Myopia in Practice: Getting the Messaging Right

Myopia control is a new concept for most parents. Even those who have myopia, thus greater awareness of the condition, and those having done some prior research of their own, will have questions when myopia management is introduced and recommended for their child.

be prepared to adapt your communication when answering questions about treatments, their effectiveness, potential side effects and mechanism of action

Initial myopia assessments at my clinic generally take around an hour. This includes carrying out an extensive array of tests – refraction, cycloplegia on indication, binocular vision assessment, biometric measurements, corneal topography and ocular health assessment. I also allow plenty of time to have a detailed discussion with the parents about their child’s myopia, the management plan they need, and to answer questions.

Educating parents on what myopia is, is the essential first step. Many parents don’t realise what the condition is about; they just know their child’s prescription keeps getting worse.

While ‘short-sightedness’ is the more common term, I prefer to use the medical term ‘myopia’ because it conveys the actual eye condition rather than the symptom. It is imperative to explain that myopia is not benign; it is not just an inconvenience that causes blurred distance vision and the need to wear glasses. Progressive myopia is a serious eye health concern that, in most cases, involves excessive eye growth and elongation, leading to stretching and thinning of the tissues within the eye.

Indeed, from research, we know any amount of myopia increases the lifetime risks of eye disease and vision impairment. The higher the myopia, the greater the risks. Mention the eye diseases associated with myopia – retinal detachment, glaucoma, myopic maculopathy, cataract – not as a scare tactic, but to inform. Only when parents are properly informed can they make the important decision to invest in their child’s future and start myopia management. I find that parents who understand will usually want what is best for their child’s vision and eye health.

DEMONSTRATE YOUR KNOWLEDGE

Parents are relying on you to provide the right information. To do so necessitates keeping up to date with the current evidence base, research and clinically relevant knowledge in this area. Some parents will know more than others, and some will want more detail than others, so be prepared to adapt your communication when answering questions about treatments, their effectiveness, potential side effects and mechanism of action. Have material prepared to help explain complex concepts such as peripheral defocus and how orthokeratology (OK) works to slow progression, and a list of relevant myopia control studies to share with parents who like to learn more.

It’s a good idea to present all options for myopia treatment when starting the discussion about management, even if your practice does not offer them all

PRESENT MYOPIA MANAGEMENT OPTIONS

It’s a good idea to present all options for myopia treatment when starting the discussion about management, even if your practice does not offer them all. Parents have a right to know what they are, and if they do their research and realise some options have not been offered, you may lose their trust. A sound approach is to broadly mention the range of interventions, then recommend the most appropriate, based on careful analysis of the child’s myopia, rate of progression, age, genetics, binocular vision status, and environment risk factors.

Having introduced the options, involve the child and parents by asking for their thoughts, preferences and concerns. They may not want their child to wear glasses – which leads to further discussion about contact lenses and OK – or they may think their child is too young for contact lenses, prompting discussion about contact lens safety and perhaps a comfort trial of soft contact lenses to help alleviate their concerns.

SET REALISTIC EXPECTATIONS

Eager parents commonly ask whether treatment will stop progression, or even reverse myopia. The truth is, it probably won’t stop all progression, and it won’t permanently reverse myopia that has already occurred.

This makes it vital to avoid disappointment by being clear about treatment strategies and expectations from the outset.

Our current evidence base indicates effective myopia control intervention can slow progression by about 50%. However, progression is also correlated with age and ethnicity – younger children and Asian children tend to progress faster and exhibit faster axial elongation.¹ Therefore, younger children should be expected to still progress on treatment, albeit at the slower rate, while older children and teenagers will appear to achieve better control and stability with treatment, due to a natural slowing of growth with age. Some progression should not be perceived as unsuccessful treatment, but a reality that there are factors involved in myopia progression beyond our control and understanding.

Parents also need to be aware that gaps in research mean we cannot say which treatment will work best on an individual before commencing. Explaining that myopia management is still relatively new, and there is a lot of research happening to find the answers, will help them understand this. Also explain that we can (and may) adapt and change treatment strategy over time once we observe the child’s response. This might mean adding atropine to an optical intervention, changing from progressive spectacle lenses to multifocal contact lenses, or making a switch from atropine to OK.

Every child and every myope is different. If one treatment works for their friend’s child, it doesn’t mean it will work the same on their own child. Even two kids from the same family can have different rates of progression and different responses to treatments. What you can promise is that, based on our current knowledge of myopia control interventions, you will do your best to look after their child… but the patient also needs to do their part. Myopia is a complex condition and treatment is only part of the equation, they still need to look after their eyes in terms of their visual environment; taking regular breaks from screen time, avoiding poor reading habits and posture, and spending more time outdoors where possible.

ATYPICAL MYOPIA CASES

There are some cases – like infants and very young children with high myopia – that fall outside typical childhood myopia, which means our current knowledge on management may not apply.

When a child’s refraction is greater than their chronological age, proceed with caution and at least one referral for ophthalmology assessment is warranted to exclude ocular pathology and potential systemic connective tissue disorders such as Marfan’s or Stickler syndrome. For parents who still wish for myopia control intervention in the hope there may be some benefit, it’s important to be clear that treatments may be less effective, or even ineffective, for these atypical cases.

