Speaker - Ramesh Kekunnaya

The rise in myopia, particularly among children, has become a global concern, with increasing cases observed across continents. Parents frequently ask if their child's glasses prescription can be reduced, highlighting the need for comprehensive management of the condition. Myopia is now recognized as a lifestyle-related disease in children, much like diabetes and cardiovascular diseases in adults. Managing myopia effectively depends on early detection and evidence-based approaches. Professionals in the field, including ophthalmologists and optometrists, must address the condition by considering pharmacological options like atropine or optical corrections such as glasses, contact lenses, and orthokeratology. Affordability and accessibility are key factors, especially since some treatments can be costly. Lifestyle modification remains the most critical intervention for myopia control. Newer options, such as light therapy and specialized lenses, including diffusion optic and peripheral defocus lenses, are being explored. These lenses target peripheral hyperopia, a risk factor for developing myopia. Advances in technology have made peripheral refraction easier and more affordable, offering simpler ways for clinics to measure and manage the condition effectively. 

A structured approach to managing myopia progression is crucial in achieving optimal results. First, it's essential to prioritize simple lifestyle modifications, such as increasing outdoor activities and reducing screen time. These can play a pivotal role in slowing down myopia's progression, especially in younger children. For more advanced cases, optical treatments, eye drops, and bifocal lenses may be necessary, particularly if the child shows signs of esophoria along with myopia progression. Contact lenses can also be beneficial for older children. Regular monitoring is key. At each visit, comprehensive assessments like cycloplegic refraction, axial length measurements, and esophoria tests should be performed. A pedigree chart can help track family history, and open refraction is vital for accurate diagnosis. If a child’s myopia presents unusually—such as a two-year-old with a prescription of -2—it could be a sign of underlying conditions like syndromic myopia or keratoconus. These cases require careful evaluation of lenticular and corneal causes before proceeding with treatments like eye drops, which are more effective for axial myopia. It's also essential to consider the overall ocular structure, including anterior chamber depth and lens thickness, especially in cases where the child might have conditions like micro-spherophakia or retinopathy of prematurity. Properly identifying and managing these factors can significantly impact the effectiveness of the treatment plan.

The Impact Myopia Guidelines present a structured approach to managing myopia progression. The first critical step is to identify true axial myopia, which requires careful diagnosis. Following this, risk factors should be mapped, particularly in children with a family history of high myopia, such as twins or those with myopic parents. Progressive myopes, defined by a 0.5 diopter change over six months to a year, require close monitoring and appropriate control strategies. The next step is to recommend the right treatment based on a base-up approach that includes consultation, counselling, combination therapy, and regular monitoring. Counselling parents is essential, as managing progressive myopia can demand more attention than even paediatric cataract surgery. Treatment should not be abruptly discontinued but tapered off based on changes in axial length and spherical equivalent measurements. The guidelines recommend managing myopia by identifying risk factors, including axial length changes greater than 0.1 mm or refraction shifts exceeding 0.5 diopters. Additional factors such as peripheral refraction and accommodation lag, should also be considered. Treatment options include defocus lenses, multifocal contact lenses, and orthokeratology, particularly for high myopia up to -10 diopters. In cases of accommodation lag, specially designed lenses or bifocals can be helpful, and low-dose atropine (0.01%, 0.05%, or 0.025%) has proven effective for certain patients. Regular monitoring every four to six months is crucial to assess the efficacy of the treatment. If one strategy proves ineffective, combination therapies should be considered. While there is no definitive timing to stop treatment, a two-year period of stability is generally recommended before tapering off interventions.

The Myopia Mantra is based on the Four M's: Master, Measure, Monitor, and Manage. First, understand that myopia has many causes and risk factors. Start by figuring out and measuring these risks. Check the progress of myopia every three to six months. Managing myopia today means more than just giving out regular glasses; it involves using a complete strategy. Proper counselling is key. If you can manage the condition, do so effectively. If not, refer the patient to ensure they get the best care. 

The use of atropine therapy requires careful consideration of dosage, timing, and patient age. For initial treatment, the concentration of atropine depends on the severity of myopia and the patient’s age. For instance, in a six-year-old child with severe myopia (e.g., -6 or -7 diopters) and a family history of high myopia, starting with a higher concentration of atropine may be appropriate. For a child with mild myopia (e.g., -2 diopters) and less family history of myopia, a lower concentration, such as 0.01%, is recommended. If commercially prepared atropine is unavailable, it can be compounded in a lab. If the stability of the compounded preparation is a concern, using a higher concentration, such as 0.025% or 0.05%, might be necessary to ensure efficacy. Atropine should be administered before bedtime to minimize potential glare issues during the day. This timing is typically advised to align with the patient’s daily routine, making it less likely that doses will be missed. In some regions, such as Singapore, evening doses are preferred for convenience, though adjustments may be made based on individual needs. There is no strict age limit for starting atropine treatment. For older patients, such as those who are 12 to 16 years old with progressive myopia, treatment can still be beneficial. Higher doses of atropine or combination therapies may be used, and options like orthokeratology can also be considered. While insurance coverage for older patients can be challenging, particularly if trials have focused on younger populations, extending treatment into the teenage years is often necessary due to ongoing progression. For patients who are 15 or 16 years old and still experiencing myopia progression, continuing atropine treatment until 17 or beyond may be crucial. Monitoring is essential, as myopia progression can continue into late adolescence. Extending treatment in such cases helps manage and mitigate ongoing progression effectively. 

42nd Congress of the European Society of Cataract and Refractive Surgeons, 6 – 10 September 2024, Fira de Barcelona, Spain.