A Comprehensive Update on Myopia Management

World Society of Pediatric Ophthalmology and Strabismus

A Comprehensive Update on
Myopia Management

Independent medical education support provided by
EssilorLuxottica (Gold), Hoya (Silver) and Cooper Vision (Bronze)

Defining the Problem: Changing Views on the Impact of Myopia

Ramesh Kekunnaya,
MD, FRCS
Director of Child Sight Institute and
Center for Technology Innovation at L V
Prasad Eye Institute, Hyderabad, India.
rameshak@lvpei.org

Introduction

For many years, myopia was regarded as a minor problem that could be easily resolved with glasses, but that view has dramatically changed. The current worldwide prevalence of myopia corroborates that we are facing an epidemic that is, unquestionably, a motive for concern. In fact, this concern was voiced by 84% of the respondents of the 2022 WSPOS Myopia Survey* who reported seeing on average around 29 myopic children in their practice per month. Remarkably, almost a quarter of those respondents reported seeing more than 50 myopic children per month.

* The WSPOS Myopia Survey was completed in November 2022 as part of the Independent Medical Education (IME) Programme on Comprehensive Update on Myopia Management. A total of 326 respondents from 64 countries participated in the survey, which included 11 questions.

Prevalence

In the past few years, myopia has been significantly increasing worldwide and continues to rise. The prevalence of myopia is particularly alarming in certain regions of East and Southeast Asia, where the influence of social factors, political decisions, and two major environmental risk factors: educational pressures and limited time outdoors collide. The identification of risk factors has been critical for the development of treatment strategies, such as behavioral modification and clinical intervention, which are already being actively and successfully pursued. So, it’s not surprising that for myopia management today, 93% of the 2022 WSPOS Myopia Survey* respondents recommend that patients spend more time outdoors and reduce time spent on devices [Figure 1]. Despite these efforts, there is still an urgent need to reduce the onset and progression of myopia. Projections suggest that by 2050, almost half of the world’s population might be myopic and around 10% might develop high myopia^1,2.

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Figure 1. 93% of the respondents to the WSPOS Myopia Survey* recommend their patients to spend more time outdoors and reduce screen time.

Pathology

The pathology of myopia is characterized by an excessive elongation of the axial length of the eye, which is also the number one determinant of refractive errors³. Axial length has a strong correlation with severity and progression of myopia and can also result in choroidal and scleral thinning, which, in turn, can lead to an increase in secondary conditions⁴. Overall, myopic patients present a higher risk of developing secondary conditions, which include glaucoma, cataracts, retinal detachment, myopic macular degeneration, and choroidal neovascularization that are exacerbated in severe myopia. High myopic patients are 1.5x more likely to develop glaucoma than patients with low myopia and 17% more likely to develop cataract than in patients with moderate myopia⁵. High myopia can also lead to uncorrectable visual impairment. 39% of high myopic patients develop uncorrectable visual impairment by the age of 75 and when axial length is 30mm or greater, almost 90% of these patients develop uncorrectable visual impairment by the age of 75⁶. Noteworthy, projections suggest that in high-risk areas, visual impairment will increase 7- to 13-fold by 2055⁶.

The impact of myopia on patient’s quality of life

Myopia is an economic burden, particularly because of the treatment cost with optical devices and the frequent and long-term management of the condition. But most importantly, myopia has a devastating impact on patients’ quality of life. Patients lose productivity and independence, and must wear glasses, which is certainly inconvenient. Losing quality of vision and having visual and ocular-comfort symptoms also limit patients’ activities and cause emotional and social concerns. Simple tasks such as playing games, recognizing friends, and seeing stairs can be very difficult for patients with severe pathologic myopia.

Myopia Progression

Myopia starts during childhood, progresses, and can, ultimately lead to high myopia, or even pathological myopia. At present, the only way to reduce the development of pathology is to reduce the onset and progression of myopia. So early intervention is key! With appropriate treatment measures, progression may be slowed or prevented to an acceptable level.

While pre-myopia is critical, it remains an unresolved clinical issue. Questions like, “Can we identify high-risk children and then start the treatment?” or “Can we identify additional markers beyond axial length?” still need to be addressed. Meanwhile, research and prevention strategies are ongoing at a global level with initiatives coming from worldwide institutions, such as the Brien Holden Vision Institute (BHVI), International Myopia Institute (IMI), American Academy of Ophthalmology Task Force on Myopia, Johnson and Johnson Vision, the Singapore National Eye Centre (SNEC) & the Singapore Eye Research Institute (SERI) Research Collaboration, INFOR Myopia Center at L V Prasad Eye Institute (LVPEI), and the National Eye Institute, to name a few.

Diagnosis

According to the International Myopia Institute (IMI), myopia is currently defined as a condition in which the spherical equivalent is ≤ -0.50 D, when ocular accommodation is relaxed, and high myopia as a spherical equivalent of ≤-6.00 D. Using these scores as reference, it is important to identify if hyperopia, pre-myopia, or myopia is present in a patient who comes to the clinic. Equally relevant are family history, lifestyle, sports, education, time spent outdoors, as well as the stability or progression of the condition, in order to find the best strategy for each patient.

Until this epidemic is controlled, it is important to remember the so-called myopia mantra: Master, Manage, Measure, and Monitor [Figure 2].

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Figure 2. The Myopia Mantra. [Courtesy of Pavan Verkicharla]

References:

¹ Holden, B. A. et al. Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050. Ophthalmology 123(5): 1036–42 (2016).
² Sankaridurg, P. et al. IMI impact of myopia. Investigative Ophthalmology and Visual Science 62(5):2 (2021).
³ Meng, W., Butterworth, J., Malecaze, F. & Calvas, P. Axial length of myopia: A review of current research. Ophthalmologica vol. 225(3): 127–34 (2011).
⁴ Mutti, D. O. et al. Refractive error, axial length, and relative peripheral refractive error before and after the onset of myopia. Invest Ophthalmol Vis Sci 48(6): 2510–9 (2007).
⁵ Williams, K. & Hammond, C. High myopia and its risks. Community Eye Health Journal 32(105): 5–6 (2019).
⁶ Tideman, J. W. L. et al. Association of axial length with risk of uncorrectable visual impairment for europeans with myopia. JAMA Ophthalmol 134(12): 1355–63 (2016).

