Australian eyecare professionals are confident in the nation’s ability to combat the global myopia epidemic. Equipped with industry-leading products, a myopia-centred practice focus, and a proactive attitude towards management, experts discuss how Australia is leading the charge.
Australia and New Zealand are fortunate to have some of the best proactivity, enthusiasm and acceptance of myopia management anywhere in the world, and a wide availability of treatments and scope-of-practice where optometrists can prescribe atropine.
Dr Kate Gifford, clinician-scientist, peer educator and professional leader based in Brisbane, is among those at the forefront of the country’s myopia management.
Alongside her husband, Dr Paul Gifford, she developed Myopia Profile, a multi-platform digital resource for education in childhood myopia management aimed at practitioners.
Although Australia is well placed, Dr Gifford cites barriers to implementing the optimal degree of myopia control.
“I think the biggest challenge that any practitioner would likely cite is the cost. The cost to the patient of these special spectacles or contact lenses, is a lot more upfront than just single vision spectacles, and they’re not necessarily covered to any significant degree or given more benefits with private health insurance, which is minimal and has barely kept pace with the cost of glasses over many years,” she says.
“I think it’s an issue of access for patients who maybe can’t afford this upfront, particularly with escalating costs of living concerns in the present day.”
A 2023 study from the Brien Holden Vision Institute explored lifetime myopia costs and found the additional early costs of early myopia management options such as low-dose atropine, antimyopia spectacles, antimyopia multifocal soft contact lenses and orthokeratology (orthoK), are substantially balanced across a lifetime by reduced refractive progression, simpler corrective lenses, fewer lens replacements, reduced risk of eye disease and vision loss, and reduced management of myopia complications.
“Modelling has shown that myopia management doesn’t cost more for the patient over their lifetime when you factor in having a lower level of myopia,” Dr Gifford says. “If you have a lower level of myopia, you won’t need complex corrective lenses. Not only do you get improved eye health outcomes, but the upfront costs you might pay for more complex spectacles, contact lenses or atropine eyedrops is very much balanced in the long term.”
In response, Optometry Australia (OA) has assembled a position statement on myopia management, that details its support of the World Council of Optometry Standards of Care Guidelines for Myopia Management (2021), which advise comprehensive eye exams, risk assessment, patient counseling, and appropriate treatment options.
OA endorses a shift from simply correcting vision to evidence-based strategies to mitigate myopia development and manage its progression.
And on a global scale, international bodies are just as active.
“The World Council of Optometry made a resolution to state that myopia management must be standard of care in 2021. From the ophthalmology point of view, the World Society of Paediatric Ophthalmology and Strabismus made a position statement just last year,” Dr Gifford says.
Early adopters
Industry momentum was accelerated in 2019 when data first showed the efficacy of soft contact lens and spectacle interventions for myopia control.
“Prior to that, we only had data for orthoK and for strong concentrations of atropine. But in 2019 we had the first publications on MiSight 1 Day contact lenses and on DIMS spectacle lens technology. We also had the landmark LAMP atropine study, which was the first to compare various low-dose concentrations of atropine.”
And in 2019, the first volume of the International Myopia Institute reports were published, which has since spurred a new era of awareness and activity in this space.
“This includes practitioner awareness, industry innovations, and the technology being matched by the scientific recognition. These consensus reports detail what myopia management is about and why it’s a necessity,” Dr Gifford says.
She says that Australia and New Zealand were quick to adopt this practice mindset shift and are now leading the way for proactive myopia management and prescribing.
“Trends show us that we’re much less likely to be prescribing single vision correction than colleagues elsewhere in the world,” Dr Gifford says.
This proactivity is reflected in recent research findings by Dr Gifford.
A survey conducted on Myopia Profile looked at what practitioners were identifying as their levels of confidence and barriers to myopia management from 2019-2023. The findings were presented at the ARVO 2024 conference.
