The Lipson/Koffler Myopia Management Treatment Protocol

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The following is the second of two articles on the assessment and treatment of myopia. The first article introduces a novel grading scale for Myopia Risk based on an innovative risk score developed by the authors based on their years of patient care experience and application of the most current scientific literature. It assesses and grades the risk of a patient becoming highly myopic (>6.00D). The treatment protocol described below starts by taking the total score from the risk assessment. 

The total score is a combination of risk scoring from seven attributes (detailed in the first article) that includes baseline axial length (Table 1). Most of the newer devices for measuring axial length using interferometry or OCT (IOLMaster, Lenstar Myopia, Pentacam AXL, MYAH, Myopia Master, Myopia Expert, Aladdin-M and others) are very accurate and repeatable. Although ultrasound devices, such as PalmScan, for axial length measurements are adequate and less costly, they are prone to variability.¹  If axial length is not available, use an alternate scale using a composite of the other six attributes (Table 2).

After scoring the attributes from the previous article on risk assessment, apply the total risk score to the appropriate Table to grade the level of risk.  If axial length is available, use Table 1 to assess the score. For example, if axial length is used, a score of 16 indicates “Moderate Risk.” The recommended treatment protocols are described in detail below. If axial length is not available, use Table 2. A score of 16 in Table 2 indicates “High Risk.”

As published literature suggests, use of the term “Myopia Control” (MC) refers to the most efficacious modalities intended to slow myopic progression and axial elongation: orthokeratology, soft multifocals, atropine, or myopia control spectacles (MCS).^2-4 The treatment protocols listed below are intended to be applied to patients who are myopic and require a correction for distance vision. “Pre-myopia” is defined as a refractive state of an eye of ≤ +0.75D and > -0.50D and a combination of baseline refraction, age, and other quantifiable risk factors provide a sufficient likelihood of the future development of myopia to merit preventative interventions.  

For all patients who are “pre-myopic,” at all levels of risk, use the recommendations below under PRE-MYOPIA in effort to delay the onset of myopia. These interventions are very impactful because it has been demonstrated that delaying the onset of myopia by just one year is equivalent to two to three years of myopia control efforts.⁵

Treatment Protocols

Treatment Protocol for PRE-MYOPIA

• Advise parents and patients of long-term risks of myopia, especially high myopia
• Advise parents and patients of myopia-inducing behaviors 
  • Reduced time spent on near tasks (recommend max of two hrs/day split into 20-30 minute sessions)
• Advise parents and patients of myopia slowing behaviors
  • Increased time spent outdoors (14 hrs/wk or more)
• In cases of high risk, consider prescribing 0.05% atropine qhs. Some studies have shown that atropine can delay the onset of myopia.⁶
• Monitor axial length and cycloplegic refraction every six months

Treatment Protocols for Patients who are Myopic (>0.50D of myopia)
Use the total risk score and the appropriate table above to grade level of risk

Lower Risk 

• Advise parents and patients of long-term risks of myopia, especially high myopia
• Advise parents and patients of myopia inducing behaviors and myopia slowing behaviors
  • Outdoor time, time on near tasks
• Delaying the onset of myopia by just one year is equivalent to two to three years of myopia control efforts⁵
• Initiate MC modalities IF parents and patient want to be proactive and age appropriate
• Consider orthokeratology, multifocal soft lenses, or myopia control spectacles 
• If not a CL candidate, atropine is a good option (may delay myopia onset)⁶, start with 0.05%
• Monitor axial length and cycloplegic refraction every six months

Low Risk

• Advise parents and patients of long-term risks of myopia, especially high myopia
• Advise parents and patients of myopia inducing behaviors and myopia slowing behaviors
  • Outdoor time, time on near tasks
• May choose to observe, but definitely prescribe increased outdoor time and reduced device time
• Start MC treatment if patient/parents desire earlier treatment
• Consider orthokeratology, multifocal soft lenses, or myopia-control spectacles 

