A Modern Approach to Collaborative Myopia Management

For the past few years, the world has been battling the COVID-19 pandemic. Working together, researchers, businesses and governments have funded and created powerful vaccines and medications that have changed the natural outcomes from this virus. Though we have not returned ‘back to normal’, the ‘new normal’ is an acceptable compromise that aims to minimise spread and reduce the impact and severity of COVID on the global population.

If optometry and ophthalmology repeat and reinforce the same message through education and correspondence, over time habits that contribute to myopia progression will be overturned

Unfortunately, we haven’t been as successful with the other pandemic that is gripping the world. Myopia is a serious and growing issue. In 2000, it was estimated that 22.9% of the world’s population had myopia, with only 2.7% having high myopia. This is projected to rise to 49.8% and 9.8%, respectively, by 2050.¹ Myopia is associated with increasing risk of cataract,² glaucoma,³ visual impairment,⁴ retinal detachment,⁵ myopic macular degeneration⁶ and blindness.⁷ 

In 2015, it was estimated that the global potential loss associated with uncorrected myopia was US$244 billion per annum,⁸ and this does not include the added costs incurred through associated disease, or the societal and individual costs of reduced vision. These numbers are projected to skyrocket as the prevalence of myopia increases around the world. Simply put, these statistics are staggering.

THE POWER OF MANY

So, what can we do about it and how can we work together to make an impact on this silent pandemic?

Ultimately, we are all trying to do what is best for our patients. However, if we are trying to do this on our own it is difficult to have a powerful impact. Instead, we need to come together to reinforce the same message and engage key stakeholders, just like what happened in the battle against COVID, to curb the impact of the myopia pandemic.

The principles of the collaborative care model I propose are simple.

Optometry and ophthalmology have different skill sets and knowledge in the management of myopia and when combined, have a synergistic impact. For example, even the simple act of monitoring myopia progression should have a collaborative approach. Axial length elongation is the most sensitive measure of myopia progression and ophthalmologists are best placed to measure this accurately. Equally, refraction is the critical measure for myopia progression and optometrists are best placed to accurately monitor this. By working together, we are better able to gather the data needed to get a true picture of myopia progression, and with this, tailor the treatment strategies to minimise its impact on the patient.

In the context of children, there are many environmental components to myopia management that caretakers of children should implement to minimise the risk of myopia progression. Again, working together, we must engage these key stakeholders where children spend their time, namely the family, schools, childcare centres and GPs, to inform and educate them on the best practices to minimise myopia progression.

If optometry and ophthalmology repeat and reinforce the same message through education and correspondence, over time habits that contribute to myopia progression will be overturned. Further, education of teachers and childcare workers has a megaphone effect, broadcasting the message beyond the family we directly treat. This leads to community awareness and, just like the campaigns on sneezing into your elbows, leads to social changes that minimise the impact of myopia.

FACTORS FOR CHANGE

With that in mind, what should we be including in our correspondence? Key areas that I feel could be included are:

Lifestyle Changes 

There are some important lifestyle changes that we should be advocating to all our myopic patients.

There is strong evidence, from multiple high-powered studies and meta-analyses, that sunlight exposure and outdoor physical activity have a protective effect on myopia progression.

After adjusting for co-variates, a meta-analysis identified a 2% reduction in myopia development per additional hour spent outdoors per week.⁹ Independent studies from Denmark (n=235),10 Taiwan (n=571),¹¹ Australia and Singapore (n=752)¹² all show a benefit of daylight exposure in reducing myopia progression.

Further, duration of near work/reading and writing distance also play a role in myopia progression, with strong evidence from the COMET trial (n=469),¹³ The Sydney Myopia Study and the Singapore Cohort Study.¹² 

Taken together, a simple rule of thumb I suggest is that children should have at least two hours per day of outdoor daylight physical activity, they should limit the duration of near based activities, try to hold reading/writing material at least 30cm from their eyes, and have good lighting when involved in near-based activities. If this simple message is reiterated with families and in correspondence forwarded to schools and childcare centres, this will play a large role in altering the behaviours that contribute to myopia progression.

