HOW TO TREAT 31 of reducing this risk. The aim is to slow axial growth by stabilising the scleral tissue. The three types of surgery are scleral buckling surgery, scleral injection-based treatments, and scleral collagen cross-linking.
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HOW TO TREAT 31 of reducing this risk. The aim is to slow axial growth by stabilising the scleral tissue. The three types of surgery are scleral buckling surgery, scleral injection-based treatments, and scleral collagen cross-linking.
Scleral buckling surgery, which involves implanting donor scleral tissue over the posterior pole of the eye, is the most widely used.
Several studies, mostly retrospective case or case-control series, have reported positive outcomes, although some lack detailed surgical information. 19 Scleral injection-based treatments and scleral collagen cross-linking are still considered experimental and have not been extensively used in clinical settings.
PROGNOSIS
MYOPIA in and of itself is not a serious condition and low levels are easy to manage and correct with spectacles or contact lenses. It is important to reduce the risk of high myopia, which has a greater potential for sight-threatening complications later in life. Increasing levels of myopia have a greater impact on quality of life, a greater financial burden associated with managing myopia and treating complications, poorer corrected vision and potentially worse outcomes associated with refractive surgery. 3, 23
The earlier in life that myopia develops, the faster it tends to progress. The greater the number of years over which the myopia progresses before the age of stabilisation( early adulthood), the greater the likelihood of the child reaching a high level of myopia.
If myopia is detected before the age of 12-13 it is more likely the child will end up with a high level of myopia; these children require more aggressive myopia control options. 24, 25 Although newer interventions can slow progression, there is no known therapy that can permanently stop or reverse progression. Thus, preventing or delaying the onset with increased outdoor exposure, particularly in those with increased known risk factors, is important to avoid future problems.
Pathological myopia describes the presence of fundal complications such as myopic maculopathy or posterior staphyloma( see figure 10). Pathological myopia affects between 1-19 % of those with low to moderate myopia( up to-3.00 dioptres) and 50-70 % of those with high myopia( at least-6.00 dioptres). 26
Pathological myopia is uncommon in childhood and more likely to develop as a person with myopia ages. The prevalence tends to be greater after the age of 40 in people with high myopia( greater than-5.0 dioptres or an axial length of 30mm or more). 27 With the rising prevalence of myopia, global rates for blindness and vision impairment from myopic macular degeneration are being reported. 28
Data from China over the past three decades show the number of people who have gone blind from myopic maculopathy increased by 200 %( 200,000 cases) and the number with moderate to severe levels of visual impairment increased by 340 %( 2.2 million cases, see figure
Box 3. Effective myopia control strategies
• Specialty optical devices:
— Spectacles and contact lenses that correct the visual symptoms centrally but have optical features in the periphery of the lenses have been shown to be beneficial in myopia control, for example, multifocal contact lenses. The underlying mechanisms for how these features impart their therapeutic effect remains unclear.
• It appears that lenses with features that create a myopic defocus( eg, positive powered lenslets [ small lenses inserted peripherally on the lens ]) in the periphery have a controlling effect on myopia, but so too do lenses that reduce contrast in the periphery. 11
• In randomised controlled trials, multifocal lenses( either bifocal or progressive) have yielded a small effect in slowing of myopia progression. 12
• Low-dose atropine eye drops:— This muscarinic antagonist( at a dose of less than 1 %) is often prescribed off-label for the management of myopia.— Higher doses have better efficacy but greater side effects, particularly with doses higher than 0.05 %; this needs to be balanced and individually tailored.— Side effects include photophobia( from dilation of pupils) and reduced near vision( from the cycloplegic effect).— Several randomised trials have demonstrated that topical antimuscarinic agents( eg, atropine, pirenzepine) are
12, 21-27
effective in delaying the onset and / or slowing the progression of myopia in children.
• This treatment has been widely used in Asia and is increasingly prescribed for children with myopia in the US.
