Research estimates myopia will affect 50% of the world by 2050, and recent COVID lockdowns appear to have only worsened the situation. As more patients – and their parents – seek effective interventions, practitioners should prepare to meet this oncoming public health demand.
Communicating with parents of paediatric patients can be challenging. Perhaps none more so than with parents whose children have been, or are at risk of being, diagnosed with myopia.
What communication methods do optometrists adopt to educate parents about the importance of long-term interventions, as opposed to only vision corrective measures?
Academics, industry experts and clinicians with a special interest in myopia contribute to the conversation with Insight, sharing their unique perspectives on what can misconstrue parents’ understanding of myopia, how to broach conversations about the safety and efficacy of treatment, the potential cost of several years’ treatment, and overcoming aversion to contact lenses.
Plano is not necessarily normal
Multilingual optometrists Mr Griffin Ngo and Ms Wendy Yeung initially opened greenfield practice, Rhodes Optometry, in Sydney’s inner west as a contact lens clinic – then quickly realised the pressing need for a dedicated myopia clinic, and established Sydney Myopia Clinic at Rhodes Optometry in August last year.
“Our patient base is typically young, professional, educated, with a strong Chinese ethnicity. Parents have often heard of orthokeratology (ortho-k), but it is often harder to explain concepts behind other interventions like atropine, and defocus spectacle lenses,” Yeung says.
She says having parents witness their child struggle with their vision during assessment is often the most effective way to convince parents that intervention is needed. But telling parents that intervention is recommended for a child who is pre-myopic is a much harder task.
“It can be hard to explain to a parent that being plano, or zero dioptres, as an eight-year-old is not a good thing. While it seemingly appears ‘normal’ to parents for their child to be zero dioptres, it’s on the verge of becoming myopic, as the normal refractive error for a child of that age is actually around +0.75. It’s hard for parents to understand this because their child’s vision currently appears as perfection.”
In this type of scenario, the challenge increases as Yeung and Ngo need to communicate the importance of preventing myopia from developing, when the parent believes nothing is ‘wrong’ with their child’s eye health.
“If we can intervene to prevent or delay the onset, we’ve met our goal – but it’s challenging to demonstrate that it’s the absence of myopia that shows intervention is working.”
To help guide parents through myopia assessment, diagnosis, prevention and treatment, Ngo and Yeung have created a brochure explaining why myopia control matters and outline potential treatment options.
They also refer to a manufacturer’s brochure, which features a graph that plots average childhood myopia progression over time if there is no intervention, versus myopia control. Parents are also directed to www.mykidsvision.org, an information tool developed by Australian optometrists Drs Paul and Kate Gifford.
“There is a lot of information for parents to take in, in one consultation,” Yeung says. “Giving parents a brochure as well as a link to a website like ‘My Kids Vision’ gives them something to take home, to refer to again and again.”
Ngo and Yeung also discuss the cost of treatment with parents.
“Explaining to parents that their child will require myopia treatment throughout their adolescence and potentially adulthood is a shock for some,” Ngo says.
“Whether or not it is ortho-k or spectacles that is the best option in terms of treatment, we discuss how many pairs of lenses their child is likely to need over the course of their treatment, and the probable cost. Gaining parents’ consent and commitment to come back is vital.”
Another hurdle is discussing the safety of various treatments.
“A lot of parents are concerned about safety issues associated with certain treatments. When we’re discussing orthokeratology, for example, we explain the precautions we’re taking in prescribing ortho-k, we explain how the lens material is designed to be safe, and how children wearing lenses overnight when they are at home with their parents means that if their child wakes with a red eye, they can seek treatment immediately,” Ngo says.
“A lot of parents also feel their child is not ready for contact lenses. If that is the case, we do one of two things; we try a spectacle lens option and complete a three-to-six-month review. If, upon review, their prescription has increased, we advise moving into contact lenses. This way, both the patient and parent are pre-warned. Alternatively, if a parent feels their child is not ready for contact lenses, we demonstrate to them the process of inserting and removing them using trial lenses. Often, the parent realises their child is more mature than they thought.”
The influence of culture and environment
Most of Professor Ian Morgan’s work focuses on myopia prevention. A Visiting Fellow at Australian National University (ANU), the biochemist and pharmacologist became interested in myopia almost by accident 30 years ago, when he was researching the effects of dopamine on the retina, axial elongation, and growth control.
“It was the 1990s and an epidemic of myopia was emerging in East Asia and Singapore. My perspective on the role of parents in the prevalence of myopia derives from that time. Since then, we’ve witnessed the rise of the ‘Tiger Mum’, and parents pushing their children to achieve academic excellence,” he says.
That cultural tendency to place high expectations on excellence has come at a cost – the health of children’s vision.
