Myopia—once considered a benign refractive error and, arguably, the “bread and butter” of many optometric practices—is today recognized as a global epidemic, representing the single most common ocular disorder in the developed world. According to the Myopia Institute, this condition currently affects 30% of our population, with estimates projected to reach nearly 50% worldwide by the year 2050.1
Ironically, one of the factors that is driving this epidemic involves the very technology that is intended to increase our productivity and broaden our access to information, such as computers, smartphones, tablets, and various other screen devices.
Additional risk factors, especially in young children, include reduced time spent outdoors as well as increased urbanization. Add to that the burden of genetics (i.e., parental myopia), gender, and ethnicity, and the recipe for myopization of our society is nearly complete.2 Although this news may seem alarming or unpleasant, it fortunately comes at a time when eyecare providers are uniquely positioned to intervene.
Today, the topic of myopia control (also known as myopia management) is one of the fastest-growing specialty areas within optometry. The use of multifocal spectacles, Ortho-K contact lenses, low-dose atropine eye drops, and new soft contact lenses designed specifically for myopia control all represent therapeutic options designed to alleviate this ophthalmic crisis.
While these management strategies may not completely abolish myopic progression or reverse myopia that has become manifest, they have been found to diminish the rate of progression by as much as 78%.3 In fact, according to a seminal publication in the Journal of the American Academy of Optometry, slowing myopia by just one diopter has the capacity to reduce the likelihood of a patient developing myopic maculopathy by up to 40%.4
The alternative strategy, of course, is to simply continue prescribing single-vision glasses and contact lenses for those with early myopia, as has been the standard practice for over a century; however, experts believe that following this course of action may actually promote myopic progression, causing the disorder to advance further and faster.5,6
In the following article, we’ll provide our perspectives, recommendations, and case illustrations demonstrating the potential impact that myopia control can have on our patients and practices. More specifically, we’ll discuss our experiences using MiSight 1 Day soft contact lenses, the first and only contact lenses approved by the FDA to slow myopia progression in children aged 8 to 12 at the initiation of treatment.7
My approach to myopia management
In my practice, any time I encounter a child who is myopic, I immediately consider and offer myopia control options. For young myopes, the sooner you initiate treatment, the better for everyone. Children actually seem to have the easiest time adapting to these strategies, and parents are happy knowing that they are taking preventative measures to ensure a better future for their sons and daughters.
Conversely, when we delay or omit the discussion of treatment options for myopia control, we are actually prohibiting parents from taking definitive action on behalf of their children. The first step in my management plan is having a detailed conversation with the parents AND the child. It’s important to remember to speak to the child directly about their expectations and discuss any concerns or fears they may have. The more comfortable the child and their parents are, the easier the process will be.
I have been offering myopia control strategies in my practice for 15 years now, and one treatment that I commonly recommend is Ortho-K, specifically using Paragon CRT lenses. I have seen how the unique design of these lenses effectively slows myopic advancement in all of my myopia control patients, and some have even shown a complete stoppage of progression.
Additionally, with the development of MiSight technology, my patients now have the option of a soft daily wear lens for myopia control. I have had many parents who themselves experienced ocular complications due to myopia, often involving retinal pathology, seek out treatment for their children.
They fear that the same fate may impact their offspring, and search for a provider who understands their concerns and is willing to help them. As an eye doctor, I want to be the first to inform them that there is something I can do to help.
Considering—and sometimes reconsidering—the myopia treatment options
There are often reasons to consider changing from one myopia control treatment modality to another. For example, daily contact lens wearers who experience irritation or discomfort—even when the lenses are properly fit and worn correctly—might prove to be better candidates for Ortho-K, in which the lenses are worn only at night.
Conversely, Ortho-K patients may fail to achieve success for a number of reasons, though most often we find that they are not sleeping in their lenses long enough to provide sustained, comfortably clear vision. In patients like these, switching to MiSight lenses can provide better, more consistently sharp vision throughout the day.
