YOUR CHILD HAS MYOPIA [IS SHORTSIGHTED] 2011

 

Myopia [short sightedness] means your child sees well close up, but cannot see distance objects clearly [such as the blackboard]. Many children with myopia also have astigmatism [another type of focussing problem].
Myopia commonly develops during school age, progresses slowly, and stabilises around 15-17 years of age.
In this handout I discuss techniques to slow the progression of 'school myopia'.

This handout is for the parents who say:
1. I HATE the idea of my child growing up increasingly dependent on ever- increasing glasses. Can't you do ANYTHING to make it better?
2. …. and I've read that with bad myopia you're more prone to get retinal detachment and go blind in one eye. Can we prevent that?

..and not for the parents who say:
1. That's nature. I 'm short sighted and wear glasses or contacts - they were fine for me and I don't want to interfere with nature.
2. …and anyhow, when she s/he's 20 s/he can have laser and that's the end of it.
3. One parent: I'm 46 now. When I take my glasses off I can read and use the computer really well, better than my partner or friends.

It is likely that myopia progression in Oriental children is more 'aggressive' than in Caucasian children. A lot of the recent research has been done in Oriental populations. It probably applies to Caucasian kids but we have to wait for the appropriate research.
One very important factor: when you read about this, you can probably IGNORE all research that does not measure 'axial length' [eyeball size] as this seems to be THE important factor to measure and modify.

A. Techniques that have been tried and have little or no effect on myopia progression/ and or axial length:

1. ALTERATION OF PATTERN OF SPECTACLE WEAR
Some people have believed that correcting myopia with full time & full strength lenses may result in the development of further myopia. This certainly happens in chickens, but probably does NOT happen in humans.
Various techniques of less- than- full- time glasses wear and less- than- full- strength glasses wear have been studied.
Some studies show no effect, some show a tiny positive effect, some show a tiny negative effect. For your child there is NO expectation of a useful benefit.

2.BIFOCALS AND MULTIFOCALS
Optometrists have been using bifocal lenses as a possible treatment for myopia since the 1940s. Recently, there have been several well-designed clinical trials of bifocal lenses conducted in children in the United States, Finland, and Denmark. There were no significant differences in the myopia progression rates.

Progressive addition multifocal lenses are more cosmetically acceptable than bifocals. Little or no benefit has been shown. In late 2010 we are expecting results of the 'COMET 2' multifocal study on patients with low myopia who also have accommodative insufficiency and a near esophoria.
3. CONTACT LENSES
Contact lenses were introduced for optical correction in 1888.There are NO studies that show significant differences in the rate of progression of myopia or axial length in contact lens wearers compared to spectacle wearers. There are some current studies on multifocal contacts that sound very interesting, but there is NO good data yet that shows an effect.
. A recent study demonstrates that orthokeratology can slow to a some extent the lengthening of the eyeball, suggesting that it could be used as a potential treatment for myopic progression.

Contacts have also been used for corneal reshaping, orthokeratology, for decades. The cornea is flattened by fitting progressively flatter rigid contact lenses until the corneal shape is sufficiently altered to achieve myopia reduction. The alteration of corneal shape and hence correction of myopia is always temporary, but allows for periods of clear unaided vision during the day without the use of lenses.

4.DROPS TO LOWER EYE PRESSURE.
These are drops normally used to treat glaucoma. These have shown little or no effect.

5. BIOFEEDBACK VISUAL TRAINING
…including the Bates methods. There is currently no conclusive evidence that biofeedback visual training is effective in retarding myopia.

6. TRADITIONAL CHINESE INTERVENTIONAL TREATMENTS
Facial "Qi Qong" eye exercises were created in the 1950s in China. It was postulated that massaging the various acupuncture pressure points around the eye improves venous blood circulation, relaxes the muscles, and reduces eyestrain. These eye exercises are part of the school routine in many parts of China, and teachers guide the children in the daily performance of these eye exercises. The evidence from two studies conducted in Singapore and Taiwan were inconclusive.
In another study of 242 adolescent eyes in Beijing, small pieces of adhesive pressure plaster with grains of Semen impatiens (Garden Balsam Seed) were evaluated. Significant treatment effects were claimed.

