Contact Lens and Anterior Eye xxx (xxxx) xxx–xxx

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Contact Lens and Anterior Eye

journal homepage: www.elsevier.com/locate/clae

Childhood and lifetime risk comparison of myopia control with contact

lenses
Kate L. Gifford
School of Optometry and Vision Science, Institute of Health and Biomedical Innovation, Faculty of Health, Queensland University of Technology, 60 Musk Avenue, Kelvin
Grove, QLD, 4059 Australia

ARTICLE INFO ABSTRACT

Keywords: Purpose: The relative risks of ocular pathology with increasing myopia have been described; the absolute life-
Contact lenses time risk of vision impairment from myopia is yet to be compared to the childhood and lifetime risks of contact
Microbial keratitis lens wear for myopia control.
Myopia Methods: Using peer-reviewed data, the absolute risks of microbial keratitis (MK) in daily disposable soft, reu-
Orthokeratology
sable soft and orthokeratology contact lens (CL) wear were calculated over both a childhood (age 8–18) and a
Vision impairment
Paediatric contact lens wear
lifetime (age 8–65) of CL wear. This was compared to the previously published cumulative risk of vision im-
pairment by age 75 based on increasing myopia and axial length. Data were converted utilizing the Council of
International Organizations of Medical Sciences (CIOMS) classification system for frequency of adverse events,
with 95 % confidence intervals included.
Results: The lifetime risk of vision impairment in axial lengths over 26 mm and more than 6D of myopia is
greater than the lifetime risk of MK in any CL modality, except for adult SCL extended wear. If axial length is
below 26 mm and myopia lower than 3D, a lifetime of CL wear is more risky in comparison, except in the case of
daily disposable wear. Ten years of childhood CL wear of any modality presents lower likelihood of MK than any
comparable risk of vision impairment.
Conclusion: The comparative lifetime risks of contact lens wear commenced at age 8 for myopia control are less
than the lifetime risks of vision impairment with myopia more than 6D or axial length more than 26 mm. When
only childhood CL wear is considered, the risk comparison is clearly skewed towards the positive impact of CL
wear, especially in daily disposable wear. Clinicians should be confident to proactively recommend myopia
control CL wear to younger children, as both the safety profile and potential preventative ocular health benefits
are evident.

1. Introduction
The globally evident increase in childhood myopia has prompted
increased academic, clinical and parental awareness of strategies for
myopia control. While pharmacological treatment of progressive
myopia with at least 0.1 % atropine has shown the greatest propensity
for slowing axial elongation, [1] it is associated with clinically un-
palatable side effects of mydriasis and cycloplegia, and restricted access
of primary eye care providers (optometrists) to atropine across the
world limits its widespread application. Contact lens options for myopia
control include dual-focus and multifocal soft contact lenses (SCLs), and
orthokeratology (OK). Demonstrating propensity for slowing both re-
fractive and axial length myopia progression by around 50 % [2,3],
contact lens options have the benefit of correcting myopia as well as
offering a treatment strategy for myopia control. By comparison,
spectacle lens options have shown less consistent success for myopia
control [1] except in one specific prismatic bifocal design [4] and a
novel multi-segment defocus design which is not yet commercially re-
leased [5]. Contact lens wear in children significantly improves quality
of life compared to spectacles [6] and hence is an attractive option for
clinicians, parents and patients alike [1].
Health care decision making requires accurate prediction of out-
comes and their impact, which can be challenging if there is a lack of
familiarity with the circumstance. Healthy people have been shown to
mispredict the impact of chronic illness and disability compared to
those with existing conditions. [7] Particularly for parents of myopic
children who are not myopic themselves, being cognisant of the short
term impact and long term benefits of myopia control is problematic,
beyond the obvious benefit of having a lower prescription. This is
complicated by the lack of professional and public awareness of the

E-mail address: kate@myopiaprofile.com.

https://doi.org/10.1016/j.clae.2019.11.007
Received 23 September 2019; Received in revised form 15 November 2019; Accepted 15 November 2019
1367-0484/ © 2019 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.

