This article contains both information from Sato Mananian, OD, and information adapted and expanded from prior contributions by Joel Kestenbaum, OD; Steven Turpin, OD; and Elisa Stefanovic, OD.
By 2050 it is predicted 50% of the world’s population will have myopia! That’s almost 4.8 billion people globally.1
These stats are alarming and suggest we will be seeing a rapid and significant increase in myopia at a time where we are uniquely positioned to help. This increase in prevalence globally demands a need for further patient education as well as peer-to-peer education on managing and preventing myopia and its associated ocular complications.
Who is at risk for developing degenerative myopia and all associated ocular complications?
The first step is to identify some known risk factors for myopia, which include:
- Parental myopia
- Outdoor activities
- Close-range activities (reading, computer work)
- Increased urbanization
If a child has two parents with myopia the child has a 1 in 2 chance of developing myopia. If only one parent has myopia the risk is 1 in 3. And, if neither parent is myopic, this child still has a 1 in 4 chance of becoming myopic. Knowing this data, we can identify potential patients before even seeing them in our chair! How? By being well informed and educating the parents and patients who are myopic that if they have children (or soon plan to), there is a higher likelihood of myopia.
All this aside, the greatest identifiable risk factor is the current refractive error. As a rule of thumb, we should begin discussing 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.
Now we have identified who is at risk for myopia, what next?
Educate! Educate! Educate!
Success with myopia control is determined before any treatment is initiated. Patient and parent education is key in ensuring compliance and long-term success. I begin by discussing the risks to ocular health associated with being nearsighted, such as retinal detachments, myopic maculopathy, glaucoma. I then explain how each of these can pose a significant threat to their vision.
I prefer to use an eye model to assist in my presentation and discuss that myopic eyes tend to exhibit axial elongation and explain this is the catalyst that leads to structural changes which can ultimately result in decreased vision.
Specifically, a spherical equivalent refractive error between -1 and -3 diopters had a 4-fold increase in risk for RD, and patients with myopia greater than -3 diopters had a 10-fold risk.³
I also like to mention that as a patient’s myopia progresses, so does the chance that they will no longer qualify for refractive correction surgeries, such as LASIK, in the future. I also take this time to discuss that the higher the power the greater dependence the patient will have on full-time correction and the greater the impact will be on quality of life. Oftentimes the parents themselves are myopic, and they readily appreciate this fact and can commiserate.
Thoroughly educating patients and parents can be time consuming initially but can alter the course of treatment by helping them to realize the impact myopia can have on their child's health.
Factors contributing to myopia progression
The etiology of myopia is not fully understood but is believed to be a combination of genetics and environmental factors (i.e., time spent doing near work).⁴
Initially the idea was nearsightedness is caused by the amount of near work and the more educated an individual was the higher the prevalence of myopia. However, recent studies have proven, once again, correlation doesn't equal causation.
The Collaborative Longitudinal Evaluation of Ethnicity and Refractive Error Study (CLEERE Study)5 was conducted to study the effects of certain activities on myopia progression over a 1-year period. The study found that it was not the near work that caused the onset of myopia. The number of hours spent on near-work activities had a clinically insignificant effect on annual myopia progression.
An additional 10 hours of reading for pleasure only correlated with an average increase of -0.08.
Time outdoors is the behavioral factor that affects the probability that an emmetropic child will develop myopia.
However, once myopia onsets, time spent outdoors does not influence myopia progression. Going forward, we as eye care professionals are in a unique position to be at the forefront of this epidemic working with community leaders and policymakers to implement change and slow progression.
What are myopia treatment options?
If the goal is solely to “control” myopia, this probably isn’t the worst option.
If you turned away your myopic patients at the door, most would land in the -2.50 to -3.00 D range with zero intervention (the reason is its own topic of discussion). Unfortunately, we as optometrists have this pesky reputation for helping improve the clarity of a patient's vision. They’ve now come to expect it. While you’re not risking causing harm to the child as a result of unknown treatment effects, no intervention is not a great practice builder. We’ll put it on the “less than ideal list.”
