Here is a case from RS that was posted in the Myopia Profile Facebook group. She was presented with a patient who had declined contact lens options and was looking how to modify a treatment regime to give better myopia control efficacy.
Is the treatment working?
While axial length is the ideal metric to judge myopia progression and control, especially in the situation of atropine which can influence refraction,1 we can look at the refractive data provided to evaluate the suitability of the current treatment.
Consider the patient’s rate of myopia progression
This patient is age 13, with a refraction of around R (OD) -6.00 and L (OS) -7.00. Her rate of myopia progression when managed wtih 0.02% atropine and corrected with progressive addition lens (PAL) spectacles is reported as -0.50D per year, compared to -1.00D per year 'before'.
The clinical data provided does indicate a slowing of historical myopia progression. DS suggested it was due to the low-dose atropine whilst PC proposed that it could just be a natural reduction in progression attributed to the child’s increasing age. Both could be true. The "illusion of inflated success" has been described by Brennan et al1 whereby an over-estimation of treatment effect can arise when using past 'measured' refractive progression as a basis to treat, or in this case, judge success.
Do we need to change treatment?
Data on annual progression in 7-12 year old children wearing single vision corrections, with myopia no worse than -6.00D, indicates a 12-year-old child of Asian ethnicity would progress by a mean of -0.50D in a year, which a non-Asian child would progress -0.35D in a year. There is a useful reference table for this in the Johnson & Johnson Vision Managing Myopia Guide (Table 5 on page 8).
Faster myopia progression (and risk of high myopia) is associated with younger age of onset. Considering this child is described to have been wearing glasses since age 8, predicted myopia progression from age 12 to 13 in a child of Chinese ethnicity (wearing single vision glasses) would be around -0.7D.2
This child's ethnicity is not stated, but her progression from age 12 to age 13 is explained as -0.50D. This indicates a limited treatment outcome in either case - whether extrapolating from the Managing Myopia Guide (-0.35 to -0.50D per year depending on ethnicity) or looking more specifically based on age of onset (-0.70D per year with Chinese ethnicity).
If the child or parent, or practitioner, wishes to switch to a more effective treatment, the first option could be increasing atropine concentration. The LAMP study indicated that 0.05% atropine slows myopia progression more effectively than 0.01% and 0.025% atropine and with a similar, minimal side-effect profile in children of Asian ethnicity.3
Consider if the treatment suits the patient
This case also highlights the importance of asking a patient questions to gauge how the treatment modality works in their day-to-day life and environment. The example here is that this patient’s reading posture was incompatible with proper use of the PAL spectacles. While this may not have influenced myopia control outcomes - given the low efficacy of progressive addition lenses1 - it could affect visual comfort if there were side effects of atropine which were not appropriately supported by the PALs.
Recent analysis has indicated that most treatment options have similar efficacy except for PALs, 0.01% atropine and "soft multifocal contact lenses that prioritize clear vision" which have lower efficacy.1 The Johnson & Johnson Vision Managing Myopia Guide notes that "knowing efficacy is similar across treatments, it is most critical that the treatment regime fits the patient's lifestyle, expectations, motivation and their abilities."
Understanding patient habits and goals for their vision is an essential part of comprehensive management. For a number of reasons, contact lenses could provide a more suitable option for this patient's myopia correction and management.
Can we reconsider contact lenses?
Compared to PAL spectacles, myopia controlling contact lenses and orthokeratology have higher efficacy in controlling myopia progression. Atropine 0.02% may have similar efficacy to these contact lens options,1 but for this highly myopic patient, there are are number of benefits in wearing contact lenses aside from myopia control. At age 13 it is still worth discussing and pursuing myopia control, especially given that the patient and their parents are already undertaking a myopia control treatment. The Johnson & Johnson Vision Managing Myopia Guide notes that myopic children aged 13+ have a possibility of continued myopia progression and that myopia control options should be presented.
In essence, this case speaks to the importance of good clinical communication in discussing a treatment option to which the parents or child have previously declined. Understanding the parents’ or patients’ fears and reservations about CLs can help us tailor the message we need to deliver to assuage their concerns. Let's start with the benefits of CL wear.
Why should this patient consider contact lenses?
For a high myope, we can highlight the advantages of using CLs to the parent and patient. These include:
- The functional benefits of CL wear for a high myope, including likely better visual acuity due to larger image size4
- The confidence, participation ability and other psychological benefits for kids wearing CLs5
- The opportunity to both correct and control myopia with myopia controlling or orthokeratology CL options as a monotherapy, instead of utilizing atropine 0.02%1
Why might parents and patients be concerned about contact lens wear?
Typical concerns can include safety and handling. Let's address each of these in turn.
