Foresightedness on nearsightedness
Excerpted from page 34 of the September 2023 edition of AOA Focus
To be or not to be a provider of myopia management?
Last summer, when the AOA polled doctors of optometry on their embrace of myopia management practices, a very healthy 87% of them reported discussing myopia and management techniques with the parents of patients between 5 and 8 years old.
Those are prime years to diagnose myopia, to apply treatments that can slow its progression and to reduce the risk of sight-threatening complications while sustaining quality of life. Early diagnosis and treatment are crucial considering myopia progresses more quickly in younger children, and early onset implies more years of progression, according to the AOA’s evidence-based clinical practice guideline Comprehensive Pediatric Eye and Vision Examination.
But the survey revealed a floater in that otherwise rosy view. Some doctors were reluctant to implement myopia management in their practices.
The AOA Contact Lens & Cornea Section (CLCS) jumped at the opportunity—doctors of optometry who practice myopia management sharing their expertise and experience with doctors who don’t. The CLCS would host three events: an opening webinar to address doctors’ questions, a “Meet the Myopia Experts” event at Optometry’s Meeting® 2023 and a wrap-up webinar in September.
“It’s a new approach to education,” says Paul Velting, O.D., CLCS immediate past chair, “with the goal of creating an opportunity for doctors to make those connections with colleagues that will last their whole careers.”
Adds Renee Reeder, O.D., CLCS chair-elect and department chair for clinical affairs at the Kentucky College of Optometry: “What we did was create a support system for those doctors who were interested in providing myopia management but had some reservations or some questions about how to move forward and implement and even try and reach some of those doctors who are thinking, ‘Do I really need to be doing that?’ Who maybe aren’t as familiar as some of us are with the research. We wanted to help them feel more confident about how and what to implement in their practices to help their patients.”
Doctors of optometry were surveyed as the profession was digging out at the lowest point of the pandemic and all it wrought for optometric practices. Stringent safety protocols had been implemented, changing the office experience for patients and staff. Telemedicine had taken off, transforming how doctors were delivering care. At the forefront of an important national conversation on the pandemic’s impact on children’s vision since 2021, doctors of optometry were reporting increased instances of digital eyestrain and myopia among children.
Doctors of optometry must take the lead in meeting the eye health and vision needs of all children, AOA President Ronald L. Benner, O.D., told more than 100 attendees at the CLCS’ kick-off myopia management webinar.
“Myopia management is a critical tool in the optometry clinical toolbox to help address rising rates of myopia,” Dr. Benner said. “However, we also fully recognize that many doctors still have questions about whether to start offering myopia management in their own practices.”
What was holding some doctors back? The survey respondents said:
- Their practice modality
- The need for better evidence
- A patient base that can’t afford myopia management
- Lack of equipment
Curiously, according to the survey results, 72% of doctors not providing myopia management now would consider providing it in the future. That’s where CLCS members thought they could help these doctors.
“We wanted to take on those stumbling blocks,” Dr. Velting says. “To walk them through the reality of myopia management and get answers in a supportive environment to real-world, practical concerns they might face. The hope is that they will come out with a network of colleagues they can bring their experiences and help empower.”
“Everybody corrects it,” Dr. Reeder observes. “But how many of us are actually thinking about it as a disease? It has a progressive nature that needs to be managed. We’ve been talking around that point for many years. It has only been for the past five or so years that we started to really see this come to the front.
“We also now have some FDA approvals in the space to help us manage the condition and, hopefully, keep folks from getting so severely nearsighted that they potentially develop damage to the back of their eye,” she says. “The hope is to identify early, intervene early and then hope to slow the progression. By doing that, you catch it early enough to prevent the severe forms of the disease.”
Each one teaching one
CLCS members led the May webinar, supported by CooperVision, HOYA and Johnson & Johnson Vision.
“Myopia breaks normal emmetropization,” said Melanie Frogozo, O.D., who practices in San Antonio. “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 23 1⁄2 millimeters by the time you are age 13.”
Axial length of more than 24 millimeters and refractive error of greater than -0.50 diopters are characteristic of onset of myopia, Dr. Frogozo added. Unchecked, 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,” she said, listing 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.
She also reported two 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.”
What instruments are needed?
During her presentation, Ashley Tucker, O.D., of Houston, had a clear and succinct 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 said. “Let’s talk about what is necessary.”
The necessary instruments—already staples in a typical practice—include:
- A phoropter
- A slit lamp
- A retinoscope (auto-refractor)
- A keratometer (auto-keratometer)
- Appropriate fitting sets
She then covered the not-so-typical equipment:
- A topographer
- An ocular biometer
“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,” Dr. Tucker said.
Just measuring for acuity or just for refraction will not give doctors the information they need to accurately troubleshoot and manage patients with myopia, Dr. Tucker said. 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.
According to Clinical Report: Myopia Management, developed by the AOA’s Evidence-based Optometry Committee and published in 2021, doctors of optometry have a key role to play in myopia management: “Doctors of optometry need to take a leading role in addressing the growing public health problem of increasing prevalence and amount of myopia in children.”
In a May 2022 article in Review of Myopia Management, Dr. Frogozo spoke to the potentially prohibitive out-of-pocket costs to patients and their families for myopia management and insurance’s lack of coverage of the “process of myopia management.”
“Vision plans are structured to drive patients to the optical—not to engage in long-term, complex medical management of ocular conditions,” she wrote.
She added in the article: “Ongoing, complex management of a common condition where the primary endpoint is the lack of something happening is beyond vision plans’ current reimbursement schema.”
During the webinar, Dr. Reeder described her practice as a “fairly rural” one—a number of her patients are uninsured or underinsured. For some patients, affordability “is a challenge because we want to be able to offer (treatment) options for those folks who need it the most,” she said.
However, she added, there are treatment options that don’t cost anything. Foremost is encouraging parents to send their children outside to play in the sunshine—rather than sitting inside, playing on digital devices too near to their eyes, Dr. Reeder says. That’s two no-cost options—playing outdoors and pulling away from or putting away their devices.
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.”
Resources doctors can use
To support doctors of optometry and raise public awareness, the AOA provides numerous resources:
- Access the AOA member-exclusive AOA’s Children’s Vision Toolkit.
- View the myopia management webinar on the AOA’s EyeLearn Professional Development Hub.
- Review the Evidence-based Clinical Practice Guideline: Comprehensive Pediatric Eye and Vision Examination.
It is said that a message must be repeated multiple times before it sinks in with an audience. During a satellite media tour, AOA President Ronald L. Benner, O.D., used that strategy to extol the essentialness of annual back-to-school eye examinations and link them to student performance in the classroom.
Change in standard of care is not yet warranted, say doctors of optometry who wrote editorial for study. Additional research is needed.