“REACH’’ for troubleshooting peripheral defocus myopia control spectacles

The worldwide increasing trends in prevalence of myopia and its associated complications led to development of various optical solutions for controlling myopia progression in the last decade. (1) With the research highlighting the importance of counteracting peripheral hyperopic defocus(2), myopia control peripheral plus or defocus spectacle lenses are made commercially available in multiple countries. These spectacles incorporate central distance clear zone with plus power in the peripheral regions, creating a peripheral myopic defocus that helps to slow down the axial elongation. Although these lenses have demonstrated good treatment efficacy(2, 3), certain proportion (abet small) of children may experience or complains about visual disturbances with these spectacles despite achieving 20/20 central visual acuity for distance viewing at the time of prescribing. It is important that the quality of vision is not altered and there are no issues with the spectacles to expect best compliance and the successful outcomes. However, the nature of these spectacle design is likely to influence visual performance in initial days of lens wear. For example, a questionnaire-based study conducted in Chinese children demonstrated that children had reduced mid -peripheral vision through the lenses compared with single vision lenses.(4)These spectacles are relatively new to the ophthalmic clinical practice and they present unique concern for the patients and practitioners that warrant attention of stake holders specially in troubleshooting.Based on clinical experience in myopia management, we present a troubleshooting guide with acronym "REACH" to address visual disturbances in children wearing peripheral defocus spectacles. This guide includes key aspects of patient-parent communication and strategies for managing concerns, illustrated through three real patient cases. The insights a practitioner gets through REACH are critical to ensuring the success of myopia management which can be seen below: R: Root out the cause: In clinical practice, it is crucial to understand child's concerns and experiences after wearing myopia control spectacles in spite of having 20/20 Visual acuity on examination. Root out the cause for the problem with these lenses engaging in open-ended discussion-driven conversations to uncover underlying problem that may impact vision and in turn, the compliance and the effectiveness of myopia control treatment. Regular follow-up visits after initiating treatment are therefore important to monitor the child's visual comfort, assess treatment progress, and address any concerns promptly. This proactive approach ensures that necessary adjustments are made in a timely manner, fostering optimal treatment success and long-term visual health.Error-free Centration: It is essential to ensure that the clear central zone of the lens is properly aligned with the center of the pupil. Peripheral defocus spectacles from various companies have central clear zone varying from 8 mm 9.4 mm respectively(2, 3, 5). Additionally, verify if there is any low riding of frame on nose such that the child is looking through the defocused zone causing blurred vision.Larger frames with minimal pantoscopic tilt may help maintain the intended optical design and prevent unintended shifts in the defocus zone.A: Adaptation of lenses: Given that theses peripheral defocus lenses are different to conventional single vision lenses it is important to indicate the need for adaptation time with these lenses at least 2-3 weeks.For children sensitive to peripheral blur, it is important to take additional care when introducing myopia control spectacles. Highlight the child needs ample time for them to adjust to the new visual experience, especially if they previously struggled to adapt to changes in single-vision spectacles or returned to the clinic soon after trying peripheral defocus spectacles. Case 1: A 12-year-old with -3.50 DS refractive error in both eyes reported occasional blackboard blur after 20 days of wearing peripheral defocus spectacles. Investigation revealed the child's habit of sitting in a corner of the classroom required him to look through the defocus zones and experience blur. As indicated in REACH, we recommended head movement strategy, aligned with the board, and using head movements to view peripheral objects. In the subsequent follow-up, the child confirmed this adjustment resolved the issue completely.Case 2: A 11-year-old with refractive error (RE: -2.50DS/-1.00DC×180, LE: -3.00DS/-1.00DC×180) returned to our clinic a month after starting peripheral defocus spectacles, reporting blurred vision with slight eye movements. On examination, visual acuity was 20/20 in both eyes, indicating good central vision. After confirming proper pupil alignment within the clear zone, we educated the child and parents on the lens design, stressing the need for adaptation and head movements to view peripheral objects. In the subsequent follow-up, the child reported complete resolution of the issue, demonstrating the value of counseling and support.Case 3: A 9-year-old with refractive error (BE: -4.00DS/-1.00DC×180 in both eyes) returned a month after being prescribed peripheral defocus spectacles, reporting blurred distance vision and frontal headache with no other ocular complaints. Examination showed a one-line reduction in vision despite the correct prescription. On examination, that child was wearing a circular round shaped frames and issue was due to misaligned lens centration caused by swapping the right and left lenses in identical round frames. Adjusting the lenses resolved her symptoms.Additionally, some children reported difficulties playing sports like tennis and badminton with these spectacles, underscoring the importance of addressing individual needs and offering tailored guidance. Based on our experience, a couple of young adults who are likely to drive also expressed some level of discomfort with the defocus spectacles.While REACH can act as a guideline to prevent any complications or for the troubleshooting, given that the complaints are multi-dimensional. It will be easy for clinician to have a check-list in the form of a structured questionnaires to enhance the evaluation of patient experiences and discomfort."REACH troubleshoot guidelines will help for success practice for eye care practitioners while prescribing peripheral defocus spectacles for myopia control. These guidelines can help eye care practitioners to tackle and to reduce multiple clinic visit, dropouts and issues related to poor compliance when peripheral defocus spectacles are prescribed. Advised aligning with board and trained proper head movement.Taught head movement strategies for viewing peripheral objects.Guided patient on proper head positioning after lens correction, especially for sports.