Myopia control in Russia

Myopia control in Russia – it’ll terrify you!

Recently I’ve been putting together my lectures for the upcoming New Zealand Association of Optometrists conference in Auckland. It’s this Friday 17th to Sunday 19th October and I’m really looking forward to visiting NZ for the first time. Aside from a lecture on Binocular Vision, I’ll also be delivering two one-hour lectures on myopia – one a literature review of myopia control, and the second on best practice myopia management. It was in researching data for the former that I came across some weird Russian stuff.

I was googling the incidence rates of myopia across the world. With a world map image on my slide, and percentage rates sitting over the USA, England, Western Europe, South Africa, the Middle East, a few Asian Countries and of course Australia and NZ, I got wondering about that enormous land mass on the top right of my slide. I’d had a brief distraction with the top left of the world map – it turns out that myopia in indigenous Greenland Inuit youth is on the rise, recently reported as 68%, and their population hasa higher than average incidence of angle closure glaucoma. And did you know the population of Greenland is only 56,000? I certainly didn’t. Anyway, back on track, Russia.

Alarm bells started ringing when I stumbled upon a website promoting ‘Excimer KIDS Clinic’. Whew, it’s not quite what you think it is – laser correction for kids – but it’s just as scary. The webpage I was reading entitled ‘Myopia in children’ starts out reasonably enough, stating that for myopia progression of no more than 0.5D per year, ‘conservative treatment methods are used’. These include glasses, eye exercises, and recommendations on sleep and visual hygiene. But then, if you are are relatively stable young Russian myope, you can also have access to ‘various therapeutic solutions’ including ‘ultrasonic and infrared laser therapy, laser stimulation, vacuum massage, magnetic therapy, electric stimulation.’ Ok, this is starting to scare me, despite the fact that the ‘effectiveness [of these treatments] is acknowledged both in Russia and internationally.’1

It goes to show how information asymmetry between patient and practitioner can be dangerous – our patients have to be able to trust that we are providing evidence based advice. Surely these frightening-sounding interventions aren’t supported by the scientific literature. I was in for more surprises…

These treatments appear to be backed by published Russian literature, based around theories of myopigenesis due to ‘systemic connective tissue dysplasia and impaired circulation due to autonomic dysfunction.’2 Such treatments include infrared laser therapy, ‘vacuum massage’ and electrim stimulation to stimulate ciliary muscle function and ‘relieve accommodative spasm’ through such mechanisms as ‘better nutrition of eye tissues’, improved ‘eye hydrodynamics and blood circulation’ and ‘optic nerve impulse conductivity.’1

Electroacupuncture has been demonstrated to slow3 and halt4 myopia progression in Russian children. Unfortunately I’m unable to access the full text versions of these papers as they’re not available in English, but I feel the abstracts are terrifying enough. One paper describes ‘transconjunctival electrophthalmostimulation (TEOS)’ as halting progression of myopia in all but 15% of cases over five years. TEOS showed a positive effect for improving acuity and accommodative function in myopes of less than 1.50D, but little effect in moderate or high myopes, and not surprisingly the eyeball got hotter by 10C during treatment, indicating ‘activation of blood supply and metabolic processes under the effect of TEOS.’5 This theme is continued in a paper citing ‘trans-scleral infrared irradiation of the ciliary muscle’improving accommodative function in 7-16 year old myopes. These treatment effects are cited as transient, so recommendation is that they are repeated annually.5,6

There are cases made for establishment of ‘school oculists’ room’ to allow for widespread implementation and access to ‘early diagnosis and correction of autonomic dysfunction [as the basis for] prevention and treatment of school myopia.’2 If you think this is scary, wait…there’s more.

