Treatment Approach for Low, Mid, and High Myopia
For all degrees of myopia in children, initiate low-dose atropine 0.01% as first-line therapy, which provides approximately 50% reduction in progression with minimal side effects, and strongly encourage increased outdoor time to delay onset and slow progression. 1
Prevention Strategy: Delaying Myopia Onset
- Increased outdoor time is the most effective behavioral intervention to reduce the onset of myopia in children who are not yet myopic or are at risk (hyperopia ≤0.5 diopters). 1, 2
- Reducing near work duration complements outdoor activity in prevention efforts. 2
Progression Control: Applicable to All Myopia Severities
Pharmacological Treatment (First-Line)
- Atropine 0.01% offers the optimal risk-benefit ratio with 50% reduction in myopia progression and no clinically significant visual side effects (no photophobia or accommodation problems requiring bifocals). 1
- This concentration is preferred over higher doses due to the favorable side effect profile while maintaining efficacy. 1, 3
- Atropine demonstrates the highest efficacy among all myopia control interventions. 3
Optical Interventions (Second-Line or Adjunctive)
Orthokeratology (overnight corneal reshaping lenses):
- Effectively slows axial length elongation, which is the primary mechanism of myopia progression. 1
- Critical caveat: carries risk of infective keratitis, requiring careful patient selection, rigorous hygiene protocols, and close monitoring. 1
- Shows moderate efficacy in controlling progression. 3
Peripheral defocus lenses (contact or spectacle):
- May slow myopic progression in a subset of children, though efficacy is lower than atropine or orthokeratology. 1, 3
- Options include defocus incorporated soft contact lenses, extended depth of focus lenses, and peripheral defocus spectacle lenses. 3, 4
Bifocal or progressive addition spectacles:
- Demonstrate lower efficacy compared to pharmacological and other optical interventions. 3
- May be considered when other options are contraindicated or refused. 3
High Myopia-Specific Considerations
Screening Requirements
- In children with high myopia (≥-6.0 diopters), evaluate for syndromic myopia through comprehensive examination and genetic assessment if indicated. 5
- High myopia carries substantially increased risk of vision-threatening complications: retinal detachment, choroidal neovascularization, early cataracts, glaucoma, and macular atrophy. 5, 2
Complication Management
- Anti-VEGF therapies for choroidal neovascularization secondary to pathologic myopia. 4
- Surgical interventions including macular buckling and scleral crosslinking for progressive pathologic changes. 4
- Regular monitoring for retinal complications, glaucoma, and cataract development is essential given the irreversible vision loss potential. 2
Treatment Algorithm by Severity
Low to Mid Myopia (<-6.0 diopters):
- Start atropine 0.01% immediately upon diagnosis. 1
- Prescribe increased outdoor time (minimum 2 hours daily when feasible). 1, 2
- Consider orthokeratology if family is motivated and can maintain strict hygiene, understanding infection risks. 1
High Myopia (≥-6.0 diopters):
- Implement same progression control measures as above (atropine 0.01% + outdoor time). 1
- Screen for syndromic causes and systemic associations. 5
- Establish regular monitoring schedule for complications (retinal examination, intraocular pressure, lens clarity). 5, 2
- Educate family about warning signs of retinal detachment and need for urgent evaluation. 2
Critical Clinical Pitfalls
- Earlier onset of school myopia predicts faster progression and greater risk of high myopia, making early intervention crucial. 2
- The global myopia epidemic is characterized by increasingly early onset, amplifying the importance of prevention strategies in pre-myopic children. 1
- Approximately one-fifth of myopic individuals develop high myopia, which becomes the primary risk factor for irreversible vision loss. 2