Seeing Beyond Efficacy In Myopia Control

In this review, Bullimore et al. discusses the important considerations of seeing beyond efficacy with myopia management strategies. The growing burden of myopia is of public concern. Specially designed spectacle lenses, soft contact lenses, atropine, and orthokeratology have shown similar results for myopia management efficacy. However, four key factors—compliance, quality of vision, quality of life, and safety—are some of the fundamental considerations when comparing overall efficacy and prescribing a myopia management plan.

A patient’s compliance to any treatment regimen has been demonstrated to directly influence efficacy regardless of the modality and should be considered. With regards to the efficacy of myopia management with optical interventions, higher compliance, in terms of wearing time, is associated with greater treatment efficacy. It is suggested that compliance should be higher with contact lenses than spectacles, especially orthokeratology, where quality of vision and comfort play little role during most of the wear time. With non-optical interventions like atropine, compliance may be a challenge, particularly if there are limited obvious benefits from the patient’s perspective. Compliance has also been shown to be influenced by a range of factors, including comfort, vision, motivation, lifestyle, and the tangible benefits associated with the modality.

Quality of vision is one of the key factors to be considered in myopia management. Patients report different levels of quality of vision with each spectacle design. Soft myopia management contact lenses may offer small differences (for example, less than half a line of visual acuity which may not be clinically meaningful) in quality of vision among different designs. On the contrary, atropine at higher concentrations appears to have a modest negative influence (photophobia, blurred vision) on near vision and minimal effect on distance vision. Overnight orthokeratology offers excellent stable vision without correction during the day.

A strong positive relationship has been established between quality of life and efficacy with some myopia management treatments, particularly in the areas of activities and appearance. Studies assessing vision-related quality of life reported higher satisfaction with contact lenses than with spectacles.

Regarding safety, the side effects of atropine for myopia management including discomfort and photophobia, are dose-dependent, however, there is no data for long-term use at effective concentrations. Spectacles are easy to use and also easy to remove. They generally offer minimal risks, with potential risks due to peripheral visual field restrictions and distortions in some designs for myopia management. Microbial keratitis associated with contact lens wear for myopia management is a rare adverse event that can be mitigated with avoidance of tap water, daily disposable lenses, good hygiene, and compliance. The overall incidence of microbial keratitis was between 2 and 4 per 10,000 patient-years for daily-wear patients for soft contact lens wearers, and 5 to 14 per 10,000 patient-years with orthokeratology. The benefits of myopia control far outweigh these risks. Children aged 8- to 12-year-olds may be safer contact lens wearers for all contact lens modalities compared to teenagers and young adults.

In summary, there are many things to be considered beyond efficacy when recommending a myopia management modality, including compliance, quality of vision, quality of life, and safety. Each of these factors are equally important with compliance also influenced by vision and comfort. Among the different myopia management strategies, orthokeratology and daily disposable soft contact lenses represent attractive options, with better vision-related quality of life than spectacles. When used appropriately, they carry a very low risk. Successful myopia management relies also on the motivation of both patient and parents. Therefore, the clinician can exercise appropriate judgment and leverage their experience when discussing the treatment plan with the patient and their parents.

PP# 2024PP11197