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SURGICAL MANAGEMENT OF ASTIGMATISM
SURGICAL MANAGEMENT OF ASTIGMATISM Editors Dimitri T Azar MD MBA Senior Director, Ophthalmic Innovations Clinical Lead, Ophthalmology Programs Alphabet Verily Life Sciences San Francisco, CA, USA Distinguished University Professor BA Field Chair of Ophthalmological Research and Former Medical School Executive Dean University of Illinois College of Medicine, Chicago, IL, USA
Jorge L Alió MD PhD FEBOphth Professor and Chairman of Ophthalmology VISSUM Instituto Oftalmológico, Alicante, Spain Division of Ophthalmology Universidad Miguel Hernández, Alicante, Spain
M Soledad Cortina MD Associate Professor of Ophthalmology, Director Comprehensive Ophthalmology Faculty Practice (COFP) and General Eye Clinic University of Illinois College of Medicine Department of Ophthalmology and Visual Sciences University of Illinois at Chicago, Chicago, IL, USA
Joelle A Hallak MS PhD Assistant Professor and Executive Director Ophthalmic Clinical Trials and Translational Center Director, Ophthalmic Data Science Laboratory Department of Ophthalmology and Visual Sciences University of Illinois at Chicago, Chicago, IL, USA
JAYPEE BROTHERS MEDICAL PUBLISHERS The Health Sciences Publisher New Delhi | London
Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +911143574357 Fax: +911143574314 Email: jaypee@jaypeebrothers.com Overseas Office JP Medical Ltd 83 Victoria Street, London SW1H 0HW (UK) Phone: +44 20 3170 8910 Fax: +44 (0)20 3008 6180 Email: info@jpmedpub.com Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2020, Jaypee Brothers Medical Publishers The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photo copying, recording or otherwise, without the prior permission in writing of the publishers. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book. This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought. Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. The CD/DVD-ROM (if any) provided in the sealed envelope with this book is complimentary and free of cost. Not meant for sale.
Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com Surgical Management of Astigmatism First Edition: 2020 ISBN: 9789389188851
Dedicated to Our families. Without their constant support, this book would not have been possible.
Contributors Afua Annor MD Ophthalmologist University of California Davis Eye Center Sacramento, CA, USA
Alanna S Nattis DO FAAO Ophthalmologist Department of Cornea and Refractive Surgery SightMD, NY, USA
Alexander Pleet MD Glaucoma Fellow Department of Ophthalmology Feinberg School of Medicine Northwestern University Chicago, IL, USA
Alfredo Vega-Estrada MD PhD Ophthalmologist Department of Cornea and Refractive Surgery Vissum/Instituto Oftalmológico de Alicante, Spain
Almutez M Gharaibeh MD Associate Professor of Ophthalmology Faculty of Medicine The University of Jordan Amman, Jordan
Andrea Arteaga MD Ophthalmology Resident Department of Ophthalmology and Visual Sciences University of Illinois Chicago, IL, USA
Andrzej Grzybowski MD PhD MBA Professor Department of Ophthalmology Chair of Ophthalmology University of Warmia and Mazury Olsztyn, Poland Head, Institute for Research in Ophthalmology Poznan, Poland
Arthur Cummings FRCS MD
Daniel G Fernández-Pacheco PhD
Medical Director Wellington Eye Clinic Consultant Ophthalmologist Head, Department of Ophthalmology Beacon Hospital, Dublin, Ireland
Faculty Department of Graphical Expression Technical University of Cartagena Cartagena, Spain
Asier Villanueva MSc
Senior Director, Ophthalmic Innovations Clinical Lead, Ophthalmology Programs Alphabet Verily Life Sciences San Francisco, CA, USA Distinguished University Professor BA Field Chair of Ophthalmological Research and Former Medical School Executive Dean University of Illinois College of Medicine Chicago, IL, USA