Please cite this article as: Kate L. Gifford, Contact Lens and Anterior Eye, https://doi.org/10.1016/j.clae.2019.11.007
K.L. Gifford
pathological nature of myopia and the increased lifetime risk of ocular
disease with increasing levels of myopia.
Flitcroft’s [8] notable analysis of the increasing risk of posterior
subcapsular cataract, retinal detachment and myopic maculopathy with
increasing levels of myopia has alerted the eye care professions to the
lifelong risks of myopia, and its consideration as a disease rather than a
simple refractive condition. The recent International Myopia Institute
White Paper reports have reaffirmed the growing public health burden
of myopia [9] and explored the research [10], industry [11] and clinical
[12,13] landscape required to meet this challenge. Projections indicate
that half of the world’s population is expected to be myopic by 2050,
with around one billion people at significant risk of sight threatening
complications from high myopia over 5D [14]. This risk has already
been realized in Asian countries, where the higher ethnicity frequency
of myopia has already resulted in myopic macular degeneration be-
coming the leading cause of monocular blindness (worse than 20/400)
in Japanese adults of middle age [15], and in new cases of blindness in
Chinese adults, where it accounts for almost 20 % of all new blindness
cases registered [16].
A large cross-sectional study from the Netherlands [17] character-
ized the absolute and odds-ratio risks of uncorrectable vision impair-
ment (defined according to the World Health Organization criteria as a
visual acuity less than 0.3 logMAR, or 20/40 Snellen [18]) by refractive
error and axial length, taking into account almost 16,000 people of
European descent with an average age of 61 years. Axial length showed
the most consistent relationship to vision impairment, with an axial
length of 26 to less than 28 mm was associated with increasing risk of
vision impairment over age 60; while 28 mm or greater was associated
with increased risk of vision impairment from age 45 years onwards.
The lifetime risk of vision impairment (by age 75) increased from 1.6 %
in eyes less than 26 mm to 13 % in eyes of 26 mm or greater. Similarly,
more than 6D myopia was accompanied by a 39 % risk of vision im-
pairment by age 75 while lower than 6D of myopia carried a 3.8 % risk.
Contact lens safety in children is a primary concern for practitioners
and parents alike. Parents have been shown to believe that contact lens
wear in adolescents is less safe than that in the general population. [19]
Parents of teens are also more likely to continue purchasing contact
lenses than parents of children [20]. This is at odds with the evidence
that children and teens appear to be at least as safe in soft contact lens
wear as adults, and in the case of children aged 8–12 years, perhaps
safer [21]. Bullimore’s review of the safety of pediatric soft contact lens
wear estimated the overall frequency of corneal infiltrative events
(CIE’s) as being 97 per 10,000 patient wearing years in children (aged
8–12 years), and 335 per 10,000 in teens (aged 13–17 years). Bullimore
[21] concluded that the risk of CIE’s in children and teens is no higher
than in adults, and that in pre-teens, it may be distinctly lower.
The frequency of the most serious form of CIE, microbial keratitis
(MK), has been demonstrated as lower than this in paediatric soft and
OK contact lens wear. In a retrospective study of 1054 paediatric, pri-
marily reusable SCL wearers and 1372 patient-wearing years, children
aged 8–12 years showed no cases of MK while teens (13–17 years)
demonstrated an MK frequency of 15 per 10,000 patient-wearing years
(95 % confidence interval (CI): 2, 48, calculated by Bullimore [21])
[22]. One prospective study of 247 children aged 8–11 years, of whom
over 90 % wore daily disposable lenses for a total of 723 patient-
wearing years, showed no cases of MK [23]. Regarding OK safety,
Bullimore and colleagues’ retrospective case analysis of 1319 OK
wearers representing 2599 patient years of wear indicated an incidence
of MK of 13.9 per 10,000 in children (CI: 1.7, 50.4) and 7.7 in 10,000
for patients of all ages (CI: 0.9, 7.7) [24]. These modalities represent the
commercially available options for myopia controlling contact lenses fit
to children [25].
Larger studies of the frequency of and risk factors for microbial
keratitis (MK) have been undertaken in adults. Stapleton and colleagues
[26] surveyed some 35,000 individuals over age 15, and found the
incidence of MK in daily disposable contact lens wear to be 2.0 per
2
Contact Lens and Anterior Eye xxx (xxxx) xxx–xxx
10,000 (CI: 1.7, 2.4) and in daily wear silicone hydrogel reusable lenses
11.9 per 10,000 (CI: 10.0, 14.6) patient wearing years. Risk factors for
MK included overnight wear and smoking, which should be dis-
couraged and are irrelevant, respectively, in paediatric wearers. In-
ternet purchase of CLs was also identified as a significant risk for adult
MK, which is potentially less of an issue for myopia controlling CL
fitting as more than 50 % of such fits to children are OK, [25] which
typically cannot be bought online. Identified risk factors for MK which
could pertain to contact lens wearing children include less than 6
months wear experience; poor storage case hygiene and higher socio-
economic class [26].
While the benefits of contact lens wear for children, [27] and for
paediatric myopia control [1] are becoming better understood across
eye care professions, a recent international survey indicates that only
2.3 % of contact lens fits to children are for myopia control [25]. This
suggests there may be professional reticence to use contact lenses as a
first line treatment for myopia control. Such reticence may be reduced
with better understanding of the risks of contact lens wear compared to
myopia associated pathologies to inform treatment choices [28]. To
date, no such comparison exists in the literature. The purpose of this
review was to collate peer–reviewed scientific data to provide a com-
parison of these risks which could be usedin the informed consent
process for myopia control contact lens treatments.
2. Methods
Peer reviewed data were sourced using PubMed which satisfied the
criteria of large epidemiological studies examining the absolute in-
cidence of microbial keratitis in daily disposable soft, reusable soft and
orthokeratology contact lens wear. Data for both children and adult
contact lens wear were sought where available. Data on the cumulative
risk of vision impairment by age 75, based on axial length and level of
myopia, was sourced from the analysis of Tideman et al. [17] for
comparison.
A model was constructed to compare the childhood and lifelong
risks of microbial keratitis in contact lens wear compared to the lifetime
risk of vision impairment due to increasing myopia and axial length.
[17] For purposes of the model, the following assumptions were made.
1 Contact lens wear was assumed to begin at age 8, in alignment with
available safety data [21] as well as to demonstrate proactive
commencement of a myopia control intervention [12]
2 A life expectancy of 75 years was chosen, in alignment with the
uncorrectable vision impairment data of Tideman et al. [17]. As
such, 57 years of uninterrupted contact lens wear and 18 years of
non-contact lens wear was assumed.
3 Where the data was available, the lifetime risk of contact lens wear
was calculated for five years at the pre-teen level of risk (8–12
years), five years at the teenage level of risk (13–17 years) and 47
years at the adult level of risk (18 and older). If this data was not
available, the child specific risk with relevant age was calculated,
with subsequent years of contact lens wear calculated at the adult
level of risk
4 To calculate lifetime risk, the contact lens wearer was presumed to
continue the same modality of contact lens wear from age 8 until 10
years before end of life, to bias the model towards the largest esti-
mation of contact lens risk. To calculate childhood risk, the same
modality was assumed from age 8 until age 18 (10 years of wear).
5 The risk of any case of microbial keratitis (MK) was utilized, rather
than the typically smaller risk of MK resulting in vision loss [26] to
again bias the model to largest estimation of contact lens risk
6 The risk of microbial keratitis (MK) in a non-contact lens wearing
population was also calculated for reference, for all non-contact lens
wearing time in the model, [29] being the first 8 years and last 10
years of life (18 years total).
K.L. Gifford Contact Lens and Anterior Eye xxx (xxxx) xxx–xxx

