August 1, 2023
By Craig Woods, BSc (Hons), PhD, MCOptom, Clinical Consultant, BHVI
Can we start the conversation with our patients/parents about the need to minimize any level of myopia and axial growth? Additionally, explain that starting treatment because of the presence of any risk factor for myopia development is justified, and we should not wait for myopia to progress.
Over the past few years, much has been published about the management and control of myopia progression. A number of publications measuring the effectiveness of various treatment strategies have recently been summarized by Lanca et al.(2023).1 We now have reasonable evidence to show these therapies work, whether utilizing atropine,2 orthokeratology,3 multifocal optics with soft contact lenses,4 or spectacles.5,6
Why Do We Consider Therapies to Control Myopia Progression?
Some may question why the fuss about managing an optical abnormality that simply requires single vision spectacles or contact lenses for correction. This view is a little short-sighted (sic!) as the evidence is very clear that low levels of myopia lead to higher levels and the associated increase in risk for ocular disease. The call to take myopia management more seriously and consider the consequences of higher myopia was very clearly articulated by Safal Khanal (2023)7 in a recent editorial in the Ophthalmic and Physiological Optics journal. We know that as myopia increases, the risk of sight-threatening diseases such as cataracts, retinal detachment, glaucoma, and maculopathies increases.8-11
Is it Just the Level of Myopia, or Are There Other Factors?
The evidence is strong that the associated increase in axial length with myopia also carries risks of complications. The potential risk factors for axial elongation complications have been reported as female, the appearance of increasing areas of peripapillary chorioretinal atrophy, and smaller retinal vascular arcade angles.12 Understanding these predisposing factors is important, especially as in another study, ongoing axial elongation in highly myopic adults was found to occur.13 Tideman et al. (2016)13 concluded that an increased lifetime risk of visual impairment was associated with axial lengths of 26 mm or greater and refractive errors of −6.00D or greater, and that higher levels of myopia are likely to lead to a reduction in the success of treatments for these associated diseases later in life.
Finally, the evidence is compelling that these risk factors for ocular disease due to axial elongation do not appear to be modifiable, leading to the conclusion that prevention of myopia may be the best approach to reduce the incidence of pathological myopia and its complications in the future.14
So, the goal in instigating any treatment to control the progression of myopia is clear: to ideally arrest progression, but realistically to minimize progression of myopia and to minimize the increase in axial length. Delivering a treatment that results in a patient having less axial length growth and a lower level of myopia is our duty of care. It sets them up nicely for reducing the risk of myopia-related disease later in life and increasing their chance of improved treatment success for those diseases. Avoiding higher levels of myopia also improves quality of life. It reduces the financial burden on families due to the higher cost of appliances, higher frequencies of eye examinations, and costs of treatment of complications.15,16
Do We Have Interventions That Work?
Not only is the evidence clear on the effectiveness of various therapies, but evidence also exists that encouraging children to have increased outdoor time of at least two hours is beneficial in preventing or delaying myopia onset. This is especially the case in pre-school and early primary school children because there is evidence that the earlier myopia onset, the greater the likelihood of developing high myopia and, hence, the greater the risk of sight-threatening complications.17
So, we are close to the point where we are convinced myopia management is effective, but more importantly, do we understand who best to treat? Can we start the conversation with our patients/parents about the need to minimize any level of myopia and axial growth? Additionally, explain that starting treatment because of the presence of any risk factor for myopia development is justified, and we should not wait for myopia to progress.
When Should We Start Therapy?
We can conclude that where both parents have significant levels of myopia and an older sibling is already under myopia management for their developing myopia, a young child who is female and without myopia should be considered for early intervention.
The concept that prevention is better than cure is ubiquitous in health care. Attributed to a Dutch philosopher, Desiderius Erasmus (circa 1500), this concept is often a fundamental principle in addressing disease. Prevention in myopia as a concept was recently echoed by Bullimore and Brennan (2023)18 in their paper urging that myopia management should start two to three years sooner than is currently the case.
So, when do we start preventive myopia eye health care? How much evidence is needed? Do we now have sufficient evidence for the effectiveness of the different treatment options for progressive myopia? Are we ready to prevent myopia rather than try to arrest its progression? All thought-provoking questions, and just maybe we are a day closer to answering them. Are you ready to change your approach to how you manage and treat your young myopic patients?