Medications 

Recent advances in medications have resulted in a paradigm shift in the management of myopia.

The ATOM (n=400 observed over two years)^14,15 and LAMP (n=438 observed over two years)¹⁶ trials have provided a high powered and strong evidence base for the benefit of atropine eye drops in limiting the progression of myopia. The ATOM trials^14,15 demonstrated a 59–77% reduction in myopia progression and a 26–95% reduction in axial length increase with atropine use, while the LAMP trial¹⁶ reported a 44–70% reduction in myopia progression and 12–51% reduction in axial length growth.

It is increasingly clear that atropine has an actual effect in limiting axial length elongation, which has implications for future risk of retinal pathologies and risk of vision impairment and blindness. Atropine has few side effects, is generally very well tolerated, and is probably the most effective measure we have in minimising myopia progression. As such, the basic principle is to begin atropine eye drops early and it is reasonable to use higher concentrations if the onset of myopia is younger, or if both parents are myopic.

Glasses and Contact Lenses 

One of the most contentious areas in myopia management is the role of various glasses and contact lenses in reducing the impact of myopia. However, I don’t think it has to be so contentious if we simply stick to the facts.

There are some strategies that have been proven to be ineffective and we can all agree to avoid.

Under-correction of myopia by as little as 0.5D has been shown to increase the rate of progression,¹⁷ while vision training demonstrated no benefit,¹⁸ and the Bates Method has been discredited.¹⁹ The role of multifocal glasses has been studied well^13,20 and though statistically significant, the benefit was so small to be clinically meaningless. In fact, the authors of the COMET trial specifically wrote that the “small effect [of multifocal glasses] does not warrant change in clinical practice”.¹³ The CLAMP trial (n=116 children followed for three years)²¹ examined the role of soft contact lenses and found that overall, soft contact lens wear does not cause or inhibit myopia progression.

As such, these techniques don’t really have a place in modern day myopia management.

With glasses, bifocals with prisms and defocus incorporated multiple segments (DIMS) appear promising in retarding myopia progression. The bifocals appear to slow myopia progression by about 40% (n=135 children followed for two years)²² while the DIMS (n=183 children over two years) reported a 52% reduction in myopia progression and 62% reduction in axial length elongation.²³ Though small numbers, the results are encouraging and, as glasses do not have any side effects, this seems like a very reasonable strategy to employ alongside atropine eye drops.

The difficulty lies with the use of contact lenses, as with the risk of microbial keratitis there is a real and present danger of significant damage to vision, as has been reported in the Australian literature.²⁴ 

Dual focus and multifocal contact lenses, and orthokeratology lenses have been shown to be effective in slowing myopia progression.

However, their study designs, number of participants, duration of follow-up and reporting of complications are extremely poor, making interpretation of their outcomes challenging. The daytime contact lens trials all had low numbers of participants (sub 150 patients) and ran for under two years.^25-27 The only trial that ran for longer is the MiSight trial (n=85)²⁸ with six years of follow-up data, which showed a sustained reduction in myopia progression with use. However, the trial was sponsored by CooperVision and the authors were employees of the organisation. Further, in the conflict of interest disclosure it is stated that CooperVision “participated in the study design, analysis and interpretation”, introducing a serious risk of bias with the results. The four major trials of orthokeratology, namely LORIC (n=35 for two years),²⁹ CRAYON (n=28 for two years),³⁰ SMART (n=109 for three years)³¹ and ROMIO (n=78 for two years),³² suggest a reduction in axial length elongation of 43–83%. However, there are some very significant gaps in the literature, such as infection risk, risk of keratoconus development, risk to limbal stem cells, and risk of myopia progression with discontinuation, that have not been studied accurately to get a complete picture.

CONCLUSIONS

So how do we put this all together?

