Please note: this transcript is not 100% accurate.
00:00
we know that we have something to offer them and it’s just not standard of care anymore to say we can’t do anything or that we’re going to wait until there’s more evidence because you could be waiting forever if you decide to set your evidence bar up here.
00:19
This is Dr. Meenal and welcome to Uncover Your Eyes, where we uncover reality. Myopia, commonly known as nearsightedness, not only affects our vision but also increases the incidence of eye diseases like cataracts, glaucoma, myopic maculopathy, and retinal diseases.
00:49
to 50% by the year 2050. But we can do something about it. We can control nearsightedness. Today, we have a special guest that can shed some light on myopia. Dr. Kate Gifford is a clinician, scientist, and the co-founder of Myopia Profile, the world’s leading educational platform for childhood myopia management.
01:19
Welcome Dr. Gifford. So thank you, Dr. Gifford, for being on this morning. Thank you. Thank you very much for having me. I’m coming to you live from south of Hobart in Australia. It’s 8 a.m. on a Saturday morning. It’s about five degrees outside, which I know isn’t Canada-level cold, but that’s pretty much Australian-level cold. Wow. Well, thank you. Thank you for doing this on a Saturday morning. I appreciate it.
01:45
And you know, it’s September and September is big for what we’re talking about, Myopia, you know, Action Month. And you know, I know you’re very passionate. You’re the co-founder of Myopia Profile. So you know, you’re passionate about Myopia. But tell me what this month really means for you. So Myopia Action Month was founded by us at Myopia Profile last year. Last year, 2023 was our inaugural year. And really what we aim to do…
02:14
was to turn my APA awareness into action. So we see so much talk about my APA awareness about my APA management at conferences in the scientific literature in amongst professional organizations, making resolutions about my APA management being standard of care. But we know that there is still a disconnect in terms of my APA awareness being put into action.
02:39
And so that’s really what we aim to do. We aim to be able to connect eye care professionals right around the world with hands-on resources, education, tools to help them really not just understand the science, but also really take action and put it into practice. Yeah. And it’s great for awareness, even amongst parents. I read a survey, I think it was on the Myopia profile, about more than half of parents are unaware of the connection between…
03:08
you know, myopia and ocular health. Can you touch on that a little bit? Yeah, absolutely. This is quite, I guess you could say scary really because we know with the rise of myopia around the world that we have more and more children becoming myopic, which means that we have parents who aren’t myopic, have no experience of it themselves, no experience of myopia progression, who we would expect to find it harder for them to conceptualize what it’s like for their child to be myopic.
03:37
for them to experience rapid changes in their vision. But survey data has actually shown that myopic parents can actually think that myopia is less of a concern, more of an optical inconvenience or a cosmetic inconvenience than anything to do with eye health. So we really have a big education piece, a big responsibility to educate parents, whether they’re myopic or not, about what myopia is, that it’s not just about a pair of glasses and…
04:05
while that may be a bit of a intimidating message perhaps for some parents, we have the good news message that there are things that we can do about it to slow myopia progression. And what, you know, for healthcare providers or optometrists that are treating myopia, like what amount of myopia matters, right? In my practice, you know, something as small as 0.5, you know, we will start myopia control and managing it.
04:33
So what is the recommended that you would recommend we should start at controlling it? Well, myopia is defined as 050 or more. So your approach absolutely makes sense from the point of view of the evidence. Global surveys on our colleagues around the world, how active they are in myopia management, show us that while there’s regional variation, for the most part, we’re sort of not taking myopia seriously until it gets to…
05:00
one or 125 or 150 or even higher. And you think about an uncorrected myopoes, 125 or 150, they’re going to be less than 612 or 2040. They’re going to be effectively functioning with visual impairment in the world. So we wanna give kids the best possible vision so that they can function with everything they need to do for school and sport and everything to do with life. So we know that kids are likely to progress.
05:28
the younger they are, the faster they’re likely to progress. So any myopic child, especially under age 16, and arguably even beyond, we should be proactively talking about myopia management and aiming to put strategies in place. And we can even start earlier than that with children at risk of myopia, children who are pre-myopes, which we can talk a little bit more about if you’d like to, but that’s if we’re going to be as proactive as possible.
