Myopia is becoming a global public health burden with its increasing prevalence in both developing and developed countries. Recent publications and researches have changed the management and perspective of childhood myopia.
This lecture will focus on treatment modalities with special emphasis on pharmacologic therapy of progressive myopia. Recent clinical trials aiming for retarding myopia progression have shown promising results. This lecture will also highlight recent findings on preventive and early interventional measures to retard myopia, and novel treatments for progression of myopia.
Lecturer: Dr. Neelam Pawar, Ophthalmologist from Aravind Eye Hospital, India
DR PAWAR: Welcome to Cybersight Live Webinar. I’m Dr. Neelam Pawar from Aravind Eye Hospital, India, and I’ll be talking about epidemic of childhood myopia, global perspective and management strategies. And I would be glad to have any questions or queries at the end of the presentation. I’m Dr. Neelam Pawar, pediatric ophthalmologist from Aravind Eye Hospital from India, and I will be talking of epidemic of childhood myopia, global perspective and management strategies. And I would be glad to have queries at the end of the presentation. Myopia has become a global public health burden, with increasing prevalence in both developing and developed countries. And recent publications and researches have added valuable information in the literature, which have changed the management and perspective of childhood myopia. So this lecture will focus on treatment modalities, with specific emphasis on pharmacologic therapy of progressive myopia. It will also discuss about prevalence and epidemiology of myopia. It will highlight recent findings on preventative and early interventional measures to retard myopia, and novel treatments for progression of myopia. So here is the poll question one. What is your current position? Are you a pediatric ophthalmologist? Are you a comprehensive ophthalmologist? Are you a fellow or resident? Medical student? Optometrist? Or a myopia consultant? Let’s just see who all has joined us today. It’s good to see that most of you are comprehensive ophthalmologists and optometrists. A few of you are medical students and pediatric ophthalmologists. And great to see that some of you are doing — some of you are myopia consultants. Brien Holden Vision Institute is a non-profit, non-governmental organization in Sydney, Australia, and it is doing wonderful work on myopia, and has established as a global myopia center. Brien Holden Vision Institute held a conference in 2015 with international experts, which led to the formation of the International Myopia Institute, and this Institute published white papers which were highlighted in a special issue of IOVS 2019. The seven reports which were generated were on classification and definition of myopia, experimental models of emmetropization and myopia, myopia genetics, myopia progression, myopia clinical trials, industry guidelines, and ethical consideration, myopia clinical trials, and myopia control progression management. So all the pediatric ophthalmologists and general ophthalmologists should at one time go to these 7 white papers, which will be beneficial for them. Brien Holden Vision Institute estimated in 2010 1.9 billion people of the world’s population were myopic and 70 million of them were high myopic. These numbers are projected to rise to 52%, and 10%, respectively, by 2050. If you see, global prevalence of myopia and temporal trends from 2000 to 2050, it is obvious that every region, from Asia, Europe, Western Europe, North America, Latin America, and southern Africa will see a surge of myopia, which will be almost double of the existing prevalence of myopia. Vision impairment related to myopia can have significant economic impact, not only on the individual, but also on the nation, in terms of cost of contact lenses, spectacles, cost of refractive surgery, and myopia-related complications of surgery. Vision impairment also has significant effect on quality of life, regarding patients’ physical, emotional, and social functioning. And globally, the economic burden is estimated to be around $202 billion per year. Which is huge. Here is the poll question two. Do you think pediatric myopia needs consideration of an epidemic? Yes, no, or not sure. Let’s see what people opine on myopia being an epidemic. Great to see that 78% of the people think that myopia needs a consideration of an epidemic. And that is why all of us are today here. 17% of you are not sure whether to consider it. Myopia is a complex disease. The causes of myopia are multifactorial. And it results due to a combination of genetic and environmental and microenvironmental factors. With the advent of genome-wide association studies, different refractive error genes have been identified, which are involved in retinal cascade signaling. Various myopia associated loci that are involved in neurotransmission, ion transport, retinoic acid metabolism, extracellular matrix remodeling, and eye development have been identified. The Consortium for Refractive Error and Myopia found various genomic variations are associated with tenfold increase in the prevalence of myopia. 