Managing myopia in children can be a different ball game in a public-facing clinic, opposed to those in a corporate, networked or independently-owned practice, new research shows.
New data on how managing children with myopia in a public health setting differs to a private optometry clinic has not yet been formally published, but those attending O=MEGA23 were the first to know.
Australian College of Optometry’s lead optometrist in paediatric services, Ms Zeinab Fakih, presented the research in her lecture entitled: ‘Implementing a myopia control clinic in a public health optometry setting.’
Fakih aimed to describe the challenges, limitations and outcomes of implementing a myopia control clinic in a public health setting.
“At the core of the Australian College of Optometry is its public service mission to provide clinical care to people from diverse cultural and socio-economic backgrounds,” she says.
Due to its not-for-profit status, Fakih says, the ACO’s myopia clinic is a unique setting for the provision of myopia control.
“We know that health literacy is a key determinant to compliance and ultimately success in applying evidence-based treatments in medicine. This principle certainly extends to myopia control,” she says.
“At O=MEGA, I presented data looking at how the management of children with myopia looks different in a public health setting compared to a private optometry clinic.”
Given the ACO’s diverse patient base, Fakih and her team looked at determinants and trends in recommendations, and perceived barriers, to treatment decision-making and compliance by ACO clinicians.
“We showed that clinicians often face barriers to the initiation of myopia control and compliance including lower socio-economic background, costs, and frequency of follow-up appointments,” she says.
Summarising what her team has noted in their review of myopia control at the ACO, Fakih says one of the most pressing findings is the apparent trend for eye drops over contact lenses.
“Contact lens options, both soft contact lenses and orthokeratology, were not recommended as commonly at the ACO compared with private practice. We inferred this was due to the requirement for multiple initial visits, increased maintenance requirements at home, and certainly cost was a big barrier,” she says.
“We found that atropine 0.05% was the most commonly prescribed myopia control option as cost was more easily spread across the year with monthly drop purchases.”
She says the study highlights the need for targeted frameworks when managing children with myopia from low socio-economic backgrounds.
“Compliance differed across patients and closer reviews were implemented when compliance was seen to be a barrier for continued control.”
As a public clinic, with clinical research capacity, the ACO is currently involved in a multicentre trial looking into the effectiveness of repeated low level red light therapy (RLRL).
Fakih says preliminary results from the research “supports findings of the very promising” effects of RLRL in myopia control found in ‘Effect of repeated low level red light therapy for myopia control in children: a multicentre randomised trial’, published in 2022 by Yu Jiang et al.
“Embedding research into a public myopia clinic is very exciting. From August, the ACO will expand its clinic research in the field as it commences a real-world study of RLRL. It’s hoped that findings of the research will help shape the way RLRL therapy is rolled out into mainstream myopia control clinics in the future,” she says.
Limited human resources
With the challenges of managing children with myopia in a public health setting, Dr Pauline Kang understands how saving time and money – in terms of the mode of treatment and chair time – can be a motivating factor for families.
Kang, who coordinates the Myopia Control Clinic at the UNSW Optometry Clinic, says limited resources can be another challenge.
“Paediatric myopia management is likely to be ongoing for several years, and depending on the type of treatment you prescribe, you may need to see a child for multiple visits. With any clinic, particularly those in a public health setting, human resources can be quite limited. To be able to manage children already on treatment, and new children coming on board, that’s one of the problems we encountered,” she says.
“Appointments would get booked months in advance, because we had to manage children that we had already seen but we also had a lot of new patients who wanted to come, but we didn’t have the capacity to be able to see them.”
Some contact lens treatments, such as soft contact lenses or orthokeratology, can potentially require the patient to attend five to 10 appointments in the space of a year, Kang says.
“You see them for the baseline, they come back for the lens fitting, teaching them how to insert and remove the lens, if the lenses don’t fit properly then they have to come back again. It requires a number of visits and once treatment is established, you may see them every three months at first, and then on a six-monthly basis. The time and resources available to be able to see patients for all those visits is a significant challenge.”
By comparison, atropine is much less demanding on chair time and clinic resources.
“As long as there’s no contraindications, any allergies to any of the components of the drug, as long as they don’t have serious side effects – and you wouldn’t typically expect any because the concentration is so low – then it’s relatively straightforward,” Kang says.
