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Association Between Refractive Error Change and Overminus Lens Therapy for Childhood Intermittent Exotropia
abstract
This abstract is available on the publisher's site.
Access this abstract nowIMPORTANCE
Increased myopic shift was found to be associated with 1 year of overminus spectacle treatment for children with intermittent exotropia (IXT). Persistence of myopic shift after discontinuing overminus spectacles is unknown.
OBJECTIVE
To compare refractive error change over 3 years in children with IXT originally treated with overminus vs nonoverminus spectacles.
DESIGN, SETTING, AND PARTICIPANTS
This study was an 18-month extension of the Trial of Overminus Spectacle Therapy for Intermittent Exotropia cohort, which previously randomized children aged 3 to 10 years with IXT and baseline spherical equivalent refractive error (SER) between -6.00 diopters (D) and 1.00 D to overminus spectacles (-2.50 D for 12 months, -1.25 D for 3 months, and nonoverminus for 3 months) or nonoverminus spectacles. Children were recruited from 56 sites from July 2010 to February 2022. Data were analyzed from February 2022 to January 2024.
INTERVENTIONS
After trial completion at 18 months, participants were followed up at 24 and 36 months. Treatment was at investigator discretion from 18 to 36 months.
MAIN OUTCOMES AND MEASURES
Change in SER (cycloplegic retinoscopy) from baseline to 36 months.
RESULTS
Of 386 children in the Trial of Overminus Spectacle Therapy for Intermittent Exotropia, 223 (57.8%) consented to 18 months of additional follow-up, including 124 of 196 (63.3%) in the overminus treatment group and 99 of 190 (52.1%) in the nonoverminus treatment group. Of 205 children who completed 36-month follow-up, 116 (56.6%) were female, and the mean (SD) age at randomization was 6.2 (2.1) years. Mean (SD) SER change from baseline to 36 months was greater in the overminus group (-0.74 [1.00] D) compared with the nonoverminus group (-0.44 [0.85] D; adjusted difference, -0.36 D; 95% CI, -0.59 to -0.12; P = .003), with 30 of 112 (26.8%) in the overminus group having more than 1 D of myopic shift compared with 14 of 91 (15%) in the nonoverminus group (risk ratio, 1.8; 95% CI, 1.0-3.0). From 12 to 36 months, mean (SD) myopic shift was -0.34 (0.67) D and -0.36 (0.66) D in the overminus and nonoverminus groups, respectively (adjusted difference, -0.001 D; 95% CI, -0.18 to 0.18; P = .99).
CONCLUSIONS AND RELEVANCE
The greater myopic shift observed after 1 year of -2.50-D overminus lens treatment remained at 3 years. Both groups had similar myopic shift during the 2-year period after treatment weaning and cessation. The risk of myopic shift should be discussed with parents when considering overminus lens treatment.
Additional Info
Disclosure statements are available on the authors' profiles:
Refractive Error Change and Overminus Lens Therapy for Childhood Intermittent Exotropia
JAMA Ophthalmol 2024 May 01;142(5)417-428, AM Chen, SA Erzurum, DL Chandler, A Hercinovic, R Wu, M Vricella, AL Waters, BH Ticho, JW Erickson, S Han, PS McDowell, Z Li, RT Kraker, JM Holmes, SA CotterFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
This study is an extension of the previously published PEDIG study in 2021 titled "Overminus Lens Therapy for Children 3 to 10 Years of Age With Intermittent Exotropia: A Randomized Clinical Trial," which showed that the short-term positive effects of overminus lens therapy in improving control of intermittent exotropia (IXT) did not persist at the 18-month follow-up period, during which the child had been weaned off the overminus lens therapy. The therapy consisted of three phases. During phase one (12 months), the child was required to wear prescription glasses incorporating a −2.50 D overcorrection relative to baseline cycloplegic refraction. Phase two consisted of a 3-month duration, during which the overminus prescription lenses were reduced to −1.25 D. Phase three was a 3-month period, during which the overminus prescription lenses were eliminated.
This article presents the results obtained by extending the previous study's follow-up period from 18 months to 36 months following the cessation of treatment. It shows two important points. Firstly, the magnitude of the IXT and its control scores at 24 and 36 months did not differ between the overminus and non-overminus groups. This reinforces the previous study's conclusion that overminus lens therapy does not have a lasting positive effect on IXT. Secondly, for children in the age range studied who had already progressed to myopia, there was a higher mean increase in myopic shift during the period of overminus lens wear than experienced by the non-overminus group of comparable refractive profiles. Although the subsequent rates of myopic progression were comparable in the two groups at the 24-month and 36-month periods, the net result was that the increased myopic shift in the overminus treatment group was not transient. Therefore, the authors concluded that parents should be apprised of the risk of overminus lens therapy resulting in a higher myopic shift during the treatment period.
Given that overminus lens therapy may result in asthenopia at near, has no long-term benefit, and can result in the acceleration of myopia during the treatment period, practitioners and parents should be cautioned about its utilization. Perhaps future studies will show utility in customizing overminus lens therapy. For example, one might use lower amounts of overminus lens treatment if the accommodative convergence–to-accommodation ratio is high and/or combine overminus lens treatment with an add based on plus lens acceptance findings at near. Lastly, the use of prisms and/or vision therapy in conjunction with individualized overminus lens treatment may have a synergistic effect.