Myopia management demands ophthalmologists’ attention

Source / Disclosures

Disclosures: Thompson reports being chief medical advisor for Euclid Systems.

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As ophthalmic surgeons, we tend to be justifiably focused on surgery.

However, it remains critical to stay abreast of developments in all areas of eye care, such as myopia management, so we can provide our patients with the best care, as well as offer advocacy, support and education throughout our communities.

Epidemic myopia

Myopia needs your attention. While the world has its eyes trained on a pandemic, a silent epidemic is encroaching. It is estimated that the epidemic myopia will affect half of the global population by 2050. Too often, myopia is considered a simple refractive error that can be easily remedied with spectacles or contact lenses. But for some patients, myopia is a disease that leads to physical changes in the eye’s structure, which can increase the risk for retinal complications, cataracts and glaucoma. Myopia can increase the risk for myopic macular degeneration by up to 845 times, retinal detachment by 2.4 to 24 times and primary open-angle glaucoma by 2 to 2.5 times. What’s more, even low amounts of myopia are associated with increased risk of developing posterior subscapular cataract.

Vance Thompson
Vance Thompson

Today, there are numerous safe and effective options to slow the progression of myopia, including orthokeratology (ortho-K) contact lenses, various types of soft multifocal contact lenses, spectacles and topical pharmaceutical agents such as atropine. Even though I do not fit contact lenses or prescribe medication to slow the progression of myopia, I stay educated about all of the developments in this area so I can counsel my patients with myopia – who in many cases are parents or potential parents of children with myopia – and refer them to eye care providers who specialize in myopia management. I recommend that all of my ophthalmic surgeon colleagues look for signs of axial elongation and ask questions about eye rubbing and “pillow diving,” so at-risk patients can be referred as early as possible to lessen the chances of developing anterior and / or posterior chamber visual disorders later in life.

Myopia management options

I am a proponent of all of the options that can help slow the progression of myopia. Depending on a patient’s lifestyle and preferences, one of these options – or a combination of interventions – will fit their needs. For instance, ortho-K lenses are appealing to patients who do not want to wear glasses or contact lenses during the day. Ortho-K lenses are worn overnight to flatten the central cornea and temporarily reduce a specific amount of myopia while the patient sleeps. These dual benefit lenses provide clear vision without the need for vision correction during the day, and they also reduce myopic progression in children. Ortho-K lenses slow axial length growth compared with single vision gas permeable contact lenses, single vision soft contact lenses and single vision spectacles. Studies supporting the safety and efficacy of this treatment are available, and as the incidence of myopia increases and the realization that, if left untreated, myopia can culminate in serious vision-threatening diseases, ortho-K is gaining the global gravitas that eluded it earlier in its evolution.

There have long been concerns about microbial keratitis with respect to ortho-K lenses because they are worn overnight. These concerns are worth respecting, but the incidence is low, especially with good care and careful hand washing techniques. According to a recent study, the risk for microbial keratitis appears similar to rates associated with daily wear soft contact lenses. It is also worth considering that unlike extended wear contact lenses, ortho-K lenses are not being worn during the day, exposing the eye to normal oxygenation. When ortho-K lenses are handled properly, the benefits outweigh the risks.

In contrast to ortho-K lenses, soft multifocal contact lenses are worn during the day. Soft multifocal contact lenses, like ortho-K, are theorized to slow myopic progression by creating myopic defocus in the periphery, which sends a “signal” to slow eye growth. Soft multifocal contact lenses have been shown to slow the progression of myopia in children by nearly 50%, which is similar to ortho-K lenses.

Myopia control experts suggest that myopia management spectacles may be appropriate for patients – or their parents – who are not yet ready to commit to contact lenses. While soft multifocal contact lenses and ortho-K have been shown to have better myopia control efficacy than progressive addition and bifocal spectacles, innovative spectacle lens technology for myopia control, such as those that rely on a peripheral defocus theory, whereby the peripheral retina receives myopic defocus as a slow down or stop signal for eye growth, is worth exploring (keeping in mind that myopia management-specific spectacles are not yet FDA approved).

Atropine drops are another viable option that have been shown to be successful in slowing myopia progression. The suggested dose is usually 0.05% to 0.025% to minimize the risk for potential side effects, including photophobia. The efficacy of atropine is well documented in the literature, as are concerns about treatment regression when the drops are stopped.

Each of these myopia management options has particular strengths for select patients. However, combination therapy has its place in myopia management, as well. For instance, spectacle lenses can be an important adjunct treatment for soft contact lens wearers, as well as when atropine is being prescribed as a first-line treatment. Furthermore, recent studies show an additive effect when combining low-dose atropine with ortho-K.

Comanagement opportunities

As the incidence of myopia continues to grow and research and development into effective solutions reflect this expanding need, myopia management represents an ideal intersection in which ophthalmology and optometry can work together. For instance, measuring axial length is key to optimizing the best treatments for myopia management. Bearing this in mind, if an optometrist expands into ortho-K treatment, this is an excellent opportunity to work with an ophthalmologist who has biometry technology.

Taking a comprehensive approach to eye care, with respect to myopia management, means staying educated about progressive refractive error treatment strategies and discussing these issues with our patients so they can be aware of the dangers of eye rubbing, “pillow diving” and other behaviors that put pressure on the eyes. It also entails bringing information about the myopia epidemic and myopia management to the community through interaction with local media sources and events such as eye health fairs. Working together to slow myopia throughout the world is a great opportunity for ophthalmologists and optometrists to improve global eye health.

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