Three clinical pillars for myopia management

Once the myopia management message has been communicated to the parent and patient - information on expectations, efficacy and safety - and the initial correction has been selected, there are three key areas of clinical focus.

Firstly, advice on visual environment is useful for both the child at risk of myopia development – those with a family history of myopia and less hyperopia than age-normal1 – as well as the myope. Simple advice summarised from the research is provided above, and you can read more on how to explain this in Keys to Communication in Myopia Management. 

Secondly, optical treatments should be discussed and offered as first line. The myopic child needs either spectacles or contact lenses for myopia correction, so it makes sense to firstly consider prescribing the best optical treatment available to you, which is suitable for that child and family.

If this is not possible, you can then consider atropine as a first line treatment and/or the next best optical treatments.

So your first prescribing question is spectacles or contact lenses? Along with wide availability of myopia controlling contact lens options, contact lens wear offers numerous functional and psychological benefits to children. Read more Kids And Contact Lenses – Benefits, Safety And Getting To ‘Yes’.

Further reading is available in these clinical articles When to prescribe spectacles for myopia control and When to prescribe atropine for myopia control. 

Finally, binocular vision is relevant to myopia management. Since binocular vision disorders such as esophoria and accommodative lag have been implicated in myopia progression,^2-6 and also when present provide the greatest efficacy results for progressive spectacle lens myopia management,^{7, 8} evaluation and management of these issues could provide added benefit to myopia control treatment.

Binocular vision status is additionally relevant to visual comfort – ensuring children have functional skills for reading and schoolwork^{9, 10} and acceptance of their correction. In time these individual factors may help to predict those who will respond best to particular corrections – for example, OrthoK appears to reduce both esophoria and accommodative lag,11-15 and a Chinese study has shown children with lower accommodative amplitude achieved a 56% better myopia control effect with OK wear over two years.¹⁶ 

In multifocal soft contact lenses, one study linked a reduced accommodative response (increased lag) in the multifocal lens with a reduced myopia control efficacy.¹⁷

In future we may be measuring some aspect of accommodation (or several measures) and then selecting a specific contact lens design - maybe smaller zone lenses for normal accommodators and larger zone lenses for underactive accommodators, as indicated by optical modelling.¹⁸ For now, including binocular vision factors can bring additional customization to your clinical management decision making, ensuring that visual acuity, visual comfort and visual efficiency are comprehensively addressed for your patient.