Several methods of myopia management are available to slow the progression of nearsightedness in children. Risk factors, such as family history, should be considered when initiating therapy in patients with myopia in its varying forms and degrees. 

Case Description

A 12-year-old Caucasian female presented to the clinic with worsening vision in her “bad eye.” She had a stable refraction of +0.50 -0.50 x 162 OD, and an uncorrected VA of 20/20. Her refraction  was -3.75 -0.25 x 172 OS, leaving her barely seeing 20/400 uncorrected in that eye. She had a myopic progression of -1.25 diopters OS that occurred in 16 months. She had not worn corrective lenses previously due to factors such as anisometropia and poor compliance.

The patient’s father is a high myope (-13.50 -3.75 x 005 OD and -9.25 -4.50 x 164 OS) with a history of retinal detachment OS, so the family was familiar with the ocular health risks associated with myopia. Due to the patient’s worsening myopia OS and family history of myopia, intervention was recommended.

All available myopia management options were discussed. Due to the patient’s anisometropia, atropine with spectacle wear was rejected. The patient was not motivated to wear soft daily contact lenses, so conventional contact lenses with atropine and soft multifocal lenses were ruled out. The patient reported being very active in swimming and other sports, and she expressed an interest in a low-maintenance vision correction option, so orthokeratology was recommended to best meet the patient’s needs and ensure the best chance of compliance.

The patient was fit into Moonlens Ortho-k (Art Optical) OS, and no lens OD. Initial lens parameters included a 9.07 mm base curve and an 11.0 mm diameter (Figure 1). The patient had a favorable outcome and was fully corrected to 20/20 OS after two nights of lens wear. She was excited to see well and have improved stereoacuity for the first time in several years.

Discussion

Initiating myopia management in a young patient showing -1.25 diopters of progression may be a natural course of action for most practitioners today. However, opting to not correct the other eye required consideration of the specific patient. This patient had a stable, hyperopic spherical equivalent refraction, a concern about compliance, and an aversion to contact lenses or glasses. In her case, close monitoring and an understanding that a myopia management strategy may be necessary in the future was an adequate outcome. 

Choosing to treat the pre-myopic eye (OD) with orthokeratology would have also been a reasonable decision. Pre-myopia is defined by the International Myopia Institute as a refraction ≤ +0.75 D and > -0.50 D numerically, with refraction, age, and other risk factors indicating the chance of developing myopia. (Flitcroft et al, 2019) Although there are few studies to support the efficacy of treating a pre-myopic patient, at least one notable longitudinal studies found that young, pre-myopic patients with progressive axial elongation do ultimately become myopic (Zadnik et al, 2015) Therefore, some clinicians may choose to treat pre-myopes before they become myopic.

Without annual eye examinations or vision screenings, monocular myopia may be easily missed when it is masked by the fellow eye. This patient may have gone on to become highly myopic in a short time without recognition and intervention. Myopia management is effective in the already-myopic eye and may be useful in the pre-myopic eye in the future.

REFERENCES: 

1.              Flitcroft DI, He MG, Jonas JB et al. IMI – Defining and Classifying Myopia: a Proposed Set of Standards for Clinical and Epidemiologic Studies. Invest Ophthalmol Visual Sci. 2019 Feb;60(3):M20–M30.

2.              Zadnik K, Sinnott LT, Cotter SA, et al. Collaborative Longitudinal Evaluation of Ethnicity and Refractive Error (CLEERE) Study Group. Prediction of Juvenile-Onset Myopia. JAMA Ophthalmol. 2015 Jun;133(6):683-689.

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Dr. Moss is an optometrist in North Carolina. She is a Fellow of the American Academy of Optometry. She discloses renumeration from Art Optical and Wink Productions.