PREVENTION OF MYOPIA PROGRESSION NOTES FROM THE AMERICAN ACADEMY OF OPHTHALMOLOGY (BY ADRIANO GUARNIERI, MD)

Martes, 23 de Junio de 2009 00:00

Doctor Guarnieri was asked by a patient's mother about his opinion related to not wearing glasses to preventing the progression of myopia. After reserching the subject, he has sent the result of his investigation about this controversial issue. Most myopic refractive errors develop and progress during childhood and adolescence. Treatments proposed to prevent or reduce the progression of myopia includeoptical correction, use of cycloplegic eyedrops, pressure-lowering eyedrops, contact lenses, and visual training. Information about the effects of nutritional changes on the progression of myopia is largely anecdotal and no scientifically valid studies are available. * OPTICAL CORRECTION Optical correction in the form of bifocal eyeglasses, multifocal eyeglasses, or removal of distance eyeglasses when performing close work, has been recommended in an attempt to reduce accommodation, since accommodation has been implicated in the progression of myopia . Studies examining distance eyeglasses alone have failed to demonstrate any overall effects on the progression of human myopia. Randomized, controlled clinical trials have compared the use of bifocal eyeglasses (with add powers ranging from +1.00 D to +2.00 D) with single-vision distance eyeglasses in myopic children, and have failed to demonstrate any significant differences in myopic progression. One study of 75 esophoric children, approximately half of whom used +1.50 D add bifocals, did show a slight reduction in the progression of myopia compared to controls. Among the children completing the 30 months of follow-up, myopia progression was statistically significantly lower for bifocals than for single-vision eyeglasses (1.00 D to 1.24 D). In a study comparing the use of multifocal eyeglasses to single-vision distance eyeglasses in myopic children, there was no statistically significant difference in the rate of myopia progression. One study of 469 children age 6 to 11 years reported that progressive addition lenses compared to single vision lenses slowed the progression of myopia by a small, statistically significant amount only during the first year. The authors concluded that the small magnitude of the effect does not warrant a change in clinical practice. Another study of 138 Hong Kong children ages 7 to 10.5 years found no evidence of retardation of myopia progression by wearing progressive addition lenses after 2 years. Thus, with the exception of one small trial, optical correction has not been shown to prevent progression of myopia. * TOPICAL CYCLOPLEGIC AGENTS Administration of atropine eyedrops has long been proposed as a treatment to prevent progression of myopia. Atropine inhibits accommodation, which may exert forces on the eye that result in axial elongation. In animal studies, atropine also appears to inhibit growth factors acting to elongate the eye independent of accommodation. The results of randomized, controlled clinical trials conducted in Taiwan and Singapore (three of which were masked) provide reasonable evidence that administration of atropine eyedrops retards the progression of myopia in school children. In one study, a range of atropine concentrations was utilized; 0.1%, 0.25%, and 0.5%. All reduced progression of myopia compared with the control group. The 0.5% concentration was the most effective. More recently, it has also been shown that atropine eyedrops are effective in populations in the West where children generally have less rapid rates of progression of myopia than in Taiwan. It is now also known that the beneficial effects remain once the use of atropine is discontinued. Potential risks of long-term atropine use are uncertain and include the risk of light toxicity to ocular structures, the potential for local allergic and systemic reactions, and the effect on accommodative amplitudes following

