TY - JOUR
T1 - Interventions for myopia control in children
T2 - a living systematic review and network meta-analysis
AU - Lawrenson, John G.
AU - Shah, Rakhee
AU - Huntjens, Byki
AU - Downie, Laura E.
AU - Virgili, Gianni
AU - Dhakal, Rohit
AU - Verkicharla, Pavan K.
AU - Li, Dongfeng
AU - Mavi, Sonia
AU - Kernohan, Ashleigh
AU - Li, Tianjing
AU - Walline, Jeffrey J.
N1 - Funding Information:
Funding source: "supported by Carl Zeiss Vision"
Funding Information:
Funding source: the study was sponsored by Coopervision Inc Disclosures: "PC is an employee of Coopervision"
Funding Information:
Funding source: National Eye Institute, National Institutes of Health, USA; Essilor of America, Inc.; American Optometric Foundation Ezell Fellowship
Funding Information:
Funding source: "supported by a collaborative agreement between The Hong Kong Polytechnic University and Menicon Co. Ltd., Japan; contact lenses and solutions and spectacles were sponsored by Menicon Co. Ltd., NKL Contactlenzen B.V., Alcon Hong Kong, Bausch & Lomb Hong Kong, Skyview Optical Co. Ltd., Hong Kong, and Hong Kong Optical Lens Co., Ltd.; and Niche Myopia Funding Grant J-BB7P for facilities at the Centre for Myopia Research"
Funding Information:
Funding source: "the study was supported by grants of RGC GRF (B-Q04G) and Niche Areas Fund (J-BB7P) from The Hong Kong Polytechnic University"
Funding Information:
Funding source: JSPS KAKENHI (Grant No. JP26462646) from the Japan Society for the Promotion of Science, Tokyo, Disclosures: the study authors declare no competing interests
Funding Information:
Funding source: supported in part by the General Research Fund, Research Grants Council, Hong Kong (14111515 [J.C.Y.]); the Direct Grants of the Chinese University of Hong Kong (4054197 [C.P.P.], 4054193 [L.J.C.], and 4054121 and 4054199 [J.C.Y.]); the UBS Optimus Foundation Grant 8984 (J.C.Y.); and the CUHK Jockey Club Children Eye Care Programme Disclosures: the study authors declare no competing interests
Funding Information:
Registration number ChiCTR-TRC-10001122 Funding source: grants from “Major State Basic Research Development Program of China (‘973’ Program, 2011CB504601) of the Ministry of Science and Technology”; “Major International (Regional) Joint Research Project (81120108807) of the National Natural Science Foundation of China”; “China
Funding Information:
Funding sources: Australian Research Council (ARC) Linkage Project Grant Scheme, BE Enterprises Pty Ltd., Capricornia Contact Lens Pty Ltd. (Australia); Boston Products Group of Bausch & Lomb (USA)
Funding Information:
Funding source: "This was a collaborative research supported by HOYA, Tokyo, Japan (PolyU grant numbers H-ZG3B and 1-87LK). In addition to the financial support, the sponsor also provided manufacturing spectacle lenses and frames. It was a joint collaboration in the design of the DIMS lens" Disclosures: the study authors declare no conflicts of interest
Funding Information:
Funding source: "this study was supported by a Collaborative Research Agreement between The Hong Kong Polytechnic University (PolyU) and Procornea Nederland B.V. and a Niche Area Funding (J-BB7P) from PolyU. We thank Menicon Company Limited for supplying Menicon O2 Care for the study"
Funding Information:
Funding source: "This work is supported by the National Natural Science Foundation of China, Grant No. 81560168."
Funding Information:
Funding source: OK lenses were sponsored by Precision Technology Services, Vancouver, B.C., Canada, and contact lens solutions by Ophtecs Corporation, Japan. Atropine eye drops were partially supported by Aseptic Innovative Medicine Co., Ltd., Taiwan Disclosures: the study authors declare no competing interests
Funding Information:
Funding source: "Funding was provided by Medical Science and Technology Research Projects of Henan Province Health Commission (Grant No. 201602073), Key Research and Promotion Special Projects of Henan Provincial Science and Technology Department (Grant No. 201801591), Key School Research Projects of Henan Provincial Department of Education (Grant No. 19A320066), Health and Family Planning Science and Technology Talents Overseas Training Project of Henan Province (Grant No. 2018038)."