Previously, it was thought that under-correction of myopia or utilizing single vision reading lenses was a sensible way to treat the progression of myopia. However, it has been shown that these treatments are ineffective and under-correction can increase myopia. Each practice may choose to employ the modalities for myopia management that suit them best.
Single Vision Distance Rx
The “gold standard.”
Also, probably the worst “control” strategy. Progression of children with full-time correction is greater than those who were not corrected at all.6.7 Yet, single vision distance correction continues to be used as the “control” group in myopia control studies even though the modality is likely accelerating the myopia progression. What are the consequences? ALL results of the randomized control trials looking at control strategies are skewed. It’s difficult to say with certainty how much they are skewed; but, the control modalities are likely less effective than the results might indicate.
Contacts and glasses cause similar rates of progression (about -0.75 D per year).8-10So between the two, contacts might be worse due to an increase in microbial keratitis risk.
Either way, bumping up the minus to temporally optimize distance acuity is a lot like putting studded tires on your car all year long. They’ll work great the few times when you need them; but, the rest of the time you’ll burn more energy trying to get to where you need to be and they’ll also wear out within the year.
Better than single vision lenses.
Executive lenses appear to be better than PALS.8,11You get about a 33% reduction in myopia progression.12 Some will argue that an executive provides a larger area of peripheral myopic defocus and that’s why they work. That could be true. The fact is that an executive is much easier to use. You look above the line to look far away and below it to look close. There is no image jump because the optical center of both lenses is directly at the line.
The question then becomes, how much add power?
That is your clinical decision based on your beliefs of what myopia really is. One group studying executive lenses used an add power of +1.50.11 Those arguing the peripheral blur theory mentioned earlier may say a higher add power (+2.00-+2.50) would provide more peripheral myopic defocus strictly based on the optics. This has not been studied. The group arguing the near point stress theory would say that add is much too high and the near add should be enough to provide some change in behavior (+0.50 at low end); but, should not exceed the fused crossed cylinder measurement, which is considered by some to be the maximum amount of plus/least minus that will be accepted at near.
As a result, most of the add powers I see going out the door by the practitioners doing this regularly are in the +0.75 to +1.25 range. That said, the choice is ultimately yours.
As for risks, a bifocal provides no more risk to the child than a single vision lens; but, you cannot guarantee they will look through the add portion when doing near work. The other risk is that parents will look at you funny when you suggest their 10-year-old wear a Ben Franklin bifocal. Buy-in is a real problem and the explanation as to why is crucial.
In addition, the reality may be that you don’t work with a lab that will do an executive or an insurance company won’t cover that design. Flat top-35s with an altered add power may be a compromise you have to make. So if contact lenses are out of the question, this may be your best option aside from atropine (more on this later).
The main players are orthokeratology, multifocal soft contact lenses, atropine, and the newly FDA-approved MiSight lenses.
(AKA corneal reshaping)
Ortho-K lenses are gas permeable (GP) lenses that are designed to steepen the mid-peripheral cornea and flatten the central cornea. They are a specific design of gas-permeable contact lenses used to change the shape of the cornea, thereby changing where the light focuses on the retina. This practice reduces myopia progression by roughly 30-50%.13The lenses are worn overnight for a minimum of 7-8 hours and have the added benefit of allowing for clear vision throughout the day when the lenses are removed. The treatment range is around -1D to -6D with small amounts of astigmatism.
The center of the GP lens has a flatter base curve than the central region of the cornea. This lens design creates increased thickness in the mid-peripheral cornea and thus creates more “plus power” in the mid-peripheral region. This leads to myopic peripheral defocus in which the image forms before the retina, and this initiates a “stop” signal for axial growth and reduces the progression of axial elongation.
The number of lens designs is growing and there are even some lenses being designed specifically for myopia control. That said, it is probably the most nuanced and technically difficult modality to use. Some tips and tricks presented at conferences border on being considered black magic. Discussing all of the potential fitting strategies and lens designs is beyond the scope of this article. It is recommended you communicate with a practitioner who has been fitting ortho-k lenses for a while if you’re just starting out.
