關於兒童近視控制所使用之散瞳劑濃度你應該要知道的事

簡單的說

1.長效型散瞳劑(睫狀肌麻痺劑)-阿托品，濃度越高，控制近視的效果越好，但副作用也隨之越強，停藥之後的近視反彈現象也越嚴重，各項視覺功能的恢復期也越長。

2.不同學童對於相同濃度藥物的副作用反應並不完全相同，真正適合的藥物濃度需要經過詳細檢查評估(瞳孔、調節、遠近視力甚至雙眼視覺功能等等...)才能確定。

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近視率高居世界之首的台灣，國內推估曾點用散瞳劑之學童約在四成左右。

但許多學童及家長並不完全清楚所點用之藥物種類、濃度、使用方式、注意事項及副作用等。

這是相當危險的事情!!

在Ophthalmology 2012期刊當中，ATOM計畫(Atropine for the Treatment of Childhood Myopia study)回顧過去所做的研究 

發現點用Atropine 1.0%兩年的期間，控制近視的效果可達80%
當濃度下降後，0.5% 可達75%，0.1%可達70%
即使低至0.01%，仍有60%的近視控制效果。

但在停藥一年之後，1.0%點用組的近視快速的增加，幾乎將兩年點用期間所控制的近視，全數奉還。共三年的實驗結果，與點用安慰劑組的結果幾乎相同(點用組-1.37 vs 安慰劑組-1.56)。

而這樣的近視回彈現象，隨著濃度的下降，也漸趨輕微，到0.01%時，已未有明顯的回彈現象。

比較0.5%、0.1%及0.01%點用期間與停藥之後的視覺功能
遠距最佳矯正視力在三組之間無明顯差異
近距視力與瞳孔大小在停用兩個月之後逐漸恢復
調節幅度則需要較長時間恢復，且三組在停藥一年之後仍有顯著差異
以上視覺功能在低濃度組皆有較快的恢復時間

三組當中，0.01%的atropine有較低的近視反彈，因此能有持續的控制效果，且有最低的瞳孔放大與調節損失，停藥後的恢復也較快。似乎對於學童控制近視在藥效與安全性之間有最佳的平衡。

另也有研究者將Atropine的副作用訂出3項目標毒性標準
分別1.為調節小於5D、2.瞳孔放大超過3mm及3.近距離視力無法看清楚J1。

以此標準實驗不同濃度的作用，結果發現當濃度高於0.05%時，皆完全無法通過此標準。
一直要低至0.012%的濃度才勉強通過

但即使是0.012%的濃度，三位受測者當中仍有一位瞳孔放大了3mm，調節幅度僅剩3.60D，且抱怨在戶外時有畏光的現象。

網路上也曾有網友自行稀釋Atropine至0.003125%的經驗分享


參考資料


Chia, A., Chua, W. H., Cheung, Y. B., Wong, W. L., Lingham, A., Fong, A., & Tan, D. (2012). Atropine for the treatment of childhood myopia: safety and efficacy of 0.5%, 0.1%, and 0.01% doses (Atropine for the Treatment of Myopia 2). Ophthalmology, 119(2), 347-354. doi: 10.1016/j.ophtha.2011.07.031

Chia, A., Chua, W. H., Wen, L., Fong, A., Goon, Y. Y., & Tan, D. (2013). Atropine for the Treatment of Childhood Myopia: Changes after Stopping Atropine 0.01%, 0.1% and 0.5%. Am J Ophthalmol. doi: 10.1016/j.ajo.2013.09.020

Chua, W. H., Balakrishnan, V., Chan, Y. H., Tong, L., Ling, Y., Quah, B. L., & Tan, D. (2006). Atropine for the treatment of childhood myopia. Ophthalmology, 113(12), 2285-2291. doi: 10.1016/j.ophtha.2006.05.062

Tong, L., Huang, X. L., Koh, A. L., Zhang, X., Tan, D. T., & Chua, W. H. (2009). Atropine for the treatment of childhood myopia: effect on myopia progression after cessation of atropine. Ophthalmology, 116(3), 572-579. doi: 10.1016/j.ophtha.2008.10.020

COOPER, J. et al. Maximum Atropine Dose Without Clinical Signs or Symptoms. Optom Vis Sci, Sep 26 2013. ISSN 1040-5488.