Table 1
Summary of studies on microbial keratitis risk utilized in building the cumulative childhood and lifetime risk models.
Modality Risk per 10,000 per year Mean Utilization in model/s Study details and notes on application to models
(95% confidence intervals)

No CL wear model
Lifetime [29]
No CL wear components added to CL
wear models [29]
Daily disposable model
Childhood wear (age 8–11) [23]
Adulthood wear [26]
Reusable SCL model
Childhood (age 8–12) [22]
Childhood (age 13–17) [22]
Adulthood with daily wear silicone
hydrogel [26]
Adulthood with extended wear silicone
hydrogel [26]
Orthokeratology model
Childhood (age 8–17) [24]
Combined childhood and adulthood risk
[24]
1.4 (1.17, 1.66) 75 years of risk for no CL wear (age 0–75) Retrospective cohort
Ages 0-85+ included
n = 302 cases of MK in cohort population of 1,093,210.
1.4 (1.17, 1.66) 8 years of risk for age 0-8
10 years of risk for age 66-75
0 (0, 0) 4 years of risk for age 8–11 Prospective
n = 247
Patient years = 723
NOTE: 93 % were wearing daily disposable lenses, the rest
reusable. No cases of MK in adverse events confirmed in
Bullimore [27].
2 (1.7, 2.4) 53 years of risk for age 12-65 NOTE: Adulthood risk applied from age 12 onwards in absence
of specific data for age 12–17.
0 (0, 0) 5 years for age 8–12 Retrospective
n = 243
Patient years = 411
15 (2, 48) 5 years for age 13–17 Retrospective
n = 811
Patient years = 1372
NOTE: Frequency and confidence interval calculations by
Bullimore [27].
11.9 (10, 14.6) 47 years for age 18–65 Prospective surveillance
n = 1798 CL wearers in cohort population of 35,914.
25.4 (21.2, 31.5) 47 years for age 18–65 NOTE: Both adult models were calculated separately with
addition of the two childhood cumulative risks.
13.9 (1.7, 50.4) 10 years for age 8-17 Retrospective
n = 677 children and n = 640 adults
7.7 (0.9, 27.8) 57 years for age 18–65 (For Patient years = 2599
childhood + adulthood model)

Fig. 1. Structure of mathematical models utilized to summate cumulative childhood risks (three instances) and lifetime risks (five instances) of microbial keratitis.
SCL = soft contact lens; SiHy = silicone hydrogel; CL = contact lens; OK = orthokeratology.

The inclusion criteria for analysis of MK risk were previously pub-
lished papers for which age was an inclusion criteria or component of
analysis, and where confidence intervals were available (Table 1). The
risk of a single case of MK across childhood (three instances of CL
modality) and across a lifetime (four instances of CL modality) was
calculated as described in Fig. 1. Confidence intervals available from
previously published MK data [21–23,26] were directly utilized in
conversion to both childhood and lifetime risk. While MK can occur
more than once, a case series analysis of 2148 patients over 16 years
found 88 % had only a single episode of bacterial keratitis [30]. The risk
of MK in a non-contact lens wearing population was also calculated for
reference, across an entire lifetime of 75 years, to give a fifth and
comparative lifetime risk (Fig. 1). [29] The cumulative lifetime risk of
vision impairment by age 75 based on axial length and level of myopia