B. Techniques that have or may have some effect on myopia progression:

1.'NEUROVISION'
This is a technique developed in Singapore based on computer-generated vision exercises [and not to be confused with the technique of the same name which tries to expand field of vision in patients with field loss]. ]. See http://www.neurovision.com.sg/ for further information
Some success is claimed for low myopia. Many studies seem to have been performed by investigators with commercial interest in the technique - further studies are necessary.

2.SPEND TIME OUT- OF- DOORS
There is some evidence that children who spend more time outside have less myopia progression. This seems to be independent of any effect of time spent on close work indoors.

Techniques that USUALLY have some effect on myopia progression:

2011 update
We have known for decades that Atropine 1% slows down progression of myopia. This is not a very nice treatment to use, however - permanently dilated pupils, light sensitivity and inability to focus close up are real problems.
In astonishing research published from Singapore, 0.01% Atropine seems to work just as well and there seem to be NO side effects!!
There is no data to answer really important questions like: what happens 2 years after I stop the drop?...5 years?....will the myopia just 'catch up' to where it was going before I started the drops?

1. ATROPINE AND PIRENZIPINE EYE DROPS
Atropine has been used in ophthalmology for over a century and is the most promising technique for slowing myopia progression when tested both in Caucasian and Oriental children. For example: in a Mayo Clinic study, normal myopia progression was at the rate of 1 unit change in 3 years in normals, and a rate of 1 unit change in 20 years in those using atropine.
Some of the long-term side effects of atropine eye drops in children are relatively unknown and are of some theoretical concern because of:
1. Pupillary dilatation and glare sensitivity whilst using the drops [complete recovery when drops are stopped]. There is theoretical concern about UV damage to the internal structures of the eye, but there have been NO actual reports of UV- related retinal damage and cataract formation as a result of atropine use for over a century.
2. Disturbance with reading vision [requiring bifocals or multifocals in all kids using atropine] might interfere with learning.

Pirenzipine is a 'cousin' of atropine that seems to have fewer side effects. Though the initial results were promising, the drug company that bought the product from its developer has not proceeded with marketing suggesting there are some undisclosed issues.

A respected colleague from Singapore writes of her experience:
Singapore has one of the highest myopia rates in the world, and 7 year olds in our schools have 20% myopia prevalence rates, increasing to some 40 percent by 12 years old. [Dr Kowal's note: about 15% in 15 year olds in most predominantly Caucasian populations]. The rate in university is around 85 to 90 %, and it seems related to educational status.
SNEC also has done a randomised trial with atropine 1% and found that it appears to be effective in slowing the myopia rate in 70% of the children it was used in a two-year study, and a subsequent study shows extended effect for another 2 years. There is an ongoing similar study using 0.5% after Taiwanese studies showed that that concentration was also effective.

I usually offer kids and parent the option of starting atropine 1% on when I see a rapid increase in the myopia rate. In Singapore the average increase for 7 year olds is -1D per year at 7 years, between 8 and 11 years between 1-1.5 Ds a year, and after 12 years 0.5D a year …. much higher than in western studies. So if they are even faster than this rate, or even at this rate, I discuss this option with them, including long term unknown risks of light exposure on the retina, lens etc.

They are put on 20% tinted or photochromatic bifocals or progressives, and also asked to put on a clip on sunshade if they are outdoors. I review after 6 months, and if it does not work, then they discontinue. If it works, (and the results are sometimes very impressive!) and parents are agreeable, we continue till age 12years, (since in middle school the increase is slower), but parents/ child can discontinue anytime. I also suggest they stop if they are planning a holiday with prolonged or excessive sun exposure. Those stable on it, I try to reduce the dosage, either by using 0.5%, or reducing it to every other day, or 2 to 3 times a week.

DR. KOWAL'S RECOMMENDATIONS

Atropine is the ONLY treatment that can fairly reliably stop or slow down the rate of myopia progression. If you want to try Atropine for your child:
1. You should commit to daily drops 1% Atropine in both eyes for at least 6 months.
2. You can stop any time, but it is not known what effect starting and stopping Atropine has on the rate of myopia progression.
3. Use 20% tinted or 'Transition' bifocals or multifocals, and add an extra clip-on when outdoors.
4. Come back every 6 months for vision, refraction and axial length measurements.