23 and Me, which is again, a large genome study group, also found different genes of myopia, related to visual cycle and neuronal development in myopia. The International Myopia Institute in it genetic report states that to date, almost 200 genetic loci have been identified in myopia. And some are common refractive error genes, while some are syndromic myopic genes. While some of them are overlapping in these two groups. We see the prevalence of myopia. It is obvious that it is 20% to 30% in White population, and prevalence is as high as 80% to 90% in East Asian population. The onset of myopia is earlier and progression is more in Asian population, compared to European population and White population. So let’s see. What are the risk factors associated with myopia? Parental myopia is an important risk factor. And in a recent study, which is population-based pediatric eye disease consortium, which was based on four different multiethnic populations, from Singapore, Sydney, Los Angeles, and Baltimore study, showed that children having myopic parents were at higher risk of myopia before school age group. An individual has 2.08 times greater chance of becoming myopic if he or she had one myopic parent, and this increases to 5.07 times greater chance, with two myopic parents. Recent study published in IOVS found that there was no association between sleep duration and bedtime with myopia progression in four-year follow-up of Chinese children. While a study done long back showed that when controlling for age, parental myopia, and gender, the taller children were having eye excellent, while children with high BMI were having hyperopic refraction. The CHAMP study, done in Danish children — in this study, the prevalence of myopia was not associated with any physical activity. Let’s come to poll question three. Do you record parental myopia history? Time spent on screen? And exposure to sunlight, when dealing with a myopic patient? Always, yes, sometimes, never. Yeah. It’s good to see that 45% of you are saying that sometimes they record these parameters, while 44% of you are always recording this. And 11% said that they never record parental myopia history and time spent on screen. Near work is also an important factor associated with myopia. The Sydney Myopia Study found that near work such as close reading distance of less than 30 centimeters and continuous reading of more than 30 minutes independently increased the odds of having myopia. The participants of the Sydney Myopia Study Group were followed in Sydney Adolescent Vascular and Eye Study. And this study found that children who became myopic performed significantly more near work, compared with children who remained non-myopic. And this was significant in a cohort of six years. While it was not significant in a cohort of 12 years of age. This point highlighted the fact that near work can be a factor for inducing the earlier onset of myopia in smaller children. Whether screen is an important risk factor in development of myopia — so there is mixed evidence, showing association between digital screen time and myopia. While recent studies in 2017 and 2019 are in favor that more is the time spent on digital screen, more is the myopia prevalence. Less time spent outdoors is also an important risk factor. And various longitudinal studies of parents and children and childhood population eye study done in children aged 8 to 15 years found that less is the time spent outdoors, more is the incidence of myopia. Higher education is also considered an important risk factor. Competitive and stressful educational systems, and higher education of parents leads to increase in the rise of myopia. So risk factors — we’ll see — what are the risk factors responsible for myopia development. In a recent article published in BMC Ophthalmology, it reviewed on the epidemiology of myopia in school children worldwide. And the common risk factors associated with prevalence of myopia listed were: Female gender, low outdoor activity, parental myopia, increasing age, time spent on near work and studying, higher socio-economic status, urban environment, high population density, and small home size were also considered important risk factors. This study came out with a very interesting fact, that use of LED lamps for homework, compared to incandescent or fluorescent lamps, increased the risk of myopia. Private schooling and watching TV over 2 hours daily, and playing mobile and video games led to the increased rise of myopia. Lower vitamin D levels, less participation in sport, and Westernized dietary habits were responsible for development of myopia. The nature and nurture plays an important role in the development of myopia. The Generation R Study provided evidence that nature and nurture are equally important in myopia development, and cornea radius ratio. Adjustment of lifestyle should be major focus in the prevention of myopia. Whether vitamin D is associated with myopia. So first, in a longitudinal study of European children, serum vitamin D was not found to be associated between time outdoors and myopia. And second, in a Mendelian randomization study by the CREAM consortium, no relationship was found between vitamin D and myopia. However, Tang et al. published in 2019 that lower 25-hydroxyvitamin D concentration is associated with increased risk of myopia. And there are two theories behind it. The light dopamine theory, which suggests that increased light intensity during time spent outdoors protects against myopia, by increased release of dopamine. And vitamin D theory suggested that increased UV light triggers the stimulation of vitamin D, which helps in prevention of myopia. Zinc, copper, selenium, manganese, vitamin E, vitamin C, glutathione, and beta carotene play an