Navigating the myopia journey

Offering myopia control is now the globally accepted standard of care when seeing a school age child with myopia.¹ To ensure the form of myopia control prescribed is the most suitable option requires ongoing consideration of not only the clinical aspects of the individual child, but also the current vision correction needs of the child in their everyday life at home, school and their extra-curricular activities.

Overall, because the eye care professional (ECP) is dealing with a child (who may be undergoing rapid refractive change) with their parent or guardian as the key stakeholder, it is a multi-faceted situation, and thoughtful communication and management is vital. This article reviews the main aspects to consider – with a particular emphasis on continuing care beyond the initial myopia diagnosis – when reviewing the child along their myopia journey.

Optical interventions with an evidence base showing a myopia controlling effect (myopia controlling soft contact lenses, orthokeratology and myopia controlling spectacles) are discussed, and it is assumed that all these product options currently offer at least 50% treatment effect when worn as intended.² 

Investing ahead – pre-myopia

In an ideal world, starting the conversation about myopia before its onset has many benefits. Many parents, even those who are myopic, do not appreciate the potential for a child to become short-sighted.³  It is worth sharing the easy-to-remember statistics with the practice team – the 2-3-4 rule:⁴

• If both parents are myopic – 50% (1 in 2) chance the child will be myopic
• If one parent is myopic – 33% (1 in 3) chance the child will be myopic
• If neither parent is myopic – still a 25% (1 in 4) chance the child will be myopic

Paying attention to the full refractive correction of the child at six years of age is a great and very simple message to communicate – a six-year-old child should have at least +0.75DS of hypermetropia (so this should be over +0.75DS of plus) – otherwise they are probably destined to become myopic.⁵

Detecting a child as being ‘at risk’ for developing myopia, before its onset, gives the parents and the child and the ECP a chance to talk about the time when they may need to begin vision correction. 

Closely following the refractive change of a child as they grow, and communicating those results to the parents, provides opportunities to discuss what their options might be ahead of prescribing and over the course of their time in education.

Additional advice about time spent outdoors,⁶ keeping an elbow distance from near work as well as time spent on near work,⁷ complement the efforts to control myopia.

Initial discussions about myopia and myopia control

The recent onset of myopia in a young child is when treatment intervention can have the most impact,⁸ and once a child is diagnosed with myopia, it is almost certainly going to get worse. This emphasises the need for a proactive communication approach with all parents.

Ordinary spectacles and contact lenses will of course provide clear vision (myopia correction), but they do not slow down the progression of myopia (myopia control). The immediate options for the parents for both newly diagnosed and existing myopic children who are being introduced to the concept of myopia control are:

• Prescribe myopia correction but delay myopia control
• Prescribe myopia control

For both new and existing myopes, the various options will need to be discussed. This conversation is likely to include that a myopia control option will allow children to see better in the future without their spectacles or contact lenses (compared with a simple myopia correction strategy), because the typical rate of progression of myopia can be slowed by about 50%.⁹ 

Additionally, such slowing can be expected to reduce the risk of longer-term myopia-related pathologies.^{10, 11} Many predictable questions occur that are best pre-handled during the initial consultation by proactive discussion supported by written information.

^{Table 1: Setting the scene of myopia and what myopia control offers}

Myopia control prescribing considerations

Knowing the range of options available and the significance of a myopia diagnosis, the parent and ECP can discuss the optimal choice for the child. Consideration includes the opinion of the child, their maturity and everyday activities.

These discussions will factor in the importance of adherence to manufacturers’ recommended wearing times, which is fundamental to the effectiveness of the treatment; a half-hearted approach risks diluting the impact of the intervention resulting in sub-optimal results.

^{Table 2 details the options for optical myopia control, so that parents can be made aware of what is available:}

Follow-up visits

General guidance suggests a follow-up interval of six months for children between seven and 15 years old with rapidly progressing myopia. It is helpful to explain to parents that more myopia progression may be seen:¹⁵

• In a child with myopia under age 10
• If myopia is higher when starting treatment
• If both parents are myopic
• During the winter months compared with summertime (hence consider change over a 12 month period)^{16, 17}
• The child is growing fast and/or Rx change >1.25DS in a 12-month period

Table 3 illustrates the anticipated average progression by age, helpful when benchmarking progression during a 12-month period.

Parents should understand that future follow-up appointments are essential not just for measuring changes in myopia and updating prescriptions as needed, but also for assessing adherence and suitability of the myopia control approach. It is crucial parents understand that blurry vision can stimulate myopic progression, emphasising the importance of maintaining clear vision with the latest prescription.²⁰

This is best managed by following the recommended review intervals. In cases where unexpected myopia shifts occur despite proper adherence, proactive discussion with parents is necessary. How the child might have progressed without intervention is unknown and could be due to an acute growth spurt or the eyes not responding to treatment.

Myopia control could span a decade or more, and alternative approaches for myopia control might need consideration as the child progresses through adolescence. At follow-up appointments, there are some key questions to ask to help understand how well the current myopia control treatment matches the everyday life of the child and their family (table 4).

^{Table 4: Questions to review the current myopia control intervention}

Follow-up and progress of children in myopia control

There are a number of possible scenarios to manage during follow-up visits, and these are discussed below.

(i) Minor changes to prescription

Myopia control treatment may not stop myopia progression completely and some changes to prescribed lens power in contact lenses or spectacles should be expected.