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Professor Craig Woods is currently an adjunct professor at the University of New South Wales, a clinical consultant for BHVI, the Executive Manager of Educational Development for the International Association of Contact Lens Educators, and Vice President of the International Society for Contact Lens Research. He is also a member of the editorial boards for the Contact Lens & Anterior Eye and Eye & Contact Lens journals. He graduated in Optometry from The City University (London), was awarded his PhD while at Eurolens Research (UMIST, Manchester, U.K.), and gained his graduate certificate in Ocular Therapeutics from the University of Melbourne. He has authored over 190 refereed and professional papers and textbook chapters in related fields of ocular surface disease and contact lenses. |
References
1 Lanca, C. et al. Topical review: Studies on management of myopia progression from 2019 to 2021. Optom. Vis. Sci. 100, 23-30 (2023) DOI: 10.1097/OPX.0000000000001947
2 Yam, J.C. et al. Myopia control and prevention: From lifestyle to low-concentration atropine. The 2022 Josh Wallman Memorial Lecture. Ophthal. Physiol. Opt. 43, 299-310 (2023). DOI: 10.1111/opo.13118
3 Lee, Y.C. et al. Effect of Orthokeratology on Myopia progression: Twelve-year results of a retrospective cohort study. BMC Ophthalmol. 17:243 (2017). DOI 10.1186/s12886-017-0639-4.
4 Chamberlain, P. et al. Long-term effect of dual-focus contact lenses on myopia progression in children: A 6-year multicenter clinical trial. Optom. Vis. Sci. 99, 204-212 (2022). DOI: 10.1097/OPX.0000000000001873
5 Lam, C.S. et al. Myopia control effect of defocus incorporated multiple segments (DIMS) spectacle lens in Chinese children: Results of a 3-year follow-up study. Br. J. Ophthalmol; 106, 1110–1114 (2021). DOI: 10.1136/bjophthalmol-2020-317664
6 Bao, J. et al. Spectacle lenses with aspherical lenslets for myopia control vs single-vision spectacle lenses: A randomized clinical trial. JAMA Ophthalmol. 140, 472–478 (2022). DOI: 10.1001/jamaophthalmol.2022.0401
7 Khanal, S. Is myopia a disease or just a dis-ease. Ophthal. Physiol. Opt. 43, 595-597 (2023). DOI: 10.1111/opo.13145
8 Younan, C. et al. Myopia and incident cataract and cataract surgery: The Blue Mountains Eye Study. Invest Ophthalmol. Vis. Sci. 43, 3625-3632 (2002).
9 Ogawa, A. and Tanaka, M. The relationship between refractive errors and retinal-detachment – analysis of 1,166 retinal-detachment cases. Jap. J. of Ophthalmol. 32, 310-315 (1988).
10 Vongphanit, J. et al. Population prevalence of tilted optic disks and the relationship of this sign to refractive error. Am. J. of Ophthalmol. 133, 679-685 (2002). DOI: 10.1016/S0002-9394(02)01339-9
11 Flitcroft, DI. The complex interactions of retinal, optical and environmental factors in myopia aetiology. Prog. Ret. & Eye Res. 31, 622-660 (2012). DOI: 10.1016/j.preteyeres.2012.06.004
12 Kim, H.K. and Kim, S.S. Factors associated with axial length elongation in high myopia in adults. Int. J. Ophthalmol. 14, 1231-1236 (2021) DOI: 10.18240/ijo.2021.08.15
13 Tideman, J.W.L. et al. Association of axial length with risk of uncorrectable visual impairment for Europeans with myopia. JAMA Ophthalmol. 134, 1355-1363 (2016). DOI:10.1001/jamaophthalmol.2016.4009
14 Du, R. et al. Continued increase of axial length and its risk factors in adults with high myopia. JAMA Ophthalmol 139, 1-8 (2021). DOI: 10.1001/jamaophthalmol.2021.3303
15 Fricke, T.R. et al. Establishing a method to estimate the effect of antimyopia management options on lifetime cost of myopia. Br. J. Ophthalmol. Early Access: March 2022. DOI: 10.1136/bjophthalmol-2021-320318
16 Sankaridurg, P. et al. IMI Impact of Myopia. Invest. Ophthalmol. Vis. Sci. 62, 2 (2021). DOI: 10.1167/iovs.62.5.2
17 Morgan, I.G. et al. IMI risk factors for myopia. Invest Ophthalmol. Vis. Sci. 62, 3 (2021). DOI: 10.1167/iovs.62.5.3
18 Bullimore, M.A. and Brennan, N.A. Myopia: An ounce of prevention is worth a pound of cure. Ophthal. Physiol. Opt. 43, 116-121 (2023). DOI: 10.1111/opo.13058
