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Myopia Management for Eye Care Professionals

EVALUATING PRE-MYOPIA AND MYOPIA

REFRACTIVE ERROR

Graphic symbol representing myopia measurement by refractive error.
  • Primary method for diagnosing myopia and a routine measurement in every comprehensive eye examination1
  • Accuracy and repeatability improve with use of cycloplegia and objective measurements (autorefraction)2
  • Strongly correlated with axial length,3 but substantially less repeatable than optical biometry even with cycloplegia4,5
  • Misleading interpretation can occur with orthokeratology and/or atropine

AXIAL LENGTH (Optical Biometry)

Graphic symbol of ruler representing myopia diagnosis by axial length measurement.
  • Primary metric for monitoring eye elongation
  • Highly repeatable measurement
  • Relates directly to the pathological processes in myopia
  • Doesn’t require cycloplegia
  • Less susceptible to changes in the anterior optics of the eye which may occur over the course of treatment such as orthokeratology or atropine therapy

EVALUATING PRE-MYOPIA AND MYOPIA image

Young boy of mixed race smiling with excitement.

MONITORING PRE-MYOPIA AND MYOPIA

KEY POINTS FOR MONITORING image

Graphic symbol of eye accompanying key points of monitoring myopia and managing myopia.

KEY POINTS FOR MONITORING

  • Young myopes will progress, so set this as the expectation.6
  • Average treatment efficacy can be referenced from randomized clinical trials.
  • Monitor myopia control therapy use, acceptance, and maintenance every six months.
  • Evaluate progression using at least one (1) year of data to avoid seasonal changes and reduce measurement noise (even with optical biometry).
  • Treatment efficacy cannot be determined for an individual patient because there is no way to know how that individual would have progressed if left untreated.
  • Refer to population-based normative data to assess progression (see Table 5).
Myopia control therapy use, acceptance, and maintenance should be frequently monitored following treatment initiation or modification and at least every six (6) months once treatment is established. Frequent monitoring helps reduce barriers to use, identify non-compliant or risky behaviors, and address any problems as early as possible, supporting safe and consistent use of the myopia control therapy.Axial length and cycloplegic refractive error may be measured at frequent intervals but should be evaluated over at least one year before considering therapeutic changes or supplemental therapy because progression can vary seasonally.7 Knowing efficacy is similar across treatments, it is most critical that the treatment regimen fits the patient’s lifestyle, expectations, motivation, and their abilities.
KEY POINTS FOR MONITORING

KEY POINTS FOR MONITORING image

Graphic symbol of eye accompanying key points of monitoring myopia and managing myopia.

KEY POINTS FOR MONITORING

  • Young myopes will progress, so set this as the expectation.6
  • Average treatment efficacy can be referenced from randomized clinical trials.
  • Monitor myopia control therapy use, acceptance, and maintenance every six months.
  • Evaluate progression using at least one (1) year of data to avoid seasonal changes and reduce measurement noise (even with optical biometry).
  • Treatment efficacy cannot be determined for an individual patient because there is no way to know how that individual would have progressed if left untreated.
  • Refer to population-based normative data to assess progression (see Table 5).
Myopia control therapy use, acceptance, and maintenance should be frequently monitored following treatment initiation or modification and at least every six (6) months once treatment is established. Frequent monitoring helps reduce barriers to use, identify non-compliant or risky behaviors, and address any problems as early as possible, supporting safe and consistent use of the myopia control therapy.Axial length and cycloplegic refractive error may be measured at frequent intervals but should be evaluated over at least one year before considering therapeutic changes or supplemental therapy because progression can vary seasonally.7 Knowing efficacy is similar across treatments, it is most critical that the treatment regimen fits the patient’s lifestyle, expectations, motivation, and their abilities.