“Once they start atropine treatment, you might see them early on to make sure they’re compliant, no adverse effects, understanding how everything works, then you might not see them for another three or six months.”
Atropine can also be a go-to treatment for children as young as five-years-old whose parents might not be comfortable with their child being prescribed contact lenses.
“Atropine is a simple-to-apply treatment that works for most patients and it’s easy to get – we’ve got the commercially available 0.01% option, although other concentrations are increasingly used,” Kang adds.
Newer, emerging treatments, such as RLRL therapy, are yet to be imbedded in public health, but online forums are discussing the latest treatment, which can be administered in-clinic and at-home.
“Repeated low level red light therapy is still quite new and we’re trying to understand the safety of repeated exposure to low level red light for children,” Kang says.
In early August, Eyerising International Pty Ltd announced TGA approval of its Eyerising Myopia Management Device, a world-first technology based on RLRL. The company says it’s “a safe, affordable, and proven technology” that can sustainably improve the way the eye functions through improved blood flow to thicken the choroidal layer of the eye wall, in turn, reducing eye elongation and myopia progression. A recent study of RLRL for myopia control in children achieved 87.7% efficacy with no significant side effects, the company reports.
“The TGA has recognised the safety and performance of the device – the first evidence-based red-light therapy with demonstrated ability to effectively and safely control the progression of childhood myopia with potential life-long benefits in avoiding later eye disease,” Eyerising International CEO Mr Paul Cooke says.
Further, a recent study involving Melbourne institutions reviewed clinical data for myopic children aged 3-17 years who received RLRL delivered by a home-use desktop light device emitting light at 650 nm for at least one year. More than a quarter had axial length shortening greater than 0.05 mm following RLRL, and the overall mean axial length change was -0.142 mm per year.
“I’ve read in optometry forums on Facebook where some optometrists are discussing the option to lend out RLRL devices to patients for in-home treatment, which in a public health clinic we might also need to consider, and may need to have multiple devices, if they want the option to lend them out,” Kang says.
While she is unsure of the unit cost of RLRL devices, she didn’t think it would be a barrier to access.
“If anything, I would argue public health settings have more financial resources to purchase new equipment. For example, our university has access to funding opportunities and because we’re a teaching facility as well, we try to get the latest equipment to educate students. We have the latest ocular biometers, whereas many private clinics don’t because they do cost a lot,” she says.
In the past, Kang says, patients have come from as far as Canberra and Campbelltown to access the services at UNSW’s Myopia Control Clinic, but this is becoming less common as more private practices are implementing myopia management.
“When myopia management was still in its infancy, and practitioners weren’t as confident about doing it themselves, we would manage a lot of children together, particularly for their initial visits when they started treatment,” Kang says. “Instead of them having to travel to us for a 15-minute appointment, we would ask them to go to the referring optometrist to get their vision or pressure checked, to make it more manageable for them, and reduce the demand on us.”
Access to modern equipment
Like UNSW, Queensland University of Technology’s Myopia Control Clinic also has “the latest and greatest” equipment, allowing final-year students to more thoroughly assess and monitor myopia progression and effective treatment,says.
“Our clinic operates on a referral basis. Optometrists in the community can refer patients, or if patients come to our paediatric clinic, they can be referred to the myopia clinic as well,” he says.
Hughes began clinically supervising students in QUT’s Myopia Control Clinic in 2017 while undertaking a PhD, and now jointly co-ordinates the clinic with its founder, Dr Emily Pieterse.
Pieterse initiated, developed and implemented the Myopia Control Clinic within the QUT Optometry Clinic in 2016 when she was completing her PhD studies.
According to Optometry Australia, it was the first such clinic established in an Australian university, and the evidence-based clinical procedures and myopia management guidelines developed by Pieterse have since been adopted by other universities when integrating myopia control into their clinical training.
“We’ve got the ability to monitor axial length, which is becoming more common in private optometry clinics, but up until the last 12 to 18 months, ophthalmology clinics and our university clinics were the only clinics that had access to biometry,” Hughes says.
Echoing one of the barriers to myopia control in a public health setting Kang described, Hughes says it’s not possible to assess patients and implement strategies immediately.
“We’ve been able to monitor myopia progression more closely using biometry but in saying that, it’s not like a private optometry clinic where patients can just call and book an appointment – there’s months of wait time between when we get a referral and when we’re able to see that patient because of limited availability and resources in the clinic.”
