Intervencije za kontrolu miopije kod djece: živi sistematski pregled i mrežna meta-analiza.
The Cochrane database of systematic reviews
Sažetak istraživanja
Pozadinska kratkovidnost je uobičajena refrakciona greška, gdje izduženje očne jabučice uzrokuje da udaljeni objekti izgledaju zamućeno. Sve veća prevalencija miopije je rastući globalni javnozdravstveni problem, u smislu stopa nekorigovane refrakcione greške i značajno povećanog rizika od oštećenja vida zbog očnog morbiditeta povezanog sa miopijom. Budući da se miopija obično otkriva kod djece prije 10 godina i može brzo napredovati, intervencije za usporavanje njenog napredovanja potrebno je provoditi u djetinjstvu.
Ciljevi Procijeniti komparativnu efikasnost optičkih, farmakoloških i ekoloških intervencija za usporavanje progresije miopije kod djece koristeći mrežnu meta-analizu (NMA). Stvoriti relativno rangiranje intervencija kontrole miopije prema njihovoj djelotvornosti. Izraditi kratak ekonomski komentar, sumirajući ekonomske procjene koje procjenjuju intervencije kontrole miopije kod djece. Održati aktualnost dokaza koristeći živi sistemski pristup pregleda. METODE PRETRAGE: Pretražili smo CENTRAL (koji sadrži Cochrane Eyes and Vision Trials Register), MEDLINE; Embase; i tri registra suđenja. Datum pretrage je bio 26. februar 2022. KRITERIJI ZA IZBOR: Uključili smo randomizirana kontrolirana ispitivanja (RCT) optičkih, farmakoloških i ekoloških intervencija za usporavanje progresije miopije kod djece uzrasta od 18 godina ili mlađe. Kritični ishodi bili su progresija miopije (definirana kao razlika u promjeni sferne ekvivalentne refrakcije (SER, dioptrija (D)) i aksijalne dužine (mm) u intervencijskim i kontrolnim grupama na godinu dana ili duže) i razlika u promjeni SER-a i aksijalne dužine nakon prestanka liječenja ('rebound'). PRIKUPLJANJE I ANALIZA PODATAKA: Pratili smo standardne Cochrane metode. Procijenili smo pristrasnost koristeći RoB 2 za paralelne RCT. Ocijenili smo sigurnost dokaza koristeći GRADE pristup za ishode: promjenu SER-a i aksijalne dužine na jednu i dvije godine. Većina poređenja je bila sa neaktivnim kontrolama. Glavni rezultati Uključili smo 64 studije koje su randomizirale 11.617 djece, uzrasta od 4 do 18 godina. Istraživanja su uglavnom sprovedena u Kini ili drugim azijskim zemljama (39 studija, 60,9%) i Sjevernoj Americi (13 studija, 20,3%). Pedeset sedam studija (89%) upoređivalo je intervencije kontrole miopije (multifokalne naočare, periferne plus naočare (PPSL), nedovoljno korigirane naočare s jednim vidom (SVL), multifokalna meka kontaktna sočiva (MFSCL), ortokeratologiju, kruta plinopropusna kontaktna sočiva (RGP), visokopropustljiva kontaktna sočiva (RGP); (MDA) i niske doze (LDA) atropina, pirenzipina ili 7-metilksantina) u odnosu na neaktivnu kontrolu je bila 12 do 36 mjeseci procjene zasnovane na direktnim (parnim) poređenjima u nastavku U jednoj godini, u 38 studija (analiziranih 6525 učesnika), srednja promjena u SER-u za kontrole bila je -0 65 D. Sljedeće intervencije mogu smanjiti progresiju SER-a u poređenju sa kontrolama: HDA (srednja razlika (MD) 0,90 D, 95% interval pouzdanosti. 01. MD). 65 D, 95% CI 0,27 do 1,03), LDA (MD 0,38 D, 95% CI 0,10 do 0,66), pirenzipin (MD 0. 32 D, 95% CI 0, 15 do 0, 49), MFSCL (MD 0, 26 D, 95% CI 0, 17 do 0, 35), PPSLs (MD 0, 51 D, 95% CI 0, 19 do 0, 82) i multifocal (MD 54 spect 1, 82) 0.08 do 0.21). Nasuprot tome, bilo je malo ili nimalo dokaza da je RGP (MD 0,02 D, 95% CI -0,05 do 0,10), 7-metilksantin (MD 0,07 D, 95% CI -0,09 do 0,24) ili nedovoljno korigirani SVLs (MD -0,9% SVL.5,0,9% 0,9) 00) smanjiti progresiju. Za dvije godine, u 26 studija (4949 učesnika), srednja promjena u SER-u za kontrole bila je -1. 