Why isn’t the myopia control strategy working?

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It’s important to note that there’s nothing currently available which can promise to STOP myopia progression in children. The current research and available options work to SLOW DOWN myopia progression - read more aboutefficacy in myopia management here。So if you’re seeing a change of -0.25 to -0.50D a year? Reassure yourself and your patient that this is expected. Sometimes however, a patient is progressing faster than they should be. Why is it occurring? And what can you do? Here's an investigation of why your myopia control strategy may not be working.

Non-compliance

在阿托品的情况下，必须考虑不合规的可能性。一项对青光眼患者的研究（他们知道他们正在接受合规性的监测！）显示，只有50％的患者在75％的时间里正确服用了药物。1It could be expected that there would be better compliance when parents are monitoring children, but be wary of children being responsible for their own drops. Practitioners have lots of tricks and tips for helping patients remember drops (sticky-tape them to your toothbrush!) however questioning patients on the reality of their regime may simply indicate that if they improve compliance, their myopia control results may improve too. This same issue goes for orthokeratology, multifocal or myopia controlling contact lens and spectacle options - if not worn to your directed schedule the treatment won’t work as expected, especially if a child is spending significant time under-corrected.

在不合规的情况下，与父母和患者进行协作讨论很重要，以确保此治疗仍然适合他们。不合规可以指出阿托品副作用，隐形眼镜舒适性或镜面镜头适应的问题。进行讨论以探索不合规，以就计划中的近视管理策略的原因和方式达成共识。

用户错误

perhaps your patient and their parent implore compliance, but the child is blinking out the atropine drop after application. Perhaps the child is having breaks from their treatment over the weekend or school holidays, leading to long periods of under- or uncorrection. Perhaps they're not wearing their orthokeratology lenses for long enough each night and you're measuring and under-treatment more so than actual myopia progression. Investigate each aspect of the treatment process to ensure issues like these don't impede success.

双眼视力

Myopes tend to be lousy accommodators. Myopic children have been shown to accommodative insufficiently to blur induced by negative lenses2并且发现了减少的适应性反应和近视进展之间的相关性。3This reduced accommodative response (higher lag) has been shown to be related to faster myopia progression when wearing single vision spectacles, and a better myopia control response to progressive addition spectacle lenses.4

New data has shown similar in multifocal contact lenses (MFCL). A test MFCL design was found to reduce accommodative response, and this reduced response was correlated with a reduced myopia control effect. Interestingly, this relationship wasn’t found in the single vision distance CL corrected control group,5指示MFCL光学和适应性之间存在复杂的相互作用。

较大的调节滞后会影响视觉舒适性甚至与隐形眼镜相关的干眼症症状。6Synthesising the studies above indicates that a large accommodative lag could also be influencing your myopia control treatment success. For help on assessing and managing binocular vision check out our free resources in theExpand my Clinical Skills portal本网站；如果您真的想认真对待BV，请查看我们全面的六小时在线课程Binocular Vision Fundamentals。The first hour of the course is available as a free preview.

High myopia

Almost all myopia control studies are undertaken on children aged 6-14 years of age, with myopia of -1.00 to -5.00D. Studies also typically exclude children with significant binocular vision disorders, amblyopia and/or strabismus. If the patient in your chair doesn't fit this criteria, then the typical or average results can't be assumed to apply.

Managing childhood myopia over 5-6D requires extra special care. In a clinical ophthalmology study of 112 children under age 10 with myopia of more than 6D, only 8% had 'simple high myopia' with no other associated ocular or systemic associations. 54% had an underlying systemic condition (eg. developmental delays, Marfan, Stickler, Downs syndrome) and the remaining 38% had further ocular problems associated with high myopia such as lens subluxation, coloboma, retinal dystrophy).7

This means that in children under 10 with high myopia, involvement of paediatric ophthalmology - even as a single referral at minimum - is important to rule out underlying ocular pathology or systemic conditions. Consider co-management with ophthalmology, depending on your scope of practice. Remember though, that primary eye care / optometry is best placed to manage the vision of these patients in the long term, and being the primary myopia 'case manager'. Read an interestingcase study on managing the very high childhood myope here。

必须解释这父母的高ly myopic children at the outset of treatment. Fast progression may still occur despite your best efforts, and it's impossible to know what the progression would have been without myopia control intervention. The key message here is that doing anything to actively manage myopia is likely better than a single vision correction, but that we have no research outcomes to guide us in what to expect of the results.

Visual environment

The picture of how outdoor time and screen time influences myopia progression is becoming clearer. Increased outdoor time, greater near work distance (more than 30cm) and taking breaks from near work every 30 minutes have been shown protective against myopia progression, although each by only around 0.25D over two years on average.8

A survey which analyzed data usage on smartphone devices found that myopic children and teens used almost double the amount of data compared to non-myopes.9While this doesn't prove causation, the association is noteworthy.

