Dual therapy against myopia progression: MIYOSMART + Low Dose Atropine

by Patrick Ng
Optometrist
Msc Clinical Optometry
28th April 2023

This article is targeted at readers who already have read about myopia control options such as atropine, DIMS lenses (Miyosmart) or myopia control lenses. If you have yet to read about those, it may be better to read about those lenses in the same blog first, before reading this article.

In the last 2 years, it has been our observation that Miyosmart lenses ( DIMS technology) when used in combination with low dose atropine has better results than atropine or Miyosmart standalone. However, we did not take the effort to do a statistical review of records. But the improvement in slowing down myopia progression is noticeable. The ophthalmologists are also noticing that too.

A European myopia control study consisting of 146 kids was concluded in Feb 2023. The study aimed to compare the efficacy of low dose atropine vs DIMS lens vs dual therapy (low dose atropine+ DIMS lens) vs control ( no therapy). The study concluded that dual therapy is the most effective at slowing myopia progression. Both Atropine and DIMS has also slowed myopia progression significantly compared to no treatment. This study confirmed what the industry have noticed with monotherapy vs no therapy and in cases of rapidly progressing myopia, with dual therapy against single therapy.

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0281816

With the findings from this study, we will be more confident to recommend children who have the potential to be highly myopic to start with dual therapy from the onset. Prior to this study, we have erred on the side of caution and start them on monotherapy ( either atropine or DIMS).

It does not mean that every child will need to go through dual therapy. Children with a later onset of myopia or a slower myopia progression will do well enough with a mono therapy. The challenges of dual therapy is that with atropine, even on a lower dose, may result in photophobia due to a slight dilation of the pupils. We had to make do with caps/hats or even clips on sunglasses. But these methods require the child to remember putting them on whilst outdoors.

Miyosmart has now launched Miyosmart SUN. The same DIMS technology, now with photochromatic technology. This means that under the sun, these lenses will change to a darker shade to reduce glare. This makes dual therapy a lot easier for parents and a lot more comfortable for the children. During this launch, HOYA has also announced that regardless the type of lens, Miyosmart or Miyosmart Sun, there will be no price difference! This is quite surprising, as traditionally, photochromatic lenses cost at least 100-200 dollars more than their non photochromatic version. The reason given by the management was that they realized that their lenses was helping a lot of children globally with myopia control, hence for kids for needed dual therapy, they do not want cost to be the deterrent. Sweet!

Speak to your pediatric ophthalmologists or optometrists about your child suitability for dual therapy myopia control. Alternatively, speak to us over WhatsApp @ +6587256911 or email precisionoptics2013@gmail.com

MIYOSMART – Probably the most effective optical myopia control product

1st published 2019, updated April 2022

MIYOSMART is an optical product invented and designed by Hong Kong Polytechnic University, manufactured by HOYA. It works based on DIMS technology ( Defocus integrated multiple segments). This will create a slight blur at the peripheral view of the lenses (hyperopic defocus, we call it). Hyperopic defocus and has been proven in many clinical research to prevent axial elongation which results in progressing myopia.

Well established products such as Myovision by Zeiss (spectacle lens) , MiSight by Coopervision (contact lenses) works on the same theory. MIYOSMART hyperopic defocus is different from the products mentioned above. It utilizes a honeycomb defocus treatment zone around a 9.1mm clear zone.

Clear viewing zone in the center. Honeycomb like defocus zone at the peripheral

When viewing through the lens, the user will feel a slight blur at the edges of your vision. This blur is slight more noticeable than Myovision. However, in a clinical trial, almost of the children adapted to it within 2 weeks. In the same double masked clinical trial, the results are very good. It slowed down myopia progression by 59% and in 21% of the cases, myopia did not increase in the 2 years clinical trial.* Third year results are currently being collected and analysed and will be out soon.

It has been 3 years since we have started prescribing these lenses and as a simple non invasive method, it has done very well. For the treatment to be most effective, the frame selection is very important. The frame has to be well adjusted and fitted to the face. The glasses serves dual function (treatment as well as corrective) and has to be worn full time. We will also recommend a 6 monthly review so that we can stack on low dose atropine to improve the efficacy if required. Miyosmart and atropine are not mutually exclusive and can be used together in a combination therapy if the child does not have extreme photophobia or sluggish accommodation ( rare in low dose atropine, more common in high dose atropine)

We also frequently have request to have blue filter added onto Miyosmart. However, it is currently not available. (to ensure that the lenses used in the research is identical to what is being prescribed). To date, there is no strong evidence that blue light can increase or decrease the rate of myopia.