First, we should all be managing myopia using a collaborative care model. Both axial lengths and careful refractions are critical in the measurement of myopia progression, and optometry and ophthalmology should work together to optimise the care of our patients.

The evidence for lifestyle changes and atropine is strong and robust. I think both optometry and ophthalmology should be reiterating these messages repeatedly to family, GPs, schools, and childcare centres.

Over time, this message will sink in with the goal that educators and carers will pre-emptively implement these strategies to protect the vision of all children in the community. My experience of sending correspondence to schools and childcare centres has been very positive and I receive notes and phone calls from principals expressing appreciation in being brought up to date in myopia management.

Finally, though the evidence is not as strong, there is evidence for the role of glasses and contact lenses in the management of myopia. As health care experts, we should use evidence from the literature and combine that with our knowledge, experience, and expertise to try to match the best treatment strategy for the individual patient. This, too, should be undertaken in a collaborative environment.

I’m fortunate in having excellent optometry colleagues who actively engage me in comanaging these patients. Often optometrists become aware of the newest literature involving glasses and contact lenses before I do, and I ask that they include this in their correspondence to me. This educates me, as well as allowing the opportunity to reinforce their message and recommendations directly to the family, and more broadly, through my correspondence to other key stakeholders. Again, this repetition leads to community awareness, which is so critical.

And just like the COVID pandemic, if we work together as a team, there is a real hope that we can get to a ‘new normal’ that is better than where we are today.

Associate Professor Chameen Samarawickrama BSc(Med) MBBS PhD FRANZCO is a clinicianscientist, named one of the Top 5 Young Scientists of 2019 by the ABC. 

He holds an NHMRC Investigator Fellowship and is head of the Translational Ocular Research and Immunology Consortium, based at the Westmead Institute for Medical Research. 

A/Prof Samarawickrama is a consultant eye surgeon at Westmead Hospital, Director and ophthalmologist at Nexus Eyecare in Sydney and a Board Member of Australian Vision Research, a notfor- profit organisation supporting ocular research. 

