What is the best course of action to slow the progression of pediatric high myopia in a 13-year-old male with high myopia (OS -6.75, OD -6.25)?

Best Interventions for Slowing Pediatric High Myopia Progression

For a 13-year-old male with high myopia (OS -6.75, OD -6.25), the most effective intervention to slow myopia progression is low-dose atropine eyedrops combined with multifocal contact lenses or spectacles, as this combination provides the greatest reduction in myopia progression and axial elongation. 1

First-Line Interventions

Pharmacological Options

• Low-dose atropine (0.01% to 0.05%) is highly effective in slowing myopia progression, with studies showing a reduction of 0.38D in refractive change and 0.13mm in axial elongation at one year compared to controls 1
• Higher concentrations of atropine (0.1% to 1.0%) show greater efficacy but have more side effects including accommodation difficulties and pupil dilation 2
• Atropine is the most effective single intervention for myopia control based on comprehensive meta-analyses 2, 1

Optical Interventions

• Multifocal contact lenses, particularly the FDA-approved MiSight daily disposable soft contact lens, have been shown to slow myopia progression without complications during 6 years of monitoring in children 8-12 years old 3
• Orthokeratology (overnight rigid contact lenses) has demonstrated effectiveness in reducing axial elongation by approximately 0.28mm over two years compared to single vision lenses 1
• Multifocal spectacles provide a modest but significant benefit, slowing progression by approximately 0.14D at one year 1

Combination Approach for Maximum Benefit

Primary Recommendation

1. Low-dose atropine (0.01-0.05%) plus one of the following optical interventions:
   • Multifocal daily disposable contact lenses (MiSight) if the child can safely handle contact lenses 3
   • Orthokeratology as an alternative if the child is compliant with proper lens hygiene 3
   • Multifocal spectacles if contact lenses are not suitable 3, 1

Environmental Modifications

• Increase outdoor time to at least 1-2 hours daily, as studies show this can help reduce myopia progression 3
• Limit prolonged near work and ensure proper reading distance and lighting 4

Monitoring and Follow-up

• Regular monitoring of refractive error and axial length every 3-6 months to assess progression 5
• Watch for signs of myopic maculopathy, as high myopes under 18 years have increased risk (12.2% showed progression over 4 years) 5
• Risk factors for myopic maculopathy progression include worse best-corrected visual acuity, longer axial length, and faster axial elongation 5

Important Considerations and Cautions

• Daily disposable contact lenses are the safest option with the lowest rate of complications for soft contact lens wear 3
• Orthokeratology carries a risk of microbial keratitis similar to other overnight contact lens wear modalities 3
• Avoid undercorrection of myopia as this may actually increase myopia progression slightly 2
• Visual training exercises and pressure-lowering eyedrops (timolol) have not been shown to be effective for myopia control 3

Ineffective Interventions to Avoid

• Undercorrection of myopia may actually increase progression by approximately 0.15D compared to full correction 2
• Timolol or other IOP-lowering drops have not shown efficacy in reducing myopia progression 3
• Visual training exercises lack scientific evidence of effectiveness 3
• Acupuncture and nutritional approaches have insufficient evidence to support their use 3

This comprehensive approach prioritizes interventions with the strongest evidence for efficacy in slowing myopia progression while considering safety and practicality for a 13-year-old patient with high myopia.