Myopia is on the rise, with over half of the global population expected to be myopic by 2050.1 As eyecare practitioners, it is well known that myopia is more than just a refractive error.
The axial elongation of the globe puts our patients at risk for sight-threatening complications, including myopic maculopathy, retinal detachments, and glaucoma.2-5 It is our duty as eyecare providers to provide our patients with preventative care and education to mitigate these risks.
The current state of myopia management
Myopia control is a highly researched and growing topic in pediatric optometry.6 Its efficacy is well-accepted in the medical world. Pediatric ophthalmologists often refer to their optometry colleagues to help manage their myopic patients.
While some may be comfortable prescribing pharmacologic interventions, they almost always look to us for optical forms of control. Optometry has an opportunity to own this with ophthalmology’s support!
As of this article, vision plans don’t cover myopia control treatments. Some medical insurance plans are starting to come around, though inconsistently. As such—we get to step away from vision plans for our myopia control patients.
Requirements for effective myopia management
Before we create a plan on how to bill for something that isn’t defined by vision plans or medical insurance, let's review what is required to effectively manage myopia.
1. Appointments every 4 to 6 months
- Monitoring for treatment efficacy AND patient compliance is so important.
- We have multiple treatment options, if one is not working appropriately, then it’s worthwhile to try an alternative or combine it with another modality.
2. Cycloplegic refraction annually (at the least)
- This is vital to determine the true amount of myopia. Young eyes love to accommodate. We’re interested in their true myopia, not their pseudo-myopia.
- Of note, orthokeratology (OrthoK) patients don’t need to be washed out, but a cycloplegic “over” refraction will help monitor for progression.
3. Binocular vision evaluation
- Know the risk factors. Is your patient esophoric at near?
- Do they have an accommodation lag? If yes, they have a higher risk of progressing.7,8
4. Axial length measurements
- Invest in technology. It is the most objective way to measure myopia progression.
- It increases your legitimacy and value as a myopia control specialist, and it will pay dividends.
5. Pharmaceutical prescription
- Establish a relationship with a reputable compounding pharmacy. This can make or break the efficacy of your low-dose atropine treatment.9 It should be noted, however, that atropine has yet to be FDA-approved and is still considered an off-label treatment.
- Determine patient cost, stability of drops, willingness to ship to patient, turnaround time, etc.
- If you can’t find someone locally, there are compounding pharmacies that are able to ship nationally (i.e., OSRX)
6. Acquire appropriate training and certification.
- Paragon CRT, NaturalVue Multifocal (MF), and Abiliti contact lenses require certification to effectively prescribe for myopia management.
- For MiSight, training with a certification program is available; however, certification is not required.
- Myopia Profile offers an atropine course.
7. Contact lens fitting and training
- Educate your staff so that they know how to talk to your patients about myopia control during their training sessions.
8. Create a game plan for troubleshooting
- Your patient is making an investment. Expect them to be invested in the details.
- It’s important to understand the mechanism of action (MOA) of each treatment. Be able to explain them in layman’s terms. A good diagram can be a life (and time) saver!
- Know your plan for patients with side effects from atropine.10
- The optical design of peripheral defocus contact lenses can cause reduced image contrast, “ghosting,” or halos/glare around bright lights. The International Myopia Institute (IMI) suggests a 4- to 7-day adaptation period.12
9. Orthokeratology
- Investing in a good topographer can help reduce the number of adjustments required.
10. Investing in educational material
- Myopia control often comes as a surprise to patients. Why do they need it? Why has no one spoken to them about it before?
- Discuss the importance of lifestyle adjustments; parents love this aspect of patient education.
- Advise patients to spend more time outside,12 take a break from their phones, and stop holding devices so close to their faces.
- You will often see mom or dad appreciatively nodding along at this point.
- Parents should also be made aware of what modalities are approved for myopia management and control.
- OrthoK is approved for myopia management, but not myopia control.
- MiSight is the only treatment approved for myopia control.
- Though the FDA has accepted a new drug application for NVK002 (a preservative-free, low-dose atropine eye drop), approval has yet to be granted. However, it is expected to be approved this year.13
- The myopia control conversation can often become lengthy. Create educational materials for families to read and discuss.
- Set up a phone call or telemedicine visit to answer any questions for both parents.
Phew! This is a lot. Do you need to do all of the above? No. But you should set up your fees based on how much you have invested to become an expert in the subject.
Setting an annual myopia management fee
Myopia control requires an investment of both your money and TIME. Due to the frequency of appointments and investment of chair time, many practitioners offer an annual myopia management fee.
This can look a few different ways:
- A single fee, regardless of treatment option (paid upfront vs. semi-annual installments).
- Varying fees based on treatment modality.
- Combined fee for exams and diagnostic testing, while charging for materials separately.
- Separate fees for exams, diagnostic testing, and materials.
Potential myopia patient resources
There are multiple ways to do this, but it’s important that you find what works for you and your patients. Inevitably, you will have a patient where cost is a concern.
The difficulty of insurance denying myopia control coverage means that the patient typically bears the burden of covering the cost. Though challenging to find, there are ways to help ALL of your patients get the treatments that they need.
Some myopia patient resources ideas include:
- Community organizations
- The Lions Club
- Low vision nonprofit organizations
- Become a study site
- There are several ongoing myopia control studies that are being conducted by industry. Enrolled patients have their costs covered by the study.
- Grants
- Apply for local or state grants that help prevent visual impairment.
- Know the most cost-effective options
- If your patient can’t afford first-line treatment options like MiSight or orthokeratology, then low-dose atropine or Biofinity MF may be an option.
In closing
With the rates of myopia consistently on the rise, most optometrists are united in the thought that myopia control needs to become a standard of care. Myopia management offers an opportunity to build your practice while serving this growing patient population.
Because myopia management is a necessity for many individuals, it is imperative that eyecare providers find ways to make it accessible and inclusive, despite the insurance and payment obstacles.
And though becoming a myopia control specialist requires an investment of time and money, it will likely pay off for your practice, both monetarily and through knowing you are enhancing the vision—and quality of life—of your patients.