Funding Information:
Funding source: Capital’s Funds for Health Improvement and Research (grant number 2018-2-4092)
Funding Information:
Funding source: CooperVision S.L. Spain provided financial support. CooperVision S.L. provided the study contact lenses and the funding to carry out the clinical trial Disclosures: the study authors declare no conflicts of interest
Funding Information:
Funding source: grants from the Region of Southern Denmark; The Danish Eye Research Foundation; Fight for Sight, Denmark; The Danish Eye Research Foundation; Disclosures: the study authors declare no conflicts of interest
Funding Information:
Funding source: "supported by grants from 'Jørgen Bagenkop Nielsens Myopi-Fond' and 'Gener-alkonsul Einar Høyvalds Fond', and by 'Øjenlæge Klaus Trier ApS'"
Funding Information:
Funding source: grant support from the Brien Holden Vision Institute. Some of the contact lenses used in the study were supplied by Sauflon Pharmaceuticals Disclosures: none
Funding Information:
Funding source: "This study was funded by Life Science Society of Liaoning."
Funding Information:
Funding source: "This study was funded by grants from NIH granted to Drs Berntsen (U10 EY023204), Jordan (U10 023206), Walline (U10 023208), Mutti (U10 023210), Frishman (P30 EY007551), and Jackson (UL1 TR001070), and Bausch + Lomb provided contact lens solutions for the study" Disclosures: 7 authors declared support from Bausch and Lomb outside the submitted work
Funding Information:
Funding source: "This study was supported by Eye-Lens Pte., Ltd., Singapore. The sponsor had no role in the design or conduct of this research."
Funding Information:
Funding source: International S&T Cooperation Program of China (grant number 2014DFA30940) and the collaborative research project with Essilor International (Wenzhou Medical University grant numbers 95013006 and 95016010). Disclosures: "Jinhua Bao is an Associate Director of Wenzhou Medical University–Essilor International Research Centre. Adeline Yang, Ee Woon Lim, Daniel P. Spiegel and Björn Drobe are employees of Essilor International."
Funding Information:
Funding source: supported by grants from the Integration, Translation and Development on Ophthalmic Technology (Jingyiyan 2016-5), the Capital Health Research and Development of Special (2016-4-2056), the Ministry of Science and Technology, Beijing Nova Program (Z121107002512055), the National Natural Science Foundation of China (81300797), Sanming Project of Medicine in Shenzhen (SZSM201512045) and the Beijing University-CMU, Advanced Innovation Centre for Big Data-Based Precision Medicine, Ophthalmic Subcenter (BHME2018-2019)
Publisher Copyright:
Copyright © 2023 The Authors. Cochrane Database of Systematic Reviews published by John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration.
PY - 2023/2/16
Y1 - 2023/2/16
N2 - Background: Myopia is a common refractive error, where elongation of the eyeball causes distant objects to appear blurred. The increasing prevalence of myopia is a growing global public health problem, in terms of rates of uncorrected refractive error and significantly, an increased risk of visual impairment due to myopia-related ocular morbidity. Since myopia is usually detected in children before 10 years of age and can progress rapidly, interventions to slow its progression need to be delivered in childhood. Objectives: To assess the comparative efficacy of optical, pharmacological and environmental interventions for slowing myopia progression in children using network meta-analysis (NMA). To generate a relative ranking of myopia control interventions according to their efficacy. To produce a brief economic commentary, summarising the economic evaluations assessing myopia control interventions in children. To maintain the currency of the evidence using a living systematic review approach. Search methods: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register), MEDLINE; Embase; and three trials registers. The search date was 26 February 2022. Selection criteria: We included randomised controlled trials (RCTs) of optical, pharmacological and environmental interventions for slowing myopia progression in children aged 18 years or younger. Critical outcomes were progression of myopia (defined as the difference in the change in spherical equivalent refraction (SER, dioptres (D)) and axial length (mm) in the intervention and control groups at one year or longer) and difference in the change in SER and axial length following cessation of treatment ('rebound'). Data collection and analysis: We followed standard Cochrane methods. We assessed bias using RoB 2 for parallel RCTs. We rated the certainty of evidence using the GRADE approach for the outcomes: change in SER and axial length at one and two years. Most comparisons were with inactive controls. Main results: We included 64 studies that randomised 11,617 