As the incidence of myopia increases and without any signs of slowing down,1 it is essential that optometrists start managing this disease more intentionally. With all the studies showing the amazing effects that myopia management treatment modalities offer patients,2 it is our responsibility as practitioners to discover ways to incorporate it into our practices.
There are many proven ways to start myopia management, but I will focus on some of the successful strategies and steps that our offices took in implementing myopia management.
Step 1: Educate yourself on myopia management
The first step is to properly educate yourself. There are many publications and continuing education courses dedicated to myopia and treatment. You need to have a solid base on the contributing factors and pathophysiology of progressing myopia. It is also important to know the studies behind the different treatment modalities and how they work.2 All this will allow you to educate patients effectively.
Also, training courses on orthokeratology are beneficial, and many orthokeratology manufacturers offer training courses on their lenses to help with the fitting process. I found it is key to reach out to other practitioners who have implemented myopia management and get their advice on different lens technologies and marketing strategies that they have used. This allows you to circumvent some of the common stumbling blocks that others have already gone through in improving their specialty.
Step 2: Identify the technologies you’ll need
The next step is determining the technologies that you will use in your office. Although it can be done without it, I believe having a way to measure axial lengths is extremely important.3,4 I like to know the patient’s starting axial lengths and how quickly they are progressing.
This way, I can have quantitative data as we begin therapy to know how effective treatment is. It is also a great educational tool to show parents where their kid is currently at and how fast they are progressing compared to normative values and then project where they may be if no intervention is applied.
There are many optical biometers on the market that are relatively affordable. Some of the more common ones are:
- ZEISS IOLMaster
- Haag-Streit LenStar
- TopCon Aladdin
- OCULUS Pentacam
- NIDEK AL-Scan Optical Biometer
The next imperative piece of equipment is a corneal topographer. If you plan on fitting orthokeratology (Ortho-k), then you must have topographies on hand when selecting initial lenses as well as to monitor the fit and the effect of treatment.5 Our offices use the NIDEK OPD autorefractor and topographer.
Step 3: Decide on treatments
Once you have your diagnostic technologies in place, you need to decide what treatments you will provide. Our office offers low-dose atropine therapy which we have compounded from a pharmacy.6 They directly ship to patients on a monthly basis.
We also offer soft multifocal lenses; I use both CooperVision MiSight and VTI NaturalVue multifocal contacts. For Ortho-K lenses, we use Euclid. After trying and meeting with many Ortho-K manufacturers, I found that Euclid has excellent customer support and makes fitting the lenses a breeze.
Step 4: Get the word out
Another step in our implementation process for myopia management was developing a marketing plan and training our staff.
Starting with staff, we focus on training at our monthly staff meetings with an overview of what myopia is, why it progresses, and management. We then do a surface-level overview of what Ortho-k is so that if patients call, the staff are able to have a brief discussion and know how to properly schedule them for a consultation.
I found it takes a consistent message and continual training before it becomes ingrained in our staff. Since I head the program of myopia management within our clinics, we made the head technician that I work with our myopia management lead within our ancillary staff. This lead organizes our myopia management handouts, does the workups for our consultations, teaches insertion and removal to the kids, and answers parents' questions when they call.
Our marketing plan utilizes internal methods such as a TV slide show in the waiting room, pamphlets at our checkout desk, an informational poster in our work-up lanes, and our staff discussing it with patients. Our external methods involve radio advertisements, including interviews that I do with local broadcasters, a written advert in a monthly newspaper sent to parents by our local school district, and conversations with pediatricians.
To learn more about how to create efficient myopia workflows for your practice, check out How to Get Staff Involved in Myopia Workflows!
Our myopia management workflow
We start the conversation about myopia management before we even see the patient. While patients wait in our reception area we have a TV that explains what myopia is and highlights our different treatments. It is present on our website, newspaper ads, and normal marketing outlets.
The other point of patient contact where we discuss myopia management is after the patient’s initial autorefraction. If the tech sees a myopic prescription or the lensometer reads a myopic correction, they will ask the parent if they have heard of myopia. From there, they will provide a very brief surface-level description of the different options to treat myopia, including Ortho-K.
Then, once the patient reaches me in the exam lane, I start to plant the seed after refracting the patient. At the end of the exam, I go through everything more thoroughly. We have a complete packet with our clinic’s branding that we give to the patient.
It includes a personal letter from myself, descriptions of what myopia is, why it is increasing, and the risk factors associated with it. It also includes brief explanations of each treatment method, as well as links to some pertinent studies.
We also include informed consent papers and our payment policy contracts. The parents can initially find this information overwhelming, so I tell them to take it home and read through it with their spouse. If they have any questions, I encourage them to call me or schedule a full myopia consultation. If we have not heard from the parents after one week our lead technician will contact them.
During the official consultation, we measure axial lengths, discuss everything in more depth, and ultimately choose a treatment method that best aligns with everyone's goals. Patients at this point are typically very intrigued about the option of Ortho-k lenses at night and then not needing correction throughout the day.
Practice pearls for fitting Ortho-k lenses
When you first start fitting Ortho-k lenses, there are a few practices that I have found helpful:
- Clear communication with the parents and child about expectations and the process: By setting the expectations on how many visits it may take, what the child will likely experience, and how we will work with the family throughout the process, we build trust that pays dividends during the initial fitting process and beyond.
- Careful patient selection: For your first few fits, I would recommend being selective and choosing patients who will set you up for success. This means choosing patients that have lower prescriptions, low amounts of corneal toricity, and normal K values. The ideal range would be myopia up to -4.50D and corneal astigmatism up to -1.50D.7 Also, in my experience, the patient's and parents' temperament and motivation are crucial to success.
- Make sure you have pristine topographical scans: Ensuring a smooth ocular surface, a wide enough scan that gets information from the entire cornea, and eliminating all artifacts from the images, including eyelashes, improves the image quality. Taking the time to have accurate topo scans will make initial lens selection easier and will mean having a good baseline to serve as the foundation for all difference maps and scans in the future.
- Be patient: Depending on the patient, treatment zones may take a few weeks to fully develop, so it's important not to always make changes in the lens design after the initial lens review.
- Leverage your relationship with your lens manufacturer: Most have great consultation services and will help you make changes and customizations to ensure the best lens for your patient.
The follow-up schedule is important in myopia management as we want to track the effectiveness of the treatments. For orthokeratology, once we have a successful lens, I will follow up with patients at least every 6 months.8 We will check how the patient is seeing and measure over refractions, topographies, and axial lengths.
Step 5: Myopia management fee schedules
The final step you must determine is how you will set up your fee schedule. There are many different ways to go about this with many practitioners finding success using different schedules.
The one that we have found works the best for our myopia patients is a 2-year contract that has a global fee. This fee is paid upfront and includes all the follow-ups and lens materials. We have special exceptions included that if they determine to discontinue after a year then we will refund a portion of the payment. We have never had this happen, but it helps give patients ease of mind.
At the end of the 2 years, the parents have the option to sign a new 2-year contract or discontinue. Once a patient has had a successful fit and the method of treatment is successful, almost every parent re-ups the contract until around age 18 to 20. In approximately ⅓ of cases, myopia progression can extend into early adulthood, and in these cases, treatment will be extended as well.9
For a deeper dive into how optometrists can set myopia management fees, check out The Simple Way to Structure Myopia Management Fees!
Key takeaways
Starting myopia management can seem like a daunting task, but there are many resources to help you along the way. Lean on industry support and your colleagues who are more than willing to lend a helping hand.
It will take all of us to tackle this growing epidemic and ensure myopia management becomes the standard of care.
