Explaining progressive myopia and myopia control to a family — OSCE

Candidate instructions (8-minute station)

You are the paediatric registrar in clinic. An 8-year-old girl has six months of squinting at the board and worsening distance vision. Both her parents wear glasses for short-sightedness, and she spends most of the day on screens with little outdoor time. Her distance vision improves to normal with a pinhole. The family has read about "atropine drops to stop myopia" and asks whether she should start them today. [1]

Your tasks are: [10]

1. Explain the likely diagnosis — myopia — in plain language, and why both parents being short-sighted and the screen time fit the picture. [1]
2. Explain why a cycloplegic refraction comes before the final prescription, and what that test involves. [10]
3. Outline the treatment — spectacles for clear distance vision, plus myopia control built on outdoor time and reduced near work, with low-dose atropine, orthokeratology or defocus lenses as options — and explain why deliberately under-correcting the glasses is not advised. [12]
4. Address the atropine question honestly — what the LAMP trial showed about 0.05 percent being the most effective of the low doses — and name the red flags that would bring her back sooner. [4]

You are not expected to start atropine in this station — the cycloplegic refraction and the shared decision with the family and ophthalmology come first. [5]

Examiner prompt to the actor (parent)

"Both of us wear glasses and now she is squinting at the board like we did at her age. I have read that atropine drops can stop the myopia getting worse — can you just prescribe them today so we do not have to come back? And should we get her weaker glasses on purpose so her eyes work harder and the myopia does not progress? She is on her tablet all day." [12]

Marking domains

• Frame and explanation (3): explains myopia as the eye growing too long so light focuses in front of the retina, in plain reassuring language; names the family history and intense near work as risk factors and the global rise in childhood myopia; acknowledges the parent's concern and desire to act. [1]
• Cycloplegic confirmation (2): explains that a cycloplegic refraction (drops to relax the focusing muscle before measuring) confirms the prescription because a child's focusing can otherwise distort the measurement or hide a long-sighted component; frames it as accuracy, not delay. [10]
• Treatment and the under-correction myth (3): explains spectacles for clear distance vision; explains that myopia control is built on outdoor time (about two hours a day) and reduced near work, with atropine, orthokeratology and defocus lenses as options; and clearly corrects the myth that deliberately under-correcting the glasses slows progression — it does not, and full distance correction is standard. [12] [5]
• Atropine and red flags (2): explains honestly that the LAMP trial found 0.05 percent atropine the most effective of the low doses, given one drop at bedtime, with monitoring for side effects; and names the red flags — vision not improving with glasses, a new squint, or a rapid worsening — that would bring her back sooner. [4] [10]

Model answer — the explanatory script

"Thank you for bringing her in. What you are describing — squinting at the board, distance blur that gets better when we look through a small hole, in a girl whose two parents are short-sighted — is almost certainly myopia, or short-sightedness. The eye has grown a little too long, so the picture focuses just in front of the back of the eye instead of on it, and distance vision goes blurry while close vision stays clear. You are right that it runs in families, and you are also right that the amount of near work and screen time matters — myopia is rising sharply in children all over the world for exactly those reasons." [1]

"Let me take your questions in order — the test, the glasses, the atropine, and what to watch for." [10]

"First, the test. Before I finalise her glasses I want to measure her eyes properly with the focusing muscle relaxed. Children focus very powerfully, and if we measure while she is focusing we can overestimate the short-sightedness or even miss a long-sighted component hiding underneath. So we use drops — cyclopentolate — to relax that muscle for a few minutes, then measure the exact prescription with a light. It is quick, it is safe, and it means her glasses are accurate rather than a guess. That is why I would not hand you a prescription today — the accurate measurement comes first." [10]

"Second, the glasses. Yes, she needs glasses for clear distance vision, and I would give her the full distance prescription — and I want to gently correct something you read. Deliberately giving her weaker glasses to make her eyes work harder does not slow the myopia; that is an old idea that the evidence has overturned. Full correction is the standard. What does slow the myopia is a different set of things entirely." [12] [5]

"Third, slowing the myopia. The foundation, which costs nothing and works, is outdoor time — about two hours a day outside — and cutting down the long stretches of near work with regular breaks. Natural outdoor light changes the chemistry of the back of the eye in a way that slows its growth. On top of that we have real treatments: low-dose atropine eye drops, overnight contact lenses called orthokeratology that gently reshape the eye while she sleeps, and special defocus lenses. None reverses the myopia, but all can slow it — and slowing it matters, because the less the eye lengthens the lower her lifelong risk of the serious problems of very high myopia." [12]

"Fourth, your atropine question specifically. The strongest study — the LAMP trial — compared three low strengths, 0.05, 0.025 and 0.01 percent, given as one drop at bedtime, and found that all three slowed the myopia, with 0.05 percent the most effective of the low doses and very few side effects. So atropine is a genuine option for a fast-progressing child like her, and I would usually offer it in partnership with the eye team, after the accurate measurement — not as something to grab off the shelf today. We watch for glare, a little blurring of near vision, and rare allergy, and we review her regularly." [4]

"And last, what to watch for. This is almost certainly straightforward myopia, but I want you to come back sooner if her vision does not get to normal with her new glasses, if you ever see a new turn in one eye or an odd head tilt, or if her short-sightedness seems to be worsening very quickly over weeks rather than months — those are the rare things we want to pick up fast, even though they are not what is happening here." [10] [4]