Myopia Profile


A two-year-old with low myopia - to correct or not?

Posted on September 18th 2020 by Connie Gan

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Here is a case of -1.50D myopia in a 2 year old child. Is myopia control beneficial for a toddler? What are the key clinical considerations? Read more here.

Would you prescribe glasses for a young child with mild myopia? Is myopia control beneficial for a toddler? What are the key clinical considerations? KB shared an interesting case about a two-year-old child with -1.50D of myopia in the Myopia Profile Facebook group.

KB What is everyone thoughts on a 2 yr old child who refracts to -1.50 R & L. With one parent being myopic. Would you issue , monitor ? This is from a basic case presented on this morning webinar . 22 of us on this course had various thoughts . No VA’s. Just based on the above facts. I would be interested to hear what others think? By the way the child is not over accommodating not a cause of pseudo myopiaKB …This case would have been a cycloplegia refraction and the final finding is -1.50. It would also been seen by the hospital Ophthalmologist, and orthoptist next door.

What are the considerations?

Limited research and patient information

EH None of the studies are done on 2 year olds (including undercorrection) so we are flying blind in this age group…KG This is not our ‘vanilla myope’ (age 7-16, -1 to -6) typically investigated in research on myopia control interventions. Ian Flitcroft is leading a new IMI paper now on Paediatric High Myopia, and when this was announced at the recent International Myopia Conference, a clinical pearl he mentioned which stuck with me was “if the child has more dioptres than years of age, they need to be properly diagnosed first.” This means a paediatric ophthalmologist ruling out syndromic conditions (ie. Marfans) before assuming it’s garden variety myopia…NR … Literature research shows huge variations as to what amount and when to rx from the USA to the UK. Then just in the UK alone there is variation with hospital Optom’s as to what rx amount would one prescribe for esp at an age like this. This child case would be in hospital and there are times when I am faced with young children age 2 who are myopic after a cyclo refraction and I need to make a decision to rx or not. A dilemma!!...SS A very interesting case. I would think that a cycloplepgic refraction is needed to make a decision.JS Not enough facts to form any sort of opinion.LM …We need to see if the patient is eso or exo at near to decide type of glasses. Also we need AL evaluated…DN is there an under correction study for this young?RC Need more info: phorias, BV, PRA NRA, posture, close work/ technology use...

Currently, there are no studies about the likelihood or typical rate of myopia progression for a two-year-old child. Without that information, we cannot justify with certainty that myopia control is required or would be beneficial at that age.

While commenters also highlighted that we lack other useful information such as the child's axial length and binocular vision status, which could influence one's management, there is question of how much value this provides in a child so young. The key management strategies at this age would be to ensure clear visual input to avoid amblyopia. If the child also had significant astigmatism or strabismus this would make the management simpler - vision correction and more active management would be required.

Even though the myopia is low, it is unusual to be myopic at such a young age - therefore it is critical to consider referring the child to an ophthalmologist to rule out any systemic co-morbidities. The mandatory nature of referral for a toddler with low myopia will depend on the scope of practice of primary eye care in your country. Once this care pathway has been satisfied according to your specific professional requirements in your country, it is likely that management of optical correction will fall back to the primary eye care practitioner. It is important to note that the case presented mentioned that the child had already seen an ophthalmologist, and the focus was on how to manage the refraction - to correct or not?

Should we prescribe optical correction?

The community's opinions were split about the management of this child. The minority said they would prescribe glasses whilst the rest would choose to monitor the child first.

'Time to treat' group

YC It's never too late to treat a myope. And also it's never too early to do so.LM Undercorrection promotes myopia progression. At -1.50, if confirmed under cycloplegia, for me form deprivation is present… So I would correct it…Other way would be regular + atropine 0.05%RC Sorry , need glasses. Misread age! Parents may still put child on technology though.

The rationale behind prescribing glasses now was to avoid under-correction, which has been suggested to be linked to increased myopia progression as highlighted in the discussions below. However it's important to note that children this young are not typically included in myopia control studies, so the influence of undercorrection on a two-year-old is unknown. The ensuing discussion highlighted that there is some conjecture on undercorrection being harmful in myopia, and how well the studies apply to this patient.

SM This paper (see reference Sun et al) actually suggests that not correcting myopia shows slower progression than correcting it. I know the other papers suggested than undercorrection sped up progression. The theory of the defocus produced with uncorrection would support animal studies and the principal of orthok/misight lenses.HO I don’t see how they can conclude anything if the SD was .49DN Is there an under correction study for this young?LM Yes this is the ONLY paper in this direction- which is doubtful... Also the group of patient was very very little myopic - non cycloplgegic if I remember well... so not the same thing. Everybody agrees that undercorrection is harmful over time..DN I thought there was as only 2 studies on under correction. I may be wrong. Perhaps all those people wearing their glasses after 6mo this are under correcting themselvesLM Look at IMI white papers....

What the research says:

  • Sun et al showed that having no myopia correction slows myopia progression.1
  • Li et al suggested full correction and undercorrection of myopia show the same rate of myopia progression.2
  • Adler et al, Chung et al and Vasudevanet al showed undercorrection promote myopia progression.3-5

The youngest subjects in all these studies were school-aged children, with vastly different visual needs and tasks to a two-year-old toddler. Hence, it would be difficult to extrapolate these conclusions for this child. To read more on undercorrection and un-correction, check out this research blog which describes a recent meta-analysis paper on the topic. The conclusion of this meta-analysis was that undercorrection doesn't appear to be beneficial in myopia and is unlikely to be suitable as an intentional clinical management strategy.