References 

1. Holden, B.A., et al. Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050. Ophthalmology 123, 1036-1042 (2016). 
2. Pan, C.W., et al. Myopia, axial length, and age-related cataract: the Singapore Malay eye study. Invest Ophthalmol Vis Sci 54, 4498-4502 (2013). 
3. Mitchell, P., Hourihan, F., Sandbach, J. & Wang, J.J. The relationship between glaucoma and myopia: the Blue Mountains Eye Study. Ophthalmology 106, 2010-2015 (1999). 
4. Holden, B., et al. Myopia, an underrated global challenge to vision: where the current data takes us on myopia control. Eye (Lond) 28, 142-146 (2014). 
5. van Leeuwen, R., et al. Association of Rhegmatogenous Retinal Detachment Incidence With Myopia Prevalence in the Netherlands. JAMA Ophthalmol 139, 85-92 (2021). 
6. Flitcroft, D.I. The complex interactions of retinal, optical and environmental factors in myopia aetiology. Prog Retin Eye Res 31, 622-660 (2012). 
7. Williams, K. & Hammond, C. High myopia and its risks. Community Eye Health 32, 5-6 (2019). 
8. Naidoo, K.S., et al. Potential Lost Productivity Resulting from the Global Burden of Myopia: Systematic Review, Meta-analysis, and Modeling. Ophthalmology 126, 338-346 (2019). 
9. Sherwin, J.C., et al. The association between time spent outdoors and myopia in children and adolescents: a systematic review and meta-analysis. Ophthalmology 119, 2141-2151 (2012). 
10. Cui, D., Trier, K. & Munk Ribel-Madsen, S. Effect of day length on eye growth, myopia progression, and change of corneal power in myopic children. Ophthalmology 120, 1074-1079 (2013). 
11. Wu, P.C., Tsai, C.L., Wu, H.L., Yang, Y.H. & Kuo, H.K. Outdoor activity during class recess reduces myopia onset and progression in school children. Ophthalmology 120, 1080-1085 (2013). 
12. Rose, K.A., et al. Myopia, lifestyle, and schooling in students of Chinese ethnicity in Singapore and Sydney. Arch Ophthalmol 126, 527-530 (2008). 
13. Gwiazda, J., et al. A randomized clinical trial of progressive addition lenses versus single vision lenses on the progression of myopia in children. Invest Ophthalmol Vis Sci 44, 1492-1500 (2003). 
14. Chua, W.H., et al. Atropine for the treatment of childhood myopia. Ophthalmology 113, 2285-2291 (2006). 
15. Chia, A., 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 119, 347-354 (2012). 
16. Yam, J.C., 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 126, 113-124 (2019). 
17. Adler, D. & Millodot, M. The possible effect of undercorrection on myopic progression in children. Clin Exp Optom 89, 315-321 (2006). 
18. Allen, P.M., et al. A randomised clinical trial to assess the effect of a dual treatment on myopia progression: the Cambridge Anti-Myopia Study. Ophthalmic Physiol Opt 33, 267-276 (2013). 
19. Elliott, D.B. The Bates method, elixirs, potions and other cures for myopia: how do they work? Ophthalmic Physiol Opt 33, 75-77 (2013). 
20. Shih, Y.F., et al. An intervention trial on efficacy of atropine and multi-focal glasses in controlling myopic progression. Acta Ophthalmol Scand 79, 233-236 (2001). 
21. Walline, J.J., et al. The contact lens and myopia progression (CLAMP) study: design and baseline data. Optom Vis Sci 78, 223-233 (2001). 
22. Cheng, D., Schmid, K.L., Woo, G.C. & Drobe, B. Randomized trial of effect of bifocal and prismatic bifocal spectacles on myopic progression: two-year results. Arch Ophthalmol 128, 12-19 (2010). 
23. Lam, C.S.Y., et al. Defocus Incorporated Multiple Segments (DIMS) spectacle lenses slow myopia progression: a 2-year randomised clinical trial. Br J Ophthalmol 104, 363-368 (2020). 
24. Tran, T., Samarawickrama, C., Petsoglou, C. & Watson, S. Recent cluster of childhood microbial keratitis due to orthokeratology. Clin Exp Ophthalmol 42, 793-794 (2014). 
25. Anstice, N.S. & Phillips, J.R. Effect of dual-focus soft contact lens wear on axial myopia progression in children. Ophthalmology 118, 1152-1161 (2011). 
26. Walline, J.J., Greiner, K.L., McVey, M.E. & Jones- Jordan, L.A. Multifocal contact lens myopia control. Optom Vis Sci 90, 1207-1214 (2013). 
27. Lam, C.S., Tang, W.C., Tse, D.Y., Tang, Y.Y. & To, C.H. Defocus Incorporated Soft Contact (DISC) lens slows myopia progression in Hong Kong Chinese schoolchildren: a 2-year randomised clinical trial. Br J Ophthalmol 98, 40-45 (2014). 
28. Chamberlain, P., et al. Long-term Effect of Dual-focus Contact Lenses on Myopia Progression in Children: A 6-year Multicenter Clinical Trial. Optom Vis Sci 99, 204- 212 (2022). 
29. Cho, P., Cheung, S.W. & Edwards, M. The longitudinal orthokeratology research in children (LORIC) in Hong Kong: a pilot study on refractive changes and myopic control. Curr Eye Res 30, 71-80 (2005). 
30. Walline, J.J., Jones, L.A. & Sinnott, L.T. Corneal reshaping and myopia progression. Br J Ophthalmol 93, 1181-1185 (2009). 
31. Davis, R.L., et al. Stabilizing myopia by accelerating reshaping technique (SMART)-study three year outcomes and overview. Advances in Ophthalmology & Visual System 2, 92-98 (2015). 
32. Cho, P. & Cheung, S.W. Retardation of myopia in Orthokeratology (ROMIO) study: a 2-year randomized clinical trial. Invest Ophthalmol Vis Sci 53, 7077-7085 (2012).