An added benefit with these lenses is within the treatment parameters patients will also enjoy clear vision throughout the day without corrective lenses. Provided you nail the fit, the obvious advantage is that the lens theoretically provides continuous peripheral myopic defocus to the retina. And it is unique in that the optics are present at all times. The child cannot simply take off the lens and put on their single vision glasses at the end of the day like they could with soft multifocal contact lens.
However, an ortho-k lens is more invasive than a spectacle lens. You’re physically changing the shape of the cornea. Ortho-K advocates will say that the change is strictly an epithelial phenomenon and the 7-day turnover rate of the tissue will completely reverse the effects of the treatment. There is convincing evidence this is the case and that long term ortho-k wear causes no permanent changes to corneal shape or physiology.14
Conversely, practitioners who are opponents of the modality have claimed to have seen long-term, permanent changes in corneal shape in past ortho-k wearers. The truth is likely somewhere in the middle. Poorly fit lenses or non-compliance could certainly result in corneal damage. Other drawbacks of orthokeratology include microbial keratitis rates similar to that of other overnight wear modalities. So if you provide ortho-k services, spend some time developing fitting skills and making sure the patient understands the risks involved and how to reduce those risks. If the job is done well, the fitting fee–which is often significantly higher than that of a soft multifocal contact lens–can be justified.
Multifocal soft contact lenses
Multifocal soft lenses offer a similar reduction in axial elongation to ortho-k lenses, 30-50%. This treatment option is an alternative a practitioner can consider for higher myopes.
These are specially designed lenses to create multiple focal points on the retina. Specifically, the theory is that if the mid-peripheral and peripheral retina received a more hyperopic correction than the central retina, the resulting stimulus would reduce eye growth. One such lens is the center-distance extended depth of focus design of the VTI NaturalVue Multifocal.
Multifocal soft lenses are similar to ortho-k (about 48%) in their ability to slow progression.15Specifically, center distance lenses. The optics presented to the eye are similar to those provided with ortho-k (myopic peripheral blur). Studies have investigated both concentric ring add designs and aspheric add designs with similar results.10, 16-18 All lenses had add powers between 2.00 and 2.50 D. None of the lens designs studied are commercially available. That said, you may have one lens in a fitting set of yours that is a center distance design. There are some doctors using this lens for myopia control.
As touched on above, when choosing a lens practitioners should choose a lens with a center-distance design. Start with the highest add power, the end goal is the highest add tolerable by the patient. Many brands offer a distance center design.
There is no reason you can’t use these for controlling myopia. Things to consider when designing a lens include center optic diameter (usually 2.0 mm), add power, add design (aspheric, concentric ring, linear) and decentration of optics over the line of sight. The peripheral blur theory would suggest the smallest center optic diameter tolerable with the largest add power and area tolerable would provide the eye with the most robust signal to stop growth. Yet, we are still in the midst of figuring out what designs work best in practice.
Another option that is less recognized as a potential modality is the center near multifocal soft lens. The argument against this lens design is that it effectively presents the eye with the inverse optics of the center distance design. And, a lens that provides optics opposite of the center distance lens should create the opposite effect, right? Wrong, while it is true the center near lens does provide a different optic to the retina, it is still simultaneously providing both hyperopic and myopic blur. Even if the blur theory of myopia holds true, as long as there is enough myopic blur presented to the retina, growth will slow down. It doesn’t matter if that area includes the fovea or not. This lens design also fits the requirements if the near point stress theory holds true.
The huge advantage of this lens design over the center distance lens is its availability.
The number of off-the-rack lenses is quite high, making it a much easier, time efficient lens to fit. Unfortunately, no one has studied center near lenses for myopia control. I have talked to a number of private practice doctors using the lenses for myopia control and have seen data suggesting progression rates similar to that of a center distance lens. The caveat of this data is that many of the patients fit in these lenses were in their early to mid-teens which is often after the peak rate of progression for your standard myope and the natural slowing of progression in these years may have padded the stats. Regardless, center near multifocal lenses will NOT increase the rate of myopia progression. So what do you have to lose by fitting a young myope in a center near multifocal if you were planning on fitting them in spherical soft single vision lens anyway?
