By Sheila Morrison, OD, MS Vision Science
Journal of Contact Lens Research and Science
Mission Eye Care
Myopia, or nearsightedness, occurs when the eye grows too long relative to the focusing power of the eye. When the eye grows too long, it is at higher risk for vision threatening diseases. The most commonly seen type of myopia progression (school-age myopia) occurs between the ages of about 5 to 16 years old. If detected early enough, the progression of school-aged myopia can be slowed by 30-60% in most children using specialized lenses or eye drops.
Myopia Control has taken a recent shift from purely a research interest and passion to those within small global research circles…today it is approaching the standard of care for Optometric practice. All ODs in the United States and Canada are graduating with at least some basic understanding or awareness about ‘modern myopia management’. Curriculum has expanded at Optometry schools to include myopia control in 100% of our North American schools. The buzz I hear amongst academics and industry key opinion leaders, is a push to continue to increase this curriculum to ensure that we do give students adequate confidence and training related to all recommended therapies used in myopia control.
Industry has gone so far as to suggest a new term to describe the revolution commonly and somewhat formerly known as myopia control, to ‘myopia management’. This has been debated extensively. In general, the thinking is that today’s myopia strategy should be considered an entire management plan. The word management apparently sounds better. Though I also know that many of our pioneers or ‘old school’ docs in this area may argue that ‘myopia control’ is still more accurate and just as appealing….
Nonetheless three key points about where we are today (2019):
The reality is that controversy exists around all current myopia management therapies and here are some of the commonly discussed viewpoints, in order of increasing ‘magnitude’ of controversy:
In regards to the proper dose to use, 0.01% has been the favorite concentration globally and in Canada for some time, but recently studies have shown that 0.01% is not effective in controlling axial elongation, whereas both 0.025% and 0.05% did control the elongation and still maintained lack of side effects. Clinicians scattered around the world still anecdotally report clinical observations of cycloplegic side effects (dilated pupil, blurred vision) with doses higher than 0.025%.
This is an editorial, so a few thoughts (commonly shared in global CE and academic settings)…perhaps consider reaching for contact lens options first, largely to respect the responsibility of evidence-based drug and medical device prescribing. We DO have a longer history of safety studies and a better understanding of the long-term effects of soft lens or orthokeratology use in children (they are safe when used as directed). If a patient is not a candidate for contact lens therapy, or progression is still too fast with just the use of contact lenses, spectacles (current designs are improving) or 0.025% atropine may be the best option. I do not go higher at this time due to insufficient evidence to convince me that 0.05% is better than 0.025%; if we can use the lowest dose that does show reduction in axial elongation then there is there any reason to go higher? My own recommendations for atropine are significantly less frequent than optical management, at this time, but as we learn more, combination therapies and drops at a younger age may become the standard course. This is an area that continues to change as scientists collect more data over longer time periods and we will see more publications coming out over the next few years to help with these clinical decisions and set the standard of care.
So what does the average OD need to know? Just like any other ocular condition, myopia needs to be managed from an evidence-based perspective that specifically is aimed to reduce risk for adverse events in patients (due to high refractive error and related ocular health consequences). Preserving vision and best vision-related quality of life starts at a young age when it comes to responsible management of myopia. Don’t be afraid to refer to clinics that are embracing this comprehensively, just like any other focus Optometry area.
From a public health perspective, the global cost and impact on quality of life due to increasing myopia is significant. It is all of our responsibility… absolutely analogous to how we would approach screening and managing amblyopia in children, or glaucoma in adults.
For any condition we are responsible to manage (including myopia), basic steps are:
Happy myopia management!