Pathological Myopia and how it can effect CL Rx

Pathological myopia

1. Pathological Myopia By Kory Locken CLS 775 - Contact Lens Grand Rounds https://reviewofmm.com/wp-content/uploads/2019/08/GettyImages-648039158-768x619.jpg

2. Case Report: Part 1 Patient summary https://reviewofmm.com/wp-content/uploads/2019/08/GettyImages-648039158-768x619.jpg

3. Profile 38-yo Asian American Female Occupational Therapist September 2022: Presented to KH for problem focused exam

4. HPI CC: itchy eye Location: OD Quality: improving Severity: 4 of 10 (6 at worst) Onset: 2 days ago Timing: constant S/S: itchy, possibly swollen, flakes in the morning Aggravating Factors: GP wear Relieving Factors: GP removal, Alaway ® (temporary)

5. Ocular History High Myopia Phlyctenular Keratoconjunctivitis - OU Dx 01/2022

6. Medical Hx Osteoarthritis Dx: 2015

7. Medications Alaway ® (Ketotifen Fumarate 0.035%) Ophthalmic solution 1 gtt OU BID

8. Surgical Hx No Prior surgeries

9. Allergies Seasonal NKDA

10. Family Hx Ocular Hx: none Medical Hx: DM II - Father HTN - both parents

11. Visit #1: Exam Findings

12. GP Parameters Acuity OD Opt. Comf. | 42.77 (7.89) | -13.25 DS | 9.5 | 7.7 | 8.75 | 12.00 (0.2) | 0.12 | + | green 20/25 OS Opt. Comf. | 43.00 (7.85) | -12.50 DS | 9.5 | 7.7 | 8.75 | 12.00 (0.2) | 0.12 | + | blue 20/20 Flat Steep OD 41.75 @ 005 x 43.00 @ 095 OS 41.50 @ 178 x 42.50 @ 088 Keratometry (auto) Entering Acuity (cc)

13. Slit lamp Exam - Anterior segment GP fitting Assessment OD: AA | Avg PC 12 & 6 | Min PC 3 & 9 | lid attached OS: AA | Avg PC 12 & 6 | Min PC 3 & 9 | lid attached Conjunctiva Bulbar: OD: 1-2+ injection, Pinguecula N & T OS: Trace injection, Pinguecula T Palpebral : 1-2+ papillae OU (OD>OS) Cornea (After GP removal) OD: 3 & 9 staining (worse temporally), few foreign body tracks OS: scattered punctate staining, few foreign body tracks TBUT OD: 3 seconds OS: 6 seconds Image: https://optometrycase.com/wp-content/uploads/2019/03/staining-3-9-oclock-01_zoom-600x315.jpg

14. Slit lamp Exam - Posterior segment Oblique insertion, Peripapillary atrophy 360 OU Dx: 12/2019 Otherwise Unremarkable

15. Where’s my 7x? Significant deposits on F1 and F2 surfaces of both lenses Worse on Right lens Successfully removed Deposits with Sereine ® Rinsed with sterile saline → returned to patient. Image: https://i.ebayimg.com/images/g/YNEAAOSwaShduv5y/s-l500.jpg

16. Assessment & Plan Dx Allergic Conjunctivitis secondary to GP deposits Plan In office GP deposit removal with Sereine ® CL cleaner Frequent PFAT OU (at least QID) - Sample given Emphasized importance of consistent use Consider switching to Olopatadine 0.2% OU QD Incorporate Clear Care ® (3% Hydrogen Peroxide) with HydraGlyde ® 2-3 x per week Review Proper GL Hygiene RTC next available for Annual comprehensive Previously recalled for 9/2022 for CE/CL

17. Subsequent exams - Off & On irritation October 2022 - PC - Comprehensive exam No complaints of pruritus/irritation Update spec Rx RTC 1 year January 2023 - PC - Problem focused CC: Redness & inflammation OD, OS Similar findings to 9/2022 Dry Eye OU - possible inflammatory component secondary to CL deposits Rx: Tobradex BID OU x 1 month Continue Dry eye management RTC 2 weeks for GP/ocular surface eval in CL dept.