“Interestingly, we found that their levels of confidence weren’t much different between 2019 and 2023 which is surprising considering the increased availability of knowledge, treatments and resources in that time. They feel as though they need to know more before they can get started,” Dr Gifford says.
“Practitioners identified their level of knowledge as the biggest barrier to myopia control, and communication as their second biggest.”
Dr Gifford attributes this to wider adoption of myopia control. Eyecare professionals engaging in myopia management education and training in 2019 were considered early adopters. Since then, ECPs across the industry have adopted myopia management as standard care, and may not be as well versed in it.
“I think the barrier with clinical communication primarily, is time. There’s lots to talk about. Instead of just, ‘Your child needs a new pair of glasses’, we can say, ‘We need new glasses, but we can also fit contact lenses or use atropine’,” Dr Gifford says.
According to Dr Gifford, the Myopia Profile website and platforms are attempting to address three challenges with its three pillars of activity: practitioner education, clinical resources and public awareness.
“Practitioners will learn about the research through Myopia Profile, and also have access to tools to put their knowledge into practice,” she says.
“The platform can be used to support practitioners who don’t consider myopia control the main part of their practice or professional interest to do their best in myopia management.”
In September, Myopia Profile is running the second global Myopia Action Month to deliver 30 days of tailored education for ECPs. It has also recently introduced a new set of Made Simple courses, with the first free course, Myopia Management Made Simple, launched in September 2023. Dr Gifford says the courses are ideal for practitioners who are time poor yet understand the necessity of implementing best myopia control in practice.
“We launched the first free myopia management and practice course in 2019, but because we’re now talking to a larger audience, most of whom aren’t the early adopters, we’ve recognised that there’s a need for practitioners to learn what they need to know as efficiently as possible,” she says.
“These Made Simple Courses are all one hour in duration and intensely practical, and designed to fill that gap for the practitioner who doesn’t feel like myopia management is their life’s calling, but recognises that they need to learn more to be able to put it into practice.
“We have launched another five courses covering spectacles, soft contact lenses, visual environment, atropine and orthoK, and they’re in process for accreditation for CPD in multiple countries.”
On a broader scale, Dr Gifford says she’d like to see proactive early intervention and preventative measures to delay the onset of myopia.
“An analysis published in 2023 said that one year of delaying the onset of myopia can give as much result as two to three years of a myopia control treatment in terms of reducing someone’s final level of myopia,” she explains.
“If we can delay or stop children becoming myopic in the first place by screening for risk factors, and by talking about visual environment, such as increased outdoor time, reduced screen and near work time, then that’s going to have a huge impact on changing the trajectory of myopia.”
Dr Gifford suggests nationwide screening of preschool and early primary school aged children, public awareness campaigns, powerful government-supported and widespread campaigns about increasing time spent outdoors and managing screen time.
She cites useful international research in schools, which could be implemented locally. In Taiwan, where approximately 80-90% of the population are estimated to be myopic by the time they’re 18, researchers assessed the effects of outdoor exposure during school on disease progression.
Half of the study cohort had intentionally more outdoor time during recess and, as result, showed a reduction in frequency of myopia onset.
Meanwhile, researchers in China have investigated the effects of classrooms with wallpaper depicting outdoor scenery compared to traditional classrooms on myopia progression.
The results showed that students in the outdoor scene classrooms showed less myopic shift compared to traditional classrooms, after one year.
Hyperopic students in the outdoor scene classrooms had significantly less myopic shift and axial elongation compared to baseline.
Dr Gifford says that myopia control solutions need to incorporate the technological culture of today’s world as close-proximity work and activities are an inevitability.
“We can’t just say, ‘Get off your screens and spend time outdoors’ when we know that’s not what modern life is like,” she says.
“Finding solutions that are realistic and work for parents without making them feel guilty are key, such as what can be done at school and implemented in a broad scope way.”