Researcher Department of Optical and Visual Sciences University of Alicante, Alicante, Spain
Brent A Kramer MD Ophthalmology Resident Department of Ophthalmology University of North Carolina at Chapel Hill Chapel Hill, NC, USA
Bryan S Lee MD JD
Dimitri T Azar MD MBA
Eric D Donnenfeld MD
Ophthalmologist Department of Cornea and Refractive Surgery Altos Eye Physicians Los Altos, CA, USA
Ophthalmologist Long Island Cornea, LASIK and Cataract Specialist Department of Ophthalmology Ophthalmic Consultants of Long Island Garden City, NY, USA
Damien Gatinel MD PhD
Eric D Rosenberg DO MSE
Chief of Service Department of Anterior Segment and Refractive Surgery Rothschild Foundation Paris, France
David F Chang MD Clinical Professor University of California San Francisco San Francisco, CA, USA
David R Hardten MD FACS Ophthalmologist and Founding Partner Minnesota Eye Consultants Minnesota, USA
Debora E Garcia-Zalisnak MD Cornea, Refractive Surgery and External Disease Specialist Clear Vision Ophthalmology Tucson, Arizona, USA
Ophthalmologist Valhalla, NY, USA
F Cavas Martínez PhD Faculty Department of Graphical Expression Technical University of Cartagena Cartagena, Spain
FJ Fernández Cañavate PhD Faculty Department of Graphical Expression Technical University of Cartagena Cartagena, Spain
George Stamatelatos BScOptom Clinical Director ASSORT Senior Optometrist New Vision Clinics Melbourne, Australia
viii Surgical Management of Astigmatism Gunther Grabner MD
Jorge L Alió del Barrio MD PhD
Noel Alpins AM FRANZCO FRCOphth FACS
Professor Department of Ophthalmology Paracelsus Medical University Salzburg, Austria
Surgeon, Cornea, Cataract, and Refractive Surgery Division of Ophthalmology Universidad Miguel Hernández Alicante, Spain
Clinical Professor and Medical Director Newvision Clinics CEO of ASSORT Department of Ophthalmology University of Melbourne Melbourne, Australia
Joao Crispim MD Ophthalmologist Department of Ophthalmology and Visual Sciences Federal University of São Paulo São Paulo, Brazil
Joelle A Hallak MS PhD
Jose de la Cruz MD Assistant Professor Department of Ophthalmology and Visual Sciences University of Illinois at Chicago Chicago, IL, USA
Assistant Professor and Executive Director Ophthalmic Clinical Trials and Translational Center Director Ophthalmic Data Science Laboratory Department of Ophthalmology and Visual Sciences University of Illinois at Chicago Chicago, IL, USA
Kai Kang MD
John SM Chang MD
Leon Strauss MD PhD
Director, Guy Hugh Chan Refractive Surgery Centre Hong Kong Sanatorium and Hospital Happy Valley, Hong Kong
John P Berdahl MD Ophthalmologist Surgeon Vance Thompson Vision Sioux Falls, SD, USA
Jonathan Rubenstein MD Professor Department of Ophthalmology Rush University Medical Center Chicago, IL, USA
Jorge L Alió MD PhD FEBOphth Professor and Chairman of Ophthalmology VISSUM Instituto Oftalmológico Alicante, Spain Division of Ophthalmology Universidad Miguel Hernández Alicante, Spain
Piotr Kanclerz MD PhD Ophthalmologist Department of Ophthalmology Medical University of Gdansk Gdansk, Poland
Assistant Professor Department of Ophthalmology and Visual Sciences University of Illinois at Chicago Chicago, IL, USA
Praneetha Thulasi MD
Laurent Bataille MSc
Renan Ferreira Oliveira MD
Director Research and Development VISSUM Instituto Oftalmológico Alicante, Spain Instructor Department of Ophthalmology The Wilmer Eye Institute The Johns Hopkins University School of Medicine Baltimore, MD, USA
M Soledad Cortina MD Associate Professor of Ophthalmology Director Comprehensive Ophthalmology Faculty Practice (COFP) and General Eye Clinic University of Illinois College of Medicine Department of Ophthalmology and Visual Sciences University of Illinois at Chicago Chicago, IL, USA
Mauro C Tiveron Jr MD ICO Fellow Department of Cornea, Cataract and Refractive Surgery Massachusetts Eye and Ear Infirmary Harvard Medical School Boston, MA, USA