Here is the protocol recommended to me by practitioners fitting center near soft lenses for myopia control:
Perform a number 7 (most plus, least minus to 20/20- OU). Add -0.50 D to number 7. Equalize Rx between eyes if aniso is 0.25 D by cutting a 0.25 in more myopic eye. Pick a lens with a low to medium add (+1.00 to +1.50).
Have patient return in 7-10 days after wearing lenses and perform number 7 again. The results should be approximately +0.50 – +0.75 greater than distance portion of the contact lens. All measurements are performed without cycloplegia.
Have patient return in 6 months perform number 7 again. Do not be too quick to change Rx if patient has picked up +/-0.25 D. Use clinical judgment if change is more than +/-0.50.
Up to a 1.00 D, possibly 1.25 D, of astigmatism can be masked with a spherical multifocal lens
The drawback with any multifocal soft lens is that not only do the children need to be responsible enough to handle and care for their lenses; they need to have them on nearly all waking hours in order to maximize treatment effect. The patients must be motivated to use this modality, especially if they weren’t even considering contact lenses when they sat down in your chair that day. But, if you can get them on board, this modality may be one of the simplest yet effective treatment options.
An eye drop that dilates the pupil, again changing the focusing ability of the eye. Doctors are still debating the minimal dosage that works.
One theory on myopia progression states it is caused by the weakening of the scleral matrix thus leading to scleral thinning and axial elongation. Scleral fibroblasts express all 5 types of muscarinic receptors. Atropine is anticholinergic and a non-selective muscarinic receptor antagonist. Thus, Atropine can be used as a nonspecific inhibitor for myopia.
In some studies, atropine has been shown to be the most effective way of controlling myopia. Rates average out to about 77%.15That said, the two studies cited most frequently, ATOM 1 and 2 used autorefractors to determine refractive progression.19-21
The ATOM 2 Study compared the safety and efficacy of varying concentration of atropine for myopia control over 5 years in 400 children. It studied the efficacy of 3 different concentrations of atropine: 0.01% vs 0.1% vs 0.5%. The study concluded atropine 0.01% drops were more effective in slowing myopia progression with fewer visual side effects compared with higher doses of atropine.
In the case of ATOM 2, the autorefractor and a-scan instrument used to measure the control group differed from that used to measure the treatment group. As such, we may want to look at the results with a healthy amount of skepticism. We also find there is a significant rebound effect when the treatment is stopped, especially with the traditional 1% atropine.
Low dose (0.01% or 0.02%) atropine has now become the most popular formulation as it has been shown to have less rebound effect than the 1% concentration. Additionally, the lower concentrations do not seem to measurably reduce the ability of a child to accommodate which is a major drawback of the higher concentrations.
The biggest advantage that atropine has over lens correction is its ease of administration. One drop in each eye once a day is all it takes. No taking lenses in and out every evening and morning.It also takes up less chair time and the patient can continue to wear their habitual glasses.
The biggest drawback of atropine therapy is that it is the most invasive method. There have been a number of case reports contributing mental toxicity and even death to topical ocular administered atropine.22 Conversely, there are many practitioners using atropine who promote its effectiveness and safety. While that may be true, your adolescent patient is still on a long term medication that is considered an off label treatment. Use your best judgement.
MiSight lenses are the first FDA-approved soft multifocal contact lens treatment modality for myopia control. The lens was approved for myopia control in children between the ages of 8 and 12 years old at the initiation of treatment. The lenses are a daily disposable, soft contact lens.
The study performed on MiSight® lenses was a prospective, randomized, and a double masked clinical trial looking at the safety and effectiveness of MiSight® lenses. Children enrolled in the study ranged from ages 8 to 12 at the start of treatment. Subjects either wore MiSight lenses or a Proclear single vision soft contact lens. The study showed that the progression of myopia was reduced, and less axial elongation was seen in those wearing MiSight® lenses.
These lenses are fitted in the same way as any other soft daily disposable lens. They need to be worn for a minimum of 10 hours per day for a minimum of 6 days per week to get the maximum treatment effect. Refractive errors with up to 0.75D of astigmatism can be fitted with MiSight® lenses.
