Myopia Control – Let’s Make It Personal!

Have you ever had a moment that changed the course of your professional life? Maybe it was a patient outcome (not necessarily a positive one), an article you read, or a conference you attended?

For me, that moment came at Vision By Design (VBD) 2014 in Chicago. I was fortunate to hear Dr. Ian Flitcroft, a paediatric ophthalmologist, give the lecture ‘The myopic epidemic – the real costs to society and heath care‘.

I had opened my private practice Sure Optical (now called Sure Eye Care) on the Central Coast of NSW back in 2005. Within three years, our industry had significantly changed thanks to the arrival of Specsavers in Australia. I discovered orthoK at OSO 2008 and was immediately drawn to this speciality. I started fitting orthoK for myopia control and soon became a raving fan… I was personally seeing the results!

I started fitting orthoK for myopia control and soon became a raving fan… I was personally seeing the results!

By 2011, I was looking for ways to differentiate my practice. Dr. Flitcroft’s 2014 lecture helped me do it – he gave me the evidence I needed to further pursue my passion for practising orthoK.

Dr. Flitcroft said myopia was:

• Not just a treatable condition, but a preventable one
• Second only to age, as a risk factor for a wide range of ocular diseases including glaucoma and retinal detachment
• More significant a risk factor for serious ocular pathology than uncontrolled hypertension or smoking was for stroke (Table 1).

A New Mission in Life That last point ‘blew my mind’. A general practitioner would not allow a patient to have uncontrolled hypertension due to the risk of stroke, yet our profession was allowing young progressing myopes to become more short-sighted despite our ability to prevent this. It became my mission in life to do everything I could to change this.

Contact Lens and Anterior Eye in April 2016 published an article entitled Global trends in myopia management, attitudes and strategies in clinical practice.¹ The research, co-ordinated by James S. Wolffsohn, looked at prescribing rates and practitioner attitudes to myopia control. It was co-authored by many brilliant minds around the world, including our very own Kate Gifford.

Reading it, I was encouraged that practitioner concern about the increasing frequency of childhood myopia was high in Australasia – median 7/10. Similar rates of concern were reported by practitioners in Europe, North and South America. The practitioners in Asia were the most concerned – 9/10.

However, the same article reported that despite their concern:

• Most practitioners prescribed either single vision (full correction) spectacles or single vision contact lenses for progressing / young myopes;
• Some practitioners still used the strategy of under-correction (which has been shown to hasten progression of myopia).

I don’t understand how one can be concerned but not do anything about it?

At Sure Eye Care, we have been offering orthoK for myopia control since 2008 and established a full scope orthoK and myopia control clinic in August 2017, which offers orthoK, MiSight and atropine. More importantly, in 2013, I began to volunteer my time to the Orthokeratology Society of Oceania (OSO) board. I wanted to share my passion for myopia control with my colleagues. I believe our profession has a duty of care, because a 50 per cent reduction in the rate of progression of myopia (proven to be achievable by orthoK, MiSight and atropine) would result in 90 per cent fewer high myopes.²

Let’s Get on Board We know that our treatment options could result in 90 per cent fewer high myopes and significantly reduce the incidence of retinal detachment and myopic maculopathy, both serious sight threatening conditions. So, why aren’t all optometrists recommending orthoK or another form of myopia control? Is it because incidence rates and rates of reduction are too abstract and don’t seem clinically relevant?

Let’s make it personal with a case study. I first met Mrs. S at a business meeting a year ago. I was raving about orthoK and myopia control, as I do at any available opportunity. She later came to me for an eye examination and asked whether she was suitable for orthoK.

Her Rx was: R -4.00/-0.75×35 L -5.25/-1.50×130 ADD +1.25

She was right eye dominant. Given orthoK naturally has a multifocal effect, I was going to aim for a target Rx of:

R -3.50/-0.75×35 L -5.25/-1.50×130

Luckily, her pupils were quite small – the treatment zone in the left eye would be an issue for an adult with large pupils as they may experience haloes driving at night.

