AOA series addresses concerns about myopia management

When in doubt about myopia management, don’t.

An AOA webinar on May 11 tackled head on the thorny issues most on the minds of doctors of optometry who might have concerns about providing myopia management in their practices. Too little evidence, too little equipment, too much money for patients—all were cited in a survey last year of doctors on why they don’t currently provide myopia management in their practices but would consider doing so in the future.

The webinar, supported by Johnson & Johnson Vision, CooperVision and HOYA, was designed to dispel doctors’ doubts.

Ronald L. Benner, O.D., AOA president, reminded webinar attendees that the organization’s members have long been advocates for children’s eye and vision health.

“In 2021, AOA held our emergency summit on children’s vision,” Dr. Benner recalled during the webinar. “At that time, we were working to assess the impact of the pandemic on children’s eye health. That summit started an important discussion related to children’s vision and, as we are now seeing, increasing rates of myopia across the globe. We know it’s critical for the AOA to set a strategic pathway forward to ensure that the eye health and vision needs of all children are met.

“Myopia management is a critical tool in the optometry clinical toolbox to help address rising rates of myopia,” he added. “However, we also fully recognize that many doctors still have questions about whether to start offering myopia management in their own practices. A recent AOA Health Policy Institute survey found that 72% of the doctors who do not currently provide myopia management in practice would consider doing so in the future. When we ask doctors who don’t provide myopia management in practice what they believe are the major barriers to offering this type of care in practices, the majority of doctors point to three major areas of concern.”

Those concerns:

• Some have questions related to the evidence base supporting myopia management.
• They lack the equipment in their practices to properly monitor progression.
• Worries about affordability for some patients and their parents.

“We recognize the validity of these concerns, and our panel of experts tonight is going to provide us information that directly addresses all three of these perceived roadblocks,” Benner said.

Moderated by Karen Deloss, O.D., an associate professor at the University of Michigan Kellogg Eye Center, the webinar received over 400 member registrants. The three doctors of optometry who presented on the webinar are members of the AOA Contact Lens & Cornea Section (CLCS) and experienced with myopia management.

What the evidence says

Melanie Frogozo, O.D., who practices in San Antonio, Texas, said her focus is on medical and specialty contact lenses, but she also sees patients who require myopia management, which she embraced from the start. She is a high myope herself.

To truly understand evidence-based myopia management, there needs to be an understanding of the normal process of emmetropization, Dr. Frogozo says. According to the Association for Research in Vision and Ophthalmology  journal Investigative Ophthalmology & Visual Science, emmetropization “refers to the developmental process that matches the eye's optical power to its axial length so that the unaccommodated eye is focused at distance.”

Axial length is the distance from the front to the back of the eye; refractive myopia (nearsightedness) and axial length are tightly linked in diagnosing myopia.

“Myopia breaks normal emmetropization,” said Dr. Frogozo, who repeatedly referenced sources in her presentation.

“Axial lengthwise at birth we start at 18 millimeters, and it continues to grow until about the age of 3 to 23 (mm) and then slowly increases to the full 23½ millimeters by the time you are age 13,” she said. “One millimeter of axial length growth equals to about two to three diopters of myopia.”

Axial length of more than 24 millimeters and refractive error of greater than -0.50 diopters are characteristic of onset of myopia. Meanwhile, Dr. Frogozo noted, the cornea is flattening and the lens is thinning to compensate for emmetropization.

Because of factors environmental (for instance, an increase in pandemic-related near activities) and genetic (parental history), myopia is being diagnosed at younger ages. Unfortunately, because the disease starts at a young age in children, the higher the risk for progression, Dr. Frogozo said.

If a doctor of optometry sees a six-year-old and they are already +50, she says, they are more likely to become myopic and myopia management options should be discussed with the parents of these patients, she says.

The measurements underscore the need for early myopic management or control to decrease progression and even prevent onset. Untreated myopia can eventually lead to blindness, impacting a child’s schooling and, later on in adulthood, their quality of life.

“I am a big proponent of starting myopia management at pre-myopia,” added Dr. Frogozo, who spoke about positive patient outcomes based on studies. “I focus a lot on treating pre-myopia and I prescribe prevention of onset measurements.”

Among the most commonly prescribed treatments by doctors of optometry to slow progression: orthokeratology, soft bifocal contact lenses, myopia management spectacles and the antimuscarinic agent atropine.

And the preventive measures?

• Encouraging children to spend more time outdoors and less time on digital devices.
• Prescribing low-concentration atropine (0.05% of children taking atropine were less likely to become myopic).