Reviewing the Available Tools to Manage Myopia Today

Overnight Orthokeratology: a Closer Look at Corneal Reshaping

Mark A. Bullimore,
OD, PhD
Independent Regulatory Consultant and
Adjunct Professor at University of Houston,
College of Optometry, Houston, Texas, USA.
bullers2020@gmail.com

Orthokeratology

Orthokeratology has a substantial history from its origins of attempting to flatten the corneal curvature with a spherical rigid contact lens. The big revolution that shaped modern orthokeratology occurred about 20 years ago with the convergence of three major components: reverse-geometry lenses, computer-assisted videokeratography, and highly gas permeable materials. Unlike conventional contact lenses, these rigid gas permeable contact lenses possess reverse geometry with a secondary curve that is steeper than the base curve, allowing greater stability and centration. Furthermore, more sophisticated corneal topography instruments allow an exquisite assessment of changes in the corneal topography. The availability of highly gas permeable materials was also crucial to overnight wear, minimizing hypoxic stress and corneal edema.

Axial Elongation

Axial elongation is becoming the preferred outcome measure to evaluate the efficacy of myopia control methods¹. Axial length is strongly associated with visual impairment and is relatively more sensitive and reliable than refractive error. Treatments like orthokeratology and atropine can induce changes in the refracting components of the eye, hence refractive error, independently of axial length.

The first publication of the effect of orthokeratology on slowing myopia was published 18 years ago², showing that treatment with orthokeratology could reduce about 0.25mm in axial length elongation. This effect was consistent in subsequent studies and irrespective of lens designs, manufactures, and geographic location³ [Figure 1]. Also consistent across myopia control treatments, including orthokeratology, was the more dramatic slowing of axial elongation during the first year¹ [Figure 2].

Orthokeratology is one among currently available effective myopia treatments, but contrary to many other treatments, there are many years of data available on overnight orthokeratology. Efficacy data from most other optical and pharmaceutical interventions are generally limited to two to three years, making long-term treatment effects uncertain. Noteworthy, two studies on overnight orthokeratology demonstrated a long-term slowing of axial length elongation of around 0.4mm over a period of up to 7 years^⁴,⁵. “These are among the greatest effects that exist in the literature at the time of me speaking.”

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Figure 1. Mean difference of axial length change between orthokeratology and control at 2-year follow-up. Adapted from Figure 2 in ³.

Figure 2. Cumulative absolute reduction in axial elongation at annual timepoints for myopia control treatments that reported data for one, two or three years. Orthokeratology in green. Adapted from Figure 10a in ¹.

Benefits and Risks

While there is an ongoing interest in overnight orthokeratology for myopia control, many optometrists and ophthalmologists still express safety concerns. Recent studies show, however, that the incidence of microbial keratitis (MK) with overnight corneal reshaping contact lenses is similar to rates associated with other daily wear soft contact lenses⁶ or overnight modalities⁷. In one FDA-approved retrospective study of 1317 patients (677 children) representing 2599 patient-years of wear, only two cases of MK were reported⁶. Both occurred in children but neither resulted in a loss of visual acuity. The overall estimated incidence of MK was 8 per 10,000 years of wear, and 14 per 10,000 patient-years for children. In another study, from an initial 23,049 (79% <18 years old) overnight orthokeratology fits between 2010 and 2018, there was an incidence of 5 cases of infiltrative keratitis per 10,000 patient-years associated with overnight orthokeratology wearers⁷.

The pertinent question that certainly arises is whether potential benefits of myopia control outweigh the risks? Based on a risk-to-benefit model considering various myopia control therapies, the conclusion was that the benefits of myopia control with contact lenses and other modalities far outweigh the risks⁸: the number needed to treat (NNT) to prevent 5 years of visual impairment is between 4.1 and 6.8, whereas fewer than 1 in 38 will experience the same loss of vision as a result of myopia control.

Unanswered questions

The British Contact Lenses Association (BCLA) recently published a thorough report on the practice of orthokeratology, including its role in myopia managementa for children, which is discussed in terms of efficacy, safety, and potential mechanisms of myopia control⁹.

There are, still, many unanswered questions to be addressed. Achieving a better understanding of the efficacy of orthokeratology on different levels of myopia is crucial. Evidence suggests that orthokeratology is more effective at higher levels of myopia² and it can be partially corrected at higher levels of myopia¹⁰. Less clear is how the manipulation of central and peripheral zones alters the efficacy of orthokeratology in slowing axial elongation. One study suggests that a smaller optical zone is more effective in slowing axial elongation¹¹. Under investigation is also the use of combined therapies. Several studies considered the combination of atropine with optical modalities. However, atropine seems to have a modest additive effect that is more pronounced at lower levels of myopia than at higher levels of myopia¹².

References:

¹ Brennan, N. A., Toubouti, Y. M., Cheng, X. & Bullimore, M. A. Efficacy in myopia control. Progress in Retinal and Eye Research 83: 100923 (2021).
² Cho, P., Cheung, S. W. & Edwards, M. The longitudinal orthokeratology research in children (LORIC) in Hong Kong: A pilot study on refractive changes and myopic control. Curr Eye Res 30(1): 71–80 (2005).
³ Wen, D. et al. Efficacy and acceptability of orthokeratology for slowing myopic progression in children: A systematic review and meta-Analysis. Journal of Ophthalmology: 360806 (2015).
⁴ Hiraoka, T., Kakita, T., Okamoto, F., Takahashi, H. & Oshika, T. Long-term effect of overnight orthokeratology on axial length elongation in childhood myopia: A 5-year follow-up study. Invest Ophthalmol Vis Sci 53(7): 3913–9 (2012).
⁵ Santodomingo-Rubido, J., Villa-Collar, C., Gilmartin, B., Gutiérrez-Ortega, R. & Sugimoto, K. Long-term Efficacy of Orthokeratology Contact Lens Wear in Controlling the Progression of Childhood Myopia. Curr Eye Res 42(5): 713–720 (2017).
⁶ Bullimore, M. A., Sinnott, L. T. & Jones-Jordan, L. A. The risk of microbial keratitis with overnight corneal reshaping lenses. Optometry and Vision Science 90(9): 937–44 (2013).
⁷ Bullimore, M. A. et al. Pediatric Microbial Keratitis with Overnight Orthokeratology in Russia. Eye Contact Lens 47(7): 420–25 (2021).
⁸ Bullimore, M. A. et al. The Risks and Benefits of Myopia Control. Ophthalmology 128(11): 1561–1579 (2021).
⁹ Vincent, S. J. et al. CLEAR – Orthokeratology. Contact Lens and Anterior Eye 44(2): 240–69 (2021).
¹⁰ Charm, J. & Cho, P. High myopia-partial reduction ortho-k: A 2-year randomized study. Optometry and Vision Science 90(6): 530–9 (2013).
¹¹ Guo, B., Cheung, S. W., Kojima, R. & Cho, P. One-year results of the Variation of Orthokeratology Lens Treatment Zone (VOLTZ) Study: a prospective randomised clinical trial. Ophthalmic and Physiological Optics 41(4): 702–714 (2021).
¹² Kinoshita, N. et al. Efficacy of combined orthokeratology and 0.01% atropine solution for slowing axial elongation in children with myopia: a 2-year randomised trial. Sci Rep 10(1):12750 (2020).

