April 3, 2023
By David Kading, OD, FAAO, FCLSA, and Lauren Downey, OD
We know that each diopter increase in myopia means a higher risk of glaucoma, macular degeneration, and retinal detachments, so it should be standard practice to do everything possible to slow down myopia in not just children but in adults as well.
A 26-year-old male patient presented to our office two years ago with a refraction of -2.25D OU. We saw the patient again this year, and he had progressed to -3.00D of myopia with no other significant findings. Each year our patient progresses by 0.25D to 0.50D. How should we be dealing with this patient? He is outside the “normal” arena of myopia progression that we deal with in our younger patients. However, the patient’s concerns are the same as our myopic child patients. Like the parents of our myopic patients, he wants to know why his prescription continues to get worse and what we can do to stop it or slow it down. We have a plethora of literature on the options for slowing down myopia progression in children, but what about those adults who are progressing?
Adults Are Progressing
Over the last three years, digital device use and time spent indoors have increased for adults.1 It is known that our visual environment plays a significant role in myopia progression, and we are starting to learn that adults are also at risk of myopia progression with a lack of outdoor time.2 No longer can we confidently say that a child’s eye growth will stop by late teen years to early adulthood.2 About 30% of young adults progressed more than -0.75D over the course of two years during the COVID-19 pandemic.1 During this time, digital device use, online education, and time spent indoors also increased.1 This is not new data by any means; Bullimore et al. looked at over 800 contact-lens-wearing patients in a retrospective evaluation of their refractive error over five years; 48% of the subset of patients aged 20-25, and 35% of the group 25-30, progressed by at least -0.75D over the five years. These numbers continue to decline as patients age, but still, 25% of the 35-40-year-old patients showed the same progression.3
The management of this adult patient base has not been studied extensively, and the literature lacks strong evidence on how best to manage these patients. However, in our office, we have elected to take a similar approach to this patient base as we do to our younger patient base, with a few exceptions.
Education is Key
First, we always start with education. Education for this patient base particularly starts with axial length discussions. We now measure axial length on all of our patients, regardless of age, so we can not only know their risk for macular degeneration, glaucoma, and retinal detachments, but also to see if there is any change from year to year. For adults with an increase in myopia and an increase in axial length, we start by asking how they spend their typical day. Usually, the patient reports spending the majority of their day inside working on a computer and then looking at their phone or watching television in the evenings after work.
Indoor light has an impact. LED displays lack a potentially very important wavelength of light that we get from natural sunlight: violet light.4 The majority of LED lights used today are cold white LED lights, which contain primarily blue light with no violet light emission.4 It has been shown that not only does violet light play a role in normal eye development in childhood during emmetropization, but it may also protect adults with high myopia from further progression.5,6
We have a retinal circadian rhythm that expects a lot of sun exposure in the morning, moderate sunlight during the day, and no sun exposure in the evening.3 Our modern lifestyles have people waking up in the dark, sitting inside the majority of the day, and being exposed to artificially bright lights at night.
It is not easy to tell an adult whose job is on the computer to spend less time on their computer and phone and spend more time outdoors, but sharing with a patient the importance of time spent outdoors may give them an excuse for spending a little more time on their lunch break outside.
How Do You Treat Adult Myopes?
Similar to the ways that we’d treat young myopes, we also offer our progressing adult myopes the three primary treatment options for myopia: soft multifocal contact lenses, orthokeratology, and low-dose atropine. Much in the same way that a young patient’s lifestyle would come into play when choosing a treatment plan, we follow a similar set of criteria when creating treatment plans for adult myopes.
Soft Multifocal Lenses
Soft multifocal lenses in our office have had great success for both kids and adults. We tend to prescribe as high of an add as we possibly can within the lens options we have available to our patients based on Walline et al.’s work.8 However, our adult patients tend to have a more difficult time adapting to higher add powers than children. As such, when using soft multifocal contact lenses, we usually compromise some myopia control when prescribing lower add powers than we may give to a child. While not a perfect solution, it can be better than no treatment.
Orthokeratology has also been a successful modality in our practice for both children and adults. It provides the patient the freedom of daytime lens wear and can give phenomenal vision. With advanced OrthoK options, correction can be done for astigmatism and presbyopia. While current studies on the slowing of myopia with OrthoK are limited to children and adolescents, they provide a glimpse that it may be beneficial for slowing the progression in adults. However, we are always guarded with this evidence due to its limited sample size.9,10
Atropine is an incredible option for myopia management. Children in our office tend to have a higher accommodative ability than adults. When treated with atropine, we see adults more affected by near problems than children. As such, we use atropine as a last resort compared to contact lenses. However, if a patient is unwilling or unable to wear contact lenses, we may elect to go with a low-concentration atropine and fit them with spectacles with an add power that assists them with their decreased accommodation.