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K.L. Gifford Contact Lens and Anterior Eye xxx (xxxx) xxx–xxx

Table 2 risk [26]; and 18 years of no contact lens wear [29]

Likelihood of each ocular health event occurring once for an individual, pre-
sented with 95 % confidence intervals. CL = contact lens; SCL = soft contact
• Wearing OK for 57 years at the overall estimated incidence of risk
[24] – this data was used rather than separate child and adult spe-
lens. cific risks, as in this review the adult specific risk was 0 per 10,000
Condition Likelihood (1 in 95 % confidence patient wearing years (0, 31.7). The likelihood of MK in 18 years of
instance) intervals no contact lens wear was also included as above [29].
Microbial keratitis – lifetime • Wearing daily disposable SCLs for 4 years at the child (age 8–11)
No CL wear 95.2 80.3, 114.0
level of risk [23]; and 53 years at the adult level of risk (from age
Reusable SCL wear with adult 7.7 5.7, 9.7 12–65) [26] with 18 years of no contact lens wear [29]
extended wear
Reusable SCL wear with adult 15.2 10.4, 20.0 The likelihood of childhood MK occurring over a total of 10 years of
daily wear
contact lens wear, as detailed below, in addition to the risk of 8 years of
Orthokeratology 21.5 6.2, 138.2
Daily disposable SCL 76.2 63.7, 90.0 no contact lens wear [29] is presented as follows:
Microbial keratitis – childhood
Orthokeratology 66.6 19.3, 379.4
• Wearing OK for 10 years at the child level of risk [24]
Daily disposable SCL
Reusable SCL
431.0
116.0
361.3, 511.2
39.5, 516.5 • Wearing daily disposable SCLs for 4 years at the child level of risk
Vision impairment by axial length (mm) – lifetime risk
(age 8–11) [23]; and 6 years at the adult level of risk [26] as teen-
Less than 24 14.5 10.6, 23.0 specific MK data are not available
24 to less than 26
26 to less than 28
26.3
3.9
15.8, 79.9
2.2, 19.2
• Wearing reusable SCLs for 5 years at the child level of risk (age
8–12); and 5 years at the teen level of risk (age 13–17) [22]
28 to less than 30 3.8 2.4, 9.3
30 or more 1.1 0.9, 1.3
Vision impairment by diopters (D) – lifetime risk 4. Discussion
More than -0.5 34.5 28.7, 43.3
−0.5 to more than -3.0 33.3 21.9, 69.8 Comparing the immediately evident risks of contact lens (CL) wear
−3.0 to more than -6.0 18.2 11.8, 39.1 with the long term risks of vision impairment associated with myopia
−6.0 to more than -10.0 5.0 3.2, 11.9
−10.0 to more than -15.0 5.0 3.0, 15.2
allows for improved eye care practitioner (ECP) understanding, and
−15.0 or less 1.2 1.0, 1.7 appropriate informed consent for paediatric CL wear. It is evident from
this analysis that the lifetime risk of vision impairment in axial lengths
over 26 mm and myopia of greater than 6D is ‘very common’ in com-
was utilized directly from the data of Tideman et al. [17], with standard parison to the lifetime risk of microbial keratitis (MK) in any modality
deviations converted to 95 % confidence intervals [31]. of CL wear, except for adult soft contact lens (SCL) extended wear. If
To allow for direct comparison of lifetime risk, the cumulative axial length is below 26 mm and myopia less than 3D, the lifetime risk
childhood or lifetime risk instances were converted to frequency by of vision impairment reduces from ‘very common’ to ‘common’, making
taking the reciprocal. The Council of International Organizations of a lifetime of CL wear more risky in comparison, except in the case of
Medical Sciences (CIOMS) and World Health Organization (WHO) daily disposable wear.
classification system for frequency of adverse events was utilized. [32] The purpose of including ‘childhood only’ contact lens related MK
While this system is typically used in description of medication side risks relates to parental concern that contact lens wear is more risky in
effects, it is an internationally agreed benchmark as follows: childhood. [19] This analysis, alongside the findings of Bullimore [21],
indicate that this concern is unfounded. This childhood risk analysis
• Very common - more than 1/10 also allows the ECP to reasonably consider paediatric modalities with
• Common (frequent) - between 1/100 and 1/10 the shorter-term view of safe childhood wear; after which time the
• Uncommon (infrequent) - between 1/1000 and 1/100 contact lens wearing risks are likely to be of less parental concern.
• Rare - between 1/10000 and 1/1000 Although children frequently wear SCLs for ametropia correction other
• Very rare - less than 1/10000. than myopia control, OK in particular could be considered a myopia
control-specific treatment in children [25] and hence requires con-
3. Results sideration of the additional risk posed compared to other SCL treat-
ments or those not involving CL wear. While comparing CL risks over
Table 2 and Fig. 2 indicates the lifetime likelihood of an adverse childhood to a lifetime risk of vision impairment is somewhat flawed, it
event, categorized in frequency according to the WHO Council of In- serves to highlight the relative safety of paediatric contact lens wear to
ternational Organizations of Medical Sciences (CIOMS) classification inform both practitioner and parental confidence. The results indicate
system. The frequency of vision impairment, categorized by axial length that the likelihood of MK in daily disposable (1 in 431) and in reusable
and myopic dioptres is presented over a lifetime of 75 years, directly (1 in 116) SCL childhood wear is ‘uncommon / infrequent’ (less than 1/
calculated from the work of Tideman et al. [17], while the likelihood of 100) while the risk in OK wear is ‘common’ at 1 in 67 – the confidence
any case of microbial keratitis (MK) is presented both over a lifetime interval overlap in these latter two modalities, however, indicates both
(75 years) in five scenarios and over 18 years of childhood in three are of a similar safety profile. This is important given that 52 % of
scenarios. The lifetime likelihood of MK is presented as follows, with 95 myopia control contact lens fits to children are of the OrthoK modality
% confidence intervals. [25]. An ECP preference for OrthoK prescribing is in alignment with the
volume of the evidence base [3], as well as more ready availability of
• No contact lens wear for 75 years [29] OrthoK across the world. Nevertheless, the safety picture is clearly in
• Wearing reusable soft contact lenses (SCL) for 5 years at the child favour of daily disposable SCLs; as new designs in this modality con-
(age 8–12) level of risk; 5 years at the teen level of risk (age 13–17) tinue to demonstrate similar myopia control efficacy to OrthoK [33]
[22]; 47 years at the adult level of extended wear risk [26]; and 18 and become more widely available, future prescribing surveys should
years of no contact lens wear (being the first 8 years and last 10 more closely reflect this favourable safety profile.
years of life) [29] Practitioner prescribing of myopia control CLs has been shown to
• Wearing reusable SCLs for 5 years at the child level of risk; 5 years at skew towards younger ages compared to non-myopia control CL fitting,
the teen level of risk [22]; 47 years at the adult level of daily wear with around 30 % fit to children under age 12, however the median age