Financial Disclosures

Dr. Mark Bullimore is a consultant for Alcon, CooperVision, EssilorLuxottica, Euclid Systems, Eyenovia, Genentech, Johnson & Johnson Vision, Lentechs, Novartis, Oculus, Paragon Vision Sciences, and Vyluma.

New Daily-Wear Contact Lenses Designed for Myopia Control

Erin S. Tomiyama
OD, PhD
Assistant Professor of Optometry at Marshall
B. Ketchum University, California, USA.
etomiyama@ketchum.edu

When to start and stop myopia management with SCL?

We know there’s a genetic component to myopia development, so if either parent is myopic or if there’s any family history of high myopia, retinal detachment, or myopic maculopathy, discussions with the parents about myopia management can start even before their child becomes myopic. Myopia management with soft contact lenses (SCL) should start as soon as the child can handle CL wear and appropriately care for their lenses.

Myopia can progress until early adulthood¹, so these children might need SCLs for many years. According to the COMET study, 50% of children’s myopia tends to stabilize by age 15 and 75% by age 18². This means, however, that 50% of children continue to progress after age 15 and 25% after age 18. At that time, daily activities like driving and sports that require sharper acuity or better visual performance might prompt teenagers to stop myopia management SCL. In these cases, it is still important to continue monitoring the progression and look for any rebound effect. Even though, there is no evidence of a rebound effect in children up to 7 years after cessation of SCLs ^³,⁴. Treatment can always be restarted if needed.

Deciding between Orthokeratology versus SCL

There are several factors to consider when deciding between orthokeratology (ortho-k) or SCL. The child’s age and maturity level must always be considered. Again, the child must be able to appropriately handle contact lens wear. The parents’ level of comfort or control with daytime versus nighttime wear is also relevant. Parents who want complete control over when their child wears the lens might opt for ortho-k. Although, ortho-k has refractive limitations (-6D myopia and -1.75D astigmatism). Other considerations are add power, amount of peripheral plus that is achievable, and safety profile. Parents are always concerned about the safety of CL wear. Overall, the safety profile is relatively the same with disposable soft lenses, reusable soft lenses and ortho-k lenses. There is also a misconception that the risk of contact lens wear is greater in children than in adults. The CLAY study looked at different age groups and found that the risk of any sort of corneal infiltrative event is greatest in the 18 to 25-year-olds⁵.

Deciding which SCL

If a SCL is selected for myopia control, the next decision is whether the child/parents can properly care for the reusable lenses or if daily disposable lenses are a better option for them. During this decision, the cost should also be taken into consideration, which is greater with daily disposable lenses. Another limiting factor is the amount of astigmatism. Higher amounts of astigmatism require toric correction, which is not available in all lenses.

Options in the US

In the US, only a limited number of SCLs are available and only one (CooperVision MiSight) is FDA-approved for myopia control in 8 to 12-year-olds. The approval was based on data obtained from a randomized clinical trial with 135 children wearing daily disposable MiSight or conventional SCLs. Recently, a 7-year follow-up of the same study was completed. Both studies demonstrated the effectiveness of MiSight in slowing change in spherical equivalent refraction and axial length over multiple years and revealed an accumulation of treatment effect^⁶,⁷.

The design of the MiSight lenses is based on concentric ring or dual-focus design, such that the center and midperipheral zone correct myopia in all gaze positions for clear distance vision and the treatment zones create myopic retinal defocus [Figure 1A]. Recently, their spherical power was expanded to up to -10D, but they do not offer toric options at this time.

Other multifocal lenses are available for myopia control, but these are considered off-label. Fortunately, children adapt well to a variety of modalities, lens materials, and designs. The center-distance CooperVision Biofinity and Proclear lenses allow distance correction in the 1.5mm central optic zone and variable add powers into the periphery, up to +4D with Proclear and up to +2.5D with Biofinity [Figure 1B]. Both have toric options. Another off-label option is the extended depth of focus (EDOF) multifocal, VTI NaturalVue [Figure 1C]. There is an absence of a spherical central optic zone and a rapid, continuous increase in add power from the center to the periphery, creating a “virtual pinhole” that allows an extended depth of focus. They have a universal add power that is effective up to +3D. Noteworthy, there is currently limited myopia management data with these lenses.

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Figure 1. SCLs available in the US A) Concentric ring multifocals design in MiSight lenses. B) Center
distance (D-lens) design in Biofinity/Proclear lenses. C) EDOF multifocal VTI. [Courtesy of Erin Tomiyama]

Options outside the US

The SwissLens Relax is CE marked in Europe for myopia control in 8 to 18-year-olds and utilizes an optimized hyperopic defocus control to correct relative peripheral hyperopia [Figure 2A]. This design is similar to a center-distance concentric multifocal design. The Esencia lens is a reverse geometry SCL that has a progressive +2D add power on the front surface [Figure 2B]. The Mark’ennovy Mylo lens has a concentric extended depth of focus design to maximize retinal image quality [Figure 2C]. It is completely customizable in terms of add powers, base curves, and diameters.

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Figure 2. SCLs available outside the US A) SwissLens Relax B) Esencia C) Mark’ennovy
Mylo lens. [Courtesy of Erin Tomiyama]

Conclusion

Currently, only a few soft daily-wear contact lenses are available in the market, but they are a good choice for children who are candidates for myopia management. Because the options available are limited, practitioners can relatively quickly gain experience with these different lens types. Unlike presbyopes, children who wear multifocals adapt well to a variety of modalities, lens materials, and lens designs. Other options for myopia control such as ortho-k and atropine should be also presented, but ultimately the patients expect a clear recommendation.

