Read more from the Q&A issue

• Methodology: Keep the questions coming
• How can optometrists efficiently schedule ocular disease patients in light of the COVID-19 pandemic?
• How can optometrists create a successful dry eye disease spa?
• How can an optometrist include the patient’s opinion when it comes to glaucoma treatment?
• How can O.D.s differentiate the neovascular form of AMD from similar diseases?
• How can an optometrist obtain diabetic patient referrals from a primary care physician?
• What is the value optometrists can provide and communicate for the fee charged?
• How can optometrists set up an appropriate fee schedule for specialty contact lenses?
• How can O.D.s get more engaged in luxury frame sales?
• How can optometrists get more new patients?
• How can an optometrist create a successful practice sans third party health plans?
• How do O.D.s create a system for quick and efficient coding?

A: Optometrists are well positioned to provide parent and patient guidance and effective management regarding myopia. Additionally, many are eager to get involved, as evidenced by the many myopia-related questions received for this year’s Q&A. What follows are excerpts from articles written by your colleagues and previously published in Optometric Management that answer these questions and include links to the full article for a more in-depth look at the answers. Stay tuned for the “Myopia Mythbusters” column and additional myopia coverage for updates.

Q: HOW DO I GET STARTED IN MYOPIA MANAGEMENT?

If O.D.s are managing myopia using dual-focus soft contact lenses or spectacle lenses, no specialized equipment is required. If optometrists are offering orthokeratology, a corneal topographer may be beneficial.

In the coming decade, axial length measurement may become the standard of care for myopia management. As such, it may become a technology worth investing in. Among cataract surgeons, optical biometers that use OCT technology or interferometry are the norm for axial length measurement. As a result, optometrists may be able to obtain such measurements from their local cataract surgeon. Regardless of whether the optometrist has an existing co-management relationship, a local cataract surgeon may be willing to have his tech measure a child’s axial length for a nominal fee or, perhaps, even as a professional courtesy. A networking opportunity awaits! (For more on tips on how to get started, visit bit.ly/3bKe6RS .)

Q: HOW DO I DISCUSS MYOPIA WITH PARENTS, SO THEY UNDERSTAND ITS SERIOUSNESS?

When discussing myopia with patients, go back to the basics: “Myopia is a common refractive error where the ocular system does not refract light properly. It tends to occur when the eye is longer than typical. As a result of these anatomical variations, the light rays converge in front of the retina, instead of on it. Myopia can be broken into low myopia and high myopia. High myopia is associated with earlier onset. All myopia can be addressed with basic refraction correction, however, earlier onset myopia requires a more aggressive approach, such as the overnight wear of special contact lenses, special soft lenses or nightly drops, and we’ll be on the lookout for this form with your child.”

In discussing the possibility of myopia progression with patients, consider using statistics about the changes the eye can go through as they age. Specifically, less than 5% of people who are age 5 are myopic. According to the study “Age-Related Decreases in the Prevalence of Myopia: Longitudinal Change of Cohort Effect?” published in Investigative Ophthalmology & Visual Science, the percentage increases to 25% by the late teens; 35% for young adults and 42% for the middle-aged. From there, the amount of myopia decreases to 20% by age 65 and less than 13% by age 80, the study shows.

Finally, given the environmental factors that place patients at risk, discussions with parents should also include suggestions on moderating the amount of time participating in near work and the importance of outdoor activities each day. (For more tips on how to discuss myopia with parents, visit bit.ly/3ynT8lo .)

MYOPIA MANAGEMENT

Respondents to OM’s Q&A Survey indicated employment of the following therapeutic approaches to manage myopia.

(Respondents could provide multiple answers.)

 

 

Q: WHAT IS CONSIDERED “NORMAL” MYOPIC PROGRESSION?

The rate of myopia progression among patients is too varied to assign a single value. The most important factors that contribute to myopia progression are age and race; the number of myopic parents also plays a significant role.

For example, in the Correction of Myopia Evaluation Trial (COMET) — a three-year clinical trial of progressive addition lenses (PALs) for myopia progression — children in the single vision lens group who were age 6 or age 7 at baseline progressed twice as fast as the 11-year-olds: – 2.19 D vs. – 1.04 D over three years. Additionally, Donovan et al. published a review of the myopia progression rates. “The estimated progression rates were dependent on baseline age, with decreasing progression as age increased,” the study says. (For more on myopia progression, visit bit.ly/3f6CE9G .)

CHALLENGES TO MYOPIA MANAGEMENT

Respondents to OM’s Q&A Survey offered the following answers to “What is your biggest business challenge regarding myopia management?”