4
K.L. Gifford Contact Lens and Anterior Eye xxx (xxxx) xxx–xxx

Fig. 2. Likelihood of each ocular health event occurring once for an individual, with 95 % confidence intervals presented on a Log scale. All likelihoods are presented
over a lifetime, except for three childhood microbial keratitis risks as indicated. The WHO CIOMS classification system for frequency of adverse events (REF) is
indicated by coloured shading – red indicates very common (more than 1/10), orange indicates common / frequent (between 1/10 and 1/100) and yellow indicates
uncommon / infrequent (between 1/100 and 1/1000). CL = contact lens; SCL = soft contact lens; DD = daily disposable; AXL = axial length; D = dioptres.

of 13 [25] is likely to still represent a less proactive approach when
considering the likely time of faster childhood myopia progression oc-
curs before age 12 [34]. The results here indicate a clearly positive risk-
to-benefit picture of fitting children with myopia controlling CLs from
younger ages, where an outcome of limiting axial length to less than
26 mm or myopia to less than 3D is feasible. If axial length can be
limited to less than 28 mm and myopia to 6D, there is an obvious skew
towards the benefit to childhood myopia controlling CL wear, and even
continued wear into adulthood shows lower risk than that of myopia-
related vision impairment. Where daily disposable CLs cannot be fit,
ensuring a high CL safety profile is achieved in younger children in-
volves reinforcement of care and maintenance instructions. A small
reduction in the percentage of children correctly answering CL care and
handling questions after three months of wear has been observed
compared to their teenage counterpart [35], although in general chil-
dren and teens demonstrate higher levels of compliance with lens dis-
infection and hand washing than their adult counterparts [36,37].
There are several limitations of the analysis presented here. Firstly,
the previously published data utilized are from a mix of prospective
[23,26] and retrospective [17,24,29] studies; selection for a prospective
study could be biased against ocular or systemic health factors which
could predispose towards infection, and hence not reflect rates in
clinical practice; however the prospective studies included are the lar-
gest of their type. Secondly, the lack of consistently available data on
child (aged 8–12) versus teen (aged 13–17) microbial keratitis risk for
each of the CL modalities required application of adult risk to some of
the child specific categories. Thirdly, the calculation of lifetime MK risk
(75 years) or early childhood (aged 0–8 years) no-CL wear risk was
made using epidemiology data from one American cohort study. This
study reported no relationship between age and MK risk, in a cohort
aged 4–100 years, although ocular surface disease was present in 18 %
of patients with a mean age of 54 years. This indicates that the risk of
MK is likely lower in early childhood; hence the application of a
potentially higher risk to the model presented here would only serve to
bias it towards increased CL risk, and the results still indicate that CL
infection risk is relatively low. As suggested by Bullimore, [21] in-
cluding children in future epidemiological research will allow improved
understanding of paediatric CL complication rates. Finally, the large
confidence intervals apparent in the data (Fig. 2) should be noted,
which could be taken to reduce the evidence of difference between the
instances of MK risk and myopia-associated visual impairment as pre-
sented. When directly comparing MK risks over childhood to MK risks
over a lifetime, the longer exposure of the latter increases risk – such
that it appears a lifetime of no CL wear is more risky than childhood
daily disposable CL wear – however the intent of this data is to compare
within age groups – being three childhood instances or five lifetime
instances of MK risk – and then to the lifetime risk of vision impairment.
The comparative impact of MK compared to vision impairment
presents some lack of balance. MK holds the immediate concern of pain
and disability, however the data utilized here presents any case of MK
and not MK with resultant reduction in best corrected acuity – inclusion
of the latter would have reduced the CL risks further. [24,26] Vision
impairment, though a thankfully remote consideration for most myopic
children, presents a clear quality of life and economic cost across a
lifetime. There is no doubt that myopia is a lifelong cost burden, being
around USD$709 per person per year [38], and this likely increases
when paediatric CL wear is included. This pales into insignificance,
though, when viewed in terms of the cost of vision impairment and
blindness to the affected person, their carers and society which is up-
wards of USD$12 000 annually per patient, increasing with the severity
of the vision impairment [39]. From a public health perspective,
modelling has shown that application of a 33 % effective myopia con-
trol strategy would result in a 73 % reduction in the frequency of
myopia over 5D, and a 50 % efficacy would result in 90 % less high
myopia, and the consequent reduction in ocular pathology risk across
the population [40]. Since the risk of vision impairment increases with