The potential of dual therapy
Optometrist Ms SooJin Nam, the force behind Eyecare Kids in NSW, says she has always been interested in children’s vision and the impact that refractive errors and binocular vision has on a child’s development.
“Vision related challenges can make learning or paying attention in the classroom more difficult. Myopia is of particular concern, because it is the one refractive error that gets progressively worse as someone gets older and associated with ocular pathology,” she says.
“At the end of the day, we’re not just looking at the child as they are now; we’re also looking at the potential difference we can make for them in their lifetime.”
When Nam began prescribing orthoK in 2004, she noticed the young myopes did not appear to be progressing as quickly as those wearing single vision spectacles. Since then, she has seen the landscape and industry evolve, as myopia’s acceptance grew, and management became an accepted treatment methodology.
“For a long time, the conception was still, ‘Is myopia nature or nurture?’ And for many years afterwards, there were still a lot of questions and skepticism as to whether myopia could be controlled by any means,” she says.
“We didn’t really get those randomised control studies until much later, but this doesn’t meant that we were not seeing those clinical outcomes in the practice.”
Beyond a growing prevalence, Nam says this has been accompanied by growing awareness among patients. She cites much of this coming from word-of-mouth or independent online research.
“I believe there’s more conversation happening on the outside that we’re not aware of,” she says.
The volume of conversations taking place outside the clinic is a step in the right direction, but Nam says the largest industry hurdle is how to communicate and subsequently manage lifestyle factors to prevent myopic progression in the first place.
“Communication to children and teenagers, regardless as to whether they’re myopic or not, that they need to spend more time outdoors and less time on screens is a big challenge. I’m a mother of two teenage boys, and I know first-hand how challenging that is.
“It’s easy to say, but sometimes it’s not as easy to implement. I encourage lifestyle changes, like choosing outdoor sports and activities, so that the time outdoors just happens naturally.”
Nam also says communication about management options can be a challenge due to the sheer volume of information available.
“Trying to make all that information clear and succinct is difficult. As well as explaining myopia management, I still have to go through their other visual needs.”
To condense all this knowledge in the allocated time frame, Nam relies on in-house resources such as action plans and information booklets – but keeping it relevant to her practice.
“There’s just so much information, so it’s about tailoring it, and recommending what is best for the patient with the products and services you have at your disposal,” she says.
“It’s so much like going to a wall full of multivitamins: you know you need something, but you don’t know which ones are the ones you should take.
Nam, along with Dr Gifford, places Australia at the forefront of understanding myopia control in the world.
“We’re also among the early adopters of clinical outcomes and research in myopia management. We have clinicians who have such a keen eye for how their patients are responding to optical products,” Nam says.
She adds that optometrists have access to all myopia control products such as peripheral defocus spectacle lenses, myopia control contact lenses, low dose atropine, the wide range of orthoK lens designs, which well places them to provide a world-class service.
“They don’t just have access to all the myopia control products, but also access to all the technology to measure, maintain and monitor patients – which isn’t so accessible in other countries.”
In terms of the future of myopia management in tertiary care, Nam says there is promising international research in gene therapy in this space, and therapies targeting the underlying causes of myopia.
And for everyday management, she cites new wearable devices as an adjunct to spectacles that monitor and encourage healthy visual habits and make meaningful changes to behaviour.
“This includes monitoring how much time people are spending looking at something close up compared to how much time they’re spending outdoors.”
For Nam, she would like to see studies evaluating the efficacy of different combinations of dual therapy.
“At the moment, we can find systemic reviews on the efficacy of combined orthoK and 0.01% low dose atropine, and some preliminary research that explores MiYOSMART and Stellest spectacle lenses with 0.01% atropine,” she says. “But I’d also like to see peripheral defocus lenses or orthoK with 0.025% or 0.05% atropine, especially as most of the current published research uses 0.01%. This is because concerns remain over the efficacy 0.01% in terms of axial length control.”
