Clinical
Which myopia control treatment works best?
In this article:
With an increasing availability of myopia control treatments, and expanding body of research, it can be a challenge for the clinician to understand which treatment to prescribe. The good news is that there are numerous highly effective treatment options, which gives you the opportunity to select what will work best for your patient’s vision, eye health, lifestyle and myopia control goals. This article explains how we can compare treatments - from scientific, clinical and patient-communication aspects.
Understanding treatment efficacy
Based on current understanding, many treatments offer similar efficacy to slow myopia progression, with no single treatment showing clear superiority, although some treatments are clearly less effective.1,2 Before getting into treatment type comparisons, here are some fundamentals on understanding and comparing efficacy of myopia control treatments.
- The gold standard for a myopia control study is the randomized controlled trial. This involves a direct comparison between a group undergoing the treatment, and an age- and refraction-matched control group with no treatment. ‘No treatment’ typically means single vision spectacles or contact lenses, or a placebo drop in the case of topical atropine.3
- Within a single myopia control treatment study, a percentage efficacy expresses how well the treatment worked compared to the control group. This is an important figure for that study, but cannot be compared directly to other studies. Differences in study duration and participant characteristics can influence these percentage outcomes.1
- When looking at outcomes, axial length data provides the most accurate measure and useful gauge for comparison. Axial length data typically yields slightly lower percentage outcomes, within a single study, as it is more sensitive at detecting changes in myopia progression.3 Consider how refraction can only be measured in 0.25D steps (around 0.1mm equivalent), while axial length can be measured down to 0.01mm.
Because percentages can’t be directly compared between studies, this means that we cannot say for sure that a 75% result in one study indicates a more effective treatment than a 50% result in another study.
Scientists are still debating how we best describe myopia control efficacy - whether as an absolute2 effect reported in millimeters or diopters, or a proportional4 effect reported by percentage. Until we learn more, there is a way we can describe efficacy in broad categories, using the advantage that percentages are easily understood - by us and by parents and patients.
Considering categories of treatments
How can we identify the most effective myopia control treatments? Instead of directly comparing percentages, leading to non-evidence-based assumptions about superiority of specific treatments, we can group treatments into simplified categories, where the research has shown that particular treatment to effectively slow axial elongation by at least 50% or around 33%, give-or-take.
Let’s say we are looking at the results of three myopia control studies. When looking at the axial length progression outcomes, if the treatment groups progressed by 75% less or 52% less or 66% less than the control groups, in these three studies, all three treatments can be put in the category of ‘at least 50%’. Here are the advantages to this approach.
- Parents easily understand what 50% means ("it will slow progression by at least half") and 33% ("will slow progression by about a third") and these percentages also clearly communicate that there is no myopia control strategy which can halt progression by providing 100% efficacy.
- It is evidence-based, easy to understand and explain, and gives you as the practitioner multiple prescribing options in the 'best' and the 'next-best' categories.
Explaining treatment options to parents and patients
The Myopia Profile Managing Myopia Guidelines Infographics use this simplified category format to both explain treatment options to parents and to determine long-term outcomes. These engaging infographics are free-to-download clinical resource designed by Myopia Profile to support clinical decision making and communication, and are available in several language translations.
Half of the infographic is a chairside reference for eye care professionals (below left - the mostly blue-coloured panels) and half is designed to guide in-room discussions with patients and parents (multi-coloured panels, below right). To describe treatment options, look to the Parent Communication Side of the Infographics - the foreground graphic and the top right panel entitled ‘What are my options?’
Let’s make that image bigger to explain this category approach to myopia control treatments. The podium presentation of treatments shown in the Infographic takes into consideration the outcomes of randomized controlled trials of myopia control treatments where there is at least 12 months of data published. It also utilizes axial length data, which is much more accurate than refraction in gauging myopia control success, and is a necessity to understand efficacy from a myopia control study.
Since current scientific understanding is that many treatments appear to offer similar efficacy to slow myopia progression, with no single treatment showing clear superiority,1,2 the myopia control treatments are grouped into percentage categories based on comparison of available research. The two key categories are '50%' and '33%'. Note that not all of these myopia control treatment options are available in all countries.
We can then communicate these simple percentage categories to parents and set treatment goals, based on average outcomes for that treatment being to slow myopia progression by "at least half" for the 50% category and "about a third" for the 33% category.
Learn about how to use these categories and the Infographic resource in long-term management, in our article Gauging Success in Myopia Management.
Which are the ‘best’ treatments?