05:55
then that’s when we really want to start, is identifying children who are at risk of developing myopia and just starting the conversation, even if it’s not necessarily an optical or pharmaceutical strategy that we’re implementing at that point. What is the definition of premyopia? So premyopia was defined as an actual thing. There was some questions about whether it was a real thing or not, but the International Myopia Institute definitions paper published in 2019 defined it as a child
06:24
not as not as hypo-opic as they should be. So there are fractions generally between Plano and plus 075. Generally that’s defined by cycloplegic terms or by controlling accommodation when you take that measure. And they also have risk factors for development of myopia. So that’s typically myopic parents, that can be visual environment risk times, risk factors, which we can summarize easily by saying too much screen time, not enough green time. There’s some nuance in that in terms of the research.
06:53
But we’ve got those risk factors. There are also binocular vision, accommodation, and vergence risk factors that can point towards development of myopia. There are also ethnicity risk factors. So we know that particular regions of the world, in particular ethnicities, have much higher levels of myopia. So those combination of risk factors, and in combination with a child who’s less hyper-optic than they should be, is a way we can identify pre-myopia. And actually, importantly,
07:23
independent of ethnicity, family history, environmental risk factors. The biggest single risk factor for a child becoming myopic is being not as hyper-opic as they should be. So if we see a child who’s say six to seven years of age, who is less than plus 0.75, then that’s a child who’s highly likely to become myopic before their teen years. So let me ask you a question, personal question. So my daughter is
07:50
seven years old, and she’s 0.5, minus 0.5, right? So if she walked into your practice, is this someone who she’s not symptomatic, but is this somebody that you would start myopia control management on? I mean, knowing that she’s not symptomatic, she doesn’t want glasses, meaning she doesn’t need it, it’s not affecting her, she’s not doing far enough work, but do you feel that this child would need to be treated?
08:15
So we would absolutely be having a conversation about the risk factors of myopia, what myopia is, what could be in store for her in future. We would also talk about whether she has myopic parents or not, how to assess her binocular vision function. And the best, most evidence-based approach we can take with pre-myopia is to talk about visual environment. So to talk about trying to achieve at least two hours of time spent outdoors each day.
08:42
And that’s very evidence-based. That doesn’t have to be sport. Kids achieve a lot of that time in breaks at school, obviously, weather-dependent and climate-dependent, depending on which part of the world we’re in, that can be harder to achieve, easier said than done. But talking about spending more time outdoors and trying to manage leisure screen time, so reducing the time spent on screens for leisure, not for schoolwork, but for leisure.
09:11
to ideally less than two hours per day. So there’s easy two hour rules is absolutely where we would start. And then it really depends on the parent and how proactive or how concerned they may be about myopia development. From the point of view of the evidence, we know that there’s very strong support for increasing time outdoors to delay the onset of myopia. But that’s not always achievable.
09:38
And so there is some interesting research now in various populations around the world on use of low dose atropine, 0.01% up to 0.05% for delaying myopia onset. And some research has shown it’s gotta be 0.05%, some research has shown 0.01% is effective, depends on ethnicity, perhaps eye color. This is what we’re sort of learning from the science. But if I had a parent who was very concerned and wanted to do more, then just
10:07
let’s talk about visual environment and review a bit sooner, then that’s perhaps where we would start. So, for pre-miopic children like her, would you suggest, you know, myopia control glasses as your first, like what would be your first line therapy for these pre-miopic children that might even be Plano, you know, putting them in, you know, glasses that have myopia control or would you start them on?
10:32
low dose atropine therapy, would that be your kind of go-to method for pre-myopes? So for a child who’s pre-myopic, say a child who is Plano, it’s going to be pretty hard for us to assure compliance with myAP control spectacles. Could be done with the right child and the right parents, or myAP control contact lens designs, which to my knowledge don’t start at Plano anyway, the spectacles do.
10:58
So atropine might actually be simplest from the point of view of compliance. And, but atropine for pre myopia, we do have a little bit of an evidence base on that. We’ve just recently published a clinical article on myopiaprofile.com on all the research we have on atropine for pre myopia. So our clinical articles are, they’re a literature review, but really answering clinical questions. And so we’ve got some guidance there of what concentration we could use and where we could start from.
