LAUREN IS A 4.5-year-old patient whom we have seen since her 6-month InfantSEE eye exam. She sees all the letters on the eyechart. She sees the bottom line and is eager to tell me the letters because she knows all her letters. In fact, she calls them out with volume and gusto. But Lauren has a problem—she is emmetropic! [Gasp!] Yes, Lauren’s eyeballs are growing faster than they should, and this is concerning.

However, some may be wondering what the problem is. She is emmetropic; that’s the problem. We do not want Lauren to be emmetropic any more than we want her to be 5 feet tall at 4.5 years old. Her growth charts (and refractive error) should match that of “normal” children, and she is way ahead of the curve. Practitioners want their 4-, 5-, 6-, and 7-year-old patients to be hyperopic.

Zadnik and colleagues (2015) evaluated more than 4,500 school-aged children and found that children 6 years or younger who had less than +0.75D of hyperopia are at an increased risk of developing myopia. Ideally, Lauren should land at emmetropia at around 8 to 10 years of age. From my experience, myopia before the age of 8 years can lead to very high myopia as a child ages.

For this reason, this is the time to use the words “this concerns me” to get Lauren’s parents’ attention. Explain how growth charts work and where we expect children to be and why perfect vision right now is not ideal. Share with parents that we must intervene, otherwise when they come into the office in a year, their child’s refractive error and axial length will be even more concerning.

Parents of children are comfortable with growth charts; they often see them at the pediatrician’s office. Growth charts related to axial length and refractive error can be found both in the literature and from contact lens researchers online.

In this case, Lauren’s parents agree to go with our plan. They understand that her current perfect vision shows a potential projection of progression into myopia if we do not intervene. We discuss more than we have to at this visit. This is a good time to give a framework for myopia management early, in order to ease parents’ concern should their child progress into myopia.

For Lauren, I initiate atropine treatment of 0.05% and at least two hours of outdoor time a day.

I share the importance of reduced LED screen time and maintaining a proper rhythm of light during the day and dark when it is getting close to bedtime (Torii et al, 2017). We agree to track her every three months over the next year with axial length measurements to see whether she is progressing or staying stable.

If she is staying stable over the next 12 months, we will consider reducing the atropine concentration in the following 12 months as we continue to monitor her. Should her myopia progress, we may initiate treatment with spectacles or contact lenses. We schedule her for an autorefraction and axial length visit with a technician to see how things progress.

Hopefully, Lauren shows up at 5, 6, and 7 years of age near emmetropia. That would be more ideal. CLS

References

1. Zadnik K, Sinnott LT, Cotter SA, et al; Collaborative Longitudinal Evaluation of Ethnicity and Refraction Error (CLEERE) Study Group. Prediction of juvenile-onset myopia. JAMA Ophthalmol. 2015 Jun;133:683-689.
2. Torii H. Kurihara T, Seko Y, et al. Violet Light Exposure Can Be a Preventative Strategy Against Myopia Progression. EBioMedicine. 2017 Feb;15:210-219.