While Australasian optometrists are near the front of the pack when it comes to myopia management, some argue more needs to be done to make a meaningful societal difference. With an urgent situation upon us, what targets can local practitioners set themselves to lift prescribing rates while mastering those crucial moments in the consulting room?
Just how engaged are Australian optometrists when it comes to myopia management? It’s an interesting question – and one that can be most reliably answered from a 2023 International Myopia Institute (IMI) survey1 assessing the attitudes and clinical strategies of eyecare professionals (ECPs) across the globe.
On most metrics, Australian ECPs who completed the self-administered, internet-based questionnaire scored well. Some topline results include the lowest use of single vision lenses in young myopes in this part of the world, while prescribing rates for myopia control spectacle lenses and contact lenses are among the highest.
Further, the minimum degree of myopia in a child to warrant an intervention is the lowest in Australasia (−0.64 ± 0.37 D), with practitioners in the region also rating their activity in myopia control 7.9 (± 1.2) out of 10, the highest alongside Asia.
With that said, research from companies like CooperVision – which has skin in the game when it comes to myopia with its MiSight 1 day contact lens – suggests there are still many children that would benefit from myopia management who have yet to undertake it.
So, what simple, practical steps can optometrists make in their busy schedules to seize those crucial moments when parents are on the fence about myopia management? Also, how does one go about breaking the news to parents and patients, and what may be some useful KPIs and deadlines practices can set themselves to lift prescribing rates for patients currently without a treatment?
Referencing the aforementioned study, ‘Global Trends in Myopia Management Attitudes and Strategies’1 by Prof James Wolffsohn et al., prominent Sydney practitioner and Optometry Australia national president Dr Margaret Lam says while Australian and New Zealand optometrists rated well globally, they still lag behind Asia and other countries in how often they prescribe better myopia management options.
“Unfortunately, despite the progress we have made, globally, the most commonly prescribed option for patients still remains single vision distance spectacles instead of many other better myopia management options such as orthokeratology, therapeutic medical therapy, myopia control spectacles and contact lenses,” she says.
“Interestingly, in contrast, the same study found that practitioners that embraced myopia control reported experiencing a lift from enhanced patient loyalty, increasing practice revenue and improved job satisfaction.”
Lam is a also member of the Childhood Myopia Working Group – a cross profession body of ANZ ophthalmologists and optometrists considered leading myopia experts. The group was established in 2018 to deliver a recommended Standard of Care describing the key elements to effective myopia management without prescribing exactly how or when to employ specific techniques.
She believes Australian and New Zealand optometrists fully appreciate the urgency of the situation. But behaviour change takes time, including acceptance of the problem, and experience to refine communications to parents.
“Yes, more can always be done, but we have come a long way from routine under-prescribing, distance only spectacles, and a lack of awareness of ‘myopia is simply a number’,” she says.
“I think consistency and persistence is the key. The behaviour change pathway is often a series of steps, those steps being, I think we have defined the need for change, defined our goals, we’ve motivated stakeholders to become engaged, and we have elements of a plan in place for better management for our patients. Now we have to manage this change collectively as a profession to lift standards to become consistent for myopia management prescribing, to set the stage for a better future more consistently with all of our patients.
“This journey just takes time and we are moving slowly and surely in the right direction. There will always be differences between individuals between early adopters, the middle of the pack and those that are more conservative. The more each practitioner can do their best influences the sum of the whole to change – and their colleagues also.”
Mr Joe Tanner, a registered optometrist and the head of professional affairs for CooperVision in Australia and New Zealand, also believes many optometrists understand the urgency. But for those who perhaps don’t, sometimes it can be down to not fully appreciating of the benefits of starting treatment at the earliest opportunity when the greatest savings in progression are possible.
Similarly, every dioptre increase significantly and irreversibly elevates the risks of vision-threatening complications in later life.
“The most cited barrier we hear from optometrists is parental resistance. Myopia management is not something with which many parents are familiar. They often need to be educated before a decision is possible. The treatments are usually more expensive than single-vision spectacles which can also be a hurdle. Experienced practitioners of myopia management have developed effective ways to educate and communicate with parents and children,” he says.
Image: fizkes/Shutterstock.com.
“I think the consequences of an increased prevalence of myopia are understood. What might be less well-appreciated is the projected increase in the proportion of high myopes from around 10% now to 20% by 2050.2 In other words, we could not only see a lot more myopes, but the average degree of myopia and the associated risks to vision could be significantly greater, too.”
In the first year of treatment, Tanner believes the “slow by 50%” rule of thumb can be misleading because this is derived from average progression rates over several years.
“In the first year, most effective treatments have an average effect of 60-70%. While every individual is different, published studies on various treatments show that dioptric progression is, on average, less than 0.28D in the first year3-6 which is less than some may expect. Greater progression than this in the first 12 months should give pause for thought,” he says.
Breaking the news
With that said, Lam believes the local industry has reached a critical mass in awareness. The next step is consistent prescribing when practitioners see a low degree of myopia rather than simply waiting for a high degree of myopia later down the track. As a result, this will help patients at all levels to manage their myopia well.
