The contenders

The range of options available to eye care professionals (ECPs) has proliferated as scientists and industry have turned their focus to addressing rising levels of myopia internationally.

“When you look at myopia from the prism of the technology adoption lifecycle, we have moved from the innovators, through the early adopters that comprise the early market for myopia management,” optometrist Craig McArthur shared.

“We have now jumped the chasm and are moving towards the mainstream,” he added.

For optometrist, Indie Grewal, it is an exciting time to be practising in the field.

“We have more products now than we ever have done. We are able to fit a lot of myopes that we see now with CE marked options licensed specifically for myopia management,” he said.

During this time of rapidly expanding options, Grewal emphasised the need to take an evidence-based approach to the management solutions ECPs offer. “It is important that ECPs read up on the products and the research behind the products so that they are fully informed,” he highlighted.

To help with this task, OT summarises clinical guidance from the International Myopia Institute (IMI) on the range of myopia management interventions that are available to ECPs.

 Lifestyle measures

Research has found that time spent outdoors can have a protective effect against myopia onset, with school-based interventions showing that an increase in outdoor time of 40 to 80 minutes per day produces a significant decrease in the incidence of myopia.

The IMI advises that encouraging children to spend more time outdoors has the potential to decrease the incidence of myopia. The evidence shows that a higher prevalence and degree of myopia is linked to the intensity and duration of education but the IMI notes that the mechanism involved is unclear.

When to start treatment?

For children who have pre-myopia or low myopia (<-0.50D), the IMI highlights that a refractive correction would not be suitable so the patient and parent or caregiver should be advised on the need for regular eye examinations.

When the degree of myopia is equal to or greater than -0.50D, then the ECP should consider the management options available in consultation with the child’s caregiver. The rate of myopia progression should also be considered before initiating treatment.

Orthokeratology (ortho-k)

This management option involves overnight wear of specially designed rigid contact lenses to gently reshape the cornea overnight to neutralise refractive error and can be used with myopic children from -0.50 to -6.00D with up to 2.50D of astigmatism.

A benefit of this option is that children are free from refractive correction during the day. However, it requires overnight contact lens wear with its associated, though rare, risk of complications. The most severe complication is microbial keratitis.

Soft contact lenses

Soft myopia control dual-focus contact lenses with up to six years of clinical trial data demonstrating safety and efficacy are now commercially available. These lenses are available in a range of powers and daily disposable options carry a lower risk of potential complications than ortho-k.

MiSight^® 1 day soft dual focus contact lenses designed specifically for myopia control has been clinically shown to slow the progression of myopia in children and was the first FDA-approved contact lens for myopia control.

McArthur shared that his practice was one of the first in the UK to offer MiSight 1 day contact lenses to patients.

“It remains my first-choice product in large part due to the quality of the ongoing study monitoring its efficacy,” he said.

Ophthalmologist John Bolger has been running a myopia control clinic for the past three years.

Within the clinic, ECPs use contact lenses (soft or overnight ortho-k) as the primary management option.

We have more products now than we ever have done. We are able to fit a lot of myopes that we see now with CE marked options licensed specifically for myopia management

Myopia control spectacle lenses

Spectacle lenses for myopia management are now commercially available, backed by up to three years of clinical trials.

Defocus Incorporated Multiple Segments (DIMS) spectacle lenses significantly slowed myopia progression and axial elongation in Chinese children between the ages of eight and 13.

McArthur described the MiyoSmart spectacle lens, incorporating DIMS technology, as an “exciting addition” to his practice’s myopia management offering. “Some families and some children are just not ready for contact lenses initially. Previously I would stand by and watch their myopia rapidly progress until I could finally convince them to try a contact lens. Now with MiyoSmart we have an immediate alternative or an adjunctive therapy for days off from contact lenses,” he highlighted.

Other manufacturers have also developed myopia control spectacles, including Essilor’s Stellest lens.

Atropine

The most effective dose of atropine has not yet been determined, but research so far suggests it is between 0.01% to 0.05%.

Atropine is not approved for use in the UK although a multi-centre study is exploring the effectiveness of 0.01% atropine drops in managing myopia. The CHAMP-UK study is monitoring children between the ages of six and 12 who are asked to instil either a placebo or atropine drop in each eye, each day, for two years. CHAMP-UK Ulster University lead, Professor Kathryn Saunders, highlighted that if atropine is approved for use in the UK, it could be a useful management option for patients who are not suitable for ortho-k, soft contact lenses or myopia control spectacle lenses.

Saunders notes that soft contact lenses and spectacle lenses require wearing times of at least 10 hours a day to be effective in modifying eye growth. She added that children with low levels of myopia are often those who do not wear glasses full-time as they can see reasonably well without them.

“Using atropine rather than expecting children to comply with full-time spectacle or contact lens wear may be a better option,” Saunders shared.

She observed that ECPs in primary care are well-placed to offer atropine if approved by the Medicines and Healthcare products Regulatory Agency.

“It would be helpful if practices were equipped with a biometer so that robust measures of axial length are made to accurately determine the need for and efficacy of treatments,” Saunders highlighted.

For ECPs without access to a biometer, tools are available (Ulster University has developed a table to estimate axial length from average corneal curvature and spherical equivalent refraction measures which are available online).

Combined and sequential treatment

The IMI highlights that combined therapy using pharmacological treatments such as atropine in addition to optical treatments seems to be more effective than a single management approach.

The effectiveness of current management options appear to decrease with time.

However, as different treatment modalities have different mechanisms of action, it may be possible to use a range of options in a sequence with greater cumulative effect.

Each time new options appear we try to gain the appropriate education and add it to our practice armoury

Research is underway in this field, with full outcomes to be published at a later date. For optometrist, Sarah Farrant, having a range of different myopia management options on offer is key.

“Each time new options appear we try to gain the appropriate education and add it to our practice armoury. The more solutions you can offer the more inclusive you can be for your patients,” she shared.

Limitations

While there is strong evidence to support a range of myopia management interventions, there are still unknowns within this developing field. Optometrist, Dr Kate Gifford, highlighted that robust data supports a variety of interventions that provide similar efficacy – including the newest generation myopia control spectacles, ortho-k, dual-focus contact lenses, and 0.025 to 0.05% atropine.

“The benefits are clear: less deterioration of visual acuity between eye examinations in the short-term, and potentially less lifelong risk of eye disease and vision impairment in the long-term,” she said.

However, Gifford added that there are limitations to the current evidence that supports different management options.

The benefits are clear: less deterioration of acuity between eye exams in the short-term, and potentially less lifelong risk of eye disease and vision impairment in the long-term

 

Most myopia control studies recruit participants between the ages of six and 14, who are between 1 and 5D myopic. “This means we have less or a minimal evidence base for younger and older children, and higher myopes – requiring us to be cautious in setting expectations and informed consent,” Gifford observed.

Optometrist and lecturer, Dr Stephanie Kearney, highlighted that although research suggests that the effects of myopia control contact lenses and spectacle lenses are significant, results can be variable. She added that there is no guarantee that every child will respond to treatment.

“We don’t yet know why this variability exists and how to predict which child will benefit the most,” she shared.