EXPECTED PROGRESSION WITHOUT MYOPIA CONTROL

Eye growth should be expected in all young patients, with even stable emmetropic eyes growing around 0.1 mm per year from age 6 to 14.8 Younger myopes will progress faster on average, with average rate of progression in 7-year-old children nearly double that of 11-year-old children.6 Individual progression near the mean values by age in Table 5 should not be considered normal or healthy, since any myopia progression will exponentially increase associated disease risk. Individual progression rates vary considerably across the population.9

EXPECTED PROGRESSION WITHOUT MYOPIA CONTROL image

Symbol of arrow pointing upwards over calendar, representing myopia progression over time as children advance in age.
EXPECTED PROGRESSION WITHOUT MYOPIA CONTROL

EXPECTED PROGRESSION WITHOUT MYOPIA CONTROL

Eye growth should be expected in all young patients, with even stable emmetropic eyes growing around 0.1 mm per year from age 6 to 14.8 Younger myopes will progress faster on average, with average rate of progression in 7-year-old children nearly double that of 11-year-old children.6 Individual progression near the mean values by age in Table 5 should not be considered normal or healthy, since any myopia progression will exponentially increase associated disease risk. Individual progression rates vary considerably across the population.9

EXPECTED PROGRESSION WITHOUT MYOPIA CONTROL image

Symbol of arrow pointing upwards over calendar, representing myopia progression over time as children advance in age.

CAUTION WITH MYOPIA CONTROL CALCULATORS

Myopia control calculators offer reasonable estimates of normal progression without myopia control therapy. The calculated myopia control effect, however, extrapolates a few years treatment effect for up to 11 years, omitting that treatment effect decreases over time and misleading users with overly optimistic treatment expectations.10

Review progression and compare to personalized goals

SAMPLE MYOPIA MONITORING SCHEDULE

Interim (6 months)
  • Focused history including at a minimum:
    • Care and maintenance of therapy
    • Frequency and usage of therapy
    • Patient acceptance and satisfaction with therapy
  • Visual acuity
  • Binocular vision and accommodation (can be impacted by myopia management therapy)
  • Measure axial length (if possible) and refractive error
  • Assess therapy-related ocular health
  • Additional testing as indicated by myopia control therapy


Annual (12 months)
  • Comprehensive eye exam (w/cycloplegic refractive error if possible)
  • Review myopia management therapy (as described above)
  • Measure axial length (if possible)
  • Review progression and compare to personalized goals

Review progression and compare to personalized goals

CAUTION WITH MYOPIA CONTROL CALCULATORS

CAUTION WITH MYOPIA CONTROL CALCULATORS

Myopia control calculators offer reasonable estimates of normal progression without myopia control therapy. The calculated myopia control effect, however, extrapolates a few years treatment effect for up to 11 years, omitting that treatment effect decreases over time and misleading users with overly optimistic treatment expectations.10

Review progression and compare to personalized goals

SAMPLE MYOPIA MONITORING SCHEDULE

Interim (6 months)
  • Focused history including at a minimum:
    • Care and maintenance of therapy
    • Frequency and usage of therapy
    • Patient acceptance and satisfaction with therapy
  • Visual acuity
  • Binocular vision and accommodation (can be impacted by myopia management therapy)
  • Measure axial length (if possible) and refractive error
  • Assess therapy-related ocular health
  • Additional testing as indicated by myopia control therapy


Annual (12 months)
  • Comprehensive eye exam (w/cycloplegic refractive error if possible)
  • Review myopia management therapy (as described above)
  • Measure axial length (if possible)
  • Review progression and compare to personalized goals

Review progression and compare to personalized goals

DETERMINING MYOPIA CONTROL EFFICACY

COMMUNICATING MYOPIA CONTROL EFFICACY

While “percentage treatment” effect is easy to understand, it leads to inconsistent representation across the progression range and fails to capture that myopia control efficacy slows over time. Myopia control treatment effect tends to be more of an absolute effect than a proportional effect.10 The best descriptor of myopia control efficacy is the cumulative absolute reduction in elongation or refractive error (e.g., total mm or D). Download full guide for more information on average myopia control treatment effect.