Assistant Professor Department of Ophthalmology Emory Eye Center Atlanta, GA, USA
Ophthalmologist, Cataract and Refractive Surgeon Sadalla Amin Ghanem Eye Hospital Joinville, SC, Brazil
Ricardo M Nosé MD Research Fellow Department of Cornea, Cataract and Refractive Surgery Massachusetts Eye and Ear Infirmary Harvard Medical School Boston, MA, USA
Roberto Fernández-Buenaga MD PhD Consultant Ophthalmologist Department of Cornea, Cataract and Refractive Surgery Vissum Corporación Madrid, Spain
Roberto Pineda II MD Associate Professor Department of Ophthalmology Director Department of Refractive Surgery Massachusetts Eye and Ear Infirmary Harvard Medical School Boston, MA, USA
Contributors
Samantha Williamson MD
Suphi Taneri MD
Cornea and External Disease Specialist Department of Ophthalmology Kaiser Permanente Mid-Atlantic Medical Group Baltimore, MD, USA
Director Center for Refractive Surgery Owner, Eye Department St Franziskus Hospital, Munster Lecturer, Ruhr University Bochum, Germany
Shilpa Gulati MD Retina Fellow Tufts New England Eye Center Ophthalmic Consultants of Boston Boston, MA, USA
Susie Drake MD Cornea and External Disease Specialist Center for Eye Care Watertown Regional Medical Center Watertown, WI, USA
Tomoaki Nakamura MD Ophthalmologist Department of Refractive Surgery Nagoya Eye Clinic Namiyose Atsuta-ward Nagoya, Japan
Verónica Vargas MD Refractive Surgery Fellow Department of Investigation, Development and Innovation Vissum Alicante, Alicante, Spain
ix
Preface Astigmatism is one of the most frequent problems encountered in the surgical management of cataract, cornea, and refractive conditions. In essence, the correction of astigmatism is part of the success of any anterior segment surgical procedure. Regardless of its types, astigmatism can be difficult to manage and may complicate surgical outcomes. In contrast to myopia, there is no single focal point in astigmatism, which poses a challenge to the modern trends in refractive and intraocular lens surgery. The modern trend is to obtain a unique quality of retinal images, not distorted by astigmatism. This is why in this book we present various solutions to the different types of astigmatism that the practical surgeon will find in today’s world of refractive and cataract-lens surgical practices. The different chapters of this book are based on scientific evidence and practice. Well-known authors, with extensive practice, offer what they consider to be pearls of their knowledge to optimize and improve surgical outcomes for the correction of astigmatism with cornea or intraocular procedures. We would like to thank all the authors and contributors of the book for sharing their knowledge and expertise through comprehensive chapters. They have worked tirelessly on their chapters. Without their consistent efforts and dedication, the book would lack the essence that we want to transmit to the readers, which is how to manage astigmatism from the diagnostic stages, instrumental examinations, surgical plannings, surgical applications, and, last but not least, analysis of outcomes. Dimitri T Azar Jorge L Alió M Soledad Cortina Joelle A Hallak
Acknowledgments We would like to acknowledge and thank our students and mentors as well as our patients for trusting us in their care, and for helping us in advancing the management of astigmatism. Lastly, we would like to thank Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director), Mr MS Mani (Group President), Ms Chetna Malhotra Vohra (Associate Director—Content Strategy), Ms Pooja Bhandari (Production Head) and Ms Prerna Bajaj (Development Editor) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for giving a go-ahead at the very beginning and helping us in every way possible to bring out this book.
