Editor’s Perspective

Not So Fast

April 1, 2021

By Dwight Akerman, OD, MBA, FAAO

When do you recommend initiating treatment for a myopic child? During the fourth quarter of 2020, Review of Myopia Management and Jobson Optical Research polled nearly 300 ECPs from around the United States to learn more about their attitudes and behaviors regarding myopia management. 

Among the questions asked in this survey was, “When do you recommend initiating treatment for childhood progressive myopia?” Overwhelmingly, eye care practitioners take a wait-and-see attitude. Four in ten (40.8 percent) surveyed said they recommend myopia management treatment “as soon as a child is diagnosed as a fast progressor (-0.75D progression or higher per year.)” The next most common response (20.1 percent) was, “as soon as a child is diagnosed with -0.50D or more of myopia.” 

According to this survey, fast myopia progression is the primary reason to intervene, but a plethora of published research suggests that past progression does not predict future progression. According to Bullimore and Richdale, a single, progression-based criterion for treatment is not feasible as the age and ethnicity of the child, parental myopia history, environmental factors, and methods of measurement can influence the rate measured and may not adequately predict the final amount of myopia. 

Progression is faster in younger children, those of East Asian descent, and those with a parental history of myopia. However, nearly all young myopes progress, which argues in favor of managing all myopic children, irrespective of their estimated progression rate. Only managing the supposedly “fast progressors” will ignore large numbers of children who could benefit from myopia management.

Perhaps the most important reason to begin myopia management early is the reduced risk of visual impairment. Bullimore and Brennan analyzed data on over 21,000 adults across three continents. They demonstrated that each diopter of myopia is associated with a 67 percent increase in myopic maculopathy prevalence. Subsequent analysis using data from 15,000 patients has shown that each additional diopter of myopia is associated with a 25 percent increase in visual impairment.

So, when should myopia management be implemented, and on which children? Progression is highly likely once a child is identified as pre-myopic or myopic. The goal of myopia management is to limit axial length and refraction as much as possible but certainly to keep the axial length below 26 mm and less than -6.00D. According to the International Myopia Institute Clinical Guidelines Report, begin clinical treatment for all myopic children with ≥ 0.50D of myopia. Furthermore, at a minimum, provide lifestyle/visual hygiene guidance to all pre-myopic and myopic children. 

I urge you to treat or refer myopic children proactively and not wait until “fast progressors” are diagnosed. It is your professional responsibility and, in many communities, the standard of care.  

Best professional regards,

Dwight H. Akerman, OD, MBA, FAAO, FBCLA
Chief Medical Editor
dwight.akerman@gmail.com

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