5
K.L. Gifford
higher levels of myopia, [17] the goal of myopia control should be to
limit lifetime risk by reducing progression at early ages for greatest
impact.
In addition to myopia control, there are clear benefits of paediatric
contact lens wear, especially in younger children aged 8–11 years who
feel that their physical appearance, athletic competence and social ac-
ceptance is improved with contact lens wear. [27] It is important for the
ECP to communicate these benefits, alongside reasonable expectations
of childhood myopia control. The current evidence base for myopia
control interventions is primarily composed of one- to two-year studies,
meaning that the longer term efficacy of many interventions cannot yet
be extrapolated past an absolute treatment effect of around 1 dioptre or
0.47 mm [41]. While seemingly modest, lower myopia means less vi-
sual disability when uncorrected; better surgical options and outcomes
in adulthood; and reduced risk of vision impairment where reducing the
final myopia outcome by 1 dioptre reduces the risk of myopic macu-
lopathy by 40 % [42]. Long term cohort studies could indicate that
greater effects are possible; and as myopia control treatments increas-
ingly become the clinical standard of care, the frequency of myopia-
associated vision impairment could be directly correlated to myopia
control intervention [12]. Until such time, though, ECPs should balance
the positive message about CL benefits for both paediatric myopia
correction and control with appropriate messaging about preventative
eye health impacts.
The myopia control evidence does indicate that a proactive ap-
proach is warranted, with interventions ideally commencing before age
12 for the greatest impact on reducing progression. [12] This proactive
approach is not reflected in current prescribing data [25], despite the
evident safety of paediatric CL presented here and by other authors.
[21,24] The effectiveness of health relevant messages depend on
framing both the gains and losses, and to what degree a particular
health behaviour is perceived as risky [43]. As such, this data indicates
that paediatric myopia controlling CL wear can be framed in discussion
as a health-affirming choice in the short term, when balanced against
uncontrolled myopia progression to more than 3 dioptres or 26 mm
axial length which increases the lifetime risk of vision impairment.
Selecting daily disposable myopia control CL options, where possible,
clearly skews the risk comparison depiction towards the positives of CL
wear, even when worn over a lifetime.
5. Conclusion
The comparative lifetime risks of contact lens wear commenced at
age 8 for myopia control, and continued throughout life until age 65,
are relatively less than the lifetime risks of vision impairment from
myopia-associated pathology when myopia is over 3D or axial length in
excess of 26 mm. When only childhood CL wear is considered, the risk-
to-benefit balance is clearly skewed towards the positive impact of CL
wear, especially in daily disposable CL wear. A direct correlation be-
tween myopia control intervention and lifetime vision impairment risk
is not yet available; however as myopia control increasingly becomes
the clinical standard of care, these long term population impacts will
emerge and allow for further advocacy. Eye care practitioners should be
confident to proactively recommend myopia control CL wear to
younger children, as both the safety profile and potential preventative
ocular health benefits are evident.
Declaration of Competing Interest
The author reports no conflicts of interest and has no proprietary
interest in any of the materials mentioned in this article. This research
did not receive any specific grant from funding agencies in the public,
commercial or not-for-profit sectors.
6
Contact Lens and Anterior Eye xxx (xxxx) xxx–xxx
References
[1] J. Huang, D. Wen, Q. Wang, C. McAlinden, I. Flitcroft, H. Chen, et al., Efficacy
