International survey of contact lens fitting for myopia control in children
Nathan Efron, Philip Morgan and co-authors collected data across 31 countries for at least 23,830 contact lens fits on children. Their data, collected from 2011 through to 2018, showed an increasing trend to prescribing both soft multifocal contacts and rigid lenses for the control of myopia, with the majority of multifocal contact lens fits taking place amongst children 8 to 15 years. The results were published in February 2020 in Contact Lens and Anterior Eye - click the heading above for the reference link.
Figure 3 from Efron, Morgan et al 2020 - Trend in the proportion of soft and rigid myopia control fits to children, as a proportion of all CL fits, across 31 countries.
The authors note that during the study, the MiSight lens by CooperVision was approved in some countries (14 out of 31) as an accepted form of myopia control, which would have influenced prescribing trends.
Overall, myopia control contact lens fitting has increased from only 0.2% of contact lens fits to children in 2011 to 6.8% of fits in 2018. That's an increase of 34 times! As shown in Figure 3 above, there has been a sharp increase from 2015 in the extent of rigid CL fits for myopia control as a proportion of all rigid lens fits to children. Austria, Germany and Hong Kong led the way, with around 25% of contact lens fits to children in these countries being for myopia control.
While frequency is increasing, these are still small numbers indicating that the primary reason children are fit with contact lenses is NOT for myopia control. In commenting on this, the authors cited the lack of on-label products, perceived practitioner opinion on effectiveness and an apparent lack of myopia awareness and myopia control benefits in general. On a brighter note, the skewed age distribution of myopia control lenses fitting in younger children (average age 13, compared to average age 15 years in non-myopia control fits - see Figure 4 below) is consistent with evidence that myopia control should be prescribed at the earliest suggestions of increasing myopia.
Figure 4 from Efron, Morgan et al 2020 - illustrating age categories of children fit for myopia control compared to children fit with other contact lens types.
Interestingly, no clear differences were seen in the demographics of children fitted with hard lenses for myopia control compared to soft lenses. The authors have suggested that this implies practitioners see no difference in the familiarity or complication of fitting the different lens types. One study bias that was noted is the survey was sent to practitioners with an established interest in contact lenses, which could result in different outcomes to looking at a more “general practitioner” population base.
Global Trends in Myopia Management Attitudes and Strategies in Clinical Practice - 2015 and 2019 findings
First published in 2016 in Contact Lens and Anterior Eye, James Wolffsohn, Antonio Calossi, Pauline Cho, Kate Gifford and others surveyed 971 eye care practitioners in a dozen countries and six languages to examine prescribing habits and attitudes around the world when dealing with myopia in 2015. The practitioners were asked about their level of concern about increasing rates of paediatric myopia, how effective they perceived different treatments to be, how often they implement them and the minimum myopia to spur action.
Practitioners in Asia had more concerns than other countries, with a similar level across Europe, North and South America and Australasia with a median of 7/10. Orthokeratology was perceived to be the most effective, followed by outside time and then pharmaceutical interventions. Compared to other optometrists, Asian practitioners thought; single vision, bifocal and progression lenses to be the more effective.
Table 2 from Wolffsohn et al 2016 - Global Trends in Myopia Management Attitudes and Strategies in Clinical Practice; Frequency of prescribing myopia correction options
According to the responses, the most popular treatment for young progressing myopes was single vision glasses (47%), or single vision contact lenses (15.2%). Orthokeratology (14.3%) and Progressive glasses (6.5%) featured next. Asian practitioners were the most likely to prescribe single vision glasses, and Australian optometrists the least likely. Glasses were prescribed from as young as five, however contact lenses and pharmaceuticals tended to be reserved for older children, or children with a myopia of greater than -2.00D. Most practitioners will treat when progression occurs between -0.25D to -1.00D per year, with Australian optometrists intervening at the lowest levels of change. Reassuringly, 72.7% of practitioners did not consider under-correction with single vision distance lenses effective, however those in South America and India used that strategy more often than their international counterparts.
