Figure 1A: Contact lenses with a concentric ring design correct distance vision at the lens center and have alternating rings of near and distance correction moving towards the lens periphery. Figure 1B: Contact lenses with an extended depth of focus design correct distance vision at the lens center and gradually increase in (add) power toward the lens periphery.
Soft daily disposable contact lenses are a crucial tool for myopia management experts. In an ongoing series of vignettes, Andrew Pucker, OD, of the University of Alabama’s School of Optometry, walks through a hypothetical case report, and details the applications of these devices for the purposes of maintaining strong vision in developing eyes for years to come.
Jack, an 11-year-old boy, reports to your clinic in the early spring with his father after being referred by his primary care optometrist, who regularly refers patients who need myopia management to you. You give the patient and his family a full overview of several myopia management options and obtain a patient history. You discover that Jack first started wearing glasses at age 9 years. He reports recently receiving an updated pair of glasses because his prescription recently jumped, and he states that he is happy with the change and has no history of contact lens (CL) wear.
He has no visual or asthenopic complaints at this visit, and his primary care optometrist’s notes indicate that Jack has normal anterior and posterior segment health with no binocular vision dysfunction. You notice that Jack brought a book about baseball to read while he waited. You note his maturity as he is attentive to your presentation, and even asked questions about soft CLs. Noting the baseball book, you ask Jack about his hobbies and interests. He reports an interest in athletics stating that he plays basketball and baseball, and will be trying soccer for the first time this summer.
After obtaining a clinical history and conducting an educational presentation, you perform your standard myopia management workup and obtain the parameters (Table 1). This information will be crucial in determining treatment selection.
Opting for Daily Disposable Contact Lenses
After reviewing the exam data, you explain to Jack’s family that he is a good candidate for all of the myopia management treatments you offer in your practice. Potential myopia management strategies include soft CLs, orthokeratology, and atropine.2 You arrive at this conclusion based on Jack’s spectacle prescription and his maturity level. You also indicate that Jack’s prescription will likely continue to progress based on his age.3 Jack’s father asks which of the 3 treatment options are most effective for someone like Jack. Citing the research, you indicate that while treatment response varies by study, soft CLs, orthokeratology, and atropine work about equally well for the average progressing myopia patient.2
After reviewing your exam findings, you recommend daily disposable CLs for Jack because of the ease in caring for them. His spectacle prescription can be easily corrected with daily disposable CLs and his maturity level shows that he can likely handle the responsibility. CLs have been shown to improve social acceptance, self-perceived appearance, satisfaction with vision correction, and one’s ability to play sports.4, 5 Daily disposable CLs are least likely to cause microbial keratitis and he can easily wear sunglasses over them while playing sports.6
Jack’s father agrees with your recommendation, but questions how myopia management CLs are different from the single vision spectacles his son wears. He also asks how myopia management CLs are thought to slow the progression of myopia.
Using a diagram of the eye, you explain that single vision CLs function by bringing the myopic image to focus on the fovea. You show Jack’s father that the point of focus is in front of the retina in patients with myopia and explain how contact lenses bring the image to focus on the fovea. You continue by explaining that when single vision CLs correct the image at the fovea, the image shell in the peripheral part of the back of the eye focuses behind the retina (hyperopic defocus). The scientific community believes that this peripheral, out-of-focus image is a growth signal that causes the eye to slowly grow longer and more myopic.7 With myopia management CLs, this image is brought to better focus across the entire back of the eye, slowing myopia progression.
You also discuss the 2 primary categories of contact lenses used for myopia management, which include concentric ring designs and extended depth-of-focus designs. In concentric ring designs , the central part of the CL corrects distance vision and subsequent rings alternate between distance and near correction (Figure 1A). Extended depth-of-focus designs provide distance vision correction in the lens center and increase in (plus) power until reaching the lens periphery (Figure 1B).
After answering the family’s questions, you decide to fit Jack with a concentric ring design CL with a center-distance add power. The treatment is FDA-approved, citing evidence from a well-designed randomized trial to support the use of this technology.8 Despite data supporting the efficacy of extended depth-of-focus CLs, the United States currently lacks an FDA-approved option for these lenses.9
Using your fitting set, you fit Jack with the appropriate lenses (Table 2). He reports great vision and initial comfort, and you determine that his CLs have good coverage, centration, and movement (Table 3).
As is often the case for juveniles, Jack’s lens insertion training has a rocky start. But you educate Jack and his father on best CL care practices and supply them with a multipurpose CL care system. This allows patients to insert a CL that has been dropped on the counter, which commonly happens during the initial training. However, you do emphasize the care system is to be used for helping with initial training and that the CLs should be discarded nightly.
