Aug. 12, 2020

Myopia Management Journey - E4

Myopia Management Journey - E4

Myopia Management Journey - E4

Dimple Veiling on a First Day Follow-up

This was an incredibly fun and educational week for me in my quest to start a myopia management clinic and become a bonafide “expert” in the field. One step at a time my friends. To begin, I had my first day 1 follow-up. I had the patient wear the retainers on Friday night and come in at 7:30am (per her request) the next morning. She wore the lenses in and after a quick over refraction, we went to the slit lamp. The right eye looked great, textbook pattern, and then we moved to the left eye. Perplexed was a mild way of describing how I felt. She had dimple veiling (a broken up air bubble under the lens) and it was dead center of the lens. Upon lens removal, there was heavy fluorescein staining in the left eye.  I have never seen this (generally it occurs with GP lens wear and usually it's in the periphery), so it threw me for a loop. Her VA was not great and the rings on her topography scans were quite distorted. I told her to wait on wearing them a second night and we would touch base with the lab on monday. 

Saturdays and Murphy's Law

Needless to say, I was kicking myself for having the follow-up on a Saturday when I couldn't consult my lab and I was determined to find some answers. After about 3 hours of research and a few online webinars, I was feeling much more comfortable. I know the patient very well and texted her to confirm that her vision had cleared up (it should clear 1-2 hours after lens removal) and to follow-up with me again on Sunday. 

Everything had cleared up on Sunday and she confided that Friday night she had worn the lenses quite a bit while awake before going to bed and obviously had needed them to drive into the office on Saturday. I figured the combination of things may have caused the dimple veiling. She wore them through the weekend and I consulted with my lab (Art Optical) Monday morning.

Get a Great Lab and Use It

Art optical has been amazing at guiding me in the fitting process and walking me through how to utilize my Medmont topographer and analyze scans. The topographer came highly recommended, but training and customer service has been lacking to put things kindly. Regardless, after analyzing her data we concluded both lenses were riding a little flat and we redesigned both lenses. A 1 degree reduction to the alignment zone would hopefully center the treatment zone on her pupils and decrease sag to eliminate any more air bubbles in the treatment zone. At her 1 week follow up and after just 1 day of wearing the redesigned retainers, the patient who started at a -5.25 OU was -0.25 OD and reading 20/15 uncorrected and -2.00 OS reading 20/80 uncorrected. I am very curious what the weekend will bring in regards to the left eye. My fingers are crossed, but I am having so much fun. This is definitely the higher level of care I have been searching for to keep me motivated and excited about my work.

Myopia Management Consultation

Additionally, I had my first actual myopia management consultation with a set of parents. It went really well and I found that giving a 30,000 ft view of myopia management as a whole and speaking about issues directly associated with the child's situation was beneficial. The best thing to come out of it were the questions a parent may ask that you did not fully prepare for. There were 2 that stood out. 1. What therapy is most effective. And 2. What happens when therapy is concluded.

To be honest, I had number 1 pretty well thought out in my preparation. Depending on the therapy and study you can expect to see a 30-60% reduction in progression. Obviously compliance plays a major role. Whether it's atropine, ortho-k, or soft contacts, if compliance is poor, the results will be as well. So, picking the option that all parties are most comfortable with is crucial. I do think that the doctor has to have a recommendation that they think is best in the case of the patient and make that known, which I did. We are the experts and should act as such taking the patient's/parents concerns into consideration. In regards to question number 2, I was not prepared and gave a roundabout answer. As you can imagine, I instantly went home and found answers that I will use going forward. In regards to atropine, higher doses of the drop saw quite a large rebound effect and myopic progression once treatment stopped. Lower doses, such as 0.01% saw less rebound, but has the least effect on axial length. In regards to orthokeratology, Paulaine Cho’s studies showed that in children under 14 years old, there is some rebound after 7 months, but this is in line with what is expected at that age. That is you get an initial reduction, and it will pick back up where it left off. However, that initial reduction will reduce their overall myopic Rx and axial length. The 7 year results from the MiSight study are still being gathered, so we will wait and see.

All in all it was a great week in myopia management!

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