important role in the antioxidative process, and in biochemical rebuilding of sclera, and thus helps in prevention of axial elongation. Recent research came with a very interesting point, that dietary vitamin A was not associated with myopia from adolescent to young adulthood. So what causes myopia? The signaling cascade from the retina to the sclera is held responsible. Amacrine cells are implicated in retinal processing of the signal. The choroid and sclera show biochemical changes that are associated with ocular growth in the animal models. Choroid is an important source of scleral growth regulator, and the local visual stimuli, whenever there is local visual stimuli, choroid respond to emmetropization and elongation. So quantitative measurement of choroidal thickness by imaging diagnostic modality in future can be helpful to understand the relationship between thin choroids and retinal complications of the elongated myopic eye. Is there any relationship between beta peripapillary atrophy and myopic progression? A recent article published in Eye Journal found that children with young age and smaller beta-peripapillary atrophy at baseline showed a faster myopic progression. And the width of the beta-peripapillary atrophy can be used as quantitative parameter for further myopia progression. So in this example, A, the beta papillary zone is small. But this patient later showed myopia progression. While in the second picture, the beta-peripapillary atrophy is wide, but this child on follow-up didn’t show any axial elongation. So hence the width of the beta-peripapillary atrophy can be potential parameter for further myopia progression. Well known complications of myopia are myopic macular degeneration, myopic choroidal neovascularization, retinal detachment, glaucoma, and cataract. Studies found that the prevalence of this myopia degeneration is common in high myopia. Although high myopia carries the highest risk of complications and visual impairment, low and moderate myopia also have considerable risk, so these estimates should alert policy makers, health industry, government, and non-government organizations, and health care professionals to make myopia a priority for prevention and treatment, so that low and moderate myopia are not converted to high myopia. So treatment of myopia progression consists of optical, which can be single vision spectacles, progressive addition lenses, Ortho-K, soft contact lenses, multifocal contact lenses, pharmacological, in the form of atropine, Pirenzepine, timolol drops, increasing outdoor and decreasing screen time. Surgical treatment is not indicated for progression of myopia and is not preferred, and combination of all these treatments can be used. Peripheral — increasing peripheral hyperopic defocus is known to be important for the development of myopia. And orthokeratology in soft multifocal contact lenses slow the myopia progression by optically decreasing peripheral hyperopic defocus, or by decreasing peripheral myopic blur. BLINK study was demonstrated that increase in peripheral refraction in myopic children with bifocal lenses can be helpful in preventing progression of myopia. The correction of myopia evaluation trial study was a multicenter randomized controlled clinical trial, and the aim of the study was to find whether there was any difference in the progression of myopia between children wearing progressive addition lens, versus conventional single vision lenses. A small statistically significant amount of difference was found, during the first year, but the size of treatment remains similar for the next two years. So the small magnitude of the effect does not warrant a change in the clinical practice. While these progressive addition lenses were effective in slowing progression in children who had larger accommodative lags, and the difference was statistically significant throughout three years. The US COMET trial, Hong Kong trial, and Japanese trial collectively — all these three clinical trials showed that progressive addition lenses are largely ineffectual modalities for myopia progression. Greater success has been reported recently with executive bifocals and prismatic bifocal spectacles in decreasing the myopia progression. Orthokeratology shows some promising results. In the first trial, the retardation of myopia in orthokeratology study, the axial elongation was slowed by an average of 43%, which was larger in younger patients and with more rapidly progressive myopic children. The longitudinal orthokeratology research in children study also showed promising results, and orthokeratology was effective in high myopia, and cases with astigmatism. The only concern with these ortho-K lenses is the increased incidence of microbial keratitis. Soft multifocal contact lenses and orthokeratology slowed myopia progression by an average of 46% and 43%, respectively. Along with soft contact lenses and multifocal contact lenses, there are some studies which show that rigid gas permeable contact lenses also slows the progression of myopia. Next to the pharmacological treatment. Atropine is a broadband muscarinic acetylcholine receptor antagonist. And it prevents myopia via a non-accommodative mechanism. So how it exerts its antimyopia effect? There is a neurosignaling cascade system, which causes myopia, and it begins at the retina level. Atropine drops are thought to be acting on these presynaptic and postsynaptic muscarinic receptors. But still, the exact mechanism is not