Frequently, we hear questions such as, “Hey Gary, I’ve got a 6-year-old kid who has 3D of myopia in both eyes. Would you start with a custom soft multifocal lens or go straight to orthokeratology?”
Or a practitioner will say, “Hey Thanh, I’ve got a 12-year-old kid who progressed 0.25mm in axial length in one month while on 0.02% atropine. What should I do? The kid is now 26.20mm in that eye.”
Sometimes the question goes something like, “Hey Thanh, the ortho-k lens on this high prescription case hasn’t eliminated some residual astigmatism. Would you consider a corneoscleral ortho-k lens design for this patient?”
Questions + Answers
These questions are common and not surprising, since virtually none of these practitioners had any formal education about myopia management while in training. The field is still relatively new and evolving. Solid clinical protocols are being developed, and there’s still developing consensus as to the proper first- or second-line treatment options.
In some sense, treating myopia is akin to treating glaucoma. Both are progressive diseases of the eye and rely on tests and data to determine diagnosis and treatment. For some patients who have glaucoma, pharmaceutical interventions are a great place to start, whereas other cases may rely on surgical intervention immediately. In the same vein, some patients who have low refractive error but high axial lengths may lean toward pharmaceutical interventions versus a high refractive error case.
So, what are some general guidelines to consider in treating myopia?
The first is an overall assessment of risk factors determined at the initial eye examination:
How old is the patient? It’s important to know this because young myopic children tend to ultimately develop into higher myopic patients than children who initially develop myopia at an older age (Hu et al, 2020).
Is there any family history? If so, is it just one parent or do both parents have myopia? Consider the patient’s lifestyle: for example, how much daily outdoor activity does he or she engage in?
These questions serve to build the case for treatment versus monitoring the condition.
A 5-year-old myopic child may be more likely to begin atropine treatment because she may not be ready for contact lenses. A patient who has only –0.25D of myopia may not get a strong peripheral plus with ortho-k, so a practitioner may opt to prescribe a daily disposable soft multifocal lens. Afterward, the practitioner may offer treatment and then evaluate its efficacy.
This is where it gets a little murky. What is considered “successful” in terms of managing myopia? Again, there are no clear rules. Traditionally, practitioners might have looked purely at refractive error, whereas now they look at axial length growth over time.
One might be happy if a 7-year-old grows less than 0.20mm per year while being treated with contact lenses for myopia management. On the other hand, one might target less than 0.07mm per year for a patient who has similar refractive error and axial length and who is 14 years old.
If a patient meets these age-dependent criteria, then by all means, continue treatment. But what happens when a 9-year-old child who is on atropine grows 0.50mm in six months? Consider adding ortho-k in combination with atropine to further diminish myopia progression. If a patient who has low refractive error misses their target, we might add low-dose atropine in combination.
It’s clear that a treatment matrix for all considerations would be helpful. The good news is that day is certainly coming. These tools are being developed and will be available to assist practitioners with current treatment protocols based on evidence and research. CLS
- Hu Y, Ding X, Guo X, Chen Y, Zhang J, He M. Association of Age at Myopia Onset With Risk of High Myopia in Adulthood in a 12-Year Follow-up of a Chinese Cohort. JAMA Ophthalmol. 2020;138(11):1129–1134.