Contents 1. Etiology, Pathogenesis, and Epidemiology of Astigmatism and History of its Surgical Management
1
Andrzej Grzybowski, Piotr Kanclerz
2. Optics of Regular Astigmatism
12
Leon Strauss
3. Optical Clinical Assessment of Astigmatism, Surgical Vector Planning, and Analysis of Astigmatism for Refractive Surgery
22
Noel Alpins, George Stamatelatos
4. Keratometry and Placido‑based Topography: Techniques, Advantages, and Limitations
25
Damien Gatinel
5. Scanning-slit, Scheimpflug, and Optical Coherence Tomography in Regular and Irregular Astigmatism
36
Ricardo M Nosé, Mauro C Tiveron Jr, Roberto Pineda II
6. Morphogeometric Analysis of the Cornea and its Relation to Corneal Astigmatism
53
F Cavas Martínez, Asier Villanueva, Laurent Bataille, FJ Fernández Cañavate, DG Fernández-Pacheco
7. Corneal and Total Aberrometry: Orthogonal/Oblique and Secondary Higher‑order Aberrations in Astigmatism
60
Andrea Arteaga, Jose de la Cruz
8. Aberrated Cornea–Irregular Astigmatism in Real-world Optics: Topography, Aberrometry, and Applications in Refractive Surgery
66
Samantha Williamson, Joao Crispim, Dimitri Azar
9. Preoperative Evaluation of Astigmatism in Cataract Surgery
79
Debora E Garcia-Zalisnak, Joelle A Hallak, Soledad Cortina
10. Surgical Planning for the Correction of Astigmatism
85
Noel Alpins, George Stamatelatos
11. Posterior Corneal Astigmatism Measurement Techniques and Preoperative Planning for Cataract Surgery Kai Kang, Jose de la Cruz, Joelle A Hallak, Soledad Cortina, Dimitri Azar
91
xvi Surgical Management of Astigmatism 12. Toric Pseudophakic Intraocular Lenses: Materials/Characteristics of Toric Monofocal, Toric Bifocal, and Toric Trifocal Intraocular Lenses
99
Roberto Fernández-Buenaga, Jorge L Alió
13. Surgical Techniques: Axis Marking, Toric Intraocular Lens Positioning, and Incisional Approaches
117
Bryan S Lee, David F Chang
14. Intraoperative Alignment Techniques
128
Afua Annor, Jonathan Rubenstein
15. Induced and Residual Astigmatism after Cataract Surgery
136
Alexander Pleet, Soledad Cortina, Dimitri Azar
16. Correcting Astigmatic Surprises Following Toric Intraocular Lens Implantation
154
David R Hardten, John P Berdahl, Brent A Kramer
17. Cataract and Refractive Lens Exchange Surgery in Keratoconus
164
Jorge L Alió del Barrio, Roberto Fernández-Buenaga, Jorge L Alió
18. Astigmatic Keratotomy and Limbal Relaxing Incisions: Principles, Indications, and Nomograms
173
Eric D Rosenberg, Alanna S Nattis, Eric D Donnenfeld
19. Femtosecond Arcuate Keratotomy: Principles, Indications, and Techniques
180
Gunther Grabner
20. Laser Profiles and Depths for Myopic, Hyperopic, and Mixed Astigmatism
186
Shilpa Gulati, Joelle A Hallak, Dimitri Azar
21. Photoastigmatic Refractive Keratectomy and Laser-assisted in Situ Keratomileusis: Surgical Management of Astigmatism
195
Susie Drake, Soledad Cortina, Dimitri Azar, Joelle A Hallak
22. Small incision Lenticule Extraction versus Laser in Situ Keratomileusis in Myopic Astigmatism
213
Suphi Taneri
23. Outcomes of Photorefractive Keratectomy, Laser in Situ Keratomileusis, and Smallincision Lenticule Extraction for Myopic, Mixed, and Hyperopic Astigmatism
221
Jorge L Alió del Barrio, Verónica Vargas, Roberto Fernández-Buenaga, Jorge L Alió
24. Custom Treatment of Irregular Astigmatism Arthur Cummings
231
Contents
25. Management of Postkeratoplasty Astigmatism
240
Praneetha Thulasi, Joelle A Hallak, Dimitri Azar, Soledad Cortina
26. Management of Astigmatism after Cataract Surgery: Excimer Laser, Astigmatic Keratotomy, Piggyback IOL and IOL Exchange
249
Renan Ferreira Oliveira, Roberto Fernández-Buenaga, Jorge L Alió del Barrio, Jorge L Alió