discontinuation of atropine. However, it has recently been reported that daily atropine usage over 2 years for the treatment of myopia has no significant effect on retinal function as demonstrated by recordings of multifocal electroretinograms in children. Other potential disadvantages include the possible need for bifocal or multifocal eyeglasses (depending on the concentration of atropine administered), photosensitivity and glare, and the inconvenience of using daily eyedrops. Cyclopentolate 1% administered nightly was evaluated in one study in school children in Taiwan. It was found to slow the rate of progression of myopia compared with controls (mean myopic progression of 0.6 D/year compared with 0.9 D/year, which is statistically significant), but not as much as atropine did (mean myopic progression of 0.2 D/year). Tropicamide 1% was evaluated in a study of monozygotic twins, and no significant difference in progression of myopia was noted compared with controls. Recently, pirenzepine hydrochloride has been evaluated in two multicenter, double-masked, placebo-controlled parallel studies to slow the progression of myopia in school-aged children. Unlike atropine, which affects both accommodation and mydriasis, pirenzepine has a relatively selective effect on accommodation. The United States study examined 174 children age 8 to 12 years,436 and the Asian study examined 353 children age 6 to 13 years. Both studies found 2% pirenzepine ophthalmic gel effective and relatively safe in slowing myopia progression over a one- year treatment period. Because of uncertainty about long-term safety and optimal dosage, administration of atropine eyedrops or pirenzepine hydrochloride to reduce myopic progression in children is recommended only in research trials. * PRESSURE-LOWERING EYEDROPS Lowering IOP has been suggested as a pharmacologic intervention that might reduce progression of myopia, presumably by reducing internal pressure on the ocular wall. One prospective clinical trial comparing administration of 0.25% timolol maleate with the use of single-vision eyeglasses failed to show any retardation of progression of myopia. * CONTACT LENSES Soft contact lens use was evaluated in a randomized clinical trial in the United States. No statistically significant difference in the rate of myopia progression could be demonstrated between the contact lens group and the group using single-vision eyeglasses. It has long been postulated that rigid contact lens use could slow the progression of myopia in children. Previous studies published were limited by methodological difficulties. A two-year randomized clinical trial evaluating the effect of rigid contact lenses on myopia progression in school children was conducted in Singapore, and another study concurrently in the United States. The study of 428 Singaporean children ages 6 to 12 years found that rigid gas permeable contact lenses did not slow the rate of myopia progression over 2 years, even among children who used them regularly and consistently. The United States study compared the effects of rigid gas permeable contact lenses and soft contact lenses on myopia progression in 116 children age 8 to 11 years. They found that rigid contact lens wearers progressed less than soft contact lens wearers, and that the corneal curvature of the soft lens group steepened more than the rigid lens group, but the axial growth was not statistically significantly different between the groups. Because some of the effect was likely Influenced by transient corneal curvature changes, the authors concluded that the results indicate that rigid gas permeable contact lenses should not be prescribed