clear. In the landmark study done in Singapore, which was the ATOM1 study, atropine for treatment of childhood myopia study, which included 400 Asian children in age group of 6 to 12 years, with myopia of -1 to -6 diopters, this study found that eyes treated with 1% atropine experienced reductions in refractive error change, and the follow-up study, effects were seen with lower concentration of atropine, with reductions in side effects of glare and discomfort. The phase 2 ATOM study showed rapid rebound increase when atropine was stopped for 12 months, and the rebound effect was less with lower concentration of atropine. In phase 3 of ATOM, those cases which had rebound effect were restarted on atropine 0.01%. So whether lower concentration of atropine works, the LAMP study, low concentration atropine for myopia progression, suggested that 0.05% atropine may be most effective concentration for myopia control. So what are the guidelines for using atropine drops? The clinical guidelines for children age 6 to 10 years with myopia more than 1 diopter and documented myopia progression 0.5 diopters per year, 0.01% for two years. If there is good response, and almost no myopic progression, less than 0.5 diopter increment over second year, then taper and stop atropine. If there is moderate response, that is myopia progression of 0.5 diopter to 1 diopter over second year. Continue atropine 0.01% for further 1 to 2 years, and then taper and stop atropine. If there is a poor response, that is, there’s a myopic progression of more than 1 diopter with second year, so these cases may be non-responder, so consider tapering and stop atropine. The role of 1% atropine in these non-responders is still not so well known. So the outcome measures are seen as changes in spherical equivalent refractive error, and changes in axial length. The ATOM3 study, which is still under trial, included patients with parental history of myopia, patients with premyopia, and those patients with spherical equivalent of -0.5 diopter, or even less. They are also being treated with atropine, 0.01%. What is the non-Asian perspective? The atropine drops are widely used in Asian countries. And atropine drops are easily available. While in non-Asian countries, they are not so frequently used, because of off-label use of atropine drops. There are a number of ongoing placebo controlled trials of 0.01% atropine, currently undergoing in United Kingdom, Ireland, and Western Australia. The Eye Journal highlighted the summarization of Cochrane reports as Cochrane Corner: Atropine, an ancient remedy for a 21st Century problem. In a meta-analysis of Cochrane database of systematic reviews on intervention to slow progression of myopia in children, this was the review study, published in 2016, and it showed that atropine was most effective at slowing myopia progression, compared to all other interventions, including refractive method. However, a dose response effect was not shown. So when myopia treatment should be implemented, and on which children? The average growth of eye in childhood is 0.2 millimeters per year. And ATOM studies recommended that treatment with atropine 0.01% should be initiated if myopia progression exceeds 0.5 diopters the preceding year, and this corresponds to elongation greater than 0.2 millimeters. Progression is faster in younger children, and those of East Asian ethnicity, and those with a parental history of myopia. So even atropine drops should be instilled earlier in these children. Then myopia treatment should be discontinued. And when to stop the treatment? Assuming the myopia control is effective, it should be continued as long as benefit outweighs the potential risks. Or additional cost associated with the myopia treatment. A recent survey conducted among pediatric ophthalmologists worldwide to decrease myopia progression reported that 80% of the ophthalmologists prescribed 0.01% atropine, while 13% of pediatric ophthalmologists uses 1% of atropine. For optical therapies, 23% of ophthalmologists prescribe PALs, while 14% fit orthokeratology. Among the pharmacological treatment offered, European physicians were offering the lowest rate. Behavioral modifications were advised in 92% of cases. While 95% of pediatric ophthalmologists preferred combination of all these treatments. In a review meeting in 2018, by WHO International Association of Prevention of Blindness, and Brien Holden Vision Institute, they came to a common consensus that pharmacological therapy is most effective in myopia control intervention, followed by orthokeratology and multifocal contact lenses. RGP lenses and peripheral defocus lenses were least promising, while undercorrection should not be advocated at all. So what is the future of myopia treatment? CooperVision MiSight daily contact lenses have shown promising results. I know they are in phase 3 with atropine formulation drop, defocus incorporated multisegment lenses have shown to slow down progression. SightGlass vision trial is still under study. So what are the behavioral treatments? Behavioral treatment should be advised, along with pharmacological treatment. Ophthalmologists should advise to decrease screen time, to increase outdoor time, and schools should make efforts to take some classes outside. Recess should be an outside playground, and there should be daily recreational activities in school. So not any light is just sufficient for prevention of myopia. And myopia follows more than 1,000 lux rules. The children