“There was a study that came out this year that showed patients who were not myopic—this was almost 500 patients not myopic, young patients, 4 to 9 years old, started on 0.05% atropine—these patients within two years did not form any refractive myopia,” Dr. Frogozo said.

Low-dose atropine in patients who are not refractive myopes prevented the development of myopia after two years of atropine,” she added. “I think this is strong evidence that we need to be treating pre-myopia.”

Myopia management instrumentation: What’s needed

Ashley Tucker. O.D., practices in Houston, Texas, with a focus on specialty contact lenses and myopia management. “I have the privilege of managing little myopes almost every single day to some extent,” Dr. Tucker said, “and it has been my pleasure to be a part of the movement to slow myopia progression in our children.”

During her presentation, Dr. Tucker had a clear message for those doctors concerned that they might not have the right equipment for myopia management.

“What I am here to tell you is that you don’t have to let equipment or lack of equipment stop you from getting started,” she says. “Let’s talk about what is necessary.”

The necessary equipment for myopia management, according to Dr. Tucker, includes:

• A phoropter
• A slit lamp
• A retinoscope (auto-refractor)
• A keratometer (auto-keratometer)
• Appropriate fitting sets

“For the most part, we should all have this stuff,” Dr. Tucker said. “We need these sorts of things to practice, in general, not specifically for myopia management.”

She then covered the good-to-haves in a practice:

• A topographer (considered the standard of care to manage and troubleshoot)
• An ocular biometer (measures axial length—the most critical measurement of myopia progression)

“If you have all the basic (technology) and you’ve practiced for a little while with that and you kind of want to upgrade yourself, topographer and ocular biometer are absolutely wonderful additions to your practice,” Dr. Tucker said. “Again, you don’t necessarily have to have these two things, but they really will allow you to elevate your myopia management game and provide the best service to your patients.”

Just having measurements for acuity or just having measurements for refraction will not give doctors the information they need to accurately troubleshoot and manage patients with myopia, Dr. Tucker says. Having a topographer, for when doctors fit orthokeratology lenses, would be beneficial to doctors and patients, she said.

“It freed me, when I got this topographer, to be able to manage patients more efficiently, more effectively and it just provided better outcomes for everyone,” Dr. Tucker said.

Addressing socioeconomic barriers

Renee Reeder, O.D., department chair for clinical affairs at the Kentucky College of Optometry, attended an orthokeratology (ortho-k) symposium over two decades ago. Ortho-k is a non-surgical option for slowing the progression of myopia. “So, I have been involved in myopia management for a very long time,” Dr. Reeder said.

She described her practice as a “fairly rural” one—a number of her patients are uninsured or underinsured, though by comparison the percentage of myopes is smaller. “Because our patients are still getting outside,” she says. “But it definitely is a challenge because we want to be able to offer (treatment) options for those folks who need it the most. There are treatment options that don’t cost anything.”

To start, Dr. Reeder says, doctors can encourage parents to send their children outside to play in the sunshine—rather than sitting inside, playing on electronic devices too near to their eyes. That’s two no-cost options—playing outdoors and moving their devices further away.

“I think (that) can make a really big difference without any costs,” she said. “We want to continue to educate our parents and our kids about things they can do to help reduce those risk factors. That’s the first place for us to start.”

And for parents who might not be able to afford expensive treatment options, Dr. Reeder recommended “planting seeds” with them. Show them. She recalled having several conversations with one family, demonstrating to them how their child’s vision deficit was impacting his sight. Concerned, they eventually found the money after more than two years.

“The family came together to figure out a way to provide what this young child needed,” said Dr. Reeder, noting that atropine drops can be more affordable than some contact lenses.

If wearing contact lenses is the best option for a patient, make that recommendation strongly to parents, she said.

“Explain what you believe is best and why,” Dr. Reeder said. “Give them the evidence. Then review the pricing with them. They may not be able to afford it today, but they may be able to prioritize it in the future. You may want to consider payment plans in your office to where it acts almost like a subscription that you monitor yourself to where you’re only purchasing small quantities at a time so they can pay for that.

“We have to think outside the box a little bit.”

What’s next?

The webinar, hosted by the CLCS, is part of a three-part series on myopia management. Next is “Meet the Myopia Experts” on Saturday, June 24, from 2 p.m. to 4 p.m., at Optometry’s Meeting^® 2023, June 21-24 in Washington, D.C. Register to attend. The series will conclude with a final webinar in September to maintain this community of doctors who share interest in myopia management.