Key words
myopia management - Europe - prevention - optical interventions - atropine
Schlüsselwörter
Myopie Behandlung - Prävention - Europa - optische Interventionen - Atropin
Background
Overall, about one-third of the global population is affected by myopia, making it
the most common refractive disorder of the eye [1]. Recent research shows the
prevalence of myopia still rising, with extreme prevalence of up to 80 – 90 percent
in certain urban Asian areas, as well as not neglectable numbers in Europe [2] – [5]. As a study from 2018 showed, the pooled estimated prevalence for Europe was 27%
(95 CI = 22.4 – 31.6) [6]. With this high
and still increasing prevalence, myopia and its related complications have become
relevant in clinical practice as well as in eye health in general. Especially high
myopia, with its associated
elevated risk for pathologies, such as myopic maculopathy and retinal detachment,
which can cause irreversible visual impairment and even blindness, has become a topic
of high relevance [7]. But even lower degrees of myopia bare a high burden of disease [8]. Overall, this has led to the statement that myopiaʼs effect on eye
health is comparable to the effect of hypertension on the cardiovascular system, and
myopia is being officially recognized as a significant global public health issue
[1], [9] – [13].
At a World Health Organization (WHO) meeting on myopia in 2015, the International
Myopia Institute (IMI) was formed, which published several reports, white papers,
and clinical summaries
declaring the relevance of myopia and summarizing current control options [14]. Besides optimization of behavioral and environmental factors [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], optical and pharmacological interventions for myopia control, such as orthokeratology
(Ortho-K) lenses [27] – [29],
bifocal/multifocal soft contact lenses (MFSCL) [30], novel spectacle lens designs [31], and atropine eye drops, are used [32], [33], [34], [35].
Despite these new myopia management options, no consensus on their use for myopia
in childhood has been established yet. Because many of the treatment options are still
in the process of
being established in clinical routine, there is a need for research on how myopia
is being managed in clinics today. The goal of this survey study was to address this
need by assessing the
methods used momentarily for myopia control in routine practice.
Methods
This online survey study included a questionnaire with a total of 11 main questions,
requiring a time expenditure of ca. 6 – 8 minutes to complete. The invitation to participate
in the survey
was sent via e-mail to members of the European Paediatric Ophthalmology Society (EPOS)
with a link to the survey. Ninety-nine EPOS members were addressed via e-mail. The
invitation e-mail was
sent on 25 June 2021 and the survey link remained available for 1 month to participate.
This was a structured, but non-standardized survey among clinical practitioners regarding
their approach to myopia control. Since no sensitive patient data was collected, no
approval of the
local ethics committee was requested. The questionnaire (see supplementary material)
was created by the authors based on their knowledge of myopia management and treatment
methods used in
practice today.
The following items and respective question areas were inquired: I. Profession and
workplace of the survey participants, as well as general knowledge about the prevalence
of myopia in the
participantsʼ country. II. Preventive measures and recommendations for myopia management
tools, a) regarding outdoor time, reading distance, and near work, b) optical tools,
i.e., application
of Defocus Incorporated Multiple Segments (DIMS) glasses, near additions, or contact
lenses, and c) the application of atropine eye drops. III. Application of additional
diagnostic tools and
frequency of clinical examinations.
Results
I. A total of 48 individuals participated in the survey between 25 June 2021 and 13
July 2021, and 43 (90%) of the participants answered all survey questions. Of the
participants, 45 (94%)
stated they were ophthalmologists. The majority declared working in larger hospitals
(n = 26; 54%), whereas a bit over a quarter work in private practices (n = 14; 29%),
see [Fig. 1]. Half of the participants (n = 24) answered that there was no data on the current
prevalence of myopia in their country, 11 (23%) declared not to be aware of any
data on myopia prevalence, and 7 (15%) responded that they knew about prevalence data
in their country. By the latter, a range of 15 – 75% prevalence values was reported.
Fig. 1 Survey participantsʼ workplace.
II. Of the respondents, 88% (n = 42) affirmed that they give advice about myopia prevention
and management strategies. [Fig. 2] illustrates the responses to the
question regarding which children preferentially are given advice or prevention measures:
little less than half (n = 20; 42%) of the survey participants give advice to all
children in their
clinics, 7 (15%) give recommendations on myopia control tools to children with at
least one myopic parent, and 8 (17%) answered they provide information only to suspect
myopic or children with
myopic progression.
Fig. 2 Specifications on the characteristics of children receiving information and recommendation
for myopia control tools (absolute count of answers depicted on the y-axis).
[Fig. 3] summarizes the results of the main questions of this analysis. a) With the exception
of one survey participant, who declared to not recommend outdoor
time, almost all others (n = 41; 85%) recommend outdoor time as a preventive measure.
Of these 41 survey respondents, 17 (42%) specified that they recommend at least 2
hours of outdoor time
per day. The recommendation regarding near distance is given less frequently, with
28 (58%) participants confirming they do recommend “safe” reading distance, and 15
(31%) negating this. The
answers regarding what a “safe” reading or near work distance is varied between 20 – 50 cm,
with 24 (86%) of the respondents indicating they recommend a “safe” reading distance
and specified
that a distance of at least 30 cm is necessary. Most participants (n = 35; 73%) affirm
they recommend taking regular breaks during “near work” time periods. Fifteen (43%)
of these 35 specified
they give the recommendation to take a break after 20 min of “near work”.
