Are you concerned about the increasing number of myopic children presenting to your clinic? Myopia—short-sightedness—is on the rise, right around the globe. At this rate, over 50% of the world’s population is set to be myopic by 2050, and 10% will be highly myopic[i].
That’s why for Brien Holden Vision Institute’s Myopia Awareness Week, I’m calling on my fellow eye care practitioners to make child myopia management part of your routine eyecare.
The cost of untreated myopia (such as retinal detachment, glaucoma, posterior subcapsular cataracts and myopic macular degeneration[ii]) creates a serious impact to both individuals and to the public health system[iii].
The truth is, we’re facing an epidemic of blindness. Unless we act fast. Fortunately, the outlook is brighter if we focus on prevention and prompt treatment.
To do this, we need to effectively communicate the long-term risks of untreated myopia to parents and carers. And we need to emphasise the importance of preventive measures.
Atropine to Ortho-K: options for child myopia management
It’s crucial to stay informed about the latest research and treatment options. While we still have a lot to learn about myopia and its treatments, modern innovations mean we have a lot more options at our disposal than a few decades ago.
The following evidence-based treatments are proven to slow myopia progression and reduce associated risks. Of course, compliance is necessary for any treatment to be effective, so it’s important to factor in input from child patients when prescribing.
Low-dose atropine eyedrops
Atropine drops are instilled in varying concentrations for myopia management, presumably working through mild dilation of the pupil and the optical aberrations it creates. It’s often used as a first-line treatment before moving on to another treatment method. It may be used alone or in combination with other treatments such as ortho-K[iv].
In some myopic children, daily low-dose atropine eye drops (0.01%) may reduce the rate of refractive error progression by as much as 75%[v], although larger population studies show reduction rates in the range of 25-38%. Atropine appears to be least effective in patients with two myopic parents, those who have very early-onset myopia or higher than average myopia progression[vi].
Multifocal spectacle lenses
Myopia-control glasses feature a special optical design. They adopt different patterns in the peripheral part of the lens to focus light in front of the retina, as opposed to the behind the peripheral retina in single-vision spectacle lenses. This is hypothesized to act as a stop-signal for myopic eye growth.
In a recent study, spectacle lenses with highly aspheric lenses were better at reducing the rate of myopia progression and axial elongation compared to single-vision lenses[vii].
Myopia-control soft contact lenses
Like myopia-control spectacle lenses in mimicking orthokeratology optics, soft contact lenses for myopia control are designed to slow accelerated eye growth by redirecting a peripheral light ray in front of the retina. Worn throughout the day, they both provide full vision correction with myopia management optics.
When selecting a soft contact lens for myopia control, look for brands backed by efficacy studies.
Orthokeratology contact lenses
Also known as ortho-K, this is the original and, in my opinion, the most loved myopia control intervention for children.
Ortho-K contact lenses are worn overnight and made from an oxygen-rich, rigid gas-permeable material. They work to correct myopia by moulding the cornea into a flatter shape centrally and steepening the cornea in the mid periphery to focus peripheral light rays in front of the retina.
How well does ortho-K work compared to other myopia treatments?
Study shows that ortho-K may provide between 36-56% myopia control effect compared to single vision spectacles or contact-lenses[viii]. A longitudinal study found that ortho-K “decreased axial elongation by approximately 50% compared to bespectacled controls”[ix]. Myopia also progressed significantly less in a study of children wearing ortho-K compared to those wearing single vision soft contact lenses[x].
A high-quality corneal topographer, like the Medmont Meridia™, allows you to design well-fitting ortho-K lenses and monitor treatment over time.
Early intervention and long-term benefits of myopia management
Studies shows that each year of delayed myopia development reduces the chance of a child developing high myopia in adulthood[xi]. Early intervention is key to managing myopia effectively. Regular eye exams, especially before starting school, can help identify and address myopia at its early stages.
