Optometry Virtually Connected: Enriching Education

A strong theme across this years’ conference content was paediatric eye care.

This topic was led by keynote speaker Dr Noel Brennan, a Clinical Research Fellow at Johnson & Johnson Vision Care (J&JVC) and internationally renowned scientist, inventor, author, educator and industry leader.

Born in Australia, Dr Brennan is currently based in the United States. Impressively, he is the only living person to be listed among the most influential in contact lenses and the most influential in myopia in Contact Lens Spectrum, as well as listed in the top 2% of scientists in the field of ophthalmology and optometry according to “the world’s most comprehensive standardised citation database” (from the Meta-Research Innovation Center at Stanford University).

if you think you’re going to predict myopia progression by following progression for a year, you’re pretty much wasting your time

An expert on myopia, for the last decade Dr Brennan has directed a global, evidence-based, myopia research program at J&JVC, studying epidemiology, metrics of treatment efficacy, and optical designs for contact lenses.

Dr Brennan described his presentation as “very high on science, and low on anecdote”. Stressing the need to “build the evidence”, he said most of the information we currently have about myopia and myopia control is of lower quality; some meta-analyses still have subjective interpretation and biased conclusions; additionally, people continue to be confused about the difference between correlation and causality.

Because we know so very little about myopia, there is a lot of scope in practice for interpretation, however Dr Brennan said optometrists need to play the role of doctor in decision making based on the best evidence available.

Whereas myopia was once described as an optical disorder (a refractive error in which rays of light entering the eye parallel to the optic axis are brought to a focus in front of the retina when ocular accommodation is relaxed), Dr Brennan said our understanding of the condition has changed. The modern definition of myopia is “a chronic, progressive disease characterised by excessive eye elongation, risk of associated sight-threatening complications, and a negative-powered refractive error”.

Although we wouldn’t tell an eight-year-old with myopia that they “have a disease”, we should give myopia the gravity it deserves by using the term ‘disease’ when advocating in public health and generating public awareness of the need for advances in control strategies and treatment.

We only need two terms to classify myopia: primary myopia (inevitably axial in nature) and secondary myopia, which has a single specific case such as drugs or corneal disease or systemic clinical syndrome.

Dr Brennan focussed on primary myopia.

The odds of primary myopia (i.e., school myopia; juvenile onset myopia, progressive myopia and physiological myopia) progressing to myopic macular degeneration, retinal detachment, cataracts and glaucoma increase by degree of myopia and so the ambition must be to lower the risk and ultimately, the incidence of these diseases.

He said there is evidence for a clear increase in the prevalence of myopia over the last 50 years. The first clinical evidence of myopia only arose in 1983 in Taiwan and by 2010-2011, 87% of 18 to 24-year-olds were myopic (≤ -0.50D). Myopia has been considered by some to be “an Asian problem” but this is no longer the case. While Asian populations have higher myopia prevalence than Western countries – the ‘big six Asian countries’ have a myopia prevalence in teen to early adult years of 80% – the prevalence in Western countries is increasing, currently sitting at around 50% of people in their teen to early adult years.

We can expect myopia prevalence to continue to rise in Western countries; according to modelling, Dr Brennan said, “by 2050, many western countries are expected to experience the myopia problem that Asia is experiencing right now”.

While some practitioners may not be convinced of the need to act on myopia, because it’s not ‘in their face’, Dr Brennan said this will change as the long-term consequences of myopia become evident in the coming years.

“The needle has probably not moved much in western countries – but that’s because of the timeline… the earliest myopia cohort might have just turned 50 and myopic pathology only becomes manifest after 50 or even 60 years of age – so we shouldn’t have seen this wave of increased pathology coming through yet – but it’s coming – it’s a tsunami of eye disease that’s heading our way.”

Dr Brennan cautioned that with a 67% increased risk of myopic macular degeneration with every dioptre of myopia, there is no safe level of myopia; while the risk of disease is low with low levels of myopia, there are so many people with low myopia that the population burden becomes significant.

By combining data sets, Dr Brennan and colleagues have predicted that myopia is likely to be the leading cause of vision impairment by 2050, ahead of age-related macular degeneration, diabetic retinopathy and glaucoma (without myopia). There will be about 307 million or 3.2% of people in the world with uncorrected or irreversible vision impairment; about 207 million of these (67%) will be myopes, which plays out to about 100 million (or 35%) of all vision impairment being solely attributable to myopia.

He noted, “that’s incredible for a condition that hasn’t been counted separately until recent times – it was lumped in with other miscellaneous vision disorders.

“The harsh reality is we don’t really have a treatment for myopic maculopathy – the world doesn’t know much about this at all. But the good news is, we are finally seeing action on an international level to better understand and then find treatments for myopia management.”

Time outdoors is the best way to reduce the risk of myopia onset. While studies have failed to identify strong genetic influence on myopia development, it is believed that children of myopic parents will lead a myopic lifestyle, which will increase their risk of myopia progression. Changing the behaviour of a child with myopia – by encouraging them to spend time outdoors – can reduce the risk of progression. There is no evidence to suggest that the use of digital devices per se increases the risk of myopia progression; quite simply, digital devices have not been around for as long as myopia has. The problem is that children who spend more time on digital devices have less opportunity to spend time outdoors.