comparison of 16 interventions for myopia control in children: a network meta-
analysis, Ophthalmology 123 (4) (2016) 697–708.
[2] S.M. Li, M.T. Kang, S.S. Wu, B. Meng, Y.Y. Sun, S.F. Wei, et al., Studies using
concentric ring bifocal and peripheral add multifocal contact lenses to slow myopia
progression in school-aged children: a meta-analysis, Ophthalmic Physiol Opt 37
(1) (2017) 51–59.
[3] Y. Sun, F. Xu, T. Zhang, M. Liu, D. Wang, Y. Chen, et al., Orthokeratology to control
myopia progression: a meta-analysis, PLoS One 10 (2015) e0124535.
[4] D. Cheng, G.C. Woo, B. Drobe, K.L. Schmid, Effect of bifocal and prismatic bifocal
spectacles on myopia progression in children: three-year results of a randomized
clinical trial, JAMA Ophthalmol 132 (3) (2014) 258–264.
[5] C.S.Y. Lam, W.C. Tang, D.Y. Tse, R.P.K. Lee, R.K.M. Chun, K. Hasegawa, et al.,
Defocus Incorporated Multiple Segments (DIMS) spectacle lenses slow myopia
progression: a 2-year randomised clinical trial, Br J Ophthalmol (2019).
[6] J.J. Walline, A. Gaume, L.A. Jones, M.J. Rah, R.E. Manny, D.A. Berntsen, et al.,
Benefits of contact lens wear for children and teens, Eye Contact Lens 33 (6 Pt 1)
(2007) 317–321.
[7] P.A. Ubel, G. Loewenstein, N. Schwarz, D. Smith, Misimagining the unimaginable:
The disability paradox and health care decision making, Health Psych 24 (2005)
S57–62.
[8] D.I. Flitcroft, The complex interactions of retinal, optical and environmental factors
in myopia aetiology, Prog Retin Eye Res 31 (2012) 622–660.
[9] J.S. Wolffsohn, D.I. Flitcroft, K.L. Gifford, M. Jong, L. Jones, C.C.W. Klaver, et al.,
IMI - myopia control reports overview and introduction, Invest Ophthalmol Vis Sci
60 (3) (2019) M1–M19.
[10] J.S. Wolffsohn, P.S. Kollbaum, D.A. Berntsen, D.A. Atchison, A. Benavente,
A. Bradley, et al., IMI - clinical myopia control trials and instrumentation report,
Invest Ophthalmol Vis Sci 60 (3) (2019) M132–M160.
[11] L. Jones, B. Drobe, J.M. Gonzalez-Meijome, L. Gray, T. Kratzer, S. Newman, et al.,
IMI - industry guidelines and ethical considerations for myopia control report,
Invest Ophthalmol Vis Sci 60 (3) (2019) M161–M183.
[12] K.L. Gifford, K. Richdale, P. Kang, T.A. Aller, C.S. Lam, Y.M. Liu, et al., IMI - clinical
management guidelines report, Invest Ophthalmol Vis Sci 60 (3) (2019)
M184–M203.
[13] C.F. Wildsoet, A. Chia, P. Cho, J.A. Guggenheim, J.R. Polling, S. Read, et al., IMI -
interventions for controlling myopia onset and progression report, Invest
Ophthalmol Vis Sci 60 (3) (2019) M106–M131.
[14] B.A. Holden, T.R. Fricke, D.A. Wilson, M. Jong, K.S. Naidoo, P. Sankaridurg, et al.,
Global prevalence of myopia and high myopia and temporal trends from 2000
through 2050, Ophthalmology (2016).
[15] A. Iwase, M. Araie, A. Tomidokoro, T. Yamamoto, H. Shimizu, Y. Kitazawa, et al.,
Prevalence and causes of low vision and blindness in a Japanese adult population:
the Tajimi Study, Ophthalmology 113 (8) (2006) 1354–1362.
[16] L. Wu, X. Sun, X. Zhou, C. Weng, Causes and 3-year-incidence of blindness in Jing-
An District, Shanghai, China 2001-2009, BMC Ophthalmol (2011) 10.
[17] J.W. Tideman, M.C. Snabel, M.S. Tedja, G.A. van Rijn, K.T. Wong, R.W. Kuijpers,
et al., Association of axial length with risk of uncorrectable visual impairment for
europeans with myopia, JAMA Ophthalmol 134 (12) (2016) 1355–1363.
[18] World health organization, international classification of diseases 11th revision,
(2018) Accessed 23 September 2019 https://www.who.int/classifications/icd/en/.
[19] F. Zeri, J.J. Durban, F. Hidalgo, J. Gispets, G. Contact Lens evolution Study,
Attitudes towards contact lenses: a comparative study of teenagers and their par-
ents, Cont Lens Anterior Eye 33 (3) (2010) 119–123.
[20] L.A. Jones, J.J. Walline, A. Gaume, M.J. Rah, R.E. Manny, D.A. Berntsen, et al.,
Purchase of contact lenses and contact-lenses-related symptoms following the
Contact Lenses in Pediatrics (CLIP) Study, Cont Lens Anterior Eye 32 (4) (2009)
157–163.
[21] M.A. Bullimore, The safety of Soft contact lenses in children, Optom Vis Sci 94 (6)
