14. M V - Non-Sx Correction & Management of Myopia III Flashcards
Atropine is a ... and is ....
It’s mechanism of action is .... It’s direct effect is on 1. ... in the ..., on the ... and on 2. ... and interferes with .... It’s indirect effects are ... and ....
Atropine is a topical, muscarinic (M) receptor antagonist and is non-selective.
It’s mechanism of action is uncertain. It’s direct effect is on 1. muscarinic receptors in the retina, on the amacrine cells and on 2. scleral fibroblasts and interferes with scleral remodelling?. It’s indirect effects are reduced accommodation and altered neurotransmitter release.
Describe the ATOM study and its major findings.
ATOM = ....
Involved # myopic children (...-... years) with spherical refraction ...-...D. It was a randomised, double-masked, placebo-controlled clinical trial and involved ... treatments. Was studying the effects of ...% atropine.
Major results were that ...% topical atropine reduced myopia progression by ...% over ... years compared with ... and ... eyes. There were no ....
Describe the ATOM study and its major findings.
ATOM = Atropine in the Treatment of Myopia.
Involved 400 myopic children (6-12 years) with spherical refraction -1.00--6.00D. It was a randomised, double-masked, placebo-controlled clinical trial and involved monocular treatments. Was studying the effects of 1% atropine.
Major results were that 1% topical atropine reduced myopia progression by 77% over two years compared with control and untreated eyes. There were no serious adverse events.
Atropine cessation
The ATOM study children stopped using atropine and were followed up for ... years.
Results: abrupt cessation seemed to result in an ... over time compared to ... and ... eyes.
Atropine cessation
The ATOM study children stopped using atropine and were followed up for 3 years.
Results: abrupt cessation seemed to result in an increased rate of change of refraction/axial length over time compared to non-treated and placebo eyes.
What are the short-term and long-term ocular side effects of 1.0% atropine?
Short-term: ... due to ..., ... due to ..., and ... and .... Potential effects on ... and ... due to ..., so kids are also prescribed ....
Long-term: ... and increased risk of ... and ...?
What are the short-term and long-term ocular side effects of 1.0% atropine?
Short-term: photophobia due to mydriasis, blurred vision due to cycloplegia, and brow ache and headaches. Potential effects on learning and ability in sporting activities due to cycloplegia, so kids are also prescribed photochromatic PALs.
Long-term: not fully known and increased risk of UV-related retinal damage and cataracts?
Describe the ATOM2 study and its major findings.
Aimed to compare the effects of ...%, ...%, and ...% atropine where the smallest amount was intended as the .... However, it was found that ...% atropine had negligible effects on ..., ..., and ....
Major findings were that ...% atropine suggested efficacy in controlling ... but ... increased compared with ATOM-1 findings, however there was no ....
Describe the ATOM2 study and its major findings.
Aimed to compare the effects of 0.5%, 0.1%, and 0.01% atropine where the smallest amount was intended as the placebo. However, it was found that 0.01% atropine had negligible effects on accommodation, pupil size, and near visual acuity.
Major findings were that 0.01% atropine suggested efficacy in controlling myopic refraction progression but axial length increased compared with ATOM-1 findings, however there was no true placebo/control group.
Describe the LAMP study and its major findings.
LAMP - ...
Assessed 0.01% atropine over ... years to try and determine how low the dose can go to ... but still ... of 0.01% atropine.
Main findings were that there was ... between ...% atropine and ... eye drops.
Describe the LAMP study and its major findings.
LAMP - Low-concentration atropine for myopia progression
Assessed 0.01% atropine over 2 years to try and determine how low the dose can go to minimise side effects but still get the effects of 0.01% atropine.
Main findings were that there was no difference between 0.01% atropine and placebo eye drops.
What are the results of the meta-analysis ...?
Efficacy in Asian vs Caucasian children: both favoured the ....
Adverse effects:
* Photophobia incidence was ...% and ... incidence was ...%, both of which increased as ... increased
* Allergy incidence was ...% and was not significantly increased as ... increased
What are the results of the meta-analysis Atropine, 0.01%, for Myopia Control?
Efficacy in Asian vs Caucasian children: both favoured the control group.