'Time to monitor' group

SS …I am of the opinion that we need to see progression to treat progression so would monitor at this stage but monitor closely due to the risk factors.JS No need for glasses so if all other ocular health is good, I’d leave uncorrected and review in 6 monthsSDF If it’s -1.50 as a dry ret... it’s probably pl with cycloplegia... check uncorrected vision whilst cyclopleged. If it’s 6/9 or better, he’s o.k. Review 3-4 months.EH …Their world is near, and that will be quite clear even if they really are -1.50 (and they may not be on cyclo) so form deprivation unlikely and probably don’t need to correct (yet). You probably can’t formally check vision, and even if you could it would probably be at 3m and overestimate if myopic... if you happened to have an axial length measure that would be helpful to monitor progression. I’d wait and see, but definitely at risk based on info so far so watch closely and consider intervening if definitely progressing.KG With this low level of myopia you may want to observe first, because as Elisse rightly points out, their world is at near anyway, but it sure wouldn’t hurt to get a paed ophthal opinion in a child so young.KB The decision in the end was not to rx as a child of 2 is doing everything close up. Also they don’t do very well in glasses age 2.EH Sounds reasonable. I do have a number of kids in glasses aged under 2, and most of them actually do much better than their parents expect in glasses.

Most commenters suggested monitoring the child first due to the lack of myopia control research for this age group. The visual world of children at this age is mostly close up. Thus, not correcting this low level of myopia is highly unlikely to lead to form deprivation amblyopia as the world at close distances is entirely clear for this child.

However, monitoring the child's myopic progression is important. And whilst not everybody would necessarily prescribe glasses at this stage, documented progression would be a stronger indicator for intervention. It is also worth highlighting again that, despite the low myopia, the community did comment that seeking an opinion of a paediatric ophthalmologist would be important. In the case presented, the child had already seen an ophthalmologist. Whether this is mandatory or not will depend on the scope of practice in your country for managing children in this age group.

In looking to consensus on prescribing for toddlers, the American Academy of Ophthalmology's Preferred Practice Patterns for Pediatric Eye Evaluations (2017) advises correction for myopia of 3D or more at age 2 to <3 years. (Table 3) This data is given with a note that "these values were generated by consensus and are based solely on professional experience and clinical impressions because there are no scientifically rigorous published data for guidance. The exact values are unknown and may differ among age groups; they are presented as general guidelines that should be tailored to the individual child." A research review published in 2011 recommended that for myopia without anisometropia or astigmatism, children 1-2 years of age be corrected for more than 2D of myopia once walking; from 2-4 years of age be corrected from 1.50D of myopia if it improves function. In both cases it's suggested to reduce the refraction by 0.50-1.00D for emmetropization until age 4. You can read this open access paper here. It appears from research and consensus that it may be appropriate to not prescribe a correction in this case, based on this first presentation.

Managing the visual environment

SDF The child must play outdoors. As much as possible. Buy him a bike, a sandpit and a puppy. Strongly limit the use of electronic devices.KG … Limiting screen time and encouraging more outdoor time are also good suggestions!

Regardless of whether one decides to correct this level of myopia at this stage, the consensus is that increasing time outside and reducing near work is an important part of managing this child.

Research shows that sufficient outdoor time can slow the onset of myopia, although there is conjecture about its role in reducing progression after myopia onset.Eyecare practitioners can recommend children spend at least 90 minutes a day outdoors. It is important to still encourage sun safety whilst doing this - that is to wear hats and sunglasses.

Excess near work is linked to increased rates of myopia progression,and according to the American Academy of Pediatrics and Australian Government Department of Health, screen time is not recommended in children under the age of two, for a variety of developmental reasons - not just visual. Children aged 2-5 years are suggested to have a maximum of one hour of screen time per day. For these weblinks and a reference to give parents, head to the My Kids Vision blog entitled Close Work and Screen Time.

Take home messages:

  1. Children under age 10 with high myopia (more than 5-6D) should always be referred and/or co-managed with paediatric ophthalmology. This child is not a high myope but is very young - consideration of seeking a paediatric ophthalmologist's opinion on management is critical in cases of very young myopes. It may be mandatory in your country, depending on the scope of primary eye care practice. In this case, it was noted that the child had already had ophthalmological review, and the focus was on refractive management.
  2. Prescribing glasses isn't always the first necessary step when you are presented with the very young myope. Considering the visual needs of the child will aid that decision, and the research and consensus guidelines do support not prescribing, and observing, in this case. Very young children have a closer 'world' of visual tasks, and the key imperative at this age is to avoid amblyogenesis.
  3. Regardless of age, the importance of outdoor time and managing near work time should be discussed with parents. Resources for parents are available on the My Kids Vision website.

Further reading on prescribing for young children

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Meet the Authors:

About Connie Gan

Connie is a clinical optometrist from Kedah, Malaysia, who provides comprehensive vision care for children and runs the myopia management service in her clinical practice.

Read Connie's work in many of the case studies published on Connie also manages our Myopia Profile and My Kids Vision Instagram and My Kids Vision Facebook platforms.

About Kimberley Ngu

Kimberley is a clinical optometrist from Perth, Australia, with experience in patient education programs, having practiced in both Australia and Singapore.

Read Kimberley's work in many of the case studies published on Kimberley also manages our Myopia Profile and My Kids Vision Instagram and My Kids Vision Facebook platforms.

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