Moderate Risk

• Prescribe MC with the modality most likely to result in compliance (orthokeratology, multifocal soft lenses, myopia control spectacles, or atropine)
• Initiate MC with monotherapy of orthokeratology, multifocal soft lenses, myopia control spectacles, or atropine
• Increased outdoor time and reduced device time
• Monitor axial length and cycloplegic refraction every six months

High Risk

• Prescribe the most efficacious MC modalities (orthokeratology, multifocal soft lenses, myopia control spectacles, or atropine)
• Prescribe MC monotherapy of orthokeratology, multifocal soft lenses, myopia control spectacles, or atropine, but also consider combination therapy (as listed below)
• Monitor axial length and cycloplegic refraction every three months 
• Modify MC regimen if showing significant progression

Very High Risk

• Prescribe aggressive MC modalities (orthokeratology, multifocal soft lenses, myopia control spectacles, or atropine)
• Combination of OrthoK and Atropine 0.05% + increased outdoor time and reduced device time
• Combination of multifocal soft contact lenses (MFSCL) and atropine 0.05% + increased outdoor time and reduced device time*
• Monitor axial length and cycloplegic refraction every three months
• Modify MC regimen if showing significant progression
• If not a CL candidate, combine atropine 0.05% and myopia control spectacles
• Also consider higher dosage of atropine (up to 0.5%)
  • *Combining 0.01% atropine with MFSCL has been shown to have similar efficacy to MFSCL alone.^7,8 But, in a group of subjects on 0.05% Atropine, myopia progression and axial elongation were significantly slower after the addition of dual-focus soft CLs.⁹

Summary

Axial elongation is both normal and expected in all children. However, children with longer-than-normal axial lengths or those who develop myopia at a younger age tend to experience faster progression of myopia, often to a greater degree. While any level of myopia carries a risk for complications later in life, the treatment protocols mentioned above can help reduce the likelihood of a child becoming highly myopic by limiting their eventual adult axial length. Therefore, interventions aimed at slowing myopic progression and axial elongation are most effective when initiated at a younger age. This straightforward and comprehensible guide is designed to equip practitioners with evidence-based and outcome-focused prescribing protocols to mitigate myopia progression and axial elongation, ultimately reducing the risk of patients developing high myopia. 

*Next-generation myopia control spectacle lenses are not yet FDA-approved or available in the U.S. at the time of publication. 

References

1. Lipson MJ. Axial Length Measurement: PalmScan Versus IOLMaster. Eye Cont Lens 2015;41: 156–159.
2. Lawrenson JG, Shah R, Huntjens B, et al. Interventions for myopia control in children: a living systematic review and network meta-analysis. Cochrane Database of Systematic Reviews 2023, Issue 2.
3. Wang M, Jib N, Yu S-A, et al. Comparison of 0.02% atropine eye drops, peripheral myopia defocus design spectacle lenses, and orthokeratology for myopia control. Clinical Exp Optom. 2024;107:813–819. 
4. Lipson MJ and Koffler BH. Advances in Ophthalmology and Optometry. 2019. Volume 4: 75–87.
5. Bullimore MA, Brennan NA. Myopia: An ounce of prevention is worth a pound of cure. Ophthalmic Physiol Opt. 2023;43:116-121.
6. Yam JC, Zhang XJ, Zhang Y, et al. Effect of Low-Concentration Atropine Eyedrops vs Placebo on Myopia Incidence in Children: The LAMP2 Randomized Clinical Trial. JAMA. 2023 Feb 14; 329:472-481.
7. Jones, JH, Mutti DO, Jones-Jordan LA, et al. Effect of Combining 0.01% Atropine with Soft Multifocal Contact Lenses on Myopia Progression in Children. Optom Vis Sci.2022;99:434-442.
8. Erdinest N, London N, Lavy I, et al. Low-Concentration Atropine Monotherapy vs. Combined with MiSight 1 Day Contact Lenses for Myopia Management. Vision 2022, 6,73. https://doi.org/10.3390/vision6040073
9. Yum, HR, Han, SY Park, SH, et al. Synergistic Effect of Dual-Focus Soft Contact Lenses and 0.05% Atropine on Myopia Control in Children With Rapidly Progressing Myopia. Eye Cont Lens: Published Ahead of Print, December 4, 2024.