Myopia Management: Transformations Over the Past Decade: Part 1
Leanne Liddicoat, OD:
Hello everyone. My name is Dr. Leanne Liddicoat. I am a neurodevelopmental optometrist practicing in Northern California. I’ve been practicing for about 25 years and I am very passionate about myopia management, so I’m excited to be able to have a conversation about that today.
Jennifer Galvin, MD:
Oh, wonderful. Well, nice to talk with you also, Dr. Liddicoat. I’m Dr. Jennifer Galvin. I’m a pediatric ophthalmologist and adult [inaudible 00:00:35] specialist, and I practice in Connecticut. I have a clinical appointment at Yale and I’ve been practicing for about 15 years. And I too am really passionate about myopia management and how much it has really transformed what we can do for our patients and enlightened their parents. Really in the last decade it has been really transformative, not only in the last five years, but certainly the last decade. So this is an exciting opportunity for us to chat.
So one of the things that we were going to talk today is about what kind of the new gold standards are for our practice, as well as what we do for our patients. So I know over the last five years there’s been hundreds, if not thousands, of articles written about the rise of myopia. And we know the global prevalence by of myopia is going to be around 50% by 2050. Certainly it’s at least around almost 35% was recorded in 2020. And one of our concerns not only for what our children and teens or experiencing now, is what they could experience in the future in terms of the secondary effects of high myopia that they may have because of the genetics of their family history. So they could be just more at risk for glaucoma, cataracts, retinal detachment, myopia maculopathy. So what are the latest clinical statistics regarding myopia in children? That’s one of the things that I have read recently. And then wanted to talk briefly about the LAMP2 study that came out in February, but it certainly is a helpful tool to know what’s going on in terms of the literature and then how it applies to our patients.
Leanne Liddicoat, OD:
Well, certainly myopia is a steadily growing epidemic worldwide, which is why the both of us are so concerned. In 2020, it was about 30% of children in the US that had myopia. By 2021 that jumped to 36%. Now we’re probably, specifically in the children’s age range, closer to 42%. And as you mentioned, by 2050 it’s projected to be 50% of the world’s population. In some parts of the world, it is approaching 90%, and those are primarily East Asian communities. But going back to the US, we have over 19 million children with myopia today. So this certainly deserves our attention.
Jennifer Galvin, MD:
Yeah. No, that’s exactly correct. I agree with you. And then I think one of the things that has been ongoing that we’ve been able to incorporate in our practice, both of us in different ways, is the results from the ATOM studies, ATOM2, LAMP, and now most recently in February that was published in JAMA is the LAMP2 study to show that actually the 0.05% dilute atropine when they compared it to 0.01% in placebo, that higher dose 0.05% actually showed a delay or perhaps a prevention of the progression of myopia in a over two years time in children who are non-myopic four to nine years old. So that’s helpful for us to know that how we’re almost going to perhaps pretreat the children who have a strong family history or reconsider how we’re treating the children that are already low myopes or moderate myopes that may be still progressing over a different dilution level of dilute atropine. That’s one aspect of something that’s definitely worth talking about, the dilute atropine.
Leanne Liddicoat, OD:
Also of note is a study that was just published earlier this year, the CHAMP study. Dr. [inaudible 00:05:09] is likely to be presenting that at ARVA this year.
Jennifer Galvin, MD:
Yes.
Leanne Liddicoat, OD:
Really looking at efficacy, but also safety. Even though we’re talking about very dilute concentrations of atropine, still we’re using this in a young population. And that is the first study that looked at the safety profile over three years. A lot of our studies before that were a two-year timeframe. And it was just really encouraging and reassuring to know that the side effects were minimal and that over that three year study that it was in fact a safe medication to use. Now they looked primarily at the 0.01 and 0.02 concentrations.
Jennifer Galvin, MD:
Yes.
Leanne Liddicoat, OD:
And in my practice, I do use those two concentrations primarily. I will occasionally use the 0.05, but I use something in that range typically.
Jennifer Galvin, MD:
Yeah. No, I agree that what you’re talking about, the CHAMP trial that just came out in JAMA in June, JAMA ophthalmology, Biluma being the preservative free and the efficacy and safety profile that has never been shown before, but it was able to be really solidified by this study. And as you mentioned, they even looked in a wider range of children from age three to 16. There are 26 sites in North America, five in Europe. So the CHAMP trial is very important for us as clinicians, because it talked about reducing the myopia progression and the axial length elongation versus placebo. And as both of us know as clinicians, the most common dose to give in general is 0.01%. So knowing about the efficacy and safety in a preservative-free presentation now known as Biluma, that was very reassuring to know. I agree with you. And I think most parents and clinicians are looking for something that’s FDA approved. And we’re not there yet, but this is one step closer.
