From November 18 to 20, 2022, eyecare practitioners (ECPs) from around the world gathered online for Eyes On 2023, a 3 day educational summit offering up to 9 hours of COPE-accredited CE and CME providing the latest innovations in the ophthalmic industry.
Enjoy this presentation from Jason E. Compton, OD, FAAO, and don't forget to check out our list of future events!
Please note these videos are provided for review only.
For years, eyecare providers were aware of a growing myopia epidemic but have had limited options for treating the symptoms. Now with recent medical innovations, it is possible to make clinically significant improvements in myopia progression in pediatric patients. This article will outline the expectations and necessary communication between the eyecare provider, practice staff, parents, and pediatric patients while managing symptoms of myopia.
📚
Watch Dr. Compton's full discussion on setting myopia management expectations!
Sign up for our newsletter to watch the full recording from Eyes On 2023.
Myopia overview
While myopia was couched in the refractive error bucket for a considerable time, our collective thought process has begun to shift rapidly based on mounting clinical evidence and scientific research.
“Subsequently, myopia is now recognized more so as a disease that can be subdivided into two categories: non-pathological and pathological.”
The former roots back to simple refractive error without an axial length component with the degree of myopia landing in mild to moderate (<6 diopters) during childhood to adolescence, typically described as “school or physiological.”
Conversely, pathological refers to a progressive disease that initiates at an early age with significant refractive error >6 diopters (D) and axial length >26.5mm. This leads to multiple risk factors for central and/or peripheral retinal changes, such as choroidal neovascularization, lattice degeneration, retinal holes/tears, and retinal detachment to name a few. As noted with this shift towards a younger age bracket, the velocity of refractive error has significantly increased in magnitude.
Current treatment strategies for myopia management:
- Orthokeratology: A reverse curve lens design that can create a myopic defocus
- Soft lenses: Optimal designs would include center distance multifocal, dual focus, and extended depth-of-focus lenses
- Low-dose atropine: Globally, it is the most widely used pharmaceutical agent in both clinical trials and in practice for myopia management
- Spectacles:
- Environment and lifestyle: Increased outdoor time can “offset” the impact of myopia and high levels of near work inclusive of multiple digital screen usage
Setting expectations when treating myopia
It is of vital importance that ECPs understand the expectations of each individual involved in each step of the process of myopia management.
This means developing practice-wide guidelines for a customized myopia treatment plan, such as: creating a viable business model to sustain the service, setting clear expectations for the role of your support staff in the process, formulating standard operating procedures for treatment and communication, and then executing by providing professional recommendations to both parents and pediatric patients.
Practitioner expectations
Identifying potential patients
It’s important to first consider which of your patients might be at an increased risk of developing myopia, whether it be non-pathological or pathological. Risk factors to look out for in young patients when treating myopia include a family history of myopia, the patient’s visual environment, binocular vision, and the child’s current refractive status.
If a child exhibits 0.50D or less of manifest hyperopia between the ages of 6 and 7, it is highly recommended to closely monitor these individuals.
Patients identified as having an increased risk of myopia require treatment as early as possible. An important step to help identify these high-risk patients is to understand the normative data based on refractive error, expected benchmarks towards emmetropization, and age.
Table 1 shows a table with normative values of refractive error and axial length expected for specific age groups.
| Refraction | Axial length | |
|---|---|---|
| Birth | +2.00D | 18mm |
| Age 2 | +1.00D | 23mm |
| Age 14 | Emmetropia | 24mm |
| Myopia | >-0.50D | >24mm |
| High myopia | >-6.00D | >26mm |
Table 1: Courtesy of Jason E. Compton, OD, FAAO
Understanding myopia progressors
Understanding the risk factors for myopia progression will help practitioners quickly identify patients who need an adjustment to their treatment plan. Succinctly, the rapid nature of the myopic progression, coupled with family history and age, should be your call to action to swiftly step into myopic progression data touch points.
Studies supporting current treatment strategies for myopia management:
- Orthokeratology (Ortho-K): A retrospective study of 66 school-age children who received overnight orthokeratology correction between January 1998 and December 2013 illustrated that overnight orthokeratology was effective in slowing myopia progression over a 12-year follow-up period and demonstrated a clinically acceptable safety profile.1
- Multifocal soft lenses: In a study comparing dual focus lenses and single vision distance (SVD) lenses without treatment zones, investigators found that in 70% of the children, myopia progression was reduced by 30% or more in the eye wearing the dual focus lens relative to that wearing the SVD lens.2
- Atropine: A study of 186 students show that 0.05% atropine was the optimal concentration, with a good balance between myopia control and patient tolerability.3 The 3-year LAMP study conferred these results in decreasing myopic progression without significant difference in axial length compared to other low-dose atropine concentrations.4
- Spectacles: A study in China showed that myopia progressed 52% more slowly for children wearing spectacles with DIMS lenses compared to those in the single-vision group.5
Treatment and patient differences
Selection of a particular myopia treatment should include consideration of functional and anatomical ocular differences, as well as the family lifestyle and level of motivation for treatment. There are specific situations where patients are better candidates for certain treatments than others.
As an example, children who have large pupils may be a bad candidate for orthokeratology. Ortho-K designs have small central treatment zones, meaning patients with large pupils will likely experience glare.
