A: Myopia is a growing epidemic with severe consequences for the patient’s vision, if left unimpeded. As a profession, we are in the process of learning much about myopia and management options, many of which are off-label and, thus, uncovered by insurance. As such, much education goes into the diagnosis and communication with patients and their parents.

Let’s review some of the big questions parents have regarding myopia management and how to discuss these topics with them.

Q: WHY IS MYOPIA MANAGEMENT IMPORTANT?

Every millimeter increase in axial length or diopter increase in prescription can lead to a higher risk of vision impairment in the future. The goal for myopia management is to slow myopic progression to prevent sight-threatening sequelae (e.g. pathologic myopia, myopic maculopathy, glaucoma, cataracts, retinal detachment) that can arise from high myopia.¹

Time should be taken to help parents understand that myopic progression increases the risk of ocular conditions that can impair vision. Many parents who are myopic themselves can understand the sequelae that can arise from being highly myopic.

Q: WHEN SHOULD I START MY CHILD ON MYOPIA MANAGEMENT?

When determining whether to strongly advocate for starting myopia management or monitor progression without management, consider:

1. Age: ^2,3 Scientific evidence shows younger onset leads to higher levels of myopia, if left untreated. Myopia begins to stabilize in the mid-teens.⁴ Therefore, consider monitoring older patients prior to initiating a therapy.
2. Refractive error:^3,4 If a myopic patient is refractively far from their age-expected hyperopic prescription at a young age, you’d expect that patient to have a higher risk for high myopia as the patient ages. (See “Age-Expected Refractive Error,” p. 23.)
3. Number of myopic parents:⁴ A child of two myopic parents have the highest risk for myopia onset and progression vs. one myopic parent and no myopic parents.
4. Ethnicity:^4-6 Asian children progress up to 50% faster than Caucasian children.
5. Axial length:⁷ Scientific evidence shows an axial length of 26 mm and higher is associated with an increased risk of vision impairment in later years in European and Asian populations.

When discussing these risk factors with parents, highlight the factors that pertain to their child specifically. During this discussion, parents will commonly ask what the chances are that their child will end up with high myopia. It is important to emphasize that you can’t predict that, due to the multifactorial nature of myopia progression.

Q: WITH CHILDREN SPENDING MORE TIME READING AND LEARNING UP CLOSE ON SCREENS DUE TO VIRTUAL LEARNING, WILL MY CHILD’S PRESCRIPTION WORSEN FASTER?

Duration or intensity of near work has been associated with myopia progression, but when looking at scientific research, it is more the reduction of outdoor time that negatively impacts myopia progression, regardless of how little or how much a child spends doing near work tasks.^8-10 For every 60 minutes of near work, I advise a minimum break of five minutes to 10 minutes focused on distance tasks or spending time outdoors. Spending about 90 minutes of outdoor time/day can have a beneficial effect in slowing the onset of myopia and myopia progression.^9-10

Q: WHAT ARE MY CHILD’S OPTIONS FOR TREATMENT, AND WHAT IS THE BEST OPTION FOR MY CHILD?

The main options for myopia management are atropine,^11-13 orthokeratology,^14-17 and soft multifocal contact lenses.^15,16,18,19 When these options aren’t viable, PALs or bifocal spectacles are possible options, though studies show that these methods are mainly only effective for patients who have large accommodative lags or who are esophoric.²⁰ Newly developed novel anti-myopia spectacle lens designs show promise in reducing myopic progression, but they are only available in Asia and Europe.^21-24 (For a more in-depth discussion on these myopia management options, see “Myopia Management: What Are the Options?” by Debbie Jones, FCOptom, F.A.A.O., at bit.ly/myopiaoptionsjones .)

To determine which option is best, look at factors, such as refractive error, keratometry, topography, binocular vision disorders, lifestyle (does the child play sports?) and compliance with glasses. For example, if the child has poor compliance with glasses, orthokeratology or soft multifocal contact lenses can be an option to ensure compliance with full-time prescription wear.