 

 

Q: WHAT IS THE AGE OF STABILIZATION?

Goss and Winkler, who analyzed the records of 299 myopes from three optometry practices, suggest that myopia stabilizes earlier in females, with cessation ranging from ages 14.4 to 15.3, and cessation in males ranging from ages 15.0 to 16.7. The authors note, however, considerable variability.

The COMET Group (detailed above) estimated the age and the amount of myopia at stabilization in their original cohort — an ethnically diverse group of 469 myopic children — 15.6 ± 4.2 years, and myopia at stabilization, – 4.87 ± 2.01 D. Additionally, there was no significant difference between the sexes.

Keep in mind that the eligibility criteria for the study had a mean age of onset of age 7 or age 8. Thus, it is unclear whether the age of stabilization in this cohort can be generalized to myopia of later onset. Intuitively, myopia emerging during the teenage years would progress, on average, beyond the age of 15.

Still, other studies demonstrate that myopia progression occurs well into adulthood, with Parssinen et al. reporting that 45% of myopes progressed by at least – 0.50 D from 23 to 31 years. Likewise, Bullimore et al. reported that 16% of 219 myopes (mean age = 31 years) progressed by at least – 0.50 D over five years.

Based on research, it is best to monitor refractive error and, if possible, axial length to inform your decisions. (For more on stabilization, visit bit.ly/3wxH4Nk .)

Q: WHAT ARE THE TREATMENT OPTIONS FOR MYOPIA?

Soft contact lenses are increasingly used as a myopia management option, with solid scientific evidence to support their use. Center distance multifocal soft lenses are shown to have a positive effect on myopia progression when fit on young myopes, and dual focus lenses and extended-depth-of-focus lenses have both been shown to slow myopia progression. Regardless of the lens design, the principle used is effectively the same: central clear distance vision with myopic defocus in the peripheral retina created by an increase in positive power away from the center of the lens.

Additionally, orthokeratology (ortho-k) has been used as a method to correct myopia for more than 50 years. In recent years, growing evidence indicates that ortho-k can successfully slow the rate of progression of myopia. The myopia control effect is similar to soft multifocal lenses, with 30% to 80% slowing of axial elongation. Ortho-k effectively eliminates the refractive error, such that no correction needs to be worn during the day. (For more on treatment options, visit bit.ly/3wqjd1m .)

Q: What are some resources for me to learn more about myopia and myopia management options?

A multitude of tools and websites discuss myopia:

   Myopia Profile – myopiaprofile.com 

 

 My Kids Vision – mykidsvision.org

 

 Brien Holden Vision Institute Myopia Calculator – bhvi.org/myopia-calculator-resources 

 

 Myopia Care – myopiacare.com

 

 Myopia Institute – myopiainstitute.com

 

 Global Myopia Awareness Coalition – allaboutvision.com/gmac.htm

 

Q: HOW CAN I DETERMINE THE RIGHT TREATMENT FOR MY MYOPIA PATIENTS?

While there is no definitive answer, binocular vision studies provide clues as to which therapies may be best for each patient, based on diagnosis. Some examples of patients:

• Children who have esophoria and children who have accommodative lags may respond better to myopia management with PALs than those who have normal binocular vision.
• Patients who have esophoria and accommodative lag are likely to improve their binocular vision status with multifocal or ortho-k contact lens wear. (For more on the “right” treatment, visit bit.ly/3oB7bjd .)

Q: FROM WHERE CAN I ACQUIRE ATROPINE?

Atropine can slow progressive myopia, but it remains an off-label treatment for myopia. O.D.s can provide patients with a list of vetted specialty pharmacies that direct mail to patients; and O.D.s can work with compounding pharmacies that formulate atropine in a sterile laminar flow cabinet to ensure sterility. (For more on atropine, visit bit.ly/3wgZO30 .)

Q: WHAT ARE MY LEGAL RESPONSIBILITIES WHEN IT COMES TO MYOPIA?

When providing treatment options to patients, informed consent should always be obtained, particularly when a myopia control treatment is off-label. For example, atropine therapy is well researched, with studies revealing benefits in myopic patients, but the use of atropine for the treatment of myopia progression is an off-label use.

Additionally, if parents and/or patients choose a treatment that the O.D. does not provide, that optometrist has a duty to refer them to a colleague who does. Patients have a right to these options regardless of whether the O.D. can provide them in her practice. (For more on the legal responsibilities, see bit.ly/2QCRz1W .) OM