A challenge from the puzzled mother of a young patient sent optometrist Narelle Hine on a journey of discovery that quickly developed into a new clinical and business passion.
My clinical interest in myopia control therapies started with reading publications of the international research data about 10 years ago. The results emerging from various clinical studies with new soft and rigid contact lens designs were both corroborative and convincingly successful in slowing the rate of myopia progression in children.
I also use aftercare visits to further engage and coach the patient (and parents) about the mechanics of myopia progression and care routines required…
Also at this time, the research journals posted evidence showing the statistical risk of sight-threatening pathology escalated exponentially with every dioptric increase in myopia. The message was: If I could reduce the natural myopia progression in a child by 50%, the risk of the child becoming a high myope (>-5.00D) could be reduced by 90%. Which optometrist wouldn’t want to achieve that outcome for their young myopic patients?
So clearly, as an optometrist serving my patients’ best vision interests, I was morally obliged to either learn the techniques for myopia control or start referring my young myopes to colleagues who did.
It was fortunate, I thought, that my patient base consisted mainly of city office workers and only a minority of children. However, my first attempt to suggest I refer a child onward for myopia control was met with the mother’s puzzled reply of “Why can’t you do it?”.
A good question.
So, I fitted this 10-year-old budding myope with distance centre multifocal contact lenses with a +2.00 ADD and monitored her progress over the next 12 months. Meantime, I purchased a topographer and embarked on a mission to learn the more demanding skill of fitting rigid orthokeratology (OK) lenses.
To fit successfully, I also needed to understand and manage the interplay of ergonomic and lifestyle drivers for myopia development, such as reading distance, continuous screen time, and access to daylight. Which factors are the most influential? There are excellent myopia control courses and webinars on offer to educate us on the latest research findings and help hone our skills.
AN ORTHOKERATOLOGY SUCCESS STORY
My first OK lens case was the son of a highly myopic (-11.00D) patient whom I had been seeing for years. At nine years of age, young Justin* was already -1.50D, which meant I needed to urgently fit him with maximal control rigid lens technology for the best chance to effectively slow his axial length growth.
Narelle Hine (below left) made the decision to develop her optometry practice, Hinesight, to manage young myopia patients.
The reward is that now, at 17 years of age, and after eight years of nightly OK lens wear, Justin still measures a low -2.00D. After high school, and now that his years of accelerated growth are mainly behind him, he might prefer to change to a soft myopia control lens. In my experience, the hectic social life of young adults rarely supports the more demanding wear schedule of OK lenses.
PREPARING MY PATIENTS
My usual approach is to assess each case individually and discuss the myopia management options with the parents and the child. I enjoy educating them with the aid of comparative myopia progression graphs and animations, so they realise the eye health component to their decision making and the real urgency to act.
The child is much less phased about the insertion and removal of a contact lens than the parents, I find. Demonstrating the comfort and ease of fitting a hydrophilic lens on eye usually dispels any concerns because the child is relaxed with the learning experience. Rarely do I need to use a topical anaesthetic for fitting rigid OK lenses because all my young patients have trialled soft contact lenses at home for one month prior and discovered the joy of vision without glasses. Psychologically, I think they are confident with lens wear and ready to wear a lens with more sensation.
For a young < -3.00D myope, with no significant astigmatism and no familial history of high myopia, I usually fit a soft, daily disposable myopia control design such as CooperVision MiSight. If this approach proves to be effective in slowing progression to less than -0.25D over a year, (a broadly accepted measure of successful intervention), then I rarely advise changing to the more complex rigid OK fitting – unless parents want a school day free of contact lens wear.
If a young myope is already more than -3.00D and is under 10 years of age and/or has a strong genetic risk of high myopia, then I advise fitting rigid OK lenses first because I need the most proven intervention to change the growth trajectory of that child’s axial length. As a rigid lens, OK lenses are very useful for correcting cases with significant corneal astigmatism too.
MOTIVATION AND MONITORING
Regular aftercare visits are crucial to measure changes in vision, corneal topography and ideally, the axial length. I also use aftercare visits to further engage and coach the patient (and parents) about the mechanics of myopia progression and care routines required to achieve our goals.
The child will be potentially wearing myopia control lenses for the duration of their childhood and teens, so motivation and monitoring the therapeutic results is key to continued success. The excessive near demand of the HSC in their final year of high school is a huge challenge to controlling progression and I will often need to revisit my OK lens design in response to Mother Nature’s push back.
To date, I am pleased to say that none of my myopia control contact lens patients have reported eye infections, apart from a stye. This prospect is always of concern to optometrists and reinforcement of hygiene is a part of every aftercare visit – as is calling me the same day, should a red eye occur.
Analysing my cases over the past eight years, I estimate that we have achieved a 90% success rate with my OK lens fits and 75–80% success with my soft myopia control lenses, which is highly encouraging. I say we, because it is teamwork. I owe a great deal of our clinical success to my patients’ dedicated following of my protocols and to the investment of contact lens manufacturing companies, which provide a range of high-performance myopia control lenses. They also offer expert technical advice when I am designing my bespoke OK lens fits. No child yet has complained that their rigid OK lenses from Innovative Optics are too uncomfortable to wear!
For my few recalcitrant cases, where myopia has progressed beyond -0.25D per year, I am researching data from studies using the additional therapy of atropine drops which reportedly work in some cases, but the mechanism is still open to speculation. The jury is still undecided about the most efficacious concentration of atropine to use for which ethnicity. And will combination therapy actually be more effective than OK lens wear alone? The body of knowledge regarding efficacy of treatments is evolving.
CHANGING FUTURES
The statistics tell us that high myopia is becoming far more prevalent in our digital age and that myopia onset is an epidemic sweeping the world. Parents and the community are just not yet aware of the ramifications. Given our training, optometrists are uniquely placed to own this discipline of vision care because we can offer effective and safe myopia control contact lens intervention to many young myopes and play a major role in public eye health. In fact, given our training, I think it is our moral obligation to step up and proactively save sight when we can. The long-term value of only prescribing standard single vision spectacle lenses or single vision contact lens designs to young myopes should now be a questionable standard of care.
Basically, my love for changing people’s daily lives through successful contact lens fitting has now extended to changing the future risk of visual impairment for child myopes. Offering myopia control therapies gives me a great sense of professional satisfaction and gives my young patients a reprieve from the ocular disease risks of life as a high myope.
*Patient name changed for anonymity.
Narelle Hine is the principal optometrist and owner of Hinesight, an optometry practice in Sydney’s CBD. She established the practice in 1994 after working and studying in both Australia and the United Kingdom, where she completed her post graduate training in contact lens fitting and contact lens research. Narelle is a past President of the CCLSA, an industry consultant and she regularly presents papers related to contact lens innovations.