The majority of patients who are fitted with MiSight are actually new to contact lens wear since most are in the approved age range of 8 to 12 years. However, some of the patients for whom I’ve prescribed these lenses are teenagers who were previously wearing standard soft hydrogel lenses.
When I make a change like this, I always take care to warn patients that these lenses are slightly thinner, and that they’ll likely notice a slight blur in their peripheral vision, which will improve after a few days of wear. Once they adapt to these changes, patients typically do well and are happy when they see that their vision has remained stable at each successive follow-up.
Changing modalities without losing faith
I always take the time to explain the pros and cons of every myopia control option with parents, affording them the opportunity to make an informed decision for their child based on my recommendations. Parents understand that I am doing my very best, and if we need to switch modalities, I always explain precisely why.
For example, when patients with flatter corneas are treated using Ortho-K lenses, they may have a slight, residual prescription during the day. In such cases, one remedy is to address the residual Rx by prescribing a pair of glasses to be used as needed for long distances, while the patient continues wearing lenses at night.
Another, and in my opinion, better option involves switching to MiSight contact lenses, which can provide full correction for clear vision throughout the day while also addressing myopic progression.
Best practices for new patients
If a young patient is apprehensive or nervous about wearing contact lenses, I usually encourage the parents to insert and remove the lenses for the child until they are comfortable doing it for themselves. This helps some children overcome the initial fear of touching their eyes.
If the child elects to do it themselves, you’ll want to provide encouragement so as to maintain and enhance that motivation. I always tell parents to support their children and to inspire them to remain positive and persistent, even if they become frustrated at times.
It’s not uncommon for young children to struggle during their initial attempts at lens insertion. If they become upset or angry, it’s best to reassure them and schedule an appointment to come back and try again.
Many children just need additional time to process the information, as well as their feelings. They often return with a completely different attitude after they’ve practiced touching their eyes at home with clean fingers, as I’ll instruct them to do.
Practice what you preach
As a testament to my belief in myopia management, I recently advocated for my own 10-year-old daughter to begin wearing MiSight 1 Day soft contact lenses earlier this summer. After just a week or two, she was doing extremely well. She sees much better now than before, and she is quite confident inserting and removing her contacts.
Regarding that peripheral blur, which is common shortly after initiating wear of MiSight lenses, her experience was exceptional. She said that the blur disappeared after only one day. She now can routinely insert her lenses on the very first try, and we have enjoyed celebrating this achievement together!
Surprisingly, many kids will initially not wish to give up their glasses, and they’ll often express this concern when we discuss myopia management. After they start wearing MiSight lenses, however, they often forget about glasses and instead focus on their new-found freedom, especially when playing sports or engaging in similar recreational activities.
Other times, children can be embarrassed to wear glasses, and they are excited for the opportunity to try contact lenses. In a number of instances, I have seen children really open up socially as well as improve their academic performance.
“Rosie” first came to my office in February of 2021, having spent all of second grade staring at her classmates and teachers on a Zoom screen. Her myopic mom (-4.00D), aunt (-8.00D), and emmetropic dad were desperate to do something about her rapidly declining vision.
At age 8, despite having been treated with 0.02% atropine drops and bifocal spectacles for an entire year, Rosie only read the 20/100 line with her most current spectacle Rx which was -4.00D OD and OS. She looked at me with thoughtful eyes as I leaned in to hear her question, whispered tentatively through her facemask—"Will my eyes explode?"
Whether their child has already seen multiple doctors or is in my chair for their very first eye exam, I initiate the same discussion with every parent or caregiver. Often surprised that even those already being treated for myopia have never undergone a cycloplegic refraction or a binocular vision workup, I present the family with a full spectrum of available options and the data behind each of them.
The value of patient and parent education on myopia control options
Rosie's parents were unaware that topical atropine, while effective, was not an FDA-approved therapy, or that bifocal glasses did not demonstrate quite the same efficacy in controlling myopic progression as alternative methods.
