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Early Detection and Treatment of Progressive Myopia
Mark Rallo, OD, discusses early detection and treatment of Progressive Myopia and when it is important that a pediatrician refer to a specialist.
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Learn more about Mark Rallo, OD
Mark Rallo, OD
Mark Rallo, OD focuses his practice on pediatric eye care.Learn more about Mark Rallo, OD
Transcription:
Early Detection and Treatment of Progressive Myopia
Melanie Cole, MS (Host): Welcome. Our topic today is early detection and treatment of progressive myopia. My guest today is Dr. Mark Rallo. He’s a Washington University pediatric optometrist at St. Louis Children’s Hospital. Dr. Rallo, explain a little bit about progressive myopia. What is it?
Mark Rallo, OD (Guest): So, let me explain first of all what myopia is. It’s also known as nearsightedness for the lay folks. Myopia is a condition in which an individual has difficulty seeing at distance. So, they may have trouble seeing the board at school, reading street signs, that type of thing. Progressive myopia is a little bit of a different animal in that it’s an excessive amount of nearsightedness. So typically, what causes nearsightedness is either the length of the eye is excessive, or the curvature of the cornea is excessive. So, light focuses somewhere in front of the retina instead of directly on the retina. So, again, progressive myopia is just an extreme case of myopia or nearsightedness. So that’s really what we’re focusing on at this time.
Melanie: When does it become apparent? What’s the clinical presentation of progressive myopia?
Dr. Rallo: Sure. So, I would say most cases, it’s early childhood. Maybe in that eight to ten-year range. Although, some people develop it as teenagers and there are even adults that sometimes don’t develop it until maybe their 20s. But typically, it’s gonna happen in, I would say, the latter part of the first decade of life or the early part of the second decade of life. One of the common things that parents can detect early on is that their child may have difficulty seeing. So, they may get closer to the TV than normal or teachers may be aware in the classroom setting that a child seems to be having difficulty seeing the board. One of the surest signs that there may be an issue is that the child may squint in order to see clearly.
Melanie: Is this a genetic condition doctor?
Dr. Rallo: Genetics can play a role. Although, the more we learn about myopia, and particularly progressive myopia, we’re starting to realize that environmental factors are probably more of a factor that we initially thought. In terms of genetics, when we look at families who have children who are diagnosed with myopia, one of the things I will ask is do either of the parents wear glasses or contact lenses? If so, are they also myopic? Statistics show that if one of the two parents is myopic, each of their children has about a 15% chance of myopia as well. That number jumps to almost 44% if both parents are myopic. So, we definitely know there is a genetic link, but I think, as I said earlier, we’re now realizing there are environmental factors that can also play a role.
Melanie: Tell us about the goal of treatment? Are there some complications if it’s let untreated?
Dr. Rallo: Sure. So, for regular myopia, it’s typically eyeglasses, contact lenses, and, of course, nowadays we have to talk about refractive surgery. Things like Lasik. And of course, with any type of surgery, there are going to be risk complications associated with it. In terms of contact lenses, you can have infections as a result of contact lens wear, particularly if they're abused. Or there can be ocular irritation associated, particularly if there’s an underlying dry eye issue. Certainly, there are risks associated with those activities.
Now, with progressive myopia, there have actually been a couple of studies previously. One was called the ATOM study. Currently, we actually are getting just about ready to get involved with what’s called the CHAMP study. We’re very excited to be a part of this. It stands for Children Using Atropine for Reduction of Myopia Progression. One of the things that we’re going to be utilizing is low dose atropine that will be put in the child’s eye over a period of time. This has been shown in previous studies to slow the progression down.
Early on when this ATOM study was being done, one of the issues was the dosing of atropine was causing blurred vision. It was also causing potential issues such as tachycardia or increased heart rate. There are behavioral changes that can sometimes be associated with this. Facial flushing and so forth. So, there can be some issues with atropine as well. One of the nice things is with the latest study, the CHAMP study, is we’re going to be using very low dose atropines. So, the effects of light sensitivity or blurred vision is going to be minimized as well as some of those other potential side effects I just mentioned.
Melanie: So then, okay so you’ve mentioned the atropine and the medicational intervention. What other modalities and have they been FDA approved the slow the progression? There’s a little bit of controversy going on with the treatments and whether or not they’re effective to slow this progression. Am I correct with this?
Dr. Rallo: You are correct. So, there are certainly physicians who are concerned about how effective is the use of atropine in decreasing the rate of which myopia progresses. I think some of these same doctors are wanting to know, okay there’s no long-term data. So, what do we really know about this treatment? It is an off label us, as you mentioned. The other thing that I would bring up at this point is that there are alternative therapies that have been tried in the past. Some have had some benefit for these individuals with progressive myopia, including the use of bifocals, multifocal contact lenses. There is a treatment called orthokeratology, which utilizes rigid gas permeable contact lenses during overnight treatment.
