Clinical

Graduating Patients from Myopia Management

October 1, 2021

By Erin S. Tomiyama, OD, MS, and Kathryn Richdale, OD, PhD

The ultimate choice of when to stop must be based on an educated discussion with the patient and parent.

As myopia management becomes more common, we often get the question from parents, “how long does my child need to do this treatment?” While research on discontinuation of myopia management is still in its infancy, we know that a child’s refractive error will eventually stabilize, and they will no longer need myopia management. Therefore, a protocol should be developed to proactively stop myopia management and transition to traditional corrections.

When to Stop Myopia Management
The primary uncertainty for practitioners in stopping or, as we call it, “graduating” children from myopia management is when this should occur. The COMET study group found that 48% of their cohort of nearly 500 myopic children reached stabilization by age 15, 77% by age 18, 90% by age 21, and 96% by age 24.1  The mean age of myopia stabilization was 15.6 ± 4.2 years. They defined stabilization of myopia as “estimated spherical equivalent refraction within 0.50D from the asymptote,” in other words, progression of up to 0.50D could continue after this age. Importantly, axial length may continue to progress slightly, even after stabilization of refractive error.2 Also of note, the age of myopia onset in the COMET group was around 7-8 years old; therefore, these estimates of stabilization may not apply to late-onset myopia.3 

The ultimate choice of when to stop must be based on an educated discussion with the patient and parent. Practitioners may suggest stopping myopia management based on limited refractive or axial length progression over the previous year or two. Patients get the most bang for their buck when the child is younger, and their progression is occurring at a faster rate. As children get older and naturally start to slow in progression, the relative amount of myopia management efficacy decreases.

There are some unique considerations for discontinuing myopia management for each treatment. Older children using atropine may find that the side effects associated with an increased pupil may affect their activities of daily living. Though usually mild, these side effects could interfere with increased schoolwork and driving, especially at nighttime. 

Visual compromise may also be a concern with contact lens treatments. Most orthokeratology patients must wear their lenses for at least seven to eight hours every night to ensure full myopia correction. Teenagers may run into the issue of not getting enough sleep each night or forgetting to apply their lenses, and thus they may not always appreciate fully corrected refractive error. Patients undergoing myopia management with soft contact lenses who have astigmatism greater than 1.00D may likely be in a reusable multifocal toric lens but may benefit from a daily disposable toric lens. The CLAY study group found that the risk for soft contact lens complications is highest among 15-25-year-old patients. The CLAY group and others have consistently found a higher rate of complications among reusable lens wearers.4 Daily disposable lenses could also be necessary for patients with chronic allergies, as we often see in the Southern U.S. 

While we may want to achieve myopia stabilization in every patient before stopping treatment, other considerations may cause parents to want to stop treatment sooner. The additional cost and visits typically associated with myopia management may be a barrier. Parents may consider the cost-benefit ratio of myopia management as their child’s progression naturally slows. As high school patients prepare to move away for college, they may still be progressing slightly, but myopia management may need to be stopped or modified to support this transition.

How to Transition Out of Myopia Management
Once the patient and parent have decided to discontinue myopia management, the next consideration is what form of correction the patient will use. Treatment options include single vision spectacles or contact lenses, and there are now many options for daily disposable spherical and toric lenses. As stated above, daily disposable contact lenses would be the preferred option since they offer the lowest risk for infection.5 

After deciding what treatment to switch to, follow-up appointments will be necessary. If switching from a myopia management soft lens to another soft contact lens brand, a one- to two-week follow-up should be scheduled to ensure optimal comfort, fit, vision, and ocular surface health. With orthokeratology, patients may need a longer period of washout – typically 1-4 weeks,6 depending on the amount of myopia and the length of time in orthokeratology. During this time, practitioners should provide daily disposable lenses in a range of powers and see patients weekly until topography and manifest refraction are stable. 

Although a few studies have suggested the possibility of a small rebound effect with orthokeratology, to date, there have been no randomized clinical trials to comprehensively assess rebound following discontinuation of orthokeratology. Both the BLINK study and MiSight trial have a one-year washout phase planned, and we look forward to learning more about any rebound effect with optical devices. Similarly, some have suggested that atropine should be tapered, but while research has shown a significant rebound effect with 1% atropine, rebound with 0.025% and 0.05% is unknown. Phase 3 of the LAMP study will provide data to make evidence-based decisions on washout with these concentrations.

With no strong data suggesting a significant rebound effect in older teenage patients, these patients could revert to annual exams. Due to the small amount of progression expected and known seasonal variations in progression, a six-month evaluation is no longer necessary. Practitioners can continue to perform axial length measurements at the next annual visit. If significant annual progression is noted, an informed decision can be made about re-initiating myopia management. 

Making Graduation Fun
Lastly, there are several ways to make this a fun experience for the family. Graduations could be enhanced with a certificate or diploma for completing myopia management, along with before and after photos to show how the child has grown over treatment. From a practice management standpoint, these success stories are great tools for marketing and can serve as encouragement for new patients. Some axial length biometers, such as the Haag-Streit Lenstar Myopia, have an optional report feature that visually represents the slowing of refractive error and axial length over time. Practitioners without access to these devices could also plot the patient’s data using any commonly available graphing software, such as Microsoft Excel.

It is important to acknowledge the commitment that both the parent and child have made to myopia management and celebrate their treatment’s success. 

 

 

Erin S. Tomiyama, OD, MS, is a teaching fellow and doctoral student at the University of Houston College of Optometry. She received her OD from Marshall B. Ketchum University and completed her Cornea and Contact Lens residency at the University of Houston.

 

 

 

 

 

Kathryn Richdale, OD, PhD, is an Associate Professor and Co-Director of the Myopia Management Service at the University of Houston College of Optometry. She received her OD, PhD, and Cornea and Contact Lens Advanced Practice Fellowship from The Ohio State University and is a Diplomate of the American Academy of Optometry Cornea, Contact Lenses and Refractive Technologies Section.

 

References:

  1. Hardy R, Hillis A, Mutti D, et al. Myopia stabilization and associated factors among participants in the correction of myopia evaluation trial (COMET). Investig Ophthalmol Vis Sci. 2013;54(13):7871-7883. doi:10.1167/iovs.13-12403
  2. Hou W, Norton TT, Hyman L, et al. Axial elongation in myopic children and its association with myopia progression in the correction of myopia evaluation trial. Eye Contact Lens. 2018;44(4):248-259. doi:10.1097/ICL.0000000000000505
  3. Bullimore MA, Richdale K. Myopia Control 2020: Where are we and where are we heading? Ophthalmic Physiol Opt. 2020;40(3):254-270. doi:10.1111/opo.12686
  4. Chalmers RL, Wagner H, Mitchell GL, et al. Age and Other Risk Factors for Corneal Infiltrative and Inflammatory Events in Young Soft Contact Lens Wearers from the Contact Lens Assessment in Youth (CLAY) Study. Investig Opthalmology Vis Sci. 2011;52(9):6690. doi:10.1167/iovs.10-7018
  5. Chalmers RL, Keay L, McNally J, Kern J. Multicenter Case-Control Study of the Role of Lens Materials and Care Products on the Development of Corneal Infiltrates. Optom Vis Sci. 2012;89(3):316-325. doi:10.1097/OPX.0b013e318240c7ff
  6. Soni PS, Nguyen TT, Bonanno JA. Overnight orthokeratology: Refractive and corneal recovery after discontinuation of reverse-geometry lenses. Eye Contact Lens. 2004;30(4):254-262. doi:10.1097/01.ICL.0000140637.58027.9B
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