The Comprehensive Myopia Assessment is designed to facilitate effective myopia management consultations and evaluations. By following this clinical roadmap and utilizing the corresponding exam template, practitioners can ensure a thorough evaluation and streamlined management plan. To maximize the assessment’s effectiveness, pair it with the Comprehensive Myopia Assessment Exam Template, which provides a structured format for documenting patient information, visual acuity, refraction data, and examination findings.
STEP 1: Gather Patient History
- Age of Myopia Onset: Children who develop myopia at a younger age are generally at higher risk for rapid and severe progression. Early onset myopia has a longer period to progress, which can lead to higher levels of myopia and an increased risk of high myopia and serious complications such as retinal detachment, glaucoma, and myopic maculopathy. Pre-myopia, indicated by a cycloplegic refractive error that is less hyperopic (or less positive) than expected for a child’s age, signifies an increased risk of developing myopia.
Age-based Pre-Myopia Indicators:
| Age | 6 | 7-8 | 9-10 | 11 |
| Pre-myopia *as determined by cycloplegia | Less than +0.75D | Less than +0.50D | Less than +0.25D | Less (or more minus) than plano/ emmetropic |
Early detection of myopia onset enables timely intervention to slow myopia progression.
- Current Spectacle Rx: Patients with higher levels of myopia are at increased risk for further progression. In addition, under-corrected myopia can accelerate progression, making it crucial to have an updated and accurate prescription.
- Previous Treatments for Myopia: Understanding prior treatments helps assess their effectiveness or lack thereof in managing the patient’s myopia. This information is critical for tailoring new treatment plans. Historical data on myopia progression, including responses to past treatments, is valuable for predicting future trends and adjusting management strategies.
- Previously Diagnosed Ocular Conditions: Note any ocular conditions, such as amblyopia or strabismus, that might impact myopia management and require a more nuanced approach. Special considerations may be needed to address these conditions alongside myopia management to ensure comprehensive care.
STEP 2: Assess Myopia Risk Factors
- Parental Myopia: Having one parent with myopia increases the odds for myopia development by 2x. Having two parents with myopia increases the odds by 5x.
- Ethnicity: Myopia tends to progress faster in certain populations, particularly among East Asian children. Some studies have show that myopia progresses 30% faster in East Asian than non–East Asian children.
- Time Spent on Near Work: Continuous reading for more than 30 minutes increases the odds of myopia by 1.5x.
- Reading Habits: Closer reading distances (<30 cm) increase the odds of myopia by 2.5x. Assess specific reading habits, including typical reading distances and posture, to educate patients on potential risks associated with these practices.
- Limited Time Outdoors: Spending time outdoors is protective against the onset of myopia; at least 90 minutes a day is recommended.
- Screen time: Research on screen time and myopia presents mixed findings. Some studies indicate a potential link, while others do not. Factors like increased near work and reduced outdoor time may complicate this relationship. Currently, there is insufficient evidence to support specific screen time limits for children, prompting the American Academy of Pediatrics to revise its media use guidelines in 2016. These guidelines emphasize evaluating the quality of children’s digital interactions rather than imposing strict time restrictions. It’s crucial to encourage regular breaks during screen use (e.g., the 20-20-20 rule) and promote outdoor activities, as both strategies may help mitigate myopia progression.
- Other: Environmental factors such as lighting conditions could be good to discuss, as poor lighting can contribute to visual strain and may affect myopia progression.
STEP 3: Examination Elements
Acuity and Refraction Assessment
- Visual Acuity Testing: Measure best-corrected visual acuity for each eye at distance and near
- Refraction Tests:
- Objective/Cycloplegic Refraction: Useful to obtain a true measure of refractive error by temporarily paralyzing accommodation to ensure accurate prescription and treatment planning. Recommended protocol: 2 drops of 1% tropicamide or cyclopentolate given 5 minutes apart. Cycloplegic refraction should be performed 30 to 45 minutes after.
- Subjective Refraction: Conduct a baseline assessment and continue to check at routine follow-ups to monitor any changes in refractive status.
