Eyeworld

75 November 2018 EW MEETING REPORTER sion, presenters shared a variety of challenging cases and how they handled them. Carol Karp, MD, Miami, shared a challenging case of diagnosing a tumor. She discussed a 65-year-old white male who was referred for primary acquired mela- nosis (PAM). There were pigmented lesions straddling the limbus, and pigment adjacent nearby. What Dr. Karp particularly noted upon looking closer was subtle opales- cence underlying the pigment on the cornea. Dr. Karp said that when en- countering ocular surface squamous neoplasia (OSSN), you will find normal epithelium and an abrupt transition and thickened hyperre- flective epithelium. After taking a high-resolution anterior segment OCT for her pa- tient, Dr. Karp did notice thickened hyperreflective corneal epithelium and an abrupt transition from normal to abnormal. She noted that this was a case of OSSN hiding in PAM. used in Phase 1: 68% progressed in the 0.5% atropine group, 59% pro- gressed in the 0.1% atropine group, and 24% progressed in the 0.01% atropine group. Based on the ATOM trials, Dr. Tan said that we have learned that atropine eye drops effectively reduce myopia progression and axial elongation in children, even at very low concentrations, but a rebound phenomenon occurs with the higher doses of atropine. He said that atropine eye drops are safe, with no serious adverse events, but in the higher doses, the side effects of pupil dilation, loss of accommodation, and near vision limits practical use. He added that atropine 0.01% had the best therapeutic index, with clin- ically insignificant amounts of pupil dilation, near vision, and accommo- dation loss. Atropine 0.01% appears to retard myopia progression by over 50%, Dr. Tan said, and retreatment after a period of treatment cessation appears to be equally effective. Challenging cornea cases During an EuCornea focus ses- controlling myopia in children. It was initiated in 1999, and the study closed out in 2004. The treatment group received 1% atropine. It was a 3-year study, with 2 years of treat- ment and 1 wash-out year. The bottom line, Dr. Tan said, was that, after 2 years of treatment, we proved that it worked. There was a 77% reduction in mean progres- sion of myopia and strong correla- tion with axial length. However, in year 3, there was significant rebound of myopia progression upon cessa- tion of atropine 1% eye drops. The problem with ATOM1 was the side effects, Dr. Tan said, so the ATOM2 study was undertaken to look at three lower doses of atropine (0.5%, 0.1%, and 0.01%). This study included a treatment phase of 2 years and a wash-out year. After the wash-out year, atropine was start- ed again for those children whose myopia had started to progress again; they were put on atropine for another 2 years, with the 0.01% atropine dose. Dr. Tan noted that it appears that 0.01% atropine is clinically similar to 0.1%, 0.5% and 1.0% in efficacy in the studies. In ATOM2, the rebound phe- nomenon was present only in high- er does, and 0.01% atropine had no rebound, and in fact, ended up with the lowest axial elongation. As far as the safety data for ATOM1 and ATOM2, the most com- mon adverse side effect was allergic conjunctivitis. There was no loss of BCVA; glare was 1% (which was re- covered on cessation of drops); there was no change in IOP; there was no cataract formation; and there was no loss of accommodation or perma- nent pupil dilation after cessation of drops. Dr. Tan noted the percentage of children in ATOM2 who continued to have progressive myopia after the wash-out period related to the original concentration of atropine hypotensive effects but are associat- ed with intense postoperative care and carry the threat of vision-threat- ening complications. New technol- ogies, such as MIGS, demonstrate acceptable clinical results and safety profiles but require randomized con- trolled trials and real-world obser- vational studies. Combined cataract surgery/MIGS has an overall safety profile similar to cataract surgery alone, and cataract alone reduces IOP effectively as well as the reliance on drops for up to 3 years. Howev- er, combined surgery means one procedure, one recovery period, and less anesthetics. Standalone MIGS lacks long-term data, study standard- ization, cost effectiveness data, and has incomplete knowledge of ideal patient selection. Pharmacological prophylaxis in myopia Donald Tan, MD, Singapore, high- lighted studies looking at myopia and using atropine. He first said that interventional approaches to reducing myopia progression in- clude spectacles, contact lenses, and pharmacological agents. Dr. Tan focused his presentation mostly on the ATOM1 and ATOM2 trials, which used different doses of atropine. ATOM1 used 1% atropine vs. placebo in 400 children over 3 years and ATOM2 used different lower doses in 400 children over 5 years. Atropine was originally used to effect accommodation paralysis, and this led to the idea that it could reduce myopia. Atropine 1% eye drops have been available for over 40 years, however, the exact mode of action in myopia control is still uncertain. Atropine also has some ocular and systemic side effects. Dr. Tan went on to describe ATOM1, which was a randomized, double-masked, placebo-controlled study to assess the safety and efficacy of atropine treatment in continued on page 76 View videos from the 2018 ESCRS: EWrePlay.org Warren Hill, MD, discusses the artificial intelligence model for the Hill-RBF formula.

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