If you look at the most significant barriers to myopia management uptake, limited awareness ranks high. In a 2022 consumer perceptions survey of Australian and New Zealand parents and carers, less than than 30% were aware of the serious future consequences of untreated myopia[xii].
As such, it’s important to effectively communicate the consequences of untreated myopia—as well as the protective lifestyle behaviours that can reduce the chance of developing high myopia in adulthood.
We have our work cut out for us.
From screens to sunshine: modifiable myopia risk factors
Good myopia management plans don’t just correct vision. They also include a discussion about the modifiable risk factors that can slow myopia progression.
It’s worth noting to patients and their caregivers that, aside from family history, lifestyle is the main risk factor for myopia. This was especially evident during the Covid-19 pandemic.
As kids spent more time in front of screens than ever before—for education, entertainment and social interaction—they also spent less time outside. A Chinese year-to-year comparison study revealed an almost 400% increase in myopia in six-year-olds between 2019 and 2020. Such a substantial myopic shift hadn’t been seen in any other comparison study by the authors[xiii]. To eye care professionals, that will come as no surprise.
This is your reminder to educate your patients and their caregivers on the following modifiable risk-factors and protective behaviours for myopia.
Modifiable myopia risk factor: Prolonged near work and screen time
Near work is any activity that requires focusing on objects within arm’s reach of the eyes—reading, writing, video games, playing certain instruments, etc.
A review of 27 studies assessing the relationship between near work and myopia found a 2% increased risk with every diopter hour* of near work time per week[xiv].
Protective behaviour:
- Take frequent breaks. Ideally every 20-30 minutes. The 20/20/20 rule is designed to reduce eye strain. Every 20 minutes of screen time or near work, look at something that is 20 feet away for 20 seconds.
- Limit screen time wherever possible. Additionally, study shows that screen contrast (white text on black background) may inhibit myopia, while the converse may stimulate myopia[xv].
- Increase the distance of near work. Longer near-working distances might be as important as breaks and longer time spent outdoors.
- Get outside more. Combine all the above for best results[xvi]!
Modifiable myopia risk factor: Low levels of outdoor activity
While there’s conjecture about whether the effect comes sunlight or wide-open spaces, mounting evidence highlights the protective effect of time outdoors on myopia [xvii].
According to Optometry Australia, children need to spend at least 90 minutes per day outside to help prevent myopia from developing and progressing. There’s no need for direct sun exposure or to undertake physical activity to gain positive benefits.
Protective behaviour:
- Have children spend more time outside. 90-120 minutes of daylight is recommended.
- Alternatively, sit near a window with natural light coming in.
You can help change the trajectory of myopia.
As eye care professionals, we play a crucial role in reducing, managing and slowing child myopia. Let’s promote early intervention and regular eye exams and the incredible treatments at our disposal. At the same time, we can educate patient caregivers on myopia’s modifiable risk factors and protective behaviours.
In doing so, we’re ensuring a brighter future for us all.
About the author
Celia Bloxsom is the principal optometrist of Eyeconic Optometry Southport. After graduating with first class honours from QUT in 2000 along with the Don Noack prize for contact lens studies, Celia worked in a Brisbane CBD practice alongside contact lens educator and designer John Mountford. It was through his mentorship that Celia found her affinity for contact lenses and began fitting lenses for all types of corneal conditions, including keratoconus and corneal grafts.
It was in these early years of practice that Celia also discovered a love for orthokeratology. Her enthusiasm for this lens type led her to become Secretary for the Orthokeratology Society of Oceania in 2003, a position that she still holds today. Through the society, Celia has been heavily involved in coordinating large international conferences to provide continuing education for fellow optometrists and has lectured extensively throughout Australia on contact lenses in all their forms.
In addition, Celia has been a guest lecturer and supervising clinician at QUT’s School of Optometry for the past fifteen years. Along with her fellow contact lens supervisors, she was jointly awarded the QUT Vice Chancellor’s Award for Excellence in Learning and Teaching in 2010 and 2013.
