Editor’s note: This is the most recent of several planned myopia management articles to appear in 2019. See articles by Dr. Thomas Aller (https://bit.ly/2lKucE3 ) and Matt Oerding (https://bit.ly/2kJa3xI .)
I, like many optometrists of 1970s, prescribed bifocals and vision therapy to slow the progression of myopia, neither of which I found worked well enough. Then, in 2000, I had a 4-year-old child who had progressive myopia and came to me with a history of a retinal detachment in one eye and the second eye at risk. After consultation with a retinologist, I put this child on atropine 1% with transitional progressive glasses. Low and behold, the child’s myopia did not progress and, happily, the child did not develop a retinal detachment in the other eye. Luck or treatment? I didn’t know at the time. It could go without saying, but, we’ve come a long way in myopia management.
From atropine to orthokeratology (ortho-k), soft contact lenses and enhanced spectacle lens options, myopia management options (off-label) are a growth sector for the industry and, possibly, for the practice. Here, I’ll take you through the methods for managing these patients in your practice.
When patients/children do not want contact lenses, are too young for contact lenses or demonstrate myopia 0.75 D or less or have lots of astigmatism, 1.50 D, atropine becomes the treatment of choice. In New York City, where I practice, many kids love their glasses. They think that they are cool; they want to keep their glasses, and thus, we prescribe atropine. In addition, the eye care community is clearly a major advocate of atropine.
Specifically, the work of Earl Smith, O.D., Ph.D., F.A.A.O., and his colleagues changed the game of myopia management.1-3 They showed that axial length growth, an indicator of progressive myopia, as a result of local visual signals, could be stopped with atropine, and is regionally controlled, i.e., the larger periphery vs. the macula-controlled feedback growth.
As research into atropine’s use continued, weaker concentrations were found to be beneficial: Shih showed the ability of atropine to slow the progression of myopia was directly related to its concentration; the ATOM1 study demonstrated that atropine 1% resulted in a 77% reduction of myopic progression; and the ATOM2 study showed that lower concentrations of atropine, i.e., .01%, was effective in slowing myopia without a rebound effect, or a significant progression of myopia when atropine is discontinued.4,5,6 Prior to the ATOM 2 study, we conducted a study to determine the lowest dosage of atropine that we could prescribe without the patient reporting symptoms. That was atropine .02%.7
Specifically, we use atropine 1% in the young (younger than age 6), in very progressive myopes (progressing more than a diopter per year), but, for most patients, we begin using atropine .02%. We reserve atropine .01% for those patients in whom we want to prevent myopia (young hyperopic children whose hyperopia decreases by 0.75 D and whose parents are myopic) and those progressing mildly (0.25 D or less per year) using either multifocal soft lenses or ortho-k.
In addition to discussing the prescription with the patient, optometrists prescribing atropine should address rebound. Although previously a pervasive issue when atropine use was in its infancy, I have found that with the tapering of the atropine concentration, this can be managed. In doing so, we advise all patients on atropine that they must not abruptly stop treatment, but allow us to taper the dosage.
Initially, neither I nor my patients had much use for ortho-k. However, while I was trudging along prescribing atropine 1% with around a 20% dropout rate, which I found is about the same as that of ortho-k or anything else, the ortho-k pioneers went on and created a new treatment regimen. And they were right! So, we added ortho-k as a treatment, a “wow” experience.
To briefly review, ortho-k works by reshaping the central cornea to eliminate the refractive error and induce peripheral plus. The amount of plus is equal to twice the refraction, so a correction of -2.00 D creates 4.00 D of plus. Now, ortho-k is our most common method of treatment, which includes most of the patients whose refractions are between -2.00 D and -5.00 D. In our experience, patients whose refractions are below -2.00 D will not achieve an effective enough change, and those above -5.00 D begin having complications, which can be avoided with soft multifocal lenses.
SOFT CONTACT LENSES
To effectively slow myopia, soft lenses need to be a center-distance design to be optically similar to ortho-k lenses.8 Initially, three monthly replacement lenses that had a center distance (more plus in the periphery) and could be considered for the off-label treatment of progressive myopia were available. Based on our experience, about 4.00 D or more of plus in the periphery is needed to be effective in treating myopia.9
One daily disposable lens has over 6.00 D of peripheral plus and can be used off-label for myopia control. In a case analysis study, this lens slowed myopic progression by 90%.9 While this commercially available lens has become our go-to soft lens for myopia control, it does not address astigmatism. A recent study provides strong support that a center-distance contact lens with concentric +3.50 D rings is effective in slowing myopia progression.10 This daily lens, which is not available in the U.S., but is available in Canada and Australia, has been shown in a 3-year, multi-center prospective clinical trial to slow the progression of myopia by 40%, as compared to a control lens. Patients with over -1.25 D of astigmatism need to either use custom lenses, to provide for toric, center-distance, multifocal contact lens solutions, or ortho-k.
