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为儿童留住光明!减轻课业负担与低浓度阿托品使用

其他  作者:国际眼科时讯  2019/3/9 17:28:00
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内容概要:近视,作为一种与人们生活密切相关的高发疾病,其关注和研究热度如同近视的患病率一样逐渐升高。

Retina China 2019

Dr. Kathryn Rose’s comment with IOT

IOT: The rise in prevalence of high myopia has an unusual pattern of development. Could you please describe this pattern in detail? 详述高度近视高发病率的模式。

Prof. Rose (00:16): The pattern of high myopia around the world has been changing over probably about the last four decades, I would think. We first noticed a major rising in high myopia in Taiwan where over about a period of roughly 20 years they noticed a doubling of the rate of high myopia amongst 18-year old in the schooling system in Taiwan. And this certainly started to raise alarm bells. But what we’ve now observe is that wherever the prevalence of myopia has gone up, once it gets over about 60% of the population you start to notice a massive increase in the rise of high myopia, and what that actually means is that when the population who are myopic comes around about 80% of the population, the number of people with high myopia amongst that group are about 1 in 4 or 5 of the population of people with myopia. Where myopia is below 60% in a country, we find that it is only about 1 in 12 people who have high myopia amongst the myopic population. So, what this is actually showing us is as the rise in myopia prevalence overall occurs we get an exponential rise in the number of people with high myopia, which is unfortunately a very unwelcomed consequence of the overall epidemic of myopia

IOT (2:00): What are the risk factors from myopia to high myopia? 近视到高度近视,危险因素有哪些?

Prof. Rose (2:06): The primary risk factor that we have identified is age of onset of myopia. So, if you become myopic at age 6, the chances are you would have high myopia that is greater than 6 diopters by the time you are about 12 or 13 years of age. However, if you become myopic at age 12, then you are likely never to become a high myope. So, age of onset is incredibly important, the earlier the age of onset, the greater the risk of developing high myopia. And that may be a simple thing of your eye has a longer period over which it can grow in the myopic direction. So, your eye is continuously growing, it has to grow. It is about 70% of your adult size when you are born, so the eye has to grow. It would appear that if you tip into to the myopic refractive state at an early age then your eyes are going to keep growing as is everybody else’s eye, but of course is just increasing your level of myopia. There is another factor though, where the prevalence of myopia again has been very high and we have these large numbers of children with high myopia in an early age, we also noticed that the rate of progression of the eye growth seems to be greater than it is in other children. So, even though we are talking about a growth mechanism that should be just pacing along with everybody else, but of course in the myopic direction, unfortunately these children with early myopia seem to also progress at a faster rate. So, this is a double, if you like, risk factor for developing myopia. If we are going to talk about risk factors for this high myopia that is probably the primary one. But, what we could look at is the risk factors for earlier onset myopia and they seem to be very related to two major factors, one being intensive education at an early age, and the other one is lack of time outdoors. Lack of time outdoors is preventative of the development of myopia while intensive schooling seems to promote the development of myopia. So, when you couple the two together, unfortunately you have created an environment in which the eye appears to become myopic at an early age. 

IOT (4:52): Intense schooling is linked to myopia. What efforts should ophthalmologists do to change the status quo?高强度的教育和近视有关,你认为我们眼科医生应当为此做出哪些努力来改变现状?

Prof. Rose (5:03): I think ophthalmologist have to become, if you like, lobbyist to government to say – this is a massive problem that is looming and in some cases it has already arrived for a number of countries. And if you think about it in a location where 20% of your population has high myopia, that is 20% of your population who is high risk of developing visual impairment and maybe even blindness. Now, that is an enormous burden on just not the individual, but on governments and health systems as a whole. So, this message needs to be delivered to politicians and governments. And this needs to say – the way we need to start controlling this is to look at ways that we can avoid having intensive schooling systems at a young age. One of the things that I always point out is that intensive schooling systems at a young age doesn’t necessarily deliver any greater educational outcome at the end of schooling. And one of the countries that has really demonstrated this has been Finland where children are not allowed to go to school until they are age 6. And then the educational system is not intensive and is in fact a very comprehensive educational system. Yet, their success in many of the OECD scores on educational outcomes, they rank very highly. So, we don’t need early intensive education to achieve good outcomes for children later in life. 

IOT (6:54): Based on your clinical practice, what strategy do you use in the treatment of myopia? 在你的临床工作中,是如何使用阿托品来控制近视的?