References:

¹ Hrynchak, P. K., Mittelstaedt, A., Machan, C. M., Bunn, C. & Irving, E. L. Increase in myopia prevalence in clinic-based populations across a century. Optometry and Vision Science 90(11): 1331–41 (2013).
² Hardy, R. et al. Myopia stabilization and associated factors among participants in the correction of myopia evaluation trial (COMET). Invest Ophthalmol Vis Sci 54(13): 7871–84 (2013).
³ Chamberlain, P., Arumugam, B. et al. Myopia Progression on Cessation of Dual-Focus Contact Lens Wear: MiSight 1 day 7-Year Findings. Optom. Vis. Sci. (E-abstract) 98: 210049 (2021).
⁴ Hammond, D., Arumugam, B. et al. Myopia Control Treatment Gains are Retained after Termination of Dual-focus Contact Lens Wear with No Evidence of a Rebound Effect. Optom. Vis. Sci. (E-abstract) 98: 215130 (2021).
⁵ Chalmers, R. L. et al. Age and other risk factors for corneal infiltrative and inflammatory events in young soft contact lens wearers from the Contact Lens Assessment in Youth (CLAY) study. Invest Ophthalmol Vis Sci 52(9): 6690–6 (2011).
⁶ Chamberlain, P. et al. A 3-year Randomized Clinical Trial of MiSight Lenses for Myopia Control. Optometry and Vision Science 96(8) 556–67 (2019).
⁷ Chamberlain, P. et al. Long-term Effect of Dual-focus Contact Lenses on Myopia Progression in Children: A 6-year Multicenter Clinical Trial. Optometry and Vision Science 99(3): 204–12 (2022).

Financial Disclosures

Dr. Erin Tomiyama is a consultant for CooperVision Specialty EyeCare and Vyluma.

Preventing Axial Length Elongation with a Pair of Spectacles: PALs, Bifocal Approaches, and Peripheral Diffusion Technology

Ian Flitcroft
MA D.Phil, FRCOphth
Adjunct Professor of Vision Science at
Technological University Dublin and
Associate Clinical Professor of
Ophthalmology at University College Dublin,
Dublin, Ireland.
ian@flitcroft.com

Where do spectacles fit in?

Spectacles are a good solution for very young children and hesitant families. No extra elements such as eye drops, are necessary. They are also easy for any optometrist to dispense as there is no need for CL fitting nor topography or AL measurements. Moreover, chair time, risks, and number of follow-ups are minimized. Spectacles are not an either/or situation as they can also be combined with pharmaceutical approaches. However, their fitting and centration are more critical than with normal spectacles and they are generally more expensive than single vision lenses.

Executive Bifocals and PALs Spectacles

Bifocals and progressive addition lenses (PALs) are familiar to many parents, as well as inexpensive. They can be particularly helpful in relation to binocular vision issues and in kids with accommodation lags. They combine well with higher doses of atropine, where kids have reading problems, however, they might not be preferred by sporty kids. Data shows that efficacy is below that of advanced DIMS and HALT approaches.

The Correction of Myopia Evaluation Trial (COMET) was particularly important in showing that optics can indeed control eye growth and confirmed the role of defocus in the progression of myopia¹. The only caveat is that while the effect was statistically significant, it was not clinically impactful. The PALs intervention had a relatively small magnitude of effect over 3 years and most of it during the first year. There was, however, a sub-group of kids with esophoria/large accommodative lags who had a greater benefit over the three years, but less than what is achieved with other technologies. Results from studies with bifocals have been more inconsistent. Some studies had convincingly shown no effect on axial length while others had shown an apparent effect^²,³. It is, therefore, no surprise that bifocals have come in and out of fashion over 30 or more years.

Highly Aspheric Lenslet (HAL)

One of the next generation treatments are the HAL spectacles, which have demonstrated impressive efficacy and acceptable visual quality for children and younger teens. The HAL technology Stellest (EssilorLuxottica) is a high refractive index lens that corrects and controls [Figure 1]. This lens has 11 concentric rings of 1,021 contiguous, aspheric, 1.1-mm lenslets across the entire lens. Unlike traditional glasses, these lenses have both a correction and a control element. Rather than creating a particular plane of focus to control the eye, the control portion of the lens produces a volume of non-focused light in front of the retina to slow down the elongation of the eye. So, the correction allows kids to see and the extra lenslets send a signal to the eye to slow down the elongation of the eye.

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Figure 1. Concept of Highly Aspheric Lenslet (HAL) Technology.

HAL spectacles can be dispensed in a single visit and there is flexibility in frame selection due to lenslet spacing. A drawback is that they are more costly and are less suitable for co-treatments with higher doses of atropine since there is no reading add. HAL can be impactful in older teens or kids in sports due to visual quality issues.

How should we judge success?

In order to judge the success of HAL spectacles some requirements must be met. Rather than just relying on trial results, we also need to have positive and meaningful impact on refraction and axial length. We want to see no rebound on cessation of wear, and we want to have minimal negative impact on visual function. At a higher barrier, we also want to see evidence of beneficial impact on the anatomical consequences of myopia progression, not just axial length.

A recently published, prospective, double-masked, 2-year clinical trial comparing spectacles with HAL, SAL (Slightly Aspherical Lenslets), and SVL (Single-Vision Lenses)⁴, showed that HAL and SAL reduced the rate of myopia progression and axial elongation throughout 2 years. Compared to SVL, the HAL lenses slowed myopia progression by 67% (0.99D) and slowed axial elongation by 60% (0.41mm) [Figure 2]. The efficacy was not affected by gender, age, and degree of myopia, but was affected by wearing time. Wearing HAL lens for 12 or more hours a day resulted in better myopia control efficacy⁵.

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Figure 2. Rate of myopia progression and axial elongation with HAL, SAL, and SVL over a period of 2 years. Adapted from Figure 2 in ⁴.

In another study it was shown that no rebound occurred when switching from HAL to SV⁶. In comparison to SVL, high contrast visual acuity and peripheral motion perception don’t seem impacted with the HAL lens and there is no loss of useful field of view⁷. High contrast reading speed was also unimpaired, but low contrast reading speeding was reduced by 10%. An indication of a potentially beneficial anatomical effect is that choroidal thickness does not appear to change over 2 years, whereas choroidal thinning is typically seen with normal myopia progression⁸. Choroidal thinning is considered to be a contributory factor in visual loss in later life as highly myopic eyes can have a dramatic reduction of choroid thickness.

Spectacles are an integral part of any myopia control strategy

Myopic children need optical correction, but SV correction is no longer an adequate standard of care. Myopia will progress for 10 or more years and during that time children’s needs, activities, maturity, and compliance will change. Myopia control approaches might therefore also need to change. Whether the solution is spectacles, contacts, orthokeratology, eye drops or combinations, what is important is to find the best solution that suits the child’s lifestyle.