18. Follow Ups - Off & On irritation (cont.) February 2023 - CL - CL fitting/FU CC: Redness/inflammation OS>OD, Improving with Tobradex BID Coalesced 2+ SPK 3 & 9 peripherally, (+) papillae No lens deposits Dx: Peripheral corneal desiccation secondary to thick edges of high minus GP Order new GPs with HydraPEG coating OD: Opt. Comf. | 42.77 (7.89) | -13.25 DS | 9.5 | 7.7 | 8.75 | 12.00 (0.2) | 0.12 | + | green | HydraPEG OS: Opt. Comf. | 43.00 (7.85) | -12.50 DS | 9.5 | 7.7 | 8.75 | 12.00 (0.2) | 0.12 | + | blue | HydraPEG Discontinue Tobradex, Continue PFAT, Rec. switch to Olopatadine 0.7% QAM

19. What is HydraPEG? P oly E thylene G lycol polymer Permanently bonded to surface Goals Maintain tear film Prevent deposits Improve Comfort Image: https://visionarylens.wpenginepowered.com/wp-content/uploads/bb-plugin/cache/hydraPEG_page_hero_1181-landscape.jpg

20. After 1 week of HydraPEG wear Subjective : No improvement in symptoms Objective : Slight improvement in ocular surface & staining patterns Plan: Discuss importance of frequent and consistent PFAT use, RTC in 2 weeks

21. 2 weeks later Subjective: Improved comfort and less irritation Objective : Improved ocular surface & staining patterns Plan: Finalized GPs w/ HydraPEG Billed through medical insurance as medically necessary CLs Continue PFATs, Olopatadine 0.7% QAM, proper CL hygiene and care.

22. Allergic inflammatory response Corneal Desiccation So… What happened? 2 insults - each insult exacerbating the other Thick edges of High Minus GP Chronic surface deposits

23. Questions ? https://media2.giphy.com/media/GfaZNzU42Snz6dlGhN/giphy.gif

24. Case Report: Part 2 Discussion https://reviewofmm.com/wp-content/uploads/2019/08/GettyImages-648039158-768x619.jpg

25. Definitions High myopia: greater than -6.00 D spherical Refractive error > 26.5 mm Axial length 1 Pathological myopia: High myopia + Posterior segment findings resulting from excessive axial elongation. Variable definitions throughout the years Image: https://www.nvisioncenters.com/wp-content/uploads/normal-vision-vs-myopia-704x350.jpg

26. Prevalence Globally PM affects up to 3% of the population 1 Highest Asian countries 4,6 https://upload.wikimedia.org/wikipedia/commons/thumb/8/80/Asia_%28orthographic_projection%29.svg/1920px-Asia_%28orthographic_projection%29.svg.png

27. Complications/signs Progressive RPE thinning and attenuation throughout fundus → PPA if adjacent to ONH Oblique ONH insertion Foveal schisis Lacquer cracks (LC) → Choroidal Neovascular Membrane (CNVM) Posterior Staphyloma https://d45jl3w9libvn.cloudfront.net/jaypee/static/books/9789352500338/Chapters/images/48-1.jpg

28. Lacquer cracks (LC) Linear breaks in the RPE &/or Bruch’s membrane due to excessive attenuation and axial elongation LCs occur in 4.2% of eyes with AL longer than 26.5 mm 1 Lead to CNVM in 29.4% of these patients 3 https://media.springernature.com/lw685/springer-static/image/chp%3A10.1007%2F978-981-13-8491-2_9/MediaObjects/468051_1_En_9_Fig7_HTML.png?as=webp https://imagebank.asrs.org/Content/imagebank/lacquer-cracks.jpg/image-full;max$643,0.ImageHandler

29. Choroidal Neovascular Membrane (CNVM) Mo st common cause of vision loss in high myopia Occurs in 5-10% of cases of pathological myopia 12,13 https://eyewiki.aao.org/w/images/1/b/bc/2octb.png

30. Posterior Staphyloma Progressive thinning of scleral tissue from excessive axial elongation Retrograde outpouching of sclera Occur in 35% of patients with high myopia 5 https://journals.plos.org/plosone/article/figure/image?size=large&id=10.1371/journal.pone.0218107.g005 https://www.retinalphysician.com/archive/2017/January/images/rp_jan_3801.jpg

31. Refractive correction Spectacle correction - Not ideal Thick edges Heavy Image minification Gas permeable contact lenses - better Advantages over spectacles Greater range of parameters & powers More aesthetically pleasing Higher quality vision Disadvantages of high minus GPs Deposit formation Corneal dryness Corneal thinning

32. Deposits Originate from environmental components and tear components 7 Dust Mucins Microbes Cosmetic residue Lipids Proteins Many other factors Difficult to see with naked eye https://www.reviewofcontactlenses.com/CMSImagesContent/2022/06/RO/010_RCCL0622_GPE-modal.jpg Accumulation on lens surface leads to irritation and blurry vision

33. Minimize deposits A strict lens care regime of… Surfactant cleaners Abrasive cleaners Enzymatic cleaners H 2 O 2 based cleaners image source image source image source Image source

