Treat pediatric vision abnormalities early to avoid problems later
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This issue’s roundtable from our pediatric ophthalmology colleagues covers two important topics: amblyopia therapy and progressive myopia treatment. Our first challenge is to diagnose these two conditions at an early age.
Vision screening programs for children are a challenge. Ideally, we would like to recognize amblyopia and progressive myopia as early as possible, at the latest by age 5 years. Vision can be tested in very young patients, and at age 5 years, children should have symmetrical vision and no myopia.
Our group at Minnesota Eye Consultants worked with Phillips Eye Institute in south-central Minneapolis for 3 decades providing free vision screening for children. First, we found that we achieved access to only a small percentage of potential children in the neighborhood. In about 10% of those screened, we recommended referral to an eye care practitioner (ECP). Unfortunately, it was rare that referred children’s parents followed through with our recommendation, primarily because of cost and access. We then offered access to our ECPs at Minnesota Eye Consultants in a neighborhood office at no cost and created a foundation to pay for the needed care, including eyeglasses. We still achieved minimal parent compliance with our recommendations. I have no answer to these challenges, but it is clear to me that when a visual abnormality such as amblyopia or progressive myopia is diagnosed early and care is directed by an ECP, a child’s visual prognosis is far better than with no treatment.
For amblyopia therapy, we now have a digital and a virtual alternative to the time-tested patching and penalization approaches for therapy. The FDA-cleared NovaSight CureSight digital amblyopia therapy system and the FDA-approved Luminopia virtual reality goggle amblyopia system both have data that are noninferior to patching. For select patients, these two approaches are valid alternatives, and some parents and children will find them attractive. For those ECPs who treat amblyopia, both companies have quality websites that share their clinical trial data and provide appropriate education regarding their technology and access.
Progressive myopia is a special interest of mine, and I consult in this field. I have previously written two perspectives on this topic, so I will not repeat those comments. About one in 10 young children evaluated in a school screening have progressive myopia. Early recognition of the progressive myope is critical. At age 5 years, any level of myopia is abnormal. Most define emmetropia as +0.5 D to –0.5 D, and anything over –0.5 D in a 5-year-old is likely the beginning of progressive myopia and deserves a discussion with parents and the offer of treatment. Conversations with myopic affluent parents are easier than those with emmetropic impoverished parents, and in the U.S. today, 42% of parents younger than the age of 54 years are myopic.
Since the work of Hubel and Wiesel in the 1960s, we know that blurry vison accelerates an eye’s axial elongation, resulting in progressive myopia. Therefore, the first important treatment is to fully correct a child’s myopia with spectacles or a contact lens and keep that correction current as the myopia progresses. In addition, encouraging outdoor activity for at least 1 hour per day and using the 20-20-20 rule of 20 seconds of distance gazing at something 20 feet away after every 20 minutes of continuous near work is a habit that every parent should encourage and every child should adopt.
We now also have specialty glasses and specialty contact lenses as well as pharmacologic eye drop treatment with dilute atropine. There are more than 10 papers reporting efficacy with atropine eye drops in Asian patients, but until recently, we lacked data in white children. In the past year, there have been two important papers published regarding atropine eye drop treatment in white patients of European descent. The first, from the Pediatric Eye Disease Investigator Group in the U.S., found no benefit for American children treated with non-preserved 0.01% atropine eye drops in a water-based vehicle. The second, from Ireland, reported a modest benefit for 0.01% non-preserved atropine eye drops in a water-based vehicle with a 16% reduction in myopia progression at 2 years. Both papers suggested that a higher concentration atropine eye drop, or an eye drop whose vehicle and preservative allow better penetration into the eye, might be more effective, and several Asian papers support this position. In addition, it is logical to me that behavioral modification, appropriate optical correction and low-dose atropine eye drops will be synergistic and additive in benefit. In every report, low-dose atropine eye drop therapy was well tolerated by children.
We have much to learn, but every diopter of myopia increases the risk for cataract, glaucoma, myopic maculopathy, retinal detachment and anxiety disorders later in life. Low myopia, usually defined as –0.5 D to –3 D, is better tolerated and potentially useful in the presbyopia years, but moderate myopia between –3 D and –6 D presents a meaningful handicap in daily activities, and pathologic myopia of –6 D and greater with an axial length of 26 mm or more is best avoided. Myopia also affects an individual’s mental health and is associated with anxiety disorders, which increase with increasing myopia. Myopia progression can continue for decades, but the rate of progression declines with age.
There is slow, moderate and fast progression of myopia. I define slow progression as –0.25 D per year, which would generate a low myope by college age. Some parents might accept this outcome. A moderate rate of progression is –0.25 D to –0.5 D per year and will lead to a moderate myope by college age. I believe these patients deserve treatment, and it will benefit their ocular and mental health. The children with fast progression can change –0.5 D to –1 D or more per year. These patients require treatment, as by college age, they will develop pathologic myopia. While a low level of myopia is fairly well tolerated and can be treated with surgery later in life, I believe progressive myopia is a disease and deserves treatment to preserve vision by reducing the risk for sight-threatening complications in later life and to reduce anxiety disorders, enhancing mental health.
Just like glaucoma, in which every millimeter of mercury IOP reduction reduces the risk for vision loss, in progressive myopia, every diopter of myopia reduction is beneficial for our patient’s ocular health and their mental well-being.
- References:
- Loughman J, et al. Acta Ophthalmol. 2023;doi:10.1111/aos.15761.
- Repka MX, et al. JAMA Ophthalmol. 2023;doi:10.1001/jamaophthalmol.2023.2855.
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