In the first of our new column on patient management, Margaret Lam provides her take on myopia control and the personal care factor.
Over the years, I’ve found that one of the things that motivates me in my professional life is a desire to look after my patients to the absolute best of my ability. I am serving those patients best if – and only if – I base that care on up-to-date, evidence-based medicine.
Off duty, another intrinsic motivation is to strive to be the best person I can be for my two kids. No surprise then, that these two motivations seem to combine when younger patients present to my practice. I find myself wanting to give them the same level of professional and individualised care that I would want any other health care professional to provide to my children.
I’m not diminishing the importance of maintaining professional objectivity. I’m simply recognising that there is a synergy in harnessing our personal ‘care factor’ to drive us further to obtain the best outcome for our patients.
The range of potential treatments for myopia
is broader today than it has ever been.
One area of concern I regularly see among my younger patients is the quiet epidemic of myopia. The relationship between our children’s extensive use of digital devices – the heavy diet of near focusing – and shortsightedness has been well established.
Paediatric ophthalmologist Flitcroft in Journal of Retinal and Eye Research states, “the calculated risks from myopia are comparable to those between hypertension, smoking and cardiovascular disease. In the case of myopic maculopathy and retinal detachment, the risks are an order of magnitude greater. This finding highlights the potential benefits of interventions that can limit or prevent myopia progression”.1
What this means for eyecare practitioners is that we should be concerned about protecting our patients from the potentially high risk of vision loss due to myopic progression. We should be as concerned about myopic progression, as the medical profession is about the systemic effects of hypertension, smoking and cardiovascular disease.
How much shortsightedness is a risk for vision loss?
Whether or not it should hold true, there is an established view that separates physiological myopia, set at an arbitrary figure of myopia under -6.00D, and myopia as a ‘disease’ of concern when it is called pathological myopia as beyond this level.2,3
There is a difference of professional opinion in the eyecare field as to whether the increasing level of myopia is correlation or causation for ocular pathology sequelae associated with high myopia. Yet epidemiological data supports validity in the concept that all myopia is likely to be a causal, high risk factor, and sometimes the primary risk factor, for vision loss due to certain ocular pathological conditions, such as retinal detachment, myopic maculopathy, glaucoma and cataract, sufficiently so that we should be concerned.4,1
This risk appears to be considerably associated with even small degrees of myopia. For those that demonstrate higher levels of myopia, myopia-associated ocular pathology appears to be an exponentially increased risk.1
Translated, this really means there is no real ‘safe’ level of myopia. With the burgeoning myopia epidemic, it is our clinical responsibility to pursue effective methods to reduce myopic progression.
What to Prescribe
As shown by Chung et al., under-correction is not only ineffective at reducing myopic progression; it results in an increased rate of progression.5
To date, interventions such as orthokeratology lenses show the strongest reduction in rates of myopic progression compared to all other management options, indeed, almost halving the rate of myopic progression.6–12
With this in mind, reducing myopic progression rates should be considered for all progressing myopic patients, and not just by those with existing specialty contact lens expertise to prescribe them.
To prescribe appropriately and to minimise risks of infection involved with overnight contact lens wear, it is critical patients are prescribed with care, due diligence and expertise. Specialty skills in orthokeratology prescribing can be developed via organisations such as the Orthokeratology Society of Oceania (OSO), and the Cornea and Contact Lens Society of Australia (CCLSA). Additionally, the Masters Course of Advanced Contact Lenses at the University of New South Wales as well as the Australian College of Optometry teach these skills, as do others. Another alternative is to co-manage patients, and certainly, our profession has begun to mature enough to do this successfully. We need only to look to how we co-manage with our ophthalmology peers, and their longstanding history of successful co-managed care with each other, to see how well it can work to the benefit of all.
All contact lens wearers require back up glasses to minimize infective/infiltrative events; in orthokeratology, even more so. We should be mindful to remember that our field and our patients are best served when we are truly acting in our patients’ best interests.
Flitcroft leaves us on a broad note of optimism: “The range of potential treatments for myopia is broader today than it has ever been, leading to the expectation that, individually, or in combination, clinically useful interventions will enter clinical practice in the coming years.”1
The Story of Three Sisters
I think we’ve reached that future in some ways.
