Wagner: This is a discussion of high myopia in children and we will be with a specific case of early onset high myopia. An 11-month-old male infant is brought to your clinic by his mother because he seems to need to get very close to objects to see them. This is their first child. The mother states that both she and her husband are myopic, and the father was diagnosed as having myopia early in his life. You do cycloplegic retinoscopy and you find −7.00 diopters (D) of myopia in the right eye and −7.50 D in the left eye. What is your decision process regarding prescribing glasses in a case like this?
Wang: I would prescribe glasses for an 11-month-old infant with this particular condition. I recommend single vision lenses and plastic frames with the strap around the back.
Wagner: Do you have a number above or below which you would not prescribe glasses in an 11 month old?
Wang: I wouldn't give less than 2.50 D to an 11 month old.
Brown: If the eye is otherwise normal, I would advise the parents that the myopic condition is likely an inheritable trait. I would give the full cycloplegic refractive error correction and single vision lenses.
Wagner: What are your criteria for when to first give glasses?
Brown: I use the following guidelines for prescribing spectacle correction: greater than 2.00 D of myopia or 4.00 D of hyperopia, greater than 2.00 D of astigmatism at a vertical or horizontal axis, and greater than 1.50 D of astigmatism at an oblique axis. This is a guideline and I consider other things (eg, the patient's age) and often will recheck the refraction in 6 months if the refractive error is borderline high.
Wagner: I think that's reasonable. I always tell residents that if you want to generate a lot of second opinions, start putting glasses on 11-month-old infants. Parents don't accept that well in many cases. There is a range in which you decide to treat or not treat, but there are certain limits where you have to do it.
Brown: In this situation when you have parents who already have myopia, they often understand the vision impact of myopia. Parents who do not have this experience are often surprised and wonder why the condition has occurred. This can be more challenging.
Guo: I agree. For an 11-month-old infant, I would give the full cycloplegic refraction for anything between −2.00 and 3.00 D. In this case, there is also a strong family history and I would observe this child more closely and do complete fundus examination and make sure the retina is healthy as well.
Wang: My concern would be that this patient has something more than the typical myopia at −7.00 D at 11 months. There are panels for Stickler syndrome that one can get genetically now if people are interested. I would take a good look at the child, particularly the jaw, tongue, and palate for submucous cleft.
Wagner: I think myopia at this age is unusual enough that you would think of some of these different conditions. Many of these children have congenital myopia that may not progress as rapidly unless there is a family history as in this case.
Brown: I often tell parents that if a child is born with hyperopia, he or she is likely to “outgrow” this and if the eyes are perfect or myopic in infancy then myopia will likely be the ultimate outcome.
Wagner: A case like that is fairly straightforward, and I think most ophthalmologists would give glasses at that age with that degree and the children usually do adapt to them well. It always amazes me how they managed before they were given the glasses. They do manage, but you worry about phenomena such as bilateral ametropic amblyopia that you would otherwise want to correct them for.Recently, we've been hearing about using low-dose atropine for the treatment of progressive myopia. Do you have any experience with it?
Wang: I have a fair amount of experience with atropine, but not in an 11-month-old child.
Wagner: When would you consider using atropine in general?
Wang: I have used atropine in school-aged children who had minor myopia that was progressing. I don't ever start it on the first visit. If I have a child who is progressing more than 1.00 D a year or 0.75 D in 6 months, who I may have put on bifocals initially for that 6 months, I will begin low-dose atropine, usually 0.01% nightly. I will see that child again in 6 months and, if the child progresses more than 1.00 D a year, I will discuss other options. If the child doesn't progress, I will continue the atropine.
Brown: I do not have personal experience with using atropine in the management of myopia progression prevention.
Guo: I do not have much experience using low-dose atropine treating high myopia, but lately we've been having a lot of patients sent to us who request it. Dr. Wang, do you have a local pharmacy that can compound low-dose atropine?
Wang: Yes, we have a local pharmacy that I send an electronic prescription to. The parents will then telephone the pharmacy to provide their insurance information and the pharmacy will mail the atropine to them.
Wagner: My main issue is finding a pharmacy to compound it for us. Many of the pharmaceutical companies are not interested in making low-dose atropine. Are you aware of other pharmacies in your area that compound atropine?
Wang: I have only used the one pharmacy, but there are other options.
Brown: We have a compounding pharmacy in Richmond that will compound necessary ophthalmic medications for our patients.
Wagner: I've had patients come in who have been receiving orthokeratology by an optometrist and want to add atropine to do everything they can to prevent this myopia. That gives you an idea of how concerned parents are about this issue.
Brown: What age group are they doing the orthokeratology for?