My recommendation is to prescribe multifocal soft lenses for patients whose parents do not like the idea of sleeping with lenses: children who have low myopia (hard to get enough plus in the periphery with ortho-k in low myopes) or who have myopia over 5.00 D.
Traditional bifocal spectacles and progressive lenses were thought to slow the progression of myopia. However, the COMET study dispelled that thought.11,12 Progressive lenses were reported to be effective the first year, but not in subsequent years. Meta-analysis suggests they are somewhat effective in Asian patients who have myopia greater than 4.00 D, progressing at a rapid rate. We do not know whether progressive lenses are additive with atropine. However, more promising is new spectacle lens technology using defocused incorporated multiple segments, or DIMS, which was shown in a study to result in a 60% reduction in the rate of progression of both refractive error and axial length elongation.13 The lens is not available in the U.S.
MYOPIA IN BUSINESS
In offering myopia management to patients, we added a profit center to our practice, one that sets us apart, as we were among the few practices providing it. We had — and still have — excited patients looking for help and who contribute to our growth.
That said, myopia is not covered by insurance. As such, optometrists need to discuss this with patients’ parents when talking about methods to slow progression. In our practice, we provide initial yearly costs and subsequent annual packages for the patient.
THE COMING YEARS
Today, researchers are concentrated on better defining, managing and solving the problem of progressive myopia in all treatment segments: atropine, ortho-k, soft contact lenses and spectacle lenses. Additionally, diagnostic tools, such as topography, allow us to measure progression and axial length. Optometrists, whether new or experienced in the area of the myopia treatment, can follow developments in research to best treat their patients in the coming years. OM
- Smith EL, 3rd. Prentice Award Lecture 2010: A case for peripheral optical treatment strategies for myopia. Optom Vis Sci. 2011; 88: 1029-1044.
- Smith EL, 3rd. Optical treatment strategies to slow myopia progression: effects of the visual extent of the optical treatment zone. Exp Eye Res. 2013; 114: 77-88.
- Arumugam B, Hung LF, To CH, Sankaridurg P, Smith EL, III. The effects of the relative strength of simultaneous competing defocus signals on emmetropization in infant rhesus monkeys. Invest Ophthalmol Vis Sci. 2016; 57: 3949-3960.
- Shih YF, Chen CH, Chou AC, Ho TC, Lin LL, Hung PT. Effects of different concentrations of atropine on controlling myopia in myopic children. J Ocul Pharmacol Ther. 1999; 15: 85-90.
- Chua WH, Balakrishnan V, Chan YH, et al. Atropine for the treatment of childhood myopia. Ophthalmology. 2006; 113: 2285-2291.
- Chia A, Chua WH, Cheung YB, et al. Atropine for the treatment of childhood myopia: safety and efficacy of 0.5%, 0.1%, and 0.01% doses (Atropine for the Treatment of Myopia 2). Ophthalmology. 2012; 119: 347-354.
- Cooper J, Eisenberg N, Schulman E, Wang FM. Maximum atropine dose without clinical signs or symptoms. Optom Vis Sci. 2013; 90: 1467-1472.
- Cooper J, Tkatchenko AV. A review of current concepts of the etiology and treatment of myopia. Eye Contact Lens. 2018; 44: 231-247.
- Cooper J, O’Connor B, Watanabe R, et al. Case series analysis of myopic progression control with a unique extended depth of focus multifocal contact lens. Eye Contact Lens. 2018; 44: e16-e24.
- Chamberlain P, Peixoto-de-Matos SC, Logan NS, Ngo C, Jones D, Young G. A 3-year randomized clinical trial of MiSight lenses for myopia control. Optom Vis Sci. 2019; 96: 556-567.
- Hyman L, Gwiazda J, Hussein M, et al. Relationship of age, sex, and ethnicity with myopia progression and axial elongation in the correction of myopia evaluation trial. Arch Ophthalmol. 2005; 123: 977-987.
- Gwiazda JE, Hyman L, Everett D, Norton T, Kurtz D, Manny R. Five-year results from the correction of myopia evaluation trial (COMET). Invest Ophthalmol Vis Sci. 2006; 47: E–abstract 1166.
- Lam CSY, Tang WC, Tse DY, et al. Defocus Incorporated Multiple Segments (DIMS) spectacle lenses slow myopia progression: a 2-year randomised clinical trial [published online ahead of print]. Br J Ophthalmol. doi: 10.1136/bjophthalmol-2018-313739
- Cooper J, Weibel K, Borukhov G. Use of Atropine to Slow the Progression of Myopia: A Literature Review and Guidelines for Clinical Use. Vision Development & Rehabilitation. 2018; 4: 12-28.