The rising prevalence of myopia, and its associated ocular risks represents a public health challenge that optometrists are at the forefront to manage. Are you ready, or will you refer to your colleague who is better equipped to do so?
Optometry has come a long way since the 1800s when Charles F. Prentice was threatened with jail for charging a fee for an eye exam.1 Since then, we as a profession, have successfully evolved our scope of practice with the emphasis on the use of innovative technology and ground breaking research into disease management to improve patient care. Now we are faced with the challenge of rising rates of myopia around the world.
In 2010, myopia affected 30 per cent of the world’s population. By 2050, nearly 50 per cent will be affected.2 In the US, myopia increased from 25 per cent to 42 per cent between 1972 and 2004.3 And already, our East Asian neighbours are afflicted by rates of myopia ranging from 80 to 96 per cent.4-6 The Sydney Myopia Study reported that 30 per cent of 17 year olds were myopic in 2011.7 There are also permanent and serious risks to vision associated with rising levels of myopia, increasing the likelihood of retinal detachments, retinoschisis and myopic macular degeneration, as well as glaucoma and cataracts.8 Already, myopic macular degeneration is a frequent, but not generally (within the community) understood cause of blindness around the world.9 Uncorrected refractive error is the number one cause of vision impairment worldwide and the second largest cause of blindness after cataracts… and the majority of distance uncorrected refractive error is due to myopia.10 Uncorrected refractive error due to myopia will only rise further.
The challenge of myopia represents an opportunity to demonstrate the tremendous value of optometrists’ expertise in effectively managing this deceptively simple and common ocular condition.
The challenge of myopia represents an opportunity to demonstrate the tremendous value of optometrists’ expertise
Precise Practice Management
Optometry’s expertise and depth of knowledge uniquely positions the profession at the forefront of myopia. We are accessible, affordable and qualified to provide the optical and pharmacological interventions, lifestyle advice and counselling required.
Management of myopia requires the precise measurement of the refractive error using cycloplegic refraction in children, along with regular follow-up visits to monitor myopia progression. Precise measurement of axial length (if available) is also critical to the success of myopia management. This is not something the patient can outsource to an app, buy online or self prescribe.
Similarly, treatment requires expertise. Slowing or controlling myopia requires the knowledge and application of the latest evidence and the ability to synthesise information such as the age of the patient, familial and environmental risk factors, and level of refractive error.
However, modern day issues that many optometrists face, such as the squeeze from Medicare freezes in Australia and the commodifying of optical appliances, make it difficult to charge equitably for services.
Although the majority of optometrists in Australia do not charge for their services, opting instead to rely on Medicare fees, myopia management should be part of a systematic management program because it requires a number of visits over the course of a year, and adequate chair time.
There are many ways to set patient fees, and some practitioners in Australia are successfully implementing a package fee for myopia management, either annually or in monthly instalments. This includes all necessary visits, procedures, optical appliances and pharmacologic treatments (for example www.collinsoptometrists.com.au /myopia-control). Patients have peace of mind about the costs they will incur, and transparency about what they will receive.
This model is not a stretch when we have seen many practices in Australia charging monthly subscription fees that provide the patient with an ongoing contact lens supply and all contact lens associated visits. Why would you not charge even a small fee for the time and expert knowledge required to perform myopia management, especially when it is so important?
Quality Chair Time
The question of chair time can be another perceived issue for optometrists interested in managing myopia. You are likely to see your young patients more frequently to monitor myopia progression because children tend to progress more at younger ages, and certain management options will require more frequent review. For example, an orthokeratology lens wearer would have slightly more risk of complications than a daily disposable multifocal contact lens wearer due to the extended wear aspect.11,12 However, the chair time for each visit should not see a significant rise because many practitioners are already performing some of the procedures required for myopia management as part of their routine evaluations. For example, in children, you may already be performing a cycloplegic refraction and binocular vision work-up, in addition to the standard eye examination. Follow-up visits to monitor patient response to management may be as simple as a refraction and axial length measurement with the annual visit requiring the full work-up of cycloplegic refraction and all other tests.
Practice Set-Up
Setting your practice up for myopia control does not necessarily have to be expensive and time consuming – it is likely that you already have the existing equipment and optical appliances at your disposal.
Executive bifocal spectacles or similar lenses, progressive addition spectacle lenses and daily disposable multifocal soft contact lenses, are already part of primary eye care. Therapeutic endorsement allows the prescribing of low dose atropine (0.01 per cent) to be made by a compounding pharmacist. OrthoK is a specialty skill.
If large capital investment is an impediment, consider a group of practices sharing instruments such as a corneal topographer and Lenstar, or referral to the UNSW Myopia Clinic, Centre for Eye Health or Australian College of Optometry for corneal topography and axial length measures.
Even if you are unable to provide all the available options, it is still important to discuss the issue of myopia with your patient and refer on within your profession to those with specialty skills. The key is to provide suitable options for your patients, compatible with their ages, lifestyles, and current refractive error status, all of which requires your professional judgement.
Reinforcing Your Value
The effect of globalisation has rapidly changed the eye care profession. In Asia optical online retailing is growing in market share. Indeed in China, online sales on optical products have increased to about 16 per cent of the total optical retail revenue. Fast-fashion stores that provide quick services, focusing on refraction and dispensing only, are growing in Asia and this is being repeated in other international markets.13 To compete with this pressure, other stores are seeing an opportunity to differentiate themselves by becoming more clinically focussed. In China, for example, where almost eighty thousand optical shops operate, some are attempting to up-skill and upgrade to become optometric practices and serve their patients better, with myopia management as a key service.
In Australia too, myopia management is enabling optometrists to differentiate themselves and reinforce their role as providers of comprehensive eye care and holistic management. It’s also a very sustainable way to build a loyal patient base as your patients developing myopia tend be children who will be under your care for many years, from childhood to university age, or even beyond. Additionally, if a patient experience is positive, there are other benefits that are likely to flow, such as referrals from word of mouth to family, friends and the like.
Maintaining Relevance
Best patient care is paramount and with the evidence building around myopia control, it is only a matter of time before myopia management is the standard of care.
For our profession to remain relevant we need to continue our professional development, move forward with evidence based practices and, eventually, standardised guidelines for myopia management. Additionally, we need to tackle education and advocacy on a practical level, educating patients as well as the wider network of health professionals (family doctors, ophthalmologists, paediatricians and pharmacists) and teachers. This is critical to successfully implementing myopia management, and to ensuring both patient compliance and support from the wider network that may be involved in your patient’s care (teachers, parents, medical professionals).
If we take the time to share with our patients why we believe myopia management will improve their lives, from the simple analogy of not wearing thick spectacle lenses to ultimately preventing future permanent risks to vision, our patients will work with us to comply. As one of the pioneers of myopia control research, Professor Brien Holden, once said, “Can you imagine having the opportunity to slow the growth of the eye and making a difference to billions of people’s lives?”
Dr. Monica Jong is a Senior Research Fellow Brien Holden Vision Institute and Visiting Fellow UNSW Australia. Professor Padmaja Sankaridurg is Head of Myopia Program at Brien Holden Vision Institute. Dr. Kah Ooi Tan is CEO of Brien Holden Vision Institute China.
References
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10. Fricke TR, Holden BA, Wilson DA, et al. Global cost of correcting vision impairment from uncorrected refractive error. Bull World Health Organ 2012;90:728-38.
11. Stapleton F, Keay L, Edwards K, et al. The incidence of contact lens-related microbial keratitis in Australia. Ophthalmology 2008;115:1655-62.
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