >> SOOJIN NAM: Thanks, Martelie. We’re running out of time, it’s 1:32, maybe we’ll just finish off by answering that last question, which is better, MiYOSMART or Ortho-K? You know, for me, that’s a loaded question, because at the end of the day, the best intervention is the one that the child will wear and will get you the biggest compliance. At the end of the day, a lot of these interventions are really looking at doing the same thing, which is changing the peripheral blur on the retina. So the overall outcome is very similar in terms of efficacy. So I would prescribe the one that I think the child will be happy to wear. That’s first. And then the other ones, what do you think? Anything else you would like to add to that question? >> MARTELIE BURGER: SooJin, I think it’s just in practice, it’s just what’s best for the patients, what they comply with the best. And because the patients are very young, Ortho-K is a very invasive procedure, not that it does not work, it’s just often the compliance to that is much worse than the MiYOSMART. So it’s just an easy option to put on glasses rather than to put lenses in. But each patient is different. And we can’t say which is better, it’s just what will be best for the patient. >> SOOJIN NAM: So true. Anyway, I think we’ve run out of time now. I don’t want to keep people waiting online for much longer. I just wanted to say thank you, Dr. Tang Yan, Martelie Burger, at which so much fun. I want to thank Cybersight for their assistance and kind invitation to present online. I hope everyone has been able to take something back to their practice that’s going to be useful and practical. And if you have any questions, you know, we’ll make sure that our contact details are available online, so you can send us questions directly. Thank you, Andy. >> TANG YAN: Thank you, Andy. >> Thank you all.