And as a note, there was a wide range of the refractive error from -0.5-6 in that CHAMP trial. So the CHAMP trial is very important for clinicians to be aware of, as well as parents. So it’s very encouraging. I agree. One of the things is that I know not every clinician, whether you’re an ophthalmologist or optometrist, who are passionate about myopia management uses a axial links as a guideline. I do. I do that every year. And one of the things is that it’s not always reimbursed. I know that often that is something that I think the practice that you’re in can address that even if it’s not reimbursed by insurances, it’s still important to do so. Whether that is a cost that is out of pocket or a fee that you absorb as the clinician. I still think it’s something that should be done. And then to put the cost factor in a separate category, but as long as we’re doing myopia management, I don’t think we should just base it off of the vision and refractive [inaudible 00:08:38]. I don’t know if you agree, Dr. Liddicoat. It’s something that is not a hot topic, but something of debate amongst some of the pediatric ophthalmologists.
Leanne Liddicoat, OD:
Well, at this point, I don’t think that we can ignore axial length. There have been studies that have shown length progression being more correlated to future pathology than even refractive error. It’s also important, since we are looking at a population of patients that are younger, having objective data is critical. Variability exists with subjective refraction, both in the technique and the instrumentation. And while that is certainly a piece of our puzzle, having objective data for us to look at such as axial length, in my opinion, is a necessary component of myopia management.
Jennifer Galvin, MD:
Yeah, I totally agree with you. It’s important for us to bring up, just because of the very fact that I know with some of my own colleagues, even though they may have the machinery because they have colleagues that do cataract surgery, they have that IOL master, but it is very critical as long as we are going to start something to either prevent myopia or prevent its progression because our patients already have myopia. Like you mentioned, it’s a very important piece of the puzzle because we don’t even know all of the answers yet, and even the true mechanism of action for the dilute atropine, even though we know that it’s been now shown to have efficacy and safety in certain dilution levels. But yeah, I agree with you entirely. And often it’s very important as a baseline because there could be mild asymmetry for not only the vision, but the refraction itself. And if there’s myopia astigmatism in one eye, but a lower level in the other, I find axial length is a very helpful data point to monitor.
Leanne Liddicoat, OD:
And what’s also exciting about axial length data, and it’s still coming in, but as you know, it varies by age and gender and ethnicity. And we’re starting to collect a reasonable amount of data of normal rates of axial length growth by those factors. And what’s so exciting is that has become a critical part of educating parents. They’re somewhat used to growth curves from bringing their child to the pediatrician. And being able to have a curve where I can show them by age, by gender, by ethnicity, this is the normal amount of growth of the eye. Here’s your child and here’s the trajectory. Here’s where they’re looking at landing. Then that sort of ushers in a conversation about the types of pathology that are associated with higher levels of myopia. So I go all the way back to axial length and think that that’s another important way that we use that information in terms of parent education.
Jennifer Galvin, MD:
Yeah, I agree. That’s an excellent point, Dr. Liddicoat. That’s excellent. And in addition to the monitoring of how the length of the eye is growing, as well as the refraction and the levels of the dilution, I also use the dilute atropine, that’s 0.01%, as well as 0.05%. I have found, like many, that often 0.05% does have more side effects in my patient population than the 0.01%, but often not every child experiences that, but that’s something that is a conversation piece that I have with the parents. So that’s something important to point out. What are you finding in California in terms of side effects versus one dilution level or the other for dilute atropine treatment?
Leanne Liddicoat, OD:
Sure. Sure. So at the 0.01% and the 0.02%, it’s almost negligible. I have been very, very happy with the lack of side effects. Now, one thing we do is we do scotopic and photopic pupil size with our atlas topographer. So if a child … some of my patients might be ruled out of atropine if they had a really large pupil size to start with. So I don’t know, that might be affecting my results a little bit, but I will have to share with you, even though I have a much smaller percentage of patients on the 0.05%, I really have not had to prescribe progressives or transitions or any of those things. I do maybe have a few patients mentioning light sensitivity, but I haven’t, other than saying, “Well, you need to be wearing your sunglasses while you’re outside anyway,” just encouraging them to do that has been more than adequate to manage that.
Jennifer Galvin, MD:
Yeah. No, that’s very encouraging to hear. I did have literally just a handful of patients that are 0.05% that did have the severe light sensitivity. And we had to, because we didn’t want them to stay indoors for things like recess or outdoor gyms, to go back to the 0.01%. But these were even children that were changed not only based on the literature that was presented, but their level of progression and very strong family history. So the thought was to try to help them with the progression even more aggressively, but the great news is that a hundred percent of those patients have been able to tolerate 0.01%, but there are just a handful of those and they just have more light sensitivity overall in their pigmentation of their iris and retina. So that’s very encouraging overall.