“Creating a system to manage recalls and giving patients good clinical evidence at every visit on clinically proven ways small changes in behaviour and lifestyle characteristics can help ensure patients are holistically looked after beyond just prescribing the bare minimum of stronger specs each time they visit,” she says.
A major part of this is the way a myopia diagnosis is communicated to parents and their children. Similarly, these interactions can be a ‘sliding doors’ moment for young myopes in their eye health and vision journey.
Lam says starting from a position of empathy and being factual about the child’s progress and what can be done to help is extremely effective. So can explaining the role of lifestyle factors and establishing a system where these tips are written down for patients to increase their retention and compliance.
“Having clear, good long-term discussions about management for your patient’s myopia really goes a long way to helping them understand the repercussions and make well informed decisions,” she says.
“From there, once you have created an aware and engaged parent, parents are open to listening to advice on better prescribing options and proactive lifestyle habits to reduce the rate of progression.”
If the parent is hesitant, Tanner says being ‘pushy’ is probably not a good idea and nor is overloading them with statistics.
“Simply asking the parent what would help them to decide can be useful,” he says. “The childmyopia.com and mykidsvision.org websites are excellent resources for parents who want to know more. Others might respond to more reassurance such as the optometrist stating that this is what they would recommend for their own child or loved one.
“While a myopia diagnosis in a child is not good news and parents need to understand that this creates a risk to vision, we also have a very positive story to tell and that may be more motivational.
“Rather than over-emphasising the potential serious consequences of progressive myopia to obtain a decision, explaining that we have the knowledge to make a significant reduction to the risks can help parents to make the right decision for their child. By agreeing to start treatment, the parent and child are taking control of the situation and they should feel good about that choice.”
Setting tangible goals
So, if an optometrist wants to be more engaged with myopia management, what may be some useful benchmarks and goals to work towards?
As a starting point, Tanner says all parents of myopes not already undertaking treatment could be given an information leaflet on arrival for an appointment and urged to read it before entering the consulting room. This could expedite the conversation that will follow with the optometrist.
On a strategic level, on the basis that many young myopes are seen annually, he suggests practices could set a simple target of ensuring all existing young myopes who need treatment will have had every opportunity to commence within a year. New young myopes should be urged to begin treatment immediately or at least within three to six months, assuming an early recall appointment, he says.
“If we could achieve this then, in a year or so, we should largely be dealing with new myopes only,” he adds. “Ideally, we should be examining many more children as they begin school and looking for the pre-myopes. Most adult patients know or have children and they should all be encouraged to bring them for testing. So, perhaps another measure is the number of examinations performed on young children each year.”
Considering what the industry knows about myopia, Tanner says few children born in Australia or New Zealand today should become high myopes. According to Holden et al.2, Australia and New Zealand are projected to have almost five million high myopes by 2050, around four times as many as now.
“But that assumes that we do not quickly and successfully implement evidence-based myopia management for all children needing it,” he says.
“Optometrists in Australia and New Zealand can make a huge change to the projected numbers of high myopes and, in doing so, help many more people to see well for a lifetime.”
More reading
Managing your practice’s myopia integration
Australian optometrists give status update on MiSight 1 day myopia control contact lens
Managing myopia in a public health setting in Australia
References
1.Wolffsohn JS, Whayeb Y, Logan NS, Weng R; International Myopia Institute Ambassador Group*. IMI-Global Trends in Myopia Management Attitudes and Strategies in Clinical Practice-2022 Update. Invest Ophthalmol Vis Sci. 2023 May 1;64(6):6.
2.Holden BA, Fricke TR, Wilson DA, et al. Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmology. 2016; 123: 1036–1042.
3.Chamberlain P et al. A 3-year Randomized Clinical Trial of MiSight Lenses for Myopia Control. Optom Vis Sci 2019;96:556–567
4.Lam CS, Tang WC, Lee PH, Zhang HY, Qi H, Hasegawa K, To CH. Myopia control effect of defocus incorporated multiple segments (DIMS) spectacle lens in Chinese children: results of a 3-year follow-up study. Br J Ophthalmol. 2022 Aug;106(8):1110-1114. doi: 10.1136/bjophthalmol-2020-317664. Epub 2021 Mar 17. PMID: 33731364; PMCID: PMC9340033.
5.Bao J, Yang A, Huang Y, Li X, Pan Y, Ding C, Lim EW, Zheng J, Spiegel DP, Drobe B, Lu F, Chen H. One-year myopia control efficacy of spectacle lenses with aspherical lenslets. Br J Ophthalmol. 2022 Aug;106(8):1171-1176. doi: 10.1136/bjophthalmol-2020-318367. Epub 2021 Apr 2. PMID: 33811039; PMCID: PMC9340037.
6.Yam JC, Jiang Y, Tang SM, Law AKP, Chan JJ, Wong E, Ko ST, Young AL, Tham CC, Chen LJ, Pang CP. Low-Concentration Atropine for Myopia Progression (LAMP) Study: A Randomized, Double-Blinded, Placebo-Controlled Trial of 0.05%, 0.025%, and 0.01% Atropine Eye Drops in Myopia Control. Ophthalmology. 2019 Jan;126(1):113-124. doi: 10.1016/j.ophtha.2018.05.029. Epub 2018 Jul 6. PMID: 30514630