spending greater time exposed to bright outdoor lighting conditions more than 1,000 lux showed significant slower myopic progression. Seasonal fluctuation can alter myopia progression. So not only the light quality, but light parameters should be considered in treatment of myopia. What are the benefits of behavioral intervention? Behavioral intervention avoids side effects of atropine and orthokeratology, and general guidelines are that children should engage in outdoor activities for at least 2 to 3 hours per day, and at least 14 to 21 hours per week. Less than 40 minutes per day of bright exposure may predispose children to faster axial length growth. Here is the poll question for what myopia treatment do you prefer for your patients? Single vision lenses, progressive addition lenses, atropine 0.01%, orthokeratology, combination therapy of pharmacological drops and behavioral treatment, multifocal contact lenses, or other modalities? Let’s see what people have in mind. So most of you are advocating a combination therapy of pharmacological drop and behavioral treatment followed by single vision lenses. Very few of you are advising progressive addition lenses and orthokeratology, while atropine 0.01% accounts for 14%. These are the guidelines for myopia management. Nicely briefed by Brien Holden Vision Institute. So whenever a patient with myopia comes to your clinic, you should take a detailed history, including family history, the time spent on outdoor activities, and near work. Age of onset and progression, visual acuity both uncorrected and best corrected, binocular vision status, corneal topography in cases of ortho-K lenses, anterior eye examination, intraocular pressure, objective and subjective cycloplegic refraction, there is no substitute for cycloplegic refraction, and fundus examination. So there is an increased risk of onset of myopia if one or both parents are myopic. Patients with East Asian ethnicity. Those with excessive near work and limited outdoor activities, and if myopia progression is more than 0.75 diopters per year. And there is risk of progression if onset is less than 9 years, parental history of myopia, progression of more than 0.75 diopters per year, and East Asian ethnicity. The management consists of — if there is no myopia and child is at risk of myopia, reduce the risk by increasing time outdoors, and frequent breaks from near work. For myopia, choose a myopia control strategy, and consider patient and career preference, and strategy. Single vision spectacle and single vision contact lenses can be given. Myopia control can be done by providing contact lenses, ortho-K lenses, progressive addition lenses, executive bifocal, peripheral defocus lenses, low dose atropine, and combination of low dose atropine with multifocal contact lenses. And these children should be followed at one week, one month, three months, six months, nine months, 12 months, when you have started the child on atropine drops or on vision contact lenses. While in children in whom you are prescribing only single vision spectacles, follow-up can be done at 6 months or 12 months. So in every follow-up, just check the anterior segment examination, pupil size and response to light, intraocular pressure, subjective and objective refraction to be done every 6 months, and fundus examination can be done annually. So if progression is not slowed, check the lens prescription, check the compliance, and consider changing the treatment plan, or design of treatment modality. And if myopia is stable for at least one year, observe for two years before considering cessation of myopia control. The biometry in myopic eyes can be done by conventional ultrasound biometry, by A scan, which was done in ATOM study done in Singapore. It can be done by optical biometry, by axial coherence interferometry, by IOLMaster 500 and 700 and Lenstar. The advantage of the non-contact biometry is that they give accurate measurements of axial length, anterior chamber depth, and IOLMaster 700 also gives us pupil measurements. So a child can be followed before starting the treatment and after starting the treatment. Pupil size can be determined with IOLMaster 700. Poll question five. Do you perform biometry, pupil size measurement, and accommodation amplitudes in all pediatric patients who are taking myopia control treatment? Yes, most of the time, or not at all? So let’s see what people are responding. 62% of you are saying that you don’t perform biometry pupil size measurement and accommodation amplitude, while it is good to see that 38% of you perform all these measurements before taking any myopia control treatment. So what are the criteria for instillation of atropine drop? It should be around 6 to 13 years. Spherical equivalent ranging from -0.50 to -6 diopter. With myopia progression of -0.5 diopter per year. There should be no history of atropine allergy, and there should be no anisometropia of -1 to 1 diopter. The role in pseudophakic myopia is still questionable. At baseline, you should see for near point of convergence, near point of accommodation, negative relative accommodation, and positive relative accommodation, pupil size, axial length measurement, keratometry, Orbscan if possible, cycloplegic refraction, and on follow-up, check for side effects, check whether there is need of progressive addition lenses, check pupillary response to light, ask about glare, and check near vision. Regularly educate patients on how to instil drops, and patients should