Table 5

Table showing mean progression of myopia in Asian and non-Asian children by axial length from ages 7 to 11.
Table 5: Mean progression for myopic Asians and non-Asians by axial length and refractive error across age6,11

AVERAGE MYOPIA-CONTROL TREATMENT EFFECT image

Graphic symbol with plus sign.

AVERAGE MYOPIA CONTROL TREATMENT EFFECT

Numerous clinical studies provide cumulative myopia control effect for individual therapies in millimeters or diopters over a 2- to 3-year period, with multiple studies providing evidence of a 0.30 mm reduction in elongation (about 0.75 D).12-15 Since the maximum effect observed to date is 0.44 mm (about 1.00 D) over a 7-year period,16 treatment should begin as early as possible. Combination therapy may enhance myopia control efficacy compared to a single treatment.17

PERSONALIZING MYOPIA CONTROL THERAPY

Treatments described here have been investigated in clinical studies for their effectiveness and safety. Efficacy and performance may vary significantly between products (e.g., for different brands) and it is important to note that some treatments are currently prescribed off-label. Choosing the right one will depend on the individual patient's lifestyle, age, maturity, and refractive error. This diagram can be helpful in guiding your conversation with patients and their parents.

Clinical Considerations

Clinical Considerations

Refractive error and astigmatism
Myopia management treatment history
Ocular health
Vision quality
Efficacy

Lifestyle Considerations

Sports/physical activity
Swimming or water activity
Patient responsibility/hygiene
Patient or parent preference
Desire for parental oversight.

Atropine Eye Drops

Atropine Eye Drops Allow complete parental control of treatment. Concentrations of 0.025 to 0.05% have demonstrated effective myopia control and limited side effects of photophobia and reduced accommodation.18 Atropine must be supplemented with glasses or contact lenses and could be combined with other myopia-control therapies.19

Orthokeratology

OrthokeratologyGas-permeable contact lenses worn overnight to temporarily reshape the cornea, allowing clear vision during the day without correction. Preferred for athletics and water activities, also offering subjectively improved appearance and social self-perception compared to glasses.16 Used overnight at home, allowing for parental oversight.

Soft Contact Lenses for Myopia Management

Graphic symbol of eye and contact lens.
Soft Multifocal Contact Lenses The optics were originally designed to improve near vision in presbyopic patients, but some have been shown to slow myopia progression. Preferred for athletics, also offering subjectively improved appearance and social self-perception compared to glasses.20 Younger children can wear these lenses21 and do not appear to be at increased risk of infection compared to older wearers.22

Myopia Management Spectacles

Graphic symbol of eyeglasses.
Myopia Management Spectacles Optics specifically designed to slow myopia progression. Safe and easy option for a range of prescriptions; subject to non-compliant wear and loss/breakage. Optical designs and myopia management efficacy vary greatly.
Use of Atropine for myopia control is currently not approved in Hong Kong.
Johnson & Johnson Vision does not currently have products containing Atropine for myopia control. The content herein is strictly intended for scientific information sharing and not intended as promoting off-label use and/or unapproved treatment options in Hong Kong. The long-term safety and effectiveness data of Atropine for myopia control is not currently fully established.

