Myopia is a risk factor for ocular diseases — such as cataract, choroidal retinal degeneration, glaucoma and retinal detachment — beyond this, another reason optometrists should become involved in diagnosing and treating the progressive refractive condition in all patients is that several recent developments may drive the control of myopia toward becoming the standard of care. These developments: the planned work of the International Myopia Institute and the FDA Myopia Workshop to create a DEWS-like report, the planned global “Myopia Awareness Week,” dates to be determined, in 2019, by the Brien Holden Vision Institute and World Council of Optometry and the inaugural June 2018 meeting of the Myopia Awareness Coalition.
With all this in mind, here, I discuss the three steps to successfully implement myopia management into your practice.
STEP 1 GET UP TO SPEED
Every optometrist knows what myopia is, but if you want to offer effective myopia management, you need to learn about the latest research and treatments.
To obtain such knowledge, seek educational conferences, such as the Vision by Design conference (Orthokmeeting.com ) and the Global Specialty Lens Symposium (gslsymposium.com *), that feature heavy doses of myopia control learning.
Regarding online education, Myopiacare.com and managemyopia.org (a website for which I recently became editor), provide education on how to properly analyze patients, in terms of their risks for myopia, and how to optimize your management of their myopia. In addition, Myopiacontrol.org , from the Michigan College of Optometry, at Ferris State University, has several useful resources, such as podcasts on the subject, and Myopiaprofile.com and Mykidsvision.org offer very useful resources, such as related articles and a risk assessment tool, respectively. Further, the Brien Holden Vision Institute provides a Managing Myopia CE Program and a free Myopia Calculator (visit https://bit.ly/2hOiJOG ), which shows the effect of a variety of myopia management strategies on the amount of myopia progression in a child. Finally, the Myappia app, which I developed, tracks myopia progression and control methods.
Something else to keep in mind: The orthokeratology (ortho-k) companies have tremendous information available to help train O.D.s to learn how to fit their lens designs and to provide as much information as they can on what is known about myopia progression control as well.
STEP 2 PICK YOUR PRACTICE MODE
As is the case with other conditions, such as glaucoma, optometrists treat, there are different ways to implement myopia management into clinical practice. (Often, doctors new to its management will start with their easiest cases, using the strategies they are most comfortable with and build from there, if interested.) These ways:
- Detect and refer. This mode of practice requires the least amount of patient management and, thus, may be appropriate if you are in a group practice with someone taking care of this patient segment. (A caveat: Those O.D.s who take this route may discover that they refer much of their patient population, as the condition is so prevalent. In fact, by 2050, visual impairment from myopia is expected to effect roughly 40 million Americans, according to the NIH.)
- Detect, diagnose and treat up to comfort level. In this practice model, the O.D. is perfectly comfortable recommending outdoor play and prescribing multifocal spectacles, particularly for those subgroups of patients who will likely benefit from such lenses. This subgroup of patients: those who have esophoria at near, high accommodative lags or large-segment bifocals.1 The doctor would refer just those cases needing a type of treatment not yet offered by him. A simple step just beyond this would be to prescribe low-dose atropine. (While optometrists may be hesitant to go off-label, they may be surprised to see in the coming years that low-dose atropine may end up being the standard of care within pediatric ophthalmology for the treatment of myopia progression.2)
- Detect, diagnose, “dabble” in management. Doctors looking to provide a higher level of myopia care to their patients, but who don’t wish to invest in a corneal topographer, may fit multifocal contact lenses. (For those leery of doing so, keep in mind that a child’s visual system, for example, is remarkably more adaptable than a presbyope’s, making the fitting experience mutually beneficial.)
This type of practice model might also allow for adding low-dose atropine to a multifocal treatment, if at six months the myopia control effect is not hitting the expected target. Skeptics might say there is no evidence that atropine in combination with any other treatment has an additive effect. With the exception of an ARVO abstract last year, they might be right.3 While I haven’t thoroughly analyzed my results over the years, there have been no cases in which patients in whom I added low-dose atropine didn’t demonstrate better myopia control six months or a year later.
- Detect, diagnose, employ ortho-k. Ortho-k has roughly the same average myopia control effectiveness as either multifocal contact lenses or low-dose atropine, but it has several unique advantages that make it a vital service in myopia care.
Ortho-k provides excellent day-time vision without additional refractive devices. It’s also great for patients who have dry eye complaints associated with contact lens wear, as there is no wear during the day. The treatment is beneficial for sports in general, as the athlete doesn’t have to worry about losing a lens during participation, for example. And, it provides unique advantages for certain sports, particularly swimming, without the risks associated with wearing soft contact lenses during water activities.
This mode of practice requires the mastery of corneal topography to ensure the best fit, and thus, the maximum benefit. The corneal topographer the O.D. chooses must be compatible with his preferred custom ortho-k lenses and, ideally, with other ortho-k companies, as well as custom lens design tools. Having an objective, precise, easy-to-perform test of axial length allows the O.D. to know with certainty whether he is achieving the treatment goals with his chosen treatment. Rather than waiting a year to be certain about the refractive outcomes, with a precision measuring device, changes can be made to the design of an ortho-k or multifocal contact lens, and low-dose atropine may be added as a combination treatment, or the dosage could be changed.
While it might surprise most optometrists, it is not at all unusual to detect small amounts of axial length reductions in patients undergoing myopia control, and there is nothing a parent, in particular, enjoys more than seeing that the treatment choice for her child slowed the worsening of his vision and actually completely stopped — even reversed — it a bit.4
Obviously, the ultimate myopia management practice will include all the evidence-based methods available, described above, for controlling myopia.
STEP 3 MARKET IT
Marketing can be as simple as doing a great job with your patients, as they can be willing referrers. Also, learn from others who have implemented successful marketing strategies, and decide whether you want to actively grow this part of your practice.
If you are considering targeted external social media marketing with Google or Facebook, decide who you are trying to reach. For example, think about the age of the child you want to reach, his demographics and the likely characteristics of his parents, or more particularly, his mother, as I have found that the mothers of young myopic children not only tend to be around age 40, highly educated and moderately affluent, but also the family decision makers. To hyper-target, remember myopia is the most prevalent in Asian-American families.
BE A TRIPLE THREAT
There is no better time than now to offer myopia management, be it for children or adults, as it is becoming more and more accepted that there is a “Tsunami of myopia.” To successfully implement myopia management into your clinical practice, follow the three steps outlined above, and be a triple threat against this progressive refractive condition. OM
* PentaVision Media, publisher of Optometric Management, runs the Global Specialty Lens Symposium.
Special thanks to Patrick Simard, O.D., Ms.C., M.B.A., F.A.A.O., for reviewing this article.
- Cheng D, Woo GC, Schmid KL. Bifocal lens control of myopic children. Clin Exp Optom. 2011; 94: 24-32.
- Gong Q, Janowski M, Luo M, et al. Efficacy and Adverse Effects of Atropine in Childhood Myopia: A Meta-analysis. JAMA Ophthalmol. 2017; 135: 624-630.
- Kinoshita N. Konno Y. Hamada N. Kakehashi A. Suppressive effect of combined treatment of orthokeratology and 0.01% atropine instillation on axial length elongation in childhood myopia. Poster B0535- ARVO Baltimore. May 2017.
- Aller TA, Liu M, Wildsoet CF. Myopia Control with Bifocal Contact Lenses: A Randomized Clinical Trial. Optom Vis Sci. 2016; 93: 344-52.