Having explained all currently available and investigational methods (e.g., Ortho-K, center-distance multifocal soft contact lenses, low dose atropine, highly aspherical lenslets, and low level red light therapy) as well as their respective status with the United States Food and Drug Administration (FDA), I was now ready for the parents to make an intelligent, well-informed decision about their preferred course of action.
Lest you think that I subjected Rosie to this diatribe, rest assured that she was treated to the highly condensed, illustrated version of what “near-sightedness" is, instructed to spend more time outdoors and also to take frequent rest breaks from close work. I should add that I am not a fan of fear-mongering, as many children and parents come to me terrified that if they do nothing, they will go blind.
Rosie and her family were reassured that no matter what happens she will always have good vision. At that point, we proceeded to instill cycloplegic drops and perform A-scan biometry, after which little Rosie went to the waiting room to play with my tech while I educated her parents.
With all the data in hand, we opted to proceed with fitting MiSight contact lenses. Then came my favorite moment of any pediatric new contact lens fit. After all the apprehension and drama that goes hand-in-hand with inserting the first lens, the little girl opened her eyes and a huge smile washed over her entire face. "I can see!” Rosie cried as she jumped up in joy. It was all I could do to get her back into the chair for that second contact lens!
Assessing pediatric patients for contact lens readiness
Some might ask, justifiably so, isn't 8 years old a little too young for contact lenses? Well, since I often examine babies who are in contact lenses for congenital cataracts from the age of 6 weeks, I am probably the wrong person to ask!
My answer is simply this:
If the parents are responsible and ready to help, and if the contact lenses will have a positive benefit that outweighs the risks, then no age is too young. If at any point I think that one of those things is untrue, then the individual is no longer a contact lens candidate, regardless of age.
Now, 4 years later, Rosie has only progressed by 0.50D and happily inserts and removes her own lenses daily. She is 12 and has sprouted 4 inches just this past year, so we will see if we can keep her under -6.00 diopters, which is my personal goal in all of these cases.
Her parents remain highly compliant with scheduled follow-up visits and Rosie has never had any infections. Most importantly, she actively participates in sports without being hampered by glasses. She is also an A student, and greatly looks forward to her 6-month check-ups, no longer afraid that her eyes will explode.
The year was 2019, and it was a seemingly typical day at my practice. Walking into the exam room, my demeanor suddenly changed to one of surprise and bewilderment. Was I seeing double? In fact, I was! It seemed that my next patients were twin 6-year-old girls—“Olive” and “Mandy”—who were accompanied by their parents. They had seen another eye doctor previously but had no vision correction at the time of presentation.
The topic of myopia management can be a challenging one for eyecare professionals like us to discuss with parents, especially if they are not myopic or subject to any visual limitations from refractive error. In this scenario, I was somewhat fortunate; these particular parents knew firsthand the importance of early diagnosis and treatment.
The girls’ father reportedly had 7.00 diopters of myopia and had been wearing corrective lenses nearly all of his life. Likewise, the girls’ mother had a similar history, although she had recently opted for refractive lens exchange in order to address her high myopia.
After a thorough history, I proceeded to evaluate these two sisters, assessing their binocular and accommodative skills, performing a refraction, and conducting a thorough ocular health assessment. Fortunately, both girls were free from any pathology, and most importantly, there was no evidence of myopia in either of them. I proceeded to educate the parents as to my findings and told them that I would like to see the girls again in one year, or sooner if any symptoms were noted.
2020 soon arrived, along with the excitement of countless potential marketing opportunities that inundated our profession, playing off of the concept of 20/20 vision. Unfortunately, as we all now know, the pandemic changed everything, and everyone. Virtually no one was spared the impact of the subsequent COVID lockdowns, including Olive and Mandy.
Although they were not particularly symptomatic, both girls were subject to myopic progression in the interim. When I finally reconnected with the family in early 2021, Olive and Mandy were just a few months shy of their 8th birthday, at which point they would be candidates for MiSight 1 Day soft contact lenses. I had a lengthy discussion about early intervention with the girls’ parents, and my recommendations were readily accepted. We planned to schedule the contact lens fitting as soon as possible.