These lenses are designed with an optic zone design that has a concentric ring design with alternating zones providing vision correction zones and treatment zones which create myopic defocus.
MiSight lenses are an exciting new frontier in myopia control allowing us another tool in our arsenal to combat the epidemic of myopia.
Becoming a Myopia Management Practice
Becoming a myopia management practice requires education on every level.
Each of our doctors took some classes and started to fit “easy” patients with a lens modality that we might not have chosen prior. We shared the many journal articles that are available and attended courses given at the optometric conferences. Contact lens representatives were also a wealth of knowledge. We then shared the results of our treatment plans with each other as an additional learning experience.
Educating our staff was the single most important thing we could have done. Our team is the first touchpoint to our practice for patients. Providing our team with basic knowledge and the ability to speak intelligently about myopia management helped to build patient confidence in our practice. From the receptionist to the techs, our staff are the ones who will field the questions before the patient sees the doctor.
Myopia control can offer tremendous practice-building opportunities while also allowing patients to minimize their risk for ocular disease—preserving their vision and quality of life.
Billing and Coding for Myopia Control
The ICD-10 codes for diseases of the eye are designated with the letter “H”, for myopia the ICD-10 is H52.1. For degenerative myopia it is H44.2. Unfortunately the H52.1 myopia code is most often not reimbursable by medical insurances however it is by Medicaid and VCPs. Degenerative myopia however is reimbursable by medical insurances, VCPS and Medicaid. Currently there is no CPT code for myopia management, and no set process on how myopia control treatments should be billed and reimbursed. Oftentimes the bulk of the financial responsibility falls on the patient. Here are some tips based on how I may bill for various treatment modalities.
When treating your young myopes with soft multifocal contact lenses you could bill their plan like any other soft contact lens fitting using the 92310 code for their contact lens evaluation and V2522 for the materials. Follow-up office visits outside of the contact lens fitting period may then be billed using the 92499 code which is used for unspecified ophthalmological services.
When treating an Ortho-K patient, the GP contact lens materials (V2510 or V2511) are reimbursable codes and can be billed using the refractive diagnosis myopia H52.1.
Since the use of topical 0.01% atropine is not FDA approved for myopia management, it is also not covered by medical insurance or VCPs.
When measuring axial length to monitor for myopia progression providers can bill the CPT code 76519 which codes for ophthalmic biometry, again used with the diagnosis code of H44.2.
As we touched on above a large portion of myopia control costs are left to the responsibility of the patient. Some patients may have the option to use their Flex Spending Accounts to cover the residual costs not that were not covered by insurance.
Conclusions: Parent education is key!
Myopia can severely impact quality of life, particularly high amounts of it. It can impact a patients’ psychological well-being, make them dependent on correction, and limit their ability to function without their glasses or contact lenses. Myopia can be a large financial burden to the patient as well.
As ODs we are in a unique position to help these patients, and this all starts with proper patient education on myopia.
Key points for proper parent education:
- Explain refractive findings as well as pathology and risks associated with high myopia.
- Hand out informational materials for the parents to take home.
- Discuss the best treatment course, or, alternatively, monitor refractive state in 6 months.
As providers we are responsible for not only explaining refractive findings but also should discuss the pathology and risks associated with high myopia.
Currently, I like to discuss the various treatment options and which treatment I recommend for the patient and why. If the parents and patient do not feel ready to take that step currently, then I ask to see them back and monitor their refractive state in 6 months.
It is very helpful to have informational pamphlets to hand out for the parents to take home because it can be hard to digest all at once.
I stress to parents that this can be prevented, and their children do not have to become highly myopic—risking future eye diseases and poor quality of life. We can impact change in their lives in a meaningful way.
Parents need to understand that children do not have to become highly myopic, increasing their risks for other eye diseases over time. We no longer have to wait and see what happens. We can intervene to attempt to change what was once considered destiny. Parents also need to understand that there are no guarantees and that doctors are using data from the most current scientific research to prescribe treatment. Ongoing investment in myopia control management is akin to investing in speech therapy. Teach a child how to speak properly now and they will be impacted for life. Prevent or reduce myopia progression and a child will be impacted for life too.
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