More recently, and as I said earlier, there are certainly flags that are starting to come up with regards to environmental factors. So, one of the things that is really being talked about is exposure to outdoor lighting. The fact that kids aren’t outdoors as much. This could be a factor in this as well. Even more recently that people are bringing up what is the effect of processed foods and the intake of these foods. So, there is a lot of discussion. Unfortunately, we don’t have an absolute answer at this point, but I think certainly we’re on the right track.
Melanie: When do you think it’s important that a pediatrician refer to a specialist such as yourself?
Dr. Rallo: So, I think one of the nice things is the pediatricians are doing these early screenings on children. They have devices that are now available including things like plus optics. So, they're able to detect if a child has significant degrees of refractive such as nearsightedness or farsightedness or even astigmatism. So, it’s very nice because there is a criteria for referral. So, they know pretty much right away after this test is done whether a child needs to be seen. Of course, screenings are just that. They're not perfect. So, we’re happy to see these children if there is a failed screening. With most things, the earlier the intervention the better.
Melanie: So, what would you like other providers to know about progressive myopia? Not only when it’s important to refer, but what they can expect from a referring physician from the ophthalmology team at St. Louis Children’s Hospital.
Dr. Rallo: Sure. So, the first thing, we’re obviously going to do a comprehensive eye exam including dilation on a child who has myopia. One of the things that we’re going to be keen on is the health of the retina. So, as I mentioned very early on, myopia and particularly progressive myopia there is an excessive lengthening on the eye. The concern we have is that this can actually cause some stretching and ultimately some thinning of the retina. So, this puts these individuals who are highly myopic at risk for retinal detachment. They can also develop a form of macular degeneration called myopic macular degeneration. In fact, they can also be at a high risk of developing things like cataracts and glaucoma.
So, we put these children through extensive testing. Certainly, we follow them up on a regular basis at least annually and in some cases, we may even see some of these kids every six months depending on just how fast the progression of the myopia is occurring. As I said, we haven’t actually started our inclusion in the study as of yet. But once we do, we will certainly offer parents the option of low dose atropine to see if we can't maybe slow that progression down and maybe help prevent some of these potential long-term complications.
Melanie: Thank you so much for joining us and explaining it and sharing your expertise. It’s really great information doctor. Thank you again. Dr. Rallo will be presenting progressive myopia in more detail during the October 26th and 27th fall clinic pediatric update for CME credits. To register or to refer a patient, call children’s direct physician access line at 1-800-678-HELP. That’s 1-800-678-4357. You're listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to stlouischildrens.org. That’s stlouischildrens.org. This is Melanie Cole. Thanks so much for listening.
Early Detection and Treatment of Progressive Myopia
Melanie Cole, MS (Host): Welcome. Our topic today is early detection and treatment of progressive myopia. My guest today is Dr. Mark Rallo. He’s a Washington University pediatric optometrist at St. Louis Children’s Hospital. Dr. Rallo, explain a little bit about progressive myopia. What is it?
Mark Rallo, OD (Guest): So, let me explain first of all what myopia is. It’s also known as nearsightedness for the lay folks. Myopia is a condition in which an individual has difficulty seeing at distance. So, they may have trouble seeing the board at school, reading street signs, that type of thing. Progressive myopia is a little bit of a different animal in that it’s an excessive amount of nearsightedness. So typically, what causes nearsightedness is either the length of the eye is excessive, or the curvature of the cornea is excessive. So, light focuses somewhere in front of the retina instead of directly on the retina. So, again, progressive myopia is just an extreme case of myopia or nearsightedness. So that’s really what we’re focusing on at this time.
Melanie: When does it become apparent? What’s the clinical presentation of progressive myopia?
Dr. Rallo: Sure. So, I would say most cases, it’s early childhood. Maybe in that eight to ten-year range. Although, some people develop it as teenagers and there are even adults that sometimes don’t develop it until maybe their 20s. But typically, it’s gonna happen in, I would say, the latter part of the first decade of life or the early part of the second decade of life. One of the common things that parents can detect early on is that their child may have difficulty seeing. So, they may get closer to the TV than normal or teachers may be aware in the classroom setting that a child seems to be having difficulty seeing the board. One of the surest signs that there may be an issue is that the child may squint in order to see clearly.
Melanie: Is this a genetic condition doctor?
Dr. Rallo: Genetics can play a role. Although, the more we learn about myopia, and particularly progressive myopia, we’re starting to realize that environmental factors are probably more of a factor that we initially thought. In terms of genetics, when we look at families who have children who are diagnosed with myopia, one of the things I will ask is do either of the parents wear glasses or contact lenses? If so, are they also myopic? Statistics show that if one of the two parents is myopic, each of their children has about a 15% chance of myopia as well. That number jumps to almost 44% if both parents are myopic. So, we definitely know there is a genetic link, but I think, as I said earlier, we’re now realizing there are environmental factors that can also play a role.
