It’s no secret that Dr Margaret Lam – optometrist, National President of Optometry Australia and founding member of the Child Myopia Working Group – is passionate about myopia management.
Recently, mivision took time out to talk to her about why managing myopia is critical and how treatment alone may impact future vision.
Recent evidence reveals that the prevalence of high myopia is growing at a faster rate than the prevalence of overall myopia
Q. How long have you been practising myopia management?
I have been practising myopia management since 2001. We’ve come a long way in establishing best practice for myopia management in that time and we have become better at communicating with our patients and their parents. The end game though, has always been to ensure we protect our patient’s vision from worsening, in the best ways we can.
Q. Why does myopia management interest you so much?
It’s an area of clinical care in which we continue to improve – even after decades of learning and achieving better long-term results, we’re still coming up with new technologies and a larger evidence base, which informs new approaches to prescribing.
And that’s important because, looking at current populations in Japan, studies by Iwase1 and Yamada2 show that complications associated with high myopia are the primary reason for irreversible blindness. These include myopic retinal stretch, myopic macular degeneration, and choroidal neovascularisation.
We now have several evidence-based management options that can significantly slow the progression of short-sightedness in children. This is critical to care because we know we can minimise the pathological health issues that are closely linked to the degree of myopia, including myopic macular degeneration, glaucoma, and retinal complications.
These options are:
• Certain soft contact lenses, which are worn during the day, featuring a special optical design that reduces myopia progression.
• Orthokeratology (OK) contact lenses that reshape the front surface of the eye during overnight wear and are then removed during daytime. Usually, this modality corrects myopia during the day after lens removal, as well as reducing progression.
• Certain myopia control spectacle lenses featuring an optical design developed especially for myopia management.
• Low-dose unpreserved atropine eye drops, of varying concentrations, which are usually administered at night before bed and reduce progression.
Q. How can we get the myopia message through to parents?
In practice, we will always come across parents of young patients who think, “Well, I am short-sighted too, and so it’s just about getting glasses, isn’t it?” Or, “My kids can just choose to do laser surgery when they’re older”.
It is important that we help parents understand that their children are developing short-sightedness, both earlier, and at a concerningly faster rate than they did when they were a similar age, and this has potential eye health risks in later life.
Once they understand that, then there are important messages to share. You can inform them that there are now far better management protocols in place and that managing myopia can save their children’s eyes from severe health issues, or even loss of vision later down the track. This is what ultimately drives my commitment to continue to improve my practise of myopia management.
Q. When considering myopia management, what practice and patient tools / resources help (or have helped) support you?
Unfortunately, when less was known about myopia management, it used to be normal practice to prescribe glasses in a single vision prescription only, or even greatly under-correct the refractive error.
Children and parents would be given little-to-no advice about options such as myopia control spectacles, soft or orthokeratology myopia control contact lenses, or therapeutic options such as atropine.
In 2018, the Australia and New Zealand Child Myopia Working Group recognised the need for a recommended Standard of Care for managing myopia, supported by the contemporary evidence base. I believe this is an exceptional tool to support optometrists.
The aim of the Standard of Care is to complement the existing Entry-Level Competency Standards for optometrists, which do not provide management techniques or protocols of specific diseases such as myopia.
It describes the key elements that the Group believes must be incorporated into the management of a person with myopia, without prescribing how or when to employ specific options or techniques.
One of the most significant recommendations has been to shift from only correcting vision to including a discussion between the eye care practitioner and the parents and carers on why and how myopia can be managed.
The Working Group’s goal is to ensure that the Standard of Care that a child will experience when they present with myopia, will include a discussion of the evidence-based myopia management options; the risks (lifestyle and family history) of myopia progression; and the provision of verbal and written information describing the risks and benefits of treatment.
I agree that a conversation around controllable risk factors is vitally important, including lifestyle, how critical sunny outdoor light exposure is for protection against further development of myopia, and other adjunctive preventative advice on protecting a patient’s myopia from worsening. The Group now considers this to be vital in any consultation with a child with myopia and their parents.