CONTACT LENS SAFETY

Some parents raise concerns about starting their child on contact lenses. Explaining current research about the safety profile of contact lenses worn by children will help.

The overall risk of microbial keratitis with overnight OK is estimated at only 13.9 cases per 10,000 patient-years,² while for soft contacts, the incidence of corneal infiltrative events in children has been found to be no higher than in adults and may even be less in younger children aged eight to 11 years.³ To put things into perspective, the comparative risks of children wearing contact lenses to slow myopia progression are lower than the lifetime risks of vision impairment from high myopia.⁴ 

I always emphasise that if the lenses are properly fitted (which is my job to do), a good standard of hygiene and lens care is maintained, and regular reviews are adhered to, the likelihood of an eye infection from lens wear is extremely low. This puts the onus on the patients to take some responsibility for their eye health. Providing parents with an after-hours contact can give them additional reassurance.

START MANAGEMENT EARLY

I often see children attend my clinic who have progressed to a high level of myopia before seeking intervention. Delays in starting treatment may be due to several reasons: some parents don’t fully understand the seriousness of this condition that can progress very rapidly; some have never been told about myopia control options before; others can be sceptical or worried about potential negative effects of treatment; and sometimes cost considerations.

No level of myopia is safe – this is the message that should be conveyed to all parents. While myopia management can, and should be started for a child with high myopia, their lifetime risk of myopia-related pathologies has already increased significantly. A one-dioptre increase in myopia is associated with a 67% increase in the prevalence of myopic maculopathy.⁵ Eyes with axial length of greater than 26mm have a 25% lifetime risk of uncorrectable visual impairment, rising exponentially to over 90% for eyes of axial length greater than 30mm.⁶ And a younger age of onset is a strong predictor of progression to high myopia.⁷ The key to good management is to start the conversation with parents early.

From a practical point of view, lower myopia cases are easier to manage than higher myopia. OK can slow progression in high myopes, however it can be less predictable in terms of vision correction outcomes, and take longer to stabilise. In cases of advanced myopia with challenging corneas or borderline corneal curvatures, a full correction may not always be possible, meaning some residual myopia will need to be corrected with glasses. Leaving myopia to progress reduces options for intervention.

VISION EXPECTATIONS

Peripheral-defocus optical interventions for myopia control, which include OK, multifocal contact lenses and peripheraldefocus spectacle lenses, create a clear central vision zone surrounded by an area of defocus in the periphery – in effect blurring the edges of vision slightly. This, of course, differs from the quality of vision achieved with regular singlevision correction.

When prescribing OK, advise your patients to expect some peripheral blur and aberrations (which will increase with the level of myopia correction), halos around lights at night, and reduced contrast in low-light conditions when pupils enlarge. This is generally more noticeable at the beginning of OK treatment, and gradually subsides over time as the treatment zone increases in size.

Also, advise on the expected time frame to achieve clear vision when starting on OK, based on your experience and the complexity of their case. As every cornea is different, one should avoid making promises that may not be fulfilled. While most patients achieve very good vision with OK, the aim should be clear functional vision maintained throughout the day, rather than the promise of 20/20, or 6/6 vision.

When prescribing multifocal contact lenses, caution that ghosting and variable vision may be experienced. Younger children adapt easily to these changes and generally don’t complain. Teenagers and young adults can be more sensitive. When explained properly, patients and parents understand these vision changes are an expected feature of the treatment to slow myopia progression.

The potential side effects of atropine treatment are well known to practitioners but should be explained to parents to avoid any distress. Treatment efficacy of atropine is dose-dependent, and so are the common side effects of pupil dilation, glare, and reduced accommodation. Explain what is likely to happen when the child starts on atropine treatment, particularly if starting on higher doses, and offer guidance on how to help reduce the symptoms – wearing a hat outdoors, sunglasses, and potentially needing progressive lenses to help with near focusing.

LONG-TERM COMMITMENT

Myopia management is a long-term commitment – it is recommended that children with myopia continue on treatment until their myopia is likely to have reached stability, in their late teens or even into their early 20s. This makes it so important to start the relationship on the right foot, and often you’ll find at the first visit, the patient’s parents are looking to see if you’re the right practitioner for them.

Good communication is essential. You need to demonstrate your experience, expertise, and that you have the clinical technologies to look after their child properly. But you also need to listen, be empathetic to their concerns, use language parents can understand, and give them the confidence to trust you to help their child.

MONITORING TREATMENT EFFECTIVENESS

Initiating myopia treatment is only the first part of the process. Regular and accurate assessment of treatment effectiveness is paramount for the child’s ongoing management.

Myopic change is most commonly measured in terms of refractive error, as changes in prescription over time. Another option is to measure and monitor axial length. This provides valuable insight on the child’s eye growth and is a more sensitive and objective metric than assessing refraction alone. In my clinic I use the Zeiss IOLMaster 500 on all myopic patients to obtain baseline axial length at first presentation, then at subsequent visits to evaluate change.