REFERENCES

1. American Optometric Association, Comprehensive Pediatric Eye and Vision Examination. https://www.aoa.org/AOA/Documents/Practice%20Management/Clinical%20Guidelines/EBO%20Guidelines/Comprehensive%20Pediatric%20Eye%20and%20Vision%20Exam.pdf, accessed September 3, 2020.
2. Morgan, Ian G., et al. Cycloplegic refraction is the gold standard for epidemiological studies. Acta Ophthalmologica 93.6 (2015): 581-585.
3. Hou, Wei, et al. Axial elongation in myopic children and its association with myopia progression in the Correction of Myopia Evaluation Trial (COMET). Eye & contact lens 44.4 (2018): 248.
4. Buckhurst, Phillip Jonathan, et al. “A new optical low coherence reflectometry device for ocular biometry in cataract patients.” British Journal of Ophthalmology 93.7 (2009): 949-953.
5. Bullimore, Mark A.et al. “The repeatability of automated and clinician refraction.” Optometry and Vision Science: Official Publication of the American Academy of Optometry 75.8 (1998): 617-622.
6. Donovan L et al. Myopia progression rates in urban children wearing single-vision spectacles. Optom Vis Sci 2012;89:27-32.
7. Gwiazda, Jane, et al. Seasonal variations in the progression of myopia in children enrolled in the correction of myopia evaluation trial. Investigative Ophthalmology & Visual Science 55.2 (2014): 752-758.
8. Mutti DO, Hayes JR, Mitchell GL et al. Refractive Error, Axial Length, and Relative Peripheral Refractive Error before and after the Onset of Myopia. Invest Ophthalmol Vis Sci 2007;48:2510-9.
9. Chua SY et al. Age of Onset of Myopia Predicts Risk of High Myopia in Later Childhood in Myopic Singapore Children. Ophthal Physiol Opt 2016;36:388-94.
10. Brennan NA, Cheng X. Commonly Held Beliefs About Myopia That Lack a Robust Evidence Base. Eye Contact Lens 2019;45:215-25.
11. Brennan NA et al. Influence of Age and Race on Axial Elongation in Myopic Children. Optom Vis Sci 2018; 95: eAbstract 180072.
12. Chamberlain, Paul, et al. "A 3-year randomized clinical trial of MiSight lenses for myopia control." Optometry and Vision Science 96.8 (2019): 556-567.
13. Lam, Carly Siu Yin, et al. "Defocus Incorporated Multiple Segments (DIMS) spectacle lenses slow myopia progression: a 2-year randomised clinical trial." British Journal of Ophthalmology 104.3 (2020): 363-368.
14. Chua, Wei-Han, et al. "Atropine for the treatment of childhood myopia." Ophthalmology 113.12 (2006): 2285-2291.
15. Chen, Connie et al. "Myopia control using toric orthokeratology (TO-SEE study)." Investigative Ophthalmology & Visual Science 54.10 (2013): 6510-6517
16. Santodomingo-Rubido, Jacinto, et al. Myopia control with orthokeratology contact lenses in Spain: a comparison of vision-related quality-of-life measures between orthokeratology contact lenses and single-vision spectacles. Eye & Contact Lens 39.2 (2013): 153-157.
17. Kinoshita et al. Efficacy of combined orthokeratology and 0.01% atropine solution for slowing axial elongation in children with myopia: a 2-year randomised trial. Sci Rep 10, 12750 (2020).
18. Yam, Jason C., et al. Two-year clinical trial of the low-concentration atropine for myopia progression (lamp) study: phase 2 report. Ophthalmology 127.7 (2020): 910-919.
19. Kinoshita, Nozomi et al. efficacy of combined orthokeratology and 0.01% atropine solution for slowing axial elongation in children with myopia: a 2-year randomised trial. Scientific Reports 10.1 (2020): 1-11.
20. Rah, Marjorie J et al. Vision specific quality of life of pediatric contact lens wearers. Optometry and Vision Science 87.8 (2010): 560-566.
21. Walline, Jeffrey J et al. Contact Lenses in Pediatrics (CLIP) Study: chair time and ocular health. Optometry and Vision Science 84.9 (2007): 896-902.
22. Bullimore MA. The Safety of Soft Contact Lenses in Children. Optom Vis Sci 2017;94(6):638-646. doi:10.1097/OPX.0000000000001078