- For patients with premyopia or low myopia (<–0.5 D), corrective lenses may not be appropriate; instead, advise the need for regular eye exams and prepare the patient and their parents or caregivers. If the myopia is ≥–0.50 D, consider discussing refractive and/or pharmaceutical correction options with the child’s caregiver.
Binocular and Accommodative Vision Testing
- Assessing binocular vision (BV) status is essential for identifying children at risk for myopia and predicting their responses to various interventions. However, the effects of managing these disorders on the progression of myopia remain uncertain.
- Certain BV conditions, such as esophoria and intermittent exotropia (IXT) have been linked to a higher prevalence of myopia.
- Pre-myopes may exhibit reduced accommodative responses and increased accommodative lag
- BV can potentially impact treatment outcomes: some studies have shown that myopic children with esophoria tend to respond more favorably to progressive addition lenses (PALs) compared to those with normal BV, while those with lower accommodative amplitudes show significantly improved myopia control with orthokeratology contact lenses.
- Key factors to monitor include reduced accommodative ability, increased accommodative lag, elevated AC/A ratios, and the presence of esophoria. Overall, attention to BV disorders can inform risk assessment and treatment strategies.
Axial Length and Corneal Topography
- Axial Length: Measuring axial length is essential in myopia management, as it correlates directly with the severity of myopia. By tracking axial length with a biometer such as Topcon MYAH, eye care practitioners can assess myopia progression, detect changes early, and adjust treatment plans to prevent further elongation and potential complications. Although there can be considerable variability in axial length measurements based on several factors, emmetropic individuals usually have an axial length ranging from 22-24.5 mm, while myopia is generally linked to axial lengths exceeding 25 mm.
- Corneal Topography: Measuring corneal topography is essential in myopia management as it provides a detailed map of the cornea’s curvature, helping to identify irregularities that can affect refractive error. Topographers, such as MYAH, can provide information crucial for customizing contact lens fittings, particularly for specialty lenses like orthokeratology, and for monitoring changes over time to evaluate treatment effectiveness. Additionally, it aids in detecting early signs of corneal conditions, ensuring comprehensive care and optimizing surgical planning for those who may consider refractive surgery in the future.
Eye Health Evaluation
- Slit-Lamp Examination:
- General: Detect signs of ocular allergies and/or dry eye that may impact contact lens fitting for myopia management
- Corneal Health: Examine the cornea for irregularities or conditions such as keratoconus that might impact myopia management.
- Lens and Iris Evaluation: Inspect the anterior segment for abnormalities like cataracts or issues affecting the iris and lens that could influence visual function.
- Pupil Examination:
- Pupillary Reactions: Monitoring pupil size, shape, and response to light and accommodation is crucial to rule out abnormalities and ensure proper function. Assessing pupillary reactions is particularly important when prescribing low-dose atropine for myopia management, as atropine can cause mydriasis. Evaluating pupil size helps confirm that the dosage of atropine is appropriate and minimizes potential side effects, such as significant blurred vision during near tasks.
- Intraocular Pressure (IOP): Myopic patients, especially those with high levels of myopia, are at an increased risk for developing glaucoma. Regular monitoring of IOP helps eye care practitioners identify potential issues early, allowing for timely intervention and management strategies to preserve overall eye health.
- Fundus Examination:
- Retinal Health: Evaluate the retina for signs of myopic degeneration or other pathologies using indirect ophthalmoscopy or fundus photography. This helps in monitoring the progression and any potential complications of myopia. Look for signs of retinal thinning, atrophy, or other structural changes, such as posterior staphyloma, which is characterized by a localized bulging of the sclera at the posterior pole.
- Optic Nerve Head: Examine the optic nerve head for any signs of myopic changes such as peripapillary atrophy.
- Optical Coherence Tomography (OCT): Utilize OCT to capture high-resolution images of the retinal and optic nerve appearance. This allows for precise assessment of retinal thickness and detection of changes associated with myopia. Baseline measurements can be helpful to retain to track future changes secondary to progressive myopia.
