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What Can Be Done For My Child?

Bullimore, Mark A.

Optometry and Vision Science: August 2000 - Volume 77 - Issue 8 - p 381

The Ohio State University

Most clinicians would agree that slowing the progression of childhood myopia is a worthy pursuit. Unfortunately, the available treatment options are imperfect. For example, the side-effects associated with long-term atropine use suggest that the treatment may be worse than the condition. The reported efficacy of other therapies, such as bifocals or rigid contact lenses, is equivocal. 1–3 The study reported by Fulk et al. in this issue of Optometry and Vision Science addresses the dilemma that confronts practitioners: to prescribe or not to prescribe? 4 Fulk and colleagues have conducted a randomized clinical trial of the effect of bifocal lenses on myopia progression in esophoric children. The rationale for the study is that accommodation is associated with myopia progression and that reducing the accommodative demand with bifocals will slow progression. The authors chose to limit their trial to esophores based on previous studies that suggested the therapy is more effective in this subgroup of myopes. 5 Subjects were randomized to two treatments, bifocals with a +1.50 D add and single vision lenses, and followed for 30 months.

Fulk and colleagues are to be congratulated on their execution of this clinical trial. They met their recruitment goals, compliance and subject retention are acceptable, and the results are being disseminated to the community in a timely fashion. The primary finding is that bifocals reduce myopia progression by around 20% in the study population—a reduction that the authors feel “falls short of what might be considered a substantial benefit.”

So what message should a clinician take away from this study? Although the results provide some support for a role of accommodation in myopia progression, Fulk et al. conclude that the findings do not justify the widespread prescription of bifocals in children. Nonetheless, the practitioner now possesses data from a well controlled study that can be presented to a concerned parent who asks “What can be done to slow the progression of myopia in my child?” The modest benefit of bifocal therapy can be discussed intelligently and weighed against the increased cost of the lenses and the attitude of the patient.

Is this study the final word on myopia control with bifocals? Probably not. First, the effect size is one-half the 40% found in the authors’ pilot study. 6 This higher value was used to derive the sample size for the trial and contributed to the results achieving borderline statistical significance. The reduction in progression is also markedly lower than that reported in a similar study published last year in Optometry and Vision Science. 7 Leung and Brown found that progressive addition lenses slowed myopia progression by 38 to 46% in Hong Kong Chinese children. In spite of the methodological differences, the contrasting results of these two studies are difficult to reconcile. The ongoing Correction of Myopia Evaluation Trial (COMET) has randomized over 400 children to progressive addition lenses and single vision lenses beginning in 1998. 8 Results of this 3-year trial should be available in the near future and may be able to resolve the differences between the results of Fulk et al. and those of Leung and Brown. 4, 7 Finally, clinicians are anticipating the results of the Contact Lens and Myopia Progression (CLAMP) Study, 9 which is comparing the effect of rigid and soft contact lenses on myopia progression, along with ongoing clinical trials of drugs for myopia progression, such as the selective muscarinic antagonist pirenzepine. 10

All of the above studies should provide a wealth of information that can be assimilated by the individual clinician and, potentially, incorporated into published practice guidelines and information for patients.

College of Optometry

Columbus, Ohio

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© 2000 American Academy of Optometry