Next, recommend what option(s) the child is a good candidate for, and develop a plan with the family and child as a team. When the child is involved in the decision-making process, in particular, I have found they have a higher rate of compliance, which, in turn, results in better visual outcomes.

Q: ARE CONTACT LENSES SAFE, ESPECIALLY WITH COVID-19?

There is no scientific evidence to suggest that contact lens wearers are at a higher risk for contracting COVID-19.²⁵ The CDC and WHO advise good hand hygiene and contact lens hygiene to help protect one’s ocular health from infections and the transmission of COVID-19, regardless of age.

Q: HOW DO I KNOW WHETHER TREATMENT IS WORKING?

When discussing efficacy with parents, make sure they understand that myopia management does not completely halt myopia progression, so it’s not a surprise when progression is seen. Comparing the patient’s progression on myopia management to progression via refractive error and axial length prior to therapeutic intervention is a helpful visual for parents.

Although myopia management’s goal is to slow myopia progression, it is also important to educate parents that there is still a subset of patients who can progress rapidly, despite myopia management.^11,14 In these particular cases, increasing the concentration of atropine¹² or initiating a combination therapy is an evidence-based management option.^26,27

Q: WHAT ARE SOME RESOURCES FOR ME TO LEARN MORE ABOUT MYOPIA AND MYOPIA MANAGEMENT OPTIONS?

A multitude of free online tools and websites discuss myopia and myopia management; they include:

• Myopia Profile (myopiaprofile.com )
• My Kids Vision (mykidsvision.org )
• Brien Holden Vision Institute Myopia Calculator (bhvi.org/myopia-calculator-resources/ )
• Myopia Care (myopiacare.com )
• Myopia Institute (myopiainstitute.com )

Myopia management is an important discussion to have with your young patients’ parents, but also with the patients themselves. Discussing myopia management options as a “team” is an important part of the myopia management process that will lead to success in the long term. OM