The myopia control treatments sitting on the ‘best’ podium have been shown to reduce axial length progression by at least 50%, compared to the single vision control group in each study. In the 'best options' category from left-to-right are atropine 0.05%,5 dual-focus soft contact lens (CooperVision MiSight 1 day),6 and orthokeratology.7
The next row shows the new generation of myopia controlling spectacle lenses with lenslets or diffusion technology. The spectacle lens graphics pictured here, left-to-right, are DIMS Technology (Hoya MiYOSMART),8 H.A.L.T. Technology (Essilor Stellest),9 and Diffusion Optics Technology or DOT (SightGlass DOT lens).10
All of these treatments appear to have similar efficacy based on their one-year randomized controlled trial studies. These interventions can all be described to parents as "slowing progression by at least half".
A new non co-axial ring-focus soft contact lens design (Johnson & Johnson Acuvue Abiliti 1-Day)11 has published six month data which looks like it is heading for the gold podium, once 12 month data is published. Additionally, a randomized controlled trial of an extended-depth-of-focus multifocal contact lens (Visioneering Technologies NaturalVue Multifocal 1 Day) is underway, with preliminary 12 month data indicating a gold podium finish is in sight.
The advantage of this comparison method is that it is evidence-based, easy to understand and explain, and gives you as the practitioner multiple prescribing options in the 'best' and the 'next-best' categories. Note that not all of these myopia control treatment options are available in all countries.
Which are the 'next best' treatments?
All of these treatments have been shown to reduce axial length progression by around 33%, give or take, compared to the single vision control group in each study. These interventions can all be described to parents as "slowing progression by about a third".
In the 'next best options' category from top left are extended-depth-of-focus soft contact lenses, known as EDOF Technology by the Brien Holden Vision Institute.12 Next is the centre-distance multifocal soft contact lens with a +2.50 Add (CooperVision Biofinity D lens).13
Bifocal and prismatic bifocal spectacles14 and 0.025% atropine5 also fit into this category.
An extremely useful article on MyKidsVision.org for parents is Understanding expectations in myopia control. In the Myopia Profile Resource Centre, you can download and print the My Kids Vision QR code sheet, which connects parents with specific information based on your discussions, including this key article.
Which treatments are minimally effective?
In the 'minimal effect' category are peripheral defocus spectacles,15 progressive addition spectacle lenses16,17 and 0.01% atropine.5
These treatments have been shown to reduce axial length progression by a minimal amount, being the least effective treatments.
Note that there is a lot of new data currently being published on novel formulations of atropine 0.01%, including the large-scale CHAMP study. This is helping to illuminate ideal candidates for this concentration of atropine. There is mounting evidence that atropine 0.01% works well to 'boost' the short-term efficacy of orthokeratology, and there is early data that it could be combined with DIMS spectacles.
Which option should you prescribe?
There are a few questions to ask yourself here, which we explore in the article What to prescribe for myopia control. These include the following.
What is the most effective treatment that you have available to you? Try to select from the ‘best’ (gold podium) category of treatments were possible.
Will spectacles or contact lenses suit this child, their lifestyle and their family best? Since the child needs vision correction, it makes sense to consider the most effective optical treatments as first line therapy, offering the dual benefit of myopia correction and myopia control.
Which treatment will achieve the best compliance? Compliance is crucial to myopia control success. Whatever treatment option is selected, prescribe it for full-time wear and/or every day use. In published studies, this means at least 12 hours per day, 7 days per week for spectacles9 and 6 to 7 days per week for contact lenses.6
There are numerous 'correct' myopia control options for your patient, since many have similar efficacy: choose the ideal treatment based on what you have available and what best suits their ocular, lifestyle and family factors.
References
Brennan NA, Toubouti YM, Cheng X, Bullimore MA. Efficacy in myopia control. Prog Retin Eye Res. 2021 Jul;83:100923.
Gifford P, Gifford KL. Descriptive statistical comparison of interventions for myopia control. Invest Ophthalmol Vis Sci 2023;64:822.
Wolffsohn JS, Kollbaum PS, Berntsen DA, Atchison DA, Benavente A, Bradley A, Buckhurst H, Collins M, Fujikado T, Hiraoka T, Hirota M, Jones D, Logan NS, Lundström L, Torii H, Read SA, Naidoo K. IMI - Clinical Myopia Control Trials and Instrumentation Report. Invest Ophthalmol Vis Sci. 2019 Feb 28;60(3):M132-M160.
Chamberlain P, Bradley A, Arumugam B, Hammond D, McNally J, Logan NS, Jones D, Ngo C, Peixoto-de-Matos SC, Hunt C, Young G. Long-term Effect of Dual-focus Contact Lenses on Myopia Progression in Children: A 6-year Multicenter Clinical Trial. Optom Vis Sci. 2022 Mar 1;99(3):204-212.
