Optometrists regularly encounter the myopic child who presents for an eye examination complaining of blurred vision while viewing the board at school. It is easy to follow the well-trodden path; prescribe spectacles with the expectation that the prescription will increase and so recommend a review in six or 12 months.
However, it is important to appreciate myopia represents more than just refractive error. This case study offers an insight into a typical myopic family, where myopic parents have had first-hand experience of the pathological consequences of myopia and would rather prevent the same happening to their three rapidly progressing myopic children.
This case is of particular interest in that it reflects that myopia management requires a personal approach, time and communication and that there is not one remedy that fits all.
Background
Back in 2014, a family with three children presented to our practice for the first time. Both parents were similarly myopic (each around -7.00 DS to -8.00 DS) and were well educated from personal experience on the risks of myopia on ocular health. Between them they had suffered:
- Retinal detachment
- A horseshoe tear
- Treatment involving a scleral buckle and cryotherapy along with LASER treatment for retinal holes.
In addition to myopia specific pathology, the father had also experienced Acanthamoeba keratitis related to his contact lens wear. At this point in time, two of their children were already in spectacles for myopia.
Lily
The eldest child was age nine at presentation with a best sphere equivalent of -2.50 DS and -2.00 DS in the right and left eye respectively. Binocular status was within normal limits, as was accommodation. Myopia management was discussed at her initial appointment. A six-month follow-up was recommended and she had progressed a further -0.50DS in the right eye and -1.00 DS in the left. At this point, both patient and parents were happy for Lily to be fitted with orthokeratology lenses for myopia management.
Only one application and removal appointment was required and, by the end of the first week, Lily was achieving stable vision throughout the day at 6/6 with a ‘plano’ over refraction. Figures 1 and 2 show the topography plots at this point. More importantly, up to the point of writing, her myopia has not progressed since (see figure 3).
‘Our optometrist told us about overnight vision correction contact lenses which could slow down this rate of deterioration. We read the available literature and research and decided to try it with our eldest child before her vision reached the stage where the lenses would no longer be effective. In the two-and-a-half years that she has been using them, her vision has remained constant and she has had no problems’
Figure 2: Topography plot of right eye after orthokeratology treatment
Twins
Tom and Lucas are non-identical twins and were six-and-a-half years old at the time of their initial attendance at the practice. Lucas was not wearing spectacles at his first presentation whereas Tom had already developed a best sphere equivalent of -1.25DS in both eyes. There were no binocular vision abnormalities in either child.
Figure 3: Progression of myopia with time for Lily
Following the successful fitting of Lily, the parents were keen to fit Tom with orthokeratology lenses due to his rapidly progressing myopia, of -1.00DS every six months. A lens fitting was undertaken, lenses ordered and the patient was happy to proceed.
However, the application and removal appointment was not successful. One lens was inserted on the first attempt but the sensation of an RGP resulted in the child getting upset. Despite the use of anaesthetic and return appointments, he did not want to continue. A soft lens trial was also tried, but the patient refused all approaches due to a negative view of contact lens comfort.
Lucas
Following the challenges of fitting contact lenses for Tom, the parents were now concerned about how his twin brother would cope. Due to his lesser prescription, they opted to monitor for now and myopia management was continually discussed at every subsequent appointment.
Figure 4: Difference map after orthokeratology fitting for Lucas’ left eye
Lucas continued to show progression with his myopia, increasing approximately -0.50DS every six months. In September 2017, and with a -3.00DS prescription, he was successfully fitted with orthokeratology lenses (see figures 4 and 5).
He completed the training appointment first time and was confident about the care of his new lenses. Although he has only had one six-month follow up so far, this was the first six-month period since correction began where he had not experienced any further myopia progression (figure 6).
‘We were surprised at how quickly two of our children managed to get used to inserting and wearing the overnight hard lenses. They can get them in and out within seconds and it doesn’t cause them any irritation while they sleep.’
Figure 5: Difference map after orthokeratology fitting for Lucas’ right eye
Figure 6: Myopia progression for Lucas
Tom
Due to the ongoing fitting of his twin brother, Tom had also become more open to the idea of contact lenses again. He unfortunately had already progressed to right -5.75D and left -5.25D by September 2017; a further two dioptres since his previous orthokeratology fit in April 2016, and now too myopic for orthokeratology.
His parents were also becoming increasingly concerned by his rapidly increasing prescription and the pathological implications for the future. We were lucky to have the MiSight 1 day contact lens for myopia control available to us and Tom was more receptive to the idea of a daily disposable contact lens made with a soft material. Prior to fitting, we let him handle a lens and this greatly improved his acceptance and motivation to proceed.
An optometrist inserted the lenses and he was instantly very happy with his vision and comfort. He required three appointments to become confident with the application and removal, and is currently happily wearing the lenses every day for 10 hours a day. Six months later and like his siblings, he has not progressed any further since fitting (figure 7).