In summary, Miyosmart is effective in slowing down myopia progression. It can also be used in tandem with low dose atropine for better efficacy if required. Speak to your optometrist.

Link below for full scientific article

https://bjo.bmj.com/content/early/2019/05/29/bjophthalmol-2018-313739

*

MiSight – myopia control contact lenses

 

MiSight is a new daily disposable contact lens that has been proven to slow down the progression of myopia in children by 59% in a 4 year study done in a few countries. As a non-pharmaceutical option to control myopia, it is a very appealing tool for optometrist.

Currently, to control myopia progression, we have special spectacle lenses (progressives, bifocals, prismatic bifocals, myopic defocus), atropine as well as Ortho-K. The myopia control spectacle lenses will work for certain children who exhibit certain binocular vision anomalies such as convergence excess and accommodative lag. The effectiveness is also contingent on the glasses being well aligned and the child using it correctly.

Atropine treatment seems to work quite well for children especially in higher concentration but parents may be concerned with potential long-term side effects (not established as yet). It also may increase glare as the pupils will be dilated. There is also an associated rebound myopia upon sudden cessation of the drops.

Ortho-k works very well to control myopia but there is always a small but real risk of a bacterial infection. During the treatment period, the lenses must be worn regularly to maintain good vision and myopia control. In the event the child has to stop wearing these lenses, the myopia will creep back resulting in reduced vision during this period. The child has to wear glasses in the interim until lens wear is resumed. The prescription will fluctuate during this period.

MiSight presents another option for us to control myopia progression. It creates a retinal myopic defocus to prevent the eyeball from elongating by using alternating rings of corrective and treatment zone on the contact lens. In a multi-center, double masked 3 year study, kids wearing MiSight lenses shown a 59% reduction in the progression of myopia versus those on regular daily disposable lenses. At the end of the 3 year study, the control group was switched over to the MiSight lenses. At the end of the 4th year, they too exhibited a slow down in the progression of myopia.

This contact lens is only available in a daily disposable to reduce the risk of allergies and infection. MiSight disposable lens uses PC Technology. Phosphorylcholine (PC) molecules attract and bind water to the surface, creating a shield that keeps the lenses clean and functioning properly. The PC molecules also help the lenses remain hydrated, which in turn, help them feel moist and comfortable all day long.

Due to the unique rings of corrective and treatment zone, it will take a few days to get used to it. I have personally tried it on myself to test the vision and comfort, under room lighting images are clear with no physical nor visual discomfort. However, when I enter a dim room, I do notice a slight halo around light sources. The lens stayed comfortable in my eye till I finish work and reach back home.

For children with astigmatism, they will have to make a pair of glasses to correct the residual astigmatism as these lenses do not correct astigmatism. The children can then choose to do wear these glasses in class so that while the treatment is taking place, it does not disrupt their vision in school. As it is a treatment administered through contact lenses, the child has to wear the lenses for 6 days per week to have a good effect on the myopia progression.

This is indeed a very promising lens. It is a safe, comfortable and effective way to slow myopia progression in children. It can also be used in tandem with 0.01% atropine if the 0.01% atropine is not working well enough.  The only drawback that foresee is the cost. A month supply costs $150. We look forward to offering this as another option alongside with the existing ones in the fight against myopia. Call or visit us now to understand more.

 

Patrick Ng Yao Min

Optometrist

Msc Clinical Optometry

Myopia – Can we control it?

As parents, we are often very concerned about many different aspects of our child’s life. We are stressed about their physical well being, their intellectual development, their social skill sets. In Singapore, one of the most pressing concern is the development and progression of myopia or more commonly known as short-sightness.

Myopia is the result of the elongation of the eyeball, causing distant objects to be blurry.  Severe myopia increases the risk of developing future eye problems such as retinal detachment, glaucoma etc. The development and  progression of myopia is multi-factorial. The current research has pointed to 3 main factors, of which 2 is modifiable

a) Genes – there are to date 24 myopic risk genetic factors. Individuals who have a higher myopia risk factor gene count has a 1000% increase in developing myopia

b) Lack of outdoor activities under the sun

c) Increase in near activities such as reading, digital devices, Lego bricks, drawing

The last 2 factors are modifiable risk factors. This means that parents can have the option to reduce the probability of myopia development and/or to slow the progression by increasing the outdoor activities and reducing the amount of near vision activities. Should these methods prove to be ineffective or insufficient, there are other modes of myopia control that is available.

