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Clinical

How to manage the highly myopic toddler

Posted on September 17th 2020 by Connie Gan

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In this article:

This case features a two-year-old with high myopia. We explore how to manage this two-year-old myopic toddler with the community.

Here we have an interesting case of involving a young child with high myopia and astigmatism. PC is looking for recommendations on how to manage this highly myopic toddler, with the discussion ranging from co-mangement, to the best optical correction, to the lifelong eye health strategies required of this case.

PC Starting the week with a little boy who just turned 2, R -5.50 L -5.00 with -2.00 cyls (cyclo ret) 😮 His mother noticed him always standing extremely close to the TV and holds everything close. He was dismissed as being fine when tested several months ago, hence the reason to seek a second opinion. General health and development unremarkable. Axial length measured a whopping R 24.02 L 23.94mm (AXL for a 2 yo is estimated around 21.2mm). There’s a family history of high myopia and retinal detachment. Unable to measure his VA with any reliability and he’s about as cooperative as can be expected at age 2. Myopia control? Well, the first thing is to provide clearer vision for functioning and eye development. I referred to paediatric ophthalmology at the Children’s Hospital for evaluation and to exclude systemic conditions. Will he progress? Most likely. But clearly he’s not a “vanilla myope” and as much as I wish to help him, the efficacy and safety of myopia control intervention in this age group with high myopia is unknown. What would you do? What glasses/Rx would you give the boy?PC Here’s part of the report from the paediatric ophthalmologist. And SVD glasses have been arranged for vision correction. “Cycloplegic findings were very similar to your measurements. On the slit lamp I found normal anterior vitreous, to the best of my assessment retinal appearance was normal. There are no syndromic myopic features or evidence of a retinal dystrophy. Thus, I think this is isolated congenital myopia. In this situation a greater role of genetic influences and lack of evidence for myopia control techniques means that I would not advocate low dose atropine. I have suggested a small under correction appropriate for age. If progression is noted then the question of atropine 0.01% can be cautiously considered. Thanks for your ongoing care.”

Step 1: Pediatric Ophthalmologist Referral

AT I'd do the same, that lvl of myopia at that age would likely has a pathological contribution. I once shadowed a paediatric opthal who saw a patient like this who had high iop, so the myopia is secondary resultMM I agree on the referral to paediatric ophthalmologist. When it comes to correction I would give glasses, but probably not full correction as the child works most at close distances.KG I would definitely advocate the referral-then-monitor management plan you’ve taken...

A 2-year-old child with such a high degree of myopia is best to be initially referred to a pediatric ophthalmologist in order to rule out any associated ocular or systemic disease. From the ophthalmologist report, this child has congenital myopia without any co-morbidities. Hence the management plan falls back to the optometrist to maximize pediatric visual development, and co-management over time can of course take place as required.

Step 2: Vision Correction

Before prescribing visual aid, the following questions should be considered1:

  1. Is the refractive error within the normal range for the child's age?
  2. Will this particular child's refractive error emmetropise?
  3. Will this level of refractive error disrupt normal visual development or functional vision?
  4. Will prescribing spectacles improve visual function or functional vision?

According to Mayer et al, a 2-year-old is estimated to have spherical equivalent of +1.2D.2 It is also possible for a myopic infant to emmetropise between 9 months old to 4 years old.3,4 In congenital myopia, the blurry images on the foveal and macular regions of the retina can disrupt normal visual development. This can become an amblyogenic factor. With partial spectacle correction, emmetropisation would not be affected whilst avoiding potential amblyopia. This will reduce the possibility of vision problems later on.3 Therefore one can decide to under-correct by 0.50D – 1.00D until the child reaches schooling age.1

Glasses vs. contact lenses

In this case, a single vision spectacle lens with slight under correction was recommended by the ophthalmologist. As emmetropisation has not fully occurred, giving the child the best visual acuity remains the priority, with myopia control strategies a secondary concern at this time. Below are some opinions from the Facebook community on managing this myopic toddler:

Glasses

JAS Specs with executive bifokal and Misight later. Keep it simpleDS I would initially give single vision spectacles until I could: 1. Repeat cycloplegic refraction to verify 2. Repeat axial length to verify...PC I am thinking of single vision spectacles too and establishing progression rate before considering MM. Executive bifocals maybe. His cyclo was done with tropicamide 1% plus cyclopentolate 1%.NB Generally I’ve not had a great deal of success with bifocals of any flavour and two year olds, they tend to be head movers. S/V until three is my rule of thumb. I would also consider the near ret in the decision making though, if significantly different I’d sway to a bifocal.

