Myopia control has been at the forefront of discussions in optometry in recent years, especially in pediatric eyecare. This new emphasis correlates with a doubling in the prevalence of myopia from 20% of children three decades ago to 40% of children today.1
If this trend in myopia continues, it is predicted that the prevalence of myopia will reach 50% globally by 2050—that’s roughly 5 billion people. Of that 5 billion, 9.8% will have high myopia, defined as -6.00D or greater.2
Review of the current understanding of myopia
Several studies have identified potential methods for slowing the progression of myopia, therefore decreasing the risk of future ocular complications. The three main methods include orthokeratology/corneal refractive therapy, soft multifocal contact lenses, and low-concentration atropine eye drops.
As with any patient treatment, whether for glaucoma, dry eyes, or in this case, myopia control, maximum effectiveness can be achieved if there is a user understanding of the role of the treatment and potential consequences if not followed. Parent understanding of myopia and the benefits of myopia management is vital to the success of the treatment.
In a 2016 study to assess parent understanding of myopia and myopia management, it was determined that 88% of parents were unaware of the potential complications of high myopia and that 87% of parents were unaware of possible methods to slow myopia progression.3
The top concern among participant parents when considering myopia control was the safety of the treatment (41%), followed by complications, cost, proven efficacy, and time involved.3 Keeping this data in mind, it is important to start with the basics when discussing myopia with parents.
Download the What Parents Need to Know About Myopia Handout
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What Parents Need to Know About Myopia Handout
Use the handout as a guide for discussions about myopia with guardians or give it to parents as an at-home resource.
Assessing myopia in pediatric patients
Before going into the exam room, I will look at the child’s current glasses prescription as well as their visual acuity and auto-refraction. This gives a good starting point for determining if the child’s prescription has increased. I’ll also tailor my questions at the beginning of the exam to help determine if a specific method of myopia control may be best for them.
Certain questions can also help determine the likelihood of progression, such as:
- Does nearsightedness run in the family?
- How much time is spent on digital devices during the day vs. how much time is spent playing outside?
While obtaining the history and checking ocular health, I’ll also usually ask if the child enjoys any specific activities or sports. I also try to gauge the patient’s maturity—will they be able to handle the situation appropriately if a soft contact lens comes out of their eye at school, or would orthokeratology be better under parent supervision? It is important to build trust with the patient and their parents during this first part of the eye exam.
When we’re ready to discuss the patient’s prescription change, I’ll start with the good news that the child’s eyes are healthy, but I am concerned about their increase in myopia. At this point, it can be helpful to define myopia or reestablish an understanding of the condition.
You could approach this conversation with parents or guardians by saying:
“Myopia is the inability to see things unless they are relatively close to your eyes. Myopia occurs when the eyeball is too long and does not allow light to reach the back of the eye to achieve clear distance vision. Without intervention, myopia may progress quickly at a young age and lead to a higher prescription, increasing the risk of eye diseases in the future. We have safe methods to slow your child’s prescription from advancing.”
Starting the myopia talk with parents/guardians
When a child is found to be myopic or at risk of developing myopia, the discussion between the optometrist and parent is of utmost importance. The parent is the main decision-maker, but the patient should be involved in the discussion when appropriate. Individuals are more likely to adhere to management options when they are personally endorsing or choosing to take action.4
As doctors, we place high importance on the health aspects of myopia control, this is likely not the driving factor for a child to be excited about starting contacts.
Once you determine the child and family’s hobbies and interests, try to tie the benefits of myopia control to these activities. Whether it's being able to see when they wake up in the morning or not needing glasses when they go to the pool or jump on the trampoline, finding something the child will be excited about will help with compliance. As optometrists, we want to combine our expertise with the values of the parent and child to choose the treatment that best fits their lifestyle.
Table 1 highlights the increasing risk of eye disease associated with increasing myopic values in pediatric patients.5-7
| Eye disease | -2.00D of myopia | -4.00D of myopia | -6.00D of myopia |
|---|---|---|---|
| Retinal detachment | 3.1x | 9.0x | 21.5x |
| Glaucoma | 2.3x | 3.3x | 3.3x |
| Myopic macular degeneration | 2.2x | 9.7x | 40.6x |
Table 1: Courtesy of Elizabeth Davis, OD
Often, I’ll use the tried and true method of holding the child’s prescription equivalent in loose lenses over the parents' eyes to demonstrate the child’s refractive error (i.e., using a +3.00D lens to demonstrate -3.00D of myopia). It can also be impactful to show the progression from the previous year and the projected prescription for the following year without intervention.
A free online tool for showing potential myopic progression
The Brian Holden Vision Institute offers a free online calculator that can estimate a child’s future prescription with and without intervention, given their age, ethnicity, and refractive error. This is only a projection based on previous studies and not a guarantee of future results, but it illustrates the impact of myopia management well.
Figure 1 features an image of the Brian Holden Vision Institute Myopia Calculator.
Figure 1: Courtesy of Brian Holden Vision Institute
Discussing treatment options for myopic pediatric patients
Depending on how much chair time you have allotted per patient, you may want to give a quick overview of each myopia control method before providing the child’s parents with a handout to review the benefits and limitations of each method on their own.