新型漸進多焦(兒控)鏡片用於近視控制的兩年實驗

視光界最權威的期刊IOVS 2014最新的文章

結果再次證實了兒控鏡片控制近視的效果只有約20%

近用時減少調節的使用對於控制近視效果真的有限，就算加上周邊屈光差也沒有改善。

還不如單獨使用周邊屈光差設計的控制近視鏡片

顯示控制近視還是要從視覺影像著手，眼球的機械性力量(調節、內聚等等)的調整，改善程度有限。


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一種新型的漸進多焦鏡片，兩年、多中心、隨機、對照控制的近視控制實驗。

此種新型漸進多焦鏡片採用新設計的周邊正非球面設計

可以同時減少調節與視網膜周邊的遠視性離焦

197位6~12歲兒童參與實驗，等值球面近視在-1.00D ~ -4.50D
隨機分為三組，單焦組，多焦加入度+1.00D，多焦加入度+1.50D

兩年後的結果
單焦組 增加 -1.39 ± 0.09 D

多焦加入度+1.50D比單焦組減少0.27 ± 0.11 D

也就是控制近視效果約20%，統計上達顯著程度。

多焦加入度+1.00D則不具顯著控制近視效果。


Invest. Ophthalmol. Vis. Sci., 2014

Myopia Control with Positively Aspherised Progressive Addition Lenses: A two-year, Multicenter, Randomized, Controlled Trial.

Hasebe, S; Jun, J; Varnas, SR

PURPOSE: To evaluate the effect of newly-designed positively aspherised progressive addition lenses (PA-PALs), which reduce both lag of accommodation and hyperopic defocus on the peripheral retina, on progression of early-onset myopia.
METHODS: PA-PALs have a near addition and a high positive distance zone aspherisation comparable to the addition power. One hundred and ninety-seven children were enrolled, 6 to 12 years of age, with spherical equivalent refraction from -1.00 to -4.50 D. The children were randomized to receive one of three lenses: single vision lenses (SVLs), PA-PALs with +1.0 D addition, or PA-PALs with +1.5 D addition. Follow-up visits occurred every 6 months for two years. The primary outcome is myopia progression evaluated by cycloplegic autorefraction.
RESULTS: One hundred and sixty-nine (86%) children completed the follow-up. Statistical analysis of adjusted progression rates showed a mean (±SE) progression of -1.39 ± 0.09 D in the control group wearing SVLs at the 24-month visit. Statistically significant (p = 0.017) retardation of SER (0.27 ± 0.11 D over 24 months or reduction ratio of 20%) by +1.5 D add PA-PALs relative to the SVLs was found, which was within the range of the percentage efficacy of myopia retardation by the conventional PALs in earlier trials over the same follow-up period. Nearly all retardation occurred in the first 12 months with no significant efficacy in the second year. PA-PALs with +1.0 D addition showed negligible efficacy.
CONCLUSION: The high positive aspherisation of the distance zone added to PALs apparently does not enhance their therapeutic efficacy in slowing myopia progression.
Copyright © 2014 by Association for Research in Vision and Ophthalmology.

PMID: 25270192
URL  - http://www.ncbi.nlm.nih.gov/pubmed/25270192?dopt=Citation

針灸可能是弱視治療的一種選擇

針灸可能是弱視治療的一種選擇，紐西蘭的研究顯示，針灸對

弱視的治療效果甚至優於一天遮眼治療2小時，約七成的弱視

孩童能提高兩行的視力。雖然樣本數不高，且進步幅度不大，

不過值得更進一步研究。

http://www.moneycontrol.com/news/health/acupuncture-could-be-option-to-treatlazy-eye-study_505066.html

Acupuncture could be option to treat 'lazy eye': Study

Published on Tue, Dec 14, 2010 at 13:02 | Updated at Tue, Dec 14, 2010 at 16:08 | Source : Reuters

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Acupuncture could be an alternative to eye patches or eye drops for older children with amblyopia, a common childhood vision problem more commonly known as "lazy eye," according to a study.

