Myopia / Nearsightedness in Kids: A Presentation

Recently, Dr. Jeri gave a presentation about Myopia in kids. Learn why myopia (commonly called “nearsightedness”) is increasing so much and about groundbreaking treatments available.

Below is a transcript of the presentation by Dr. Jeri Schneebeck, O.D., F.C.O.V.D.:

Thanks for joining me this evening, for this presentation.  It’s about myopia management and our goal is with that to significantly slow the progression of nearsightedness. At Highline, we’ve always been in the forefront of trying to slow the progression of nearsightedness in our patients. Tonight, we’re going to talk about why this is so important, and review the variety of technologies that are available, and introduce a new lens that’s just been released.

WHAT IS MYOPIA OR NEARSIGHTEDNESS?

It’s the inability to see clearly at distance. On the left, the picture shows emmetropia, which is when there is no refractive error. The light rays enter the eye and automatically focus on the retina. With the myopic eye, on the right, you can see that the light rays enter the eye and focus in front of the retina leaving distance objects blurry.

CAUSES OF MYOPIA

Genetics is one of the things that’s very important. So, the likelihood of a child developing myopia increases to 50% when both parents have myopia, 33% when one parent has myopia, and 25% when neither parent has myopia. We also know that lifestyle is a big piece of developing myopia.

Research shows that modern lifestyles may influence the development. Insufficient time spent outdoors is believed to be one reason. Currently our children spend an average of 30 minutes a day outside. We also believe that prolonged time spent reading and playing and working on digital devices is a component of it. The same children who are only spending 30 minutes a day outside are spending an average of 7 hours a day in front of electronics. The statistics show that this may have serious consequences on their health and well-being. When our doctors are counseling patients, we recommend 2 hours of outdoor play daily to reduce the potential of developing myopia.

Think of the other benefits, more outdoor play can lessen obesity and lower body mass index, improve fitness, grows motor skills, muscle strength, reduced incidence of depression, improved relationships with peers and parents, and it develops an appreciation for the environment.

Myopia is becoming more widespread and more severe than ever. In the early 70s, only 25% of Americans were nearsighted. Today, more than 40% of Americans are nearsighted. That number’s increasing at an alarming rate, especially among school-aged children. By 2050, 58% of the North American population is predicted to be nearsighted.

LONG TERM IMPLICATIONS OF MYOPIA

Myopia is measured in quarter diopter steps. For every full diopter of increase in myopia, there’s a 30% increased risk of retinal detachment, and a 67% increased risk of myopic maculopathy. In addition to these health implications, if we can keep a child’s myopic prescription lowered, when they get old enough, their candidacy for refractive surgery, LASIK, or PRK may be improved, and the results may be better. Leaving myopia unmanaged may contribute to severe eye health complications and sight threatening conditions later in life.

MYOPIA RISK ASSESSMENT

You’ll notice that every single one of these risk levels has that recommendation for limiting screen time, limiting close work outside of school, and encouraging at least 2 hours of outdoor play per day. How do we know if a child’s in need a myopia management program?

LOW RISK

Low risk is if they’re a little bit farsighted, a little bit more than +.75 (farsightedness) at age 6 or younger, is what that tells us that there’s going to be a bit less of a risk for them becoming nearsighted.

Ideally a child is slightly farsighted, or hyperopic is the other word for that, which does then bring less risk for becoming myopic.

MEDIUM RISK

A medium risk happens when, even if they’re just a little bit lower than +.75 at age 6 or younger. At that age, if we’re not seeing nearsightedness yet, but we’re seeing a zero prescription, you would think that would be great, but, in reality, it does put them at a medium risk of developing myopia later. So, we watch for changes in their prescription over a short period of time at that time. It’s one reason why we recommend that school-aged children have their eyes checked every year.

HIGH RISK

The high risk comes if there’s any myopia at all confirmed in any pre-school or school-aged child. If we aren’t going to immediately enroll them in a myopia management program, we want to watch them extremely carefully at this point. We’re going to follow them every three to six months. And the ideal is, if they are changing at all, if their myopia is increasing at all, we want to get them going in a myopia management program.

MYOPIA MANAGEMENT TODAY – FOR THE FUTURE

For children who begin a myopia management program (the earlier, the better), their vision will not only be corrected today for distance, but the progression of myopia over the child’s growing years may be slowed. So, it will minimize the long-term impact of myopia:

• Reduced eyeball elongation. Remember that one of the reasons for myopia is elongated eye.
• We slow the progression of nearsightedness, and
• We have a potential reduction in the health complications found more frequently in myopic patients.

Some of the methods we use at Highline to slow myopia progression.

