Interventions to slow progression of myopia in children

Abstract

Background: Nearsightedness (myopia) causes blurry vision when looking at distant objects. Highly nearsighted people are at greater risk of several vision-threatening problems such as retinal detachments, choroidal atrophy, cataracts and glaucoma. Interventions that have been explored to slow the progression of myopia include bifocal spectacles, cycloplegic drops, intraocular pressure-lowering drugs, muscarinic receptor antagonists and contact lenses. The purpose of this review was to systematically assess the effectiveness of strategies to control progression of myopia in children.

Objectives: To assess the effects of several types of interventions, including eye drops, undercorrection of nearsightedness, multifocal spectacles and contact lenses, on the progression of nearsightedness in myopic children younger than 18 years. We compared the interventions of interest with each other, to single vision lenses (SVLs) (spectacles), placebo or no treatment.

Search methods: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 10), MEDLINE (January 1950 to October 2011), EMBASE (January 1980 to October 2011), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to October 2011), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) and ClinicalTrials.gov (http://clinicaltrials.gov). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 11 October 2011. We also searched the reference lists and Science Citation Index for additional, potentially relevant studies.

Selection criteria: We included randomized controlled trials (RCTs) in which participants were treated with spectacles, contact lenses or pharmaceutical agents for the purpose of controlling progression of myopia. We excluded trials where participants were older than 18 years at baseline or participants had less than -0.25 diopters (D) spherical equivalent myopia.

Data collection and analysis: Two review authors independently extracted data and assessed the risk of bias for each included study. When possible, we analyzed data with the inverse variance method using a fixed-effect or random-effects model, depending on the number of studies and amount of heterogeneity detected.

Main results: We included 23 studies (4696 total participants) in this review, with 17 of these studies included in quantitative analysis. Since we only included RCTs in the review, the studies were generally at low risk of bias for selection bias. Undercorrection of myopia was found to increase myopia progression slightly in two studies; children who were undercorrected progressed on average 0.15 D (95% confidence interval (CI) -0.29 to 0.00) more than the fully corrected SVLs wearers at one year. Rigid gas permeable contact lenses (RGPCLs) were found to have no evidence of effect on myopic eye growth in two studies (no meta-analysis due to heterogeneity between studies). Progressive addition lenses (PALs), reported in four studies, and bifocal spectacles, reported in four studies, were found to yield a small slowing of myopia progression. For seven studies with quantitative data at one year, children wearing multifocal lenses, either PALs or bifocals, progressed on average 0.16 D (95% CI 0.07 to 0.25) less than children wearing SVLs. The largest positive effects for slowing myopia progression were exhibited by anti-muscarinic medications. At one year, children receiving pirenzepine gel (two studies), cyclopentolate eye drops (one study), or atropine eye drops (two studies) showed significantly less myopic progression compared with children receiving placebo (mean differences (MD) 0.31 (95% CI 0.17 to 0.44), 0.34 (95% CI 0.08 to 0.60), and 0.80 (95% CI 0.70 to 0.90), respectively).

Authors' conclusions: The most likely effective treatment to slow myopia progression thus far is anti-muscarinic topical medication. However, side effects of these medications include light sensitivity and near blur. Also, they are not yet commercially available, so their use is limited and not practical. Further information is required for other methods of myopia control, such as the use of corneal reshaping contact lenses or bifocal soft contact lenses (BSCLs) with a distance center are promising, but currently no published randomized clinical trials exist.

Conflict of interest statement

DECLARATIONS OF INTEREST

Jeffrey J Walline, OD, PhD was the Principal Investigator of the Contact Lens and Myopia Progression (CLAMP) Study which was an RCT to examine the effects of rigid gas permeable contact lenses (RGPCLs) on myopia progression in children. Susan Cotter, OD, MS was the Principal Investigator on a trial evaluating pirenzepine ophthalmic gel for slowing myopia progression in children. Both studies were included in this review.

Jeffrey J. Walline received research funding, consulted for companies, received honoraria from companies, and has pending grants with companies, all relating to myopia and/or myopia progression. Susan Cotter’s institution received grant funding for participation in the following NIH/NEI-funded multicenter study related to myopia: Correction of Myopia Evaluation Trial — 2 (COMET-2).

Figures

Analysis 1.1

Comparison 1 Undercorrection vs. Full correction spectacles, Outcome 1 Change in refractive error from baseline.

Analysis 1.2

Comparison 1 Undercorrection vs. Full correction spectacles, Outcome 2 Change in axial length from baseline.

