Pediatric Myopia Management: Why It’s More Than Just a Pair of Glasses

Pediatric myopia is a condition affecting almost a quarter of the world’s population, with prevalence varying among individuals of different ethnicities and geographic locations.^1,2 Despite the differences in prevalence between members of these various ethnic groups, one theme remains constant — myopia prevalence often increases with age during childhood. Research shows that among children aged 6 to 72 months, myopia prevalence is 1.2%, 3.7%, 3.98%, and 6.6% in patients who are White, Hispanic, Asian, and Black, respectively. Upon reaching the age of 5 to 17 years, overall myopia incidence increases to 9.2%. Stratified according to race, these values are 4.4%, 6.6%, 13.2%, and 18.5% in children who are White, Black, Hispanic, and Asian, respectively.¹

Both genetic and environmental factors may contribute to pediatric myopia. Several chromosomal loci are associated with myopia development, and parents with myopia are more likely to pass these alleles to their children.¹ Congenital myopia, while often non progressive, can be vision threatening and present with other ocular diseases, including retinopathy of prematurity and inherited retinal disorders. It has also been associated with systemic conditions and syndromes, which include Marfan syndrome, Stickler syndrome, Noonan syndrome, and Down syndrome.^3,4 Prematurity and low birth weight are associated with a greater risk of early-onset high myopia (spherical equivalent refractive error [SER] of more than −6 diopters [D]), and the additive effect of near work, and time spent outside cannot be ignored.^1,3

Refractive and Binocular Vision Dysfunction Risk

In children aged younger than 10 years, myopia increases the likelihood of refractive amblyopia, strabismus, and anisometropia. Overall, children with higher degrees of myopia exhibit reduced best corrected visual acuity and contrast sensitivity.^3,5 This visual impairment can affect quality of life, behavior, and educational performance and become a source of depression and anxiety.⁶ While spectacles can provide refractive error correction, they can also create the challenge of minified retinal images and aberrations.^4,5

Retinal Structural Degeneration in Pediatric Myopia

Myopia onset at a younger age not only increases the risk of further progression, it elevates the risk of ocular disease during a patient’s lifetime. Axial length increases can result in pathological myopia that subsequently causes degenerative changes to the eye.^1,2 These complications become more apparent in high myopia and likely result from the prolonged mechanical stretching of the ocular structures.⁵ A younger age at onset allows this stretching to occur for a longer period of time, increasing the risk of disease severity later in life.²

Structural changes resulting from pathological myopia may create deformities in the sclera, choroid, and retina.⁷ Staphyloma, or posterior elongation of the globe secondary to progressive scleral thinning, was originally thought to be rare in pediatric myopia, but the use of widefield optical coherence tomography (OCT) has challenged that thinking, revealing early signs of posterior staphyloma in 12.7% of children between the ages of 6 and 9 years.⁴ Myopic maculopathy, a consequence of high myopia, may involve Bruch membrane lacquer cracks, chorioretinal and macular atrophy, and choroidal neovascularization. Research shows that 83% of adult patients with myopic maculopathy have signs of diffuse peripapillary choroidal atrophy as children.¹ Compared with children who do not have myopia, children with myopia demonstrate decreased choroidal thickness with age that complements their axial elongation. 

The progressive elongation of the myopic eye stretches the retina, creating an imbalance between pro-angiogenic and anti-angiogenic factors. Ultimately, this leads to abnormal blood vessel growth, fibrovascular membranes, and scar formation.¹ In individuals with more refractive error than −8.00 D, foveoschisis becomes more of a threat as abnormal vitreous traction on the inner retina causes splitting of the macular retinal region. The changes in vitreous volume from axial elongation also contribute to earlier development of posterior vitreous detachments and potential macular holes.^1,7

Peripheral retinal findings, which include lattice degeneration and retinal holes, are common findings in children with high myopia, becoming more prevalent as axial length increases. They also increase the risk of retinal detachment, which can be almost 10 times greater among patients with more refractive error than −3.00 D.⁵ Children with more refractive error than −10.00 D often experience worse postsurgical outcomes following retinal detachment surgery compared with individuals with less refractive error than −10.00 D.⁴ Approximately half of children with pathological myopia will have visual acuity worse than 20/200 secondary to myopic maculopathy or retinal detachment.³

Myopia also affects the optic nerve and crystalline lens. Structural changes include prominent scleral crescents, larger areas of peripapillary choroidal atrophy, and tilted and large optic discs, which may result in a thinner lamina cribrosa.

Myopic progression can also increase the risk of glaucomatous optic neuropathy, and myopia before the age of 20 years is a risk factor for cataract development, especially posterior subcapsular opacities.⁵

Treating and Monitoring Pediatric Myopia Progression

Given the increased pathological risks associated with myopia progression, children with myopia, or those who are predisposed to it, must undergo routine comprehensive eye examinations. Referrals may be made as early as 12 months of age. According to the American Association of Pediatric Ophthalmology and Strabismus (AAPOS), children younger than 48 months with more refractive error than −3.00 D and children aged 48 months and older with more refractive error than −2.00 D should be referred for care.⁸  

Clinicians must be sure to obtain a thorough patient history, which includes information pertaining to parental myopia and systemic disease. This will help the optometrist to evaluate myopia risk and its association with other syndromes and ocular conditions.⁴ Performing careful and thorough refractions can reduce the risks of overcorrection or undercorrection, which have the potential to accelerate myopic progression.^7,9 Anterior segment and dilated fundus examinations can help reveal degenerative changes among these patients. Clinicians can use ocular biometry to confirm axial elongation and  imaging, particularly OCT and fundus autofluorescence, to document posterior changes.⁴

Optometrists can employ various therapies to prevent or slow myopia progression. These interventions, which include atropine treatment, orthokeratology, and multifocal spectacle or contact lenses, not only slow axial and SER progression, they can also help mitigate potential pathologies. Non clinical activities, such as spending more time outdoors, can also reduce this risk — one investigation states that the risk is reduced by 2% for every hour of increased outdoor activity.⁹  

Myopia is increasing in prevalence and threatening children at earlier ages. The associated pathologies can be devastating to vision, and the risk increases as axial myopia progresses and affects these patients for longer periods of their lives. Patients with pediatric myopia and their caretakers must be made fully aware of not only the symptoms of myopia progression, but the complications that arise from progressive myopic errors and inadequately treating and screening for them. As researchers continue to investigate and develop new myopia control therapies, the current treatments designed to limit myopic progression offer a promising pathway to safeguard children from the effects of high and degenerative myopia.