02 D. Sljedeće intervencije mogu smanjiti progresiju SER-a u poređenju sa kontrolama: HDA (MD 1.26 D, 95% CI 1.17 do 1.36), MDA (MD 0.45 D, 95% CI 0.08 do 0.83), LDA (MD 0.24% CI, 0.24% CI, 0.51% CI, 0.51% do 1.36) pirenzipin (MD 0,41 D, 95% CI 0,13 do 0,69), MFSCL (MD 0,30 D, 95% CI 0,19 do 0,41) i multifokalne naočare (MD 0,19 D, 95% CI 0,03). PPSL (MD 0,34 D, 95% CI -0,08 do 0,76) također mogu smanjiti progresiju, ali rezultati su bili nedosljedni. Za RGP, jedna studija je pronašla korist, a druga nije pronašla razliku u kontroli. Nismo pronašli nikakvu razliku u promjeni SER-a za nedovoljno korigovane SVL (MD 0,02 D, 95% CI -0,05 do 0,09). U jednoj godini, u 36 studija (6263 učesnika), srednja promena aksijalne dužine za kontrolne grupe bila je 0,31 mm. Sljedeće intervencije mogu smanjiti aksijalno izduženje u odnosu na kontrolne: HDA (MD -0,33 mm, 95% CI -0,35 do 0,30), MDA (MD -0,28 mm, 95% CI -0,38 do -0,17), LDA (MD -0,13 mm do -0,5), -0,5 % CI, -0,5. ortokeratologija (MD -0,19 mm, 95% CI -0,23 do -0,15), MFSCL (MD -0,11 mm, 95% CI -0,13 do -0,09), pirenzipin (MD -0,10 mm, 95% CI -0,23 do -0,15), -0,18s do -0,102 mm 95% CI -0 24 do -03) i multifokalne naočare (MD -0,06 mm, 95% CI -0,09 do -0,04). Našli smo malo ili nimalo dokaza da RGP (MD 0,02 mm, 95% CI -0,05 do 0,10), 7-metilksantin (MD 0,03 mm, 95% CI -0,10 do 0,03) ili nedovoljno korigirani SVLs (MD 0,50% CI -9,05% CI 11) smanjiti aksijalnu dužinu. Za dvije godine, u 21 studiji (4169 učesnika), srednja promjena aksijalne dužine za kontrolne skupine bila je 0,56 mm. Sljedeće intervencije mogu smanjiti aksijalno izduženje u odnosu na kontrolne: HDA (MD -0,47mm, 95% CI -0,61 do -0,34), MDA (MD -0,33 mm, 95% CI -0,46 do -0,20), ortokeratologija (MD -0,958% CI -0,958% CI -0,25% 19), LDA (MD -0,16 mm, 95% CI -0,20 do -0,12), MFSCL (MD -0,15 mm, 95% CI -0,19 do -0,12) i multifokalne naočale (MD -0,07 mm, 95% CI može smanjiti na -0 -0,20 mm, 95% CI -045 do 0,05), ali smo pronašli malo ili nimalo dokaza da nedovoljno korigovani SVL (MD -0,01 mm, 95% CI -0,06 do 0,03) ili RGP (MD 0,03% CI). aksijalna dužina nije konzistentno prijavljivana o tome da li prestanak liječenja povećava progresiju kratkovidosti, a samo jedna studija nije prijavila ekološke intervencije u djece s miopijom, a nijedna ekonomska evaluacija nije procijenila intervencije za kontrolu kratkovidosti kod djece i upoređivali su uglavnom opsežne studije. sa neaktivnim komparatorom. Efekti u jednoj godini pružili su dokaz da ove intervencije mogu usporiti promjenu refrakcije i smanjiti aksijalno izduživanje, iako su rezultati često bili heterogeni. Manji broj dokaza dostupan je za dvije ili tri godine, a ostaje neizvjesnost u pogledu trajnog efekta ovih intervencija. Potrebne su dugoročne i kvalitetnije studije koje upoređuju intervencije kontrole miopije koje se koriste samostalno ili u kombinaciji, kao i poboljšane metode za praćenje i prijavljivanje štetnih efekata.
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Interventions for myopia control in children: a living systematic review and network meta-analysis.
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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- DOI
- 10.1002/14651858.cd014758.pub2
- PMID
- 36809645
- PMCID
- PMC9933422
- Provjereno
- 2026-07-26
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