Useful phrases to use:

“From the examination today, I’m pleased to say that <insert name of child>’s myopia appears to be well-controlled. The vision with the current prescription shows a slight change, and this is about half of what we might expect in a child this age over this period of time. I am confident that we should continue with this treatment approach given that it is clearly working so well for <insert name of child>”

(ii) Concerns about adherence and/or myopia advancing beyond expectations

If the prescription shift looks like 12 months of change has occurred in only six months, it is important to provide reassurance that change comes in fits and starts and not gradually – just like changes in height. As such, the next six-month review provides an important and more complete assessment of change, which is best judged over a full 12-month period. Offering to update the prescription to the new result will be based on the need to maintain good visual acuity and clinical discretion.

Useful phrases to use:

“On examination today, <insert child’s name>’s has changed a little more than average since we last saw them, but still within what we might expect for their age. The next six months will give us a clearer picture, as we know that we need to assess the change over a full 12 months to account for the effect of the light differences in summer and winter and time spent outdoors. Perhaps <insert child’s name> can tell me what they have to do to get the best out of their treatment?”

Myopia progressing beyond expectations in spite of treatment having been implemented is uncommon, but statistically will happen.^21-23 It is important to be prepared to discuss the progress and encourage everyone involved to openly review the current strategy to help establish if only more attention to behaviours and adherence is required, or if a change in treatment is warranted (to better fit the needs of the child and/or family life, eg new everyday activities do not work well with spectacles).

As there is evidence of dose-response with myopia control (ie more use of the treatment delivers a better outcome), exploring adherence is important.²⁴

Key questions to ask to determine adherence include:

• How many times a week do you wear your <spectacles/contact lenses/ortho-k>?
• How much time each day do you spend outside (including school break times)?
• How much time per day are you on your phone/iPad/computer/game station?
• Where do you tend to hold your phone?
• What kind of breaks do you take when you are using a screen at home?

When lack of adherence is suspected or confirmed, a useful phrase to use is:

“I appreciate from what you say that the <insert current myopia control modality> are not being worn as much as is required for maximum treatment effect. In what way do you think we could improve on this for <insert child’s name>. And <insert child’s name>, how do you feel about this?”

Myopia control recommended but not yet adopted

As myopia control therapies become established, it remains likely to see a myopic child who is wearing ordinary single vision spectacles and/or contact lenses. It cannot be assumed that parents appreciate the visual impact of uncorrected/under-corrected myopia, and that this is the ongoing short-term reality a myopic child will experience in between eye examinations as their myopia progresses.  

Phrases such as:

‘I’m delighted you’ve brought <insert name of child> to see me again to review how their short-sightedness is today. As you mentioned, <name> has grown since we last saw them, and this growth spurt is also showing in the vision and prescription measurements today. This change will have impacted <name>’s vision both in the classroom at school, when taking part in sport/outdoor activities and even watching television at home.

‘Due to these findings today, and what <name> has told us about their vision, I’d like to recommend either myopia control contact lenses or spectacles for <name> that may help to slow down these changes in <name>’s vision caused by the short-sightedness increasing as they grow. Choosing to use this new optical technology means that <name> should spend less time with blurry vision in between visits, and slowing this growth down can also reduce the lifelong risk to eye health and vision that is associated with these increasing levels of short-sightedness.’

If the parent and child are willing, and they understand the benefits and risks of myopia control treatment, they can be immediately moved into the treatment deemed to be the best fit for them and their family. Discussions around moving to a myopia control option might be easier than when prescribing the first myopic correction, as the parent has now spent a few months or even longer observing their child both with and without their ordinary vision correction, as well as potentially noticing a deterioration over the recent months.  

Duration of treatment – moving to adult correction

Myopia control contact lenses and spectacles have been available for some time. This means that some patients may have started treatment as older teenagers and their prescriptions are beginning to stabilise analogous to changes in height. Given that myopia progression slows with increasing age, the information collected over the years of managing the individual child assists with the decision to exit, and move to using ordinary contact lenses and spectacles, or continue to remain in treatment.

The Comet study reviewed myopia progression with age across different ethnicities and looked at the numbers of patients with stable myopia with the following key findings by age:¹⁵ 

• Age 15 – 50% of subjects still progressing
• Age 18 – 25% of subjects still progressing 
• Age 21 – 10% of subjects still progressing

A negligible change in refractive error over the past three years may signal a logical move to conventional myopia correction. Once the decision has been made to exit myopia control, an interim review is recommended with the option to return to myopia control for a time should that be necessary.

In Our Hands

ECPs are at the forefront of managing childhood myopia progression and are in the best position to have detailed conversations with parents and their families of all children about their future vision and eye health. How effectively a child’s myopia journey is navigated depends on building trusted relationships from the outset, so the most appropriate treatment can be prescribed and adhered to. The ultimate goal is to provide the child with good vision, minimise their progression of myopia and maximise their quality of life in spite of myopia.

Educating parents about eye growth and its relationship to myopia progression helps to communicate the urgent need for myopia control treatment to minimise the impact on the delicate structures of the eye – to reduce the risk of myopia-related ocular health conditions. Given the evidence base, waiting for progression before taking action is not an acceptable position.

Eye care professionals who are committed to taking proactive measures against myopia progression lead the way in taking myopia seriously.

• Sarah Morgan is an optometrist and communication specialist. At the University of Manchester, she lectures and leads clinical sessions where she holds the post of Vision Sciences Fellow.

Disclosure

This article was supported by an educational grant from CooperVision, Inc.

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