Mastering myopia management: who and when to treat

Paper title: Juvenile-onset myopia—who to treat and how to evaluate success

Authors: Mark Bullimore¹ and Noel A. Brennan²

1. University of Houston, College of Optometry, Houston, TX, USA
2. Johnson & Johnson Vision, Jacksonville, FL, USA.

Date: 14 September 2023

Reference: Bullimore MA, Brennan NA. Juvenile-onset myopia-who to treat and how to evaluate success. Eye (Lond). 2023 Sep 14.

[Link to paper]

Juvenile myopia is a significant risk factor for severe eye diseases like myopic macular degeneration, retinal detachment, and glaucoma.² As myopia rates rise, even low levels pose a global health threat.^3-4 This paper focused on five key areas of myopia management to combat the growing myopia issue: 

• Who to treat: There's no substantial link between age of myopia onset and age of stabilization, meaning early-onset myopes have both faster and longer progression. From a public health standpoint, it makes sense to treat all children and teenagers immediately on myopia diagnosis to reduce progression, regardless of the age of onset, as earlier treatment lowers the risk of developing severe myopia. 
• Measurement of progression: Assessing progression by measuring axial length is more accurate and sensitive than refractive error. Not all practices have access to optical biometry; refraction and keratometry can therefore provide crude axial length estimates. Cycloplegic auto-refraction is more repeatable and less vulnerable to clinician bias compared to subjective refraction and is also a useful tool for measuring progression. 
• Factors influencing rate of progression: Age is the primary determinant of progression, with younger myopes progressing faster. Race plays a role, with East Asian children progressing 30% faster than white children. Gender and parental history of myopia influence progression to some extent. More time spent outdoors is associated with a lower incidence of myopia.
• Interpreting growth charts and models: Tools like the Brien Holden Vision Institute Myopia Calculator can predict myopia progression based on age, race, and prescription. Percentile growth charts can identify abnormal axial length and rapid elongation. Recent models help clinicians monitor progression and treatment efficacy, setting goals for individual children. 
• Setting goals: Goals for myopia management should aim for below-average annual progression based on age and race. These goals need to be interpreted for each child's unique situation and communicated to parents.

For eyecare practitioners, this research highlights several key considerations. First, there's a growing emphasis on early intervention for pre-myopic and myopic children and teenagers, regardless of the age of onset. Monitoring myopia progression is crucial, with a focus on measuring axial length and refractive error. Setting clear treatment goals for each child, such as aiming for below-average annual progression based on age and race, is also recommended. Regular check-ups, typically every six months, are essential to track progress. Additionally, compliance with prescribed treatments should be a central concern. It's vital for optometrists to differentiate between primary myopia in school-age children and high myopia in younger children with syndromic associations, as treatment effectiveness can vary. 

Ultimately, a personalized, individualized approach to myopia management is crucial, considering each child's unique risk factors, progression rate, and treatment response.

• While the paper provides valuable information and research findings, the practical applicability of its findings in practice is not captured. Evidence-based practice must also consider patient preferences,⁵ hence commencing treatment upon first myopia diagnosis may not be possible every time although recommended.  
• As with any review article, potential biases and confounding factors may exist in the selection and interpretation of the included studies. The quality of evidence from various studies may vary, and it's essential to critically assess the strength of the presented findings.
  
  
  

The risk of eye diseases such as myopic macular degeneration increases with the level of myopia, but there is no safe level of myopia and the burden of lower degrees of myopia remains considerable. Effective treatments are available that slow progression and thus limit the final degree of myopia. In this review, the rationale for slowing progression is summarized, and a case made for treating all myopic children. Measurement of refractive error and axial length is reviewed, stressing the precision of optical biometry, but also the need for cycloplegic autorefraction. The factors influencing progression are considered and the available tools for interpretation of progression rate are discussed. Finally, the need to set attainable treatment goals is emphasized.

[Link to paper]