As an example, I highlight the case of a lovely family who all attend my practice, despite the fact that they live in Thailand and it is a 15,330km round trip, every time they come for an eye examination.
Both parents are considerably short sighted. The father is approximately -4.00 in both eyes, the mother approximately -9.50, with loss of best-corrected visual acuity from myopic maculopathy. They have three daughters and their genetics and their earlier onset of myopia were pointing to them very quickly overtaking their mother: the eldest daughter was at -4.00 at 14 years old, and the twins at -2.00 at 12 years of age.
However, with regular reviews and four years’ of orthokeratology, the three sisters show an identical amount of myopia and no myopic progression. Not one of the girls has become worse over the four years.
Because they live in Thailand, we’ve set up systems: they email me if there is anything of concern, they have a reputable local contact… just in case. They haven’t missed a scheduled appointment with me once.
Everyone is as pleased as punch – I know that I’m fulfilling my professional obligations to look after these young patients to the best of my ability while they get the freedom to see clearly without the use of glasses, and are protecting their eyes from progression as best they can.
I’m happy and humbled they consider my expertise and care a vital and essential part of their lives. And, when it all comes down to it, that’s what life is all about – to make a meaningful difference.
Margaret Lam graduated from the University of NSW in 2001 and started theeyecarecompany in 2005 and today has practices in greater Sydney and Sydney CBD. Margaret practices full scope optometry, but with a passionate interest in contact lenses, retail aspects of optometry and successful patient communication. She has extensive experience in specialty contact lens fitting in corneal ectasia, keratoconus and orthokeratology, and has been a past recipient of the Neville Fulthorpe Award for Clinical Excellence.
Margaret is a guest lecturer at UNSW and works in several advisory roles with leading contact lens companies.
She currently serves as the NSW President of the Cornea and Contact Lens Society of Australia and is a regular public speaker on topics spanning business building, retail aspects of optometry, contact lenses, specialty contact lenses, and patient communication.
1. Flitcroft DI. The complex interactions of retinal, optical and environmental factors in myopia aetiology. Progress in Retinal and Eye Research 31 (2012) 622–660
2. Curtin, B.J., 1985. In: Curtin, B.J. (Ed.), The Myopias. Harper and Row, Philadelphia. Davies, L.N., Mallen, E.A., 2009. Influence of accommodation and refractive status on the peripheral refractive profile. Br. J. Ophthalmol. 93, 1186–1190
3. Morgan, I.G., Ohno-Matsui, K., Saw, S.-M., 2012. Myopia. The Lancet 379, 1739–1748.
4. Wong, T.Y., Foster, P.J., Johnson, G.J., Seah, S.K., 2003. Refractive errors, axial ocular dimensions, and age-related cataracts: the Tanjong Pagar survey. Invest. Ophthalmol. Vis. Sci. 44, 1479–1485.
5. Chung K, Mohidin N, O’Leary DJ. Undercorrection of myopia enhances rather than inhibits myopia progression. Vision Res. 2002; 42: 2555–9
6. Cho P, Cheung SW, Edwards M. The Longitudinal Orthokeratology Research in Children (LORIC) in Hong Kong. A pilot study on refractive changes and myopia control. Curr Eye Res 2005; 30:71–80.
7. Walline JJ, Jones LA, Sinnott LT. Corneal reshaping and myopia progression. Br J Opthalmol. 2009; 93: 1181–5
8. Kakita T, Hiraoka T, Oshika T. Influence of overnight orthokeratology on axial elongation in childhood myopia. Invest Ophthal Vis Sci. 2011; 52: 2170–4
9. Chen CC, Cheung SW, Cho P. Myopic Control using Toric orthokeratology (TO-SEE study). Invest Ophthalmic Vis Sci 2013;54:6510–6517
10. Charm J, Cho P. High Myopia – Partial Reduction Orthokeratology (HM-PRO) study: A 2-year randomised clinical trial. Optom Vis Sci 2013;90:530–539.
11. Zhu MJ, Feng HY, He XG, Zhu JF. The control of orthokeratology on axial length elongation in Chinese children with myopia. BMC Opthal 2013;14:141
12. Swarbrick HA, Alharbia, Lum E, Kang P. Myopia controla during orthokeratology lens wear in children using novel study design, Ophthalmology. 2015; 122:620–30.