London Ontario Optometrist Provides Hope for Children with Progressive Myopia

London Ontario Optometrist Dr. Michael J. Fenn came upon treatments to stem the growing epidemic of nearsightedness, properly known as myopia, out of concern for his patients after over 15 years of seeing desperate patients and their parents looking for options to help stop the sometimes visually devastating effects of myopic progression.  "I have a family member who has had two retinal detachments due to very high myopia.  “I've also had a gentleman in my practice become blind as a result of his myopia and found it frustrating not being able to offer my patients options to help them."  "I felt I had to do something to help these patients and as a result I began studying the growing science behind myopia control."   

Myopia is a common condition due to a progressive lengthening of the eye that causes blurry vision when viewing objects that are far away.  Its prevalence appears to be increasing and varies throughout the world.1-5It is much more prevalent in industrialized countries and in cities compared to rural areas.6-10,5  In the United States, the prevalence rate has increased from 25% between 1971-1972 to 41.6% between 1999-2004.11,12,5Some countries in Asia are seeing prevalence rates as high as 80% or more.13,14,5This rapid increase in prevalence raises some public health concerns.5For many people, low levels of myopia are a nuisance and just may mean you are dependent on glasses or contact lenses to see things at distance.  However, with high levels of myopia the consequences can be sight threatening due to induced anatomical changes that involve a progressive lengthening of the eye.  Persons with higher degrees of myopia have a greater risk of visual impairment or blindness from myopic macular degeneration, cataract, glaucoma, retinal holes and tears, and retinal detachments.13,14,15,16,5  Thus, finding ways to slow the progression of myopia is important in decreasing the associated ocular consequences and increasing peoples quality of life.

“I came to dread the conversation with patients and their parents when a child’s myopia would progressively increase without being able to offer them any options other than hope things don’t change at the next appointment.”  This often is never the case as most myopia progresses approximately -0.50D per year until a persons 21st birthday, however some patients can progress well into their 20’s.17“Imagine any other medical condition that we would watch get worse and not do anything to help prevent or slow its course. “  

The biggest risk factor for children developing myopia unfortunately is one they can’t change: their parents.  Children of parents who are myopic are at higher risk of developing myopia.19 However increasingly studies have found environment may play an important role.  Primarily, the amount of time spent outside in the development and progression of myopia.18,20-22“The first thing I recommend to parents, especially to those who are myopic themselves and worry about their children is to ensure their children have lots of play time outdoors.”  “Studies have shown that children are less likely to become myopic if they spend close to 14 hours a week playing outside and progress at a slower rate if they already are myopic.”18-21 This appears to be independent of the amount of time spent reading.18-21

Once the child becomes myopic, interventions may include orthokeratology, which involves the use of a specially designed rigid gas permeable lens which moulds the cornea while the patient sleeps so when they wake up and remove the lens they don’t require contact lenses or glasses to see for the day.  Children and adults like the procedure as it frees them from daytime visual correction, plus studies show that it has the added benefit of slowing the growth of the eye by 30-57% in children. 23-27    

Another option is the use of a soft contact lens multifocal lens that is usually prescribed to older patients who want to wear contact lenses and have age related problems with reading that is used off label in children to slow the progression of myopia.  Studies show it appears to slow the progression of myopia similar to that of orthokeratology.28-30  

The last treatment Dr. Fenn has available is atropine eye drops.  Atropine is normally used when treating inflammation of the eye.  However, it does appear to also decrease the progression of myopia.  When used at its pharmacologically available dosage it appears to decrease myopia progression by 77% over a two year period.31The drop at this concentration can be difficult to tolerate for children as their pupils are constantly dilated and they can’t focus for near tasks and are very light sensitive. Much more tolerable for a patient is having the drug diluted to one 100th of its dosage by a compounding pharmacy.  “I have yet to prescribe the 1% concentration of atropine because of the risks of adverse events and side effects even though it appears quite effective.” The 0.01% concentration does not require any special lenses, studies show it slows the progression of myopia by 50% over a two year period, and the minimal concentration and dosage makes the likelihood of any adverse events very low.32In my experience patients tolerate it very well.   My major concern which I communicate to patients and parents is the lack of long-term studies on the effects of atropine especially in children, and as a result, it is not the first line of treatment I recommend.  Other treatments that have been tried include bifocal and multifocal glasses but have proven to be less effective and only work on children with specific ocular characteristics.33,34

For more information please feel free to visit Dr Fenn’s website at: www.orthoklondon.ca

 

References

1. Fotouhi A, Hashemi H, Khabazkhoob M, Mohammad K. The prevalence of refractive errors among schoolchildren in Dezful, Iran. Br J Ophthalmol 2007;91(3):287-92.

