Treating the Myopia Pandemic Part II

josePh PaviGlianiti, MD

Last month we reviewed how the incidence of myopia was increasing at an alarming rate, both here at home in the USA and globally. Rather than this being just a “nuisance,” the axial lengthening of the eye that causes myopia can cause significant visual and career-ending problems, in the form of retina detachments, which are much more common in longer eyes. Therefore, slowing down myopia in childhood can theoretically lower the rate of myopia-associated retina issues as our patients and our own children/ grandchildren get older. Slowing down the axial lengthening of eyeballs must be done in childhood…once an eye is “too” long, we can’t shrink it. Refractive procedures/LASIK can change the cornea shape to eliminate glasses, but they have no effect on the underlying long eye that caused the glasses in the first place. Therefore, the post-LASIK patient is forever at risk for myopicrelated retina issues later. Clearly, axial lengthening is the enemy, and the goal is to control it/minimize it during childhood.

Sooo…how do we slow down the axial lengthening of pediatric eyeballs? If your parents had long eyes, you are likely going to have long eyes. Therefore, the biggest thing one can do is choose non-myopic parents. But if you messed that one up, The World Society of Paediatric Ophthalmology and Strabismus recently updated their consensus statement on slowing down the progression of myopia. Some things work, some things don’t. Some things are myths. Some beliefs we had during ophthalmology residency training have been challenged and maybe disproven.

THINGS THAT DON’T WORK to slow down myopia:

1. Under correcting myopes/keeping myopes out of glasses. As recently as 25 years ago, when I was in training, myopic “under correction” was widely accepted as a way to slow down myopia. Recent studies have proven otherwise, and it may actually accelerate myopia. This method is no longer advocated.

2. Pin hole glasses. Yes, these are for sale on Amazon. No Effect on slowing myopia.

3. Blue light glasses. No effect on myopia control.

4. Putting kids in progressive bifocals “for myopia control”. Minimal to no effect. NOTE that bifocals for the control of “accommodative esotropia” are greatly effective and most kids are wearing bifocals for that purpose. Bifocals do NOT have any significant effect on myopia control. Bifocals in kids are for treating eye crossing, not myopia.

5. Regular soft contact lenses/RGPs/ glasses have no effect on slowing down myopia, nor do they aggravate it. They should be worn so you can see, but they don’t offer any “myopia control.”

THINGS THAT APPEAR TO WORK to slow down myopia

1. Increased time spent outdoors. Sunlight causes retina dopamine release, which reduces ocular axial elongation. The current recommendation is that children should spend two hours outside every day. If your child or grandchild is addicted to reading, or their iPad or smartphone, send them outside to do it. Debatable whether this “outdoor” time is helpful once kids are myopic but deemed helpful in preventing the initial onset of myopia.

2. Reduced time on smart phones/near digital devices/near tasks. Yup, you knew it. Get them off their devices and send them outside to play. A working distance of less than 20 cm has been shown to be a risk factor for myopia progression. Doing their tasks in dim light has also been shown to be a possible risk factor for myopia progression (again, another 180 degree turn from how I was trained 25 years ago when dim lighting was studied at length and was NOT considered a risk factor at all). Unfortunately, near work tasks are part of daily education in today’s world, so taking breaks from near tasks/IPAD/IPHONE/laptop is possibly helpful. This is the 20/20/20 rule, which states that for every 20 minutes a person looks at a screen, they should look at something 20 feet away for 20 seconds. Not sure if that has been proven, but definitely not harmful. Furthermore, the size of the monitor used at work/school seems to correlate with myopia. Near work done on smart phones and iPads had a greater risk of myopic progression during the pandemic versus kids who were using television monitors and projectors at home with larger screens for the near work. Having a viewing distance of greater than 20 cm also appears protective. Maybe I can parlay this idea into a “90 inch” TV once my spouse reads this article?

3. Defocus Incorporated Multisegment Spectacle lenses (DIMS glasses). These are not yet approved by the FDA in America, but are available in Canada, Asia and Europe. These glasses consist to be central distance optical zone of 9 mm surrounded by an annular mid peripheral zone of multiple (approx. 400) small round segments, each segment being 1.1 mm diameter with +3.50 diopters of add power. This allows clear central vision and allows myopic defocus of the peripheral retina.

In a Chinese study, these spectacles reduced myopic progression in half… It didn’t stop it, but it slowed it down. Kids DID complain of mid peripheral blurry vision wearing these glasses. These glasses are too new to know whether they are “catching on” and whether they are tolerated well. Managing expectations will be a big issue. Kids want to see clearly out of their glasses and their periphery will be blurred with these glasses. Time will tell, but kids in general don’t like putting on glasses that blur their vision, as their amblyopic friends have proven. Furthermore, these glasses will likely be costly and ugly, furthering the economic disparity of healthcare.

4. Highly Asherical Lenslet Spectacles (HALS). These are another type of glasses not yet available in the United States and are a variation on the above DIMS-glasses theme.

5. Soft Multifocal Contact Lenses. Not all bifocal contact lenses slow down myopia; these are different than the traditional multifocal contact lens prescribed for presbyopia because they have concentric zones of relative plus power through the lens periphery. These are sold under the brand name: MiSight contact lenses from CooperVision and have been shown to have a 59% reduction in myopia progression over a threeyear period in children ages 8 to 12.

