Is childhood progression related to final adulthood myopia?

Paper title: Myopia progression from wearing first glasses to adult age: the DREAM Study

Authors: Polling, Jan R (1,2); Klaver, Caroline (3,4); Tideman, Jan W (3)

1. Ophthalmology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
2. Orthoptics & Optometry, Hogeschool Utrecht, Utrecht, The Netherlands
3. Ophthalmology and Epidemiology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
4. Ophthalmology, Radboudumc, Nijmegen, Gelderland, The Netherlands

 Date: June 2022

Reference: Polling JR, Klaver C, Tideman JW. Myopia progression from wearing first glasses to adult age: the DREAM Study. Br J Ophthalmol. 2022 Jun;106(6):820-824.

[Link to open access paper]

Myopia typically occurs initially during childhood, with the greatest progression seen in younger children. The age of onset varies with parental myopia, gender and ethnicity.¹ Risk factors for earlier onset include intense education and more time spent indoors and on near work.^2-5

Onset and progression can also be seen in teenagers, with full stabilisation of myopia occurring by age 21 for 90% of myopes and by 24yrs for nearly all myopes.¹ Adults who are highly myopic are thought to have developed myopia at a young age and progressed quickly during childhood.^6-8

This study investigated myopia progression and growth trajectories in a large European cohort of children and explored the association between their first myopia prescription and final refractive error.

The Drentse Refractive Error And Myopia (DREAM) study was a retrospective analysis of anonymised spectacle and contact lens order data supplied by a chain of opticians practices in the Netherlands between 1985 and 2015.

Subjects who had ordered at least 2 forms of myopia correction over an interval of 1yr or more until 25yrs old were included in the study. The first spectacle prescription supplied was defined as having spherical equivalent refractive error (SER) of between -0.50D to -3.00D. High myopia was defined as being -6.00D or stronger. The final degree of myopia was measured when the subjects were aged between 22-25yrs old.

Data was available for 2555 subjects (female, n = 57.3%), with 946 having SER between -0.50 and -3.00D (female, n = 59.2%). The SER range once the subjects were adult was -0.50 to -12.75D (median correction of -3.00D). Earlier initial myopic correction before age 10yrs was significantly associated with a final adulthood median SER of -4.48D. Furthermore, all children who had SER of -3.00D or stronger before the age of 10yrs developed high myopia of at least -6.00D. 

The greatest degree of myopia progression was also seen for those with corrections before they were 10yrs old. Adults with high myopia had progressed the fastest by an average of -0.71D per year up to the age of 10yrs. Those with milder myopia progressed slower at the same age.

The median progression rates of SER as a function of age were calculated and were seen to decrease with age:

• -0.50D for up to 10yr olds
• -0.38D for ages 10-12yrs
• -0.19D for 13-15yrs
• -0.09D for 16-18yrs
• -0.08D for 19-21yrs.

Gender was only seen to give a significant difference in one category: for females in 19-21yrs category (-0.09D progression versus -0.06D for males).

The risks of developing high myopia by age 25yrs increased with SER severity during childhood:

• 32.6% risk for SER between -0.50 to -1.50D at 10yrs
• 46.0% risk for SER -1.50 to -3.00D at 10yrs

However, the risks for high adult myopia were already reduced for those who were 10-12yrs, where there was a 3% risk for SER between -0.50 and -1.50D and 18.2% risk for SER -1.50 to -3.00D.

Having SER of -1.50 to -3.00D and -3.00 to -4.50D at age 15yrs gave 11.8% and 23.2% risk of adult high myopia, respectively. Those who had SER of -0.50 to -1.50D at later stages showed nearly no risk of high myopia in adulthood.

This study found that:

• 60% of those who developed high myopia had a myopic correction before they were 10yrs old and
• all children who were at least -3.00D before 10yrs experienced faster progression into high myopia in adulthood.

However, low myopes all but ceased progression after their mid-teens and within 1-2yrs after turning 10, the risks for high myopia were already decreasing for corrections up to -3.00D.

The results on SER progression mirror those found from other studies with data on SER progression, suggesting that the results can be applied to a wider European population.

• Subjects in this study who had their first myopia prescription before they were 10 had a median SER of -4.48D once adults. This corresponded with results from the American Correction of Myopia Evaluation Trial (COMET) where children with myopia onset between 6-11yrs had a mean SER of -5.04D when their prescription stabilised.¹
• The median annual SER progression for 10yr olds in this study was -0.45D, and -0.38D for 10-12yr olds. The progression rate for the 8-12yrs control group in the MiSight lens study was -1.24D over 3yrs⁹

It was also shown that even if children had low myopia under the age of 10, it did not preclude them from high myopia later in life. Any myopic correction found for children younger than 10 indicates a child at risk of future high myopia, so should be monitored carefully.

Establishing the existence and degree of myopia in early childhood is vital to identify children at risk of high myopia in adulthood. The severity of myopia in childhood is an indicator of future high myopia.

Some limitations of this study include:

• Being a retrospective design meant that children were included who became myopic between 1980 and 2000. Children born after may have different lifestyles that involve more near work and less time outdoors.
• Risk factors for myopia such as outdoor time and near activities were not assessed. These may be reasons behind myopia development and progression in children.
• The first myopia correction was classified as being between -0.50 and -3.00D, rather than using onset of myopia as a variable.
• Despite the optical practice chain supplying the data were spread across several provinces, the cohort was representative of the north of the Netherlands only, with only 37% of people living in an urban environment.
• Ethnicity was also not assessed in this study. The percentage of inhabitants with non-western background was 3% in 19080, rising to 5% in 2015. The results from this study may not be applicable to ethnicities with differing myopia prevalence and progression rates.
• The data from the practices did not include axial length values, due to a lack of equipment at the time. It would be valuable to know if axial length growth correlated with refractive error increases or if axial growth took place before, during or after SER changes.

Title: Myopia progression from wearing first glasses to adult age: the DREAM Study

Authors: Polling, Jan R; Klaver, Caroline; Tideman, Jan W

Purpose: Data on myopia progression during its entire course are scarce. The aim of this study is to investigate myopia progression in Europeans as a function of age and degree of myopia from first prescription to final refractive error.

Methods: The Drentse Refractive Error and Myopia Study assessed data from a branch of opticians in the Netherlands from 1985 onwards in a retrospective study. First pair of glasses prescribed was defined as a spherical equivalent of refraction (SER) ≤−0.5 D to ≥−3.0 D. Subjects with prescriptions at an interval of at least 1 year were included in the analysis.

Results: A total of 2555 persons (57.3% female) met the inclusion criteria. Those with first prescription before the age of 10 years showed the strongest progression (−0.50 D; IQR: −0.75 to −0.19) and a significantly (p<0.001) more negative median final SER (−4.48 D; IQR: −5.37 to −3.42). All children who developed SER ≤−3 D at 10 years were highly myopic (SER ≤−6D) as adults, children who had SER between −1.5 D and −3 D at 10 years had 46.0% risk of high myopia, and children with SER between −0.5 D and −1.5 D had 32.6% risk of high myopia. Myopia progression diminished with age; all refractive categories stabilised after age 15 years except for SER ≤−5 D who progressed up to −0.25 D annually until age 21 years.

Conclusions: Our trajectories of the natural course of myopia progression may serve as a guide for myopia management in European children. SER at 10 years is an important prognostic indicator and will help determine treatment intensity.[Link to open access paper]