2. Rudnicka AR, Owen CG, Nightingale CM, Cook DG, Whincup PH. Ethnic differences in the prevalence of myopia and ocular biometry in 10- and 11-year-old children: the Child Heart and Health Study in England (CHASE). Invest Ophthalmol Vis Sci 2010;51(12):6270-6.

3. Naidoo KS, Raghunandan A, Mashige KP, Govender P, Holden BA, Pokharel GP, et al. Refractive error and visual impairment in African children in South Africa. Invest Ophthalmol Vis Sci 2003;44(9):3764-70.

4. Saw SM, Goh PP, Cheng A, Shankar A, Tan DT, Ellwein LB. Ethnicityspecific prevalences of refractive errors vary in Asian children in neighbouring Malaysia and Singapore. Br J Ophthalmol 2006;90(10):1230-5.

5. Cooper J, Schulman E, Jamal N. Current status on the development and treatment of myopia. American Optometric Association.  2012 May 31;83(5):179-99.

6. Uzma N, Kumar BS, Khaja Mohinuddin Salar BM, Zafar MA, Reddy VD. A comparative clinical survey of the prevalence of refractive errors and eye diseases in urban and rural school children. Can J Ophthalmol 2009;44(3):328-33.

7. Saw SM, Hong RZ, Zhang MZ, Fu ZF, Ye M, Tan D, et al. Near-work activity and myopia in rural and urban schoolchildren in China. J Pediatr Ophthalmol Strabismus 2001;38(3):149-55.

8. Garner LF, Owens H, Kinnear RF, Frith MJ. Prevalence of myopia in Sherpa and Tibetan children in Nepal. Optom Vis Sci 1999;76(5): 282-5.

9. Sapkota YD, Adhikari BN, Pokharel GP, Poudyal BK, Ellwein LB. The prevalence of visual impairment in school children of upper-middle socioeconomic status in Kathmandu. Ophthalmic Epidemiol 2008;15(1):17-23.

10. Nangia V, Jonas JB, Sinha A, Matin A, Kulkarni M. Refractive error in central India: the Central India Eye and Medical Study. Ophthalmology 2010;117(4):693-9.

11.Vitale S, Sperduto RD, Ferris FL, 3rd. Increased prevalence of myopia in the United States between 1971-1972 and 1999-2004. Arch Ophthalmol 2009;127(12):1632-9.

12. Saw SM, Katz J, Schein OD, Chew SJ, Chan TK. Epidemiology of myopia. Epidemiol Rev 1996;18(2):175-87.

13. Lin LL, Shih YF, Hsiao CK, Chen CJ, Lee LA, Hung PT. Epidemiologic study of the prevalence and severity of myopia among schoolchildren in Taiwan in 2000. J Formos Med Assoc 2001;100(10):684-91.

14. Saw SM, Carkeet A, Chia KS, Stone RA, Tan DT. Component dependent risk factors for ocular parameters in Singapore, Chinese children. Ophthalmology 2002;109(11):2065-71.

15. Fong DS, Epstein DL, Allingham RR. Glaucoma and myopia: Are they related? Int Ophthalmol Clin 1990;30(3):215-8.

 

16. Haug SJ, Bhisitkul RB. Risk factors for retinal detachment following cataract surgery. Curr Opin Ophthalmol 2012;23(1):7-11.