Modern myopia control glasses are an effective and ideal starting point for many children. Latest technologies have been pioneered in Asia and more studies in European children are needed to look at efficacy, acceptability, use patterns, and impact on life quality.

References:

¹ Gwiazda, J. et al. A randomized clinical trial of progressive addition lenses versus single vision lenses on the progression of myopia in children. Invest Ophthalmol Vis Sci 44(4): 1492–500 (2003).
² Grosvenor, T., Perrigin, D. M., Perrigin, J. & Maslovitz, B. Houston myopia control study: A randomized clinical trial. part II. final report by the patient care team. Optometry and Vision Science 64(7): 482–98 (1987).
³ Cheng, D., Woo, G. C., Drobe, B. & Schmid, K. L. Effect of bifocal and prismatic bifocal spectacles on myopia progression in children: Three-year results of a randomized clinical trial. JAMA Ophthalmol 132(3): 258–64 (2014).
⁴ Bao, J. et al. Spectacle Lenses With Aspherical Lenslets for Myopia Control vs Single-Vision Spectacle Lenses: A Randomized Clinical Trial. JAMA Ophthalmol 140(5): 472–478 (2022).
⁵ Drobe, B. et al. Influence of wearing time on myopia control efficacy of spectacle lenses with aspherical lenslets. Invest. Ophthalmol. Vis. Sci. 63(7): 4324-A0029 (2022).
⁶ Weng, R. et al. Progression of myopia with novel myopia control spectacle lenses. Invest. Ophthalmol. Vis. Sci. 63(7): 252-A0106 (2022).
⁷ Gao, Y., Lim, E. W., Yang, A., Drobe, B. & Bullimore, M. A. The impact of spectacle lenses for myopia control on visual functions. Ophthalmic Physiol Opt 41(6): 1320–1331 (2021).
⁸ Huang, Y. et al. Effect of spectacle lenses with aspherical lenslets on choroidal thickness in myopic children: a 2-year randomised clinical trial. British Journal of Ophthalmology: bjophthalmol-2022-321815 (2022).

Financial Disclosures

Dr. Ian Flitcroft is consultant ophthalmologist at Children’s University Hospital, Temple Street and a consultant/advisory board
member for Dopavision, Essilor, Johnson & Johnson Vision, and Thea. Dr. Flitcroft is also co-founder of Ocumetra Ltd, where
he is the Medical Director and Head of Research and Development. He’s received research funding from Health Research
Board (Ireland), Vyluma, and CooperVision; and has two patents pending (one in myopia management data analytics and one
in biomonitoring for low dose atropine treatment in myopia).

Preventing Axial Length Elongation with a Pair of Spectacles: DIMS and HAL Technology

Carly Lam
PhD, Professor
Professor at Center for Myopia
Research, School of Optometry at
the Hong Kong Polytechnic
University and Center for Eye and
Vision Research (CEVR), Hong Kong.
carly.lam@polyu.edu.hk

Peripheral defocus

The eye isn’t a perfect sphere, and the retinal shape might not be spherical either. Therefore, when the light rays go through the eye to focus onto the fovea, peripheral light rays might fall behind (peripheral hyperopic defocus) or in front (peripheral myopic defocus) of the retinal surface¹ [Figure 1A]. Mechanisms based on peripheral retinal defocus appear to have a significant role in emmetropisation and refractive error development.

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Figure 1. A) Uncorrected myopia with peripheral hyperopic and myopic defocus. Adapted from ¹. B) Myopia correction
using traditional contact lens. Adapted from ². C) Optimal correction in myopia. Adapted from ³.

Reduction of peripheral hyperopic defocus

Traditional myopia correction using single-vision (SV) spectacle lenses can increase hyperopic retinal defocus² [Figure 1B]. So, attempts are being made to develop alternative strategies, such as peripheral optical treatments³, to provide optimal myopia correction [Figure 1C]. Three novel spectacle lenses (MyoVision by Zeiss) were developed to reduce peripheral hyperopic defocus while maintaining clear central vision. These lenses were investigated in Chinese⁴ and Japanese⁵ children over a period of 12 and 24 months, respectively, and neither study could verify a significant therapeutical effect for slowing down myopia progression. Noteworthy, the treatment effect was greater for lenses type III in Chinese children with parental history of myopia (mean difference=0.29D; axial length difference=0.09mm), but this needs further validation in a more targeted study.

Contrast reduction between adjacent photoreceptors

Light diffusion technology is another treatment strategy that is being pursued to create a clear central zone surrounded by multiple dots that reduce the peripheral retinal contrast by at least 30 to 60%. This lens design is based on a mechanism that occurs at the retinal photoreceptor level and on the hypothesis that high contrast signals at the retinal photoreceptors induce the eye to grow while the opposite happens under low contrast. The optical design uses non-vergence optics to achieve a contrast reduction at the retina between adjacent photoreceptors. Using light diffusion technology, the D.O.T. lenses (SightGlass Vision) have been developed. A 3-year randomized clinical trial is ongoing in 14 US and Canada sites. Results from the one-year interim report showed that these novel design lenses could retard myopia progression up to 74% compared with SV lenses⁶. The 2-year study was recently published on two-thirds of the study subjects, considered “full-time wearers”. It was found a statistically significant change from baseline of AL (-0.21mm) and SER (0.52D) in the type I lens group⁷.

Defocus Incorporated Multiple Segments (DIMS)

The DIMS lens (MiYOSMART by HOYA) has been around since 2018 and is now available in 28 countries [Figure 2]. The lens design is based on the hypothesis that the natural process of emmetropization in human is regulated by the equilibrium between the opposite hyperopic and myopic defocus. The lens is intended to correct refractive error and provide clear vision at all distances. Simultaneously, there is a myopia defocus signal in the mid-periphery that is distributed in around 400 multi-segments of +3.5D [Figure 2].

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Figure 2. DIMS lens technology with distance correction in the central zone and simultaneous myopic defocus in surrounding multi-segments. Adapted from ⁸.

The 2-year randomized clinical trial with the DIMS lenses in Chinese children found a 52% efficacy in slowing myopic progression and 62% in slowing axial elongation⁸. Follow-up studies showed that the treatment effect could be sustained up to 6 years, with an annual rate of -0.15D and 0.1mm^⁹,¹⁰. The 6-year study investigated also the effect of treatment cessation in subjects who started as DIMS wearers, which switched to SV lenses and in subjects who started as SV wearers, which switched to DIMS lenses, and then back to SV lenses. In both cases, once the treatment stopped myopia progression and axial elongation increased¹⁰. A 3-year study estimated an average axial length growth of 0.1mm/year in DIMS wearers, which is comparable to the normal physiological eye growth¹¹. This is aligned with the treatment target which was suggested to be 0.1mm/year.

