We know the prevalence of myopia is increasing rapidly worldwide, and we finally have multiple treatments to slow the progression. Currently, about 30% of the world is myopic, and if trends continue as predicted, about 50% of the world will be myopic by 2050.1
If we can slow that trend for our young myopic and even pre-myopic pediatric patients, we will have fewer highly myopic adults. It’s important for practitioners to be familiar with all the myopia control options to discern which patients will most benefit from each strategy.
Current myopia management treatments
In North America, we have three approaches to address myopia progression: atropine, specialty contact lenses including orthokeratology (ortho-K), and the spectacle lenses MiyoSmart and Stellest. Let’s discuss the qualities, benefits, and limitations of each modality.
Contact lenses
If a pediatric patient is willing, mature enough, and capable, contact lenses for myopia control can be a fantastic option. Practitioners have been utilizing several ortho-K designs and fitting center-distance multifocal soft lenses for years.
However, now there are two FDA-approved contact lens-based options for myopia control:
- MiSight 1 Day by CooperVision: Soft dual focus daily disposable contact lens approved for myopia control in children ages 8 to 12.
- ACUVUE Abiliti: Ortho-K RGP lens worn overnight that temporarily reshapes the cornea and is approved for myopia management.
Spectacles
Currently available spectacles for myopia management include:
- Stellest by EssilorLuxottica: With highly aspherical lenslet target (HALT)
- MiyoSmart by Hoya (Canada only): Utilizes defocus incorporated multiple segments (DIMS) technology.
Atropine
Compounded into a low dose concentration, varying between 0.01% and 0.1%. Patients use one drop at bedtime. Atropine is contraindicated in patients who are hypopigmented (ocular albinism) or have a history of heart disease.2
Focus on visual quality in myopia treatments
Since all the myopia control options are optically different than single-vision lenses or potentially affect pupil and accommodative function, vision quality is different than traditional vision correction. Most patients perceive those differences but adapt quickly.
MiSight
MiSight has a central optical zone for clear distance vision and a peripheral optical zone that produces a relative myopic defocus. Researchers saw a minimal reduction in contrast sensitivity or ghosting after adaptation.3
The same study showed that 80% of kids stayed in the MiSight lens after they had 3 consistent years of single-vision lenses, suggesting that the MiSight optics were very tolerable and functional for kids ages 11 to 16 who were accustomed to single-vision optics.3
ACUVUE Abiliti
The Abiliti affords clear visual clarity during waking hours when worn consistently and for the appropriate number of hours. If a night is skipped or the patient gets less sleep than normal, the quality of vision suffers.
In my experience, some patients report issues such as halos and glare during the adaptation period, but these become less noticeable. Teen patients starting to drive may be more aware of halos and glare, as well as patients involved in sports with night games.
Stellest / MiyoSmart glasses
MiyoSmart glasses provide clear central vision with minimal adaptation time. Some patients report slight peripheral blur in the lenslet areas, but the overall visual comfort is rated high.4
Low-dose atropine
Low-dose atropine may induce mild light sensitivity and near-blur, especially at higher concentrations and in lighter eyes. The vision quality will also be affected by the pupil size.5
A comparison of compliance and adherence in myopia control options
Contact lenses
MiSight allows patients to enjoy the convenience and safety of a daily disposable contact lens. A single-use lens reduces the risk of complications compared to multiple-use lenses.
Make sure the pediatric patient is comfortable in the lens all day and able to safely insert and remove the lens, which may require parental oversight. For most young patients who are good candidates for MiSight, the hassle factor with contact lenses is less than that of broken or lost glasses.
Many kids, especially active children, prefer daily disposable contact lenses over spectacles. The ability to see without glasses can improve some kids’ self-perception of physical appearance, social acceptance, and even athletic performance.
ACUVUE Abiliti typically shows good compliance. If the lens is not worn overnight, the patient’s quality of vision suffers. Children generally want to see clearly, so there is good compliance built into ortho-K.
Spectacles
Stellest / MiyoSmart spectacle lenses are familiar, easy to use, and non-invasive. Some parents or patients are reluctant to wear glasses due to social stigma, aesthetic concerns, or fear of breakage. Make sure your patient understands these glasses provide reported myopia control if the glasses are worn 10 hours/day, 6 days/week.6
One study showed that the overall compliance rate for kids with spectacles was only 40%.7 The most commonly cited reasons for non-compliance were broken/lost spectacles, forgetfulness, and parental disapproval, followed by headache, teasing by peers, and dislike of spectacles.
Atropine
Atropine is easy in theory, but also has compliance issues. It requires nightly use and often help from an adult. It’s easier to forget than ortho-K or MiSight since those modalities have a visual penalty, whereas atropine does not. Adherence can decline without structured follow-up at home.
Efficacy and evidence of myopia management treatments
The most important job of any myopia control treatment is to be effective.
MiSight: A trailblazing treatment
It should be noted that MiSight was the first FDA-approved treatment in the US to slow the progression of myopia. The initial 3-year trial showed approximately 52% less axial elongation and a 59% reduction in spherical equivalent refraction (SER).8
SER is used to summarize a person's refractive error by averaging the spherical and cylindrical components of their prescription, and the effect was maintained over 6-year extension studies when the patients were refitted into single-vision lenses.9 In addition, 41% of children wearing MiSight had refractive stability, meaning no Rx change after 3 years of wear.
On average, children changed < 1D in 6 years of wearing MiSight lenses. Most notably, eye growth after 6 years of treatment (in MiSight) was reached in approximately 2 years by the untreated eyes, emphasizing the dramatic slowing of growth during treatment.3
Orthokeratology
ACUVUE Abiliti is the only FDA-approved ortho-K treatment for myopia management, but experienced clinicians have seen this benefit for their ortho-K patients for years.
Due to the variability in orthokeratology designs and practitioner expertise, statistics vary on the efficacy of myopia control. The ROMIO study looked at off-label ortho-K efficacy and reported a 43% slowing of progression.10
Spectacles
Myopia control spectacles have demonstrated notable reductions in progression as follows:11,12
- Stellest: A 6-year study showed a 57% reduction in spherical refraction progression and a corresponding 52% reduction in axial elongation.
- Miyosmart: The data at 2 years indicated 60% slower progression compared to single-vision lenses.
Atropine
Atropine can be effective in the right dose for the right patient. A challenge is the consistency of dosage since all low-dose atropine is compounded, and lower concentrations can be very effective in some populations, but ineffective for others.
It’s also important to taper to avoid a rebound effect. One recent study suggests that being on atropine for only 1 to 2 years has no statistical significance in the amount of myopia and axial length 20 years later,14 which is discouraging, but also suggests we need an intervention for longer periods of time when children’s eyes are growing the fastest.
Low-dose atropine is currently used off-label in both the US and Canada pending FDA approval.
Conclusion
Lifestyle, patient maturity, parental motivation, and clinical data are all important when selecting appropriate treatment. Choosing the right tool for each patient determines success.
You are instrumental in reducing future myopia-related eye disease, and the wins against myopia provide immediate gratification for both doctor and patient alike.