• Multifocal or anti-fatigue design spectacle lenses. These are used for children too young to wear contact lenses.
• We use very low dose atropine drops, or can do that as a method to try to slow myopia progression.
• CRT lenses. They are contact lenses called corneal refractive therapy, and we’ll go into those a little bit more and explain how that type of a contact lens works.
• And then finally, we will discuss the MiSight^® daily disposable soft contacts, which is the new lens just released with some really nice research behind it.

MULTIFOCAL OR ANTI-FATIGUE DESIGN SPECTACLES

For many years, multifocals have been the only option for trying to control myopia progression with spectacles. There are some new spectacle designs being released, being developed, right now that have the peripheral retinal defocus properties to slow myopia progression.

That’s a mouthful, I know. So, without going into too much detail, all myopia control modalities operate by creating a defocus on the retinal periphery while simultaneously providing clear central vision. From 2010 to the present there’s been a shift toward developing myopia management devices that alter periphery retinal defocus based on the landmark studies that found that the peripheral retina had a significant role in refractive error development.

You’ll hear me say that the number of our modalities is kind of the ultimate goal to create a clear central image at distance while creating a peripheral retinal defocus. That helps to stop the elongation of the eye.

LOW DOSE ATROPINE DROPS

These are used one drop in each eye before bed. They’ve been shown to significantly decrease myopia progression in children within a year. And, they can be used in conjunction with some of our other myopia control measures, so that’s a nice. If you have somebody you really feel is progressing rapidly, we may want to use more than just one method to try to control that.

They’re ordered from a compounding pharmacy with a cost of about $45 a month, so, they’re not real expensive. And, the disadvantages are this is a prescription medication and it does take motivation of parents and child to get the drops in nightly. Again, the atropine drops work by creating peripheral retinal defocus. So, again, that’s shown to slow that elongation of the eye that causes progressive myopia.

Benefits of choosing a contact lens-based myopia management approach

• The vision is corrected for daily actives such as school and sports.
• It’s thought to be a more comfortable experience for children versus wearing glasses, there’s some studies about self-esteem and so forth with contact lens wear versus wearing glasses.
• There are no glasses to lose or break, although, I will say that “back up glasses” are always recommended for contact lens wearers. In the event that they can’t wear their contacts a given day due to an eye infection or whatever reason. We do recommend that with these contact lens modalities that we’re going to be talking about with that do the control of myopia, that they are worn a minimum of six days a week. So, it is a commitment to wearing the contact lenses.
• Contacts accommodate a more active lifestyle versus wearing glasses. So, in this short term, the benefits of a contact lens-based myopia manage approach may look very much like correcting vision with traditional contacts. However, the design of all of these lenses is very different from a standard contact lens.

CRT LENSES – CORNEAL REFRACTIVE THERAPY

The first contact lens that we’ll talk about are the CRT lenses. That stands for corneal refractive therapy. They’re a rigid gas permeable lens that’s worn overnight while you’re sleeping. They work by gently reshaping the curvature of the cornea while you sleep. Then you remove them upon awaking and your vision is corrected throughout the day.

So, it’s a great choice for athletes, that’s why I’ve put these pictures up here. For swimmers especially, because you really should not be wearing soft contact lenses in a swimming pool at all. These are great for athletes who may lose or get daily wear contacts dirty and it may also be the lens of choice for those having moderate amounts of astigmatism and some of our other choices do not correct for astigmatism. And again, this lens design creates the peripheral defocus on that retina that’s needed to slow the progression of myopia.

MISIGHT DAILY CONTACT LENS

They’ve called it the Brilliant Futures Myopia Management Program. It’s a comprehensive approach built around that MiSight lens. I’m going to give you a little more information about that lens tonight. Because then the other things that we’d talked about, just because they were just released, and they have ten years of research to support their effectiveness.

Many studies involving contact lenses are retrospective. They use existing data that’s been collected from the eye exams that have already been done. And, they use that information to put together the success of the contact lens. MiSight lenses were studied for ten solid years before they were brought to market with randomized double blind placebo-controlled studies that are the gold standard in research.

Our program fee includes all of these things:

• An annual supply of MiSight daily disposable lenses, they’re single use lenses, you put them in in the morning, you throw them away at night. They’re considered the healthiest alternative for children to wear.
• Free shipping and free returns whether the prescription changes or not.
• App: There’s a very helpful app that will help with appointment reminders, payment options, and a way to track program progress, and to communicate with our office. It will have periodic surveys to see how the child’s doing. So that we can figure out very early on if there are problems that are going to cause the child to fail with the lenses. We really want them to be successful.
• It includes regular progress evaluations and
• Access to the website support tools.