Conclusion

There is evidence that axial elongation can be prevented with spectacles when applying three current concepts: reduction of peripheral hyperopic defocus, reduction of contrast between photoreceptors, and simultaneous incorporation of myopic defocus and vision correction. But there are other factors to consider. It is not yet confirmed whether the “myopia control signal” comes from the central or peripheral retina neither what is the optimal dose of this signal. It has not been concluded whether it is defocus, contrast modulation, or something else. We also need to test the area proportion of vision correction and stimulus, as well as how many hours of spectacles wear is needed. So, there are still unanswered questions, and the mechanism still needs to be studied.

Current use of (spherical equivalent refraction) SER as an indicator may not achieve the ultimate goal of controlling myopia progression. There should be a wider use of ocular biometry to ensure more accurate evaluation of AL as a treatment effect. Knowing that eye growth during childhood is physiological and that eye growth is more rapid at younger age is also very important to consider when calculating treatment efficacy or absolute change.

References:

¹ Gifford, P. & Johnson, K. Use of contact lenses in myopia control: a case study. Clinical Lenses Update (2011).
² Lin, Z. et al. Peripheral defocus with single-vision spectacle lenses in myopic children. Optometry and Vision Science 87(1): 4–9 (2010).
³ Smith III, E. L. The Charles F. Prentice Award Lecture 2010. A case for peripheral optical treatment strategies for myopia.
Optom Vis Sci 88(9): 1029–44 (2012).
⁴ Sankaridurg, P. et al. Spectacle lenses designed to reduce progression of myopia: 12-month results. Optometry and Vision Science 87(9): 631–41 (2010).
⁵ Kanda, H. et al. Effect of spectacle lenses designed to reduce relative peripheral hyperopia on myopia progression in Japanese children: a 2-year multicenter randomized controlled trial. Jpn J Ophthalmol 62(5): 537–43 (2018).
⁶ Rappon, J. et al. Control of myopia using diffusion optics spectacle lenses: 12-month results of a randomised controlled, efficacy and safety study (CYPRESS). British Journal of Ophthalmology: bjophthalmol-2021-321005 (2022).
⁷ Rappon, J., Neitz, J., Neitz, M., Chung, C. & Chalberg, T. W. Two-year effectiveness of a novel myopia management spectacle lens with full-time wearers. Invest Ophthalmol Vis Sci 63(7): 408 (2022).
⁸ Lam, C. S. Y. et al. Defocus incorporated multiple segments (DIMS) spectacle lenses slow myopia progression: A 2-year randomised clinical trial. British Journal of Ophthalmology 104(3): 363–368 (2020).
⁹ Lam, C. S. Y. et al. Myopia control effect of defocus incorporated multiple segments (DIMS) spectacle lens in Chinese children: results of a 3-year follow-up study. British Journal of Ophthalmology 106(8): 1110-14 (2022).
¹⁰ Lam, C. S. Y. et al. Long-term myopia control effect and safety in children wearing DIMS spectacle lenses for 6 years. Sci Rep 13(1): 5475 (2023).
¹¹ Kaymak, H. et al. Myopia treatment and prophylaxis with defocus incorporated multiple segments spectacle lenses. Ophthalmologe 118(12): 1280–86 (2021).

Financial Disclosures

Dr. Carly Lam is involved in collaborative research sponsored by HOYA Lens Thailand Ltd, subsidiary of HOYA Corporation
(Tokyo, Japan), with whom she co-developed the DIMS patent.

The Science Behind Pharmacological Modulation for Myopia Control

Seo Wei Leo
MBBS, FRCSEd
Medical Director at Dr Leo Adult
& Paediatric Eye Specialists Pte
Ltd, Mount Elizabeth Medical
Center, Singapore.
drleosw@gmail.com

How does atropine work in myopia?

Atropine is a non-selective muscarinic antagonist that has been used for myopia control for a long time¹. The clinical effect of atropine on the progression of myopia is evidence-based²-⁴. While the exact mechanism of action remains elusive and debatable, it is known that is non accommodative⁵ and involves a complex interplay between atropine and receptors on different ocular tissues at multiple levels. Hypothetically atropine exerts its action through a neurochemical cascade that begins with M1/M4 receptors at the retina or directly on the sclera via a non-muscarinic mechanism [Figure 1].

Lower or higher dosage?

The dose dependent inhibitory effect of atropine on myopia progression is well documented and its efficacy is reported as 30-65% with low doses (0.01-0.10%) and 60-80% with high doses (0.5-1%).

ATOM1 and ATOM2 studies

The landmark ATOM1 (Atropine for the Treatment of Myopia 1; Figure 2) study in Singapore demonstrated that 1% atropine eyedrops for 2 years were well tolerated, reduced myopia progression by 77%, and maintained axial length (AL) unchanged⁶. Side effects included mydriasis causing photophobia and cycloplegia resulting in decreased near vision. This is the reason why children on atropine treatment might need photochromatic progressive additional lenses. Cycloplegia is fully reversible after cessation of the eyedrops. Undesirably, rebound can also occur 1 year after the treatment is stopped.

The ATOM2 study [Figure 2] further investigated the effect of lower atropine doses (0.5%, 0.1%, and 0.01%) on myopia progression and AL⁷. The effect was found dose dependent but with comparable efficacy. Atropine 0.01% had a negligible effect on accommodation and pupil size, no effect on near vision acuity, minimal side effects (allergic conjunctivitis and dermatitis), and less rebound⁸. Among the dosages tested, atropine 0.01% was considered the most effective in slowing myopia progression over a period of 5 years⁹.

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Figure 1. Hypothetical mechanisms of action
for atropine in myopia.

Noteworthy, in ATOM1 and ATOM2 studies was identified a small group of children who continued to progress despite atropine treatment. These non-responders were younger, exhibited higher myopic spherical equivalent (SE) at baseline, and had myopic parents¹⁰.

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Figure 2. Summary findings from the ATOM1 and ATOM2 studies.
Adapted from Figure 6 in ⁹.

