Myopia Profile


Getting started - choosing a treatment for fast myopia progressors

Posted on July 19th 2021 by Connie Gan

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Myopia control is vital especially for fast myopia progressors. This case describes risk factors and treatments for fast progressors.

The decision to commence a myopia control treatment is simple when the parent asks for it, seeing rapid progression in their children as concerning. When getting started, how to do you select and discuss the best strategy? PC opened a discussion about the decision-making process of deciding on initial myopia treatment in the following case involving fast myopia progressors with a family history of very high myopia.

PC A pair of siblings came to see me today for myopia assessment. Family history: Dad -11.00, has glaucoma and previous retinal detachment, age 40. Mum -3.00, had refractive surgery. Girl, age 9: 6 months ago R -1.75 L -1.50 Now R -3.00 L -2.75 (wearing recently-made SVD of same Rx) AXL: R 24.65 L 24.53mm Flat K's: R 43.75 L 43.50 Boy, age 7: 6 months ago R -1.25 L -1.25 3 months ago R -1.50 L -1.50 Now R -2.50 L -2.75 (just had SVD made by previous optom of same Rx) AXL: R 25.92 L 26.01mm Flat K's: R 41.75 L 41.75 No discussions about myopia control had taken place previously, but their mum became concerned after the significant Rx increases at their recent eye tests. They also saw an ophthalmologist yesterday who recommended using 0.01% atropine and discouraged the use of contact lenses. There were still some residual effects from mydriatic drops from the ophthalmology consultation so will bring them back next week for BV workup. Also gives me some time to consider the management plan and for the parents to think about the options that I’ve discussed with them so far. How would you manage these siblings?

Considering the risk factors

In assessing risk for myopia progression, these siblings have two key factors that indicate the need for a proactive myopia control strategy.

  1. Young age - being under age 9 at myopia onset1
  2. Parental myopia - Both parents are myopic, including one with very high myopia2

Their ethnicity is not mentioned, but children of Asian ethnicity are additionally at risk of faster myopia progression.3 Ethnicity is important because Asian ethnicity is a key risk factor for myopia onset and progression, compared to other ethnicities, regardless of country of residence. Each of these three risk factors - age, parental myopia and ethnicity - are of course not modifiable, but important to identify as a myopia managing practitioner. You may choose not to discuss ethnicity as a risk factor with parents, where there may be sensitivity or it may not seem helpful, but even so it is worth keeping in mind clinically to help drive a proactive treatment strategy.

Additional need for myopia control is indicated by:

  • Current myopia intervention - both children are wearing single vision distance optical correction, so myopia progression is not controlled
  • Myopia progression - around 1D in six months, indicating fast progression. it is important to note, though, that prior progression doesn't always predict future progression as a single factor - bringing age of onset and parental myopia into consideration is important4
  • Axial length - the 7-year-old boy's axial length is close to 26mm, which is especially concerning given this appears to be the delineator for a significant increase in lifelong risk of ocular disease and vision impairment.5

First suggestion - atropine

The post reports that these two siblings had recently seen an ophthalmologist, who recommended 0.01% atropine. Given that the efficacy of atropine as a monotherapy has been shown most recently to be concentration-dependent,6 it would make sense to consider a higher concentration for better efficacy.

PC Low-dose atropine is certainly safe enough for most children, but the efficacy of 0.01% atropine to slow progression of very fast progressors (particularly in regards to axial length - the 7 year old is already at 26mm) is the questionable factor.SD Those axial lengths are important info, especially for the 7 year old. With him also being a young male, I would do 0.05% atropine. For the 9 year old, I would discuss the available options with her and see which she prefers for best compliance, with final recommendation based on her maturity and lifestyle (swimmer? Etc), but monitor every 3 months due to her fast progression. Great cases PC!PC Yes while both children are fast progressors, the 7 year old is arguably the higher risk child due to his axial lengths. With the limitation of 0.01% atropine to slow axial elongation, a higher dose is what I’m thinking of also.

The LAMP study showed a dose-dependent efficacy of low-dose atropine, whereby 0.05% atropine was twice as effective than 0.01%.6 If low-dose atropine is used as monotherapy, then 0.05% atropine would perhaps be the best starting point. To read more about deciding on prescribing atropine, check out When to prescribe atropine for myopia control.

What about an optical strategy?

SDF 0.01 atropine. Both. Also, multi-focal spectacles. Flip them over to myopic control SCL @ 12 yrs/age.BR For people concerned about contacts in kids. It is safe as long as you discuss the risk factors. I myself started contact lenses in third grade because I was a dancer and my glasses were always broken. If you are not comfortable fitting 6-12 year old with contacts refer to someone who is. They are life changing in many ways.BR my son developed an accommodative esotropia at 2.5 years of age. He has worn silicone hydrogels since the age of 3.5. Every day. He’s now 18. I know they’re great. I’m an optometrist. Most parents know what’s best for their kids. They will decide in the end. Most parents want to minimise harm to their own kids. Atropine harm potential< contact lens harm potential < ortho K harm potential. If you work with the parent but gently guide them along, everybody wins in the end. 👍

With moderate myopia, the children need an optical correction, and there are options for myopia correction and control with specific spectacle and contact lens types. Most commenters recommended contact lens options, noting the safety and efficacy of contact lens options for children, especially under age 12.

