“Life cannot be saved for tomorrow. It always happens in the present.” Rubem Alves

The prevalence of myopia and high myopia continues to increase worldwide^1,2. The association between high myopia, pathologic myopia, and visionthreatening eye diseases imposes the need to implement health policies to limit eye elongation and minimize its adverse visual consequences³⁵. Recent interventions that can delay the onset and slow the myopia progression in children and teenagers fall into the categories: of environmental (behavioral), pharmacological, and optical^6,7. In addition, a better knowledge of how to detect the risk of myopia and how to manage its progression makes relevant the choices of therapeutic intervention and the most appropriate time to intervene and initiate myopia management in children and teenagers⁸.

All children under 9 should be encouraged to adopt good visual hygiene habits. Children with hyperopia of less than +0.75 D and those with myopic parents deserve special attention. The guidelines on screen time of the World Health Organization recommend that children aged from 5 to 17 have no more than 2 hours of recreational screen time daily and that preschoolers have only 1hour daily⁹. Increased screen time reduces sleep and school performance¹⁰, whereas outdoor activities were shown to inhibit myopia progression in myopic children aged 67 years by 30% in 1 year¹¹. Myopia present at age ¹³ was related to children who had hyperopia less than +0.75 D at age 67 years¹². A study showed a negative association between outdoor time and myopia where additional time outdoors in the 39year age group was associated with reduced incidence of myopia from 10 to 15 years¹³. Furthermore, another study found 7 independent parameters associated with accelerated eye elongation in 69yearsold children, , which are as follows: parental myopia; reading one or more books weekly; time spent reading; not playing sports; nonEuropean ethnicity; less time spent outdoors; and axial lengthtocorneal radius ratio. Based on these results, the authors pointed out that behavioral changes are of major importance in these children and that preventive measures should be considered¹⁴. Emmetropic children with one myopic parent have a threefold increased risk of becoming myopic; if both parents are myopic, they have a sixfold increased risk¹⁵. Having siblings who are already nearsighted also increases the risk, regardless of parental myopia¹⁶.

Implementation of interventions to delay the onset and slow myopia progression in children and teenagers follows identifying risk factors and diagnosing myopia progression. The following are considered risk factors: age under 9 years, parenteral myopia, time spent outdoors ≤1.5h/day; time spent with near vision activities >3h/day, hyperopia <+0.75D at 67 years of age, and anteroposterior diameter ≥23.6 mm¹⁷. In addition, myopia progression is identified when the refractive error under cycloplegia increases >0.50D in 1 year, when the annual rate of eye elongation is ≥0.3 mm/year until age 10, or >0.2 mm/year from age 11 onward¹⁷.

Regarding pharmacological intervention for managing myopia progression in children, up to now, topical atropine, which is now widely used as an approved or offlabel product, has dominated both clinical trials and practice¹⁸. There are two trends regarding the choice of the initial dose of atropine¹⁹. In the first trend, treatment begins with the lowest concentration (0.01%), and the child is followed for 1 year; if control is not achieved, the dose is increased to 0.025% and, if necessary, to 0.05% after 1 year, according to the same criteria. In the second trend, the concentration is decided according to preestablished criteria of myopia progression in the child and adolescent population, i.e., age, annual progression rate (APR), refraction, and anteroposterior diameter (APD). For ages between 5 and 8 years, the dose of 0.025% atropine should be started, while for ages between 9 and 15 years, if APR is >0.50D/year, refraction is <-4D and APD is <24.5 mm, 0.01% atropine should be started. If these criteria exceed the above values described above, the dose of 0.025% atropine should be started. Furthermore, for patients over 15 years of age, 0.01% atropine is suggested.

Cunha et al.²⁰ showed that the use of 1 drop of 0.025% atropine at night for 2 years was effective in decreasing myopia progression by 65% in Brazilian children aged 612 years with spherical equivalent (SE) between -1.00 and -6.00 D, and APR ≥-0.50D. The control of myopia progression with atropine is dose dependent. The most frequent side effects of lowconcentration atropine are photophobia, blurred near vision, and allergic conjunctivitis. At 2 years of age, photophobia was experienced by 8.6%, 4.7%, and 5.5% of children using atropine at concentrations of 0.05%, 0.025%, and 0.01%, respectively²¹.