LAMP study

Lower dosages (0.05%, 0.025%, and 0.01%) of atropine were investigated in the LAMP (Low-Concentration Atropine for Myopia Progression) study in Hong Kong¹¹. After 1-year, SE was reduced by 67%, 43%, and 27% and AL was reduced by 51%, 29%, and 12% with atropine 0.5%, 0.025%, and 0.01%, respectively. The second-year efficacy remained similar with atropine 0.5% and 0.025% but improved mildly with 0.01% atropine. Overall, changes on the pupil size and in accommodation were minimal.

Although there were subtle differences between the ATOM and LAMP studies, namely LAMP participants were younger, 0.01% atropine in the ATOM2 study showed similar anti-myopia effect as 0.05% atropine and stronger effect than 0.01% atropine in the LAMP study. In the LAMP study, 0.05% atropine was found as the optimal concentration over a period of 3 years¹². Stopping the treatment at an older age and lower concentration were also associated to smaller rebound.

WA-ATOM study

The recently published Western Australian (WA)- ATOM study showed a much more modest myopia-control effect with 0.01% atropine eyedrops¹³. Interestingly, they noted a significant interaction effect between treatment and ancestry on SE and AL change. Specially in the first 18 months, European children demonstrated greater benefit than Asian children.

Meta-analyses studies

There has been some conflicting evidence for AL elongation inhibition with atropine 0.01%. To address this issue, a systematic review and meta-analysis with the latest evidence was conducted¹⁴. This recently published study showed that, indeed, AL elongation was significantly slower with 0.01% atropine. Another meta-analysis ranked the clinical outcomes of various concentrations of atropine and found that the ranking probability for efficacy was not proportional to dose, i.e., 0.05% atropine was comparable with that of high-dose atropine (1% and 0.5%). Although pupil size and accommodation amplitude were dose related. When assessing overall myopia progression by relative risk, 0.05% atropine was the most beneficial concentration.

When to start and stop atropine?

The treatment should start when there is documented progression. Special attention should be given to younger children with high myopia and other risk factors such as family history of pathological myopia. In higher risk cases, higher doses should be considered at the beginning of the treatment. In these cases, parents should be warned about non-responders. Growth and percentile charts for myopia-related parameters are available in different populations. These charts can be shown to the parents when discussing starting with atropine. Once the treatment is started, it is important to monitor cyclorefraction and AL, aiming for <0.3mm/year in children younger than 9 years old and <0.15 mm/year in older children. The younger the child, the more axial elongation is expected per year. The atropine treatment should be stopped when the child is older and more stable. Importantly, the atropine treatment should be tapered and never stopped abruptly.

As in all eyedrops treatments, especially in paediatric patients, administration can be challenging. Children might be resistant to the administration of the eyedrops and parents might be reluctant to administer them. Developing administration methods and providing guidance on their administration are additional challenges. Currently in the pipeline is a microdose formulation of atropine (MicroPine by Eyenovia), that allows children to self-administer. MicroPine reduces dose-related side effects and presents Bluetooth capability to ensure patient adherence. A clinical trial is in progress.

Conclusion

Atropine is currently the most researched pharmacological treatment for myopia control. Although it is effective even at different dosages, it’s important to remember that patients may need different dosages at different periods of their lives. Combination therapy should also be considered.

References:

¹ Curtin, B. The myopias: basic science and clinical management. (Harper and Row, 1985).
² Yen, M. Y., Liu, J. H., Kao, S. C. & Shiao, C. H. Comparison of the effect of atropine and cyclopentolate on myopia. Ann Ophthalmol 21(5): 180–2, 187 (1989).
³ Shih, Y. F. et al. An intervention trial on efficacy of atropine and multi-focal glasses in controlling myopic progression. Acta Ophthalmol Scand 79(3): 233–36 (2001).
⁴ Shih, Y. F. et al. Effects of different concentrations of atropine on controlling myopia in myopic children. Journal of Ocular Pharmacology and Therapeutics 15(1): 85–90 (1999).
⁵ McBrien, N. A., Moghaddam, H. O. & Reeder, A. P. Atropine reduces experimental myopia and eye enlargement via a nonaccommodative mechanism. Invest Ophthalmol Vis Sci 34(1): 205–15 (1993).
⁶ Chua, W. H. et al. Atropine for the Treatment of Childhood Myopia. Ophthalmology 113(12): 2285–91 (2006).
⁷ Chia, A. et al. Atropine for the treatment of childhood Myopia: Safety and efficacy of 0.5%, 0.1%, and 0.01% doses (Atropine for the Treatment of Myopia 2). Ophthalmology 119(2): 347–54 (2012).
⁸ Chia, A. et al. Atropine for the treatment of childhood myopia: Changes after stopping atropine 0.01%, 0.1% and 0.5%. Am J Ophthalmol 157(2): 451–7 (2014).
⁹ Chia, A., Lu, Q. S. & Tan, D. Five-Year Clinical Trial on Atropine for the Treatment of Myopia 2 Myopia Control with Atropine 0.01% Eyedrops. Ophthalmology 123(2): 391–9 (2016).
¹⁰ Loh, K., Lu, Q., Tan, D. & Chia, A. Risk factors for progressive myopia in the atropine therapy for myopia study. Am J Ophthalmol 159(5): 945–9 (2015). ¹¹ Yam, J. C. et al. Two-Year Clinical Trial of the Low-Concentration Atropine for Myopia Progression (LAMP) Study: Phase 2 Report. Ophthalmology 127(7): 910–19 (2020).
¹² Yam, J. C. et al. Three-Year Clinical Trial of Low-Concentration Atropine for Myopia Progression (LAMP) Study: Continued Versus Washout: Phase 3 Report. Ophthalmology 129(3): 308–21 (2022).
¹³ Lee, S. S. Y. et al. Low-concentration atropine eyedrops for myopia control in a multi-racial cohort of Australian children: A randomised clinical trial. Clin Exp Ophthalmol 50(9): 1001–12 (2022).
¹⁴ Tsai, H. R., Chen, T. L., Wang, J. H., Huang, H. K. & Chiu, C. J. Is 0.01% atropine an effective and safe treatment for myopic children? a systemic review and meta-analysis. J Clin Med 10(17): 3766 (2021).

Best Practices for Patient Education

Célia Nakanami
MD, PhD
Chair of Pediatric Ophthalmology
and Low Vision at Federal University
of Sao Paulo (UNIFESP),
Sao Paulo, Brazil.
ce.nakanami@gmail.com

How to communicate with parents and patients?

As myopia continues to increase worldwide it is crucial to develop education programs specifically targeted to patients and parents, who must be provided with information that is simple, clear, and easy to understand. Awareness of good eye care behaviors, healthy lifestyle habits and engagement of the parents are essential components of myopia management¹. To this end, eye care practitioners can play a key role as they can strongly influence parents to take up myopia control interventions².