HOW MISIGHT 1 DAY WORKS

So, this a little tricky. This central purple area is the correction zone. That’s what corrects the vision and creates that focal point that gives you clear distance vision. And this is a nice little diagram because it’s going to show you what I’ve been talking about, this myopic defocus, this peripheral retinal defocus, that has to happen in order to stop the progression of the nearsightedness. And then the dark zones, the darker purple zones, are the treatment zones that create that defocus out here in the periphery of the eye. By including both types of zones in the lens is simultaneously corrects the child’s vision today while training the eye to resist changing shape. And that goal is to preserve vision for the future and to slow that progression of near sightedness.

EFFECTIVENESS OF MISIGHT 1 DAY

Over a three-year period, children in MiSight lenses had 3/4 of a reduced increase in myopia than children in standard daily disposables, and that equates to an average of 59% reduction in prescription change compared to a standard daily contact lens at 3 years. Those same children also had a reduced increase in axial length, that elongation of the eye. And again, that equates to a 52% reduction in the eye lengthening with the MiSight lenses compared to standard soft contacts.

CHILDREN LOVED THEIR MISIGHT LENSES

Children did really well with MiSight lenses. These studies were done on children 8 to 12 years old. That doesn’t mean that other aged children can’t be fit with those lenses. It’s just the way the study was done. And these young children did extremely well with contacts.

• Over 90% of them preferred wearing them compared to their glasses,
• Over 90% could apply and remove their MiSight lenses on their own.
• And, parent reported that their child was happy wearing the lenses. They noted comfort, vision, ease of use, and freedom from glasses as benefits.

And, all the while their vision was clear for distance, for school, for doing their close work, for playing video games, for playing their sports. So, they had the best of all worlds.

Sequence of care in our office for being fit with these lenses.

1. We have the initial comprehensive eye health and vision evaluation, which is covered either by your vision plan or is paid privately.
2. After that, we talk a little bit about the myopia control, if the child is looking like a good candidate for myopia management, we provide the parents with the myopia management pamphlets, and then we email you the MiSight parent education digital book. Which gives you a lot of the information that I’ve gone over this evening.
3. Then we schedule a follow up consultation to go over pricing, answer questions, discuss the program. It’s advantageous for both parents to be present for this part. This can be done virtually, if for sometimes that’s easier to get both parents at the same time, that way.
4. And sometimes, number three and four are actually put together, and we’ll do the fitting at the same time as the consultation. Including teaching the child how to insert and remove their lenses, and at that time we set up the app access, so that you’ve got all those features available to you.
5. Number 5 is only for CRT lenses: We do see CRT patients at a one day progress evaluation. And that is, with CRT lenses that’s the only visit where people come in wearing the lenses. We have them come in so we can see how they did sleeping in those lenses the first night. And then we take the lenses out and check their vision after that. The rest of the time when they come for progress checks they will bring their contacts with them but will not come in wearing their lenses. With MiSight lenses, they will always come in wearing their contact lenses. We want to see the lenses on their eyes after they’ve had a chance to settle and watch for any problems that might be occurring as they’ve worn the lenses.
6. So, we do a one week progress evaluation. At that time the down payment’s required, and we order lenses. We do wait for that one week progress evaluation in case there’re just any problems, the child just absolutely is not going to wear the lenses. Those kinds of things we don’t want you to have lenses ordered that you’re not going to be able to use. So, we wait to that one week progress eval to order the lenses.
7. Then we do a one month progress evaluation
8. And then a six month progress evaluation

All of those numbers 2 through 8 are all included in the program fee along with a supply, the annual supply of lenses. All of that’s included. And honestly, if other progress checks are needed for any reason during that 6-month period, that would be included in the program as well.

HOW LONG SHOULD WE CONTINUE USING INTERVENTIONS WHEN WE’RE TRYING TO SLOW MYOPIA PROGRESSION?

A large study out of the University of Waterloo followed 6400 people and found that the average age when myopia stopped progressing was between 24 and 27 years old. I would say that average age appears a little bit more of the study. Historically, practitioners kind of think that myopia stops progressing at puberty or around the ages of 14 to 18. However, another large study showed that at age 15, 50% of pediatric myopes were still progressing. And at age 18, 25% were still progressing.

We can’t predict how any single individual child is going to respond to any intervention for myopia, but based on the averages, it’s best to keep them in the interventions into their mid-20s. I will tell you, especially with this year, with people being on computers more, we’re seeing a more rapid increase in myopia than ever before. So, with children now being on computers so much more than they ever were before, this is even more important that we keep the interventions in place so that we can keep that myopia to the minimum amount possible.