1) Ophthalmic lenses

a) Zeiss Myovision

The theory suggests that in a myopic eye, correction with a traditional device such as a spectacle lens causes the image to focus on the retina centrally but comes to a focus behind the retina at the periphery resulting in blur that could drive the eye to elongate and for myopia to increase. The lens designs reversed this by moving the peripheral image forward, onto or in front of the retina, while simultaneously positioning the central image on the retina, resulting in clear vision.  A 30% reduction in myopic progression in two hundred 6-12 year olds with a history of parental myopia was seen with one of the designs.
http://journals.lww.com/optvissci/Fulltext/2010/09000/Spectacle_Lenses_Designed_to_Reduce_Progression_of.4.aspx

For Myovision to work well, the centering of the glasses is of utmost importance. The fitting of the frame should be firm and not sliding the bridge to ensure that the center clear zone is at eye point. Little or no adaptation is required. At our practice, we would recommend this lenses if the myopia progression is not rapid.

b) Add lenses such as Progressives or bifocals

Progressives lenses work to reduce accommodation on a young child whilst reading. These lenses will work fairly well if the accommodative convergence ratio (aka AC/A ratio) is higher than normal. However, the main issue with progressive lenses is that it is difficult to ensure that the young child is using the correct lower prescription of these lenses to read. Bifocals will be a better choice than progressives as it allows the child to access the full reading zone easily.  The frames selected should be well fitting to ensure that the child can access the reading zone easily. Progressive lenses may not be the ideal choice for children with exotropia (outward squint)

c) Prismatic Bifocals (Myopilux Max)

Prismatic Bifocals work to reduce accommodation as well as reduce accommodation and the need to convergence (which drives accommodation again). These lenses are easy to adapt but the visible line may become a cosmetic concern with kids as they grow older. These lenses ARE not suitable for young children with convergence excess (inward squint) problems.

2) Medical Means

Atropine used in varying dosage may retard progression of myopia in children. The most recent study of 0.01% atropine suggest that it is effective in slowing myopia progression with minimal side effects. We usually notice a very slight increase of about 1-2 mm increase pupil size especially so in lighter irises. Photo grey lenses may be then prescribed to alleviate the glare from ambient light.

During subsequent reviews, should the 0.01% not be as effective as desired, the ophthalmologist may suggest changing to a stronger atropine dosage such as 0.1%, 0.125% or even 1%.  Most of the time, we do see better results in terms of stabilising/ slowing down the progression of myopia when this course of action is taken. However, these children will experience a larger pupillary dilation and a  more relaxed/ sluggish accomodation. This results in them feeling more glare and a noticeable effort to switch focus between distance to near vision. They will likely need photogrey lenses with bifocal or progressive lenses to cope with the academic demands while on such treatment.

Atropine treatment is not be desirable for kids who exhibit a outward squint for either distance or near.  Kids with history of eczema may need a closer monitoring to ensure that the eyedrops does not trigger any allergies around the eye.

 

3) Orthokeratology

Ortho-K lenses is a special gas permeable lenses that moulds the shape of the cornea to create a peripheral defocus. These lenses are typically worn to sleep to effect a change on the cornea. The lenses will be removed during waking hours and the patient will be able to have good vision throughout the day. In order for the effects to sustain, the patient has to be on such lenses every night. Ortho-k has been very effective at controlling the myopia progression if well fitted.  Hence it is very important to choose the right orthokerathologist.

However, with overnight wear of lenses, there will be a small but recurring risk of eye infections. The orthokerathologist and child, with the assistance of the parents must work together to reduce the risk. The most pressing concern amongst practitioners and parents is the development of microbial keratitis. Hence, Ortho-K lenses should be treated as a medical device and there must be regular follow up with the optometrist.

4) Bates programme

Highly controversial…. most of the results has been anecdotal without any clinical trials or even studies done. Certain part of the programme that encourages good visual habits, rotation of the eyeball and exposure to sun may by useful to relax the eye muscles or secretion of dopamine that may have a similar effect to atropine.

So… are you more confused?

Bring your child to an optometrist for a consult and check what myopia control may be most suitable for your child. Do remember that clinical decisions and emotive decisions can differ and these influences the options.

 

updated 12th November 2017