Lecture: Managing Myopia in Resource-Limited Settings: Insights & Innovations

>> Greetings from India. Welcome to Cybersight. And I’m going to talk about managing myopia in resource-limited settings. I have gone through the questions that were submitted and added content that takes care of how do you manage myopia. What are simple steps to be followed. Then I have slides on what’s the importance of axial length. And then how do you really go about preventing myopia in your routine clinical setting. These are my financial disclosures but I would like to highlight that this lecture is not intended to endorse or promote any specific product. Just making that clear. Before we begin the lecture, let me understand who you are. I’m anophthalmia Tom tryst, a scientist researching on myopia. I would like to see to which professional group you belong to. So you can please click and let me see the responses. We’ll wait 10 more seconds. All right. 47 percent of you are optometrists and 40 percent are ophthalmologist and ophthalmic assistants and a few from the industry and a few others. Thank you so much for joining in. Now I have a follow up question. The talk is all going to be about myopia. So could you please take a moment to tell me if you’re offering myopia control treatment at this time? Yes, you’re doing it. Two, not yet but you are keen on starting myopia management. You can also say you don’t know at this point in time. Or you can say I done want to prescribe. Or you can say that you’re already working in a hospital or any other setting where they do offer myopia clinical services. That’s a mixed group. Great. 44 percent saying that you are already practicing myopia and 35 percent, a sizable number are indicating that not yet but willing to prescribe in the future. And I hope that today’s lecture will help you to do that. If I look at the keywords from the topic that was given, managing myopia in resource-limited settings. I want to highlight the first word is managing myopia. Now we’re talking about myopia management because it’s not just a refractive condition but we’re calling it a disease given the complications that are linked with the axial elongation. Just a few pointers. It’s a new pandemic. We’re looking at 50 percent approximately to have myopia by the year 2050. Then the costs are both direct and indirect. When I say the direct, of course, the cost of the consultation or the purchase of spectacles or refractive correction. And then the indirect costs which are less discussed with the psychological stress the child has to go through or the bullying that the child undergoes, and the occupational limitations that they may have. I think a lot of the indirect costs which are less discussed. And the third one is to say that myopia is multifactorial. Unfortunately, the cause is still unknown. I think there is a huge scope of a lot of us to contribute to this profession to combat myopia. Good news is it can be prevented. We have multiple solutions now. I will take you through that in the next few minutes and progression can be controlled. We have various myopia control options that are available thanks to the industry which is enabling us to combat myopia better. Myopia management is beyond single vision correction. I use the word myopia control or myopia management and I use the word myopia. What are these terms? There is a recent publication in the IOVS in the special issue as part of the international myopia institute nicely indicating when to use myopia correction, when to use myopia control, and when to use myopia management. So let’s spend some time at the start to go through the definitions. Correction, as the name indicates, we’re just talking about correcting the refractive error. Through devices and interventions that correct the optical focusing without providing any benefits in relation to the myopia control or in relation to the slowing the progression of myopia or you’re not talking about regulating the axial length or controlling the axial length. This is only correction. You give the correction to ensure there is best corrected visual acuity and you’re not worried about the changes that happen in the eyeball length. Let’s go to the control. This is a clinical application of the evidence-based interventions specifically intended to slow the progression of myopia and axial elongation. Now, the first one was the correction. Second, we are talking about the control, what do we control? We’re talking about controlling the progression of myopia and looking at the change in the refractive error and also the change in the axial elongation and we’re putting them on some sort of treatment strategy to control these changes. This is essential component of the myopia management and it involves the regular monitoring. It’s not one time. It’s not like the correction but you’re saying, okay, I’m correcting now. I’m aiming at controlling the progression of myopia for which I need to monitor much more regularly. And the single agenda worldwide, you want to be at the back of the eye, stopping the elongation of the eyeball. What is myopia management? It’s a much more comprehensive eye and vision care. Comprehensive term where we’re talking about the vision care approach and myopia and pre-myopia, early detection, correction and control, and monitoring and also the management of complications. This is a diagram that I want to look at when we talk about prevention. You’re talking about not someone that develops myopia but also someone who has not developed myopia yet. You can call them pre-myopia. A younger age risk of developing myopia because there is parental myopia positive and the refractive error is not so much in the plus side or less than the plus points. To prevent myopia, you look at controlling the myopia, you correct and identify children at risk for the serious complications. You manage the complications as well. That is a holistic gamut that we’re looking at when we talk about myopia management. Now, how do you manage? You have multiple solutions to control the progression of myopia. All the way from the lifestyle modifications to prescribing bifocal spectacles to contact lens, multifocal contact lens. We have orthokeratology. We have spectacles. We