Adverse effects:
* Photophobia incidence was 25% and poor near visual acuity incidence was 7.5%, both of which increased as dosage increased
* Allergy incidence was 2.9% and was not significantly increased as dosage increased
What is the highest dose of atropine that does not produce significant clinical symptoms?
0.02%
With regards to atropine, what should be done in practice?
...% atropine may reduce ... change but does not appear to slow .... The evidence suggests that ...%/...% may be beneficial or even ...% atropine (keeping in mind ...). Although, 12% of ATOM children with ...% atropine progessed >...D in the first year.
Seems to suggest that at risk children may benefit from ... doses during the ... year and then ... as maintenance therapy.
With regards to atropine, what should be done in practice?
0.01% atropine may reduce refractive change but does not appear to slow axial elongation. The evidence suggests that 0.02%/0.025% may be beneficial or even 0.05% atropine (keeping in mind side effects). Although, 12% of ATOM children with 1% atropine progessed >0.50D in the first year.
Seems to suggest that at risk children may benefit from slightly higher doses during the first year and then tapered down as maintenance therapy.
What are the current MEC protocols for atropine?
In kids with ..., ... age of onset, and/or ... axial length start with ...% and ...% in kids with ..., ... age of onset, and/or ... axial length.
Need to review in ...-... days and determine if a ... is required (based on ..., ..., ..., and ...) and if ... lenses might be beneficial (based on ... and ...).
What are the current MEC protocols for atropine?
In kids with fair pigmentation, older age of onset, and/or lower axial length start with 0.025% and 0.05% in kids with darker irides, younger age of onset, and/or longer axial length.
Need to review in 5-7 days and determine if a near add is required (based on near VA, near NPA, MEM, and Phoria) and if photochromatic lenses might be beneficial (based on pupil size and symptoms).
Can atropine be safely stopped to avoid rebound effects?
More significant rebound in younger kids; recommended to continue treatment until at least 12years old and ideally 15-18years old in younger-onset myopes.
What important evidence gaps remain for atropine?
(3 points)
- Mechanism of action?
- When and how to discontinue atropine?
- Combination/transfer of therapy?
Explain the LAMP2 study and its major findings.
Goal: ...
There were 474 children with refraction between ...-...D (on a cycloplegic refraction) who were randomised to 0.05%, 0.01%, and placebo groups. 353 children finished the study where the ... was the following for each group: ...% for the placebo group, ...% for the 0.01% atropine group, and ...% for the 0.05% atropine group.
Explain the LAMP2 study and its major findings.
Goal: to determine if atropine can be used for myopia prevention
There were 474 children with refraction between plano-+1D (on a cycloplegic refraction) who were randomised to 0.05%, 0.01%, and placebo groups. 353 children finished the study where the incidence was the following for each group: 53% for the placebo group, 46% for the 0.01% atropine group, and 28% for the 0.05% atropine group.
Combination treatment for myopia:
OrthoK + atropine 0.01% vs OrthoK alone: ...
Soft MF CLs + atropine 0.01% vs soft MF Cls alone: ...
DIMS + atropine 0.01% vs DIMS alone vs atropine 0.01% alone: ... however ....
However, data is limited to ... month treatment time.
Combination treatment for myopia:
OrthoK + atropine 0.01% vs OrthoK alone: benefit occurs for first six months, and then gradients even out
Soft MF CLs + atropine 0.01% vs soft MF Cls alone: no benefit
DIMS + atropine 0.01% vs DIMS alone vs atropine 0.01% alone: both alone are effective, but together is even more effective however children were allocated to their groups by parents' choice.
However, data is limited to 12 month treatment time.
What is still needed to be understood about combination therapy for myopia control?
(3 points)
Whether different doses of atropine show differential effects?
Whether subsets of patients might be better suited?
When combinations should be used over single?
What is the difference between a ‘listed’ and ‘registered’ therapeutic good and some examples?
Listed = lower risk, e.g. Vitamins, minerals, herbal medicine
Registered = higher risk, e.g. all prescription medicine and most OTC medicine
What does off-label mean?
Prescription of a registered .../... for a use that is .... There are additional ..., ..., and ... considerations. The patient needs ... including ..., ..., and ....
E.g. Atropine for myopia control is off-label because it’s .... OrthoK for myopia control is off-label because it’s ....
What does off label mean?
Prescription of a registered medicine/device for a use that is not included in the product information. There are additional clinical, safety, and ethical considerations. The patient needs informed consent including reason for use, alternatives, and risks vs benefits.