be reminded in every visit that these atropine drops are not magic drops, and lifestyle modification should always be done, along with these pharmacological treatments. Let’s see an example of rebound effect of 0.01% atropine. This child came to us at initial examination. He had -4 diopters of myopia in both eyes. And he was showing the progression of more than -0.5 diopters, and when he reached -5 diopters, we started him on atropine, 0.01% drop. At baseline, axial length was 25.78 millimeters in right eye and in left eye it was 25.92 millimeters in 2018. Patient took treatment for almost two years and compliance was good. And when the treatment was stopped, within 4 months, the myopia rises from -5 to -6.5. And axial length in right eye increased to 26.71 millimeters, and in left eye to 26.46 millimeters. So this suggests that rebound effect of even 0.01 atropine can be seen, and therefore patients should be followed periodically, and if any rebound effect is there, they should be started on atropine drops. So for this particular patient, we started again on atropine drops. The myopia calculator is a beneficial tool, given by Brien Holden Vision Institute, and it is useful to visualize the average potential outcome based on research. And if you log into this myopia calculator here, you will see ethnicity. Right now it is only for Asian and non-Caucasian population. Child age in years, refractive error, and what myopia management option you are going to plan. So by entering all these details, the calculator will give you what is the myopia progression at the age of 17 years. Here the red line indicates the myopia progression at age of 17 years, and this green line shows what will be the effect of myopia treatment on the refractive error. So let’s see an example. This child came to us in 2013, at age of 7 years. He was having refraction of -1.5 diopters and -50 cylinder in both eyes. And in 2019, at age of 14 years, his myopia increased, and he had -5 diopter spherical with -0.50 cylinder in right eye, and -4.5 diopter sphere and -0.50 cylinder in left eye. So if we enter these details in myopia calculator, it shows that at age of 17 years, if any myopia treatment is not started, child will end up with myopia of 6.68 diopters. And if atropine drops would have been advocated in the initial phase, this myopia could have been reduced to just -3.62 diopters. So unfortunately, atropine was not available that time. But right now, the child is on myopia treatment. The society of pediatric ophthalmologists and strabismus society gave a myopia consensus statement that undercorrection does not work. What probably does not work is also bifocals and contact lenses. What might work is ortho-K lenses and peripheral retinal defocus, and what does actually work is atropine eye drops. So if we see myopia control in 2020, in the first six months of 2020, there were more than 15 papers on myopia and myopia progression. And these evidences are enough to show that myopia has reached a stage of an epidemic, and it needs a serious management. Ophthalmologists and optometrists should work in collaboration with schools and school administrators, and along with government and non-governmental organization to have a pediatric myopia referral system, and should have programs like national myopia program, and should have myopia awareness week, to create an increased awareness in myopic patients, and parents of myopia. So that myopia progression can be delayed. Or can be treated. So the future of fewer myopic patients lies in your hands. Choose best myopic treatment for your pediatric patient. The future of your country. A pandemic has taught us a lot, and epidemic of myopia can be dealt if ophthalmologists and optometrists are at the front line. Simple myopia is not so simple, but it needs a serious approach for its treatment. Thank you very much, and thank you Cybersight. And I hope you enjoyed this lecture on myopia progression. And thanks, Cybersight, for giving this opportunity to present. And if we can take any questions before leaving… >> Great. Thank you, Dr. Pawar. You can stop your screen share, and we have a couple of questions open. If you open up the Q and A, you can answer as many questions as you have time for.
DR PAWAR: So there’s a question. What is the earliest age of a child that you can start low dose atropine? So if you see published studies, most of the studies advocate that the child should achieve emmetropization, and only once the child has achieved emmetropization only then should the myopia treatment be started. So the minimum age limit is 6 years, and maximum age is 13 to 14 years. While only one study has shown that they started atropine drops in 5 years of age. And so there is another question. Do you recommend diluting atropine drops? I don’t think so. It is a good idea to dilute atropine drops. Because then the efficacy of these prepared drops is not well established. And I don’t think so, whether there will be — it will be helpful in reducing the progression. What is the earliest age when you can start contact lenses in a child? It depends on the parent. Sometimes we discuss all these options with parents, and it depends on how the child is cooperative. Even with ortho-K lenses, they can be given at an earlier age, but if the child is not cooperative, then better to start contact lenses at a later age. So there’s one more question. Are there any data studies done in Black or African countries? Yes, I am not aware