Unfortunately, these have been priced in the USA as a package “similar to how orthodontia is priced” and the price is relatively steep, further adding to the economic disparity of eyecare. Plus, many kids can insert contact lenses and many kids can’t, especially in the younger age groups. Hopefully, the prices of this contact lens myopia control system will decrease much like the price of dilute atropine has decreased.

6. Orthokeratology. These are “overnight,” reverse geometry, rigid gas permeable contact lenses, which “reshape” in the cornea at night such that no glasses are needed during the day. These lenses are more effective with “lower” amount of myopia. Orthokeratology has been around since the 1940’s, but never is really caught on because of the waning efficacy in later parts of the day. Much like a corset, when the RGP lens is removed in the morning, the cornea slowly starts to go back to its natural shape during the day, meaning that many people find they need to put their glasses back on after lunch. However, as a form of myopia control, orthokeratology has shown some promise similar to those seen with MiSight lenses and/or with dilute atropine. Its use for this in America, though, has been hampered by the fact that the ophthalmology profession has long eschewed children sleeping in contact lenses, and gas permeable lenses in general tend to be less comfortable than their soft counterparts. However, it’s all in managing expectations and this is an area of myopia control that should be further investigated. Again, very pricey; multiple trips to the eye doctor. Wearing uncomfortable contacts overnight. Probably the same success rate as getting your kids to wear their retainers at night over many years.

7. Dilute Atropine to slow down myopia progression. It has long been known that certain dilating drops that block muscarinic receptors can slow down myopia. It’s believed that atropine acts directly on the retina/sclera, inhibiting stretching of the sclera and thereby slowing down axial lengthening. But who wants to walk around dilated all the time? Then, in 2012, the ATOM Study (Atropine for the Treatment of Myopia) showed that DILUTED atropine (regular strength is 1%, diluted is 0.01%) can slow down child of myopia progression without the annoying dilation/blur. And the drop doesn’t sting like most other pediatric dilating drops. Later studies have shown that .02% and .05% dilute atropine may be more effective. However, as this percentage gets closer to full strength atropine, there’s definitely an increased complaint of dilated visual blur from children. Using dilute atropine is becoming much more popular on a daily basis. Even though this eyedrop is NOT FDA approved for the indication of “myopia control,” many parents come into the office requesting it, particularly parents who are themselves highly myopic. Furthermore, the cost of dilute atropine, which must be made at a compounding pharmacy, has really come down to now be approximately $30-$40 per month. Insurances are slowly thinking about covering this, but unfortunately through the typical time-intensive prior authorization process. Also, dilute atropine, particularly at the higher strengths, has a well-known rebound effect when the eyedrops are stopped, such that there is some catchup in myopia. This can likely be avoided by continuing atropine (maybe at lower doses) to later in the teen years, so that when it is stopped, the kids are near the end of their growth curve. Dilute atropine is a great choice for myopia control!

8. Combinations of the above.

9. Most importantly: choosing your parents wisely. Children of hyperopic parents who are themselves hyperopic, can likely play on their IPADS in dim lighting at close range til their hearts content. Kids of myopic parents: not so lucky.

In the ophthalmology world, pediatric eye problems have long been given short shrift. Kids don’t vote, don’t belong to AARP, and don’t have any clout on their medical issues; therefore, their ophthalmic issues often don’t receive as much attention (or research funding) that adult eye issues do. Their Medicaid reimbursement is way below what Medicare reimbursement for adults is, so many healthcare professionals don’t want to see pediatric patients anymore. The scarcity of pediatric ophthalmologists, and pediatricians in general, is becoming frightening, locally and nationally. However, childhood myopia eventually turns into adult myopia and later predisposes to a host of retina problems that can be visually catastrophic. Clearly, there is a need to slow down axial elongation in children, particularly in children of highly myopic parents who are at the greatest risk. By incorporating behavioral measures, such as increased time spent outside, less time spent on near devices, particularly small ones, increasing distance from eyeball to monitor, using dilute atropine (perhaps combined with orthokeratology and/or peripheral defocus contact lenses/spectacles (some of which are not approved for use in the United States… yet) may help to slow down the pandemic of childhood myopia and the subsequent catastrophic effect on adult vision 40 to 50 years from now.

Sources:

He, M, et al. Refractive Error and Visual Impairment in Urban Children in Southern China. Invest Ophth Vis Sci. 2004: 45(3)793-9.

Hsu, CC, et al. Prevalence and Risk Factors for Myopia in Second Grade Primary School Children in Taipei: a Population-Based Study. J Chin Med Assoc. 2016: 79(11): 625-32.

Matsumura, S, et al. Global Epidemiology of Myopia. 2020. In Ang, M and Wong, T (editors): Updates on Myopia. Springer.

Theophanous, C, et al. Myopia Prevalence and Risk Factors in Children. Clin Ophthal. 2018: (12):1581-1587.

Sun J, et al. High Prevalence of Myopia and High Myopia in 5060 Chinese University Students in Shanghai. Invest. Ophth Vis Sci. 2012: 53(12):7504-9.

World Society of Paediatric Ophthalmology and Strabismus: Myopia consensus Statement 2023.