E.g. Atropine for myopia control is off-label because it’s technically listed for dilation of the pupil and accommodation control. OrthoK for myopia control is off-label because it’s listed for myopia correction.
What is Repeated Low-level Red-light Therapy?
Brief exposure (... min), ... per day, ... days per week. ...nm light with luminance ... lux and ...mW for a 4-mm pupil. It is equivalent to a child getting ....
Initial study of 246 kids showed ...mm less change in axial length and ...D less change in refraction. ... was similar in both groups with ....
Follow-up study showed that if RLRL therapy is abruptly ceased in ... children, gradient for axial length and refractive error change is ... compared to not ceasing the RLRL.
One case of ... post-RLRL therapy and VA decreased from 20/20 to 20/..., and then back to 20/... after ... weeks.
What is Repeated Low-level Red-light Therapy?
Brief exposure (3 min), twice per day, five days per week. 650nm light with luminance ~1600 lux and 0.29mW for a 4-mm pupil. It is equivalent to a child getting outdoor exposure.
Initial study of 246 kids showed 0.26mm less change in axial length and 0.59D less change in refraction. BCVA was similar in both groups with no adverse effects reported.
Follow-up study showed that if RLRL therapy is abruptly ceased in Chinese children, gradient for axial length and refractive error change is steeper compared to not ceasing the RLRL.
One case of retinal damage post-RLRL therapy and VA decreased from 20/20 to 20/30, and then back to 20/25 after 2 weeks.
What were the results of the systematic review and meta-analysis regarding the efficacy of RLRL?
Most studies lasted ...-... months and only in ... children. The ... safety and ... are currently not well known. The ... of the light, ... of the test, and ... of the treatment are not well defined.
What were the results of the systematic review and meta-analysis regarding the efficacy of RLRL?
Most studies lasted 6-12 months and only in Chinese children. The long-term safety and rebound effects are currently not well known. The optimal wavelength of the light, power duration of the test, and frequency of the treatment are not well defined.
Outdoor activity and its effect on myopia progression.
... can influence eye growth and ... in eye growth and refractive error progression has been noted.
Associations between less time outdoors and ..., ..., and ... have been found.
Outdoor activity and its effect on myopia progression.
Ambient light exposure can influence eye growth and seasonal variations in eye growth and refractive error progression has been noted.
Associations between less time outdoors and presence, development, and progression of myopia? have been found.
Risk of myopia development - insufficient time outdoors (<... hours/day)
Less time outdoors ... myopia and time outdoors ... of myopia and .... There’s a stronger effect in children aged between ...-... years. Mechanism is unclear; not related to ... or .... The current major hypothesis is ....
When considered as an intervention, outdoor time has ... in eyes that were already myopic.
Risk of myopia development - insufficient time outdoors (<2 hours/day)
Less time outdoors predicts myopia and time outdoors potentially offset parental history of myopia and increased amounts of near work. There’s a stronger effect in children aged between 6-12 years. Mechanism is unclear; not related to physical activity or UV exposure. The current major hypothesis is protective effect via light-stimulated release of dopamine which inhibits axial elongation.
When considered as an intervention, outdoor time has not shown to be beneficial in eyes that were already myopic.
Risk of myopia development - near work
Associations between ... and ... have not been consistently observed. The mechanism was originally thought to be ... but there was also a hypothesised role for ... creating retinal defocus.
Odds of myopia increases by ...% for every ... dioptre-hour more of near work/week. Dioptre hour = 3 x (hours ... + hours ...) + 2 x (hours spent ... or on ...) + 1 x (hours spent on TV).
... while doing near work and a lack of ... after 30minutes is associated with higher risk of myopia progression.
Risk of myopia development - near work
Associations between time spent reading and myopia have not been consistently observed. The mechanism was originally thought to be accommodative effort but there was also a hypothesised role for accommodative lag creating retinal defocus.
Odds of myopia increases by 2% for every 1 dioptre-hour more of near work/week. Dioptre hour = 3 x (hours reading + hours studying) + 2 x (hours spent gaming or on computer) + 1 x (hours spent on TV).
Shorter eye-object distance, <30cm, while doing near work and a lack of 10min break after 30minutes is associated with higher risk of myopia progression.
