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Managing a 5-year-old pre-myope

Posted on October 19th 2020 by Connie Gan

In this article:

Pre-myopes can be readily identified. What treatment is necessary and evidence based? Here is a case study of a 5-year-old pre-myope.

According to the International Myopia Institute (IMI) Defining and Classifying Myopia report,1 pre-myopia is defined as a refractive state of an eye between +0.75 and more than -0.50D in children where a combination of baseline refraction, age, and other quantifiable risk factors provides a sufficient likelihood of the future development of myopia to merit preventative interventions. Here is a case shared by PC with the Myopia Profile community that involves a child who fits the definition of a pre-myope.

PC Kate and I mentioned pre-myopia the other day. Here’s a real life example I just saw. I treated the older brother (8yo) recently for MM with OK, R -1.50 L -2.75 (no previous glasses or history). AXL R 24.34 L 25.04mm. FH of myopia, dad -6.50, mum -2.00. Tested younger brother today, age 5, first eye test. Vision seems fine. VA 6/6 R&L Rx: R +0.75 L +0.50 (pushing max plus) Ks: R 8.35 (40.50) L 8.38 (40.25)... very flat AXL: R 23.92 L 24.01mm... long for age Mx: Environmental advice re. outdoor time, reading/screen time etc. Review 6 months. My prediction is that it’s only a matter of time before he becomes myopic but hopefully can delay the onset.

What features define a pre-myope?

Here is a checklist of risks for pre-myopia and/or myopia development, with the last highlighted as the key risk factor defining pre-myopia, independent of the others.

  • Age (5-9 years old)
  • Asian ethnicity
  • Parental myopia
  • Binocular vision disorders
  • Insufficient outdoor time
  • Excessive time spent on near work
  • Refractive error (Being less than +0.75D at age 6-7)

This child is clearly a pre-myope because he is 5 years of age and with not enough age normal hyperopia - only R +0.75 L +0.50. The family history of myopia is clear; binocular vision and outdoor / near work time risk factors aren't described. You can read more about How to identify and manage pre-myopes via the link.

Another concerning feature in this child’s clinical findings is the high axial length for his age. While the child's ethnicity is not given in the case, an axial length of around 24mm at age 5 is beyond the 75th percentile for boys of both European and Chinese ethnicity, indicating a high risk of future myopia. You can read more about this in the clinical case study entitled Axial length measurement in myopia management - how often and how much change is normal?

Additional risk factors - binocular vision status?

RM You have only given half of the optometric profile. what were the phorias? What was amplitude of accommodation? cross cyl at near? They could need plus at near, anti fatigue or Access. Get used to relaxing focusPC His BV didn’t seem abnormal to me hence no specific mention. 2 exo near, normal ACA 2, accom amplitude and facility all ok, MEM 0.75, no near symptoms. I’m not convinced near Rx would help, would you try for a case like this? …RM Sometimes i find accom low, about 5 or they can wind up really high and clear -9. If these ones also get the near cross cyl going minus i am worried about myopia developing. It is easier to justify if there is a lag and eso, but 2 exo is Not quite normal and if there is family history i would suggest Access lenses. Often a 6 month review is what is decidedKT Did you check for eso posture. What was his ACA? / NFR values?PC Yeah he’s exo, ACA and other basic BV parameters within normal range. Myopic brother also exo - interestingly what appeared to be an intermittent alt exoT at first presentation now resolved with OK (better fusion from correction of anisometropia maybe) KT … Eso, lag and high AC/A ratio have been found in kids who become myopic but unfortunately no studies have been done on the effect of intervening with BV

Checking a child’s binocular vision status is import as children at risk of myopia development can exhibit binocular vision (BV) disorders such as increased lag of accommodation and high AC/A ratio.3,4 Commenters suggested treating any BV disorders to delay the onset of myopia. Logic may dictate that addressing BV disorders will reduce a child’s risk of developing myopia, however there is currently no direct evidence to confirm this relationship between intervention and outcome. In this case, the child appears to have a normal picture of binocular vision function.

Should we manage pre-myopes prophylactically?

BR Are you treating these kids prophylactically? PC That would be good but I don’t see clear evidence for prophylactic treatment in the literature at this point.KC The young brother has AL much longer than his chronological age should present. I’ve had a similar case today where the 9 yo girl used to be hyperopic at +1.50 six months ago. Now hanging around +.25 to +.50 (max plus). Parents (or even some practitioners) may not recognize this as ‘pre-myopia’; yet it is indeed. Good news is her AL remains <23mm. Yet I educated her parents that her unaided vision needs to be monitored closely. Prophylactic Tx is yet to be validated; yet doable upon parents’ proactive understanding. Extensive documentation is recommended.

Currently, research on interventions for pre-myopia are limited to one small, retrospective study of 0.025% atropine which showed positive results,5 and stronger, meta-analysis evidence on increasing outdoor time.6 Commenters on the case considered both.

