Myopia Management Intervention Guide

This guide serves as a simplified resource for understanding various interventions for myopia management. Each section details treatment options, including overviews, benefits, potential drawbacks, and safety profiles, helping caregivers and healthcare providers make informed decisions. 

Note: Not all products or services included are approved or available in every market; labeling and instructions may vary by country. For specific details relevant to your region, please visit the corresponding regional website. 

Orthokeratology (Ortho-K) 

Overview 

Orthokeratology (Ortho-K) involves wearing specially designed rigid gas-permeable contact lenses overnight to reshape the cornea, allowing for clear daytime vision without glasses or contact lenses. This method can slow myopia progression by about 50% on average compared to traditional single-vision spectacle correction and is supported by a robust body of evidence regarding its efficacy. The unique design of Ortho-K lenses creates a controlled peripheral defocus, which signals the eye to slow its growth and helps manage the progression of myopia. Proper fitting, patient education, and ongoing monitoring are essential for optimal safety and effectiveness. 

Pros of Orthokeratology 

  • Clear Unaided Vision: Offers significant clarity during the day without the need for corrective lenses, making it ideal for individuals with active lifestyles, such as swimmers and athletes. 
  • Evidence-Based Efficacy: Backed by extensive research demonstrating its effectiveness in myopia control, particularly beneficial for younger children with rapidly progressing myopia and those with high myopia (partial Ortho-K). 
  • Improved Binocular Vision: Some studies indicate that Ortho-K lens wear may enhance esophoria and accommodative lag. Patients with lower accommodative ability often experience a better response to myopia control with Ortho-K. 
  • Control of Anisometropic Myopia: Recognized as the only effective treatment documented for managing anisometropic myopia. 

Cons of Orthokeratology 

  • Fitting Challenges: More difficult for patients with high myopia, high astigmatism, or flat corneas with low corneal eccentricity (e<0.50); typically more effective for low to moderate myopia.  
  • Increased Chair Time: The fitting process may require more clinic time compared to other options. 
  • Potential Discomfort: Initial fitting may cause discomfort for some patients or require a longer period of lens adaptation. 

Safety Profile 

  • Incidence of Microbial Keratitis (MK): The risk is similar to that of other overnight contact lens types, with an incidence of 1-2 cases per 2,000 wearers, comparable to daily soft lenses. 
  • Best Practices: Patients must be educated on proper lens care and hygiene, including the use of a protein deposit remover to help prevent biofilm formation. 
  • Complications: Although generally safe, potential complications can include corneal staining. Other side effects observed could include epithelial iron deposits and prominent fibrillary lines. 

Multifocal (MF) Soft Contact Lenses 

Overview 
The National Eye Institute (NEI)-funded BLINK* study provided compelling evidence that multifocal contact lenses are a safe and effective method for controlling myopia in children. Children as young as 7 have achieved optimal visual acuity and adapted to wearing multifocal lenses similarly to single-vision contact lenses. Numerous contact lens options have been studied for their efficacy in slowing myopia progression, each demonstrating varying levels of effectiveness. Notably, the U.S. Food and Drug Administration approved MiSight® 1 day lens specifically for myopia control in 2019 for slowing the progression of myopia in children 8-12 at the start of treatment. 

Multifocal lenses are generally designed with a center portion that corrects distance vision and an outer portion that focuses peripheral light rays in front of the retina. This unique design signals the eye to slow its growth, addressing the underlying cause of myopia while simultaneously correcting the blur associated with the condition. In contrast, single-vision lenses direct peripheral light behind the retina, which can potentially encourage further eye growth. 

*Bifocal Lenses In Nearsighted Kids (BLINK) Study 

Pros of Multifocal Contact Lenses 

  • Efficacy and Evidence: FDA-approved soft multifocal lenses are supported by extensive clinical trials. These lenses exhibit strong safety and efficacy, significantly reducing myopia progression by 50% with studies showing a sustained impact over a period of six years.  
  • Ease of Fitting: The fitting process is straightforward and similar to that of regular soft lenses. Many parents are already familiar with soft multifocal lenses, which helps alleviate concerns about their children’s safety. 
  • Ocular Health Consideration: Soft lenses can help protect the cornea in patients with conditions like entropion and trichiasis, providing both comfort and ocular protection. 

Cons of Multifocal Contact Lenses 

  • Parameter Limitations: parameter availability can be limited for those with high myopia and/or astigmatism. Limited evidence for the efficacy of slowing myopia progression with toric soft multifocal lenses 
  • Contact Lens-Related Dry Eye: Patients may experience dryness from extended wear, but generally children are less likely to exhibit symptoms of dry eye compared to adults. 
  • Compliance: For optical myopia control, it is recommended to wear lenses for at least 10 hours per day for at least 6 days per week. Good lens hygiene is essential to ensure safe and effective treatment. Back-up spectacles are needed for visual correction when not wearing contact lenses (i.e. on days patients are feeling unwell).  

Safety Profile 

  • Incidence: The incidence of contact lens-related eye events (CIEs) in children is lower than in adults. Specifically, the incidence of microbial keratitis in children is 2.7 per 10,000 patient-years, comparable to that of adults. When combining data from both prospective and retrospective studies, the overall MK incidence is 4.8 per 10,000 patient-years, with no reported cases of vision loss. 
  • Tips for Improving Safety 
  • Adult Oversight: Ensure children are monitored during lens wear. 
  • Daily Disposable Modalities: Recommend daily disposables to minimize risks. 
  • Promoting Good Tear Film Quality: Educate patients on maintaining ocular health to enhance lens comfort and safety. 