have the famous eye drops that are the low-dose atropine, wildly used for a few decades and diffusion options. On the right side, you see a forest plot that shows that we do a systemic review and realize that the various treatment options do indicate good efficacy in controlling the axial elongation. What is important is under correction does not work. Under correction did not give good outcomes from controlling the progression of myopia. Of course, high dose atropine is high but the complications with high dose atropine need to be kept in mind. And we have controlling options in the spectacles or contact lenses as well. Look at myopia management. Let’s look at the other term that is here now, what is resource-limited setting? I did some search and bumped into this publication published in 2021 that indicates a resource-limited setting or low-resource setting indicates there is inadequate intra-structure. Shortage of skilled personnel. Limit to access to technology. Low awareness or beliefs dependent. Then there challenges especially in geographic? Monitoring of the health. And overall leading to suboptimal services. Now, this nicely fits into the Mr. Management we are talking about. Whichever country you belong, I think all of us are belonging to a resource-limited setting if you look at either the people managing myopia are really limited, which means a shortage of skilled personnel. Inadequate infrastructure, you need to start a myopia clinic, maybe there is lack of infrastructure there. Limited access to technology. A couple of slides before this I’ve indicated there are multiple myopia control options. Now, to, whatever country you belong to, I’m sure there is limitation in acquiring them or the lack of some approvals. We are not having spectacle option. In the context of India, we don’t have higher concentrations of atropine. We don’t have dot technology. We don’t have myocytes but we have others. If you’re coming from a different country, you can relate to — you may not have all these available technologies with you. Making us located in a resource-limited setting in relation to the myopia context. And there are more publications more recently that indicates a lack of awareness among the stakeholders about myopia and its management. The practitioners don’t know when to start or stop the management. Two, the parents are not aware that the myopia progression can be controlled. We lack the monitoring equipment or monitoring systems. We say that lifestyle needs to be modified. Behavioral modifications need to be made. But not everybody has access to the factors that can do the job of quantifying children spending time-out doors. Now people come to the clinic and we say how much time do you spend outdoors. The child can say one hour or two, but we don’t have any way to know confidently the child is only spending two hours. We are providing suboptimal services, not having access to any of these parameters that I’ve discussed so far. We are at the resource-limited setting when we talk about myopia. One of the resource that we always talk about when we talk about myopia is axial length. I want to understand what your perspective is if you think that measuring axial length is important in myopia practice. You can say yes, it’s a game changer or you can say that it’s good to have but not important. Or you can also say axial length is not an important parameter. And you can also say you’re not sure. We will wait 10 more seconds. Five, four, three, two, one. Wow! I don’t have to convince the audience that axial length is really important. 11 percent of you think that it is not — it’s important but it’s good to have. All right. Great, thank you for your feedback. Let me share with you my five reasons for why axial length is important. I did a quick search and we know people in the field have written nice articles emphasizing the importance of axial length in myopia management. If you look at the top, I really like this title which indicates should myopia management be renamed as axial length management? Now you will see that I looked at the questions that were indicated during the registration and I have added some slides to ensure I cater to the questions that were asked. If there are questions, you can drop in the chat box as we proceed. My five reasons, No. 1, clearly when we talked about myopia, we are worried about the axial length. You all know the greater the risk of complications when the eyeball is longer and have indicated that single agenda that we’re in now is to control the axial length from growing or the eyeball from growing. And the debate is also there about is it a refractive condition or a disease. The complications more recently, the scientific and clinical community are indicating it’s a disease given the complications and risk of impairment. The IMI is the international myopia institute. And it clearly indicates if available, axial length measurements should be taken at every 6 months. That’s the importance of axial length that we’re talking about. What’s reason No. 2? When we talk about myopia, there is also this aggressive type of management that goes in with all the available technology that we have or all the availability of the solutions and we tend to prescribe these lenses left, right, and center at times. Now, I want to emphasize that all myopes are not necessarily axial myopes. Unless you have this axial measurement, it would be difficult to understand what type of myopia it is. If I give you this example of a 10 year-old child with minus 7 myopia, straight away we think the myopia is on the higher side. The child is young, let’s start myopia control treatment. If I show you the axial length, it’s only 22.7. It’s not really correlating and the other eye is 22.6. The cornea, 43, not so steep. Refraction we realize that it’s plus 1. So it’s important that we understand different forms of myopia that we have. It could be refractive myopia, cornea can be steeper, the lens can be thicker and steeper. Or it can be the anterior shift in the lens, the anterior positioning of the lens leads to more myopia. It can be increase in the refractive index. But all we’re interested in is axial myopia for which you might want to have an