The future of myopia management will focus on customising the options available to maximise treatment efficacy.
“So, there’s still a long way to go to understanding what the best options are,” Nam says.
A pathway to ‘Standard of Care’
By Jagrut Lallu
There is a critical need for myopia management to become a global standard of care. As eyecare professionals, we face both a challenge and an obligation to integrate myopia management into every practice. Since launching New Zealand’s first myopia management clinic in 2009, I’ve dedicated my work to advancing this field, which was once not a priority.
Today, the clinic is thriving. We’re passionate about myopia and the ability to help children better now than ever before. We banned the use of single-vision distance glasses for treating myopia and instead offer all the available options globally. Our clinic receives referrals from local optometrists, ophthalmologists, and other specialists in the Hamilton area. We then create a treatment plan, working with the referring practitioner to co-manage the patient’s myopia.
Over the past 15 years, New Zealand practitioners have advanced significantly in myopia management, surpassing many others globally in treatment options and implementation. The availability of specialised lenses, other eyecare tools, and knowledge of myopia management practices varies by region. We must continue sharing our expertise to help areas with less advanced practices enhance their myopia management capabilities.
That’s why I agreed to become an ambassador for the WCO CooperVision Myopia Management Navigator (myopianavigator.info). The World Council of Optometry (WCO), in partnership with CooperVision, launched the navigator in April 2024 to further its mission to make myopia management a standard of care globally.
It’s an interactive and educational online guide that is free for eyecare practitioners to access. Think of it as a cheat sheet for getting started with myopia. You can look through the navigator relatively quickly and be upskilled with the current evidence and myopia treatment options. It takes you through three steps: mitigation, measurement, and management, providing evidence-based resources for each.
The mitigation section walks you through how to talk to parents and children about the risk of developing myopia and how to slow its progression. It provides lifestyle-related advice, such as maximising time outdoors and limiting screen use. It also discusses risk factors for children, including spending time on near work and having myopic parents, as well as myopia’s link to other serious eye health problems.
The measurement section gives you an overview of what measurements to incorporate into a child’s eye exam to determine whether the child has myopia or is at risk of developing it. It includes four standard assessments and three additional checks for myopia. It also guides you through how often to follow up with patients and what to look for, including four key things to check and what to measure at six-month and one-year follow-up appointments.
The management section provides an overview of probing questions to ask a child and their parents so you can understand the myopia management intervention most suitable to the child’s lifestyle, the family’s budget, and the time available. It shares proven, effective clinical interventions available to manage progressing myopia, such as soft dual focus or multifocal contact lenses, orthokeratology, spectacle lenses, or atropine. Under this section, you’ll also find patient profiles to help you think about a child’s lifestyle and how it factors into which interventions best suit them.
As an ambassador, my goal is to raise awareness about the navigator and answer any questions to encourage more eyecare professionals to use it. To me, this is important because we need to ensure we lead the way in establishing the minimum standard of care. We are very fortunate in Australia and New Zealand that we have almost all available myopia management treatment options, and all practices have access to at least two or three of those options. Resources like the navigator help facilitate conversations, leading to a change in societal behavior.
There is a future health risk, with cases of myopia continuing to rise at an alarming rate. The most important thing you can do is to start doing something. Use the navigator, spread the word about it, or reach out for mentorship or guidance from people like me who are happy to share knowledge. Teamwork makes the dream work.
BIO: Jagrut Lallu is a partner of Rose Optometry in Hamilton, New Zealand. He is also the director of Innovatus Technology, which develops software to make contact lens design accessible to practitioners. In 2009, Lallu set up the first myopia control clinic in New Zealand devoted to evidence-based methods for management. In 2023, he established the New Zealand Eye Research Centre. Lallu is also a clinical senior lecturer at the Deakin School of Optometry in Geelong, and is an honorary teaching fellow at the University of Auckland. Lallu is one of four WCO-appointed global myopia ambassadors.
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