Low-Dose Atropine Therapy  

Overview 

Low concentrations of atropine (0.01%, 0.025%, and 0.05%) have been shown to effectively slow myopia progression in children without adversely affecting quality of life. Current research indicates that 0.05% atropine can reduce progression by about 50% compared to placebo. Low-dose atropine for myopia management is typically administered once daily at night. Although the precise mechanism by which atropine slows myopia progression remains uncertain, ongoing investigations are likely focused on how atropine influences the transmission of chemical signals in the retina.  

Pros of Atropine Therapy 

  • Proven Efficacy: Research shows that lower concentrations can effectively slow myopia progression, with minimal side effects compared to higher doses.  
  • Ease of Implementation: Atropine eye drops are straightforward to administer, requiring no fitting or adjustments, making them suitable for children with high refractive astigmatism or those intolerant to contact lenses. Parental oversight is also facilitated, as parents can administer drops at home. 
  • Cost-Effective: Atropine is generally less expensive to prescribe than contact lens options and could be a more accessible treatment choice for families (subject to the clinician’s billing practices and policies) 

Cons of Atropine Therapy 

  • Compounding Variability and Preservatives: In the U.S., atropine 0.05% can only be obtained through compounding pharmacies, which vary in adherence to United States Pharmacopeia (USP) guidelines. A study on 0.01% atropine revealed significant variability in product labeling and concentrations among different pharmacies. Atropine formulations may contain preservatives such as BAK that can cause ocular irritation in some patients. 
  • Potential side effects: Low-dose atropine therapy typically results in minimal side effects due to the low concentrations utilized, but some potential issues can still arise. Mild pupil dilation (mydriasis) may occur, affecting vision and increasing light sensitivity. Additionally, atropine may limit the eye’s ability to focus on nearby objects, leading to near-vision difficulties. Some individuals may also experience dryness or redness of the  eyes. 
  • Need for Additional Correction: Atropine should be supplemented with glasses or contact lenses for effective refractive correction of myopia and clear vision. 

Safety Profile 

  • Monitoring: Regular observation is crucial to identify potential side effects, such as reduced accommodation, mydriasis (pupil dilation), and allergic reactions. Near blur can be managed with additional near-vision correction, while photochromic lenses or sunglasses can alleviate glare for those experiencing light sensitivity. 
  • Health Considerations: While atropine is generally safe, children with certain health conditions (e.g., congenital heart issues) or those taking specific medications (e.g., some asthma or antidepressants) may be at higher risk for side effects. Parents should consult healthcare providers with any concerns and adhere to the prescribed treatment plan. 
  • Secure Storage: Atropine should be stored out of reach of children to prevent accidental ingestion, which can lead to serious systemic effects, including increased heart rate, reduced sweating, elevated body temperature, and delirium. 

Myopia Control Spectacle Lenses 

Overview 
Myopia control spectacles are specially designed lenses aimed at slowing the progression of myopia in children and adolescents. While traditional options like bifocals and progressive addition lenses (PALs) have shown limited effectiveness in slowing myopia progression, newer designs are emerging globally that demonstrate significant promise. Although none are currently available in the US, this new generation of spectacles is anticipated to enhance myopia management strategies and provide an effective alternative for children who prefer not to wear contact lenses or pursue other treatments. 

Pros of Myopia Control Spectacles 

  • Effective Myopia Management: Certain designs, such as the Defocus Incorporated Multiple Segments (DIMS) and Highly Aspherical Lenslet Target (H.A.L.T.) lenses, have shown substantial reductions of at least 50% in myopia progression and axial elongation in clinical studies 
  • Ease of Use: Spectacles are simple to wear and require minimal maintenance compared to contact lenses, making them user-friendly for children. 
  • Variety of Designs: New spectacle designs offer individualized solutions for children, with unique mechanisms: 
  • DIMS: Utilizes a central distance vision correction zone with surrounding lenslets in an annular zone to create myopic defocus. 
  • H.A.L.T.: Features over 1,000 invisible lenslets, which produce a three-dimensional volume of myopic defocus, signaling the eye to slow axial growth. 
  • Diffusion Optics Technology (DOT): Employs microscopic lens diffusion elements to scatter light and modulate retinal contrast. 

Cons of Myopia Control Spectacles 

  • Limited Peripheral Vision: Spectacles may not provide the same field of view as contact lenses, which can be a drawback, especially for children with higher myopic prescriptions. 
  •  Cosmetic Concerns: Some children may feel self-conscious about wearing glasses and prefer the aesthetics of contact lenses. 
  •  Less Suitable for Active Lifestyles: Glasses may be less ideal for sports or vigorous activities due to the risk of slipping or breaking. 

Safety Profile 

  • Low Risk of Infection: Spectacles do not come into direct contact with the eye, posing no risk of eye infections associated with contact lens wear. 
  • Durability: Shatter-resistant lens materials should be utilized, and care should be taken to prevent breakage during physical activities. 

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