April 2021
Olive’s contact lens prescription was found to be OD -0.50, OS -1.50. Biometry showed her axial length to be OD 22.66mm and OS 22.95mm. Mandy’s Rx was OD -0.50, OS -0.50, and her axial length measured OD 23.58mm and OS 23.51mm.
Both girls were prescribed MiSight contact lenses in the stipulated powers and, after providing proper education regarding care and handling and ensuring the fit was acceptable, they were scheduled for a 6-month follow-up appointment.
November 2021
Upon their return, neither Olive nor Mandy showed any need for a change in prescription. Olive’s axial length showed a small increase, measuring OD 22.72mm and OS 23.18mm. Mandy’s axial length was quite stable, even demonstrating a slightly decreased value (within the margin of error), measuring OD 23.41mm and OS 23.33mm. Again, a 6-month return was scheduled.
April 2022
At the next visit, the girls continued to display stability of refractive error, with no prescription change warranted. Their respective axial length measurements were stable as well, with Olive measuring OD 22.79mm and OS 23.31mm, and Mandy measuring OD 23.47mm and OS 23.33mm.
November 2022
Then, 6 months later, all remained consistent once again. No change was indicated in the Rx for either of the girls.
Axial length measurements were as follows:
- Olive: OD 22.79mm and OS 23.31mm
- Mandy: OD 23.48mm and OS 23.35mm
June 2023
More than 2 years after the original contact lens fittings, Olive and Mandy (now both 10 years old) were doing quite well. Olive’s axial length measured OD 22.89mm and OS 23.40mm; her cycloplegic refraction showed OD Plano -0.75 x 173, OS -1.75-0.50 x 171; however, no change was made to her MiSight contact lens prescription.
Mandy was also quite stable, showing only a slight increase in axial length to OD 23.67mm and OS 23.55mm. Her cycloplegic refraction was OD -0.75-0.50 x 176, OS -0.50-0.50 x 008.
Based on these findings, I decided to increase her MiSight CL prescription by a quarter-diopter to -0.75 OU.
January 2024
Once again, refractive error and biometry readings remained relatively stable. Olive’s axial length was measured at OD 22.93mm and OS 23.56mm, while Mandy’s values were OD 23.92mm and OS 23.83mm. No changes were made to either girl's Rx.
June 2024
At the girls’ most recent visit just a few months ago, Olive and Mandy displayed some progression, although these changes were anticipated, given that they had recently celebrated their 11th birthday. Olive’s axial length now measured OD 22.99mm and OS 23.84mm. Refractive error remained stable in her right eye at -0.50, but the left eye warranted a change in power to OS -2.50. Her net increase in myopia from April 2021 to June 2024 was OD plano, OS -1.00.
Likewise, Mandy’s axial length had increased to OD 24.28mm and OS 24.23mm, with a concurrent worsening of her refractive error. Her MiSight Rx was increased from OU -0.75 to OU -1.50. Her net increase in myopia from April 2021 to June 2024 was OD -1.00, OS -1.00.
While both girls ended up with some myopic progression during their 5 years under my care, it was far less than might be anticipated given their family history and other risk factors. I am convinced that, without the intervention of MiSight 1 Day soft contact lenses, their myopia would likely have skyrocketed. Today, both girls enjoy excellent visual acuity with correction and remain in the “low myopia” camp (i.e., less than -3.00 diopters).
Both are compliant with their 12 hours/day wear regimen 6 days/week and use spectacles on the 7th day to promote good corneal health. Their parents have been extremely supportive and encouraging throughout this journey, and are thrilled that their daughters have not been subject to the extreme impact of myopia that they have had to endure throughout their lives.
Conclusions
The evidence regarding the need for myopia control in today’s society is overwhelming, and both the research and real-world experience with MiSight 1 Day soft contact lenses suggest that we now have an effective FDA-approved tool in our arsenal to fight this battle.8-11
These real case studies demonstrate the tremendous impact that we as eyecare providers can have on patients’ lives if we remain true to our calling and honest with ourselves regarding the best course of action for young, developing myopes.