34. High minus GPs Inherently thick edges relative to center thickness Poor interaction between the lids, tear film, & corneal surface → poor lubrication/nutrition → desiccation & thinning → ulceration, neovascularization, and scarring 8 Poor lid, tear, corneal surface interaction Improper lubrication, nutrition, & O 2 delivery Ulceration, Neovascularization Corneal Desiccation & thinning scarring

35. Refractive Surgery? LASIK / PRK unable to fully correct myopia over -10.00 D with accuracy and the absence of complications 9 Clear lens exchange Very similar to CEIOL, which is the most performed outpatient procedure in the US 10 Major disadvantage: NO accommodation

36. Implantable Collamer Lens (ICL) Procedure is similar to CE-IOL & Clear lens exchange BUT… nothing is removed. Soft, flexible, & biocompatible collamer material Surgically implanted into the posterior chamber Anterior to the crystalline lens Posterior to the iris Advantages over other methods of refractive surgery Less higher order aberrations & improved contrast sensitivity 11 Greater functional ability Higher patient satisfaction

37. Rationale and changes CHANGES Look into Lenticulated or Aspherical edge designs Thinner edge = improved lid interaction Reduce OAD Smaller lens = thinner edge Consider scleral lenses… again If fitted properly Better comfort Less epithelial disruption/desiccation TIPS LOOK at the lenses 7x, slit lamp, lab microscope, etc. DOCUMENTATION Lots of recommendations of lubrication & CL hygiene in the plan Very Few, if any documentation obtained during case Hx of what the patient was actually doing If it's not written down… it didn't happen!!

38. Questions ? https://gifdb.com/images/file/minion-waiting-for-your-questions-hvgu4y486g1ggty9.gif

39. References Ryan SJ. Retina . 5th ed. Saunders/Elsevier; 2013. Accessed March 30, 2023. Wong Y-L, Sabanayagam C, Ding Y, et al. Prevalence, Risk Factors, and Impact of Myopic Macular Degeneration on Visual Impairment and Functioning Among Adults in Singapore. Investigative ophthalmology & visual science . 2018;59(11):4603-4613. doi:10.1167/iovs.18-24032 Richard F. Spaide, Kyoko Ohno-Matsui, Lawrence A. Yannuzzi. Pathologic Myopia. Vol 2nd ed. Springer ; 2021. Wong Ty, Ferreira A, Hughes R, Carter G, Mitchell P. Epidemiology and Disease Burden of Pathologic Myopia and Myopic Choroidal Neovascularization: An Evidence-Based Systematic Review. American Journal of Ophthalmology . 2014;157(1):9-25e12. doi:10.1016/j.ajo.2013.08.010 Raecker ME, Park DW, Lauer AK. “Diagnosis and Treatment of CNV in Myopic Macular Degeneration.” Eyenet 2015; 4:35-37. Ruiz-Moreno JM, Puertas M, Flores-Moreno I, Almazán AE, García ZM, Ruiz-Medrano J. Posterior Staphyloma as determining factor for myopic maculopathy. American Journal of Ophthalmology . January 2023. doi:10.1016/j.ajo.2023.02.017 Tan A, Milthorpe BK, Huff JW. A technique for quantitation of protein deposits on rigid gas permeable contact lenses. The CLAO journal: official publication of the Contact Lens Association of Ophthalmologists, Inc. 1997;23(3):177-184. Accessed March 31, 2023. Businger U, Treiber A, Flury C. The etiology and management of three and nine o’clock staining. International Contact Lens Clinic . 1989;16(5):136-140. doi:10.1016/S0892-8967(89)80019-7 Alió JL, Muftuoglu O, Ortiz D, et al. Ten-year follow-up of laser in situ keratomileusis for high myopia. American journal of ophthalmology . 2008;145(1):55-64. doi:10.1016/j.ajo.2007.08.035 Karaca Z, McDermott KW. High-Volume Invasive, Therapeutic Ambulatory Surgeries Performed in Hospital-Owned Facilities, 2016. PubMed . Published 2006. Accessed March 31, 2023. Igarashi A, Kamiya K, Shimizu K, Komatsu M. Visual performance after implantable collamer lens implantation and wavefront-guided laser in situ keratomileusis for high myopia. American journal of ophthalmology . 2009;148(1):164. doi:10.1016/j.ajo.2009.02.001 Richard F. Spaide, Kyoko Ohno-Matsui, Lawrence A. Yannuzzi. Pathologic Myopia . Springer; 2014. Accessed April 10, 2023. https://search.ebscohost.com/login.aspx?direct=true&db=edsebk&AN=672093&site=eds-live Neelam K, Cheung CMG, Ohno-Matsui K, Lai TYY, Wong TY. Choroidal neovascularization in pathological myopia. Progress in retinal and eye research . 2012;31(5):495-525. doi:10.1016/j.preteyeres.2012.04.001