Myopia Management: Where to Begin

Q: How do I best manage my patient who is displaying myopic progression?

It has been well established that excessive axial elongation underlying myopia causes significant structural ocular changes. The higher the patient’s level of myopia, the exponentially higher their risk of developing sight threatening ocular health conditions, including retinal holes, tears or detachments, myopic maculopathy, glaucoma, and cataract.^1,2

We need to identify and explain risk factors for future myopia progression…

We need to identify and explain risk factors for future myopia progression to patients and their parents or guardians, set clear guidelines for ongoing management and, with these factors in mind, carefully select and prescribe appropriate treatment strategies.

The benefits, risks, side effects and expectations of different myopia control treatments should be discussed with the patient and their parents or guardians. Informed consent forms, including details such as the off-label nature of treatment (where relevant), and expectations from patients regarding ongoing myopia management are recommended.

Q: What are the most important considerations for managing progressive myopia?

To offer the best evidence-based clinical management to mitigate progressive myopia, we need to take a holistic approach.

An eye examination will determine patient eligibility for different myopia control treatments.

Key factors to consider include risk factors for myopia progression, a patient’s visual behaviour and environment, and suitability and efficacy of current optical and pharmacological myopia control interventions.³ 

Q: What tests should I conduct when examining a patient with progressive myopia?

The International Myopia Institute Clinical Guidelines Report³ recommends the following standard procedure for examination:

1. History taking – in addition to standard history and symptom questions for primary care examinations, information regarding family history of myopia, age of myopia onset, history of myopia progression and previous myopia control treatment should be obtained and noted,
2. Refraction and visual acuity – non cycloplegic or cycloplegic refraction is recommended every 12 months, at a minimum, to monitor for myopia progression,
3. Binocular vision and accommodation assessment – currently, there is no consensus on gold standard methods. However, clinicians should conduct some basic measure of binocular vision and accommodative function,
4. Ocular health assessment – intraocular pressure should be measured as a standard, and due to associations with increased risk of retinal health issues, central and peripheral fundus examination and imaging is recommended, particularly in high myopes,
5. Corneal topography – this should be undertaken if indicated, particularly for contact lens and orthokeratology fittings, and
6. Axial length (where possible) – although clinical studies often measure axial length to assess myopia progression, and it is a useful measurement in managing progressive myopia, ocular biometry is not routinely used in clinical practice.

Q: What myopia management options are available?

There are now a significant number of myopia management options to prescribe to our patients who demonstrate myopia progression. Table one summarises the latest research and prescribing options currently available to Australian and New Zealand optometrists.

Any discontinuation of myopia control treatment should also include a significant period of observation to evaluate the risk of further progression. Any signs of future progression should be looked at carefully, with clinician advice about recommencing treatment or reconsideration of treatment options.

Q: What are the important summary messages about myopia management for patients?

Currently, there are several treatment options that are significantly effective in mitigating myopia progression.²⁶ To continue to improve best practice patient care guidelines in myopia progression, further large scale clinical trials with longer term follow-up are required.³

In summary, important factors to consider when prescribing for a patient include a patient’s epidemiology of their myopia, their risk factors, visual environment interventions, and optical and pharmacological myopia control treatment efficacies.

To provide the most effective treatment for your progressive myopic patient, an evidence based and holistic approach should be used, considering all aspects of the particular patient including managing their risk to reduce their rate of future myopia. This will allow you to reduce their progression and guide you in selecting the most suitable myopia control treatment for your patient.

Table 1. *Treatment periods varied between different studies. Further, different study designs were used to investigate efficacy of different myopia control treatments, thus
comparisons between different treatment options should be made with caution.

Dr Margaret Lam is the National President of the Cornea and Contact Lens Society of Australia, a National Director of Optometry Australia and a Director of Optometry NSW/ACT. She teaches at the School of Optometry at UNSW as an Adjunct Senior Lecturer and works as the Head of Optometry Services for George and Matilda Eyecare.

Dr Pauline Kang is a Senior Lecturer at the School of Optometry and Vision Science. Her research centres around myopia control treatment and gaining better understanding of mechanisms underlying the development and progression of myopia in children. She also coordinates the Myopia Clinic at the UNSW Optometry Clinic. 