Melanie: Tell us about the goal of treatment? Are there some complications if it’s let untreated?
Dr. Rallo: Sure. So, for regular myopia, it’s typically eyeglasses, contact lenses, and, of course, nowadays we have to talk about refractive surgery. Things like Lasik. And of course, with any type of surgery, there are going to be risk complications associated with it. In terms of contact lenses, you can have infections as a result of contact lens wear, particularly if they're abused. Or there can be ocular irritation associated, particularly if there’s an underlying dry eye issue. Certainly, there are risks associated with those activities.
Now, with progressive myopia, there have actually been a couple of studies previously. One was called the ATOM study. Currently, we actually are getting just about ready to get involved with what’s called the CHAMP study. We’re very excited to be a part of this. It stands for Children Using Atropine for Reduction of Myopia Progression. One of the things that we’re going to be utilizing is low dose atropine that will be put in the child’s eye over a period of time. This has been shown in previous studies to slow the progression down.
Early on when this ATOM study was being done, one of the issues was the dosing of atropine was causing blurred vision. It was also causing potential issues such as tachycardia or increased heart rate. There are behavioral changes that can sometimes be associated with this. Facial flushing and so forth. So, there can be some issues with atropine as well. One of the nice things is with the latest study, the CHAMP study, is we’re going to be using very low dose atropines. So, the effects of light sensitivity or blurred vision is going to be minimized as well as some of those other potential side effects I just mentioned.
Melanie: So then, okay so you’ve mentioned the atropine and the medicational intervention. What other modalities and have they been FDA approved the slow the progression? There’s a little bit of controversy going on with the treatments and whether or not they’re effective to slow this progression. Am I correct with this?
Dr. Rallo: You are correct. So, there are certainly physicians who are concerned about how effective is the use of atropine in decreasing the rate of which myopia progresses. I think some of these same doctors are wanting to know, okay there’s no long-term data. So, what do we really know about this treatment? It is an off label us, as you mentioned. The other thing that I would bring up at this point is that there are alternative therapies that have been tried in the past. Some have had some benefit for these individuals with progressive myopia, including the use of bifocals, multifocal contact lenses. There is a treatment called orthokeratology, which utilizes rigid gas permeable contact lenses during overnight treatment.
More recently, and as I said earlier, there are certainly flags that are starting to come up with regards to environmental factors. So, one of the things that is really being talked about is exposure to outdoor lighting. The fact that kids aren’t outdoors as much. This could be a factor in this as well. Even more recently that people are bringing up what is the effect of processed foods and the intake of these foods. So, there is a lot of discussion. Unfortunately, we don’t have an absolute answer at this point, but I think certainly we’re on the right track.
Melanie: When do you think it’s important that a pediatrician refer to a specialist such as yourself?
Dr. Rallo: So, I think one of the nice things is the pediatricians are doing these early screenings on children. They have devices that are now available including things like plus optics. So, they're able to detect if a child has significant degrees of refractive such as nearsightedness or farsightedness or even astigmatism. So, it’s very nice because there is a criteria for referral. So, they know pretty much right away after this test is done whether a child needs to be seen. Of course, screenings are just that. They're not perfect. So, we’re happy to see these children if there is a failed screening. With most things, the earlier the intervention the better.
Melanie: So, what would you like other providers to know about progressive myopia? Not only when it’s important to refer, but what they can expect from a referring physician from the ophthalmology team at St. Louis Children’s Hospital.
Dr. Rallo: Sure. So, the first thing, we’re obviously going to do a comprehensive eye exam including dilation on a child who has myopia. One of the things that we’re going to be keen on is the health of the retina. So, as I mentioned very early on, myopia and particularly progressive myopia there is an excessive lengthening on the eye. The concern we have is that this can actually cause some stretching and ultimately some thinning of the retina. So, this puts these individuals who are highly myopic at risk for retinal detachment. They can also develop a form of macular degeneration called myopic macular degeneration. In fact, they can also be at a high risk of developing things like cataracts and glaucoma.
So, we put these children through extensive testing. Certainly, we follow them up on a regular basis at least annually and in some cases, we may even see some of these kids every six months depending on just how fast the progression of the myopia is occurring. As I said, we haven’t actually started our inclusion in the study as of yet. But once we do, we will certainly offer parents the option of low dose atropine to see if we can't maybe slow that progression down and maybe help prevent some of these potential long-term complications.
Melanie: Thank you so much for joining us and explaining it and sharing your expertise. It’s really great information doctor. Thank you again. Dr. Rallo will be presenting progressive myopia in more detail during the October 26th and 27th fall clinic pediatric update for CME credits. To register or to refer a patient, call children’s direct physician access line at 1-800-678-HELP. That’s 1-800-678-4357. You're listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to stlouischildrens.org. That’s stlouischildrens.org. This is Melanie Cole. Thanks so much for listening.