estimate of what the axial length is. Not everybody is an axial myope. There are pseudo-myopes. It’s increasingly common with anxiety and stress and strife. I think it’s important that we eliminate the pseudo-myopes. Keratoconus is not that common. The numbers are increasing and it’s important that we diagnosis keratoconus and not give myopia treatment just because they have myopia. Unlike myopia, if you’re looking at pseudo-myopia, the axial length is not so much. There will be — there is pseudo-myopia as well but usually one point to note, these are not really the longer eyeballs. That is something that you might want to keep in mind. Reason 3 is control in refractive error does not always mean control in axial length. Myopes have better depth of focus, better blur tolerance. And even with a change in axial length, they will not accept a new power. This is an example on the left. You are seeing one of the cases that I had. And maybe if you concentrate on the last two lines here, the third is March 2023. The eyeball length is 25.67 and it became 25.96 in October. Left eye became 25.74. Looking at the .3 mm change in the right eye and .2 mm change in the left eye. If you look at the refractive error from the glass prescription it was minus 2 and no change. If we get a clear insight, there is clear change in axial length, let me try to intervene for controlling the axial elongation. The cornea was flatter in this case. That is where it was not really correlating. Now, the fourth reason that axial length is important is instruments have a good resolution. It will help you to understand small changes as well. The resolution of these biometers like the myopia master, these have a resolution of 10 micro meters which is 0.01 mm. Even small changes, you can pick them up. The fifth or the final reason that I have is it gives a lot of confidence the moment that you know, all right, I’m seeing changes in the eyeball length correlate with refractive error, the treatment, is it working or not. If you see a case where I have given a bifocal, for example, in the first four months there was no treatment and the eyeball length changed by.18 mm in the right eye. Bifocals were prescribed and in the next few months the changes were .12. Having this value gives me an indication that after I started the treatment, the eyeball length changes are only .12 which is less than what it was in just four months. And same is the case in the left eye. Without treatment, in 4 months time, the eyeball length increased by.16 mm and then in the next 12 months .14. Whatever happened in the first four months, we controlled it for the 12 month duration. This gives me confidence to say the treatment is working. Hang on, continue with the same treatment. This is another case where for the first one year, the child was on the extended focus contact lens and the changes are 0.08 mm in the right eye and 0.02 mm in the left eye. Minimal, great. For some odd reason the child decided not to wear the lenses after one year. They came back in 4 months and suddenly there is an increase. This increase is only with a single vision. They were not on myopia control treatment, no contact lens, no control treatment. Only single vision spectacles and you see there is a big jump. Because of this axial length measurement available, I could say, there are significant changes. I don’t want to wait and watch. And let me put you on the smart lens because the child was not interested in contact lens. And we could bring back the changes. That’s good to have. These are five reasons why we need a biometer. Traditionally, maybe two decades ago, ultrasound systems were used. The scans to get the axial measurement. This is contact technique. Relatively invasive measurement because you’re touching the cornea, there is high risk. You need a skilled person to get the measurements done. This is inexpensive. The talk is concentrated what do you do if you’re in a low-resource setting. If you cannot afford the biometer, don’t worry. There are tons of biometers that are available. If you’re worried is this showing good agreement, can I use this, is it comparative to the gold standard? I think there is enough evidence to say the axial measurement are comparable. This is a recent publication to show the plots that show in — the plus/minus, the 95 percent limits are about plus or minus .2 mm. So you will get an estimate of what an axial length is. Any measurement is a measurement. And something is better than having nothing. What could be the future, what is already in the present. These are devices that do refractive error assessment and the axial value measurement. This is something that we validated a year ago and it showed good outcomes in comparison to the lens star. What’s coming in the future. You see me smiling very happy because I was looking at this new device from the pristine, called OBM-2L. It gives two variables in one shot. And I’m smiling because it can complete the measurement of both eyes in just 25 seconds. We have been doing an evaluation at this point in time. This is a work in progress. I thought I would show you two examples. This is a myopic eye. The top is the lens star and the bottom is the OBM. Not different. Same for the left eye. Not very different. Great. If you take a high myope, 27 mm axial length, 27.10. And 28.73 and you see the highlighted region. This is great. This is work in progress and stay tuned to get more updates on this. So far, the message from my last few slides was axial length is an important parameter. If you can collaborate with somebody, if you run an axial length, I think that is great. We will move forward with the next section of my talk which concentrates on when do you start treatment? What’s a protocol that you need to follow? Before that, do you think we should start myopia control treatment for all the myopic children given the associated complications. Of course, no, not for everyone, or your not sure. Great. The majority 63 percent said yes, the minute you see a myope, you should start treatment. And 33 percent said not for everybody. The answer for this will come in the next few slides. And let’s see. When you talk about the myopia management, wherever you are, you’re tacking about a low-resource setting. We developed guidelines called impact myopia management. Six steps. IMPACT, develop the — with a combination of scientists. There were optometrists and ophthalmologists and we came up to consensus and developed this IMPACT myopia guidelines. 