Prof. Rose (6:59): I don’t directly treat children with high myopia, but as a researcher I look at the evidence that is available. At the moment the evidence most strongly, I think, supports the administration of low-dose atropine. The work done in Singapore has with a randomized control trial using different levels of atropine eye drops shows quite clearly that the administration of low-dose atropine is very successful in the long term of about 5 years of slowing the rate of progression of myopia. There are other devices, there are some optical devices that are now available, but I think again long-term rigorously control of randomized control trials are needed to demonstrate fully their efficacy. But I must say myself that if I had a child age 6 who was becoming myopic I would seriously consider a strategy to intervene and make sure that they didn’t progress at a fast rate because that would inevitably lead to high myopia. 

Thank you!

编者按:近视,作为一种与人们生活密切相关的高发疾病,其关注和研究热度如同近视的患病率一样逐渐升高。高度近视,作为近视中的一种类型,常因其导致的并发症严重危害患者的视力。2019中国眼底病论坛暨国际视网膜研讨会(Retina China 2019)上,《国际眼科时讯》记者就高度近视的一些相关问题对澳大利亚悉尼科技大学Kathryn Rose教授进行了采访。

高度近视现状
 
Rose教授介绍说,世界各地的高度近视情况在过去的四十年里可能一直都在不断发生变化。在台湾,首先发生了一次高度近视患病率的显著上升,并在之后大约20年的时间里,台湾学校18岁青少年的高度近视率增加了一倍,这无疑给人们敲响了警钟。现在人们发现,无论在哪里出现近视的患病率上升,当近视患者超过人口数量的60%时,高度近视的数量便会大幅度增加。这实际上意味着当近视患者约占人口数量的80%时,高度近视患者的人数约为近视患者人数的1/4或1/5。如果一个国家的近视患者低于人口数量的60%,高度近视患者的人数约仅为近视患者人数的1/12。这表明,随着近视患病率的普遍上升,高度近视患者的数量呈指数增长,这对近视的整体流行现状来说并不是一件好事。
 
近视“进阶”危险因素
 
目前已明确的主要危险因素是近视发病年龄。如果在6岁时形成近视,那么在大约12或13岁时就可能发展成为高度近视。如果在12岁时形成近视,那么很可能永远也不会发展成为高度近视。因此,近视的发病年龄非常重要,发病年龄越早,发展成为高度近视的风险就越大。对于一个人的眼睛来说,由于眼球一直在发育,所以近视度数也在增长。在出生时,眼球大小大约是成年人的70%,所以眼球肯定会发育。如果一个人在很小的时候便进入近视的屈光状态,他的眼球还是会像其他人的眼球一样继续发育,只是增加了近视的水平而已。另外,近视的患病率一直很高,而且有很多儿童在很小的时候就患有高度近视。人们发现,这些近视儿童眼球发育的速度较其他儿童要更快。尽管大家一直在讲每个人都有伴随的生长发育机制在内,但在近视方面,近视儿童的变化速度似乎更快。因此,这是近视发生发展的双重风险因素。如果要讨论高度近视的危险因素,可能那就是最主要的。近视早发的风险,似乎与两个主要因素密切相关,一个是早期高强度的教育,另一个是户外活动时间不足。缺乏户外活动时间和强化学校教育任务似乎都可以促进近视的进展。不幸的是,当两者结合在一起时,我们就为眼睛在幼年时形成近视创造了发生环境。
 
眼科医生要做的事
 
Rose教授认为,如果眼科医生个人愿意,每个人都应该成为政府的说客。这是一个迫在眉睫的大问题,甚至在某些情况下已经影响到了许多国家。如果一个人所在的地方有20%的人口存在高度近视,那就意味着有20%的人口存在发生视力障碍甚至失明的高风险。现在,这已不仅仅是个人负担,而且还是整个政府和卫生系统的巨大负担。因此,需要将这一信息传递给政治家和政府。同时要告诉他们,控制这一现象的办法是避免幼年时期进行高强度学校教育的方法。Rose教授认为,幼年时期的高强度学校教育并不一定能在学校教育结束时带来更显著的教育成果。这一点在芬兰得到了证实。在芬兰,儿童要年满6岁才被允许上学。尽管教育强度并不大,但教育体系却非常全面。他们在经济合作与发展组织的教育成果评价中取得了成功,排名非常高。因此,我们并不需要通过进行早期的强化教育以使儿童在以后的生活中取得更加良好的成绩。
 
阿托品控制近视
 
Rose教授说,自己作为一名研究人员,查阅现有的证据后她认为最有力的支持证据是低剂量阿托品的使用。在新加坡进行的一项使用不同浓度阿托品滴眼液进行的随机对照试验结果明确表明,低浓度阿托品给药在约5年长期减缓近视进展方面非常成功。现在有一些光学设备可供选择,但还需要长期严格控制的随机对照试验来充分证明其疗效。Rose教授说,如果自己有一个6岁的孩子得了近视,她会认真考虑采取策略进行干预,并确保它不会快速进展,否则将不可避免地形成高度近视。

 


 
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