The incidence and prevalence of myopia are increasing at an alarming rate all over the world.
Let’s say you have a 6 year old patient in your chair, and after cycloplegic refraction you come to the conclusion that this child, who was slightly hyperopic a year ago, is now a -0.50sph myope.
What do you do?
Prescribe glasses or contacts?
Discuss visual hygiene?
All of the above may be part of the treatment plan for all myopes. But how about attempting to control the myopia to keep it from increasing?
Here is my plan of attack.
STEP 1: Picking the right patient based on the following risk factors:
- Genetics - one or more myopic parents.
- Current prescription - already myopic by age 7, or is showing an increase over time. Some doctors consider an increase of -0.50D per year a normal average increase. However, depending on the child’s age, I might even address just an average increase. Early, genetic myopia progresses faster and is more severe than a later, acquired progression.
- Binocular efficiency - presence of esophoria and/or accommodative lag.
- Activities: Outdoor exposure (less than 2 hours per day).
- Visual Demands: Long periods of time doing close visual tasks, not including school work (more than 2-3 hours).
STEP 2: Discussion with parents.
- Explain refractive findings as well as pathology and risks associated with high myopia.
- Hand out informational materials for the parents to take home.
- Discuss the best treatment course, or, alternatively, monitor refractive state in 6 months.
STEP 3: Choosing a treatment pathway.
There is an excellent article on NGO by Dr. Courtney Dryer on the various treatments.
I choose to work with multifocal contacts, 0.01% atropine, and glasses as my methods of treatment.
- Biofinity center distance MF CLs with +2.50 ADD (or highest ADD tolerated) Occasionally the ADD power needs to be lowered to allow for better functional distance vision.
- Atropine 0.01%. The drops have to be ordered from a compounding pharmacy (see source #2 for info on choosing among Atropine 0.5% / 0.1% / 0.01%.) I practice in New York City, and the pharmacy I rely on is Westchester Compounding Pharmacy. The cost for a 10ml bottle of compounded atropine is $65, with an expiration date of 4 to 8 weeks, or as advised by the pharmacist. Having an informed consent form for off-label use of atropine is recommended.
- For children presenting with esophoria and accommodative lag, studies show that PALs with a high ADD are also beneficial. PALs have no statistically significant effect on myopia in children with normal binocularity.
STEP 4: Following up.
I schedule the first return visit one month after starting therapy, and then at six month intervals for cycloplegic refraction.
For continued effect, treatment needs to continue for as long as there is a risk of myopia increase, which may be through the college years.
A scientifically based myopia control protocol is a relatively modern concept among many of us, but it is my hope that as more research is done, it becomes standard practice for all optometrists and ophthalmologists. And that with time, short sightedness will become a thing of the past!
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- Dr Jeffrey Cooper! http://coopereyecare.com/