June 1, 2020
By Sally M. Dillehay, OD, EdD, FAAO
As more information is released into the lay press about myopia1 and its potential for vision loss,2 patients and parents may inquire about ways to slow its progression. They may also seek second opinions, which raises the question: When is treatment for myopic progression not warranted?
To answer this question, examining the main risk factors for the development of myopia is helpful (see sidebar).3 Some of these factors apply more to onset than to progression of myopia, but it is useful to assess each potential contributor as part of the overall evaluation. The more risk factors that are present, the more likely a child will become myopic and/or progress.
Using these factors as guidelines,3 here are a few examples where treatment for myopia management may not be warranted.
Example 1: Ashley is a 7-year-old caucasian female. Her -1.00DS glasses were prescribed about one year prior; she does not wear them very often. Her father has never worn glasses, but her mother had LASIK. Ashley is active in soccer, spends five to seven hours per week outside and about three to four hours per day on a tablet device. Her previous eye care professional prescribed low dose atropine, but Ashley developed irritation and redness from the drops and refused to continue. Her mother wants to discuss other options to help slow the increase in Ashley’s prescription. At the time of the examination, her cycloplegic refraction is -1.50D OU, and axial length measurements are 23.3mm OU.
In terms of risk factors,3 Ashley is a young female with one myopic parent, limited outdoor time, and high digital near work time each day. She has also been under-corrected for the better part of a year since she will not wear her glasses. Her mother is open to orthokeratology and soft multifocal contact lenses. Still, Ashley flatly refuses to wear any type of contact lens as she is afraid to have anything in her eyes.
This is a case where myopia management is needed but one in which patient compliance severely limits treatment options. Although current spectacle options have limited evidence for slowing down the progression of myopia,4 they are the only reasonable option at this time. An executive bifocal with prism is the best evidence-based spectacle treatment available to most practitioners.4 But given the difficulties getting Ashley to wear her current spectacles, that is not likely to be a successful option due to cosmesis.
At a very minimum, Ashley needs to be wearing full distance correction, and her parents need to reinforce this need. Starting with sports/safety glasses for soccer may be beneficial, and hopefully, Ashley will appreciate the visual clarity of the distance correction. If she does, then full-time wear of a PAL spectacle may be a possible treatment but one that has demonstrated little clinical improvement in decreasing the amount of progression.4 Even though once a child is myopic outdoor time has not been shown to slow progression,3 getting Ashley outdoors as close to two hours per day every day and having her take frequent breaks when working at near may be beneficial. Soft multifocal contact lenses would eliminate any potential concern that Ashley has about wearing glasses, and orthokeratology would allow her not to wear any type of correction during the day. Unfortunately, Ashley remained fearful of putting anything into her eye and was not open to these possibilities. A six-month re-evaluation should be scheduled, at which time Ashley might be more mature and possibly open to different treatment modalities.
Example 2: Justin is a 2-year-old Eastern Asian male. Gestational history and developmental milestones are unremarkable. His parents have noticed him squinting quite a bit and are concerned as they are both highly myopic. They estimate that he spends about an hour outside each day. He is transfixed on a cell phone video and is holding it quite close. Cycloplegic retinoscopy reveals -9.00D OU, with an axial length of 25.5mm OU.
In this case, Justin meets (and exceeds) almost every known risk factor for myopic progression.3 He is already very highly myopic with an enlarged eye.5 The natural inclination might be to “throw everything possible” in this case and get him on high-dose atropine along with a PAL and photochromic spectacle lenses. But when a child’s dioptric refraction is greater than his age in years, caution is warranted.4 It is possible that this is a different type of myopia, and perhaps one caused by an underlying medical condition, such as a collagen disorder.4,6 Further testing is advised to look for a potential underlying cause, probably including genetic testing.6
Example 3: Henry is a 14-year-old caucasian male. He just started high school and has been a patient for six years. Neither parent is myopic. He currently wears a single vision spherical daily disposable contact lens. He spends most of his time indoors playing video games or programming computers. His cycloplegic refraction is -3.00D OU, which has increased 0.25D since his last eye exam two years ago. Axial length is 23.50 mm OU. His K readings are quite steep at around 47.00/47.50 OU. DFE shows a normal retina without tessellation of the fundus or peripapillary atrophy.
Although Henry spends a lot of his time indoors and on digital devices, he does not appear to be at high risk for progression, nor is his axial length approaching a level of increased concern for potential vision loss (i.e., close to 26 mm).7 The lack of tessellation8 and peripapillary atrophy9 are reasonable indications that retinal stretching has been minimal. Approximately 50 percent of children stop progressing by age 15.10 and Henry’s current progression was less than the average expected (0.55D/year for caucasians).11 Henry and his parents are advised that no treatment for myopic progression is warranted at this time. His next exam is scheduled for one year, as he may have increased progression with increased near work demands in high school.
The process of managing myopia involves complex decision making, with available evidence on risk factors sometimes unknown or confounded by other risk factors.4 Lack of sufficient data on long term efficacy and safety of treatment options, access to treatment options, patient motivation, cost, and patient acceptance may limit the myopia management strategies that can be utilized for a given case.12 It is important to treat progressive myopes as early as possible, using available treatment options. When treatment options are limited for a variety of reasons, frequent follow-up and monitoring are recommended.
