ONE-TO-ONE: THOMAS ALLER

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Thomas Aller, OD, FBCLA, launched an educational and informational website, ManageMyopia.org, last month. Aller, who has been conducting myopia control research for more than 25 years, is the clinical content editor and curator for the website, which will summarize the latest data on myopia. He is a visiting scholar at UC Berkeley School of Optometry and an adjunct professor at University of Houston College of Optometry and serves on several boards. Aller also developed Myappia, an app for Android devices that lets ODs predict the progression of a child’s myopia in 10 years.

Jeffrey Eisenberg: You’re considered an authority on myopia. Will you tell us more about your experience?
Thomas Aller, OD: I’ve been actively treating myopia with various methods for over 25 years. I first started getting interested in optometry as an ortho-K patient myself. Just the ability to make significant changes in people’s vision was somewhat enticing and probably led me on some level to think about optometry.

There wasn’t really any research to back up being able to control myopia [progression]when I was a student. We were taught that myopia was largely genetic and that it would start at age 8 or 9 and stop at age 16 or 17. In my area in the Silicon Valley and the Bay Area, everybody’s on computers. It didn’t seem like people were stopping at age 16 or 17. That’s when I had to decide: Either I’d been a lousy optometrist or my professors must’ve been wrong. That’s what led me on a quest to see which of those was actually the case, and it’s been quite a journey since then.

JE: Why did you start this particular website?
TA: I had some websites for my business. They mostly feature my work in myopia and my practice but nothing intended for the larger profession.

About two years ago, I started working with a new contact lens from Visioneering Technologies, Inc. called the NaturalVue Multifocal 1 Day. We started working together and doing a pilot study in my practice. I did a little speaking for them. They had an interest in developing a website that would be directed toward practitioners interested in myopia control, and they asked me to be the editor for it. So, they did the groundwork to set it up, and they’ve given me resources to update it and maintain it. They’ve allowed me to have a board of advisors that I’ve selected from the field to give me the benefit of perspectives from other areas of expertise.

It officially launched in conjunction with the Vision By Design Conference. What we intend it to be is an up-to-date, useful resource for practicing optometrists or ophthalmologists interested in either starting or improving a myopia control practice. I think it’ll be a good opportunity to try to move the profession into the area of myopia management.

JE: Isn’t myopia management something ODs already do as part of their overall services?
TA: Myopia has been considered simply to be a refractive error that you correct with lenses to put the focus back on the retina. There has been increasing interest in incorporating methods for actually controlling myopia progression into hopefully everyone’s practice.

We know that there are a number of ways that myopia progression can be controlled. Just increasing the number of hours spent outdoors, primarily before a child becomes nearsighted, has been shown to delay the beginning of myopia. That’s valuable and free, and every kid can do it.

There are some eyeglass strategies that are helpful for certain categories of patients. Some innovations are coming in spectacle designs that may make these types of lenses more effective than they have been in the past.
Then, the three big ones that generate a lot of interest and a lot of research would be low-dose atropine, orthokeratology, and bifocal and multifocal contact lenses. A consensus has been developing that these are all effective treatments that are reasonable for any optometrist or ophthalmologist to provide for their patients. At some point, I hope that these types of treatments will be their standard of care and that every progressing young myope will be offered one of these types of methods for slowing down their myopia progression.

JE: What do you expect to be some of the future areas of myopia research?
TA: Right now, one of the big challenges for the contact lens industry is that contact lens manufacturers are aware that they could create contact lenses that would control myopia if they’re not already doing so and that practitioners are already using their lenses. But, none of the lenses in the U.S. have an indication from the FDA for the treatment of myopia progression. So, pretty much everything in the U.S. is off-label. In Europe, for instance, there are contact lenses that have achieved a CE mark for myopia control. In those markets the manufacturers are a little bit more free to make claims about what their lenses can do.

The FDA had a meeting in 2016 to try to develop new standards for evaluating and granting approval to a contact lens for the control of myopia. They’re likely to require studies that might be three to four years in length that would have to perhaps show a 50% control of myopia progression as compared to a control group. The control group might be spectacles or standard contact lenses. You’re going to want research to prove that when children wear contact lenses they have no higher rates of infection than adults.

There have been some interesting eyeglass innovations, and then there are some atropine studies. There’s a multi-site study in the U.S. on low-dose atropine 0.01% through the Pediatric Eye Disease Investigator Group. There are some pharmaceuticals.

JE: On your website you talked about the long-term impact of myopia. It sounds as though this research is really necessary to delay some of these other problems that can result.
TA: Projections have been done by the Brien Holden Vision Institute. They looked at current rates and projected in all the countries for which they had data what the likely number of myopes would be by the year 2050. What they came up with was an estimate of five billion people with myopia by the year 2050. Of that number, one billion are projected to have high myopia.

It’s in the high levels of myopia in which we expect there to be significant impact on the health of the eye. There’s a range between four and 15 times increase in retinal detachment with higher levels of myopia. Even cataracts show a two to five times increase with myopia. Glaucoma is running about a two to three times increase with myopia. And then there’s a newly recognized disease: myopic maculopathy. It’s not quite the same as macular degeneration from age-related reasons, but it targets the macula and causes scarring. There’s a 60 times increase in that condition in people with high myopia.

Myopia is now the number one leading cause of new blindness in some areas in Asia. All of these conditions, including myopia itself, are irreversible for the most part. In terms of their linkage to myopia, you can think of them as preventable. At least you can lower the risks.

A paradox has been pointed out by Irish ophthalmologist Ian Flitcroft: There’s a higher risk of all these pathologies with any level of myopia. Even a low myope has an increased risk, so he would urge his colleagues and has urged everyone to treat myopia a little bit more seriously, even the low levels. The other point he likes to make is that there are quite a few more people in the world with -1.00D to -5.00D of myopia, levels that are considered low to moderate. But, because there are so many more of those people, you’re actually going to find more pathology in low to moderate myopes. There are so many more of them than patients with -7.00D to -8.00D, so he doesn’t think that we should think of myopia in terms of these two different levels as though they’re different conditions.

JE: What do you plan to add to ManageMyopia.org in the future?
TA: We’re expanding the content from what’s on there now to be more inclusive of each of the various treatments that are available. We’re going to have content available only to registered doctors that will include practice-management tips from clinicians who have a lot of experience in practicing myopia control. We’re going to have a lot of information on consumer marketing, social media strategies, how to get referrals and how to build a referral network. We’ll have some sources that give us some guidance on how parents view myopia, what concerns them, and what might drive them to consider specialty care in this area. I hope to deliver a lot of very useful information for the practicing doctors.

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