40 percent of you indicated you were willing to start myopia management. If you’re unsure where could be a starting point, please remember IMPACT, this can be the first step. Let’s go step by step. The first one is I. I is identify true axial myope. Not everyone is a myope. It can be a steeper cornea, just the anterior positioning of the lens and for them, there is no need to start myopia management. So first step is if doing refraction and use a retina no scope, identify there is no split reflect and no keratoconus. You can look at the readings. These days they give the keratotomy values. These are largely the ones that come to us when you are starting your myopia practice. Map the risk factors. Myopia is multifactorial. According to me it’s a sin to start myopia treatment based on central refraction and visual acuity. We know myopia is multifactorial. The combination of genetics and environment. We are talking about environment like light, near work. A lot of parameters play a role. A lot of times lifestyle modifications can do wonders. For doing lifestyle modifications you want to understand what sort of behavior the child is living in. Is the child having a working distance or spending a lot of time on screen, does the child bend and write. What type of environment the child is living in. If you have a retinoscope, get the LR value, is there a glad, a leave (ph.). In our clinic, we also do peripheral refraction. You can use open field auto refraction or you can use very recently developed something called SPAR (ph.) it enables you using the retinoscope, you can understand what — if you have bifocals maybe you’re better off. Maybe the peripheral type of spectacles can do the job. There are studies that show the treatment option that target the periphery of the eye, are less efficacious if the pattern is already myopic. You want to target someone with hypermetropia based on the evidence and maybe you will see good outcomes. Mapping the risk factors is crucial. Pick a progressive myope. When I say that, understand there are changes in the axial length. There are changes in the refractive error. For example, if you look at the case for a 10 year-old young child and for two or three years the power did not change. That is a stable refractive error. Why do we treat? Case two is an example where currently the glasses are minus 5. Refraction in the clinic it’s minus 6. So I start in case two but not in case one. This is important that we pick a progressive myope. Advise appropriate treatment. You want to pick the right strategy to combat the right risk factor. I have indicated that lifestyle modifications do wonders. Talking about myopia prevention and myopia control, lifestyle modifications can be included into your prescription strategy. Now for the myopia, you want to consult regularly, 4 to 6 months you will see change. If they are rapid progressor, you will see a change in refraction. If they’re not so rapid progressors and you have a measurement device, you can call them in 4 to 6 months and map the axial length change. You have an understanding of what trajectory they’re in. Combined treatment. You start with mono treatment first. Once the treatment does not work or they are non-responders or poor responders. Again, I waited one year, if they elongate in the same manner with and without treatment, okay, seems like there is no response. Let’s combine treatment. This is important when one treatment does not give you good outcomes and monitor in 4 to 6 months. Another million dollar question, when do you stop. T stands for tapering. There are studies that say for atropine, you might want to taper and then stop. But I want to indicate you might want to consider late teenage. If you start a treatment, I think until late teenage, there are signs of myopia progression, monitor closely for two years. If there is no change in refraction after the intervention and they’re touching late teenage, you think maybe I should now take them off of the treatment. Monitor regularly. Do not leave them off. Monitor regularly even when you take them off the treatment. You want to see if there is rebound. There are reports that indicate even with the optical strategies, there is rebounding. In fact, one of the cases that I’ve shown, I don’t know if you want to call it a rebound, once the lens is taken off, in four months there is an increase. You can restart the treatment. Why do you think late teenage? If you look at refractive surgeons they operate at late teenage or 20 years of age. They are looking at the stability. They are looking at the stability in the axial length. The same analogy can be applied to myopia. You’re looking at eyeball strength and stability in the eyeball. Same analogy can be applied for why late teenage is good. So that’s about the impact myopia guidelines and I will give you the India context before I talk about the preventive strategies. In India, we published this paper in the year 2020-2021. 2020 actually. We say the India trajectory for myopia is similar to the global arena because we’re looking at 48 percent of the children living in our population and cities have myopia. In India, we have clear differences in myopia prevalence between the rural and the urban population. Say in rural it’s less than 5 percent. In the urban cities it’s touching 25 percent as of now. We’re talking about 25 percent of myopia prevalence in children age 5 to 15 years. If we’re talking about progression, 20 percent of them have rapid myopia progression. I have indicated, why do I give treatment to all myopes left, right, and center when the progression is not in everybody, it’s only in 20 percent of them who are rapidly progressing. In fact, not everybody will have progression. So there are a few stable myopes from the beginning. For them, maybe you don’t want to do anything there because they’re already stable. The unfortunate thing is the indoor centric lifestyle that we have now will escalate