children, aged 4 to 18 years. Studies were mostly conducted in China or other Asian countries (39 studies, 60.9%) and North America (13 studies, 20.3%). Fifty-seven studies (89%) compared myopia control interventions (multifocal spectacles, peripheral plus spectacles (PPSL), undercorrected single vision spectacles (SVLs), multifocal soft contact lenses (MFSCL), orthokeratology, rigid gas-permeable contact lenses (RGP); or pharmacological interventions (including high- (HDA), moderate- (MDA) and low-dose (LDA) atropine, pirenzipine or 7-methylxanthine) against an inactive control. Study duration was 12 to 36 months. The overall certainty of the evidence ranged from very low to moderate. Since the networks in the NMA were poorly connected, most estimates versus control were as, or more, imprecise than the corresponding direct estimates. Consequently, we mostly report estimates based on direct (pairwise) comparisons below. At one year, in 38 studies (6525 participants analysed), the median change in SER for controls was −0.65 D. The following interventions may reduce SER progression compared to controls: HDA (mean difference (MD) 0.90 D, 95% confidence interval (CI) 0.62 to 1.18), MDA (MD 0.65 D, 95% CI 0.27 to 1.03), LDA (MD 0.38 D, 95% CI 0.10 to 0.66), pirenzipine (MD 0.32 D, 95% CI 0.15 to 0.49), MFSCL (MD 0.26 D, 95% CI 0.17 to 0.35), PPSLs (MD 0.51 D, 95% CI 0.19 to 0.82), and multifocal spectacles (MD 0.14 D, 95% CI 0.08 to 0.21). By contrast, there was little or no evidence that RGP (MD 0.02 D, 95% CI −0.05 to 0.10), 7-methylxanthine (MD 0.07 D, 95% CI −0.09 to 0.24) or undercorrected SVLs (MD −0.15 D, 95% CI −0.29 to 0.00) reduce progression. At two years, in 26 studies (4949 participants), the median change in SER for controls was −1.02 D. The following interventions may reduce SER progression compared to controls: HDA (MD 1.26 D, 95% CI 1.17 to 1.36), MDA (MD 0.45 D, 95% CI 0.08 to 0.83), LDA (MD 0.24 D, 95% CI 0.17 to 0.31), pirenzipine (MD 0.41 D, 95% CI 0.13 to 0.69), MFSCL (MD 0.30 D, 95% CI 0.19 to 0.41), and multifocal spectacles (MD 0.19 D, 95% CI 0.08 to 0.30). PPSLs (MD 0.34 D, 95% CI −0.08 to 0.76) may also reduce progression, but the results were inconsistent. For RGP, one study found a benefit and another found no difference with control. We found no difference in SER change for undercorrected SVLs (MD 0.02 D, 95% CI −0.05 to 0.09). At one year, in 36 studies (6263 participants), the median change in axial length for controls was 0.31 mm. The following interventions may reduce axial elongation compared to controls: HDA (MD −0.33 mm, 95% CI −0.35 to 0.30), MDA (MD −0.28 mm, 95% CI −0.38 to −0.17), LDA (MD −0.13 mm, 95% CI −0.21 to −0.05), orthokeratology (MD −0.19 mm, 95% CI −0.23 to −0.15), MFSCL (MD −0.11 mm, 95% CI −0.13 to −0.09), pirenzipine (MD −0.10 mm, 95% CI −0.18 to −0.02), PPSLs (MD −0.13 mm, 95% CI −0.24 to −0.03), and multifocal spectacles (MD −0.06 mm, 95% CI −0.09 to −0.04). We found little or no evidence that RGP (MD 0.02 mm, 95% CI −0.05 to 0.10), 7-methylxanthine (MD 0.03 mm, 95% CI −0.10 to 0.03) or undercorrected SVLs (MD 0.05 mm, 95% CI −0.01 to 0.11) reduce axial length. At two years, in 21 studies (4169 participants), the median change in axial length for controls was 0.56 mm. The following interventions may reduce axial elongation compared to controls: HDA (MD −0.47mm, 95% CI −0.61 to −0.34), MDA (MD −0.33 mm, 95% CI −0.46 to −0.20), orthokeratology (MD −0.28 mm, (95% CI −0.38 to −0.19), LDA (MD −0.16 mm, 95% CI −0.20 to −0.12), MFSCL (MD −0.15 mm, 95% CI −0.19 to −0.12), and multifocal spectacles (MD −0.07 mm, 95% CI −0.12 to −0.03). PPSL may reduce progression (MD −0.20 mm, 95% CI −0.45 to 0.05) but results were inconsistent. We found little or no evidence that undercorrected SVLs (MD -0.01 mm, 95% CI −0.06 to 0.03) or RGP (MD 0.03 mm, 95% CI −0.05 to 0.12) reduce axial length. There was inconclusive evidence on whether treatment cessation increases myopia progression. Adverse events and treatment adherence were not consistently reported, and only one study reported quality of life. No studies reported environmental interventions reporting progression in children with myopia, and no economic evaluations assessed interventions for myopia control in children. Authors' conclusions: Studies mostly compared pharmacological and optical treatments to slow the progression of myopia with an inactive comparator. Effects at one year provided evidence that these interventions may slow refractive change and reduce axial elongation, although results were often heterogeneous. A smaller body of evidence is available at two or three years, and uncertainty remains about the sustained effect of these interventions. Longer-term and better-quality studies comparing myopia control interventions used alone or in combination are needed, and improved methods for monitoring and reporting adverse effects.