Sally M. Dillehay, OD, EdD, FAAO, is CEO of ClinTrialSolutions, a medical research organization assisting companies with medical device research, clinical trials, submissions to regulatory agencies and medical marketing. She serves as an expert contributor for the Brien Holden Vision Institute Global Myopia Centre.
SIDEBAR: The main risk factors for the development of myopia
Age: Increased rates of progression are observed in younger children.13 Additionally, the younger that a child becomes myopic, the more likely they will develop higher levels of myopia.4
Amount of outdoor time: Low outdoor time (less than 90-120 minutes per day) has been associated with a 2-3X increased risk for the onset of myopia.14
Amount and type of near work: Although studies are very mixed, more recent studies indicate that increased near work time (> 3 hours per day)14 may increase the risk of myopia.15
Results of studies on the type of near work are also mixed,15, but again more recent studies tend to support that near work on digital devices may be associated with a 2-3X increase in the development of myopia with as little as 30-60 min/day, at least in some children.16
Ethnicity: Increased prevalence and rates of progression have been observed in children of East Asian descent versus Caucasian.11
Parental myopia: If one parent is myopic, the child is at 3X the risk to develop myopia, and 6X the risk if both parents are myopic.17
Refractive error: If a child is less hyperopic than +0.75D at age 6, they are at increased risk of becoming myopic.18
Gender: In general, girls tend to progress more quickly than boys.4
- Mackey D. Short sightedness in kids was rising long before they took to the screens. theconversation.com. January 6, 2020. Accessed May 14, 2020.
- Smith A, Griff AM. What to know about myopia. https://www.medicalnewstoday.com/articles/myopia. March 26, 2020. Accessed May 14, 2020.
- Brien Holden Vision Institute. globalmyopiacentre.com Accessed May 14, 2020.
- Bullimore MA, Richdale K. Myopia Control 2020: Where are we and where are we heading?Ophthal Physiol Opt 2020;40:254–270.
- Chua SY, Sabanayagam C, Cheung YB, et al. Age of Onset of Myopia Predicts Risk of High Myopia in Later Childhood in Myopic Singapore Children. Ophthalmic Physiol Opt 2016;36:388-394.
- Logan NS, Gilmartin B, Marr JE et al. Community-based study of the association of high myopia in children with ocular and systemic disease. Optom Vis Sci 2004; 81: 11–13.
- Tideman JW, Snabel MC, Tedja MS, et al. Association of Axial Length with Risk of Uncorrectable Visual Impairment for Europeans with Myopia. JAMA Ophthalmology 2016;134:1355-1363.
- Jagadeesh, D., Philip, K., Naduvilath, T.J., Fedtke, C., Jong, M., Zou, H. and Sankaridurg, P. (2019), Tessellated fundus appearance and its association with myopic refractive error. Clin Exp Optom, 102: 378-384.
- Yokoi T, Jonas JB, Shimada N, Nagaoka N, Moriyama M, Yoshida T, Ohno-Matsui K. Peripapillary Diffuse Chorioretinal Atrophy in Children as a Sign of Eventual Pathologic Myopia in Adults. Ophthalmology. 2016 Aug; 123(8): 1783–1787.
- COMET Group. Myopia stabilization and associated factors among participants in the Correction of Myopia Evaluation Trial (COMET). Invest Ophthalmol Vis Sci 2013; 54:7871–7884
- Donovan L, Sankaridurg P, Ho A, Naduvilath T, Smith EL, 3rd, Holden BA. Myopia progression rates in urban children wearing single-vision spectacles. Optom and Vis Sci: Official publication of the American Academy of Optometry 2012;89:27-32.
- Sankaridurg P. Do standard single vision soft contact lenses and spectacles accelerate refractive error? Review of Myopia Management 2020 (Feb 4). Accessed May 14, 2020.
- Sankaridurg PR, Holden BA. Practical applications to modify and control the development of ametropia. Eye 2014;28:134-141.
- Rose KA, Morgan IG, Smith W, Burlutsky G, Mitchell P, Saw SM. Myopia, lifestyle, and schooling in students of Chinese ethnicity in Singapore and Sydney. Archives Ophthalmol 2008;126:527-530.
- Lanca C, Saw, S‐M. The association between digital screen time and myopia: A systematic review. Ophthalmic Physiol Opt 2020; 40: 216– 229.
- Saxena R, Vashist P, Tandon R, Pandey R, Bhardawaj A, Gupta V, Menon V. Incidence and progression of myopia and associated factors in urban school children in Delhi: The North India Myopia Study (NIM Study). PLoS One. 2017; 12(12): e0189774.
- Mutti DO, Mitchell GL, Moeschberger ML, Jones LA, Zadnik K. Parental myopia, near work, school achievement, and children’s refractive error. Invest Ophthal & Vis Sci 2002;43:3633-3640.
- Zadnik K, Sinnott LT, Cotter SA, et al. Prediction of Juvenile-Onset Myopia. JAMA Ophthalmology 2015;133:683-689.