Myopia Management in the netherlands: advice and outcomes from a new protocol

Paper title: Myopia management in the Netherlands

Authors: Caroline Klaver (1,2,3), Jan Roelof Polling (1,4), Erasmus Myopia Research Group

1. Department of Ophthalmology and Department of Epidemiology, Erasmus Medical Centre, Rotterdam, the Netherlands
2. Department of Ophthalmology, Radboud University Medical Centre, Nijmegen, the Netherlands
3. Institute for Molecular and Clinical Ophthalmology, Basel, Switzerland
4. Department of Optometry and Orthoptics, Hogeschool Utrecht, University of Applied Science, Utretcht, the Netherlands

Date: March 2020

Reference: Klaver C, Polling JR; Erasmus Myopia Research Group. Myopia management in the Netherlands. Ophthalmic Physiol Opt. 2020 Mar;40(2):230-240. (link)

This study from the Erasmus Myopia Research Group in the Netherlands explored factors to consider when managing children's myopia, and described their own myopia management protocol based on axial length centile growth charts. 

Part 1: Lifestyle advice. The Erasmus protocol includes providing lifestyle advice to all myopic children as follows.

• limiting close work/screen time to 2 hours maximum children 5-12yrs
• holding close work no closer than 30cm
• using the 20-20-2 rule of looking afar for 20 seconds every 20 mins and spending 2 hrs outside daily

Part 2: Proactively treat children at risk of high myopia with 0.5% atropine. Children with axial lengths on or above the 75th centile are at risk of high myopia (6D or 26mm) and hence should receive the most effective treatments. Atropine 0.5% is prescribed for these children and the concentration adjusted six-monthly according to progress, which is plotted on axial length growth curves where success is indicated by reduction in percentile. Side-effects of photophobia (noted in 72% of children) and near vision blur (noted in 38%) were managed by prescribing all of these children photochromic multifocal spectacles with a +3.00 Add. In a real-world study of almost 80 children prescribed this protocol, 74% had less than 0.2mm per year axial growth compared to an average of 0.34mm per year in a non-treated historical comparison group. Around 17% of children still progressed by more than 0.3mm per year.

Part 3: Manage remaining myopic children with other treatments. For children under the 75th centile, treatments with less side effects are offered: atropine 0.05%, orthokeratology and dual-focus or multifocal soft contact lenses. Atropine is considered for children over 6 and contact lenses for children over 8 years. Follow up occurs every six months, using the growth charts to plot progress. For all myopic children, the authors report that visualization of treatment progress using the growth charts is "an enormous stimulus for parents to adhere to treatment."  

Part 4: Ceasing treatment in the late teens. The authors state that treatment generally occurs until age 15, or beyond if required for children in the highest percentiles. When axial length growth has stabilized to less than 0.1mm per year for more than a year, atropine concentration is tapered. Treatment is ceased when the rate of eye growth is less than 0.05mm per year.

This protocol is the first to set out how to use axial length percentile growth charts for diagnosis, monitoring and treatment cessation. It is logical and evidence-based, but the use of growth charts and atropine 0.5% may not suit all practice settings. The key messages are to provide visual environment advice to all myopes, and to be proactive in identifying and treating children at greatest risk of progression to high myopia. If you're not measuring axial length, as was used for risk identification here, younger current age (especially under age 9) is the greatest risk factor for fast progression.¹  If you don't have access to atropine or are hesitant to prescribe such a high concentration, then orthokeratology, myopia controlling soft contact lenses and the new myopia controlling spectacles provide robust options.

We are still learning how axial length percentile growth charts apply across various populations - the Erasmus protocol benefits from growth charts built on large-scale data from their country. Given the significant side effects of 0.5% atropine, it would be interesting to see if its long-term efficacy is actually higher than the best spectacle and contact lens options, as the real-world outcomes cited don't appear to indicate a far superior efficacy.² Long-term compliance with 0.5% atropine could also present an issue compared to optical treatments or lower-concentration atropine.

Title: Myopia management in the Netherlands

Authors: Caroline Klaver (1,2,3), Jan Roelof Polling (1,4), Erasmus Myopia Research Group

Purpose: A trend that myopia is becoming gradually more common is shown in studies worldwide. Highest frequencies have been found in East Asian urban populations (96.5%) but also a study in Europe shows that nearly half of the 25-29 year olds has myopia. With the increase in prevalence, high myopia, i.e. a spherical equivalent of -6 or more and an axial length of 26 mm or more is also on the rise. High myopia particularly carries a significant risk of ocular pathology related to the long axial length. This highlights the need for myopia management in children with progressive myopia, in particular progression to high myopia.

Results: During the last decade, many intervention studies for myopia progression have emerged. Although lifestyle adjustments are effective, pharmacological and optical interventions have shown the highest efficacy on reduction of eye growth. High concentration atropine (0.5%-1.0%) shows the most reduction in axial length progression, but has drawbacks of light sensitivity and loss of accommodation. Nevertheless, when these side effects are mitigated by multifocal photochromatic glasses, the long-term adherence to high dose atropine is high. Lower concentrations of atropine are less effective, but have less side effects. Studies on optical interventions have reported reduction of progression for Ortho-K and multifocal contact lenses, but are in need for replication in larger studies with longer duration.

Conclusions: The field of myopia management is rapidly evolving, and a position on the best approach for daily clinics is desirable. Over the last 10 years, our team of clinical researchers has developed a strategy which involves decision-making based on age, axial length, position on the axial length growth chart, progression rate, risk of high myopia, risk profile based on lifestyle and familial risk, side effects, and individual preference. This personalised approach ensures the most optimal long-term myopia control, and helps fight against visual impairment and blindness in the next generations of elderly.