On the other hand, children who have small pupils may be bad candidates for soft multifocal lenses because this modality is most effective when the add power is placed within the center of the pupil. Furthermore, a patient with small pupils may be unable to tolerate having the full add effect placed within the pupil.
Table 2 compares different traits to consider when trying to match a myopic patient to the best-fitting treatment.
| No treatment | SLCs | Ortho-K | Atropine | Specs | Combo | |
|---|---|---|---|---|---|---|
| Astigmatism >-0.50 | X | X | ||||
| Pupils <4.5mm | X | X | ||||
| Pupils >4.5mm | X | X | ||||
| Rx <-3.00 | X | X | X | |||
| Athletes | X | X | ||||
| Compliance | X | |||||
| Social issues | X | X | ||||
| Low risk | X | X | ||||
| Medium risk | X | X | X | |||
| High risk | X | |||||
| 2 myopic parents | X |
Table 2: Courtesy of Jason E. Compton, OD, FAAO
Practitioner pearls to remember
The expertise of the eyecare provider is vital for setting realistic expectations around myopia management. It’s important to internally ask if you are ready to “manage” a myopia management practice. Your personal level of experience and comfort will help determine where you are on the spectrum from beginner to expert.
Parent expectations
To convince parents who are declining treatment options with no clear reason why, you can approach this conversation using motivators based on clinical evidence, potentially personal experience, and/or research. Additionally, parents need to clearly understand if and when the treatment will conclude and that the prescribed therapy is aimed at slowing the progression of myopia.
“To ensure this happens, parents should be provided with take-home materials or access to additional resources before the initiation of treatment.”
Lastly, it's imperative to communicate to parents the practitioner’s definition of treatment success. The general understanding followed by most ECPs is that a 50% reduction in the rate of progression is clinically significant.
Parent conversations
In order to be effective in addressing myopia in pediatric parents, ECPs need to educate the parents. Communicating with parents cannot be done with a one-shoe-fits-all approach. Instead, it's best to make note of the general disposition of the parent and adjust the method of communication based on what type they fit most closely. Parent types are separated into the categories of permissive, authoritative, uninvolved, and authoritarian.
Permissive parent communication
A permissive parent tends to either not set or rarely enforce rules and expectations with their child and goes to great lengths to keep their kids happy, even at their own expense. This means that when treating the patient, it's best to speak directly to the child and make sure they feel involved in the decision-making process.
Authoritative parent communication
An authoritative parent sets clear rules and expectations for their kids while practicing flexibility and understanding. They communicate frequently and guide their children through open and honest discussions to teach values and reasoning. For these parents, be very detailed with explanations, as often they are very involved in their child’s life and might feel upset that they missed this issue.
Uninvolved parent communication
A neglectful parent rarely implements rules, offers little guidance or attention, and has limited engagement with their children. While you should attempt to educate the parents, patient education is vital and should be overemphasized. Another approach is to connect with other family members of the patient.
Authoritarian parent communication
An authoritarian parent often sternly disciplines their child and will talk to their child without wanting input or feedback. During treatment, although the child’s input should be acknowledged, all communication needs to be with the parent, and the expectations for treatment need to be outlined in detail. It is not uncommon for an authoritarian parent to try to direct the course of the treatment.
Patient expectations
Communicate clearly with pediatric patients about the length of the visit and the necessity of sitting still during the exam. It’s also helpful to clearly explain how the dilation drops might feel.
For patients new to contact lenses, children are often exhausted after 30 minutes of attempting to insert and remove their new contact lenses. So instead of pushing the child further, commend them for the progress they have made that day and recommend picking it back up in a few days.
Another way to engage the patient is to give them homework between sessions, like using artificial tears to practice opening up their eyelids and looking straight at the bottle for contact lens insertion. This allows them to become more accustomed to touching their eyelids and bringing a foreign object closer to their eye.
Staff expectations
All members of the practice team should understand myopia, how prevalent it is, and the increased risk if no action is taken. The support staff often fields the first calls from parents about the practice’s services, so it is important that they are familiar with what treatments the practice offers.
Prepare staff by educating them on procedures, bringing them into the exam room, organizing staff meetings, and offering them cheat sheets. Make a list of recommendations for management schedules based on the treatment type selected. Regardless of the chosen treatment, children should be monitored every 6 months thereafter for efficacy, compliance, and safety.
Table 3 compares different treatment modalities for myopia with the appropriate follow-up schedule.
| Treatment modality | Initial year follow-up schedule |
|---|---|
| Multifocal soft lenses | 1 week, 1 month, 6 months |
| Orthokeratology | 1 day, 1 week, 1 month, 3 months, 6 months |
| Spectacles | 1 month, 6 months |
| Atropine | 1 week, 1 month, 3 months, 6 months |
Table 3: Courtesy of Jason E. Compton, OD, FAAO
Final thoughts
While myopia is a global health dilemma, there are still serious knowledge gaps and misunderstandings regarding myopia care for children. It is essential for optometrists and ophthalmologists to know how to navigate not only communicating and setting expectations for treatment but also taking feedback and proactively reacting to necessary changes to enhance patient care and dampen the myopia progression curve for future generations.