Eye care practitioners should communicate clearly with the parents to ensure they understand that their child has myopia, which tends to progress and needs to be properly addressed. Providing relevant evidence is important, but parents should not be overloaded with too much information. Showing illustrations or using didactic eye models might be helpful during the initial conversation. On the other hand, scientific terms or words that might scare the parents, or the child must be avoided. Guidelines from organizations like the International Myopia Institute (IMI)³ and recommendations from eye care societies are accessible and should be considered.

What should be included in a discussion about myopia management?

Simple and clear concepts of myopia should be provided and discussed with the parents and the child. Normal eye growth, myopia progression, excessive eye elongation, high myopia and related ocular abnormalities, as well as myopia progression control are among the concepts that should be covered during the conversation with the parents. The influence of behavioral and environmental factors should be also mentioned and providing evidence-based examples can be helpful. The COVID-19 pandemic and the consequent lockdown is one of those examples that can be used during the conversation^⁴,⁵. Associations between myopia and various measures of educational pressure, years of education, and time spent outdoors have been consistently confirmed⁶.

Parents need to understand that the treatment should start as early as possible, and that several safe and effective interventions to control myopia progression are currently available⁷. Treatment plans should be provided and properly explained in terms of their efficacy, benefits, and risks. Several interventions are still off-label in most countries so parents should be informed. Parents must also understand that these are long-term treatments (≥ 2 years) possibly until eye growth stabilizes (≥ 15 year-old) and that not all patients respond to treatment. Over the years, the initial treatment can also change or be combined with other interventions. Setting realistic expectations and goals and establishing healthy lifestyle habits are extremely important even before starting the treatment.

During the diagnosis it is important to acquire relevant information such as age of onset, refractive status of the parents, and visual environment (education intensity and time outdoors) and perform baseline exams to assess refractive error and binocular visual function [Figure 1].

Parents should be informed that once the treatment starts follow-up appointments are necessary every 6 months to monitor and evaluate cycloplegic refraction, axial length growth, and anterior corneal curvature. Patients must understand that the child may be treated until myopia progression stabilizes around the age of 15, which applies to about 50% of the cases. And even after the treatment is stopped the patient must be monitored as rebound can occur. To avoid dropouts of the treatment, costs should be discussed beforehand.

Children Compliance

Treatment compliance is the key for a good control of myopia. Yet this is currently an issue in paediatric patients⁸. It is important to realize that parents have a great impact on children’s behavior and choices, so devoted, persistent, and adherent parents can increase children’s compliance. Unfortunately, some parents are indifferent to their child’s myopia and unaware of the impact of blurred vision on their child’s daily life. A simulator/trial lens frame might be useful to make parents understand what their child’s vision is actually like. Parents must be provided appropriate and easy to understand documentation and referred to educational, unbiased, non-commercial websites. They must comprehend the strategies employed in a myopia management program and that the goal of the proposed intervention is to retard the progression and not to stop the eye growth entirely. Some interventions are not approved by legal authorities in some regions or countries, which is why an informed consent form and an agreement on compliance are encouraged.

How to convince the child to be compliant?

Eye care practitioners must also listen the children and understand their doubts, fears, worries, and expectations. Tell them about the benefits of the treatment and encourage the child and the parents to face the myopia progression. If available provide references and printed materials, use analogies, draw pictures, or use the globe anatomic model to help them visualize. Present all options of treatment and let the child and the parents choose the treatment together. Always keep a dynamic interaction and use tips and techniques for effective communication.

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Figure 1. Common risk factors for myopia.

Modification of environmental factors

Increasing time exposed to outdoor light seems to be a simple and effective preventive measure to delay myopia onset⁹. Thus it should be recommended that children spend more time outdoors, at least 2h/day. Playing outside and getting more physical activity like running around and riding bikes helps the physical and cognitive development of the child. It is also important to have children take breaks every 20/30 minutes while performing near work. A simple rule to follow is the 20/20/20 rule: look up from the screen or close-up work every 20 minutes and focus at least 20 feet away for 20 seconds.

Conclusion

The goals of myopia management are good eye health, improving quality of life and reducing the potential for future eye disease [Figure 2]. Early patient education for parents and children, even when they are not yet myopic, increases awareness of the myopia issue and ensures more compliance to the treatment and better outcomes. So, all efforts should be done to increase the awareness and compliance that will ultimately improve the child’s quality of life.

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Figure 2. Goals of myopia management.

References:

¹ Keel, S. et al. The WHO-ITU MyopiaEd Programme: A Digital Message Programme Targeting Education on Myopia and Its Prevention. Front Public Health 10: 881889 (2022).
² Yang, A., Pang, B. Y., Vasudevan, P. & Drobe, B. Eye Care Practitioners Are Key Influencer for the Use of Myopia Control Intervention. Front Public Health 10: 854654 (2022).
³ Gifford, K. L. et al. IMI – Clinical management guidelines report. Invest Ophthalmol Vis Sci 60(3): M184–M203 (2019).
⁴ Limwattanayingyong, J., Amornpetchsathaporn, A., Chainakul, M., Grzybowski, A. & Ruamviboonsuk, P. The Association Between Environmental and Social Factors and Myopia: A Review of Evidence From COVID-19 Pandemic. Front Public Health 10: 918182 (2022).
⁵ Wang, J. et al. Progression of Myopia in School-Aged Children after COVID-19 Home Confinement. JAMA Ophthalmol 139(3): 293–300 (2021).
⁶ Morgan, I. G. et al. IMI risk factors for myopia. Invest Ophthalmol Vis Sci 62(5): 3 (2021).
⁷ Chia, A. & Tay, S. A. Clinical management and control of myopia in children. In: Ang, M. & Wong, T. (eds.) Updates on Myopia, Springer (2020).
⁸ Winnick, S., Lucas, D. O., Hartman, A. L. & Toll, D. How do you improve compliance? Pediatrics 115(6): e718-24 (2005).
⁹ Eppenberger, L. S. & Sturm, V. The role of time exposed to outdoor light for myopia prevalence and progression: A literature review. Clinical Ophthalmology 14: 1875–90 (2020).

Financial Disclosures

Dr. Célia Nakanami is council member of the Brazilian Society of Pediatric Ophthalmology (SBOP) and consultant of Essilor
Luxottica.

World Society of Pediatric Ophthalmology and Strabismus