Yam JC, Jiang Y, Tang SM, Law AKP, Chan JJ, Wong E, Ko ST, Young AL, Tham CC, Chen LJ, Pang CP. Low-Concentration Atropine for Myopia Progression (LAMP) Study: A Randomized, Double-Blinded, Placebo-Controlled Trial of 0.05%, 0.025%, and 0.01% Atropine Eye Drops in Myopia Control. Ophthalmology. 2019 Jan;126(1):113-124.
Chamberlain P, Peixoto-de-Matos SC, Logan NS et al. A 3-Year Randomized Clinical Trial of Misight Lenses for Myopia Control. Optom Vis Sci 2019;96:556-67.
Sun Y, Xu F, Zhang T, Liu M, Wang D, Chen Y, Liu Q. Orthokeratology to control myopia progression: a meta-analysis. PLoS One. 2015 Apr 9;10(4):e0124535.
Lam CSY, Tang WC, Tse DY et al. Defocus Incorporated Multiple Segments (DIMS) Spectacle Lenses Slow Myopia Progression: A 2-Year Randomised Clinical Trial. Br J Ophthalmol 2020;104:363-8.
Bao J, Huang Y, Li X, Yang A, Zhou F, Wu J, Wang C, Li Y, Lim EW, Spiegel DP, Drobe B, Chen H. Spectacle Lenses With Aspherical Lenslets for Myopia Control vs Single-Vision Spectacle Lenses: A Randomized Clinical Trial. JAMA Ophthalmol. 2022 May 1;140(5):472-478.
Rappon J, Chung C, Young G, Hunt C, Neitz J, Neitz M, Chalberg T. Control of myopia using diffusion optics spectacle lenses: 12-month results of a randomised controlled, efficacy and safety study (CYPRESS). Br J Ophthalmol. 2022 Sep 1:bjophthalmol-2021-321005.
Cheng X, Xu J, Brennan NA. Randomized trial of soft contact lenses with novel ring focus for controlling myopia progression. Ophthalmol Sci 2022:Oct 18.
- Sankaridurg P, Bakaraju RC, Naduvilath T, Chen X, Weng R, Tilia D, Xu P, Li W, Conrad F, Smith EL 3rd, Ehrmann K. Myopia control with novel central and peripheral plus contact lenses and extended depth of focus contact lenses: 2 year results from a randomised clinical trial. Ophthalmic Physiol Opt. 2019 Jul;39(4):294-307.
- Walline JJ, Walker MK, Mutti DO, Jones-Jordan LA, Sinnott LT, Giannoni AG, Bickle KM, Schulle KL, Nixon A, Pierce GE, Berntsen DA; BLINK Study Group. Effect of High Add Power, Medium Add Power, or Single-Vision Contact Lenses on Myopia Progression in Children: The BLINK Randomized Clinical Trial. JAMA. 2020 Aug 11;324(6):571-580.
- Cheng D, Woo GC, Drobe B, Schmid KL. Effect of bifocal and prismatic bifocal spectacles on myopia progression in children: three-year results of a randomized clinical trial. JAMA Ophthalmol. 2014 Mar;132(3):258-64.
Sankaridurg P, Donovan L, Varnas S, Ho A, Chen X, Martinez A, Fisher S, Lin Z, Smith EL 3rd, Ge J, Holden B. Spectacle lenses designed to reduce progression of myopia: 12-month results. Optom Vis Sci. 2010 Sep;87(9):631-41.
Gwiazda JE, Hyman L, Norton TT, et al. Accommodation and related risk factors associated with myopia progression and their interaction with treatment in COMET children. Invest Ophthalmol Vis Sci. 2004; 45: 2143–2151.
Berntsen DA, Sinnott LT, Mutti DO, Zadnik K. A randomized trial using progressive addition lenses to evaluate theories of myopia progression in children with a high lag of accommodation. Invest Ophthalmol Vis Sci. 2012 Feb 13;53(2):640-9.
Meet the Authors:
About Kate Gifford
Dr Kate Gifford is an internationally renowned clinician-scientist optometrist and peer educator, and a Visiting Research Fellow at Queensland University of Technology, Brisbane, Australia. She holds a PhD in contact lens optics in myopia, four professional fellowships, over 100 peer reviewed and professional publications, and has presented more than 200 conference lectures. Kate is the Chair of the Clinical Management Guidelines Committee of the International Myopia Institute. In 2016 Kate co-founded Myopia Profile with Dr Paul Gifford; the world-leading educational platform on childhood myopia management. After 13 years of clinical practice ownership, Kate now works full time on Myopia Profile.
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