11:27
But for a pre-myopia, I think we’re going to be talking about visual environment, absolutely, as best practice. And then we might potentially think about atropine, maybe spectacles if we’re likely to have a very compliant child and perhaps you’ve got a young girl who wants to wear glasses from a fashion point of view. So compliance might be quite good. But then if we’re talking about a child with myopia, say we’ve got a child who’s minus 0.50, minus 0.75, maybe they’re not too bothered from a vision perspective.
11:57
That can also be a challenge to compliance if they don’t feel their spectacles or contact lenses are doing that much to improve their vision compared to a child with more myopia. Again, it’s a discussion about what’s gonna suit the child, what’s gonna suit the family, also what you have available to you in your scope and setting of practice, because we know that myopic control spectacles, myopic control contact lenses, and appropriate concentrations of atropine appear to be similar in terms of efficacy.
12:27
which means we’ve got a lot of tools in the toolkit to really determine what’s going to best suit that child and what’s going to assure compliance. Compliance is the number one thing we need to get decent results from IAPA control. Right. You know, touching on atropine, you know, we were talking about dosage and I know they, I believe it’s the LAMP-5 study just came out recently, you know, and I think there’s varying evidence and I don’t think there’s a right or wrong, but, you know, I want to hear from you as the expert.
12:56
There’s the 0.01% which is great for long term, fewer side effects, and then there’s the 0.05% which is great for, on a progression standpoint initially, maybe more side effects.
13:08
What is sort of your rule of thumb or how do you choose which percentage you’re going to give? I know some clinicians will choose only 0.01 as the dual therapy, so as the secondary add-on, but initially if they’re only treating with atropine, they might even go strong as 0.05. Do you have a rule of thumb that you kind of follow? It would be lovely to have a simple rule of thumb, but I think the research is complex and layered and what we’re starting to learn.
13:36
from the LAMP study, which was the very first to compare 0.01, 0.025, and 0.05% to a placebo, through to this new raft of 0.01% studies, which have been published in the past year, is that one concentration won’t suit every child. So 0.05% definitely has a strong evidence base for controlling myopia effectively. And the side effect profile appears to be minimal, at least in the…
14:05
populations of children in East Asia in which it’s been studied. But we might potentially have more side effects in kids who are blue-eyed or of Caucasian ethnicity. There’s a little bit of data on that and we’ve had a new raft of 0.01% studies published in the past year which instead of investigating compounded formulations where there can be some variability and quality and consistency are we actually getting 0.01 or more or less?
14:34
These are using commercially prepared formulations that have to adhere to good manufacturing practices. So we know we’ve got some consistency, preservative free formulations. And these for the first time have been studied in children in North American populations and European populations, where we have a majority of kids who are of European or white or Caucasian ethnicity. And what we’re finding is that 0.01% might actually be an effective starting point for those kids.
15:02
maybe not quite as effective as our best optical treatments, but we can’t say that for sure because we haven’t done a head-to-head study. But I think it’s really going to depend on the child. And let me give you two examples, I guess, to illustrate the extremes. If I’ve got a child with blue eyes, with maybe perhaps a slower level of myopia progression, and let’s say on top of that, they also have a little bit of an accommodative lag or a little bit of an esophoria, maybe their
15:31
ideal, where I’m a little bit more concerned about the side effects of a stronger concentration of atropine, maybe we might start on 0.025% for that child. Maybe we might even have to drop back to 0.01 if we see side effects. But if I’ve got a child of East Asian ethnicity showing faster progression, you know, those other risk factors that we’re seeing younger, then straight to 0.05% because that’s definitely where the evidence seems to sit.
15:59
We’re learning and when it comes to combinations, we have basically no data except for some some, you know, early reported anecdotal observations or some research abstracts, conference presentations. We have no data on any combinations of anything but 0.01%. So 0.01% with Atropine, sorry, 0.01% Atropine with AuthOK. That’s got a strong evidence base for combining.
16:27
But 0.01% with anything else, we’re only just starting to get early data on that and stronger concentrations than 0.01%. In combination with optical treatments, we don’t know. So we have to use our clinical judgment in that respect and take into account all of those factors, as I’ve talked about, to determine what’s going to best suit that child. And that might evolve over time. You might start with something and then need to go higher or lower with the concentration.