Discuss visual environment with parents and patients as a key controllable factor in their overall myopia management success. For resources to provide to parents and patients, theMyKidsVision.orgwebsite includes a blog and How-To video guides - key references include:

Non-responders

无反应者是那些在近视控制研究中表现出最低疗效的儿童。通过简单的优点，即具有“平均”疗效对肌病控制治疗，将会有一些孩子低于该平均水平。影响因素是年龄较小，近视较高和较高的近视进展。在我们的博客中，阅读有关关键近视控制干预研究中非反应者的百分比Non-Responders To Myopia Control Treatments.

What should you do?

  • Evaluate expectations.Consider whether the child in your chair is an 'average' myope likely to experience 'average' efficacy with their intervention strategy. Are they younger, a higher myope, a faster prior progressor, an amblyope? The usual results may not apply.
  • Revisit the treatment.这包括涵盖合规性和治疗过程（用户错误）问题，并确保它仍然是该孩子及其家人能力的合适治疗方法。如果有一种可用的治疗方法可以更好地工作 - 例如，从渐进式添加镜头镜头转变为控制隐形眼镜的近视，请考虑更改治疗方法。请记住，全面的近视管理包括对视觉环境的讨论，因此也考虑“治疗”的这一部分。
  • Add atropine.There are early studies showing a potential synergistic effect of atropine 0.01% and orthokeratology.10基线数据已在阿托品0.01％加上多灶性接触透镜（生物金属中心距离+2.50添加）上显示，表明组合治疗的短期耐受性良好，并具有遵循功效的数据。11
  • Review more frequently.对于不合规和用户错误的情况，这可能特别有用。如果您以更长的时间间隔进行一次，请考虑每3-6个月检查一次。
  • Remember that some progression will occur。在10岁以下的儿童中，每年约0.25至0.50d的进展代表了一个很好的治疗结果，而单一视力磨损中可能的年度进展为0.75-1.25d。在10岁以上的儿童中，每年0.50D或更多的进展可能代表近视控制治疗的无反应。有关衡量儿童年龄和治疗类型的成功的更多帮助，包括将其与父母和患者进行交流，请查看我们的博客在近视管理方面取得成功and our管理近视指南 - 临床实践信息图和父母小册子。

阅读有关“何时不起作用”主题的更多信息：

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About Kate

Dr Kate Giffordis a clinical optometrist, researcher, peer educator and professional leader from Brisbane, Australia, and a co-founder of Myopia Profile.

Cassandra Haines Bio Image 2019_white背景

关于卡桑德拉

Cassandra Haines是一名临床验光师，研究人员和作家，具有澳大利亚阿德莱德的政策和倡导背景。她对儿童的视野和近视控制充满兴趣。

References

  1. Okeke, C. O. et al. Adherence with Topical Glaucoma Medication Monitored Electronically: The Travatan Dosing Aid Study. Ophthalmology 116, 191-199, doi:https://doi.org/10.1016/j.ophtha.2008.09.004 (2009)（关联）
  2. Gwiazda J, Thorn F, Bauer J, Held R. Myopic children show insufficient accommodative response to blur. Invest Ophthalmol Vis Sci. 1993;34(3):690-4.
  3. Gwiazda J，Bauer J，Thorn F，保持R.近视与模糊驱动的儿童的动态关系。视觉res。1995; 35：1299-304。
  4. Gwiazda JE，Hyman L，Norton TT，Hussein Mem，Marsh-Tootle W，Manny R等。与近视进展有关的住宿及相关危险因素及其与彗星儿童治疗的相互作用。投资Ophthalmol Vis Sci。2004; 45：2143-51。
  5. Cheng X, Xu J, Brennan NA. Accommodation and its role in myopia progression and control with soft contact lenses. Ophthalmic Physiol Opt. 2019;39(3):162-71.
  6. Rueff EM, King-Smith PE, Bailey MD. Can Binocular Vision Disorders Contribute to Contact Lens Discomfort? Optom Vis Sci. 2015;92:e214-221.（关联）
  7. Marr JE, Halliwell-Ewen J, Fisher B, Soler L, Ainsworth JR. Associations of high myopia in childhood. Eye. 2001;15(1):70-4（关联）
  8. Huangp，，，，Hsiaoy，，，，TsaiC ，，，，et al近视儿童近视患病率和进展的近工作和户外活动的保护行为：一项为期2年的前瞻性人群研究。br jOphthalmol 2020; 104: 956-961.（关联）
  9. McCrann, S., Loughman, J., Butler, J.S., Paudel, N. and Flitcroft, D.I. (2020), Smartphone use as a possible risk factor for myopia. Clin Exp Optom. doi:10.1111/cxo.13092（关联）
  10. Tan Q, Ng AL, Cheng GP, Woo VC, Cho P. Combined atropine with orthokeratology for myopia control: study design and preliminary results. Curr Eye Res. 2019 Jun 3;44(6):671-8（关联）
  11. Huang J, Mutti DO, Jones-Jordan LA, Walline JJ. Bifocal & Atropine in Myopia Study: Baseline Data and Methods. Optom Vis Sci. 2019 May 1;96(5):335-44（关联）
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