References
[i] Holden, Brien A. et al. Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050. Ophthalmology; 123(5):1036 – 1042
[ii] The impact of myopia and high myopia: Report of the Joint World Health Organization – Brien Holden Vision Institute Global Scientific Meeting on Myopia. University of New South Wales, Sydney, Australia. 16-18 March 2015. Accessible at www.childmyopia.com
[iii] Naidoo KS, Fricke TR, Frick KD, Jong M, Naduvilath TJ, Resnikoff S, Sankaridurg P. Potential lost productivity resulting from the global burden of myopia: systematic review, meta-analysis, and modeling. Ophthalmology. 2019. Vol 12(3):338-346
[iv] J Cooper, K Weibel, G Borukhov – Vision Dev Rehabil, 2018 Use of atropine to slow the progression of myopia: a literature review and guidelines for clinical use Vision Development & Rehabilitation Vol 4, Issue 1 2018 March
[v] Myles W, Dunlop C, McFadden SA. The Effect of Long-Term Low-Dose Atropine on Refractive Progression in Myopic Australian School Children. J Clin Med. 2021 Apr 1;10(7):1444. doi: 10.3390/jcm10071444. PMID: 33916204; PMCID: PMC8036859.
[vii] Bao J, Y. A. (2022). One-year myopia control efficay of spectacle lenses with aspherical lenslets. British Journal of Ophthalmology, 106: 1171-1176
[viii] Clinical trial: Information provided by Jennifer Harthan OD, Illinois College of Optometry Effectiveness of Orthokeratology in Myopia Control
[ix] Zhu, MJ., Feng, HY., He, XG. et al. The control effect of orthokeratology on axial length elongation in Chinese children with myopia. BMC Ophthalmol 14, 141 (2014). https://doi.org/10.1186/1471-2415-14-141
[x] Davis RL, Eiden SB, Bennett ES, et al. Stabilizing myopia by accelerating reshaping technique (SMART)-study three year outcomes and overview. Adv Ophthalmol Vis Syst. 2015;2(3):92-98. DOI: 10.15406/aovs.2015.02.00046
[xi] Modjtahedi, B. S, Abbott RL, Fong DS, Lum F, Tan D on behalf of the Task Force on Myopia. Reducing the global burden of myopia by delaying the onset of myopia and reducing myopic progression in children: The Academy’s Task Force on Myopia. Ophthalmology. 2020. Vol 128(6): 816-826
[xii] Myopia in Australia and New Zealand: 2022 Consumer Perceptions Survey, commissioned by CooperVision Australia & New Zealand and conducted online by YouGov Research between 16-24 June 2022.
[xiii] Wang J, Li Y, Musch DC, Wei N, Qi X, Ding G, Li X, Li J, Song L, Zhang Y, Ning Y, Zeng X, Hua N, Li S, Qian X. Progression of myopia in school-aged children after COVID-19 home confinement. JAMA Ophthalmology. 2021. Vol 139(3):293-300
[xiv] Huang HM, Chang DS, Wu PC. The Association between Near Work Activities and Myopia in Children-A Systematic Review and Meta-Analysis. PLoS One. 2015 Oct 20;10(10):e0140419. doi: 10.1371/journal.pone.0140419. PMID: 26485393; PMCID: PMC4618477
[xv] Aleman AC, Wang M, Schaeffel F. Reading and Myopia: Contrast Polarity Matters. Sci Rep. 2018 Jul 18;8(1):10840. doi: 10.1038/s41598-018-28904-x. PMID: 30022043; PMCID: PMC6052140.
[xvi] Hung et al. 2019, Protective behaviours of near work and time outdoors in myopia prevalence and progression in myopic children: a 2-year prospective population study
[xvii] He M, Xiang F, Zeng Y, Mai J, Chen Q, Zhang J, Smith W, Rose K, Morgan IG. Effect of time spent outdoors at school on the development of myopia among children in China: A randomized clinical trial. JAMA. 2015. Vol 314:1142-1148