Three clinical pillars for myopia management

Once the myopia management message has been communicated to the parent and patient – information on expectations, efficacy and safety – and the initial correction has been selected, there are three key areas of clinical focus.

Firstly, advice on visual environment is useful for both the child at risk of myopia development – those with a family history of myopia and less hyperopia than age-normal1 – as well as the myope. Simple advice summarised from the research is provided above, and you can read more on the visual environment in myopia in this summary by Associate Professor Scott Read, of QUT in Brisbane, Australia.

Secondly, contact lens options should be discussed and offered, as OrthoK and multifocal soft contact lenses show the best average efficacy for myopia management while also effectively correcting the ametropia. Where the child is not suitable for contact lens wear, spectacle lens options are available and the possible additive effect of atropine can also be employed. Decision trees for selecting a treatment are available.

Finally, binocular vision is relevant to myopia management. Since binocular vision disorders such as esophoria and accommodative lag have been implicated in myopia progression,2-6 and also when present provide the greatest efficacy results for progressive spectacle lens myopia management,7, 8 evaluation and management of these issues could provide added benefit to myopia control treatment.

Binocular vision status is additionally relevant to visual comfort – ensuring children have functional skills for reading and schoolwork9, 10 and acceptance of their correction. In time these individual factors may help to predict those who will respond best to particular corrections – for example, OrthoK appears to reduce both esophoria and accommodative lag,11-14 and a Chinese study has shown children with lower accommodative amplitude achieved a 56% better myopia control effect with OK wear over two years.15 In future we may be measuring some aspect of accommodation (or several measures) and then selecting a specific contact lens design – maybe smaller zone lenses for normal accommodators and larger zone lenses for underactive accommodators, as indicated by optical modelling.16 For now, including binocular vision factors can bring additional customisation to your clinical management decision making, ensuring that visual acuity, visual comfort and visual efficiency are comprehensively addressed for your patient.

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About Kate

Dr Kate Gifford is a clinical optometrist, researcher, peer educator and professional leader from Brisbane, Australia, and a co-founder of Myopia Profile.

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References

  1. Zadnik K, Sinnott LT, Cotter SA et al (CLEERE Study Group). Prediction of Juvenile-Onset Myopia. JAMA Ophthalmol. 2015;133:683-9.
  2. Gwiazda J, Bauer J, Thorn F, Held R. A dynamic relationship between myopia and blur-driven accommodation in school-aged children. Vision Res. 1995;35:1299-304.
  3. Charman WN. Near vision, lags of accommodation and myopia. Ophthalmic and Physiological Optics. 1999;19:126-33.
  4. Drobe B, de Saint-André R. The pre-myopic syndrome. Ophthal Physiol Opt. 1995;15:375-8.
  5. Gwiazda J, Thorn F, Held R. Accommodation, accommodative convergence, and response AC/A ratios before and at the onset of myopia in children. Optom Vis Sci. 2005;82:273-8.
  6. Mutti DO, Jones LA, Moeschberger ML, Zadnik K. AC/A Ratio, Age, and Refractive Error in Children. Invest Ophthalmol Vis Sci. 2000;41:2469-78.
  7. Gwiazda J, Hyman L, Hussein M et al. A randomized clinical trial of progressive addition lenses versus single vision lenses on the progression of myopia in children. Invest Ophthalmol Vis Sci. 2003;44:1492-500.
  8. Yang Z, Lan W, Ge J et al. The effectiveness of progressive addition lenses on the progression of myopia in Chinese children. Ophthal Physiol Opt. 2009;29:41-8.
  9. Narayanasamy S, Vincent SJ, Sampson GP, Wood JM. Impact of simulated hyperopia on academic-related performance in children. Optom Vis Sci. 2015;92:227-36.
  10. Quaid P, Simpson T. Association between reading speed, cycloplegic refractive error, and oculomotor function in reading disabled children versus controls. Graefe's Arch Clin Exp Ophthalmol. 2013;251:169-87.
  11. Gifford KL GP, Hendicott PL, Schmid KL. Binocular visual function in orthokeratology contact lens wear for myopia. Invest Ophthalmol Vis Sci. 2017;58:ARVO E-Abstract 2683878.
  12. Tarrant J, Liu Y, Wildsoet CF. Orthokeratology Can Decrease the Accommodative Lag in Myopes. Invest Ophthalmol Vis Sci. 2009;50:4294.
  13. Felipe-Marquez G, Nombela-Palomo M, Palomo-Álvarez C, Cacho I, Nieto-Bona A. Binocular function changes produced in response to overnight orthokeratology. Graefes Arch Clin Exp Ophthalmol. 2017;255:179-88.
  14. Gifford KL GP, Hendicott PL, Schmid KL. Near binocular visual function in young adult orthokeratology versus soft contact lens wearers. Cont Lens Anterior Eye. 2017;40:184-9.
  15. Zhu M, Feng H, Zhu J, Qu X. The impact of amplitude of accommodation on controlling the development of myopia in orthokeratology. Chinese J Ophthalmol. 2014;50:14-9.
  16. Faria-Ribeiro M, Amorim-de-Sousa A, Gonzalez-Meijome JM. Predicted accommodative response from image quality in young eyes fitted with different dual-focus designs. Ophthalmic Physiol Opt. 2018.

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