Morgan, a member of the ARC Centre for Excellence in Vision Science at ANU, is chair of the International Myopia Institute’s Environmental Risk Factors in Myopia Taskforce. They produced a white paper, published last year, outlining the latest scientific evidence on causal risk factors for myopia.
“Education and time outdoors – these are the two major risk factors for school-aged myopia,” Morgan says.
“In regard to education, parents – particularly in East Asia – need to be made aware of the potential consequences of placing too much burden on young children to perform academically, early in their schooling.
“However, the Chinese government is taking major steps to reform education to shift the burden or pressure away from preschool to senior high school, more like in the general Western population.”
He says research has demonstrated children in East Asia have certain patterns of behaviour when it comes to their education – and are correspondingly more myopic – and migrants to Australia carry those cultural attitudes to education with them.
“Shifting competitive pressures may help alleviate the pressure parents in East Asia place on their children to gain entry into the most desirable primary schools,” he says.
The second major driver to prevent myopia is time outdoors: “The evidence is overwhelming. The more time children spend outdoors, the more they are protecting from myopia.”
A randomised controlled trial (RCT) carried out in China showed that more time outdoors in schools would slow the onset of myopia (He et al 2015).
“Two papers reported an association between myopia and time outdoors in 2007-8. Singapore adopted a policy promoting outdoor activities in 2008, but as a parental responsibility. Taiwan first implemented it in schools from 2010, but the first RCT was small in 2013, followed by a larger trial in 2015. The excellent recent paper is a subset of the work going on in Taiwan,” Morgan says.
He is referring to a recent survey in Taiwan, undertaken before and again during the coronavirus pandemic, on the prevalence of myopia after implementing a policy promoting outdoor activities in pre-schoolers.
A total of 21,761 pre-schoolers, aged five to six from seven school-year cohorts (2014 to 2020), were included in the analysis.
Since August 2014, in Taiwan, myopia prevention strategies, such as increasing outdoor activities (two hours per weekday), have been promoted in all kindergartens, and countywide school-based eye examinations, including cycloplegic autorefraction, and caregiver-administered questionnaires have been carried out annually for participants.
The survey results, published by the American Academy of Ophthalmology, showed the prevalence of myopia continuously decreased for two years after implementing these strategies.
“This study in Taiwan demonstrated time spent outdoors can counteract the effects of studying. How much time is spent outdoors is in the control of parents and it plays a huge role in prevention. That is a major lesson for parents; get your children outside as much as possible, two hours a day minimum,” Morgan says.
“The introduction of time outdoors, two hours per weekday, in the Taiwanese school system reduced the rate of myopia for the first time in 40 years. If they start earlier, at the beginning of pre-school, and continue through primary school, it can have a massive impact on progression.”
Professor Padmaja Sankaridurg is head of the myopia program at the Brien Holden Vision Institute (BHVI) and Conjoint Professor at the School of Optometry and Vision Science at the UNSW. She’s also a member of the International Myopia Institute’s Advisory Board.
Sankaridurg has been managing the myopia program at BHVI since its inception in 2003, accumulating nearly two decades of ‘intel’ into myopia and the role parents play in their child’s treatment outcome.
“With a childhood onset condition such as myopia, parents/carers are the change agents with respect to adopting and promoting new behaviour strategies and myopia treatments,” Sankaridurg says.
She believes communication methods need to be tailored to specific populations taking into account socio-economic status, cultural and social beliefs, and attitudes to change.
“As an example, in countries with high pollution levels or high density living or attitudes to sun exposure and skin colour, a message to send children outside each day may not resonate with the population. Taking into account the circumstances on the ground and providing further information on when and how to achieve the required time outdoors may help engage them,” Sankaridurg says.
Additionally, communication methods need to consider the awareness level of parents.
“For example, in countries where the prevalence is already high or parents that have myopia are possibly well informed and aware of the problem, parents might be more interested in treatments or recommendations to reduce risk. In this situation, even passive websites offering information on newer treatment methods is likely to help parents make an informed choice,” she says.
“On the other hand, there may be parents/carers who are unaware of the problem, and they need to be targeted more actively to raise their level of awareness and draw their focus to the eye health of their child.”
CooperVision’s ‘Global Myopia Attitudes and Awareness Study’, released last year, revealed 54% of eyecare practitioners believe parents don’t understand the risks of significant eye health issues associated with myopia.
Delving further into this, Sankaridurg explains that the eye health issues related to higher levels of myopia mostly occur at a much later age and therefore, even if parents have experienced myopia within their close circle, they are unlikely to know the real impact.
“Educating parents and the patient (if they are old enough) is the key. Indeed, the same study indicated that 87% of parents are willing to learn about myopia management solutions. Facts should be presented in simple, uncomplicated terms and should include available options to mitigate the risk,” she says.
“Available calculators and percentile charts can demonstrate a ‘what if’ scenario that can be used to educate parents. It’s also critical to establish a rapport with the parent and child so parents feel comfortable and confident with any decision making.”