primarily for myopia control. Although it has been suggested that orthokeratology can slow the progression of myopia in children, there is no randomized controlled trial evidence to support this. A two-year pilot study was conducted to determine whether orthokeratology can effectively reduce and control myopia in children. Thirty-five Hong Kong children age 7 to 12 years undergoing orthokeratology treatment were compared with 35 children wearing single-vision eyeglasses from an earlier study (control). The study found a statistically significant change in axial length for the orthokeratology group and the control group (0.29 0.27 mm and 0.54 0.27 mm respectively). However, there are substantial variations in changes in eye length among children and there is no way to predict the effect for individual subjects. Because of lack of efficacy and associated risks, orthokeratology is not recommended for prevention of myopia progression in children. * VISUAL TRAINING Visual training purported to reduce myopia includes exercises such as near-far focusing change activities. There are no scientifically acceptable studies that document that these treatments are clinically effective, and therefore, this therapy is not recommended. References: 53. Grosvenor T, Perrigin DM, Perrigin J, Maslovitz B. Houston Myopia Control Study: a randomized clinical trial. Part II. Final report by the patient care team. Am J Optom Physiol Opt 1987;64:482- 98. 54. Jensen H. Myopia progression in young school children and intraocular pressure. Doc Ophthalmol 1992;82:249-55. 55. Parssinen O, Hemminki E, Klemetti A. Effect of spectacle use and accommodation on myopic progression: final results of a three-year randomised clinical trial among schoolchildren. Br J Ophthalmol 1989;73:547-51. 60. Shih YF, Chen CH, Chou AC, et al. Effects of different concentrations of atropine on controlling myopia in myopic children. J Ocul Pharmacol Ther 1999;15:85-90. 61. Shih YF, Hsiao CK, Chen CJ, et al. An intervention trial on efficacy of atropine and multi-focal glasses in controlling myopic progression. Acta Ophthalmol Scand 2001;79:233-6. 420. Ong E, Grice K, Held R, et al. Effects of spectacle intervention on the progression of myopia in children. Optom Vis Sci 1999;76:363-9. 421. Jensen H. Myopia progression in young school children. A prospective study of myopia progression and the effect of a trial with bifocal lenses and beta blocker eye drops. Acta Ophthalmol Suppl 19911-79. 422. Fulk GW, Cyert LA. Can bifocals slow myopia progression? J Am Optom Assoc 1996;67:749-54. 423. Fulk GW, Cyert LA, Parker DE. A randomized trial of the effect of single-vision vs. bifocal lenses on myopia progression in children with esophoria. Optom Vis Sci 2000;77:395401. 424. Gwiazda J, Hyman L, Hussein M, 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 2003;44:1492-500. 425. Edwards MH, Li RW, Lam CS, et al. The Hong Kong progressive lens myopia control study: study design and main findings. Invest Ophthalmol Vis Sci 2002;43:2852-8. 426. Oishi T, Lauber JK. Chicks blinded with formoguanamine do not develop lid suture myopia. Curr Eye Res 1988;7:69-73. 427. Tigges M, Iuvone PM, Fernandes A, et al. Effects of muscarinic cholinergic receptor antagonists on postnatal eye growth of rhesus monkeys. Optom Vis Sci 1999;76:397-407. 428. Lind GJ, Chew SJ, Marzani D, Wallman J. Muscarinic acetylcholine receptor antagonists inhibit chick scleral chondrocytes. Invest Ophthalmol Vis Sci 1998;39:2217-31. 429. Yen MY, Liu JH, Kao SC, Shiao CH. Comparison of the effect of atropine and cyclopentolate on myopia. Ann Ophthalmol 1989;21:180-7. 430. Chua WH, Balakrishnan V, Chan YH, et al. Atropine for the treatment of childhood myopia. Ophthalmology 2006;113:2285-91. 431. Chiang MF, Kouzis A, Pointer RW, Repka MX. Treatment of childhood myopia with atropine eyedrops and bifocal spectacles. Binocul Vis Strabismus Q 2001;16:209-15. 432. Syniuta LA, Isenberg SJ. Atropine and bifocals can slow the progression of myopia in children. Binocul Vis Strabismus Q 2001;16:203-8. 433. Kennedy RH, Dyer JA, Kennedy MA, et al. Reducing the progression of myopia with atropine: a long term cohort study of Olmsted County students. Binocul Vis Strabismus Q 2000;15:281-304. 434. Luu CD, Lau AM, Koh AH, Tan D. Multifocal electroretinogram in children on atropine treatment for myopia. Br J Ophthalmol 2005;89:151-3. 435. Schwartz JT. Results of a monozygotic cotwin control study on a treatment for myopia. Prog Clin Biol Res 1981;69 Pt C:249-58. 436. Siatkowski RM, Cotter S, Miller JM, et al. Safety and efficacy of 2% pirenzepine ophthalmic gel in children with myopia: a 1-year, multicenter, double-masked, placebo-controlled