Analysis 2.1

Comparison 2 Multifocal lenses vs. Single vision lenses, Outcome 1 Change in refractive error from baseline (1 year).

Analysis 2.2

Comparison 2 Multifocal lenses vs. Single vision lenses, Outcome 2 Change in refractive error from baseline (2 years).

Analysis 2.3

Comparison 2 Multifocal lenses vs. Single vision lenses, Outcome 3 Change in refractive error from baseline (3 years).

Analysis 2.4

Comparison 2 Multifocal lenses vs. Single vision lenses, Outcome 4 Change in axial length from baseline (1 year).

Analysis 2.5

Comparison 2 Multifocal lenses vs. Single vision lenses, Outcome 5 Change in axial length from baseline (2 years).

Analysis 2.6

Comparison 2 Multifocal lenses vs. Single vision lenses, Outcome 6 Change in axial length from baseline (3 years).

Analysis 2.7

Comparison 2 Multifocal lenses vs. Single vision lenses, Outcome 7 Change in corneal radius of curvature from baseline-Horizontal (3 years).

Analysis 3.1

Comparison 3 Novel lens spectacles vs. Single vision lenses, Outcome 1 Change in refractive error from baseline (1 year).

Analysis 3.2

Comparison 3 Novel lens spectacles vs. Single vision lenses, Outcome 2 Change in axial length from baseline (1 year).

Analysis 4.1

Comparison 4 Bifocal soft contact lenses vs. Single vision soft contact lenses, Outcome 1 Change in refractive error from baseline (1 year).

Analysis 4.2

Comparison 4 Bifocal soft contact lenses vs. Single vision soft contact lenses, Outcome 2 Change in axial length from baseline (1 year).

Analysis 5.1

Comparison 5 Rigid gas permeable contact lenses vs. Control, Outcome 1 Change in refractive error from baseline.

Analysis 5.2

Comparison 5 Rigid gas permeable contact lenses vs. Control, Outcome 2 Change in axial length from baseline.

Analysis 5.3

Comparison 5 Rigid gas permeable contact lenses vs. Control, Outcome 3 Change in corneal radius of curvature from baseline.

Analysis 6.1

Comparison 6 Anti-muscarinic agents vs. Placebo, Outcome 1 Change in refractive error from baseline (1 year).

Analysis 6.2

Comparison 6 Anti-muscarinic agents vs. Placebo, Outcome 2 Change in refractive error from baseline (2 years).

Analysis 6.3

Comparison 6 Anti-muscarinic agents vs. Placebo, Outcome 3 Change in axial length from baseline (1 year).

Analysis 6.4

Comparison 6 Anti-muscarinic agents vs. Placebo, Outcome 4 Change in axial length from baseline (2 years).

Analysis 7.1

Comparison 7 Timolol 0.25% eye drops vs. No eye drops, Outcome 1 Change in refractive error from baseline.

Analysis 8.1

Comparison 8 Bifocal spectacles vs. Single vision lenses + Timolol, Outcome 1 Change in refractive error from baseline.

Analysis 9.1

Comparison 9 Atropine + Multifocal lenses vs. Placebo + Single vision lenses, Outcome 1 Change in refractive error from baseline (1 year).

Analysis 9.2

Comparison 9 Atropine + Multifocal lenses vs. Placebo + Single vision lenses, Outcome 2 Change in axial length from baseline (1 year).

Analysis 10.1

Comparison 10 Atropine + Multifocal lenses vs. Cyclopentolate + Single vision lenses, Outcome 1 Change in refractive error from baseline (1 year).

Analysis 11.1

Comparison 11 Atropine vs. Tropicamide, Outcome 1 Change in refractive error from baseline (1 year).

Analysis 11.2

Comparison 11 Atropine vs. Tropicamide, Outcome 2 Change in refractive error from baseline (2 years).

Figure 1

Results from searching for studies for inclusion in review.

Figure 2

Risk of bias summary: review authors’ judgements about each risk of bias item for each included study.

Figure 3

Forest plot of comparison: 1 Undercorrection vs. Full correction spectacles, outcome: 1.2 Change in refractive error from baseline (1 year).

Figure 4

Forest plot of comparison: 2 Multifocal lenses vs. Single vision lenses, outcome: 2.1 Change in refractive error from baseline (1 year).

Figure 5

Forest plot of comparison: 5 Rigid gas permeable contact lenses vs. Control, outcome: 5.1 Change in refractive error from baseline.

Figure 6

Forest plot of comparison: 6 Anti-muscarinic agents vs. Placebo, outcome: 6.1 Change in refractive error from baseline (1 year).