16:55
Do you find that in your practice, so because they have similar efficacy in terms of atropine therapy, you know, glasses, are you really just choosing based on the patient and, you know, parents, right, because of the efficacy? So is that kind of your rule of thumb, just choosing based on the patient’s needs? Yeah. Look, it’s only in the past few years that we’ve had all of these options on the table to be able to present to parents. And if I go back to 10 years ago.
17:24
in my myopia management practice, I was very much focused on OrthoK because it had the best evidence base. We had no myopia control spectacles. We had a little bit of research 10 years ago on bifocal spectacles, progressive edition lenses didn’t appear to be effective. We had some very early data, like case report data on multifocal soft contact lenses, those which were originally designed for presbyopes. So OrthoK was really where it was at.
17:53
in terms of the evidence base. But that’s evolved, that keeps evolving every year now. And that’s exciting. That can be intimidating to our colleagues who don’t find this an area of their passion for them to go, well, if it’s changing all the time, maybe I’ll sit back and I’ll wait until everyone figures it out. But we never figure everything out in medicine. We never figure everything out with individual variation amongst patients.
18:21
So the fact that we’ve got so many tools available to us means that we can think, okay, spectacles versus contact lenses, what’s gonna best suit this child? Because it’s really important we remember that contact lenses can have enormous benefits for kids, functional and psychological benefits. And then if those aren’t available to you or aren’t suitable for that child, I’ll tend to go for optical treatments first because I like the idea of the dual benefit of myopia correction and control, myopia correction and myopia management with the one treatment.
18:51
But if that’s not suitable or not available, then that’s when atropine might be, would tend to be my second choice if an optical treatment as a monotherapy can’t do the entire job or isn’t suitable. What is your rule of thumb of the amount of myopia that should be corrected for it not to be a stimulus for progression uncorrected? There’s a simple answer from the literature and then there’s the nuanced answer depending
19:22
So the simple answer from the literature is that 075, children who were under-corrected by 075 or to 612 or 2040, that was shown to speed up myopia progression. So we absolutely don’t want to under-correct a child by 075. We also wouldn’t want to under-correct a child to 612 or 2040 anyway because that meets the criteria for visual impairment. We know they’re not visually impaired because we can fix it, but why would we not give children the best vision they can possibly have?
19:52
So that’s from the research perspective. But from the individual perspective, we all know as clinicians that minus 0.50 means massively different things to different people. And even minus 0.25 with some patients. So if you have the minus 0.50 patient, say you’ve had a child who’s in a treatment like my epi-control spectacles and they’ve progressed and you’re trying to figure out, do I update the prescription or not? Minus 0.25.
20:21
might mean nothing to them visually. Minus 050, one kid might be 6’9 or 20’30. Another kid might be still 6’6 or 20’20. So I think the 050 is where it’s going to get a little bit, you know, it’s going to be subject to individual variation and how the patient responds to that. You know, you touched on Orth-OK a little bit, right? Because that was the main method of treatment, you know, before this. So
20:48
Can you speak to that? Like, cause I know a lot of doctors are, you know, we have two extremes, I want to say the doctors who are pro-ortho K and then the doctors who are actually scared of ortho K zone will talk patients out of it. We have soft contact lens options that can control myopia effectively. So where does ortho K play a role in this, in this day and age now? So, so you’re right.
21:14
the treatment of choice really from an evidence-based perspective because it was back in 2005 and 2009 that we had the first publication showing a robust myopic control efficacy with OrthoK and that wasn’t matched by anything else at the time except 1% atropine which is a bit mean I think as a treatment approach. It doesn’t necessarily make our patients like us 1% atropine. So I never prescribed that, not when I had OrthoK available.
21:43
think myopia management as a clinical interest and as a specialty, has sort of really grown from the early adopters who were fitting with OK, because of those early reports of myopia control and because it really had the lead it was out in front in terms of the evidence base. Now we have myopia control self contact lens designs, we have myopia control spectacle lens designs, which appear to match with OK in terms of their efficacy.
