Maximum plus correction
P. Sarita Soni, OD, MS: My recommended correction for a child whose myopia is progressing rapidly very much depends on the refractive and accommodative status as well as the maturity demonstrated by the child. While I carefully evaluate the accommodative status, I am not inclined to use bifocal glasses or contact lenses. I believe that the evidence for the use of bifocal correction to correct myopia in children is weak and needs to be substantiated with a large-scale clinical trial. Therefore, my choice is maximum plus correction with either contact lenses or spectacles.
If during the examination it is clear to me that the child is not capable of handling contact lenses, no matter now old, I do not prescribe them. I especially do not prescribe contact lenses if the parent is doing all of the talking and the child is relegated to the role of a silent observer. On the other hand, if the child is interested in contact lenses and demonstrates in conversation and by his or her actions that he or she may be capable of handling contact lenses, I am inclined to suggest contact lenses. However, I am always looking for a supportive parent. It is critical that parents be involved in reinforcing compliance.
As for a preference between soft or rigid gas-permeable contact lenses, I believe the jury is still out on the issues of myopia control with rigid contact lenses, and we have shown that soft contact lenses do not adversely affect myopia progression. Hence, I use the usual consideration (participation in sports, etc.) in deciding whether to fit with soft or rigid contact lenses. Finally, with soft contact lenses, I recommend the most frequent replacement schedule the parents can afford. I tell the parents that if they do not wish to worry about compliance with lens care, then the daily disposable modality is the best for children.
- P. Sarita Soni, OD, MS, is the director of the Borish Center for Ophthalmic Research and a professor of optometry and vision science at the Indiana University School of Optometry. She may be reached at 800 E. Atwater, Bloomington, IN 47405; (812) 855-7877; fax: (812) 855-7045; e-mail: firstname.lastname@example.org. Dr. Soni has no direct financial interest in the products mentioned in this article, nor is she a paid consultant for any companies mentioned.
Philip F. Kearney Jr., OD: I recommend comprehensive testing and multifaceted treatment. I ascertain the age of onset and the initial amount of myopia. Children who are myopic before age 10 progress by 0.56 D a year, vs. 0.28 D a year after age 10. (Braun CL, et al. The progression of myopia in school age children: data from the Columbia Medical Plan. Ophthalmic Epidemiol. 1996;3(1):13-21). Children with more than 1 D of myopia at their first exam progress at a significantly faster rate.
Our Cearnaigh lifestyle myopia risk profile then evaluates 30 hereditary, environmental, visual, nutritional and psychological factors that lead to the progression of myopia. Next, refraction, phorometry, tonometry and accommodative and vergence facility testing are performed. Highly progressive myopes show an intraocular pressure (IOP) greater than 16 mm Hg and, often, reduced accommodative flexibility and insufficient vergence facility (Svirin AV, Lapochkin VI, Khashem AB. Statistical evaluation of the role of elevated intraocular pressure and weakened accommodation in progressive acquired myopia. Vestn Oftalmol. 1990;106(3):36-38). All data are collated to estimate continued myopic progression rate and total endpoint myopia.
To contain the myopia, lifestyle myopia risk factors should be vigorously remediated by correcting reading distance, illumination, posture and
nutrition, along with practicing accommodative relaxation techniques and reducing stress. Also, we prescribe the HTS computerized vision skills home training system for any inadequate accommodative and vergence skills. Nearpoint esophores receive a reading prescription.
No progression is achieved in most patients using our multicontouring, myopia-control lenses that are fit based on estimated rates of progression. For average myopes, we fit the Emcee lens (G.P. Specialists, Phoenix), 1.50 D flat, in a large diameter. For early onset myopes, highly progressive myopes, those with higher corneal rigidity and members of highly myopic ethnic populations, we fit the Falcon lens (G.P. Specialists) 2 D flatter than K. (Interestingly, as these lenses maintain excellent centration, we achieve effective containment in low to mild myopes with just night wear. The materials in these lenses are approved by the Food and Drug Administration for night wear.)
All youngsters are taught an eyelid relaxation technique that optimizes comfortable lens instruction and induces full rigid gas-permeable lens adaptation in just 1 to 2 days. Patients are referred for comprehensive information and motivation to our Internet site: www.westol.com/pfkod.