REFERENCES

1. Flitcroft DI. The complex interactions of retinal, optical and environmental factors in myopia aetiology. Prog Retin Eye Res. 2012;31(6):622-660.
2. Zadnik K, Sinnott LT, Cotter SA, et al. Prediction of juvenile-onset myopia. JAMA Ophthalmol. 2015;133(6):683-689.
3. Jones-Jordan LA, Sinnott LT, Manny RE, et al. Early childhood refractive error and parental history of myopia as predictors of myopia. Invest Ophthalmol Vis Sci. 2010;51(1):115-121.
4. Donovan L, Sankaridurg P, Ho A , Naduvilath T, Smith EL, Holden BA. Myopia progression rates in urban children wearing single-vision spectacles. Optom Vis Sci. 2012;89(1):27-32.
5. COMET Group. Myopia stabilization and associated factors among participants in the Correction of Myopia Evaluation Trial (COMET). Invest Ophthalmol Vis Sci. 2013;54(13):7871-7884. Published 2013 Dec 3.
6. Donovan L, Sankaridurg P, Ho A, Naduvilath T, Smith EL 3rd, Holden BA. Myopia progression rates in urban children wearing single-vision spectacles. Optom Vis Sci. 2012 Jan;89(1):27-32.
7. Tideman JW, Snabel MC, Tedja MS, et al. Association of Axial Length With Risk of Uncorrectable Visual Impairment for Europeans With Myopia. JAMA Ophthalmol. 2016;134(12):1355-1363.
8. Rose KA, Morgan IG, Ip J, Kifley A, et al. Outdoor activity reduces the prevalence of myopia in children. Ophthalmol. 2008;115(8):1279-1285.
9. Wu PC, Tsai CL, Wu HL, Yang YH, Kuo HK. Outdoor activity during class recess reduces myopia onset and progression in school children. Ophthalmology. 2013;120(5):1080-1085.
10. Wu PC, Chen CT, Lin KK, et al. Myopia prevention and outdoor light intensity in a school-based cluster randomized trial. Ophthalmology. 2018;125(8):1239-1250.
11. Chia A, Lu QS, Tan D. Five-year clinical Trial on atropine for the treatment of myopia 2: myopia control with atropine 0.01% eyedrops. Ophthalmology. 2016;123(2):391-399.
12. Chua WH, Balakrishnan V, Chan YH, et al. Atropine for the treatment of childhood myopia. Ophthalmology. 2006;113(12):2285-2291.
13. Yam JC, Jiang Y, Tang SM, et al. Low-Concentration Atropine for Myopia Progression (LAMP) Study: A randomized, double-blinded, placebo-controlled trial of 0.05%, 0.025%, and 0.01% atropine eye drops in myopia control. Ophthalmology. 2019;126(1):113-124.
14. Hiraoka T, Kakita T, Okamoto F, Takahashi H, Oshika T. Long-term effect of overnight orthokeratology on axial length elongation in childhood myopia: a 5-year follow-up study. Invest Ophthalmol Vis Sci. 2012;53(7):3913-3919.
15. Cho P and Cheung SW, Retardation of myopia in Orthokeratology (ROMIO) study: a 2-year randomized clinical trial. Invest Ophthalmol Vis Sci. 2012;53(11):7077-7785.
16. Walline JJ, Jones LA, Sinnott LT, Corneal reshaping and myopia progression. Br J Ophthalmol. 2009;93(9): 1181-1185.
17. Cho P, Cheung SW, Edwards M, The longitudinal orthokeratology research in children (LORIC) in Hong Kong: a pilot study on refractive changes and myopic control. Curr Eye Res. 2005;30(1):71-80.
18. Walline JJ, Greiner KL, McVey ME, Jones-Jordan LA, Multifocal contact lens myopia control. Optom Vis Sci. 2013;90(11):1207-14.
19. Walline JJ, Walker MK, Mutti DO, et al. Effect of high add power, medium add power, or single-vision contact lenses on myopia progression in children: The BLINK Randomized Clinical Trial. JAMA. 2020;324(6):571-580.
20. Gwiazda JE, Hyman L, Norton TT, Hussein ME, Marsh-Tootle W, Manny R, Wang Y, Everett D. Accommodation and related risk factors associated with myopia progression and their interaction with treatment in COMET children. Invest Ophthalmol Vis Sci. 2004;45(7):2143–2151.
21. Sankaridurg P, Donovan L, Varnas S, et al. Spectacle lenses designed to reduce progression of myopia: 12-month results. Optom Vis Sci. 2010;87(9):631-641.
22. Bao J, Wang Y, Zhuo Z, et al. Influence of progressive addition lenses on reading posture in myopic children. Br J Ophthalmol. 2016;100(8):1114-1117.
23. Lam CSY, Tang WC, Tse DY, et al. Defocus Incorporated Multiple Segments (DIMS) spectacle lenses slow myopia progression: a 2-year randomised clinical trial. Br J Ophthalmol. 2020;104(3):363-368.
24. Rappon J, Woods J, Jones D, Jones WJ, Tolerability of novel myopia control spectacle designs. IOVS, 2019. 60: 5845.
25. Jones L, Walsh K, Willcox M, Morgan P, Nichols J. The COVID-19 pandemic: Important considerations for contact lens practitioners. Cont Lens Anterior Eye. 2020;43(3):196-203.
26. Kinoshita N, Konno Y, Hamada N, et al. Efficacy of combined orthokeratology and 0.01% atropine solution for slowing axial elongation in children with myopia: a 2-year randomised trial. Sci Rep. 2020;10(1):12750.
27. Kinoshita N, Konno Y, Hamada N, Kanda Y, Shimmura-tomita M, Kakehashi A. Additive effects of orthokeratology and atropine 0.01% ophthalmic solution in slowing axial elongation in children with myopia: first year results. Jpn J Ophthalmol. 2018;62(5):544-553.

DR. MOLINA is an assistant clinical professor at the University of California, Berkeley School of Optometry and an associate optometrist at Lunettes Optometric in San Francisco. She is also involved in myopia management research for Eyenovia’s CHAPERONE study and for Google.