22:11
So that’s when we can really think about, well, what are the benefits to the wearer of each? And Ortho-K absolutely has massive benefits to the wearer in terms of daytime unaided vision correction. If we have a child who does a lot of water sports, for example, it’s gonna be much safer for them to have nothing on their eyes than to be wearing soft contact lenses in the pool. There might be other reasons. For example, there’s been research in…
22:38
young adults, not in children, but research in young adults to say that young adults with symptomatic contact lens related dry eye did better in Ortho-K when they were refit to Ortho-K. So those sorts of situations where if we compare the two modalities, they have different benefits. But what you mentioned there that I think is really important I’d like to address is safety. And there is concern that Ortho-K is far less safe than self-contact lenses.
23:07
And the research shows us that daily disposable soft contact lenses hands down are the safest way to wear contact lenses. The risk of infection with those are microbial keratitis, not of any interruption to contact lens wear, but of our most concerning outcome, microbial keratitis. The risk with daily disposables is one per 5,000 patient years of wear. So if I’m explaining that to a patient, I’ll say the risk of an eye infection, if you wear these for 5,000 years.
23:37
which you probably won’t because probably not the same pair. But if you wear daily disposables for 5,000 years, you’re likely to get one eye infection and everyone has a giggle and they realize that the risk is quite remote. Now the risk with Ortho-K is very similar, at least the research indicates to us, to reusable soft contact lenses. So if we were thinking about fitting a two weekly or a monthly soft contact lens to kids,
24:06
the risk of infection with orthok is similar. And in fact, more recent data from large group practices that have really sort of well controlled the patient care process show it might even be a tiny bit lower. So the risk with orthok or reusable soft contact lenses is about one per 1,000 patient wearing years. So if you wear these orthok lenses for 1,000 years, not the same pair, 1,000 years, you’re likely to have one eye infection.
24:35
And so I think that helps to give us, hopefully that gives our listeners some clinical tips to explain this in practice and also to understand that if it’s appropriately managed, if we have you with field hour after cares, we’re ensuring appropriate care and maintenance of ortho K lenses, the risk is really remote. Right. You know, I know a lot of patients are in ortho K and then there’s combination therapy with atropine.
25:01
What is your rule of thumb, whether it’s Ortho-K or even myopia control glasses, what is your rule of thumb? When would you add combination therapy on for your patients? What is your, you know, the average age of change, the average rate of change per year for a child should be about 0.5 per year, or is normally that? If they’re on myopia control glasses, but they’re changing, you know, from a minus one every year to a minus 0.5 every year, is that satisfactory to you? Or would you like,
25:31
So is it, what is your rule of thumb that you would actually add that combination on? I know it’s individual dependent, but do you have like sort of a, I want to say a calculation. Yeah. So our best calculation or our best rule of thumb, we’ve put together and made available in the Myopia profile, Managing Myopia Guidelines Infographics. They’re available to download in 20 languages. If you’re smart enough to know 20 languages, I unfortunately only know one.
25:58
But we have 20 languages. We’ve been very fortunate to have colleagues generous with their time right around the world who’ve helped to verify these translations. And the reason I mentioned that is that gauging success in my APM management is absolutely one of the biggest challenges. And this infographic includes two sides, one side which guides you through a parent communication process and another side which is a chair side reference. And the final panel on the chair side reference side is gauging success.
26:27
Now the average progression per year, if a child was in a single vision correction, varies by age. So if you’re under 10, it’s more like one or one to five per year. If you’re over 10, it’s more like 050. So if I have a seven year old, progressing by half a diapter per year in my peer management, that’s actually probably a pretty good result because we’re slowing progression by half.
26:52
compared to what it could be in a single vision correction. On average, of course, there’s no such thing as the average kid, but that’s our best calculational rule of thumb. Whereas if we had a 12 year old progressing by half a diopter per year in their myopia management treatment, that’s not satisfactory. And so that’s the child where we would look to add, we would think about adding atropine as a combination treatment. So for younger children, we have to expect faster progression.
27:20
it’s really important that we understand what the expectations are. Because if we see any progression and we’re concerned about it, we’re not confident to tell parents that this is a good result, then we’ll actually set ourselves up for just for not being able to do this successfully. So it really depends on, of course, we can get out of answering any question by saying it depends on the individual, but we can use the data that we have.