things. I think we will see more myopia across different regions. One of the best strategies that we have is the environment lifestyle modifications. Time outdoors as a preventative option for myopia. Why time outdoors? There are multiple reasons that we see on the screen. If I’m outside, I’m more relaxed in the cornea. The spectral composition is different indoors and outdoors. The exposure to UV. Dopamine release is known to be protective for the axial elongation. There are various theories and it’s all proposed hypothesis for why time outdoors would be great. Lifestyle modifications cannot be only light but we should look at the near work as well. Now, we did this overview of systemic review a few years ago. We indicated that the light exposure, outdoor light exposure is good for myopia prevention. However, its role in slowing the progression is controversial given the clinical insignificant values that you see. Mean reduction is not so much. Now, but is it really light? It’s difficult to tease out. It can be a substitution effect also. It’s great for myopia prevention for sure. Purely an outdoor environment, is it time outdoors that is controlling the myopia but it can be a substitution effect. I have read various theories. Which one could lead to the control? We are unaware at this point in time to pinpoint and say this is the only reason. But it can be substitution effect because you’re not doing near work if you’re in the outdoor environment. When we recommend the lifestyle modifications, I realize these are oversimplified. Time outdoors, increase the time outdoors but we’re not saying or indicating where outdoors. For outdoor environment, they can be playing under a tree, under a canopy or between buildings or in a parking area where there is no sunlight. If you see this light exposure levels, we did a simple study looking at the UV levels in different locations. If you concentrate only at the direct, the light levels are higher only in open area and if you’re in translucent or shade. If you’re under a tree or between the buildings, the light levels are really low. The child is outdoors but doesn’t have beneficial effects on myopia? That is debatable. Maybe with the recommendations we have to mention when we say outdoors, it’s an open play area. The other entity is the spectral composition is very different as you go from outdoors to inside. Much more evolving, the recent trend is to see which spectrum of light the composition is playing a role. We did this study in 2021 and we found that the blue light exposure on a short-term basis led to the — did not increase the eyeball. Let me put it that way. Whereas the red and green colors, the exposure, the red light and green light exposure led to increase and blue light did not lead to increase. I want to acknowledge that renowned people in the field are looking at this light exposure and studies indicate there are few reports to say red light is way too great. There are reports that say that white light is great. And sunlight is working great as well. I think this is an area that we need to watch out for. This is me with the wearables that we are testing — they are very much open and looking at what level of light is good in the long term. A few other questions that come is reading on a hard copy the same as reading from the smartphone or watching a video? We found that reading from hard copy led to greater changes compared to watching on a video. So video is moving the content is regularly moving. You don’t have to accommodate as much compared to reading text on a hard copy. I want to highlight that people assume that smartphones are the culprits. Please, understand that the first smartphone came in after year 2000. Myopia prevalence peaked before that. So it’s not the smartphone but any sort of near work. Another question that people ask, is it near work, time outdoors, what is it? We did an experiment in the lab where we had the same individuals read 20 cm from the eye, same content indoors and in the outdoor setting. This is outdoor, bright sunny day. Pre and post we got the eyeball length measurement. Indoor, same people, same distance. We map the exposure. We found that near work, wherever you are, indoors or outdoors does not really matter. It’s going to trigger for the changes in the axial length. If you’re outdoors and not doing anything, then that is better compared to if you’re outdoors and reading. Maybe you will ask, you’re thinking why this experiment? Parents ask, one of the parents asked me, I want my child to concentrate on academics: I will put that child in a balcony setting, on a patio or outside but I want him to read. Will the outdoor effects still be beneficial? Not really. If you are starting your practice, if you do not know where to start, you can see something that we developed. You have to put in what’s the age of the child, the current spectacle power and the previous spectacle power and the time outdoors and it will indicate if you’re low or high risk for the myopia progression. So this is already scientifically validated and you can access it from here. This is available from wherever you belong. To summarize, I want to indicate that so far we started off with what are the definitions for myopia correction, Mr. Control, myopia management. Then we discussed about the importance of axial length measurement. We spent some time understanding ultrasound technique versus not contact biometers. And then discussed the impact and myopia guidelines and last I focused on the preventive strategies and how these myopia recommendations or lifestyle are oversimplified. Myopia management is beyond single vision correction. There are multiple options available. Axial length is an important parameter. It will give you a lot of confidence if you want to start. Either you collaborate or get a device that can help you get the values but these days, you can also understand what is an approximate axial length using various equations. Impact guidelines, you want to start, the 6-step guidelines are easy to follow. Lifestyle recommendations are over simplified currently. This is not great if you want to see good outcomes. One case at a time. Each case is extremely different and one size does not