AB - Background: Myopia is a common refractive error, where elongation of the eyeball causes distant objects to appear blurred. The increasing prevalence of myopia is a growing global public health problem, in terms of rates of uncorrected refractive error and significantly, an increased risk of visual impairment due to myopia-related ocular morbidity. Since myopia is usually detected in children before 10 years of age and can progress rapidly, interventions to slow its progression need to be delivered in childhood. Objectives: To assess the comparative efficacy of optical, pharmacological and environmental interventions for slowing myopia progression in children using network meta-analysis (NMA). To generate a relative ranking of myopia control interventions according to their efficacy. To produce a brief economic commentary, summarising the economic evaluations assessing myopia control interventions in children. To maintain the currency of the evidence using a living systematic review approach. Search methods: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register), MEDLINE; Embase; and three trials registers. The search date was 26 February 2022. Selection criteria: We included randomised controlled trials (RCTs) of optical, pharmacological and environmental interventions for slowing myopia progression in children aged 18 years or younger. Critical outcomes were progression of myopia (defined as the difference in the change in spherical equivalent refraction (SER, dioptres (D)) and axial length (mm) in the intervention and control groups at one year or longer) and difference in the change in SER and axial length following cessation of treatment ('rebound'). Data collection and analysis: We followed standard Cochrane methods. We assessed bias using RoB 2 for parallel RCTs. We rated the certainty of evidence using the GRADE approach for the outcomes: change in SER and axial length at one and two years. Most comparisons were with inactive controls. Main results: We included 64 studies that randomised 11,617 children, aged 4 to 18 years. Studies were mostly conducted in China or other Asian countries (39 studies, 60.9%) and North America (13 studies, 20.3%). Fifty-seven studies (89%) compared myopia control interventions (multifocal spectacles, peripheral plus spectacles (PPSL), undercorrected single vision spectacles (SVLs), multifocal soft contact lenses (MFSCL), orthokeratology, rigid gas-permeable contact lenses (RGP); or pharmacological interventions (including high- (HDA), moderate- (MDA) and low-dose (LDA) atropine, pirenzipine or 7-methylxanthine) against an inactive control. Study duration was 12 to 36 months. The overall certainty of the evidence ranged from very low to moderate. Since the networks in the NMA were poorly connected, most estimates versus control were as, or more, imprecise than the corresponding direct estimates. Consequently, we mostly report estimates based on direct (pairwise) comparisons below. At one year, in 38 studies (6525 participants analysed), the median change in SER for controls was −0.65 D. The following interventions may reduce SER progression compared to controls: HDA (mean difference (MD) 0.90 D, 95% confidence interval (CI) 0.62 to 1.18), MDA (MD 0.65 D, 95% CI 0.27 to 1.03), LDA (MD 0.38 D, 95% CI 0.10 to 0.66), pirenzipine (MD 0.32 D, 95% CI 0.15 to 0.49), MFSCL (MD 0.26 D, 95% CI 0.17 to 0.35), PPSLs (MD 0.51 D, 95% CI 0.19 to 0.82), and multifocal spectacles (MD 0.14 D, 95% CI 0.08 to 0.21). By contrast, there was little or no evidence that RGP (MD 0.02 D, 95% CI −0.05 to 0.10), 7-methylxanthine (MD 0.07 D, 95% CI −0.09 