Interestingly, knowing a patient’s progression or axial elongation history does not seem to help with clinical decision making – you can’t tell whether the child in front of you will be one to progress a lot or not progress much at all. With this in mind Dr Brennan said, “if you think you’re going to predict myopia progression by following progression for a year, you’re pretty much wasting your time”. His key message was, “What we do know is that no level of myopia is safe; although higher degrees of myopia carry a greater risk of impairment to the individual, the population based burden of lower degrees of myopia remains considerable – if we want to reduce the impact of myopia we have to treat all young myopes to slow their progression – the initial instinct should be to treat them to slow the progression and it should be the exception when you don’t undertake steps to reduce progression.”

For further information on efficacy of treatment, Dr Brennan referred delegates to the paper Efficacy in Myopia Control.¹ This is the most consistently downloaded paper, over the last 18 months, in the Ophthalmology journal ranked number one by impact factor.

THE ART OF PAEDIATRIC EXAMS

Ophthalmologist Dr Christolyn Raj commenced her presentation by noting that the paediatric eye examination is by no means a simple task and any clinician who attempts it deserves a pat on the back.

She then offered some simple yet helpful approaches that optometrists can incorporate in their examination techniques to elicit answers to key questions that are part of a paediatric eye exam.

“Objective measurements in children’s eye assessment are just as valuable as the subjective measurements obtained from examining an adult,” she noted. “These can be as simple as observing visual behaviour when the child is in your waiting room or watching how they react on a cover test of each eye. The latter not only provides a ‘fun activity’ but will also tell you a lot about the presence of amblyopia.”

Reading a vision chart is not the only way to test vision and visual function. Apart from simple observation, more sophisticated testing, including a 20 base out prism test, will offer information about sensory fusion. Similarly, a stereopsis test is vital in children as their depth perception should increase with age and this can be documented on each review to gauge visual development.

Amblyopia is one of the key issues that separates an adult’s eye assessment from that of a child. Detecting amblyopia in a child needs to be done before eight-yearsof- age when the visual system is still plastic and amenable to treatment.

Importantly Dr Raj said, “We all need to suspect amblyopia and search for it during the exam. It’s one of those ‘silent’ conditions – if we don’t actively look, we will quite often miss it. A great way to check for amblyopia is using the phenomenon of ‘crowding’ letters and symbols.”

Strabismus is one of the most common referrals made to eye professionals. This can vary from an obvious manifest strabismus to an intermittent one only occasionally noticed.

“A neat trick when asking caregivers about an eye turn is to ask them to show you pictures of the child when they believed a turn was present; this can help confirm a diagnosis and will also give you valuable information about a timeline of onset,” Dr Raj said.

A dilated eye exam is crucial in every child but particularly in those with strabismus to help eliminate any organic pathology that may change the course of management.

Assessing the vision of a child can be daunting to both the examiner and patient. To demonstrate her point, Dr Raj used a painting by Dorothea Tanning circa 1950, which depicts the artist’s thoughts on her family’s traditional ‘Sunday formal dinner’. Through the eyes of Dorothea as a child, we see the image of daunting, brooding parents but relatable family pets, and the focus on her favourite foods on the table.

“In the same way, we need to appreciate that our equipment and manner may sometimes be construed by our ‘little patients’ as daunting, but there are certain things we can employ when assessing children to eliminate these feelings. Try a game of ‘peek-a boo’ or play a video or cartoon in your waiting room; have a visually eye-catching poster in your exam room and consider ‘smelly’ stickers or other fun rewards when the child shows some co-operation.

“The take home message being, be patient and kind to yourselves, it’s a fast-learning curve but certainly very rewarding!”

A VIRTUAL SUCCESS

While optometrists have enthusiastically embraced the return of face-to-face conferencing, Optometry Virtually Connected proved that there is definitely a place for continued online education.

Indeed, a recent survey conducted by EventMB2 revealed that event planners will remain committed to a virtual strategy even as in-person events return, while 65% of event planners said that hybrid events are the future.

Optometry Australia CEO, Lyn Brodie said, ‘When we first conceived Optometry Virtually Connected COVID wasn’t even on the horizon. We are always looking to innovate and had recognised the value of online learning to complement face-to-face education provided by our state divisions. It was timely, as within months of beginning our planning the world was feeling the full brunt of the pandemic with countries in strict locked down conditions.”

She added that the virtual format not only provides attendance flexibility but also helps optometry reduce its environmental footprint – something that is important to Optometry Australia and firmly embedded in its strategic plan.

References 

1. Brennan NA, Toubouti YM, Cheng X, Bullimore MA. Efficacy in myopia control. Prog Retin Eye Res. 2021 Jul;83:100923. doi: 10.1016/j.preteyeres.2020.100923 
2. mcec.com.au/news-and-awards/2022/06-june/ mcec-event-trends-2022-virtual-and-hybrid?utm_ source=Customer_EDM&utm_medium=Email&utm_ campaign=June_EDM_Event_Trends_Digital_In_Demand