fit all. With this, I would like to invite you to join us for the fifth Indian myopia awareness and research conference. This is conducted in Hyderabad, India. That is my details. I can be contacted via email or what’s app. I want to show the support that I get from various industry partners. I’m happy to take any questions. I will look at the chat box and I will … We’ll go to — I will stop share. Great. There are a lot of questions. We have at least 10 to 15 minutes to go through that. Okay. First question, what if we don’t have access to axial length measurement equipment? I’m not saying without it, you shouldn’t start myopia manage. You should be smart enough to rule out the — No. 1 and there are some questions about — you can use that or try to collaborate for getting more confidence. It will give you that extra boost if you have the axial measurement. Okay. What is the most cost-effective axial measurement. I have indicated, you have various devices. I think more recent ones are looking at making it cost effective. I know — is trying to do that. And you have something called portable axial device. Not commercially available yet. OCUTI (ph.) that might be available soon. If you want to do contact, then ultrasound is relatively inexpensive compared to the noncontact biometers. Which medical instruments are used to detect myopia? You may need to have the refractive value, you can use an autorefractor, open field. Retinoscope. And that’s the answer. What about drugs induced refractive myopia? I think there are a few drugs that induce refractive myopia. When we talk about myopia management, myopia control. It’s all about the change in axial length. Anything that is not axial myopia, we should not be looking at treatment to control the axial length. You should be treating the cornea and the lens and understand what could be triggering it. At times no treatment is required. For example, say there is a case of minus 4 dye opters of myopia. Cornea is 47 diopters. You know that the steep cornea is leading to the myopia that you’re seeing. Okay. Drugs is done. Can you explain — optometrists — contribute to the myopia. If you’re an ophthalmologist, a lot of complications because of the stretching of the eyeball. It’s huge. If I called professor Brian Holden in 20, I think 2011 or 2012 if I’m not wrong, it clearly indicates that the eye care practitioner should be in the front line of this battle. And we need to combat myopia. Seriously. Okay. There is a question in Spanish, unfortunately I cannot understand Spanish but I will try. Importance of controlling the progression of myopia. If you’re asking me about atropine, how does it control myopia, there are various theories that are proposed why atropine can help in regulating the axial lengths. Studies say it’s working in a non-accommodative mechanism. In India, we have only 0.01 percent unless you want to compound it. Is it a placebo or is it really working? Various studies indicate that atropine is showing good outcomes. The contraindications for low dose are less than high dose. I tried to convert and understand what it was asking in Spanish. Should I contact you about more eye diseases. I have my email listed there. Can you please share your thoughts — diffusion optics technology. There are theories coming along to say that you play around with the on/off pathway. And that’s known to control the progression of myopia. More recently, there are two-year studies that were released showing efficacy for the diffusion optics technology. In India, I do not have first-hand experience of using it but the research evidence seems to quote it as high. Do you think under correction needs to study really well to see the impact before we build a treatment modality. I think this is great. Under-correction, there are limited papers to say that under correction does not work great. If you probe deeper into the changes in axial length, what’s the mean deviation, these are not extremely negative as well. There is one study that shows that under correction works and one study that shows it doesn’t work. Understanding what we have until now is that under-correction is not helping in controlling the progression of myopia. Will it aggravate or not have much effect? That is where we [inaudible] but given that there are much more better treatment strategies, I think the clinical management completely shifted towards using various myopia control options. What’s the significance of peripheral refraction in myopia management? Again the focus lenses as the name indicates were developed to counteract the hyperactive defocus. If that is true, you might want to give this treatment option for somebody who is having relative peripheral hyper mytropia. You put them on myopia control lenses and make it more myopic and see good outcomes. If that philosophy is true, understanding what pattern peripheral refraction the person has may add value. I must admit, this is debatable with some publications indicating it’s usability and some publications indicating maybe it’s not really useful. In fact, one of the recent publications, IOVS, we have shown that based on spherical prevalence alone, you can have nine different patterns of peripheral refraction. Medial and temporal, meridian, all the combinations are possible. Do we have an understanding if this is a specific pattern, I think maybe we need more research on it at this point in time. Effective information about the effectiveness of — not easy to obtain. There is evidence, William, on the various myopia control options. Again, a few studies that go through 6 year outcomes or 7 year outcomes. We have done a living systemic review in Cochrane, you can also search for living systemic review on interventions to control myopia. I think that will be a good summary for you as well. When should I consider stopping for a patient who is 11 years stable refraction for 4 years? Like I said, usually I would wait for the late teenage. 