Q. What other resources are available to help optometrists with myopia management?
There are now many resources available to help practitioners deliver the best myopia management advice. These include resources from the Brien Holden Vision Institute, Myopia Profile and on-demand training via the CooperVision Academy. Information about myopia for parents is also accessible from resources such as Optometry Australia’s Good Vision for Life campaign and the Child Myopia website.
The latter website includes myopia reports, videos, and a myopia vision simulator. All of these are valuable resources to support discussions with a parent or carer and to help them understand and engage with their practitioner.
Q. What else do you believe optometrists need to do?
As eye care practitioners I believe it is imperative that we take the advice from the Standard of Care and always talk to parents about the options available for their child.
We need to discuss, formulate, and implement an agreed management plan with the parent or carer and patient (child). We need to discuss the evidence supporting each option with the parents or carers, building in a discussion around the risks and duration of treatment, and any potential rebound effects. Addressing the cost and lifestyle implications of each management option is also important – all of these factors will play a role in the decision-making process.
Q. The latest adjunct Myopia Report implores parents and carers to get their children’s eyes tested and, if diagnosed with myopia, talk about its management. What are your top tips for your peers on how to discuss the matter and encourage parents to commence myopia management for their child?
Eye examinations should become a routine part of every child’s regular health check because understanding the early signs of myopia may help delay the onset of myopia and slow progression.
My advice is threefold:
1. Don’t hesitate – get started!
Many practitioners feel a bit overwhelmed when they first start offering myopia management advice to patients – but offering any of the evidence-based management options is better than prescribing single vision spectacles. It becomes easier to build your confidence once you see the improvement in outcomes from these evidence-based solutions. This is turn will help you to grow your practice of myopia management and gradually offer more options to patients.
2. Ask colleagues in the field for help and support.
Our fellow optometrists and ophthalmologists in the field are generally very supportive, and your intentions to help your patient come from a great place. Don’t be afraid to put yourself out there and learn more – we are an ever-evolving field and open-minded colleagues will help you to learn more.
3. Start the conversation with patients today.
Patients can feel a bit overwhelmed with learning their child’s vision has worsened, and really appreciate their eye care practitioner taking the lead in educating and suggesting management options about their child’s myopia. I’ve often found parents and their children are very grateful when I take the extra time to explain concepts and take a consultative approach to help protect their child’s vision over the long term.
Q. What would your advice be to an optometrist/practice manager looking to integrate the Standard of Care framework into their practice setting?
Recent evidence reveals that the prevalence of high myopia is growing at a faster rate than the prevalence of overall myopia.3 Intervention, therefore, needs to start as soon as possible.
My advice is to take advantage of the plethora of myopia management resources out there. The Child Myopia Working Group Standard of Care is a great starting point that offers accessible strategies for practitioners to work comfortably within their competency. And connect with your peers via online groups, such as the Child Myopia Working Group LinkedIn group.
The time to manage myopia is now – I urge every eye care practitioner to get started.
The vision a person with uncorrected myopia progression may experience over time.
Dr Margaret Lam is the Head Optometrist for 1001 Optical in Bondi. She is also an Adjunct Senior Lecturer for the School of Optometry and Vision Science at the University of New South Wales, and she mentors and teaches undergraduate and Masters Students in Advanced Contact Lenses. The National President of Optometry Australia and a founding member of the Child Myopia Working Group, her areas of expertise include myopia management, dry eye, and specialty contact lens fitting. She has been a past recipient of the Neville Fulthorpe Award for Clinical Excellence.
The establishment of the Child Myopia Working Group has been enabled by CooperVision Australia & New Zealand.
References
1.Iwase A., Araie M.,Tomidokoro A., et al., Prevalence and causes of low vision and blindness in a Japanese adult population: the Tajimi study. Ophthalmology 2006;113:1354–1362.e1.
2.Yamada M., HiratsukaY., Roberts C.B., et al., Prevalence of visual impairment in the adult Japanese population by cause and severity and future projections. Ophthal Epidemiol 2010;17:50–7.
3. Sankaridurg, P., Tahhan N., Kandel H., et al., IMI Impact of Myopia. Invest Ophthalmol Vis Sci 2021;62:2.