Discussing other modifiable risk factors can also allow parents and children to take a more active role in adjusting their lifestyle to help slow myopia. Based on the recommendation of the American Academy of Pediatrics, limit screen time to 2 hours per day.8
Other recommendations include holding devices and books at least 12 inches away from the face, taking breaks from near activities every 30 minutes, and spending at least 2 hours outdoors per day.9,10
Table 2 compares different features of the various myopia control methods available to pediatric patients. *Daily is approved, monthly is off-label.
| Lifestyle considerations | Ortho-k/CRT overnight RGP contact lenses | Soft multifocal contact lenses | Low-concentration atropine eye drops |
|---|---|---|---|
| Simplifies sports/outdoor activities | X | X | |
| Enables swimming/water activities | X | ||
| Independence from daytime glasses wear | X | X | |
| Level of patient responsibility/maturity required | Medium | High | Low |
| Allows parental oversight during treatment | X | X | |
| Requires less in office time and follow ups | X | ||
| FDA approved for myopia management | X | X* | |
| Requires 7+ hours of sleep nightly | X |
Table 2: Courtesy of Elizabeth Davis, OD
Orthokeratology/corneal refractive therapy
This method uses rigid gas-permeable (RGP) contact lenses to reshape the cornea overnight. The analogy of a retainer to keep teeth straight can be helpful to illustrate that this method is not permanent but rather temporarily reshapes the cornea and needs to be used daily to maintain the effect.
This option can be great for patients who are active in sports (especially when helmets or goggles are required) or for parents who would like to oversee their child’s contact lens use.
Parents, especially those who wear soft contacts, have likely heard that they should not sleep in their contacts due to the risk of eye infections. They should be reassured that, with proper hygiene, these lenses have the same safety profile as soft contact lenses worn during the day.11
Soft multifocal contact lenses
Multifocal contact lenses have been a mainstay of off-label myopia management with a good safety profile and the benefit of being familiar to most parents. With the recent FDA approval of Coopervision’s MiSight 1-day contact lens for children 8 years and up, an extra layer of credibility is added for parents with safety concerns about their child wearing contacts.
If cost is prohibitive or the child has >1.00D of astigmatism, I’ll prescribe monthly multifocal contact lenses with a distance center high add-power. I’ll discuss the responsibilities of contact lens wear, like ensuring contacts are never slept in or overworn and hands are washed before insertion or removal.
Atropine therapy
Atropine is the best option for young children or those who may not be good candidates for contact lens wear. It is important that parents are aware of potential side effects, which include decreased near vision, increased glare, and light sensitivity due to dilated pupils.12 I’ll discuss with guardians that these eye drops are sometimes used in conjunction with orthokeratology or multifocal contact lenses if a high rate of myopic progression persists.
Questions guardians often ask about myopia
Despite our best efforts, there are still some misconceptions among parents about myopia control. The following are commonly asked questions with ideas for how to respond to each with the supporting data.
1. How long will my child need to be on treatment?
Usually, by the mid to late teens, there will be a slowing of myopia progression. This is different for each individual and is evaluated on a patient-by-patient basis. The COMET study found that 48% of their cohort of nearly 500 myopic children reached stabilization by age 15, 77% by age 18, 90% by age 21, and 96% by age 24.13
2. Is it safe for my child to wear contact lenses?
Yes, multiple studies have shown that kids can safely wear contact lenses.14,15 Contact lens hygiene is the most important part of ensuring no complications develop. Daily disposable contact lenses are the preferred option since they offer the lowest risk for infection compared to reusable contact lenses.16
3. Why is atropine considered off-label for myopia control?
The FDA does not approve compounded prescriptions as a rule.17 Atropine 1% has been around for decades and is FDA approved for mydriasis, cycloplegia, and amblyopia as an alternative to patching therapy.18
The concentration of atropine prescribed is related to the child’s age, degree of myopia, progression rate, and family history. It would cause blurred vision to use a full 1% concentration eye drop, which is why compounding is necessary.
4. Why hasn’t this been offered to us before?
I will discuss with parents that we now have options for slowing myopia progression that had yet to be discovered when we were growing up. Previously optometrists could only watch and update glasses and contact lens prescriptions as their patient’s myopia continued to increase.
We now have effective and safe options for the next generation to limit their myopia, allowing for more functional uncorrected vision while limiting the risk for future eye diseases. Computerization has enabled us to better track corneal shape and axial length, allowing us to monitor myopia more accurately.
Following up with pediatric myopia patients
If a resolution is not reached at the initial exam, I will typically have a follow-up phone conversation with the parent in the week following the visit to discuss treatment options and answer any questions. If your office has the capability to offer telehealth exams, this can also be a great way to schedule a follow-up.
In the event the parent decides to hold off on treatment, remember that it’s still beneficial to have these conversations, even if the parent chooses not to act on the information right away. Emphasize the risk for change and the importance of seeing the child back in 6 to 12 months, depending on risk factors, to monitor for progression.
Takeaways for communicating with guardians about pediatric myopia:
- Start the discussion around myopia management early with parents.
- Discuss the future ocular health and lifestyle benefits of myopia control.
- Demonstrating the effects of myopia by using loose lenses or with a myopia calculator to show potential progression can impact parental understanding.
- Consider family and patient interests and hobbies when recommending myopia control methods.
- Provide take-home information for parents at the end of the exam to provide additional information.
- If treatment is not initiated at the first visit, follow up with parents via phone call in the following weeks. If treatment is declined and rapid untreated progression is likely, follow up with an office visit in 6 months.
Final thoughts
As the primary eyecare provider, optometrists have a key role in discussing myopia management with parents. Presenting the information clearly and concisely, focusing on what is best for the child’s visual and ocular health, is the best way to get parents on board with treatment.
As the methods of myopia control continue to evolve and improve, optometrists should work to keep themselves up to date on the latest advancements.