27:49
from understanding how quickly a child would tend to progress in single vision correction to then make that decision. Is that on par? Is that slower than what we’d expect? Is that faster? And then how might we change things? Now it can depend on the parent too, because even with on par progression, the parent might be concerned, we might reassure them they’re still concerned, we might want to do something extra. And so doing something extra is adding atropine to an optical treatment.
28:17
But also I just want to point out talking about visual environment. You can fit the most beautiful orth OK. You can prescribe the most evidence-based myopi control spectacles. And if the child is spending, you know, five hours a day staring at their screen at 10 centimeters, you know, we’re not going to get what we want. Or if they’re not compliant, we’re not going to get what we want. So it is really important that we consider compliance and visual environment. As well as.
28:46
combination treatments if we’re trying to improve our outcomes. Now, I mean, I think a lot of doctors are choosing spectacle therapy as their first-line treatment, safe, effective. Can you touch on the different technologies, right? We have the DIMMs, we have the HALT technology. Do you have a preference, you know, your sort of perspective on the two technologies?
29:11
So I think your preference should be what you have available to you because the evidence seems to indicate to us that DIMMs, highly aspherical lenslet or HALT technology and diffusion optics technology, dot lenses, they all appear to be similar, at least in terms of our understanding. They haven’t been compared in head-to-head clinical trials. So we have an article on myapiaprofile.com which is enduringly one of the most popular every year.
29:40
which is called the next generation, my AP control spectacles. So it’s dims, halt, dot, and also there’s a new technology called care as well, which has been released in some countries. So I think that’s enduringly popular because in that article, we’ve got a lot of space to go through the similarities and differences in the designs and to talk about efficacy. The bottom line being, they seem to be fairly similar at this point, but the way they’re all similar.
30:08
is that they’re all essentially say a single vision background spectacle lens with a small zone in the middle that is free of the treatment. And that zone might be five millimeters or nine millimeters in diameter, but a central zone. The patient doesn’t have to see through that all the time and move their head around like crazy to use that. It’s in some cases put there to make lens verification a little simpler, but that’s how they’re similar. They’re similar in that they have a surrounding zone of treatment.
30:39
And that might be lenslets or diffusion, but we’ve got that surrounding zone of treatment with across the single vision background lens. But then they different in terms of the optical profile that they are generating or casting on the retina. And so some are using spherical lenslets, some are using a spherical lenslets, some are using diffusion, some are using cylinders just to manipulate higher order aberrations. So we can get into the.
31:06
sort of the nerdy detail of that. I don’t mind a bit of optics, even though it is a Saturday morning, but that’s probably not so appealing to the listeners. I’d point to that article if, you know, if our colleagues want to delve into that further, but we can think of them all, I sort of think of them as a spectacle lens being as good as a contact lens. So the great thing about the optical profile we create from a contact lens is it moves with the eye.
31:35
And so it’s the same in all directions of gaze. And that’s really what’s being attempted. Of course, it’s not exactly the same, but that’s really what’s been attempted and achieved with these myofecal control spectra lenses. That’s so great because I mean, I know nowadays there’s so many options, right? So like you said, it’s really fitting the lifestyle of the patient, the parent, and obviously the environmental factors on top of that. I interacted with somebody one day that showed me an email from an optometrist
32:05
said that I will not treat your child for myopia, you know, with myopia control methods, because there is not enough evidence out there to back that. Once there is enough evidence and there is a consensus amongst, you know, the profession, then only will I start treatment. That was a recent email. So, you know, I didn’t really know there was, you know, such a thought process behind, you know, myopia control.
32:35
you know, are there words that you would express to other optometrists that are listening about the evidence and about it being strong? Is there something you’d want to say to them? So there totally is consensus. The first consensus was published in 2019, which was the International Myopia Institute volume of reports and in particular for clinicians, the clinical management guidelines of which I was the lead author. So there was consensus then that myopia management was a thing.
33:04
And while the way that we would approach it or the treatments we had available has changed enormously since 2019, the guidance there about how to talk about it, candidates, long-term tests that we should do, so clinical tests, long-term management, that all is enduring information that’s been in place since 2019. From the point of view of professional organizations, we have more and more national and international organizations in eye care advocating for my peer management.
