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When myopia management is not working after COVID-19 home confinement

 Posted on November 8th 2021 by Connie Gan

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COVID-19 became a global pandemic in 2020 and spurred governments to impose home confinement in many countries. Eye care practitioners were mostly spared the full brunt of the manifestations of COVID-19 clinically, as the most common ocular sign is a mild conjunctivitis and has been reported to be self-limiting.1

However, did the mandatory home confinement imposed to control the spread of COVID-19 in fact worsen myopia? Early data from China indicates that this may be the case.2 As we know, increased outdoor activity and regular breaks plus reducing total near work time can delay the onset of myopia.3 While home confinement was imposed, opportunities for outdoor activities were limited and school education went online, leading to increased near work.2 

Could these lifestyle changes have affected the efficacy of myopia management as well? MW shared a case of a patient who started myopia treatment before the home confinement and suffered significant myopic progression after 12 months.

MW I hope you don’t mind me asking as I am new to myopia management and just started back to work in a practice that does lots. Young girl 10 years old. Last test 12 months ago R-1.25 L -1.75. Only record I have, first glasses at 8 yrs old Mum approx -16D Dad approx -6. Fitted with myopia controlling contact lenses 6 months ago to last Rx, VA 6/6 CL fit. Today’s VA with Rx above R 6/36 L 6/12. Dry Rx R -3.25 L -2.75. Mum upset at progression. Booked her in to return for cyclo. No axial length measures available. Will check phorias before instill cyclo. What else should I look for? Would Ks tell me anything?

Over the course of six months of myopia controlling contact lens wear, the child progressed by -2.00D and -1.00D in her right and left eye respectively. This is very fast progression compared to what could be expected for her age, especially considering that there is a myopia control strategy in place. The average amount of progression for a child of this age in single vision spectacles would be around -0.75D per year,4 so this much progression in six months, in a myopia control strategy, indicates a very poor result.

What are the possible reasons for progression?

1. Insufficient contact lens wear

CJ Hi MW, has she been wearing lenses full time? Makes me wonder what progression would’ve been without contact lens. Would be interested to see results of cyclo.MW Nice to hear from you. She says wears cl six days a week and SVD glasses one day a week…IG I'm finding a lot of children progressing at this time. The most significant issue is they're not wearing their CLs anymore despite what they say. I had a 10yo return 6 months of unopened CLs having been fitted 12 months ago. They may assume that don't need to wear them when not at school. All other factors combined mean there was going to to be progression. No MM strategy at the moment guarantees to stop progression. I know parents can become dis-heartened but these are unprecedented times and we're all using our eyes in a different way, the new normal has changed everything. With children on holiday now and possibly reducing their lens wear over holiday times, there could be another increase in myopia in the winter months as children spend more time indoors and possibly on mobile devices. I feel sure another chat with the Px and parents will allow you to put all the pieces of the jigsaw together. Please do share your findings with the group this is such an education case.BS I had a patient return after lockdown with a -1.50ds progression. 9 months since the last test. I asked them to return any unused lenses so I could replace them with the new Rx. She brought back 5 months of lenses️ she had hardly been wearing themPC just had a girl try to fake compliance on orthoK, swears she’s wearing them nightly but topography tells otherwise. Asked her mum to supervise lens insertion, sure enough next visit her maps looked much better.

The first and most reasonable presumption is that perhaps the child has not been compliant with contact lens wear. Indeed, when schooling from home and presumably spending most of the time looking at near, the child and parent may not realize that full time wear of the myopia control strategy is still required. One study of a novel design of soft myopia controlling contact lens found a correlation between reduced wearing time and a reduced myopia controlling effect. Wearing time of at least 8 hours a day led to the best outcomes.5

The other significant effect of reduced wearing time is the child suffering undercorrection or un-correction of their myopia, which has shown a link with faster myopia progression.6

IG mentioned also that some children take a break from contact lens wear when they are on holidays. This would mean that they could be spending more time in non-myopia controlling optical correction, or in no correction, than expected. This would then explain the lack of myopia control effect. Some commenters suggested that requesting patients to bring in the balance of their contact lens supply is a good way to ascertain whether they have been compliant in keeping to advised wearing times.

2. Excess near work

MW … Admits to more close work especially tablet.BS it could be a lot of growth during this period and a strong genetic element. She may have spent most of the lockdown in her bedroom reading for 10 hours a day?RT I’ve done a few a Ortho-K follow ups and asked parents if they mind their kids showing me their screen time app. 9hours 47 mins is the record so far 😱 Hits the point homeMW I can imagine. Especially with lockdown and its unfair to expect child or parent not to use right now. Mum is aware but thinking I might do an advise leaflet for screens to give at next visit. Will look at screen time app.

As home confinement was imposed, in-person classes were cancelled, and students were forced to learn the curriculum virtually. This led to increased screen time and near work. The impact of screen time specifically on myopia is varied according to a systemic review,6 however, there is an association between near work activities and myopia in children, where the odds of myopia are increased with the more the time spent on near activities.7

3. Genetics

PC I see many of these cases where there is a strong genetic component. The amount of progression, even with treatment, is scary. Need to treat aggressively. I would do combination treatment - keep her on myopia controlling contact lenses but add 0.05% atropine. I recently had a 8yo child like this, mum -15D, 2 months into OrthoK and I could see his AXL continue to skyrocket and added 0.05% atropine right away, which has since shown some slowing of AXL change.

As both parents are highly myopic, this patient is at risk of faster myopia progression.9 This could lead to consideration of a more effective strategy - combination treatment with atropine is mentioned. There is growing evidence that combining atropine with orthokeratology can increase short-term myopia control efficacy, but currently no evidence base for combining atropine with other optical interventions.10

4. What else should be considered?

The original poster, MW, asks if corneal curvature measurements are important. The answer to this is yes - typically, corneal curvature doesn't change much in childhood myopia progression,11 so any contribution of steepened corneal curvature to the refractive change should be ruled out with keratometry or corneal topography. Read more about this in Are you measuring the cornea in myopia management?

Take home messages:

  1. There appears to be an association between home confinement and myopia progression, at least based on data from China. This may be due to reduced outdoor activity and excessive near work.
  2. When myopia progression is faster than expected, it is important to rule out other possible factors that influence myopia progression such as treatment compliance and the effect of visual environment. Both of these factors can be modified with the right clinical advice.
  3. Family history cannot be modified, but can also play a factor in faster progression. It is also important to ensure that parents understand that myopia control treatments can slow, but not stop, myopia progression in their children.

Read more about managing treatment outcomes

Meet the Authors:

About Connie Gan

Connie is a clinical optometrist from Kedah, Malaysia, who provides comprehensive vision care for children and runs the myopia management service in her clinical practice.

Read Connie's work in many of the case studies published on MyopiaProfile.com. Connie also manages our Myopia Profile and My Kids Vision Instagram and My Kids Vision Facebook platforms.

About Kimberley Ngu

Kimberley is a clinical optometrist from Perth, Australia, with experience in patient education programs, having practiced in both Australia and Singapore.

Read Kimberley's work in many of the case studies published on MyopiaProfile.com. Kimberley also manages our Myopia Profile and My Kids Vision Instagram and My Kids Vision Facebook platforms.

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