CooperVision’s survey also found 58% of eyecare practitioners said parents don’t want to put their children in contact lenses – and for parents who would consider contact lenses, they preferred their children to start at 12 years of age.
This statistic illustrates a familiar conundrum for Sankaridurg.
“The two main areas of concern for contact lens wear in children are the risk of complications and ability of the child in handling lens wear. With respect to the latter, there is substantial data that demonstrates that children as young as six to seven years of age can independently care for their lenses,” she says.
“With regards to complications, the risk of adverse events in children is no more than that observed with adult contact lens wear – and with daily disposable lens wear the risk of serious infections is quite low. Despite this data, there is a general reluctance to introduce young children to contact lenses and is likely related to negative publicity around complications and the lack of information on the positive outcomes.”
An optometry graduate from the University of Melbourne who completed postdoctoral research at the University of Toronto, Dr Monica Jong worked with the late Professor Brien Holden as part of the grassroots myopia control research and advocacy at BHVI, and went on to become executive director of the International Myopia Institute for six years.
Jong is now global director of professional education in myopia at Johnson & Johnson (J&J) Vision and a Visiting Fellow of the School of Optometry and Vision Science, UNSW Australia.
“My perspective on parents and myopia is global, working with experts and speaking with optometrists worldwide. Practitioners across the world no matter where they are, experience similar challenges in navigating a lack of awareness in parents about myopia as a serious ocular health issue – it’s a huge challenge,” she says.
“Optometrists have been correcting myopia for years – and doing it well. So well, in terms of visual function, that the parent and child don’t recognise that myopia is not a normal state of the eye. There isn’t enough public awareness that myopia is a problem. We need to change perceptions and behaviours.”
Jong says, generally speaking, the public is accustomed to the (misguided) idea that when a child develops myopia, they are inevitably going to wear (single vision) glasses, their myopia will likely progress over time and there is no available treatment.
“But they don’t realise myopia is associated with other sight-threatening complications, and may increase risk of glaucoma, myopic macular degeneration, retinal detachment, and permanent vision loss,”1,2 she says.
“Today there are evidence-based treatment options that have been reported in the literature to both correct myopia and slow its increase in children.3 But the challenge is to convey this in an easy-to-understand manner. We don’t want to scare parents with statements about vision loss or overwhelm them by throwing lots of statistics at them. It’s a matter of gauging their level of initial understanding and providing a balance between communicating the urgency to manage myopia without scaring them.”
Jong says practitioner-facing websites are excellent in guiding myopia management but more patient-facing websites, like Myopia Profile’s ‘My Kids Vision’, are needed to send a positive message that detecting myopia early and treating it is the best way to reduce the risk of related complications.
“Today most parents are turning to Google first and so having a high-quality evidence-based website is really helpful to get the conversation started with patients and to build a myopia management practice. Having simple, easy to understand practitioner materials ready in your practice, and prepared answers to frequently asked questions is useful for practitioners and their staff,” Jong says.
“Using simple messages with the public is key, for example, spending time outdoors, reducing near work and taking regular breaks such as the 20-20-20 rule, proposed by Professor Caroline Klaver.”
(Klaver proposes after 20 minutes of close work, children should gaze at objects 20 feet away for at least 20 seconds, and they should be outside intermittently for at least two hours daily).
A growing level of sophistication in myopia instrumentation is also advancing the conversation to better educate parents.
“Industry has realised the need for improved instrumentation to support practitioners in myopia management, such as ocular biometry to monitor axial length. These have been used in clinical trials as the primary measure of eye growth and increasingly being adopted in clinical practice,” Jong says.
“But you can still do myopia management without it. Some of the ocular biometers have axial growth curves in their software which displays to parents where their child’s eye growth is compared to the average for their age and ethnicity and helps demonstrate the effect of a treatment.
“Several groups have developed online myopia calculators, so a child’s refraction measurements can also be plotted against an average guide, with and without treatment. There are fantastic tools available and new monitoring devices being trialled that measure time outdoors and near work exposure, to help support treatment.”
Stepping into a global education role at J&J Vision is giving her the opportunity to do more.
“Myopia management is about understanding the patient holistically, in terms of their risk factors, age, refraction, lifestyle and preference to recommend the most appropriate treatment. Having a conversation with parents and child, taking a good history and integrating that with clinical findings are part of the process,” Jong says.
“Ultimately, for parents, communication is critical to build awareness. As clinicians, we need to strike a balance in what we communicate. We don’t want to scare parents but it’s imperative they understand that today there are bonafide treatments backed by scientific evidence available. It is now possible to slow the increase in myopia in children and correct vision at the same time.”
Disclaimer: Monica Jong is an employee of J&J Vision but this is not a J&J Vision-sponsored article. The views expressed are from her professional opinion. References available in the online version of this article.