Myopia Profile

Clinical

Axial length growth at an extraordinary speed

 Posted on August 8th 2022 by Connie Gan

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In this article:

This case involves a child whose rate of axial length growth is 5x faster than the average fast myopic progressor. Read to find out more.

Myopia prevalence is increasing around the world, and the past two years of pandemic lockdowns and home-based schooling has unfortunately led to many observations of further increased rates of myopia in children. Here, PC shares a case illustrating this situation.

PC This is what a 2.00D/year progressor looks like! Patient attended in May 2020 for an unrelated concern. At the time, subjective refraction was +0.25 R&L (+0.50 dry ret). With little hyperopic buffer at the age 7, advice was given about outdoor time and near work, and a baseline AXL measurement was taken. Then came to Melbourne’s extended Covid lockdowns (now up to our 6th). Recently she saw her local optometrist after noticing blurred vision. Found to be myopic, she was referred back to me for management. She’s now R -2.25 L -2.50! That’s one big myopic shift in just 15 months! 1.24mm of axial elongation in each eye, equating to growth of 0.95mm/year – about 5 times to the normal eye growth rate! Axial change confirms the progression is real and not from over-accommodation. I see many fast progressors for management, but rarely have prior axial measurement to compare like this.

According to the CLEERE study, the average axial growth for a fast myopia progressor is 0.22mm/year.2 The patient in this case experienced approximately 2.50D of myopia progression in one year. This is corroborated by the axial length change of 0.95mm in that period - almost 5 times the rate of the average fast myopic progressor. This is speedy myopic eye growth indeed.

BS We're there any other signs of a potential change? BV or accommodative issues?PC Not significantly last year. +0.75 accommodation lag and 1 near esophoria and not symptomatic. Now with the myopia corrected she exhibits more esophoria (3-5), and after several days on 0.05% atropine this increased to 9 esophoria with markedly reduced amplitude of accommodation. I expect this to settle slightly with some adaption time to lens correction and atropine, but she would benefit from a near add and exophoric shift. Will need to manage the myopia progression and BV going forward.BS unfortunately, its just one of those things that happens. Is the child a keen reader?PC Will be starting OrthoK in addition to the atropine. Will adjust atropine dosage once wearing orthoK and assessing her BV. Customising a small treatment zone to boost the “add” area and expected to give an exophoric shift. May also prescribe SVN for close work if still esophoric.PC A lot of study more than reading for leisure. Asian parents tend to push their kids pretty hard academically.BS In my experience, I've found that kids who are reading or studying heavily seem to progress faster than kids who are using computers or digital devices. In the UK 10 year olds study for an exam to get into selective high schools, I've seen many kids progress faster during this year.

What contributes to myopia progression?

Intense near work has been found to drive myopia development and progression.3 The hyperopic defocus from deficient accommodative response is considered to be a mechanism linking near work and myopia.4 A meta-analysis also showed children who perform more near work have 80% higher risk of having myopia.3 As children spent most of their time indoors and engaged in a much greater amount of screen-based tasks during lockdown periods, it is unfortunately not surprising to see an increase in myopia prevalence.

Management for this patient

In this case, PC prescribed orthokeratology lenses with low-dose atropine to form his myopia management strategy. Combining low-dose atropine with ortho-k has been shown to slow axial elongation more effectively than ortho-k lens alone.5

PC also notes that the child had become more esophoric with atropine use. This may seem counter intuitive as one would assume that with atropine relaxing the accommodation system, it could improve esophoria. However, there have been some case studies exploring how low-dose atropine may worsen the esophoric condition.6,7 This is explored more thoroughly in the Case Study What Happens To Binocular Vision During Cycloplegia.

An important note on this case is PC mentioned how the axial length measurement confirmed that the myopic shift was genuine. This highlights the importance of measuring the whole eye in myopia, to determine what has contributed to the myopic shift - in this case it was the axial length, but it is also important to measure the cornea and ensure an accurate refraction to avoid any pseudomyopia.

Measuring axial length for all patients

GA please, do axial length measurements to all junior siblings all of your patient's It's a great way to help parents not feel guilty about lost time.MG In Argentina, after long 18 month we have the similar results. We measure the progression in 2028,2019 and 2020 to see the different. Now we have the first myopic refraction in the pre-myopes. 1.10 D

A lesson from this case is that having baseline axial length data is useful when monitoring children in their pre-myopic stage. It gives greater confidence for diagnosing true myopia (as opposed to pseudomyopia) and in confirming progression. It also forms a useful tool to educate parents on the axial length growth of their children and reinforce the importance of myopia management.

Take home messages

  1. Axial length data is a crucial part of the clinical picture in myopia progression, helping to determine the contributing factor to a shift in myopic refractive error and also helping to rule out pseudomyopia.
  2. Combining ortho-k and low-dose atropine has been shown to have additive efficacy and hence can be a useful strategy for fast myopia progressors.
  3. A child's binocular status (e.g. esophoria) may change with the chosen intervention, such as low-dose atropine.

Further reading

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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