parallel study. Arch Ophthalmol 2004;122:1667-74. 437. Tan DT, Lam DS, Chua WH, et al. One-year multicenter, double-masked, placebo-controlled, parallel safety and efficacy study of 2% pirenzepine ophthalmic gel in children with myopia. Ophthalmology 2005;112:84-91. 438. Jensen H. Timolol maleate in the control of myopia. A preliminary report. Acta Ophthalmol Suppl 1988;185:128-9. 439. Horner DG, Soni PS, Salmon TO, Swartz TS. Myopia progression in adolescent wearers of soft contact lenses and spectacles. Optom Vis Sci 1999;76:474-9. 440. Jessen GN. Contact lenses as a therapeutic device. Am J Optom Arch Am Acad Optom 1964;41:429-35. 441. Morrison RJ. The use of contact lenses in adolescent myopic patients. Am J Optom Arch Am Acad Optom 1960;37:165-8. 442. Stone J. Contact lens wear in the young myope. Br J Physiol Opt 1973;28:90-134. 443. Stone J. The possible influence of contact lenses on myopia. Br J Physiol Opt 1976;31:89-114. 444. Grosvenor T, Goss DA. The role of bifocal and contact lenses in myopia control. Acta Ophthalmol Suppl 1988;185:162-6. 445. Grosvenor T, Perrigin J, Perrigin D, Quintero S. Use of silicone-acrylate contact lenses for the control of myopia: results after two years of lens wear. Optom Vis Sci 1989;66:41-7. 446. Perrigin J, Perrigin D, Quintero S, Grosvenor T. Silicone-acrylate contact lenses for myopia control: 3-year results. Optom Vis Sci 1990;67:764-9. 447. Andreo LK. Long-term effects of hydrophilic contact lenses on myopia. Ann Ophthalmol 1990;22:224-7, 229. 448. Katz J, Schein OD, Levy B, et al. A randomized trial of rigid gas permeable contact lenses to reduce progression of children's myopia. Am J Ophthalmol 2003;136:82-90. 449. Walline JJ, Mutti DO, Jones LA, et al. The contact lens and myopia progression (CLAMP) study: design and baseline data. Optom Vis Sci 2001;78:223-33. 450. Walline JJ, Jones LA, Mutti DO, Zadnik K. A randomized trial of the effects of rigid contact lenses on myopia progression. Arch Ophthalmol 2004;122:1760-6. 451. Cho P, Cheung SW, Edwards M. The longitudinal orthokeratology research in children (LORIC) in Hong Kong: a pilot study on refractive changes and myopic control. Curr Eye Res 2005;30:71- 80. 452. American Academy of Ophthalmology. Complementary Therapy Assessment. Visual Training for Refractive Errors. San Francisco, CA: American Academy of Ophthalmology; 2004. Available at: http://one.aao.org/CE/PracticeGuidelines/Therapy.aspx. 453. Bates W. The Cure of Imperfect Sight by Treatment Without Glasses. New York: Central Fixation Publishing Co., 1920. 454. Lim KL, Fam HB. NeuroVision treatment for low myopia following LASIK regression. J Refract Surg 2006;22:406-8. Adriano Guarnieri, MD Madrid, Spain Good night, LL Luis W. Lu, MD, FACS Director, Elk County Eye Clinic Senior Staff Member, Pennsylvania Eye Consultants www.elkcountyeyeclinic.com

J Am Optom Assoc. 1998 Apr;69(4):262-6.

Relation of childhood myopia progression rates to time of year.

Goss DA1, Rainey BB.

Author information Abstract

BACKGROUND: One potential method for assessment of the effect of near work on childhood myopia progression is to compare progression rates overtime spans that have differing near-point demands. METHODS: Myopia progression rates were calculated for a 6-month period during the school year (called school rate in this article) and for a 6-month period that included the 3 months of summer vacation (called summer rate). Data used for analysis were right eye spherical equivalents from manifest subjective refractions of 27 children in a longitudinal study at Northeastern State University in Oklahoma, and 15 children in a longitudinal study at Indiana University. All subjects wore single-vision spectacle lenses. RESULTS:

The mean summer rate for the 42 subjects was -0.39 diopters per year (D/yr) (SD = 0.46). The mean school rate was -0.72 D/yr (SD = 0.57). The rates during the two periods were significantly different by two-tailed paired t-test (p = 0.006). CONCLUSIONS: The differing amount of nearpoint activity during the school year and the summer is a potential explanation for the different rates of myopia progression during those two time periods.
PMID: 9585666 [PubMed - indexed for MEDLINE]

Medscape Medical News

Myopia Risk Lowered When Children Play Outdoors

Linda Roach

May 07, 2013


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Myopia Risk in Children May Be Reduced by Outdoor Activity

Myopia Incidence 'Much Higher Than Expected' in Large Study More Time Outdoors Reduces Nearsightedness
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Elementary-school-aged children who spend more time playing outdoors are less likely to develop myopia than their peers who sometimes prefer to stay indoors during school recesses, according to a report by Taiwanese researchers published in the May issue of the journal Ophthalmology. In a separate article published in the same issue, researchers who studied myopic children in Denmark found that seasonal changes in the mean number of daylight hours correlated significantly with 3 indicators of myopia progression: eye elongation (P = .00), myopia progression (P = .01), and corneal power change (P = .00). The figures increased in winter, when daylight is present for about 7 hours in Denmark, the study reports. During the 17.5hour days of summer, myopic progression still occurred, but the increases were not as large, the report said.

