Identifying Children to Treat for Myopia and Evaluating Management Success

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April 1, 2024

By Dwight Akerman, OD, MBA, FAAO, FBCLA, FIACLE

Juvenile-onset myopia is a significant public health concern, as it can lead to various ocular complications that affect visual function, including retinal detachment, myopic macular degeneration, cataracts, and glaucoma. The authors of this research review, Mark A. Bullimore and Noel A. Brennan, provide a comprehensive overview of who to treat and how to evaluate treatment outcomes.

The authors note that the level of myopia is directly related to the risk of developing eye diseases, and although effective treatments are available that slow progression and limit the final degree of myopia, there is no safe level of myopia. Therefore, treating all myopic children is essential to reduce the burden of the disease. The authors argue that delaying the onset of myopia, reducing its progression, and limiting its final degree are primary goals of myopia management.

The authors review several methods for measuring refractive error and axial length, which are critical in myopia management. They emphasize the precision of optical biometry, which is the most accurate method for measuring axial length. However, the authors also stress the need for cycloplegic autorefraction. This method is essential for accurate measurement of refractive error in children and is particularly important in clinical trials.

Finally, the authors discuss the need to set attainable treatment goals in myopia management. They argue that the ultimate goal of myopia management should be to reduce the risk of ocular complications associated with high myopia. The authors provide tools for interpreting the rate of myopia progression and suggest that clinicians should evaluate the efficacy of treatments by comparing the progression rate of treated versus untreated eyes. Furthermore, the authors recommend that clinicians should use a combination of treatments, including optical, pharmacological, and environmental interventions, to achieve the best outcomes in myopia management.

In conclusion, the authors provide a comprehensive review of the current knowledge on who to treat and how to evaluate success in myopia management. They emphasize the importance of treating all myopic children, measuring refractive error and axial length accurately, considering the factors that influence myopia progression, and setting attainable treatment goals. This research review provides valuable information for clinicians who manage juvenile-onset myopia and highlights the need for continued research in this field.

Key Points:

1. Rationale for Slowing Progression:
   1. The risk of eye diseases, such as myopic macular degeneration, increases with the severity of myopia.
   2. However, there is no universally safe level of myopia, and even lower degrees of myopia impose a significant burden.
   3. Effective treatments exist that can slow myopia progression, thereby limiting the final degree of nearsightedness.
2. Treating All Myopic Children:
   1. The authors advocate for treating all children with myopia.
   2. Measurement of refractive error and axial length is crucial.
   3. Precision optical biometry is preferred, but cycloplegic autorefraction (using 1% tropicamide or 1% cyclopentolate) is also necessary for accurate assessment.
3. Factors Influencing Progression:
   1. The authors discuss various factors that impact myopia progression.
   2. These may include genetics, environmental factors (such as time outdoors), and lifestyle choices.
   3. Understanding these influences helps tailor treatment approaches.
4. Tools for Interpreting Progression Rate:
   1. The authors highlight available tools for assessing myopia progression and the effectiveness of interventions.
   2. These tools include the BHVI Myopia Calculator and percentile growth charts for refractive error or axial length.
5. Setting realistic treatment goals is essential to achieving successful outcomes.
   1. Treatment goals should be communicated to parents in diopters or mm rather than percentages.

Abstract

Juvenile-Onset Myopia — Who to Treat and How to Evaluate Success

Mark A. Bullimore and Noel A. Brennan

The risk of eye diseases such as myopic macular degeneration increases with the level of myopia, but there is no safe level of myopia, and the burden of lower degrees of myopia remains considerable. Effective treatments are available that slow progression and thus limit the final degree of myopia. In this review, the rationale for slowing progression is summarized, and a case made for treating all myopic children. Measurement of refractive error and axial length is reviewed, stressing the precision of optical biometry, but also the need for cycloplegic autorefraction. The factors influencing progression are considered and the available tools for interpretation of progression rate are discussed. Finally, the need to set attainable treatment goals is emphasized.

Bullimore, M. A., & Brennan, N. A. (2024). Juvenile-onset myopia—who to treat and how to evaluate success. Eye, 38(3), 450-454

DOI: https://doi.org/10.1038/s41433-023-02722-6