References 

1. Flitcroft DI. The complex interactions of retinal, optical and environmental factors in myopia aetiology. Prog Retin Eye Res 2012;31:622-660. 
2. Haarman AEG, Enthoven CA, Tideman JWL, et al. The complications of myopia: a review and meta-analysis. Invest Ophthalmol Vis Sci 2020;61:49. 
3. Gifford KL, Richdale K, Kang P, et al. IMI – Clinical Management Guidelines Report. Invest Ophthalmol Vis Sci 2019;60:M184-M203. 
4. Chua WH, Balakrishnan V, Chan YH, et al. Atropine for the treatment of childhood myopia. Ophthalmology 2006;113:2285-2291. 
5. Chia A, Chua WH, Cheung YB, et al. Atropine for the treatment of childhood myopia: safety and efficacy of 0.5%, 0.1%, and 0.01% doses (Atropine for the Treatment of Myopia 2). Ophthalmology 2012;119:347-354. 
6. Tong L, Huang XL, Koh AL, et al. Atropine for the treatment of childhood myopia: effect on myopia progression after cessation of atropine. Ophthalmology 2009;116:572-579. 
7. Yam JC, Jiang Y, Tang SM, et al. Low-Concentration Atropine for Myopia Progression (LAMP) Study: a randomized, double-blinded, placebo-controlled trial of 0.05%, 0.025%, and 0.01% atropine eye drops in myopia control. Ophthalmology 2019;126:113-124. 
8. Yam JC, Li FF, Zhang X, et al. Two-year clinical trial of the Low-concentration Atropine for Myopia Progression (LAMP) study: phase 2 report. Ophthalmology 2020;127:910-919. 
9. World Health Organisation. The impact of myopia and high myopia: a report of the joint WHO-BHVI Global Scientific Meeting on Myopia, UNSW, Australia, 2015. Geneva; 2017: Licence: CC BY-NC-SA 3.0 IGO. 2015. 
10. Chia A, Lu QS, Tan D. Five-year clinical trial on Atropine for the Treatment of Myopia 2: myopia control with atropine 0.01% eyedrops. Ophthalmology 2016;123:391-399. 
11. Bullimore MA, Sinnott LT, Jones-Jordan LA. The risk of microbial keratitis with overnight corneal reshaping lenses. Optom Vis Sci 2013;90:937-944. 
12. Chalmers RL, Wagner H, Mitchell GL, et al. Age and other risk factors for corneal infiltrative and inflammatory events in young soft contact lens wearers from the Contact Lens Assessment in Youth (CLAY) study. Invest Ophthalmol Vis Sci 2011;52:6690-6696. 
13. Rah MJ, Walline JJ, Jones-Jordan LA, et al. Vision specific quality of life of pediatric contact lens wearers. Optom Vis Sci 2010;87:560-566. 
14. Santodomingo-Rubido J, Villa-Collar C, Gilmartin B, et al. Myopia control with orthokeratology contact lenses in Spain: a comparison of vision-related quality-of-life measures between orthokeratology contact lenses and singlevision spectacles. Eye Contact Lens 2013;39:153-157. 
15. Cho P, Cheung SW. Retardation of Myopia in Orthokeratology (ROMIO) study: A 2-year randomized clinical trial. Invest Ophthalmol Vis Sci 2012;53:7077-7085. 
16. Santodomingo-Rubido J, Villa-Collar C, Gilmartin B, et al. Myopia control with orthokeratology contact lenses in Spain: refractive and biometric changes. Invest Ophthalmol Vis Sci 2012;53:5060-5065. 
17. Walline JJ, Jones LA, Sinnott LT. Corneal reshaping and myopia progression. Br J Ophthalmol 2009;93: 1181-1185. 
18. Kakita T, Hiraoka T, Oshika T. Influence of overnight orthokeratology on axial elongation in childhood myopia. Invest Ophthalmol Vis Sci 2011;52:2170-2174. 
19. Lam CSY, Tang WC, Tse DY, et al. Defocus Incorporated Multiple Segments (DIMS) spectacle lenses slow myopia progression: a 2-year randomised clinical trial. Br J Ophthalmol 2020;104:363-368. 
20. Correction of Myopia Evaluation Trial 2 study group for the Pediatric Eye Disease Investigator Group. Progressiveaddition lenses versus single-vision lenses for slowing progression of myopia in children with high accommodative lag and near esophoria. Invest Ophthalmol Vis Sci 2011;52:2749-2757. 
21. Cheng D, Schmid KL, Woo GC, Drobe B. Randomized trial of effect of bifocal and prismatic bifocal spectacles on myopic progression: two-year results. Arch Ophthalmol 2010;128:12-19. 
22. Sankaridurg P, Donovan L, Varnas S, et al. Spectacle lenses designed to reduce progression of myopia: 12-month results. Optom Vis Sci 2010;87:631-641. 23. Chamberlain P, Peixoto-de-Matos SC, Logan NS, Ngo C, Jones D, Young G. A 3-year randomized clinical trial of MiSight lenses for myopia control. Optom Vis Sci 2019;96:556-567. 
23. Sankaridurg P, Bakaraju RC, Naduvilath T, et al. Myopia control with novel central and peripheral plus contact lenses and extended depth of focus contact lenses: 2 year results from a randomised clinical trial. Ophthalmic Physiol Opt 2019;39:294-307. 
24. Cooper J, O’Connor B, Watanabe R, et al. Case series analysis of myopic progression control with a unique extended depth of focus multifocal contact lens. Eye Contact Lens 2018;44:e16-e24. 
25. Wildsoet CF, Chia A, Cho P, et al. IMI – Interventions Myopia Institute: interventions for controlling myopia onset and progression report. Invest Ophthalmol Vis Sci 2019;60:M106-M131