The 2 studies are part of a worldwide boom in myopia researchthat has occurred during the last decade. The research began with the aim of illuminating the causes of large increases in prevalence of this refractive disorder during the second half of the 20th century. Myopia prevalence has increased in the United States from 25% in 1971-1972 to 41.6% in 1999-2004, according to a 2009 report from scientists at the National Eye Institute. However, the prevalence has increased even more dramatically in Asia. "Myopia has become very high in the last 30 years in Taiwan. It is a very severe public health problem," explained lead author Pei-Chang Wu, MD, PhD, in an interview with Medscape Medical News. "Ninety percent of college students in Taiwan have myopia. But in previous generations, the prevalence was about 10%." Dr. Wu is director of ophthalmology at the Department of Ophthalmology, Kaohsiung Chang GungMemorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan. In the comparative, 1-year study Dr. Wu and colleagues performed autorefractions and measured axial length in 571 students at 2 elementary schools in a suburban area and collected other data on the children and their families via a parent questionnaire. The myopia prevalence in the 7- to 11-year-old children was nearly 50% at both schools. After baseline measurements, one school began a simple intervention with its students (n = 333): They turned off classroom lights and encouraged children go outdoors during their 80 minutes of recess from class each day (6.7 hours per week). In the control school, there were no special recess programs, and children were allowed to stay indoors during recess periods. Both groups had 2 hours of outdoor physical education per week. At the end of a year, the researchers retested the children's eyes. The measurements showed significantly fewer new cases of myopia in the test group (8.41% vs 17.65%; P < .001). There also was less myopic shift in the intervention group (0.25 D/year vs 0.38 D/year; P = .029). Bright, Natural Light Needed These outcomes demonstrate how small changes might be able to expose children to the bright, natural light that their eyes apparently need to grow normally, Dr. Wu told Medscape Medical News. "Kids spend a lot of time in school. Therefore, if the educational design could change a little bit, we might get a change in myopia prevalence," he concluded. In the Danish study, investigators looked for correlations between a surrogate measure of daylight exposure (the total number of daylight hours during winter and summer periods of 6 months each) and myopic progression in 235 myopic children between 8 and 14 years of age.

The scientists confirmed that lower total hours of daylight correlated with higher numbers in the 3 parameters they tested, and vice versa. With an average of 1681 hours of daylight over the course of 6 months, axial eye growth was a mean 0.19 0.10 mm, myopia progression was 0.32 0.27 D, and the corneal power change was 0.04 0.08 D. This compared with axial eye growth of 0.12 0.09 mm, myopia progression of 0.26 0.27 D, and corneal power change of 0.05 0.10 D during summer with 2782 hours of daylight. Dongmei Cui, MD, PhD, the study's first author and an associated professor of ophthalmology at State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, Peoples Republic of China, says it still is not clear what the light is actually triggering in th e eye to arrest growth. However, it is not too early for parents of children with myopia to heed the common underlying message of the 2 studies. "I suggest the parents make sure their children spend an adequate amount of time in outdoor activities," she said. Kate Johnson, BAppSc(Optom)Hons, GradCertOcTher, a Brisbane, Australia, optometrist who fits myopic children with orthokeratology contact lenses because of recent research indicating that they slow down progression, said she routinely asks parents about their children's myopia risk factors, including how much time they spend on outdoor activities. "If they spend all their time on an iPad, if they spend spent less than 1.5 hours outside every day, they're at risk," she said. The Taiwanese study was supported by the Chang Gung Medical Research Project Research Grants from Kaohsiung Chang Gung Memorial Hospital, Taiwan. The Danish study was supported by the National Natural Science Foundation of China and by the Fundamental Research Funds of State Key Laboratory of Ophthalmology, in Guangzhou, People's Republic of China. Dr. Wu, Dr. Ciu and Johnson have disclosed no relevant financial relationships. Ophthalmology. 2013;120:1074-1079, 1080-1085. Wu abstract, Cui abstract