Figure 7: Myopic progression for Tom
Outcome
All three children are now currently in myopia management lenses and different approaches were taken with each child. We can say with confidence that, not only have the lenses slowed down the progression of myopia, but also that all three children have had no further myopic progression.
The children have also benefited from being free from spectacles during school, especially during the many sports they participate in. They are all able to perform sports without the risk of breaking their spectacles.
‘Since they started using the lenses, none of our children’s eye sight has changed. We feel certain that, had our children not been using these lenses, their myopia would have continued putting them at risk of eye complications in the future.’
Myopia management in practice
With all our myopia management patients, including orthokeratology and MiSight 1 day, we review patients every six months on a direct debit payment scheme which is inclusive of all clinical care and contact lens products. It is important to consider that myopia management may initially require more chair time and therefore this has to be factored into the flexibility of the clinic diary.
We have a specific contact lens disclaimer which is signed by the patient to show they understand the wearing requirement of the lenses, hygiene and risk of infection as well as the commitment needed to optimise the myopia management outcome.
We give realistic expectations; myopia management is a long-term treatment that results in the slowing of progression rather than prevention or cure. Due to the peripheral defocus of the lenses, peripheral distortion can also be observed initially, so patients are advised about this. In practice, we monitor all patients using refraction and topography.
When children present for routine eye exams, the risk of myopia development is discussed with both the patients and parents. Binocular vision assessments may also be helpful to understand the level of risk of myopia progression. There are various clinical and patient-friendly tools available, such as:
- Brien Holden Calculator – available at www.calculator.brien holdenvision.org
- Kate Gifford Risk Profile – available at www.myopiaprofile.com
These online tools support communication with parents and children about myopia in general, and also help to demonstrate clearly the difference between correction and non-correction of young progressing myopes.
We actively engage in discussions about screen work and the importance of time spent outdoors with all children and practice resources on myopia management, MiSight 1 day and orthokeratology are useful to raise awareness of options available to parents and patients.
Summary
This case has resulted in the successful stabilisation of childhood myopia in the hope of lowering the risk of the typical pathological myopic changes already experienced by the parents. There is not always one option that suits all patients and clinicians have to constantly discuss myopia management options to plant the seed.
Intervention is required at the earliest possible stage as there may be obstacles in the way which delay the fitting of the child as seen in this case with the consequence of myopia progression. Overall, however, both parents and children can be very accepting of myopia management and have the potential to also spread the word of myopia management.
What do the parents think?
What were the main reasons why you felt myopia control contact lenses were important for your children?
Both my husband and I are very short sighted and I, in particular, have suffered problems with my eyes at a relatively young age associated with myopia, such as detached and torn retinas. All of our children are myopic and for some of them, their myopia was increasing at an alarming rate. In the case of one of our sons, every six months he had a check-up, his prescription changed.
Our optometrist told us about overnight vision correction contact lenses which could slow down this rate of deterioration. We read the available literature and research and decided to try it with our eldest child before her vision reach the stage where the lenses would no longer be effective. In the 2.5 years that she has been using them, her vision has remained constant and she has had no problems. We then started using them for our son, who has also had similar success.
How do the children find the myopia control contact lenses?
We were surprised at how quickly two of our children managed to get used to inserting and wearing the overnight hard lenses. They can get them in and out within seconds and their presence doesn’t cause them any irritation while they sleep. One of our sons found inserting the lenses more difficult, however, as he was more squeamish about putting things in his eye and having inserted a lens incorrectly once, he was unable to overcome the fear of doing so again.
We would have waited until he was older to try again, but his vision quickly passed -5.0 (the limit for ortho-keratology lenses). Our optometrist therefore recommended the MiSight lenses which are soft, daily disposable contact lenses, suitable for more myopic individuals. Being soft lenses rather than hard ones, our son found them more comfortable even if they were inserted incorrectly initially. He can now manage these easily and he doesn’t have any issues with them irritating him or with them popping out during the day.
Having said that, he does always carry a spare pair with him and likes to take them out early evening to avoid his eyes getting dry. My only criticism of the MiSight lenses are that they are larger than the ortho-keratology lenses and as the son who uses these is very small for his age, he does have to open his eyes very wide to get them in. It therefore takes him slightly longer to get the lenses in than it does our other children.
All of our children have taken the warnings about hygiene seriously, although we do continue to remind them of the importance of this, particularly when staying away from home. They certainly enjoy the freedom it has given them to be without glasses during the day, particularly as they are keen on sports.
What are your views on myopia control now that the children have been wearing the lenses for a reasonable amount of time?
Since they started using the lenses, none of our children’s eye sight has changed. We feel certain that had our children not been using these lenses, their myopia would have continued putting them at risk of eye complications in the future.
Laura Williams is an independent prescribing optometrist who works at BBR Optometry in Hereford. She has a particular interest in contact lenses and myopia control and has recently been presented with the 2017 BCLA Young Contact Lens Practitioner of the Year Award.