So what was holding people back? The perception that strategies were uneconomical (35.6%), insufficient information about the strategies (33.3%) and the perceived unpredictability of outcomes (28.2%). As a group researchers found that Orthokeratology was correctly agreed to be one of the most effective methods, but largely people were overestimating the impact of recommending outdoor time and underappreciating the role of pharmaceuticals. Over two thirds of children are still being prescribed single vision spectacles as the overwhelming treatment. The authors were concerned that despite growing evidence of the negative impact of myopia, and the moderate practitioner concern, update of treatments globally is poor.
Global trends in myopia management attitudes and strategies in clinical practice- 2019 Update
An update was published in 2020, [Link to open access paper]
This time with 1336 respondents from 16 countries, the authors highlighted in this 2020 update that "uptake of appropriate techniques has improved, but remains generally poor; this is despite growing evidence of the negative impact of even low levels of myopia on health economics and moderate levels of practitioner concern and perceived activity, particularly where the prevalence of myopia is highest."
Table 2 below, from the 2020 paper, can be compared directly to Table 2 above from the 2016 paper. The biggest changes can be seen in a halving of Australasian practitioners prescribing single vision, with a large increase in pharmaceutical and multifocal soft prescribing, and a small reduction in OrthoK prescribing. Europe shows a similar trend, although a smaller reduction in single vision prescribing. North America shows a slower trend away from single vision and towards contact lens and pharmaceutical options to Australasia and Europe. South America and Asia have the highest rates of single vision prescribing, maintained from 2016 to 2020, and fairly static prescribing rates of other options. This is despite practitioners in Asia reporting the highest level of concern about increasing frequency of childhood myopia; and equal highest level of perceived clinical activity in myopia control (with Australasian colleagues) - see Figure 2 below.
Figure 2 from Wolffsohn et al 2020 - perceived level of clinical activity in the area of myopia control for practitioners located in different continents. N = 1336. Box = 1 SD, line = median and whiskers 95 % confidence interval.
Globally, most practitioners feel -0.75D (-0.82D +/-0.58D) is the lowest level of myopia to warrant correction, and the majority of respondents felt a progression of -0.50D to -0.75D per year required a form of myopia control. Disappointingly however, the majority of young myopes globally are still being prescribed single vision spectacles and contact lenses as the most frequent mode of correction, as seen in Table 2.
Figure 3 from Wolffsohn et al 2020 - minimum annual amount of patient myopia progression, in dioptres per year (D/year), that practitioners located in different continents considered to necessitate a myopia control approach.
More positively, the majority of practitioners acknowledged that under-correction was not an effective form of myopia control, and this number has gone down since 2015, however it is still practiced in some regions, especially in South America - see Figure 4 below.
Figure 4 from Wolffsohn et al 2020 - use of single-vision distance under-correction as a strategy to slow myopia progression by practitioners located in different continents.
Orthokeratology was again, like in the 2015 paper, agreed to be the most effective treatment worldwide, and reflecting the increased education and literature on the topics, the confidence in pharmaceutical controls and soft contact lens options has increased. The same barriers are still present in 2019 as they were in 2015: increased chair time, lack of confidence in the effectiveness of the treatments (1/3rd of respondents) and the cost of the treatments (1/3rd of respondents). As a whole the level of myopia at which practitioners will commence active mangagement has decreased, from -2.00D in 2015 to -1.50D in 2019, but given what we know of low levels of hyperopia and the predictors of myopia in children, waiting until medium levels of myopia are present is likely late for proactive intervention.
As the enormous body of evidence continues to grow, education of practitioners increases and regulatory bodies catch up with new treatments available, indicators of proactive management - age at which to commence intervention and the rate of change for intervention - will continue to improve globally. However, single vision corrections are still prescribed to 52% of progressing and/or young myopes in 2019 compared to 68% in 2015. This is an improvement, but there is still a long way to go to align with best practice. In the interim, continuing to advocate, educate and discuss myopia management is crucial for clinicians and educators alike.