• A network meta-analysis comparing trials of various atropine concentrations( ranging from 0.01-1 %) found that 0.05 % was the most effective at slowing myopic progression while having the fewest visual side effects. 28
Jonas JB et al. Eye Vis 2020 / CC BY / bit. ly / 3vR3ehS
• Orthokeratology:— Orthokeratology( OK) is the use of rigid contact lenses worn only during sleep.— These lenses cause central corneal flattening— correcting visual symptoms centrally. There is a ring of corneal steepening around this central flat zone, which, as with other optical interventions, creates a relative myopic defocus in the periphery.— This remoulds the cornea to correct visual symptoms so that visual correction is not needed in the daytime.— While limited data suggest that OK may reduce myopic progression more robust studies are needed. 19, 29 The authors do not prescribe OK; however, they do not discourage their patients from seeking this treatment elsewhere. Inform patients who choose this treatment that there is a risk of microbial keratitis from sleeping with contact lenses.
• Combination therapies:— The combination of two or more of the above is an emerging area of research; more data are required to clarify which combinations have the potential to improve efficacy beyond that of a single therapy.— OK in combination with atropine was found to be 27 % more effective at slowing the progression of myopia than OK alone. 11
• Light therapy:— The safety of light therapy is yet to be established.— Despite this being an emerging area of research, recent studies have shown that two three-minute bursts of direct exposure to low-level red light( 635-650nm) per day, spaced at least four hours apart, using laser-diode devices has high levels of efficacy for myopia control. 11
— A 2023 report showed some evidence that use of violet light( 360-400nm) emitting spectacles resulted in small but not significant slowing of axial elongation in 6-12-year-old children over a two-year period. 11
• Spending time outdoors:— Increasing the time spent outdoors is a simple strategy to reduce the risk of developing myopia and / or slow its progression. 13-19
— The precise mechanism is uncertain but is likely related to increased light exposure and reduced time on the visual tasks of reading and writing( near work) activities. 20 In a cluster randomised trial of 1913 schoolchildren( mean age 6.6) in China randomised( by school) to an additional daily 40-minute outdoor class or usual activity, the cumulative incidence rate of myopia over three years was lower in the intervention group compared with the control group( 30 vs 40 %). 17
Number of cases( in millions)
3.5 3
2.5 2
1.5 1
0.5 0
200 %
Blindness
1990 2020
Figure 11. Cases of myopic macular degeneration in China over the past three decades.
Figure 10. Fundus photograph of a highly myopic eye with myopic maculopathy category 4( macular atrophy or macular Bruch’ s membrane defect), and with parapapillary gamma zone( green arrows) and delta zone( black arrows).
340 %
Moderate-severe visual impairment
Box 4. Risk factors that require exploration
• Season.
• Geography.
• Ethnicity.
• Amount of time spent on the visual tasks of reading and writing( near work).
• Other biological or behavioural factors.
• Effects of sleep and circadian rhythms.
• Level of physical activity.
• Height
• Diet.
• Birth order.
• Socioeconomic status.
Source: Morgan IG et al 2021 2
11). 29 In 2020, blindness and vision impairment from myopic maculopathy was more prevalent than that from diabetic retinopathy. 29
Despite the availability of an increasing number of medical treatments for myopia-related complications, these do not always improve visual outcomes. Anti-vascular endothelial growth factor therapy, used for age-related macular degeneration, is used for myopic maculopathy where there is subretinal neovascularisation. Surgical treatments are available for retinal detachments and epiretinal membranes; however, there is currently no treatment for the more frequently occurring complication of myopic staphyloma. 27
CURRENT AND FUTURE RESEARCH
DESPITE a rapidly growing body of evidence around the development and management of this condition over recent decades, there are still many unanswered questions. The underlying aetiological pathways and the mechanisms by which current management options impart their therapeutic effect remains unclear.
There is strong evidence for the benefits of increased time outdoors in preventing the onset of myopia. 2 However, once the condition has developed, the evidence is less clear regarding the impact of increasing time outdoors in terms of reducing or slowing the progression of myopia. 2
Although many studies indicate that more outdoor time is better, there are inconsistencies in the methodological approaches taken, and the exact thresholds recommended are unclear. Other confounding factors that require investigation regarding their impact on the development of myopia appear in box 4. Larger scale studies with improved and consistent methodological approaches are required.
CASE STUDIES
Case study one
RON, an 18-year-old male, presents to an optometrist complaining of significantly reduced vision bilaterally and debilitating glare. His ocular history is significant for pathological myopia.
On examination, his spherical equivalent( taking into account the spherical component plus half the cylindrical component) refractive error level is-13.50 dioptres in the right eye and-13.00 in the left eye.