Concerning optical intervention in the management of myopia progression, we currently rely on orthokeratology, 1day disposable contact lenses (MiSight^®1day), and spectacle lenses that correct peripheral hyperopic defocus (Hoya’s MiyoSmart^® and Essilor’s Stellest^®).

Orthokeratology uses specially designed contact lenses to reshape the cornea temporarily. It is an effective and promising treatment option to control myopia in children. Generally, the 2year inhibitory effect on axial elongation ranges from 30% to 55% compared with singlevision spectacles and contact lenses^22,23. However, a rebound phenomenon in myopia progression occurs after discontinuing orthokeratology and the duration of treatment for maximum effect remains unknown²³.

MiSight^® 1 day (Cooper Vision) is a multizone soft contact lens indicated for controlling myopia progression in children 812 years of age at the start of treatment24. The center of the lens focuses on distance error correction, while alternating rings around the center create myopic defocus to slow eye elongation²⁴. For 3 years, there was a 59% reduction in myopia progression (SE) and a 52% reduction in eye elongation (mm)24. Over 6 years, children using MiSight^® 1 day contact lenses progressed by an average of less than 1.00 D²⁵.

MiyoSmart^® (Hoya) spectacle lenses feature a 9.4mm central area for distance error correction surrounded by a treatment area composed of 396 spherical lenses with dioptric power of +3.50D that creates a myopic defocus surface in front of the retina to slow eye elongation (Defocus Incorporated Multiple Segments Technology)²⁶. The results of a 3year clinical trial showed a reduction in myopia progression (SE) and axial elongation (mm) of 86% and 61%, respectively²⁷.

Stellest^® (Essilor) spectacle lenses feature a 9.0mm central zone for distance error correction surrounded by a treatment area composed of 11 rings containing 1021 highly aspherical lenslets with dioptric power varying from +3.50D to +5.00D that creates a myopic defocus volume in front of the retina to slow eye elongation (Highly Aspherical Lenslet Technology)²⁸. The results of a 2year clinical trial with these lenses compared to the historical control group (singlevision lenses) showed a reduction in myopia progression (SE) and axial elongation (mm) of 67% and 60%, respectively²⁹.

Considering that no intervention strategy (behavioral, pharmacological, or optical) effectively inhibits myopia progression in children, we need to explore combination therapies as an approach to improve treatment efficacy⁷. For example, during the 2year followup period, the combination of orthokeratology and 0.01% atropine was more effective in slowing axial elongation than orthokeratology alone in children with myopia, especially in the first year and children with low initial myopia³⁰.

The current epidemic of myopia shows no signs of abating. Despite the limited effectiveness of the available interventions and the potential for recovery, the projected decrease in the risk of complications later in life provided by even moderate reductions in myopia progression suggests that treatment should be considered for young people with myopia, especially those aged 12 years or younger³¹. Bullimore and Brennan³² showed a 67% increase in the risk of myopic macular degeneration (MMD) with each 1.00D increase in myopia. Even a 0.25D reduction in myopia progression (equivalent to 0.1mm) decreases the risk of MMD by approximately 10%. Given the relatively modest effect size expected for the interventions discussed in this editorial, we recommend that eye doctors educate children to practice good visual hygiene to delay the onset of myopia and to be bold in implementing pharmacological and/or optical therapies aimed at slowing the progression of the condition in myopic children³¹.

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AUTHOR’S INFORMATION

» Milton Ruiz Alves
https://orcid.org/0000-0001-6759-5259
http://lattes.cnpq.br/6210321951145266

» Keila Monteiro de Carvalho
http://lattes.cnpq.br/0606513121982929
https://orcid.org/0000-0002-7976-8017

Received on: January 24, 2023.
Accepted on: January 26, 2023.