27. Surgical Management of Corneal Ectatic Disorders Using Intracorneal Ring Segments, Corneal Collagen Cross-linking, and Thermokeratoplasty Procedures 262 Alfredo Vega-Estrada, Renan Ferreira Oliveira, Jorge L Alio
28. Topography-guided Surgical Correction of Astigmatism: Indications, Techniques, Limitations, and Complications
271
John SM Chang
29. Toric Implantable Collamer Lenses for the Correction of Astigmatism
283
Tomoaki Nakamura
30. Iris Clip Toric Phakic Intraocular Lenses for Keratoconus and Irregular Astigmatism
296
Almutez M Gharaibeh, Jorge L Alió
Index 309
xvii
CHAPTER 1 Etiology, Pathogenesis, and Epidemiology of Astigmatism and History of its Surgical Management Andrzej Grzybowski, Piotr Kanclerz
CORE MESSAGES ll
ll
ll
ll
ll
This chapter covers the etiology, pathogenesis, and epidemiology of astigmatism, as well as the history of surgical treatment. The lack of standardized methods for populationbased studies on astigmatism make comparisons challenging. Visual impairment caused by astigmatism ranges from 2.2 to 34%. The 19th century contributed greatly to our under standing and management of astigmatism, with the first attempts to alter the refraction in astigmatic patients by changing the shape of the cornea made in the final two decades of the 19th century. The occurrence of acquired astigmatism is an issue in several ophthalmic procedures.
EPIDEMIOLOGY According to the World Health Organization, in 2004, a total of 153 million people (range of uncertainty: 123–184 million) were estimated to have visual impairment due to uncorrected refractive errors, of whom 8 million were blind.1 Other sources report that uncorrected refractive errors and cataract are the principal causes of visual impairment globally (43 and 33%, respectively).2-4 Naidoo et al. put focus on the increase in vision impairment due to uncorrected refractive errors: 15% in years 1990–2010.5 Visual impairment caused by astigmatism ranges from 2.2 to 34% depending on the region and the urban/rural
setting.1 This gives an estimate of 2.7 up to 62.5 million people with vision loss as a result of this disorder.2-5 In some studies, the prevalence of astigmatism in people aged over 50 years reaches 77%.6,7 Assessment of the prevalence of astigmatism encounters a number of technical problems. Compa risons between studies might be problematic, as no standardization has been introduced. Refractive error measurements in population-based studies are usually noncycloplegic. Commonly, stationary autorefractors are used, however, home evaluation with handheld autorefractors was employed in single studies. In children, diagnostics of the refractive error are determined by objective refraction under cycloplegia and subjective refraction. In infants and preschool children, most measurements are obtained by retinoscopy. Astigmatism is usually defined as a refractive error of ≥1.00 cylindrical diopter, less commonly as ≥0.75 cylindrical diopter.8 The axis of the cylinder is classified as with-the-rule if the minus cylinder axis is 0 ± 15°,8,9 against-the-rule if the axis is 90 ± 15°, and oblique astigmatism when the axis does not comply the preceding criteria. In some studies, the range was 45° (0 ± 22.5° for with-the-rule, 90 ± 22.5° for against-the-rule).10 Moreover, a range of 40° or 60° is used in some papers.11 Several studies lacked information regarding the preceding criteria.12,13 Furthermore, there is a deficiency of cross-sectional reviews. Several studies relate to a specific age group or are related to very limited geographical areas.