- The risk of CL associated microbial keratitis eye infection in a teenager is no higher than in an adult.
- For orthokeratology or a reusable soft CL, this is around 1 per 1,000 patient wearing years6,7
- For a daily disposable soft CL, this risk is around 1 per 5,000 patient wearing years6
- Children only take 10-15 minutes more time to fit with CLs than teens, which is primarily taken up with learning to appy and remove lenses. Teenagers take around 30 minutes on average to learn to handle their CLs, which is similar to typical time taken for adults.8
Other clinical considerations
If the patient and parent are willing to reconsider contact lenses for the variety of myopia correction and control benefits they offer, then these could be used as a monotherapy and atropine 0.02% could be discontinued.
- Consider rebound effects of 0.02% atropine. While these have not yet been shown, it should be presumed1 and hence tapering should be employed. For guidance on this, read When to prescribe atropine for myopia control.
- Combination treatment - atropine with an optical intervention - currently only has an evidence base for orthokeratology (OK) combined with atropine.9 Only two, 2-year studies have been published which indicated improved efficacy of 0.025% with OK10 or 0.01% with OK in myopes of 1-3D only.11
Take home messages:
- Myopia control treatment for young teens and higher myopes is worth pursuing to reduce their long term risk of eye disease, but can present a challenge in determining the success of a treatment strategy
- With many treatment strategies providing similar efficacy, it is important to consider options for myopia correction and control which are most suitable to the patient's characteristics and capacity
- Just because a patient or parent has declined an intervention, in this case contact lens options, does not preclude discussing the reasons you would recommend it, and its benefits. Being provided more information, backed up with scientific evidence, could change their mind.
- Contact lenses are a great option for children, and especially for high myopes. Explaining the benefits, high safety profile and good handling ability that children and teens typically exhibit in CL wear can help allay parent and patient concerns.
Further reading on contact lenses and managing outcomes
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- Brennan NA, Toubouti YM, Cheng X, Bullimore MA. Efficacy in myopia control. Prog Retin Eye Res. 2020 Nov 27:100923. (link) [link to Myopia Profile paper review]
- Hu Y, Ding X, Guo X, Chen Y, Zhang J, He M. Association of Age at Myopia Onset With Risk of High Myopia in Adulthood in a 12-Year Follow-up of a Chinese Cohort. JAMA Ophthalmol. 2020 Nov 1;138(11):1129-1134. (link)
- Yam JC, Jiang Y, Tang SM, Law AK, Chan JJ, Wong E, Ko ST, Young AL, Tham CC, Chen LJ, Pang CP. Low-concentration atropine for myopia progression (LAMP) study: a randomized, double-blinded, placebo-controlled trial of 0.05%, 0.025%, and 0.01% atropine eye drops in myopia control. Ophthalmology. 2019 Jan 1;126(1):113-124.(link)
- Collins JW, Carney LG. Visual performance in high myopia. Curr Eye Res. 1990;9:217-24. (link)
- Walline JJ, Jones LA, Sinnott L, Chitkara M, Coffey B, Jackson JM, Manny RE, Rah MJ, Prinstein MJ. Randomized trial of the effect of contact lens wear on self-perception in children. Optom Vis Sci. 2009;86:222-32. (link)
- Stapleton F, Keay L, Edwards K et al. The Incidence of Contact Lens Related Microbial Keratitis in Australia. Ophthalmol 2008;115:1655-1662. (link)
- Bullimore MA, Sinnott LT, Jones-Jordan LA. The risk of microbial keratitis with overnight corneal reshaping lenses. Optom Vis Sci 2013;90:937-944. (link)
- Walline JJ, Jones LA, Rah MJ et al. Contact Lenses in Pediatrics (CLIP) Study: chair time and ocular health. Optom Vis Sci 2007;84:896-902. (link)
- Gao C, Wan S, Zhang Y, Han J. The Efficacy of Atropine Combined With Orthokeratology in Slowing Axial Elongation of Myopia Children: A Meta-Analysis. Eye Contact Lens. 2021 Feb 1;47(2):98-103. (link)
- Wan L, Wei CC, Chen CS, Chang CY, Lin CJ, Chen JJ, Tien PT, Lin HJ. The Synergistic Effects of Orthokeratology and Atropine in Slowing the Progression of Myopia. J Clin Med. 2018 Sep 7;7(9):259. doi: 10.3390/jcm7090259. (link)
- Kinoshita N, Konno Y, Hamada N, Kanda Y, Shimmura-Tomita M, Kaburaki T, Kakehashi A. Efficacy of combined orthokeratology and 0.01% atropine solution for slowing axial elongation in children with myopia: a 2-year randomised trial. Sci Rep. 2020 Jul 29;10(1):12750. (link)