Interventions to slow progression of myopia in children

BACKGROUND: Nearsightedness (myopia) causes blurry vision when one is looking at distant objects. Interventions to slow the progression of myopia in children include multifocal spectacles, contact lenses, and pharmaceutical agents. OBJECTIVES: To assess the effects of interventions, including spectacles, contact lenses, and pharmaceutical agents in slowing myopia progression in children. SEARCH METHODS: We searched CENTRAL; Ovid MEDLINE; Embase.com; PubMed; the LILACS Database; and two trial registrations up to February 2018. A top up search was done in February 2019. SELECTION CRITERIA: We included randomized controlled trials (RCTs). We excluded studies when most participants were older than 18 years at baseline. We also excluded studies when participants had less than ‐0.25 diopters (D) spherical equivalent myopia. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methods. MAIN RESULTS: We included 41 studies (6772 participants). Twenty‐one studies contributed data to at least one meta‐analysis. Interventions included spectacles, contact lenses, pharmaceutical agents, and combination treatments. Most studies were conducted in Asia or in the United States. Except one, all studies included children 18 years or younger. Many studies were at high risk of performance and attrition bias. Spectacle lenses: undercorrection of myopia increased myopia progression slightly in two studies; children whose vision was undercorrected progressed on average ‐0.15 D (95% confidence interval [CI] ‐0.29 to 0.00; n = 142; low‐certainty evidence) more than those wearing fully corrected single vision lenses (SVLs). In one study, axial length increased 0.05 mm (95% CI ‐0.01 to 0.11) more in the undercorrected group than in the fully corrected group (n = 94; low‐certainty evidence). Multifocal lenses (bifocal spectacles or progressive addition lenses) yielded small effect in slowing myopia progression; children wearing multifocal lenses progressed on average 0.14 D (95% CI 0.08 to 0.21; n = 1463; moderate‐certainty evidence) less than children wearing SVLs. In four studies, axial elongation was less for multifocal lens wearers than for SVL wearers (‐0.06 mm, 95% CI ‐0.09 to ‐0.04; n = 896; moderate‐certainty evidence). Three studies evaluating different peripheral plus spectacle lenses versus SVLs reported inconsistent results for refractive error and axial length outcomes (n = 597; low‐certainty evidence). Contact lenses: there may be little or no difference between vision of children wearing bifocal soft contact lenses (SCLs) and children wearing single vision SCLs (mean difference (MD) 0.20D, 95% CI ‐0.06 to 0.47; n = 300; low‐certainty evidence). Axial elongation was less for bifocal SCL wearers than for single vision SCL wearers (MD ‐0.11 mm, 95% CI ‐0.14 to ‐0.08; n = 300; low‐certainty evidence). Two studies investigating rigid gas permeable contact lenses (RGPCLs) showed inconsistent results in myopia progression; these two studies also found no evidence of difference in axial elongation (MD 0.02mm, 95% CI ‐0.05 to 0.10; n = 415; very low‐certainty evidence). Orthokeratology contact lenses were more effective than SVLs in slowing axial elongation (MD ‐0.28 mm, 95% CI ‐0.38 to ‐0.19; n = 106; moderate‐certainty evidence). Two studies comparing spherical aberration SCLs with single vision SCLs reported no difference in myopia progression nor in axial length (n = 209; low‐certainty evidence). Pharmaceutical agents: at one year, children receiving atropine eye drops (3 studies; n = 629), pirenzepine gel (2 studies; n = 326), or cyclopentolate eye drops (1 study; n = 64) showed significantly less myopic progression compared with children receiving placebo: MD 1.00 D (95% CI 0.93 to 1.07), 0.31 D (95% CI 0.17 to 0.44), and 0.34 (95% CI 0.08 to 0.60), respectively (moderate‐certainty evidence). Axial elongation was less for children treated with atropine (MD ‐0.35 mm, 95% CI ‐0.38 to ‐0.31; n = 502) and pirenzepine (MD ‐0.13 mm, 95% CI ‐0.14 to ‐0.12; n = 326) than for those treated with placebo (moderate‐certainty evidence) in two studies. Another study showed favorable results for three different doses of atropine eye drops compared with tropicamide eye drops (MD 0.78 D, 95% CI 0.49 to 1.07 for 0.1% atropine; MD 0.81 D, 95% CI 0.57 to 1.05 for 0.25% atropine; and MD 1.01 D, 95% CI 0.74 to 1.28 for 0.5% atropine; n = 196; low‐certainty evidence) but did not report axial length. Systemic 7‐methylxanthine had little to no effect on myopic progression (MD 0.07 D, 95% CI ‐0.09 to 0.24) nor on axial elongation (MD ‐0.03 mm, 95% CI ‐0.10 to 0.03) compared with placebo in one study (n = 77; moderate‐certainty evidence). One study did not find slowed myopia progression when comparing timolol eye drops with no drops (MD ‐0.05 D, 95% CI ‐0.21 to 0.11; n = 95; low‐certainty evidence). Combinations of interventions: two studies found that children treated with atropine plus multifocal spectacles progressed 0.78 D (95% CI 0.54 to 1.02) less than children treated with placebo plus SVLs (n = 191; moderate‐certainty evidence). One study reported ‐0.37 mm (95% CI ‐0.47 to ‐0.27) axial elongation for atropine and multifocal spectacles when compared with placebo plus SVLs (n = 127; moderate‐certainty evidence). Compared with children treated with cyclopentolate plus SVLs, those treated with atropine plus multifocal spectacles progressed 0.36 D less (95% CI 0.11 to 0.61; n = 64; moderate‐certainty evidence). Bifocal spectacles showed small or negligible effect compared with SVLs plus timolol drops in one study (MD 0.19 D, 95% CI 0.06 to 0.32; n = 97; moderate‐certainty evidence). One study comparing tropicamide plus bifocal spectacles versus SVLs reported no statistically significant differences between groups without quantitative results. No serious adverse events were reported across all interventions. Participants receiving antimuscarinic topical medications were more likely to experience accommodation difficulties (Risk Ratio [RR] 9.05, 95% CI 4.09 to 20.01) and papillae and follicles (RR 3.22, 95% CI 2.11 to 4.90) than participants receiving placebo (n=387; moderate‐certainty evidence). AUTHORS' CONCLUSIONS: Antimuscarinic topical medication is effective in slowing myopia progression in children. Multifocal lenses, either spectacles or contact lenses, may also confer a small benefit. Orthokeratology contact lenses, although not intended to modify refractive error, were more effective than SVLs in slowing axial elongation. We found only low or very low‐certainty evidence to support RGPCLs and sperical aberration SCLs.