2
Surgical Management of Astigmatism
Major Cross-sectional Studies The European Eye Epidemiology Consortium conducted a meta-analysis of data from 33 adult cohort and cross-sectional studies. Refractive data were collected between 1990 and 2013, mostly from Northern and Western Europe. Fifteen population-based studies met the eligibility criteria. In patients aged over 15 years, the prevalence of astigmatism was 27.3% with an agestandardized prevalence of 23.9%.12 Astigmatism rates were fairly constant in the analyzed studies (15–25%), but were higher after the age of 65. As data on ethnicity were available for only 50% of participants with minimal ethnic diversity, analysis of ethnicity was not carried out. Across all age groups the prevalence of astigmatism was higher in men than in women, and this difference was particularly pronounced in middle aged individuals. As most of the studies were conducted in Northern and Western Europe, no conclusions regarding predominance in particular regions could be drawn.11 The prevalence of astigmatism in the United States was evaluated in the National Health and Nutrition Examination Survey on 14,213 adult participants, which were examined in the years 1999–2004.13 The reported rates varied by age; for age groups of 20–39, 40–59, and ≥60 years, prevalence estimates were 23.1, 27.6, and 50.1%, respectively. The prevalence of astigmatism varied slightly by race–ethnicity category. In those aged 60 years and older, astigmatism was more prevalent among males (54.9%) than among females (46.1%). The Blue Mountains Eye Study was a populationbased assessment of visual impairment of the representative older Australian community sample. The examinations were performed in years 1992–1994.8 The prevalence of astigmatism (equal or higher than 0.75 cylindrical diopter) was 37%, and high cylinder values (higher than 1.5 D) were reported in 13% of eyes. The gender-adjusted mean cylinder increased with age: for ages 49–59, 60–69, 70–79, and 80–97 years, it was −0.6 D, −0.7 D, −1.0 D, and −1.2 D, respectively. There was no statistically significant difference in the mean cylindrical error between men and women. Furthermore, a trend of increased cylindrical error with the spherical error (either myopic or hyperopic) was found. There was no difference in the axis of astigmatism by gender or age group.
Most of the aforementioned population-based studies on refractive errors correspond to European or Europeanderived populations. Some large population-based studies in Asian populations have been conducted in Singapore, Nepal, Hong Kong, China, and Malaysia.14 The Singapore Epidemiology of Eye Disease Study reported the prevalence of astigmatism as 58.8% in a multiethnic cohort aged 40 years and over.15 The prevalence of astigmatism increased with increasing age, while no sex difference was found. The prevalence of astigmatism in the Chinese Singaporeans was significantly higher in all age groups compared with that in Singaporean Indians. Furthermore, the authors observed that the prevalence of astigmatism increased significantly during the 12 years of the study. The major increase in the astigmatism rate was due to the increase in the myopic astigmatism rate, which accounted for 72% of the observed increase in the rate of astigmatism, while hyperopic astigmatism accounted only for 16%. Therefore, the authors postulated that the increase in myopic astigmatism was due to the rise in environmental factors such as a more competitive education environment. The Baltimore Eye Study was a population-based survey of ocular disorders among patients aged 40 years and older living in East Baltimore, Maryland, United States. It was conducted in the years 1985–1988. The rates of astigmatism were higher for White people than for Black people at all ages. In this study, astigmatism increased with age in men and was more prevalent in men than in women.16 These results were similar to the findings from the European Eye Epidemiology Consortium. Most of the studies found that the rates of astigmatism are higher in men or revealed no differences between genders. However, some reports from China and Bangladesh noted a higher prevalence of astigmatism in women.17-19 A correlation between astigmatism and cataract formation has been found, however, the mechanism by which cataract induces astigmatism is not always clear. It is argued that mainly cortical cataract can lead to astigmatic shift and it might be caused by asymmetrical refractive index changes within the parts of the cortex of the lens.20 Moreover, an association between nuclear cataract and astigmatism was described.19 Other epidemiological risk factors for astigmatism include lower educational background and living in an urban population.11,17,19
Etiology, Pathogenesis, and Epidemiology of Astigmatism and History of its Surgical Management
Relationship between Age and Astigmatism Nearly half of 0- to 6-month-old infants have significant astigmatism of one or more diopters. The prevalence found in the first year of life is greatly reduced by the age of 4, reaching