For the (lack of) love of Myopia…

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):

1. Myopic progression is multifactorial and there are likely different types of myopia that may overlap. The etiology of myopic progression is multifactorial. There are likely different types of myopia (ie school-aged versus pathologic); the type of myopia that we target today with clinical strategies that include pharmaceutical or optical treatments is what is considered ‘school-aged’ myopia.
2. Optimizations of optical and pharmaceutical therapies are continually evolving but we DO have scientific evidence on the efficacy and safety of these therapies to indicate their use. Optical therapies include spectacle and contact lens use; contact lens use either involves daytime use of soft multifocal lenses, or nightly use of orthokeratology lenses (jury is still out but generally considered about equally effective for reducing the rate of myopic progression). The most commonly used pharmaceutical intervention is low dose atropine; research is still pending about the best concentration to use (see below for controversies section).
3. Early intervention is best. The most powerful clinical predictors of myopia in children are genetics (one or more parents, siblings) and refractive error outside ‘emmetropic’ age norm (for example -0.50 in a 1yo is considered a significant risk factor).

 
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:

1. Criticism of spectacle use: efficacy has been shown with current and past use of bifocal or PAL, to be significantly lower or not clinically significant.
   Some patients are not suitable candidates for contact lenses or pharmaceutical therapies. Doing something is definitely better than nothing and in these cases spectacles will not work as well as contact lens options, or atropine, but generally are still advised over no treatment. The industry has improved spectacle lens designs over the past few years and efficacy reports with spectacles will likely go up over time as the technology improves.
2. Criticism of contact lens use (ortho-k or soft): contact lens use in children is not safe.
   When used as directed contact lenses have low risk for complications in children (both orthok and soft lenses). Complication rates are higher in young adults than children. Patient education, compliance, and proper follow-ups with OD are key in prevention of contact lens related complications in all patients.​
3. Criticism of atropine: we do not fully understand the long-term effects of this drug on the accommodative system and development in children, and short-term side effects are unwanted. The exact concentration to use is not known and needs further study before being advised for use.
   ​Many researchers will shy away from widely recommending atropine, for good reason, due to a need for continued study, however most that also see patients in the clinic, will still prescribe when indicated; when attempts to control axial elongation with contact lens therapies are not effective enough. Like most areas in medicine we still have more to learn about atropine therapy for myopia management … there has however been a high volume (all over the world, over many years) of quality scientific work done in this area already, on which we base our decisions on. Combination therapy is starting to be more widely discussed and we will certainly see this come up in the scientific community as well as our clinical reports.

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:

1. Identify risk factors (case and family history)
2. Evaluate for clinical findings outside of ‘normal’
3. Provide education
4. Treat with therapies aimed to achieve:
   1. Best visual outcome
   2. Reduction of health risks

​Happy myopia management!

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Dr. Sheila D. Morrison, OD MS attended The Pacific University College of Optometry in Forest Grove, OR, where she earned her Doctor of Optometry, Master of Vision Science, and residency in Cornea & Contact Lenses. Dr. Morrison is currently on faculty at the University of Houston College of Optometry where she serves as chief of the Contact Lens and Cornea clinic, at the University Eye Institute and teaches in advanced contact lens, ocular topography, and orthokeratology. Her primary clinical and research interests include corneo-scleral topography, myopia control, orthokeratology, GP contact lens design.