In addition to initial visits, a 3-month checkup is followed by semiannual visits. Should any mild progression be noted in a patient, risk factors are again evaluated and remediated, lenses are fit somewhat flatter, wearing time is added and visual skills are reassessed and corrected as necessary. Unquestionably, doctors should now expect no progression at all in 90% to 95% of myopes.
- Philip F. Kearney Jr., OD, CHt , specializes in the prevention, containment and elimination of myopia. He has designed four lenses for use with ortho-K and recently developed Deep Relaxation Suggestion Therapy, which manipulates psychological variables to significantly enhance both ortho-K and myopia containment results. He can be reached in Mt. Pleasant, Pa., at (724) 547-3110; e-mail: email@example.com. Dr. Kearney has a direct financial interest in the Emcee and Falcon lenses. He is not a paid consultant for any companies mentioned.
Minimum lens power
Glen T. Steele, OD, FCOVD: With the assumption that no ocular disease factors are involved, there are many factors to be considered relating to the development of myopia. It is often difficult to determine the primary cause of myopia, and it is equally difficult to determine the appropriate treatment. Progressive myopia often consists of a genetic predisposition with environmental triggers. Because, as of yet, nothing can be done to alter the genetics of myopia, intervention is directed toward modification of prescriptive or environmental factors.
Individual evaluations of the following areas guide me in determining what to prescribe. First is history, including genetic predisposition, favorite activities and level of participation in those activities. For instance, what is his or her habitual environment? Quite often, the childs favorite activity involves a significant amount of reading. This requires considering a nearpoint prescription in addition to the farpoint prescription. Another consideration is the parents long-term objective for vision care for the child.
Next, what is the minimum amount of lens power that provides reasonable distance visual acuity? Responses to lenses out of phoropter at both distance and near are important. Frequently, the binocular distance visual acuity is improved when the child is outside the phoropter; consequently, the distance lens power can be reduced.
Retinoscopy at far and near and the differences between these findings also guide prescribing. When there is a considerable accommodative lag
at nearpoint, the amount of minus indicated for good distance visual acuity can usually be reduced. Likewise, when there is no lag or a lead of accommodation, the minus required for distance will progress more quickly, and decreases in distance power should be minimized.
Distance minus requires the patient to expend additional effort to sustain nearpoint activities. Reduced accommodative findings at nearpoint, including accommodative facility, are significant factors that should be considered in prescribing. In rapidly progressing myopia, this additional effort can be alleviated by reducing the amount of minus at near, most often in a bifocal format.
The parent should be made aware of specific environmental factors that contribute to the progression of myopia, such as improper lighting, close working distance and prolonged reading without taking a break. In summary, I prescribe the minimum amount of lens power at far and near that allows the patient to operate easily and effectively in his or her present environment.
- Glen T. Steele, OD, FCOVD, can be reached at Pediatric Vision Associates, 857 Mt. Moriah Rd., Memphis, TN 38117; (901) 767-7024; fax: (901) 767-0168; e-mail: firstname.lastname@example.org. Dr. Steele has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
Three-diopter add at home, pinhole glasses at school
Donald Rehm: Reading glasses or bifocals have been shown by numerous studies to slow the movement into myopia, not stop or reverse it. This failure is due to the fact that a full 3 D add is not given, because it would overly disrupt the accommodative/convergence relationship. I recommend the Myopter (see www.myopia.org/myopterpaper.htm) with a 3-D add for all close work at home, reading slightly beyond the far point with a little blur and forcing the eyes to relax. This should undo the stress that has been set up during the days schoolwork so the next days work can be done without building on the ciliary spasm of the previous day.
That first pair of minus glasses should not be prescribed just to enable the child to see the blackboard. Pinhole glasses would be a far safer solution and should also be used for close work in school. (For more on pinholes, see www.myopia.org/pinholes.htm). Of course, using the Myopter for close work in school would be ideal. See How to Save Your Childs Vision at www.myopia.org/savechild.htm for more on the Myopter/pinhole solution. The tragic consequences of the myopic elongation of the eye justify these strong measures, regardless of how inconvenient they may be.
- Donald Rehm is the unpaid president of the International Myopia Prevention Association, a nonprofit organization. He can be reached at 1054 Gravel Hill Rd., Ligonier, PA 15658; (724) 238-2101; fax: (508) 519-8014; e-mail: email@example.com; Web site: www.myopia.org. Mr. Rehm has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
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