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REFERENCES

REFERENCES

1. American Optometric Association, Comprehensive Pediatric Eye and Vision Examination. https://www.aoa.org/AOA/Documents/Practice%20Management/Clinical%20Guidelines/EBO%20Guidelines/Comprehensive%20Pediatric%20Eye%20and%20Vision%20Exam.pdf, accessed September 3, 2020.
2. Morgan, Ian G., et al. Cycloplegic refraction is the gold standard for epidemiological studies. Acta Ophthalmologica 93.6 (2015): 581-585.
3. Hou, Wei, et al. Axial elongation in myopic children and its association with myopia progression in the Correction of Myopia Evaluation Trial (COMET). Eye & contact lens 44.4 (2018): 248.
4. Buckhurst, Phillip Jonathan, et al. “A new optical low coherence reflectometry device for ocular biometry in cataract patients.” British Journal of Ophthalmology 93.7 (2009): 949-953.
5. Bullimore, Mark A.et al. “The repeatability of automated and clinician refraction.” Optometry and Vision Science: Official Publication of the American Academy of Optometry 75.8 (1998): 617-622.
6. Donovan L et al. Myopia progression rates in urban children wearing single-vision spectacles. Optom Vis Sci 2012;89:27-32.
7. Gwiazda, Jane, et al. Seasonal variations in the progression of myopia in children enrolled in the correction of myopia evaluation trial. Investigative Ophthalmology & Visual Science 55.2 (2014): 752-758.
8. Mutti DO, Hayes JR, Mitchell GL et al. Refractive Error, Axial Length, and Relative Peripheral Refractive Error before and after the Onset of Myopia. Invest Ophthalmol Vis Sci 2007;48:2510-9.
9. Chua SY et al. Age of Onset of Myopia Predicts Risk of High Myopia in Later Childhood in Myopic Singapore Children. Ophthal Physiol Opt 2016;36:388-94.
10. Brennan NA, Cheng X. Commonly Held Beliefs About Myopia That Lack a Robust Evidence Base. Eye Contact Lens 2019;45:215-25.
11. Brennan NA et al. Influence of Age and Race on Axial Elongation in Myopic Children. Optom Vis Sci 2018; 95: eAbstract 180072.
12. Chamberlain, Paul, et al. "A 3-year randomized clinical trial of MiSight lenses for myopia control." Optometry and Vision Science 96.8 (2019): 556-567.
13. Lam, Carly Siu Yin, et al. "Defocus Incorporated Multiple Segments (DIMS) spectacle lenses slow myopia progression: a 2-year randomised clinical trial." British Journal of Ophthalmology 104.3 (2020): 363-368.
14. Chua, Wei-Han, et al. "Atropine for the treatment of childhood myopia." Ophthalmology 113.12 (2006): 2285-2291.
15. Chen, Connie et al. "Myopia control using toric orthokeratology (TO-SEE study)." Investigative Ophthalmology & Visual Science 54.10 (2013): 6510-6517
16. Santodomingo-Rubido, Jacinto, et al. Myopia control with orthokeratology contact lenses in Spain: a comparison of vision-related quality-of-life measures between orthokeratology contact lenses and single-vision spectacles. Eye & Contact Lens 39.2 (2013): 153-157.
17. Kinoshita et al. Efficacy of combined orthokeratology and 0.01% atropine solution for slowing axial elongation in children with myopia: a 2-year randomised trial. Sci Rep 10, 12750 (2020).
18. Yam, Jason C., et al. Two-year clinical trial of the low-concentration atropine for myopia progression (lamp) study: phase 2 report. Ophthalmology 127.7 (2020): 910-919.
19. Kinoshita, Nozomi et al. efficacy of combined orthokeratology and 0.01% atropine solution for slowing axial elongation in children with myopia: a 2-year randomised trial. Scientific Reports 10.1 (2020): 1-11.
20. Rah, Marjorie J et al. Vision specific quality of life of pediatric contact lens wearers. Optometry and Vision Science 87.8 (2010): 560-566.
21. Walline, Jeffrey J et al. Contact Lenses in Pediatrics (CLIP) Study: chair time and ocular health. Optometry and Vision Science 84.9 (2007): 896-902.
22. Bullimore MA. The Safety of Soft Contact Lenses in Children. Optom Vis Sci 2017;94(6):638-646. doi:10.1097/OPX.0000000000001078

HKM20230630_002