17. Chua WHBalakrishnan VChan YHTong LLing YQuah BLTan D. Atropine for the treatment of childhood myopia.  Ophthalmology. 2006 Dec;113(12):2285-91

18. Wu Pei-Chang, Tsai Chia-Ling, Wu Hsiang-Lin, Yang Yi-Hsin, Kuo His-Kung, Outdoor activity during class recess reduces myopia onset and progression in school children, Ophthalmology, 2013May;120(5):1080-1085

19. Mutti DO, Mitchell GL, Moeschberger ML, Jones LA, Zadnik K, Parental Myopia, Near Work, School Achievement, and Children’s Refractive Error, Investigative Ophthalmology & Vision Science;.December 2002 vol. 43 no. 12 3633-3640

20. Cui D, Trier K, Ribel-Madsen SM, Effect of Day Length on Eye Growth, Myopia Progression, and Change of Corneal Power in Myopic Children, Ophthalmology 2013 May;120(5)1074-1079

21. Rose KA, Morgan IG, Smith W, Burlutsky G, Mitchell P, Saw S-M, Myopia, Lifestyle, and Schooling in Students of Chinese Ethnicity in Singapore and Sydney, Arch Ophthalmol. 2008;126(4):527-530.

22. Jones-Jordan LA, Sinnott LT, Manny R, Cotter SA, Kleinstein RN, Mutti DO, Twelker D, Zadnik and the Collaborative Longitudinal Evaluation of Ethnicity and Refractive Error (CLEERE) Study Group, Early Childhood Refractive Error and Parental History of Myopia as Predictors of Myopia, Investigative Ophthalmology & Vision Science; January 2010; Volume 51(1):115-121

23. Cho P1Cheung SWEdwards M, The longitudinal orthokeratology research in children (LORIC) in Hong Kong: a pilot study on refractive changes and myopic control; 2005 Jan;30(1):71-80.

24. Walline JJ, Jones LA, Sinnott LT, Corneal Reshaping and Yearly Observation of Nearsightedness (CRAYON), British Journal of Ophthalmology; 2009-82:1181-1185

25. Santodomingo-Rubido J , Villa-Colla C, Gilmartin B, Gutiérrez-Ortega R, Myopia Control with Orthokeratology Contact Lenses in Spain (MCOS): Study Design and General Baseline Characteristics, Journal Of Optometry 2009;Vol 02 Num 04:215-22

26. Richdale K, Troilo D, Contact Lens Treatments for Myopia Control: Emerging Evidence Based Practices, American Academy of Optometry Continuing Education Denver, Colorado, November 2014

27. Cho P, Cheung SW, Retardation of myopia in Orthokeratology (ROMIO) study: a 2-year randomized clinical trial, Investigative Ophthalmology & Vision Science, 2012 Oct 11;53(11):7077-85

28.  Sankaridurg  P , Holden B, Smith III, Naduvilath T, Chen X, Lazon de la Jara P, Martinez A, Kwan J, Ho A, Frick K, Ge J, Decrease in rate of myopia progression with a contact lens designed to reduce relative peripheral hyperopia: one-year results, Investigative Ophthalmology & Vision Science, 2011 Dec 9;52(13):9362-7

29. Antice NS, Phillips JR, Effect of Dual-Focus Soft Contact Lens Wear on Axial Myopia Progression in Children, Ophthalmology June 2011, Volume 118(6):1152-1161

30. Walline JJ, McVey L, Myopia Control With a Soft Bifocal Contact Lens, Optometry and Vision Science 2011 VOL 88 - Issue 3 pp 395-403

31. Chua W, Balakrishnan V, Tan D, Chan Y and ATOM Study Group, Efficacy Results from the Atropine in the Treatment of Myopia (ATOM) Study Invest Ophthalmol Vis Sci 2003;44

32. Chia A, Chua W-H, Cheung Y-B, Wong W-L, Lingham A, Fong A, Tan D, 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),February 2012 Vol. 119, Issue 2, Pages 347-354

33. Fulk GW, Cyert LA, Parker DE. A randomized trial of the effect of single-vision vs. bifocal lenses on myopia progression in children with esophoria. Optom Vis Sci 2000;77(8):395-401.

34. Cooper J, Schulman E, Jamal N, Current Status on the Development and Treatment of Myopia, Optometry. 2012 May 31;83(5):179-99.