33:34
and acknowledging that it must be standard of care, that it’s not enough just to prescribe single vision correction to children with myopia anymore. And so the World Council of Optometry made a resolution of myopia management as standard of care in 2021. The World Society of Pediatric Ophthalmology and Strabismus made a consensus statement in 2023. So it’s really digging our head into the sand to say there isn’t consensus because there is, there’s academic, there’s organisational, there’s professional.
34:02
There’s so much consensus. Now we could always continue to use that explanation or let’s call it an excuse, as long as we want to by saying, we don’t have information for, or evidence for your particular child. Your particular child is minus five with three dark decils. That child isn’t included in any studies. We could say, we don’t have evidence for a five-year-old because a lot of the studies start from age six or seven. Yes.
34:30
we could say we don’t have evidence for 16 year olds, because they don’t tend to be included at the commencement of studies. So that’s always the case. But that’s the case with so many things in medicine. And in eye care that we have a clinical trial, we’ve got absolutely enough evidence to show a robust effect for numerous treatments. We may have patients who fall outside of the norm or the average, but we know that we have something to offer them. And it’s just not standard of care anymore to say,
34:59
We can’t do anything or that we’re going to wait until there’s more evidence because It could be waiting forever if you decide to set your evidence bar up here But there’s a lot of people around the world who are agreeing that the evidence bar has been jumped and that we have to do This is standard of care, right? You touched on the age a little bit there. So, you know, what is the oldest? Child that you know, I don’t even say child doesn’t have to be a child oldest person that you have treated
35:29
for myopia and that you would treat for myopia. Yeah. So if we’re talking about myopia management in terms of slowing myopia progression, we absolutely are clear in the fact that progression is fastest when you’re younger, especially under age 10, and that it tends to slow down in your teens. Around half of my apes will be stable by age 16, but if we stopped myopia control treatment or didn’t offer it for 16 year olds and older,
35:58
then we’d be doing the wrong thing by half of our patients because half are still progressing. And we also know that young myopes into their 20s can progress. So we can have young adult onset of myopia. That happened to me, I’m not a young adult anymore, but I did have young adult onset of myopia when I was studying optometry, ironically. And we can also have progression of myopia in young adults in their 20s, much more so in their 20s than say in their 30s and 40s.
36:28
So if we have started a myopia management treatment, say before age 16 and we’re figuring out when to stop, we ideally want to carry on throughout childhood, if we have the opportunity to do so, and into the first half of the 20s, if possible, to try and cover off that entire likely period of myopia progression. But if I’m seeing a 16 or a 17 year old for the first time and they’ve had no myopia management and they’ve come to me,
36:56
Well, I want to do something proactive, and that’s going to depend on a little bit on their history, on the profile of their risk factors for my AP progression, such as visual environment and family history. And I think anything we do there is with the caveat of saying that we don’t necessarily have the evidence on starting this treatment for 16 year olds now. We have a lot of evidence of how well this works for younger kids, and there’s no reason why we wouldn’t expect it to be safe and well tolerated.
37:26
and to provide us our best chance to slow myopia progression in your child. So if you had a seven-year-old, just say a six-year-old, who you started on myopia control and you chose the method of atropine therapy as the sole method, would you continue that method all the way up until their 20s potentially or their late teens? Yeah, if we have the chance to do so.
37:55
high school, they get to college or university age and they’re starting to think, well, will I keep wearing Orth-AK? Because it’s a bit of a bother. So they want to go out and have a lot of beers and then still, you know, put their lenses in. It’s maybe not as convenient to their life anymore. And from my clinical experience, around half of those young adults who discontinue Orth-AK end up going back into it because they go, well, I can either pick the bother in the morning of, you know, wearing
38:22
specs or contact lenses, or I can pick the bother at nighttime. So I’m just going to pick, pick my bother. You know, being myopic is not just a bother as we’ve talked about, but there are obviously enormous benefits to young adults wearing contact lenses, wearing or theque. If they’re a myopic, they still have to wear their spectacles or contact lenses to see. So we probably want to try and continue them provided they’re not having problems.