about atropine drop usage in Black or African communities. But there are some studies in which Africans living in other countries — they have shown promising results with atropine drops. Here’s another question. Do you use atropine for myopia prevention in your clinic? If so, what dose and how long? I believe we start atropine treatment after the age of 6, and if the child is showing a progression of more than 0.5 diopters per year, and we start with low dose atropine, 0.01%, and one drop daily at night for two years, and if there is no progression, then only we stop the atropine treatment. But as I have shown in the example, there can be rebound effect, even if there is a stable refraction. So even after two years, if patient is showing a rebound effect, you can again restart the treatment. Atropine 0.01% is quite a safe drop, and we rarely see any potentially harmful complications, so they can be continued for a long time. But it depends on the iris color and light intensity in different countries. For Asian population, it really works. Are there any studies that confirm if myopia comes before the near work? Or the near work occurs as a result of myopia? Yeah, most of the studies shows that earlier the child starts reading or earlier the child starts doing near work for more than 30 minutes, earlier is the onset of myopia. And it is quite evident in Asian populations, where the robust education system pushes them to early education at 2.5 to 3 years of age. They’re subjected to read books. This may be the cause that in Asian populations we see the onset of myopia at an early age, compared to Western and European population. So what is microenvironment? Microenvironment includes all the things like light intensity of bulbs, living in small houses, even in the environment which might act as a risk factor — we include those as microenvironment. This one and other questions: Full correction or undercorrection — which one is the best way for correction of myopic patients? So 10 to 15 years back, the hypothesis was you should undercorrect the patient to prevent increase in myopia. But this theory is absolutely obsolete now. And the current thought is that every child should be given prescription which is — should be given full myopic prescription. Because undercorrection, again, acts as a stimulus factor for increase in axial elongation, and leads to myopia. There’s another question. What do you think about the use of crosslinking to retard the progression of high myopia? That’s good. There are some surgical interventions reported by international myopia institute group research papers. And there are a few studies which show that crosslinking of the sclera can lead to decrease in the axial elongation. Here’s another question. Do you combine progressive lenses with atropine 0.01% therapy? Yeah, usually we don’t combine, but there is no harm in combining progressive lenses with atropine 0.01% therapy. Progressive bifocal lenses don’t work so well, but along with atropine 0.01%, they could be beneficial. They could actually help the child in reading and doing near work. Though most of the children never complain that they’re having any near work problems. Only a few children sometimes — they say that sometimes they’re having problems in reading. So in those cases, this combination will work effectively. And I think for the rest of the questions, we have already answered. And we have already discussed in my presentation. There’s another question. So you confirm that progressive addition lenses are not better than single vision lenses in prevention of myopia progression. Yeah. But this does not fit for all patients. We have to check the accommodative amplitudes. And if the patient is having higher or larger lag of accommodation, progressive addition lenses can be beneficial. Another question: Once the myopia has onset, outdoor activity does not help? Yeah, there’s a report by one author who says that once the myopia has onset, the role of outdoor activity does not play any role in progression of myopia. But recently, there are published studies which proves this theory to be wrong, and any amount of outdoor activity can help in reducing the myopia progression. Definitely it will not decrease it to normal once the myopia has onset, but regular outdoor activities, more than 40 minutes of daily outdoor activity, can definitely help in decreasing the myopia progression. There’s another question. What constitutes a responder versus non-responder to atropine therapy? Do we base it solely on one to two years of trial of therapy? Yeah. To say a patient is a responder or non-responder, it is not just in terms of one or two years. You have to see the myopic progression. If on treating the patient with atropine drops, if there is no improvement within one year, and if the progression is more than 1 diopter per year, then definitely it is a failure of treatment, and those cases can be considered as non-responder. So how would you taper atropine drops? Atropine drops are usually given on a daily basis, at night. And these can be tapered off by giving atropine drops first for a few months. Only for five days in a week. Then they can be tapered slowly for four days, three days, two days, and one day per week. And slowly it can be stopped. So I think we are done with most of the questions. And any other questions we can discuss with you by email. So thank you. Thanks again for joining us today for this Cybersight live webinar. Stay safe. Thank you.