In this case, the ophthalmologist recommended against the use of contact lenses for the two siblings. Common concerns with contact lens use in kids surround safety. Read more about this in  Contact Lens Safety in Kids.

For atropine monotherapy, progressive addition (multifocal) spectacles with photochromic treatment can be important to manage potential side effects of atropine. The low-dose atropine for myopia progression (LAMP) study found that around 30% of children requested photochromic spectacles due to glare symptoms, regardless of the atropine dosage (0.01%, 0.025% and 0.05%) - and even on the placebo treatment too. Only a 1 or 2 out of a hundred had near vision symptoms, again similar across the groups, and were prescribed progressive addition spectacle lenses.6

Only accommodative amplitude was tested and questions of near vision symptoms was asked in the LAMP study. Aside from this, there has been minimal investigation of other clinical measures of accommodative function in atropine treatment. One recent study found that 0.01% atropine did not affect accommodative facility in Chinese children wearing single vision spectacles. These results could potentially be different with stronger concentrations and in children with lighter iris colours, who may show greater mydriatic response.7

Combining atropine with an optical strategy

DJ I would probably start with low dose atropine on them both. Maybe entertain the idea of ortho-k with the older sister first, and then the younger brother a few months later.JG Is there research you could use to enter into a discussion with their ophthalmologist regarding combined orthokeratolohy and atropine?PC Yes there’s a couple of recent papers on potential synergistic effects of orthokeratology and atropine that I’ve drawn the parents’ attention to.RG … Combine (OK lens) with low dose Atropine if needed for better control.NB …Present all the valid options, explain why, make a family choice. That’s our standard. I’d be looking very closely at orthoK for the boy with the recent evidence of atropine not necessarily stabilising axial length.PP Right into ortho-k with BOTH. Check in 6 months to see if any progression. If is progression, go with 0.05% atropine.

In combining atropine with an optical strategy - myopia controlling spectacles or contact lenses - the only data available is that on combining orthokeratology (OK) with varying concentrations of atropine, mostly 0.01%. A recent meta-analysis showed that this combination reduces axial elongation by a weighted mean difference of 0.09mm compared to OK alone over one year. This was from the basis of three short-term (1, 6 and 12 month) and two long-term (24 month) retrospective studies, neither of which were randomized.

The first prospective, randomized controlled trial on OK and 0.01% atropine has shown similar results. In myopes of -1.00 to -3.00D, axial elongation was 0.18mm less over two years in the combination treatment group. In myopes of -3.01 to -6.00D, axial length increased more slowly overall and there was no difference when atropine was added to OK.9

More clinical trials are currently underway, including the first on combining 0.01% atropine with multifocal soft contact lenses. Initial results have shown good short-term tolerance of the combined treatment.10

What happened in the end?

PC An update on this case: Both children had moderate amounts of near esophoria (girl 5es, boy 7es) with their SVD Rx. They might have been better served by wearing progressive lenses if this had been identified prior. Dad’s AXL measured R 29.97 L 30.96mm (RD was in LE). Parents, both medical doctors, carefully considered the research I presented them with and ended up deciding on Ortho K for both children, plus 0.01% atropine. And if there is still significant progression after 6 months the plan is to increase the atropine dosage in combination with OK.NB The BV would determine what I kept on the table - absolutely perfect BV would push multifocals / bifocals to the side…SDF 0.01 atropine with SCL m.focal or spec m.focal to neutralise the N eso was a no?PC That would be an option if they preferred to stay in glasses but parents wanted to give OrthoK a go.

In the end, the parents decided to try orthokeratology lenses with 0.01% atropine. This is an evidence-based choice, to both correct and control myopia based on the latest research.

Further testing has revealed that the children exhibit near esophoria in their single vision corrections. The esophoria could have been managed with progressive addition spectacle lenses, which have also shown mild myopia controlling effects for such children.11 Orthokeratology, however, will also offer a small exophoric shift compared to a single vision correction.12

Take home messages:

  1. In considering the clinical findings and cluster of risk factors for fast myopia progression in these children, a proactive myopia management strategy is needed. Younger age and parental myopia indicate a higher risk of faster progression, alongside Asian ethnicity. Prior fast progression doesn't always predict future fast progression but it can be a factor.
  2. An optical correction of spectacles or contact lenses is required for myopes, so considering a treatment strategy which both corrects and controls myopia is ideal. There is early evidence for combining low-dose (most frequently 0.01%) atropine with orthokeratology to achieve additive efficacy, with more research underway. Atropine 0.01% as a monotherapy is not the most effective strategy to select as a first line treatment, based on current evidence.

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.

This content is brought to you thanks to unrestricted educational grant from


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