More research is needed on the effects of atropine, OrthoK, and soft multifocal contacts in adults because we are likely to continue to have an increase in adults whose myopia continues to worsen. We know that each diopter increase in myopia means a higher risk of glaucoma, macular degeneration, and retinal detachments,7 so it should be standard practice to do everything possible to slow down myopia in not just children but in adults as well.
|David Kading, OD, FAAO, FCLSA, has been recognized as one of the Top 50 Most Influential in Optometry, as one of the top 250 innovators by PCON, and as a CooperVision Best Practice. His three practices in Seattle focus on dry eye, specialty lenses, and myopia management. He co-owns Optometric Insights, which is changing the way students and doctors perceive practice. He performs research as part of the post-graduate Residency program that he hosts in Seattle. He lectures internationally and has written thousands of papers and articles. His podcasts: The OI Show and The Myopia Podcasts are released weekly and downloaded by practitioners worldwide. Dr. Kading sits on several boards of both medical and charity organizations. Most of all, Dr. Kading loves spending time with his three daughters and optometrist wife, Kristi Kading, OD, FAAO, FCOVD.
|Lauren Downey, OD, is currently a cornea and contact lens resident at Specialty Eye Group in Seattle, WA. She graduated from NECO last year and is originally from Southern California. Dr. Downey specializes in myopia management, dry eye management, and specialty lenses. Her residency has increased her interest in myopia management, specifically orthokeratology, so she continues to stay up to date on the latest research so she can bring it back to her patients.|
- Kohmarn, Thitika, et al. “Outbreak of COVID-19-Related Myopia Progression in Adults: A Preliminary Study.” Clinical Optometry, vol. Volume 14, Aug. 2022, pp. 125–31. DOI.org (Crossref), https://doi.org/10.2147/OPTO.S374155.
- Lee, Samantha Sze-Yee, et al. “Incidence and Progression of Myopia in Early Adulthood.” JAMA Ophthalmology, vol. 140, no. 2, Feb. 2022, p. 162. DOI.org (Crossref), https://doi.org/10.1001/jamaophthalmol.2021.5067.
- Bullimore, Mark A., et al. “A Retrospective Study of Myopia Progression in Adult Contact Lens Wearers.” Investigative Ophthalmology & Visual Science July 2002, Vol.43, 2110-2113. doi:
- Zhang, Chenchen, et al. “Ubiquitous Light-Emitting Diodes: Potential Threats to Retinal Circadian Rhythms and Refractive Development.” Science of The Total Environment, vol. 862, Mar. 2023, p. 160809. DOI.org (Crossref) https://doi.org/10.1016/j.scitotenv.2022.160809.
- Torii, Hidemasa, et al. “Violet Light Exposure Can Be a Preventive Strategy Against Myopia Progression.” EBioMedicine, vol. 15, Feb. 2017, pp. 210–19. DOI.org (Crossref), https://doi.org/10.1016/j.ebiom.2016.12.007.
- Torii, Hidemasa, et al. “Violet Light Transmission Is Related to Myopia Progression in Adult High Myopia.” Scientific Reports, vol. 7, no. 1, Nov. 2017, p. 14523. DOI.org (Crossref), https://doi.org/10.1038/s41598-017-09388-7.
- Bullimore, Mark A., and Noel A. Brennan. “Myopia Control: Why Each Diopter Matters.” Optometry and Vision Science, vol. 96, no. 6, June 2019, pp. 463–65. DOI.org (Crossref), https://doi.org/10.1097/OPX.0000000000001367.
- Walline, Jeffrey J., et al. “Effect of High Add Power, Medium Add Power, or Single-Vision Contact Lenses on Myopia Progression in Children: The BLINK Randomized Clinical Trial.” JAMA, vol. 324, no. 6, Aug. 2020, p. 571. DOI.org (Crossref), https://doi.org/10.1001/jama.2020.10834
- González-Méijome JM, Carracedo G, Lopes-Ferreira D, Faria-Ribeiro MA, Peixoto-de-Matos SC, Queirós A. Stabilization in early adult-onset myopia with corneal refractive therapy. Cont Lens Anterior Eye. 2016 Feb;39(1):72-7.
- Gifford KL, Gifford P, Hendicott PL, Schmid KL. Zone of Clear Single Binocular Vision in Myopic Orthokeratology. Eye Contact Lens. 2020 Mar;46(2):82-90