While QUT’s Myopia Control Clinic offers the full scope of evidence-based myopia control treatments – including atropine, soft contact lenses, orthokeratology, and spectacle lenses – one treatment is more common. “We are probably in a similar situation to the Australia College of Optometry, in that we prescribe quite a lot of atropine. From parents’ point of view, it’s definitely viewed as an easier treatment to manage, but it’s also seen as the less expensive of the four treatment options, when comparing upfront costs,” Hughes says.
For patients who are using atropine drops as their sole treatment, Hughes says most would be using spectacles, most likely single vision.
“With the low concentration formulations, our experience is that most children tolerate the side effects well such that they don’t require anything more than multifocal or anti-fatigue spectacles, although we strongly encourage sun protection – either sunglasses or photochromatic lenses,” he says.
Frame and lenses start at around $150 for basic single vision lenses through the QUT clinic. In Queensland, single vision spectacles are available at no charge through the Medical Aids Subsidy Scheme (MASS) Spectacle Supply Scheme, but eligibility is restricted to pension and health care card holders.
“Orthokeratology is our most popular treatment secondary to atropine, probably because our clinic offers lower cost orthokeratology compared to private practice – our low comparative cost is only because students undertake the contact lens fitting, overseen by qualified optometrists. We therefore don’t charge the same as what community optometry is charging so we have quite a lot of patients using orthokeratology.”
A fifth treatment option – RLRL therapy – is not available at the QUT clinic, yet. While treatment compliance at QUT’s clinic isn’t dramatically more or less than in community practice, and patients are managed much the same as in community practice, one observation stands apart.
“We probably make different management decisions at times because of the fact that we have access to ocular biometry. Often, we’ll have a patient come back, they’ve had no refractive change, but their axial length has increased, which might trigger a change in treatment strategy, as opposed to if it was in community optometry without biometry, where they might be told to come back in another six months,” Hughes says.
“I think biometry definitely alters how we manage patients and how we adapt treatment – that’s probably the fundamental difference between managing myopia in a public health setting versus private.”
Cost comparison
Australian researchers Tim Fricke, Professor Serge Resnikoff, Dr Nina Tahhan and Professor Mingguang He are among seven authors of a study on establishing a method to estimate the effect of antimyopia management options on lifetime cost of myopia.
The study led by Brien Holden Vision Institute was published in the British Journal of Ophthalmology in March 2022.
Using examples in Australia and China, the authors demonstrate a process for modelling lifetime costs of traditional myopia management (TMM = full, single-vision correction) and active myopia management (AMM) options with clinically meaningful treatment efficacy. AMM included low-dose atropine, antimyopia spectacles, antimyopia multifocal soft contact lenses and orthokeratology.
Myopia care costs were collected from published sources and key informants. Refractive and ocular health decisions were based on standard clinical protocols that responded to the speed of progression, level of myopia, and associated risks of pathology and vision impairment.
“We used the progressions, costs, protocols and risks to estimate and compare lifetime cost of myopia under each scenario and tested the effect of 0%, 3% and 5% annual discounting, where discounting adjusts future costs to 2020 value,” the authors explained.
Lifetime cost of traditional myopia management with 3% discounting was US$7,437 in Australia and US$8,006 in China. The lowest lifetime cost options with 3% discounting were antimyopia spectacles (US$7,280) in Australia and low-dose atropine (US$4,453) in China.
They found the additional early costs of active myopia management (AMM) options 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. The cheapest lifetime cost of all scenarios tested was low-dose atropine in China, regardless of discount level.
The authors also noted that specialty contact lenses represent a significant step in commitment and cost for a family who otherwise intended to wear spectacles, but a relatively small step for a family who intended to pursue regular contact lenses regardless of any AMM option.
However, they acknowledged the limitations of their methodology.
“In reality, clinicians make adaptive, iterative decisions based on evidence and observation. They are likely to change management as cases evolve, potentially to a different AMM if rapid myopia progression continues with the first option, or ceasing intervention if progression drops below an acceptable threshold,” the authors wrote.
“The rigidity of our assumptions is a sensibly conservative modelling approach, increasing our estimated cost of AMM options compared with TMM.”
More reading
Don’t forget about myopia progression in adults
Why axial length matters in myopia management