Wagner: Usually the children are older, in the 7 to 9 year age range. I've had cases where I've looked at the cornea centrally and saw some little epithelial defects on the corneal surface that I think were probably related to the type of lenses that they use. I know most ophthalmologists don't do it, but many optometrists do it. It is something families consider. I have patients I've seen for years where other family members or the parents are myopic. I've seen these children become myopic at 6 or 7 years of age and progress. I've had a 3 year old with +0.50 D of myopia and 1 year later the child is plano. Those are the ones who would probably benefit the most from atropine, if I were going to use it. Occasionally there are complaints of light sensitivity even with the low dose, and I do think most of them complain about the pain when they instill the drops at night. Having to put those drops in every night is another factor that would dissuade some people from using atropine.
Guo: Dr. Wang, from your experience, do those children who are using low-dose atropine daily have trouble reading? Do they have to depend on reading glasses in school?
Wang: I did a study with several optometrists in which we titrated doses of atropine and checked for pupillary dilatation and accommodative amplitudes. We found that 0.02% atropine doesn't affect either, so 0.01% shouldn't affect either. Obviously, children with very light-colored or blue eyes may dilate a little more. We had a lot of blue-eyed individuals in that study. So it should be half the dose. When you get over 0.02%, you start dilating the pupil. When you get over a little more than that, you start affecting accommodation.
Wagner: In December 2017, the American Academy of Ophthalmology and Optometry published a statement about atropine for the prevention of myopia progression in children. They cited data that we are familiar with. Most myopia in children comes from Asian countries, and one of the concerns was whether using atropine in the United States would be as effective as it would in some Asian countries because of differences in the behavior of the population groups. Future studies are needed to focus on the optimal ages, refractive errors, and perhaps other populations as far as determining whether atropine will be effective. I don't think there is currently a Pediatric Eye Disease Investigator Group (PEDIG) study on this.
Guo: I understand that PEDIG is interested in and will open a multicenter and large sample clinical trial on low-dose atropine for treatment of myopia in the near future. Most of the clinical trials in the literature follow these children for only 2 or 3 years and progression of myopia can take longer than that. What “happens” to the progression of myopia after the atropine is discontinued? There are a lot of questions that need to be answered.
Wang: There have been some studies on those questions. The literature is complicated. Nobody knows why atropine prevents myopia. If you look at a dose of 1% versus 0.01%, 1% almost eliminates the axial growth of the eye. But 0.01% doesn't change axial length the same way. The rebound seems to be greater with 1% than with 0.01%, but 1% works better with bifocals. A dose of 0.01% has much less rebound over time and seems to be the way to go.
Wagner: I think we all need to be aware of the discussions about atropine because families are asking about it. There are certainly benefits and drawbacks.
Wang: One of the drawbacks is that using atropine for myopia is not approved by the U.S. Food and Drug Administration and that leads to issues in terms of reimbursements, hospital policy, and whether we should be using it at all.
Brown: A well-designed study by a large multicenter group would help address the issues we've been discussing. It is important to understand how atropine works and interacts with the other factors that we know seem to induce myopia.
Guo: I agree. Dr. Wagner gave a grand rounds at Rutgers University that discussed factors such as inadequate lighting conditions and extensively using electronic devices for a lot of near work that may increase the progression of the myopia. There are a lot of unknown factors, so multicenter clinical trials should be helpful.
Wagner: Something I just thought of now is the discussion about the emmetropization process and gradient contact lenses. When you correct with a simple contact lens, you're correcting the myopia centrally in the eye at the fovea. However, peripherally there is hyperopia and so that is supposedly a stimulus to become more myopic in this process. It is possible that the orthokeratology lens eliminates that as an issue and so may other types of gradient contact lenses. It makes sense, but have any of you had experience with that?
Wang: The experimental literature is really interesting. If you have hyperopic defocus, even in the periphery of the eye, that part of the eye will expand. So you could use optical means to get one part of the eye to expand and become myopic. That occurs even if you cut the optic nerve. In monkeys, if you break the fovea of one eye and create a hyperopic periphery, that eye becomes myopic. You don't need the fovea or optic nerve to do it. It's some kind of local phenomenon. So it's a complicated subject.
Brown: Then we are reminded of children who have uncorrected congenital cataracts and the axial myopia that occurs. We see this in a population of patients in the Caribbean where access to early surgery is not as readily available as it is in the United States.
Wagner: Thank you for participating in this discussion. There's a lot of information that still needs to be gathered, but I think this is going to be a really active topic in the next 5 to 10 years.
This Eye to Eye session was conducted on Sunday, March 18, 2018, during the annual meeting of the American Association for Pediatric Ophthalmology and Strabismus in Washington, DC.