The commenters suggested single vision or bifocal spectacle lenses. Single vision lenses would help achieve visual correction. Bifocal and myopia controlling lenses could both be considered as both can correct vision and have a myopia control effect. However, there was comment about how well a bifocal would be used in a 2-year-old, and while there is no available data, the modified optics of some myopia controlling spectacle lenses could potentially interfere with visual development in a child so young, where visual clarity has been prioritized in his initial management.

Contact lenses

KT Misight could be an option but the immense struggle with insertion or fulltime antibiotics plus risks with overnight wear... OR Do recommend MTO soft Silicone hydrogel disposable multifocal by MarkEnnovy in Espana with 225 add and all refraction done on 3 meters max for the environment the child is in.DS ...If myopia control was desired I think I would custom design a corneal RGP with peripheral defocus zones. This modality has a reasonable track record in this age group...PC ...Would be a challenge to try and insert a CL but RGP may be more manageable than SCL. Potentially could try down the track. Which Oz lab could make an RGP with peripheral defocus zones?KG ...As you’ve said this isn’t our ‘vanilla myope’ so the contact lens suggestions are just going to make life excessively complicated at this age, for everyone involved, with questionable benefit.AD ...or with MF corneal RGPCL .RGP are a safer option than individual soft lenses, correct the corneal cyl and thus give better vision and they are easy to handle at 2yo. yes David, it can be loud initially 😃, but once they discover great vision with cl, they become very cooperative...

Applying contact lens on a 2-year-old child is a challenge for both the practitioner and the parent. As a result, we require full parental commitment to help with applying, removing and cleaning contact lens. The risks of overnight wear - likely in this age group to simplify parental handling - also need to be considered and discussed. As this option may end up requiring much time, money and energy for little gain, it may not be the ideal choice.

If parents choose the contact lens route, one can expect RGP lenses to be more manageable and healthy than soft contact lenses. Some suggested soft MFCLs or RGP MFCLs for the myopia control effect. It is important to consider the pros and cons of using MFCLs. This is because these forms of correction at such a young age could affect the visual development of the child, where achieving good visual clarity is the main goal of management.

Atropine

KT Interesting case... say the pt is 100% healthy without underlying eye disease.. would anyone think of low dose atropine or something when there's progression? I know there's hardly dataJS I wouldn't think of atropine in such a young kid, whose brain is developing.SD There are two cases reported here, both unusual and the atropine may not have been the direct cause in one, and an accidental overdose of atropine occurred in the second. I do sometimes hear people using 1% in these young children, because there isn't any good evidence, and they think it is one of the few things that might help. But given what is in this report, I would be very careful in any child under age 3, as even in this post-market surveillance, there was not enough data to determine safety in that age range.OR ... please advise honestly full disclosure on the known side effects of atropine...DS ... It may be worth contemplating an atropine cycloplegia in this case...

The potential systemic side effects of atropine are mainly cardiovascular in nature. This includes palpitations, tachycardia and atrial arrhythmia. Siurana et al found that while 0.01% atropine was safe for their subjects (mean age 10.2 years), 3 months of use did lead to a significant decrease in heart rate.5 Because of these risks, extreme caution must be taken when prescribing atropine to children below 3 years old. Read more about Systemic Side Effects of Atropine Eye Drops here.

Step 3: Parent Education

When a young child has significant levels of myopia, this will be the beginning of a lifelong myopia management journey for the parents and child.

In addition to discussing myopia correction and control, it is important to educate the parents on the importance of visual environment. They must also be aware of the increased risk of rapid myopia progression with early onset, and the higher risk of ocular disease across their child's lifetime. This will help them understand the importance of implementing myopia control strategies later down the track, once this initial correction and early visual development phase has been managed.

Step 4: Future Plan for Myopia Management

The options mentioned by the Facebook community are all potential myopia management strategies. The choice between glasses or contact lenses - now and in future - would ultimately depend on the child's ocular conditions, along with his and his parents' capacity.

If there is rapid myopia progression, one can also consider combination treatment with atropine at a later stage.  Data is early but promising on combinations of atropine with orthokeratology and multifocal soft contact lenses.

Regardless of the myopia control strategy chosen, a crucial part of myopia management for this child will be frequent follow up to monitor changes in refractive error and ocular health.

Take home messages:

  1. When managing a myopic toddler, early optical correction is vital to prevent amblyopia, prioritising visual clarity and full time wear of the correction. Most colleagues in this discussion advocated single vision spectacles as the first choice for this child.
  2. In pediatric high myopia, initial co-management with ophthalmology is critical, to rule out any potential systemic co-morbidities. Ongoing co-management of these cases will be needed if there are co-morbidities, retinal health concerns and/or if your scope of practice requires this additional support.
  3. When children are this myopic at this young an age, parents need to be aware of the lifelong commitment to managing the myopia that will inevitably progress.

Further reading on prescribing for young children


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 MyopiaProfile.com. 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 MyopiaProfile.com. 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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