to 0.24) or undercorrected SVLs (MD −0.15 D, 95% CI −0.29 to 0.00) reduce progression. At two years, in 26 studies (4949 participants), the median change in SER for controls was −1.02 D. The following interventions may reduce SER progression compared to controls: HDA (MD 1.26 D, 95% CI 1.17 to 1.36), MDA (MD 0.45 D, 95% CI 0.08 to 0.83), LDA (MD 0.24 D, 95% CI 0.17 to 0.31), pirenzipine (MD 0.41 D, 95% CI 0.13 to 0.69), MFSCL (MD 0.30 D, 95% CI 0.19 to 0.41), and multifocal spectacles (MD 0.19 D, 95% CI 0.08 to 0.30). PPSLs (MD 0.34 D, 95% CI −0.08 to 0.76) may also reduce progression, but the results were inconsistent. For RGP, one study found a benefit and another found no difference with control. We found no difference in SER change for undercorrected SVLs (MD 0.02 D, 95% CI −0.05 to 0.09). At one year, in 36 studies (6263 participants), the median change in axial length for controls was 0.31 mm. The following interventions may reduce axial elongation compared to controls: HDA (MD −0.33 mm, 95% CI −0.35 to 0.30), MDA (MD −0.28 mm, 95% CI −0.38 to −0.17), LDA (MD −0.13 mm, 95% CI −0.21 to −0.05), orthokeratology (MD −0.19 mm, 95% CI −0.23 to −0.15), MFSCL (MD −0.11 mm, 95% CI −0.13 to −0.09), pirenzipine (MD −0.10 mm, 95% CI −0.18 to −0.02), PPSLs (MD −0.13 mm, 95% CI −0.24 to −0.03), and multifocal spectacles (MD −0.06 mm, 95% CI −0.09 to −0.04). We found little or no evidence that RGP (MD 0.02 mm, 95% CI −0.05 to 0.10), 7-methylxanthine (MD 0.03 mm, 95% CI −0.10 to 0.03) or undercorrected SVLs (MD 0.05 mm, 95% CI −0.01 to 0.11) reduce axial length. At two years, in 21 studies (4169 participants), the median change in axial length for controls was 0.56 mm. The following interventions may reduce axial elongation compared to controls: HDA (MD −0.47mm, 95% CI −0.61 to −0.34), MDA (MD −0.33 mm, 95% CI −0.46 to −0.20), orthokeratology (MD −0.28 mm, (95% CI −0.38 to −0.19), LDA (MD −0.16 mm, 95% CI −0.20 to −0.12), MFSCL (MD −0.15 mm, 95% CI −0.19 to −0.12), and multifocal spectacles (MD −0.07 mm, 95% CI −0.12 to −0.03). PPSL may reduce progression (MD −0.20 mm, 95% CI −0.45 to 0.05) but results were inconsistent. We found little or no evidence that undercorrected SVLs (MD -0.01 mm, 95% CI −0.06 to 0.03) or RGP (MD 0.03 mm, 95% CI −0.05 to 0.12) reduce axial length. There was inconclusive evidence on whether treatment cessation increases myopia progression. Adverse events and treatment adherence were not consistently reported, and only one study reported quality of life. No studies reported environmental interventions reporting progression in children with myopia, and no economic evaluations assessed interventions for myopia control in children. Authors' conclusions: Studies mostly compared pharmacological and optical treatments to slow the progression of myopia with an inactive comparator. Effects at one year provided evidence that these interventions may slow refractive change and reduce axial elongation, although results were often heterogeneous. A smaller body of evidence is available at two or three years, and uncertainty remains about the sustained effect of these interventions. Longer-term and better-quality studies comparing myopia control interventions used alone or in combination are needed, and improved methods for monitoring and reporting adverse effects.
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U2 - 10.1002/14651858.CD014758.pub2
DO - 10.1002/14651858.CD014758.pub2
M3 - Article
C2 - 36809645
AN - SCOPUS:85148287877
SN - 1465-1858
VL - 2023
JO - Cochrane Database of Systematic Reviews
JF - Cochrane Database of Systematic Reviews
IS - 2
M1 - CD014758
ER -