You then provide Jack with 10 trial CLs for each eye stating that he can wear his CLs as many hours as he wants to start. You mention that gradually increasing wear time during the first week of wear is not necessary and encourage him to wear his CLs for as many hours as he can to receive a good treatment effect.10 You remind Jack to wear a pair of his CLs to his next visit, so you can evaluate them after a few hours of wear, and schedule him for a 7-day follow-up visit.
Jack returns to your office in 1 week expressing satisfaction with both the CL vision and comfort. He also indicates that he is able to wear his CLs 12 hours or more each of the past 7 days, and that his comfort level did not change throughout the day. You evaluate his current trial CLs, and confirm that they provide great vision and fit well (good coverage, centration, and movement) (Table 4). You also note that his vision improved by 1 line on the Snellen chart. This may be attributed to neural adaptation, which likely occurs after adjusting to multifocal CL wear. You finalize his CL prescription and schedule him for a 6-month follow-up. At that time, you will perform a full myopia management work up and evaluate Jack’s CL fit to ensure that a clinically meaningful change in power has not occurred.
Jack returns for his 6-month visit on schedule. He states that he still has great vision and comfort in his CLs and it is clear that he is performing proper CL hygiene. You proceed to evaluate his CL fit and power, and note that there are no changes since his last visit. You perform your myopia management workup and obtain the necessary values (Table 5). You compare these values with the baseline visit and determine that there has been no clinically meaningful progression. You arrive at this conclusion because Jack did not need a change in spectacle prescription and his axial length progressed by less than the typical patient with emmetropia. Patients with emmetropia typically progress about 0.10 mm in axial length per year while the average 11-year-old with myopia progresses 0.45 D and 0.22 mm a year.11, 12 You relay the great news to Jack and his father and schedule him to return in 6 months.
Jack returns for his 12-month visit and reports no visual or asthenopic complaints. You evaluate his vision with the CLs and find that, with loose lenses, he noticed a significant improvement in his vision with an extra -0.25 D in his left eye (Table 6). This results in a 1 line improvement in visual acuity, so you update his CL power accordingly (Table 7). You complete your standard myopia management workup and obtain the values in table 8. Comparing these values with his previous visits, you determine that there has been minimal myopia progression and believe that the treatment is working better than anticipated. You share the good news with Jack and his father and schedule him for his next 6-month evaluation.
Jack’s case demonstrates that, for the right patient, concentric ring daily disposable soft CLs are an excellent option and can help maintain a patient’s ability to participate in sports and other hobbies. The key to making these devices work is a patient with strong compliance to proper hygiene. By factoring in a combination of case history, clinical exams, and follow-up results, you can potentially keep patients from progressing.
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3. Comet Group. Myopia stabilization and associated factors among participants in the Correction of Myopia Evaluation Trial (COMET). Invest Ophthalmol Vis Sci. 2013;54(13):7871-7884. doi:10.1167/iovs.13-12403
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5. Walline JJ, Jones LA, Sinnott L, et al. Randomized trial of the effect of contact lens wear on self-perception in children. Optom Vis Sci. 2009;86(3):222-232. doi:10.1097/OPX.0b013e3181971985
6. Stapleton F, Keay L, Edwards K, Holden B. The epidemiology of microbial keratitis with silicone hydrogel contact lenses. Eye Contact Lens. 2013;39(1):79-85. doi:10.1097/ICL.0b013e3182713919
7. Smith EL 3rd, Hung LF, Huang J. Relative peripheral hyperopic defocus alters central refractive development in infant monkeys. Vision Res. 2009;49(19):2386-2392. doi:10.1016/j.visres.2009.07.011
8. Chamberlain P, Peixoto-de-Matos SC, Logan NS, Ngo C, Jones D, Young G. A 3-year randomized clinical trial of MiSight lenses for myopia control. Optom Vis Sci. 2019;96(8):556-567. doi:10.1097/OPX.0000000000001410
9. Cooper J, O’Connor B, Watanabe R, et al. Case series analysis of myopic progression control with a unique extended depth of focus multifocal contact lens. Eye Contact Lens. 2018;44(5):e16-e24. doi:10.1097/ICL.0000000000000440
10. Pucker AD, Steele S, Rueff E, et al. Contact lens adaption in neophytes. Optom Vis Sci. 2021;98(3):266-271. doi:10.1097/OPX.0000000000001662
11. Chamberlain P, Lazon de la Jara P, Arumugam B, Bullimore MA. Axial length targets for myopia control. Ophthalmic Physiol Opt. 2021;41(3):523-531. doi:10.1111/opo.12812
12. Nixon A, Brennan NA. Managing myopia: a clinical response to the growing epidemic. Johnson & Johnson Vision. Published April 13, 2021. Accessed February 12, 2022. https://www.jnjvisionpro.com/education-center/resource-library/managing-myopia-clinical-response-growing-epidemic