Fig. 3 Summary of answers regarding different myopia management tools (absolute count of
answers depicted on the y-axis).
b) The answers about the utilization and recommendation of optical tools, such as
near addition (bifocal/progressive) glasses were more heterogenous: 8 (17%) survey
participants do advise
using near addition glasses or progressive glasses, while 36 (75%) do not. Similarly,
35 (73%) respondents do not apply DIMS glasses. Eight respondents (17%) recommend
or do apply them. The
proportion of participants who recommend myopia-reducing contact lenses was slightly
higher, with 14 (29%) participants recommending myopia-reducing contact lenses, while
30 (63%) declare they
do not recommend the use of any sort of myopia-reducing contact lenses. The most recommended
contact lenses were Ortho-K lenses (9 of 14 participants who recommend using myopia-reducing
contact lenses). Undercorrection of myopia is mostly not recommended, with 36 participants
(75%) declaring so.
c) Regarding the application of atropine eye drops for myopia control, 29 (60%) survey
participants confirmed prescribing atropine eye drops to slow myopia progression,
while 14 (29%) do not.
All 29 participants who recommend atropine drops declared to be ophthalmologists at
the beginning of the questionnaire. Nearly all survey participants (28 of 29, 97%)
who prescribe atropine
eye drops take the decision of doing so depending on the myopia progression rate over
1 year. Of the respondents (n = 25) who prescribe atropine, 86% use atropine 0.01%
eye drops. Four out of
29 prescribe atropine 0.02% eye drops and 3 out of 29 indicated they also use atropine
0.05% eye drops. The answers regarding minimal acceptable patientʼs age for atropine
eye drops ranged
from 2 to 10 years, with 18 (62%) survey respondents specifying a minimal age of at
least 5 years. Of the 29 participants prescribing atropine drops, 10 (34%) stated
that their patients
reported adverse events after using atropine eye drops. Out of these 10 doctors, 8
specified that their patients complained about photophobia and near visual disturbances.
Also, individual
cases of allergy, dry cough, and pain were also reported. Of the participants prescribing
atropine eye drops, 25 (86%) obtain the drops via a pharmacy. Most participants could
not indicate the
cost of atropine eye drops, with the few answers given varying between 2 and 50 euros
for a 10-mL flask. The answer to the question regarding patient load and the number
of patients treated
yearly with atropine was, in most cases (48%), less or equal to 20 patients.
III. Before starting treatment, 32 (67%) of all survey respondents perform refraction
in cycloplegia, and 18 (38%) measure axial length in their patients. The majority
(n = 22, 46%) of the
participants see their patients 6 months after the start of treatment. Fifteen (31%)
use the IOLMaster® as a specific myopia management instrument, while other diagnostic tools such
as the Myopia Master or Myah are rarely applied.
Discussion
In 2015, the WHO published a much-noticed report about myopia, identifying it as the
refractive error with the most significant risk for ocular pathology leading to legal
blindness [36]. A later report in 2019 encouraged every eye care practitioner to take action to
address myopia progression [37]. The IMI and other
expert groups are establishing clinical guidelines for myopia interventions and management.
However, momentarily, a consensus or even clear myopia control guidance is missing.
The results of
this survey study highlight the lack of information among clinical experts and show
different cliniciansʼ approaches in the use of available myopia control tools and
recommendations. Seeing
the fact that most of the survey participants could not indicate the prevalence of
myopia in their respective countries, there seems to be a clear need for strengthening
general knowledge on
myopia. This seems in line with Wolffsohn et al., who conducted a large scale survey
among eye care practitioners around the globe regarding awareness and interventions
for myopia control,
observing that the general concern about myopia in Europe is lower compared to Asia
[19], [38]. Despite the signs of a general lack of
concern and awareness, it seems that most ophthalmologists are at least aware of the
effectiveness of modulating environmental factors, such as recommending increased
outdoor time and reduced
prolonged near work activities. Regarding optical versus pharmacological myopia management
instruments, the survey indicates that ophthalmologists preferentially use atropine
eye drops for
myopia control. This stands in contrast to previously published data by Wolffsohn
et al. from the IMI, who found Ortho-K as being perceived the most effective method
for myopia control [38]. This discrepancy may be explained by the fact that in the present survey, the participants
were mostly ophthalmologists, whereas in Wolffsohnʼs survey, 72.4% of the
respondents were optometrists and only 18.6% ophthalmologists. Regarding the different
optical instruments, there seems to be less of a clear opinion. Myopia-reducing contact
lenses and
spectacles were not of great value to the survey participants at the time of survey
conduction. It can be debated that there was not yet such a high degree of familiarity
with the DIMS glasses
(e. g. MiYOSMART) in the summer of 2021, when the survey was conducted.
The presented survey has several limitations. Most importantly, the small number of
survey participants limits its generalizability. Furthermore, the questionnaire is
an authorʼs customed
summary of questions, without any proof of validity or standardization. Nevertheless,
it provides valuable information from different European eye care practitioners who
volunteered in
contributing information to the community without any further interests. The survey
and this publication may further raise awareness among stakeholders and eye care practitioners
about the
management options to slow myopia progression in children. Also, collecting data from
European pediatric ophthalmologists might encourage national authorities and eye care
practitionersʼ
societies to articulate evidence-based recommendations and guidelines for childhood
myopia management.
Conclusion
In conclusion, preventive and therapeutic management of myopia should be essential
in the daily routine of pediatric ophthalmologists, but consensus and clear guidelines
are needed. This
survey shows a large agreement about the protective role of outdoor time (85%) and the most common interventional approach is the administration
of atropine eye drops (60%).
Conclusion Box
Already known:
Newly described:
-
The analysis of current common practices among European Paediatric Ophthalmologists
shows that there is a large agreement regarding the protective role of outdoor time.
However there is
little or no consensus regarding interventions, both for medical, such as atropine
drops, and optical interventions.
