Treating Myopia, Inside and Outside

Combining behavioural interventions, such as ensuring children spend at least 2 hours a day outside, with optical or pharmaceutical treatments may do a better job of preventing and slowing childhood myopia than relying on a single treatment, according to Ken K Nischal MD.

Professor Nischal pointed to differences in outcomes for children treated with low-dose atropine to prevent or slow myopia progression and axial elongation. Studies in Singapore, Taiwan, China, and Hong Kong clearly show it works, he noted. But a study last year in the US found no effect.

So, what’s the difference? Public health policies, Prof Nischal suggested. These may include requiring schools to limit reading and other near work to 30 minutes at a time, ensuring adequate lighting, and providing an hour of outdoor activity every day, as well as encouraging parents to get children outside 2 hours a day.

Starting with South Korea in 1997, countries throughout East Asia have adopted such policies, but the US and Europe have not, Prof Nischal noted. “If you have a public health policy, it makes sense anything you do above that will be more efficacious than if you don’t. We need to look at the public health background when we read these studies.” However, the authors of the US study wrote that differences in study design and genetic differences in the study groups may be at play.¹

Other research supports combining myopia treatments, said Erin Tomiyama PhD. “We see studies adding atropine to [orthokeratology] or soft multifocal contact lenses as more effective.” It may be that different therapies have different mechanisms of action, “so we are hitting myopia from more than one angle,” she added. Early intervention is also critical, with a year of prevention equal to 3 years of treatment.

Prof Nischal cautioned that understanding the specific cause of myopia is essential for successful treatment. “Not every myope has a long eyeball. Some have steep corneas.”

But treatment does work, and slowing myopia progression or preventing it altogether can have a massive impact on a patient’s life, Prof Nischal added. “What we do today will affect millions of children and adults 20 years [from now]. Can anybody think of an intervention in ophthalmology that will prevent disease like this?”

Engaging parents

So how can general ophthalmologists address childhood myopia in daily practice? Dominique Bremond-Gignac MD, PhD suggested three actions.

First, when treating adults for refractive myopic errors, counsel them to get any children they have screened for myopia because they have a higher risk than the general population, Prof Bremond-Gignac said. Parents should also be reminded of environmental preventive steps such as going outside frequently and participating in sports. Early screening can help spot pre-myopia in young children who have less hyperopia than normal for their age, allowing for preventive treatment.

Second, when seeing children with myopia, the diagnosis should be made by cycloplegic refraction. “You need an accurate baseline to detect later progression, even if it is a low myopia, such as -0.50 D.”

Third is treatment. Even if referring to a paediatric ophthalmology subspecialist, explain to parents that treatment is available to reduce progression beyond environmental prevention, Prof Bremond-Gignac said. This may include defocus contact lenses, orthokeratology, or low-dose atropine. Referring for an initial evaluation and then following in a general practice is an option, she added.

When talking with parents about their children with pre-myopia or myopia, explain that treatments are available and why they are needed, said Ramesh Kekunnaya MD. Not only can treatment improve vision and prevent future complications such as retinal tears and glaucoma, but it can also reduce the hidden psychosocial effects of wearing high-refraction spectacles for their entire life.

“Parents don’t want to see their children go from -1.00 D to -6.00 D,” he said. “When you give them this perspective, adherence to suggested modalities becomes much better. Generally, it takes a few minutes to explain. Education of patients—children—and their parents is the most important.”

Specific recommendations depend on the child’s condition, Dr Kekunnaya added. “For pre-myopes, we focus on behaviour modifications. For those with myopia already, we talk about behavioural modifications, plus either a pharmacological or optical treatment.”

Dr Kekunnaya emphasised conveying accurate information and addressing any misinformation, such as drops correcting astigmatism, which they can’t. He recommended parental brochures from the World Society of Paediatric Ophthalmology and Strabismus, available in English, Spanish, Mandarin, and Portuguese. Public health messages in bus stops and other high-traffic areas can also help increase awareness. “Buy-in from parents is extremely important.”

All verbal comments were made on iNovation Day at the 2024 ESCRS Congress in Barcelona.

Ken K Nischal MD, FAAP, FRCOphth is professor and chief of pediatric ophthalmology and strabismus at UPMC Children’s Hospital of Pittsburgh, Pennsylvania, US. nischalkk@upmc.edu

Erin Tomiyama OD, PhD, FAAO is assistant professor of optometry at Marchall B Ketchum University, Anaheim, California, US. etomiyama@ketchum.edu

Dominique Bremond-Gignac MD, PhD, FEBO is professor and head of the ophthalmology department at University Hospital Necker-Enfants-malades and Paris University, Paris, France. dominique.bremond@aphp.fr

Ramesh Kekunnaya MD, FRCS is director of the Child Sight Institute, Eye & Brain lab, Center for Technology Innovation and network director at the L V Prasad Eye Institute, Hyderabad, India. rameshak@lvpei.org

1. JAMA Ophthalmol, 2023 Aug; 141(8): 756–765.