38:48
continue them with myopia control treatment to get them through say college and university and up until their mid 20s, which is probably covering off the most likely period of myopia progression. So if somebody is in myopia control glasses, just say, or any method, even if it’s ortho K and they want to switch and it’s an effective method for them. So their progression has slowed down to quarter a year, just say, and they want to switch to
39:16
soft contact lenses for convenience from ortho K or spectacle lenses. What are your thoughts on that? Like, do you feel that sometimes by changing the method, we might run the risk of a myopia increase at that moment? If it’s too soon, 100%. And I know this isn’t the example you’ve described, but there was research to show ceasing kids in ortho K before age 14 led to faster progression, putting them back into spectacles or.
39:45
single vision soft contact lenses. So I think we would do that very carefully, very judiciously. We would also make sure that from a visual function point of view, that that’s working well for them. I’m very into contact lens practice and binocular vision as well. So binocular vision assessment is an important part of every examination for kids and young adults. And in fact, any of my patients which have two eyes, which is hopefully most of them.
40:13
that have two eyes, binocular vision is important because they have two eyes. So I would also think about that because we know that single vision soft contact lenses in my oops, demand a little bit more of the accommodation system compared to OrthoK compared to perhaps some multifocal soft contact lenses, not dual focus, they don’t appear to influence accommodation. So there would be those sorts of factors that we would consider, but we also would be thinking, okay, for that patient,
40:42
What’s convenient for them? What’s working for their lifestyle now? What about cost if that’s potentially an issue as well? So balancing up all of those elements. What about switching from ortho-K and myopia control spectacles to a myopia control soft lens option? So it’s just changing the method of the myopia control. Do you feel there will be a loss of efficacy in the first year or some rebound effects in that first year of switching methods?
41:13
I wouldn’t think so. We don’t have one of the most common questions I’m asked by colleagues, particularly when I’m lecturing to our younger colleagues and new graduates is, can we combine optical treatments as in part-time myopia control, self-contact lenses and part-time myopia control spectacles? And the answer is, we don’t know. No one’s done a study on it, but it makes sense to me that if the child is exposed to a myopia control treatment,
41:41
to the the optical defocus profile that we presume is the Mechanism by which these work and they’re exposed to that effectively full-time Even if that’s three days a week spectacles four days a week contact lenses Then that should work and if we are approaching or utilizing treatments that appear to have similar efficacy Which is most of them we know there are some that are less effective but in terms of those treatments there’s no reason that we would expect to have a rebound or
42:11
a loss of treatment or faster progression. If I did see that in practice, I’d be concerned about compliance. That’d be the first thing I’d be thinking about. Okay, if we switched you from OFK to self-contact lenses and suddenly you’re going, I’m not going to wear them on the weekend. I’m not going to wear them on school holidays. I’m not going to bother, then that’s probably more likely what I’d be suspicious about as an influencing factor.
42:40
Interesting. This is, this has been so great. You know, thank you for all of this information. It’s, it’s wonderful. I think it’s going to really help, you know, all healthcare providers, but especially, you know, optometrists who are getting into and starting myopia control therapy or those that are already into it and want to learn more. So, you know, thank you so much. Can you tell our listeners where they can find you? I know we talked a little bit about myopia profile, but please, you know, go ahead where they can find you.
43:08
Absolutely. So if you want to look at all of the education, articles, courses, clinical resources that we have available, almost all of them are free on myapiereprofile.com. Check out that website. We’ve also developed our public awareness website, mykidsvision.org, which is designed to support you in clinical communication. So it helps to shortcut what can end up being quite lengthy conversations in practice to save you some time.
43:37
If you want to get in contact with me specifically, you can find me on LinkedIn, you can find me on Facebook, we have the MyAPI profile Facebook group, MyAPI profile, LinkedIn profile, Instagram as well. And I’m happy to take DMs and that sort of thing. My email address is Kate at myapiprofil.com and I quite regularly get messages which are along the lines of, I’ve got this patient, or what do you think about this particular approach? You know, those sorts of things I’m happy to help with.
44:06
I pretty much talk, well I do talk about my OPR all day, every day. All day. That is so great. Thank you so much for your time today, Dr. Gifford. Thank you. Thank you for having me. Thank you listeners and viewers for tuning in. If you want to catch more episodes of Uncover Your Eyes, make sure to follow or subscribe on your favorite podcast platform and on YouTube. To learn more about me, follow me on Instagram @Dr.MeenalAgarwal
44:35
until next time, keep those eyes uncovered.