1. Would low dose atropine work?

BR it will be interesting what the ATOM 3 study shows as this is what they are looking atBR I do this as well but as a -6 myself I would have no issue treating my son with low dose at bed time when he is in that pre-myope range.DW if there is no risk or downside then even a “maybe” benefit makes it an easy decision. Whether the risks of low dose atropine are negligible/zero, or least are outweighed by the potential benefits, I don’t know and would leave to others to comment.PC Yes the ATOM3 study I’m interested in. I have had a couple of families use atropine on the younger non-myopic siblings when another child is already using it for MC - they said they might as well given the bottle has more than enough for 2 kids per month.KG …Low dose atropine in pre-myopia has one small study but the risk-to-benefit thing makes it tricky…

Some practitioners suggested the possibility of prescribing low dose atropine to a pre-myope to delay myopia onset, especially if there are overwhelmingly strong risk factors for myopia.

Fang et al showed 0.025% atropine could delay myopia onset and reduce myopic shift in pre-myopic school aged children, in a one year, retrospective study.The ATOM3 Clinical Trial, currently underway, is investigating the effectivity of low dose atropine in preventing the onset and progression in pre-myopia. It is estimated for completion of data collection in mid 2023. Read more detail on atropine and pre-myopia in our blog How to identify and manage pre-myopes.

As the evidence slowly mounts for atropine, is it worthwhile considering it as a treatment for pre-myopes right now? The risk-to-benefit may not make such an endeavour worthwhile, but some parents may be keen on this for those in the high-risk category. Such a strategy would warrant thorough discussions with the parents and patient, so they are fully informed.

2. Emphasising outdoor time and visual environment

AT Outdoor sports can be good prophylactic treatmentBB With this family hx have you suggested adopting out to an Amish family where devices are prohibited and farming is normal daily life?KG To confirm for everyone - increasing outdoor time is definitely a validated ‘prophylactic’ treatment for pre-myopia. It’s also no risk and maximum benefit!...DW I don’t think we need to wait for evidence that prophylactic strategies such as outdoor time, and “visual hygiene” for near tasks, are beneficial for pre-myopes. I say that because there is no financial cost, no risks or downsides (assuming sensible sun protection), and it’s easy to argue there are other benefits, other than visual, to spending more time outdoors. So I always recommend outdoor time to pre myopes regardless of a lack of specific evidence.

The strongest evidence for prophylactic (preventative) treatment in pre-myopes is the link between increased outdoor time and reduced risk of incidence of myopia as confirmed by a meta-analysis.6. This meta-analysis attempted to find a dose-response effect and found that less than 13 hours a week was associated with the highest odds ratio for incident myopia. Hence, aiming for at least 2 hours a day of outdoor time, on average, will overcome this risk.

Near work has also found to be associated with myopia, with the odds of myopia increasing by 2% for every one dioptre-hour more of near work per week.Therefore, it is important to emphasize measures such as reducing leisure screen time to less than two hours per day in school aged children, and taking regular breaks from close work. Here are some helpful links which you can share with parents from on this topic.

  1. blog - Close work and screen time in kids
  2. blog - How much time should my child spend outdoors?
  3. How-To Guides - Creating a healthy visual environment for children (two shareable videos)

The best part of visual environment strategies are that they're free, have arguably no downside and only the potential of benefit for the young patient.

3. Is there value in prescribing optical correction for a pre-myope?

KT if a plus 1 or 150 add doesn’t shift his exo at near too far out and keeps his nfrs within reasonable Limits would you consider a bifocal . I’ve had decent success controlling Esos with huge acas and very mild exos with small acas with about a 150 add . Also tried using base down yoked to try relax them out which may help too (not sure if there’s any research supporting this but all anecdotal)PC Compliance might be an issue with bifocal for a non-symptomatic child with good VA - who would want to wear BF if it doesn’t seem to do anything? I would find that hard to convince parents too. Is the myopic peripheral defocus effect beneficial to a pre-myope? I’m not sureKL There isn't data but I use low plus for near work for this demographic. Hope to be vindicated by research one day.PC Out of interest, what’s been your success with this low plus approach?KL So far so good but it has admittedly been just a limited number and haven't followed up yet on all of them.PC … I’ve heard of practitioners using CD MFSCL for these cases, maybe a bit of peripheral plus helps? Sitting on the fence here.

One commenter shared that she was currently prescribing low-plus optical corrections to pre-myopes. There were suggestions also that prescribing bifocal/center distance multifocal contact lens may be effective. The rationale behind is to avoid hyperopic defocus on the retina that might trigger myopia.

The literature does not currently suggest that these methods might be effective in delaying myopia onset. Hence, parent communication is extremely important if your clinical instincts might lead you to suggest these methods. Treating binocular vision disorders associated with myopia development - such as higher AC/A ratios and esophoria, accommodative lag and intermittent exotropia - may have a logical basis to delaying myopia onset but do not have direct research evidence. For a comparison, read this clinical case on whether to manage esophoria in a pre-myope.

This child, however, is cited to have a normally functioning binocular vision system - hence there is likely little orthoptic or myopia controlling benefit to prescribing any optical correction for him.

Take home messages:

  1. When a child is identified as a pre-myope, it is important to place them on close follow-up (eg six-monthly reviews)
  2. The most strongly evidence-based prophylactic (preventative) treatment for pre-myopes is increasing outdoor time to around two hours per day on average
  3. There is much anticipation for the role of low-dose atropine in delaying myopia onset, with early evidence being positive. Watch this space for future updates.

More on managing pre-myopia

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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