We have all had that young patient who comes in every year; the phoropter “click, click, clicks” as more power is added to their already nearsighted prescription. With each click, the parent’s face turns into despair as they realize a new pair of glasses is required once again.
But what many of them don’t know is that now there is a way to help slow their nearsightedness. No longer are children destined to become whatever their genetics and environment decide. As optometrists, we can now help to change our patient’s fate—and that is with myopia control.
Parents will have many questions about their children’s eyesight and even more about your proposed treatment. Here are a few of the most common ones and how to address them!
Is my child at risk for becoming visual impaired from progressive nearsightedness?
The first step is to identify which patients are considered good candidates for myopia control. I will often bring up myopia control as an option if the patient is < +0.75 at age of 6, <+0.50D at 7-8 years, <+0.25D at 9-10 years, and less than plano at 11 years or if the patient’s progression is >0.50 D a year.1 There is no age too young to treat, but compliance and ability to maintain treatment have to be considered.
How will nearsightedness affect my child’s vision?
Once you identify the right patient, you should mention to the parent that you are concerned about the level/ progression of their child’s nearsightedness and that it could lead to potential serious visual impairments.
Usually, I will start out by saying:
“The prescription has increased another diopter this year, which is a faster rate than considered normal. This is a concern since the more nearsighted your child becomes the higher the risk of vision loss as they gets older. Furthermore, your child will continue to need thicker, more expensive glasses and may no longer be a candidate for LASIK when their eyes stabilize."
This allows the parent to better grasp real world limitations that come with progressive near-sightedness.
How will nearsightedness affect my child’s risk of ocular disease?
One topic that is often overlooked is to discuss health risks that are involved with being more nearsighted, such as retinal detachments, holes and tears. Myopic eyes typically demonstrate excessive axial elongation and structural changes, making them more at risk of developing retinal holes, tears or detachments, myopic maculopathy, glaucoma, and cataracts.2
Specifically, a spherical equivalent refractive error between -1 and -3 diopters had a 4-fold increase in risk for RD, and eyes with myopia worse than -3 diopters had a 10-fold risk.3
Going over these statistics can really make the parent realize that it is not just an aesthetic issue but also can lead to permanent ocular disorders.
What are the treatment options to slow near-sightedness?
At this point in the conversation, the parents jaw may be on the floor, but this is where the doctor can save the day by saying “However, we now have a way to not just band-aid the problem with new glasses every year but actually SLOW the progression of near-sightedness and help reduce the risk of visual impairment for your child.” I will then review the three types of treatments that are currently available and successful for treatment of myopia: orthokeratology, soft multifocal contact lenses, and atropine.
I summarize what is involved with each type of treatment and the benefits of each, such as orthokeratology helps to correct vision for the day, which is great for sports, or that atropine can be used if the patient is not ready for contact lenses. I recommend which treatment would be best for their child and after some discussion I ask the parent which of the treatments they seem most interested in.
What are the risks, benefits, and cost of myopia control?
Before they leave, I print out the consent forms for each treatment, which review cost, follow-up frequency, eye measurements, and inherent risk involved. If the parents are ready to start that day, I have them sign the consent form and set up the follow-up appointment. If not, I tell the parents to discuss at home and call me when they have decided which treatment they want to start and answer any questions they may have.
While the consent forms are printed, the parents may bring up the subject of cost, which is always a tricky subject since myopia control treatments are not covered by insurance. I like to have an overall yearly price for each of the treatments that encompasses all materials and exam follow-ups.
Often the price of orthokeratology gets the most sticker shocked looks, but when I break down all that the yearly fee covers (cost of lenses, design time for lenses, follow ups, etc) they tend to feel the price is justified.
Also, we include an axial length measurement taken at our corneal specialist’s practice, which is a measurement we use to determine whether treatment is working. Most parents do not know the benefits of axial length measurements. However, they need to understand that it is not just slowing the child’s prescription, but also slowing the growth/stretching of the eye itself, which is what leads to retinal detachments, myopic maculopathy, etc.
The parents are paying for your specialized knowledge and expertise, and it is important to treat myopia control with the seriousness as you would any other ocular disease.
How successful is myopia control treatment?
The parents may wonder how effective each treatment is and if there is a guarantee of success. Although most treatments show a 30-50% reduction in scientific studies, different treatments work better for some than others. Although there is no guarantee the treatment will work as well as in the studies, in my experience most show around 50-80% reduction in progression than they would if the treatment was never started.
How long will my child be getting treated?
Parents often ask how long their child will have to be in myopia control treatment. Since studies have shown that approx. 96% of myopes stabilize around the age of 24.4 I tell the parents that likely until they around 20-24 years of age. I also let them know that if they ever want to discontinue the myopia control treatments, it is safe to do so, and the child will likely rebound back to their baseline value at the beginning of treatment and not catch up to what they would have been if they never started treatment.
Unfortunately, there has not been published myopia control studies longer than five years, so we are still slightly unsure how effective these treatments are long-term.
Is there anything I can do to help slow nearsightedness aside from clinical treatment?
Lastly, parents will often inquire about smart phones and screens and how it impacts the acceleration of their nearsightedness. I tell them that although studies have not been conclusive about how near-work impacts the progression of nearsightedness, they have shown that the risk of myopia development and progression is significantly associated with reading at very close distances (<20 cm) and for continuous periods of time (>45 minutes) rather than being associated with total time spent on all near activities.5
Also, children who become myopic appear to spend less time outdoors compared with their nonmyopic counterparts.6 This makes the parent feel like they can do something for their child while at home (and get their eyes off those darn cell phones).
Why is it such an involved treatment?
Overall, it is important to be calm but firm with the parents that you truly believe this is the best care for their child and that you are trying to do anything in your power to help prevent further visual impairment.
As myopia control practitioners we are responsible for monitoring and adjusting the treatment as needed, whether that is doing a combination therapy such as atropine and contact lenses or changing the treatment completely. Also, new types of treatment and studies are always coming out, and it is up to us to stay on top of the latest discoveries.
Try to focus less on the cost and more on the long-term benefits in a way that the parents can understand and even relate to. Whether or not they decide to go ahead with the treatment, you have presented all the options to the parents and the patients, and now they can make an informed decision.
References
- Zadnik K, Sinnott LT, Cotter SA et al. Prediction of juvenile-onset myopia. JAMA Ophthalmol 2015; 133: 683–689.
- Flitcroft DI. The complex interactions of retinal, optical and environmental factors in myopia aetiology. Prog Retin Eye Res. 2012;31:622–660
- Risk Factors for Idiopathic Rhegmatogenous Retinal Detachment. The Eye Disease Case-Control Study Group. Am J Epidemiol 1993;137:749-57.
- COMET Group. Myopia stabilization and associated factors among participants in the Correction of Myopia Evaluation Trial (COMET). Invest Ophthalmol Vis Sci 2013; 54:
- 7871–7884
- Li SM, Li SY, Kang MT, et al. Near work related parameters and myopia in Chinese children: the Anyang Childhood Eye Study. PLoS One. 2015;10:e0134514.
- Xiong S, Sankaridurg P, Naduvilath T, et al. Time spent in outdoor activities in relation to myopia prevention and control: a meta-analysis and systematic review. Acta Ophthalmol. 2017;95:551–566