(2017) 638–646.
[22] R.L. Chalmers, H. Wagner, G.L. Mitchell, D.Y. Lam, B.T. Kinoshita, M.E. Jansen,
et al., Age and other risk factors for corneal infiltrative and inflammatory events in
young soft contact lens wearers from the Contact Lens assessment in Youth (CLAY)
study, Invest Ophthalmol Vis Sci 52 (9) (2011) 6690–6696.
[23] J.J. Walline, L.A. Jones, L. Sinnott, R.E. Manny, A. Gaume, M.J. Rah, et al., On
behalf of the ACHIEVE study group, a randomized trial of the effect of Soft contact
lenses on myopia progression in children, Invest Ophthalmol Vis Sci 49 (2008)
4702–4706.
[24] M.A. Bullimore, L.T. Sinnott, L.A. Jones-Jordan, The risk of microbial keratitis with
overnight corneal reshaping lenses, Optom Vis Sci 90 (2013) 937–944.
[25] N. Efron, P.B. Morgan, C.A. Woods, J. Santodomingo-Rubido, J.J. Nichols, C.
International Contact Lens prescribing Survey, International survey of contact lens
fitting for myopia control in children, Cont Lens Anterior Eye (2019).
[26] F. Stapleton, L. Keay, K. Edwards, T. Naduvilath, J.K.G. Dart, G. Brian, et al., The
incidence of contact Lens related microbial keratitis in Australia, Ophthalmol 115
(2008) 1655–1662.
[27] J.J. Walline, L.A. Jones, L. Sinnott, M. Chitkara, B. Coffey, J.M. Jackson, et al.,
Randomized trial of the effect of contact lens wear on self-perception in children,
Optom Vis Sci 86 (2009) 222–232.
[28] K.L. Johnson, Are we myopic about myopia control? Cont Lens Anterior Eye 37
(2014) 237–239.
[29] B.H. Jeng, D.C. Gritz, A.B. Kumar, D.S. Holsclaw, T.C. Porco, S.D. Smith, et al.,
Epidemiology of ulcerative keratitis in Northern California, Arch Ophthalmol 128
K.L. Gifford
(2010) 1022–1028.
[30] R. Kaye, A. Kaye, H. Sueke, T. Neal, C. Winstanley, M. Horsburgh, et al., Recurrent
bacterial keratitis, Invest Ophthalmol Vis Sci 54 (6) (2013) 4136–4139.
[31] A. Hazra, Using the confidence interval confidently, J Thorac Dis 9 (10) (2017)
4125–4130.
[32] Council of International Organizations of Medical Sciences (CIOMS) and World
Health Organization (WHO), Evidence synthesis and meta-analysis for drug safety,
(2016) Accessed 23 September 2019 (2016) www.cioms.ch.
[33] P. Chamberlain, S.C. Peixoto-de-Matos, N.S. Logan, C. Ngo, D. Jones, G. Young, A 3-
year randomized clinical trial of MiSight lenses for myopia control, Optom Vis Sci
96 (8) (2019) 556–567.
[34] L. Donovan, P. Sankaridurg, A. Ho, T. Naduvilath, E.L.I. Smith, B.A. Holden, Myopia
progression rates in urban children wearing single-vision spectacles, Optom Vis Sci
89 (2012) 27–32.
[35] J.J. Walline, L.A. Jones, M.J. Rah, R.E. Manny, D.A. Berntsen, M. Chitkara, et al.,
Contact Lenses in Pediatrics (CLIP) Study: chair time and ocular health, Optom Vis
Sci 84 (2007) 896–902.
Contact Lens and Anterior Eye xxx (xxxx) xxx–xxx
[36] A. Sulley, Fitting children with contact lenses: part one, Optician 237 (2009) 26–30.
[37] Y. Wu, N. Carnt, F. Stapleton, Contact lens user profile, attitudes and level of
compliance to lens care, Cont Lens Anterior Eye 33 (2010) 183–188.
[38] Y.F. Zheng, C.W. Pan, J. Chay, T.Y. Wong, E. Finkelstein, S.M. Saw, The economic
cost of myopia in adults aged over 40 years in Singapore, Invest Ophthalmol Vis Sci
54 (2013) 7532–7537.
[39] J. Koberlein, K. Beifus, C. Schaffert, R.P. Finger, The economic burden of visual
impairment and blindness: a systematic review, BMJ Open 3 (11) (2013) e003471.
[40] N.A. Brennan, Predicted reduction in high myopia for various degrees of myopia
control, Cont Lens Anterior Eye 35 (S1) (2012) e14–e15.
[41] X. Cheng, N. Brennan, Y. Toubouti, Modelling of cumulative treatment efficacy in
myopia progression interventions, Invest Ophthalmol Vis Sci 60 (2019), https://doi.
org/10.13140/RG.2.2.32179.68640.
[42] M.A. Bullimore, N.A. Brennan, Myopia control: why each diopter matters, Optom
Vis Sci 96 (6) (2019) 463–465.
[43] A.J. Rothman, P. Salovey, Shaping perceptions to motivate healthy behavior: the
role of message framing, Psychol Bull 121 (1997) 3–19.