The problem, in which one eye is less farsighted or nearsighted than the other, can be corrected with glasses or contact lenses if caught at an early age. But both are less effective for children beyond about the age of 7, who traditionally have been treated by patching the stronger eye.

But Robert Ritch of the New York Eye and Ear Infirmary and Chinese colleagues found that children treated by a certified acupuncturist had similar improvement in their affected eyes as those who wore a patch for a couple of hours each day.

Both advanced two lines or more on an eye chart over the course of the study, which was published in the Archives of Opthalmology.

"Acupuncture has been used for a lot of things in Chinese medicine. And it's being used more and more in the West," Ritch told Reuters Health.

"But evidence-based medicine to see what it actually does is relatively lacking."

Ritch and Chinese colleagues studied 88 children in China between the ages of 7 and 12 who suffered from amblyopia and had already been wearing glasses for at least 16 weeks.

They randomly assigned the children to wear a patch over the good eye for two hours every day, or to attend five acupuncture sessions weekly. The acupuncture needles were inserted at sites on the body associated with vision in traditional Chinese medicine.

All the children were also given new glasses to wear and asked to perform an hour of daily near-vision activities.

By the end of the 25 week study, sight in the affected eye had improved by at least two lines on an eye chart for 28 children in the patched group, or 66.7%, and 31 in the acupuncture group, or 75.6%.

More than twice as many children who received acupuncture overcame the condition compared to those who wore an eye patch, 42% against 17%.

Some experts were sceptical, noting the small size of the study and the fact that there was no untreated group to use to see if doing nothing, or simply wearing glasses and doing daily exercises, would work just as well.

Matthew Gearinger at the University of Rochester in New York, who was not involved in the study, told Reuters Health it was encouraging to hear of alternate treatment methods.

"Patching can be annoying for kids. It can be socially tough to wear a patch at school, and wearing a patch at home can interfere with homework."

But he too noted the small size of the study and questioned whether the treatment option was practical, given that there are few acupuncturists in the United States with experience treating amblyopia.

Ritch and his team are following up with more studies.

"Don't knock Chinese medicine. It's been around for more than 3,000 years and there's a lot we don't understand yet," he said.

度數配不足對於近視惡化的影響

小朋友近視了!

常見的問題之一就是，度數要配足嗎?  

啊不是要減一點? 不然會頭暈而且度數增加很快喔~

事實上，配不足才會讓度數增加較快!

1.美國一位私人的視光診所回顧性的研究，近視的惡化速度正相關於未配足度數
，也就是度數配得越不足，近視增加越快。

J Optom. 2014 Jul-Sep;7(3):147-52. doi: 10.1016/j.optom.2013.12.007. Epub 2014 May 10.

Under-correction of human myopia - Is it myopigenic?: A retrospective analysis of clinical refraction data.

Vasudevan B1, Esposito C2, Peterson C2, Coronado C2, Ciuffreda KJ3.

2.前瞻性的研究，配不足75度(0.75D)與全矯正相比，近視惡化速度一年多23度(0.23D)

一年近視增加度數--矯正不足組：-1.00D vs 全矯正組：-0.77D

Vision Res. 2002 Oct;42(22):2555-9.

Undercorrection of myopia enhances rather than inhibits myopia progression.

Chung K1, Mohidin N, O'Leary DJ.

3.同樣是前瞻性的研究，配不足50度(0.50D)與全矯正相比，近視惡化速度一年多17度(0.17D)
一年近視增加度數--矯正不足組：-0.99D vs 全矯正組：-0.82D

Clin Exp Optom. 2006 Sep;89(5):315-21.

The possible effect of undercorrection on myopic progression in children.

Adler D1, Millodot M.

視網膜影像清晰程度會嚴重影響近視的進展，度數配不足對於調節的幫助不大，但卻犧牲影像品質，反而使近視增加較快。