11 year-old you may have a growth spurt and everything changes. I want to be conservative on my approach. I would wait for some time just to get to the teenage and then slowly, if you want to take them off, if you’re confident it’s really stable, no change in the axial length, maybe take them off for 4 to 6 months. See them in the clinic. If there is a change it should be really less and you should be able to manage it. Red light therapy is evolving. There are multiple clinical trials conducted in China showing good efficacy of red light therapy. There is some concern about safety and requesting longer duration clinical trials. But the studies conducted in China indicate good outcomes at least. I do have a — but lack guidelines. I think my team members have messaged that you can contact me and we will be able to take care of that. Which — sorry, which control is better, atropine or — it’s difficult to say which is better. Everything has positives and negatives. When you sit in front of a patient, why we think that okay because of ABC factor, I want to give this specific treatment. But you need to look at what is the cost. What can they afford. Can they be compliant. Can they be coming back to do follow ups. Can they wear the lens. Multiple options come into the picture but I will give my view. For me, anything that can take care of the correction and control in one shot is better. Because to see things, myopes have to wear a correction in the form of spectacle or contact lens. You can start with that. So in one shot you do two things. One is correction, and two, is controlling the progression. Compliance is better because they will also wear spectacles or contact lens, the compliance is better. The consciousness, the parent doesn’t have to worry about putting a drop. They wear the spectacle and leave it and there is less stress. The only worry now is the cost if you look at optical correction. But the future looks bright. I hope we have more cost effective strategies. >> How do you correct pseudo-myopia? You want to do a proper refraction to pick this up. At times, there is no intervention required. It depends on what refractive error they have. And then you will treat the pseudo-myopia. So you want to do refraction, you might want to do atropine refraction if required to really get that lens not so fluctuating. All right. Which myopia control treatment? We covered that. Then we have, up to what age we can use atropine? Any treatment, my mind reference is late teenage. Late teenage, two back to back year, stable refraction, you can think of removing them. If the refraction is not stable, you should treat them longer. I have patients who are 20 plus and still on myopia control treatment. And yeah. So age is only a number. Can you tell more about preteen [inaudible], maybe you can email me and I can talk about it more for more details. It’s a noncontact bio meter. It does 12 parameters in one shot. It gives measurements of axial length, all the parameters in just 25 seconds. It’s a noncontact bio meter. Okay. Then we have a how to control progression of myopia? Various myopia control treatment options are available. You might want to pick appropriate treatment. Understand the risk factors. What is the risk factor? Lifestyle modification can do the job, leave it to the lifestyle modification. Start with mono treatment. If that doesn’t work, go to the combination treatment for myopia. What is rebound effect? This is an interesting question. Can you explain rebound effect of myopia treatment? The atropine especially is known to cause the rebound effect. You are on treatment for some duration of time, you take the treatment off and suddenly there is jumping of the refractive error and the axial length. This is not good. This is rebound. Now, to avoid rebound, you may want to taper the dosage or you want to add some other treatment or you want to monitor closely, take the treatment off and monitor closely. If there is significant changes you should restart the treatment. What would be essential set of tests establishing myopia in practice? I think the first set of, of course a good refraction. Understanding the detailed history. Develop a medical record system where you can capture so the parents understand. Educate them. I spend a lot of time educating what myopia is, why I’m giving special treatment. You need to give extra chair time. Otherwise, the child will not understand what you’re doing. The parents will ignore the consequences of the treatment. Have a proper information to educate the children, the child and the parent. Refraction if you use that, understand the parameters related to accommodative error. Is it esophoria, exophoria. If you believe in peripheral refraction, you use the retinoscope to see the refraction in the periphery of the eye. If you don’t have an open field auto-refractor, obviously. Axial length, corneal readings are good to have. If you have keratometry — the readings, they look at the A scan and look at the age. I look at the A scan, the axial length, the K readings, anterior depth, anterior ACD and the lens thickness. In one shot it gives me a picture is it axial or non-axial. If you value, a biometer it’s great, it gives you a lot of information. But retina scope, accommodation parameters, lifestyle, detailed documentation of lifestyle. What do they do. What’s their working distance. What do they go out. Where do they spend outdoors. I think those are all important questions to be asked. What is the latest age? I think see the clinical trials are conducted from the age of 5 to 6 years. I think largely 6 and above because you might want to factor the change in the various ocular parameters. And about 5, you’re good to go and like I say the cut off can be anything. If there is axial length elongation, you should continue with the treatment. Parents also have myopia, what would be the environment change — what would be the environment change to be done? Jennifer, if the child’s parents also have myopia, clearly, if the parents have myopia, it increases the risk of myopia in the child. So if the child does not develop myopia, you label them as pre-myopia. If they’re young, the values goes up. You say, okay, you’re a pre-myopia, I’m not starting you on treatment. Lifestyle modification. Go outside every day. Spend, maintain posture, maintain distance for the reading material. Minimize screens as much as possible. I think these are things that you might want to indicate. And monitor closely. Lens material