Using axial length to monitor myopia progression is useful across the full range of treatment modalities, including OK and atropine therapy. Plotting this data on a graph enables a clinical profile to be built for each child, and provides parents with clarity on how the child’s treatment is working to slow their eye growth. It also helps to identify, explain and swiftly implement a change in treatment strategy when required.

A 50% reduction in the rate of progression would be considered a good outcome, and of course, the less progression the better. Practitioners should be transparent and upfront about treatment outcomes – parents who have invested time, money and emotional energy on this journey want to see real results.

TREATMENT COMPLIANCE

No treatment is effective if the patient isn’t compliant. Patients need to be reminded that myopia control treatments are for the long term and must be used regularly for best effect. Optical interventions tend to have better compliance than atropine eye drops, due to the positive feedback of clear vision when the appliance is worn – it is easy for children to occasionally forget and miss their nightly atropine treatment.

A tell-tale sign of non-compliance with atropine may be a lack of notable pupil dilation compared to baseline. Noncompliance with OK may reduce the corneal reshaping effect at a review visit. Any suspicions about non-compliance should be raised with the parents, and parental supervision of eye drop instillation or lens insertion may be recommended.

CASE STUDY

An 11-year-old boy visited my clinic, as his parents were seeking a second opinion for his progressive myopia. He had started wearing glasses four years prior, at R -1.50D, L -0.50D, and, under the care of an ophthalmologist, had received 0.01% atropine for the previous three years. His myopia had continued to progress and had reached R -5.50D, L -4.75D. His axial length measured a very long R 27.37mm, L 26.56mm, and he had flatter-than-average corneas with keratometry R 41.25D, L 41.50D. While his parents had known about OK, they were discouraged from trying contact lenses by their ophthalmologist. The boy’s mother had very high myopia, at -16.00D, and was understandably concerned.

I explained our current understanding that 0.01% atropine is not particularly effective at slowing axial elongation, compared to higher doses,⁸ and went on to explain the safety aspects of contact lenses and OK for children. I described the implications on long-term eye health if we were to allow his already-long axial length to progress further. Additionally, I discussed the likely success that could be achieved with OK treatment, in terms of vision correction given his high myopia and relatively flat corneas; and cautioned that full correction and being glassesfree was possible but not guaranteed. I also outlined alternative treatment options, being multifocal contact lenses, or a higher dose of atropine (eg. 0.025% or 0.05%). I provided a summary of information on various aspects of myopia management, so they could make an informed decision in their own time.

Within a week they had made up their mind to start their child on OK treatment. Following a successful fitting with custom-designed OK lenses, the boy achieved 6/6 vision unaided in both eyes. Three months after commencing treatment, there was no notable increase in axial length. Both the child and his parents were very pleased.

While still early days, we are seeing promising signs that his myopia progression is slowing. Longer term observation of his eye growth will determine whether any additional treatment is needed.

Having educated the parents on myopia, and commenced treatment on their son, I am now treating their eight-year-old daughter who has mild myopia. The family has trusted my judgement to start her on MiSight 1 day soft contact lenses for early intervention, in the hope that she can avoid the fast progression of her brother at the same age.

Philip Cheng is the practice owner at Eyecare Concepts in Melbourne. He has a particular interest in myopia control and orthokeratology. 

References 

1. Brennan NA, Cheng X, Toubouti Y, Bullimore MA. Influence of Age and Race on Axial Elongation in Myopic Children. Optom Vis Sci 2018;95:E-abstract 180072. 
2. Bullimore MA, Sinnott LT, Jones-Jordan LA. The risk of microbial keratitis with overnight corneal reshaping lenses. Optom Vis Sci. 2013 Sep;90(9):937-44. doi: 10.1097/ OPX.0b013e31829cac92. PMID: 23892491. 
3. Bullimore, Mark A. The Safety of Soft Contact Lenses in Children, Optometry and Vision Science: June 2017 – Volume 94 – Issue 6 – p 638-646 
4. Gifford KL. Childhood and lifetime risk comparison of myopia control with contact lenses. Cont Lens Anterior Eye. 2020 Feb;43(1):26-32. 
5. Bullimore MA, Brennan NA. Myopia Control: Why Each Diopter Matters. Optom Vis Sci. 2019 Jun;96(6):463-465. 
6. Tideman JW et al. Association of Axial Length With Risk of Uncorrectable Visual Impairment for Europeans With Myopia. JAMA Ophthalmol. 2016 Dec 1;134(12):1355-1363. 
7. Chua SY et al. Age of onset of myopia predicts risk of high myopia in later childhood in myopic Singapore children. Ophthalmic Physiol Opt. 2016 Jul;36(4):388-94. 
8. Yam JC et al. Low-Concentration Atropine for Myopia Progression (LAMP) Study: A Randomized, Double- Blinded, Placebo-Controlled Trial of 0.05%, 0.025%, and 0.01% Atropine Eye Drops in Myopia Control. Ophthalmology. 2019 Jan;126(1):113-124. doi: 10.1016/j. ophtha.2018.05.029. Epub 2018 Jul 6. PMID: 30514630.