Mrs. S told me she was 42 when she had a retinal detachment. “I lost some vision in my left eye. I have permanent distorted vision in that eye and my eye has never been the same. It constantly feels irritated, red and sore,” she said.

Mrs. S decided not to proceed with orthoK at the time. However, about six months later she brought her daughter, Miss. S (age 12) to see me. Mr. S (dad) had taken Miss. S to another optometrist on the weekend (we weren’t open) and they had said she was short-sighted and had recommended distance only glasses. Given Mrs. S’s history of retinal detachment, and remembering what I had told her, she wanted some form of myopia control for her daughter.

Miss. S’s unaided VA was R 6/9.5 1- L 6/7.6 OU 6/6.

Her Rx was: R -0.75/-0.25×100 L -0.75DS

I have heard some optometrists say they would not even correct a child at this stage, given that the unaided visual acuity with both eyes open was 6/6. But that effectively leaves the child under-corrected and, let’s remember, under-correction has been shown to increase the rate of progression.

Having discussed the options, Mrs. S and I agreed that orthoK would be best. I recently asked her why she made this decision at the time and whether she had any reservations. “No, I didn’t want her eyes to become as bad as mine and risk her suffering from a serious eye problem like I did,” she said. “When you told me about orthoK lenses, I was very interested. I did some of my own research on them and was excited.”

Miss. S was fitted with an Emerald (from Australian Contact Lenses) and after one night of wear her unaided vision was R 6/4.8 1- L 6/6 2-. After one week of wear it was R 6/4.8 1- L 6/4.8.

Six months after fitting Miss. S with her orthoK lenses, I asked her a few questions. Her responses were insightful:

1. How easy or difficult was it to learn to use orthoK lenses?

“I thought it would be hard but it was easier than I thought.”

2. How do you find using orthoK lenses now?

“Easy. Sometimes if I’m really tired it’s a bit difficult, but most of the time it’s easy. Sometimes I forget they are in.”

3. Is it exciting that you may never have to wear glasses?

“Yes”

4. Has it made a difference to school or sport?

“In school, I can read the board clearly even when I’m sitting at the back of the class. I play netball and it’s good that I don’t have to wear glasses.”

5. Were you worried you wouldn’t be able to sleep with them in your eyes?

“Yes, and I also thought when I woke up during the night I wouldn’t be able to see or open up my eyes because it wouldn’t work if I did. But now I know it’s easy to sleep in them and I can open my eyes at night and see, and it’s all ok.”

The last question is something I have learnt to talk to kids about. It is a common fear that they won’t be able to sleep if they have something in their eye. We know that is not the case, so I used to forget to even mention it. Reassurance early is key.

Do Something Extraordinary Dr. John F. Demartini has said, “Deep inside every human being there is a yearning to do something extraordinary and to be of great, vast service to humanity.”

I believe it is of great service to humanity to help prevent avoidable blindness with orthoK and other forms of myopia control. To me it is an extraordinary privilege to tell people like Mrs. S (usually with tears of gratitude in my eyes), “I’m not just going to watch your daughter get worse. I am going to do everything I can to slow her myopia, so she is more likely to have a lifetime of great vision.”

Amanda Rungis is the owner of Sure Eye Care in West Gosford. A qualified optometrist, Ms. Rungis holds a Bachelor of Optometry with honours and a Master of Optometry from the University of New South Wales. She is Vice President of the Orthokeratology Society Oceania, a board member of the International Academy of Orthokeratology and Myopia Control, a member of Optometry Australia and a national committee member of Optometry Giving Sigh

References
1.www.sciencedirect.com/science/article/pii/S1367048416300145
2. Brennan, N. A. (2012). Predicted reduction in high myopia for various degrees of myopia control. Contact Lens and Anterior Eye, 35, e14–e15. https://doi.org/10.1016/j.clae.2012.08.046