matters. I don’t know, a lot of people talk about Polycarbonate. I don’t know if the material of the lens in itself has any, has any role per se. But there is debate about the blue blocking lenses. Are they good? There is debate about which wavelength is good, which wavelength is bad for the eye. So at this point in time, blue blocking lenses, people use for relieving the symptoms. Maybe reading on the screen and things et cetera. But scientific evidence does not had a lot of value for that. Lens material? I’m not sure if it has any role. And just adding another layer to the blue blocking lenses, I don’t know if that will add any extra value as well. Otherwise, appropriate myopia control strategies. When I say appropriate myopia control strategy, it’s about looking at the multiple options. What could be triggering in that individual. And you discuss ABCDE options and say, according to me, this could be the best option for you. And again, it comes to the cost. It comes with the complaints. You need to look at the patient, the child, and the environment they live in and then put them on an appropriate treatment options. Can digital screen exposure be realistic improved in areas with limited education and awareness? Digital screen exposure, what you have raised is an important and sensible question. We say minimize screen time. Stay away from the screens. Is it really practical and possible? I have my own opinions. Two of my patients say, this is great but you don’t have much homework to be done on screens. Now it’s also unfair for us to keep this generation away from the screens, right. I think there is something sensibility they have to use. You cannot say get away from the screens completely. But I think we also have on screen technology which monitors how much time you are on the screen. How much distance that you are using. Remember these technologies will evolve in the future. Maybe it can become a new normal for everybody to have that. These days we have the smart watches where you monitor, you count the steps and then you worry about the health. Like that, I think more wearable trackers or the technologies are coming in that can take care of screen time or monitoring the lifestyle. You’re asking a lot of questions. Thank you. What about younger adults who are at university. That’s a good question. Even in young adults, even, in fact, we’ve done research recently. I think we found that 4 percent of the younger adults, age 18 and above tend to have some sort of myopia progression. Which means, this small percentage need myopia control options. So age is only a number, I’m repeating multiple times. Even if it is young adult, you might want to start myopia control treatment. Now to me there are two zones which are gray at this point in time. No. 1, pediatric early onset high myopia. You know, you give some treatment, will it work. There is less evidence there for myopia control options. And young adults, if you give this treatment, will you still see the same beneficial outcomes or will the efficacy drop or be better. These are two extreme entities that need to be looked at. Question on dopamine mechanism. I’m not completely sure. My research on that is relatively less. But whenever there is light exposure, especially bright light exposure, the studies have shown there is increase in the dopamine. The retinal cells, the dopaminergic cells release the dopamine and these high levels are good for eyeball. Which means it’s a happy hormone, happy neurotransmitter and does not allow the eyeball to go. There are also studies about what could be the effect of caffeine. I think there is a study that looked at caffeine and if — add caffeine along with the atropine, is there any beneficial outcomes. This is ongoing research. There is also a publication on this that showed the caffeine did not reduce atropine’s efficacy at least. There is a new treatment. We’re looking at xanthine, a metabolite of caffeine already available and tested in Danish population. That is also made available. It’s a tablet formulation. That is also there. That is known to I think strengthen the collagen. Sunny came with another question. Apart from — any other FDA approved strategy? I’m not aware. Ipratropium is one of the treatment strategies approved. Then I said only two questions but there are more questions there. How to minimize hypo-optic defocus? These are patterns that naturally exist. The hypo-optic defocus in the periphery can naturally exist. To counteract that, you might want to use peripheral defocus spectacles that changes the hypo-optic defocus to hyper optic defocus. So that’s the only way you can use auto keratology and multifocal contact lens. When I say multifocal contact lens, ladies and gentlemen, I’m saying central distance multifocal contact lens. Central distance, more plus, more myopic defocus. Now there are researchers joining, I also want to maybe complicate this a bit. There is a poster recently that indicates that both the hyper optic defocus lenses and myopic defocus lenses work in favor of controlling the progression of myopia. Like I said, myopia is evolving. Everybody can contribute to this field. And every bit counts. So I request more people to do myopia research because the ground is really empty. Everybody has their own hypothesis. I think there is a long way to go. Eye exercises helping myopia management? I do not have any evidence on that. Eye exercises to control the myopia management. But I think this is, again, an evolving area where there are studies slowly testing eye movement, on the screen, or help with a specific pattern could control the progression of myopia. I’m talking based on my learnings from the recent article that happened in the month of May. Can you manage pathologic myopia? Yes. Unilateral myopia, even if one eye alone is having myopia, one eye alone is undergoing the progression of myopia, you can give treatment to only that eye. If there is unilateral, I usually go with the contact lens option. And I have one individual who is young adult, only one eye is progressing and the myopia is in control. I thank all the audience. People who are joining from different parts of the country. I hope there is some learning from today’s lecture.