If your child progresses by 1D or more per year, you are recommended to consider ‘scleroplasty’, which is ‘used to strengthen the posterior segment of the eye sclera and activate eye layer metabolism’.1 Delving into the literature on this shows that this form of scleral buckling is accepted in the international literature for highly myopic eyes with vitreo-macular tractional changes and posterior staphyloma.7-9 This is the whole reason to be cognisant of active myopia management in optometric practice – to avoid these types of pathological sequelae. For control of progressive myopia, though, scleral reinforcement has generally been discredited after its advent several decades ago, and persists only in Eastern Europe and some parts of Asia. The exception is one study published in Eye (UK) Journal which challenges the prevailing sentiment in demonstrating that this surgery performed on pathologically progressing adult myopic eyes of at least 9D resulted in axial length control compared to untreated fellow eyes over five years.7

Adults, that is. A response to this paper from a Russian author in 2010 described use of scleroplasty for progressive myopia, citing a 95% control effect but without specific data on patient age, refraction or follow up period. I started to get scared again when I read that these authors’ cited criteria for this form of scleral grafting from only 5-6D, or with ‘an increase in dystrophic changes in the retina and vitreous body, even when there was no increase in the degree of myopia’.9 Paediatric scleroplasty for myopia is further supported by Eastern European authors.10

I’m a little off the topic of optometric management of myopia now but I really fell down a nightmarish rabbit hole there. There will always be a tension between evidence based practice and clinical pioneering – anecdotal experience frequently directs novel clinical techniques or management approaches that eventually are backed by the literature. Common sense and reasonable justification to your peers are essential litmus tests for the clinical pioneer – unfortunately these unusual myopia treatments range from kooky to downright dangerous. And yet we still have many colleagues concerned that the risks of fitting OrthoK or soft multifocal lenses outweigh the benefits in progressing myopes. In fact, the lifetime risks of myopic pathologies such as myopic maculopathy, cataract, glaucoma and retinal detachment frequently outweigh the immediate concerns of contact lens infection – for more on this, see the editorial I’ve recently written for Contact Lens and Anterior Eye Journal12 or read my blog post entitled Which is more likely – microbial keratitis or retinal detachment? There’s no doubt that we should all be doing something for our progressing myopic patients – single vision correction just isn’t evidence based any longer – but I think I’ll be sticking with Orthok, soft multifocal lenses, managing binocular vision disorders and advising on lifestyle changes, and will leave the electric shock therapy to our overseas colleagues.  Sheesh, that was terrifying!

REFERENCES

  1. The Excimer Eye Clinic – Russia. http://en.excimerclinic.ru/babyvision/kidsmyopia
  2. Volkova LP. Prevention of myopia in children. Vestn Oftalmol 2006;122:24-7.
  3. Neroev VV, Chuvilina MV, Tarutta EP, Ivanov AN. Reflex therapy, massage, and manual therapy in the treatment of progressive myopia in children and adolescents. Vestn Oftalmol. 2006;122:20-4.
  4. Valkova IV, Niurenberg O. Use of electroacupuncture reflexotherapy in myopia. Vestn Oftalmol. 1989;105:33-5.
  5. Okovitov VV. Transconjunctival electrostimulation of eye in pathogenetic therapy of progressive myopia. Vestn Oftalmol. 1997;113:24-6.
  6. Anikina EB, Shapiro EI, Gubkina GL. Use of low-energy laser irradiation in patients with progressive myopia. Vestn Oftalmol. 1994;110:17-9.
  7. Ward B, Tarutta EP, Mayer MJ. The efficacy and safety of posterior pole buckles in the control of progressive high myopia. Eye 2009;23:2169-74.
  8. Zhu Z, Ji X, Zhang J, Ke G. Posterior scleral reinforcement in the treatment of macular retinoschisis in highly myopic patients. Clin Exp Ophthalmol 2009;37:660-3.
  9. Müller B, Joussen AM.  Myopic traction maculopathy – vitreoretinal traction syndrome in high myopic eyes and posterior staphyloma. Klin Monbl Augenheilkd. 2011;228:771-9.
  10. Balashova NV, A Ghaffariyeh A, Honarpisheh N. Scleroplasty in progressive myopia. Eye 2010;24:1303.
  11. Gerinec A, Slezakova G. Posterior Scleroplasty in children with severe myopia. Bratislava Med J 2001;102:73-8.
  12. Johnson KL. Are we myopic about myopia control? Cont Lens Anterior Eye 2014;37:237-9.

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