Myopia Management: Implementing an evidence-based Standard of Care

At the completion of this article, readers should be confident of the steps required to implement and monitor myopia management strategies for patients and their families. Including:

• An understanding of how low levels of outdoor activity affect myopia
• An understanding of the Australia and New Zealand Child Myopia Working Group recommended Standard of Care for myopia management
• Knowledge of the key elements of a myopia management plan, and how to implement them
• Knowledge of the key elements of an informed myopia referral

The recommended best practice Standard of Care from the Australia and New Zealand Child Myopia Working Group outlines the steps to prevent, manage and reduce the impact of myopia. Scientia Professor Fiona Stapleton says the six-step model will help practitioners have informed discussions with parents to ensure every patient receives the best management option.

Scientia Professor Fiona Stapleton
BSc MSc FCOptom PhD FTSE
Head, Eye Research Group, School of Optometry and Vision Science
UNSW, Sydney, Australia
Chair of the Child Myopia Working Group

The understanding of myopia and myopia management continues to advance, with the latest evidence and data continually informing best practice. However, since 2018 and the release of the first Australia and New Zealand Child Myopia Report, we have witnessed a shift in trends, awareness and understanding of myopia.¹

What has changed?

Few of us would have predicted a global pandemic in that time. The COVID-19 pandemic has had a significant impact on the progression of child myopia in those populations who endured extended lockdowns, bringing the issue to the attention of a wider audience than ever before. 

Myopia prevalence rose significantly in young school children during the COVID-19 pandemic. According to one large Chinese study, prevalence increased almost 400 per cent in six- year-olds.² This substantial myopic shift (approximately −0.30 dioptres) has not been seen in any other year-to-year comparison, making the cause possibly due to the unusual concurrence of home confinement, online schooling and increased use of digital devices in 2020. 

Researchers also hypothesised that the impact was greater for younger children, those aged six to eight years old, as they are more sensitive to environmental change, given they are in an important life stage for the development of myopia. The findings of this research have global implications; children have completed months of home and online schooling during the pandemic, including in Australia and New Zealand where schools were closed and sports cancelled. 

Environmental insights 

The evidence of the protective effect of time outdoors, on myopia, continues to grow. Low levels of outdoor activity may influence the development of myopia,³ so balancing screen time with green time for children is imperative. Spending time outdoors, with or without requiring physical activity or direct sunlight exposure, appears to have a protective effect against myopia onset.⁴

According to Optometry Australia, children need to spend at least 90 minutes per day outside to help prevent myopia from developing and progressing.⁵ Ethnic and geographical differences in terms of myopia prevalence also need to be acknowledged as influencing factors, as does the urban or rural environment in which an individual resides.⁶

It is estimated that children living in predominantly urban environments have 2.6 times greater chance of developing myopia than those living in rural environments.⁷ Regions that have undergone rapid economic transition, south and east Asia for example, have also experienced a rapid rise in rates of myopia.⁷ 

The challenges reported above and reported impact on myopia during the pandemic, provide the evidence for changing how myopia is managed with intervention starting as soon as possible.

For Australia and New Zealand, the forecast rate of myopia by 2050 is projected to be 55%. Currently 36% of the population is estimated to be affected by myopia.⁸ Furthermore, Australia is expected to have 4.1 million high myopes and New Zealand over 600,000 high myopes by 2050, unless myopia management is widely implemented. 

These forecasts (from 2016) highlight the scale of the problem that is facing the eyecare profession given Australia in 2020 had an estimated 1.1 million, and New Zealand more than 200,000, high myopes.⁸

What needs to be done?

It’s vital that eyecare professionals have an agreed-upon, updated Standard of Care that reflects the recent evidence. It’s equally important to ensure that this information is widely disseminated. Myopia management must move from a service offered by a minority of eyecare practitioners to being universally available. 

The Standard of Care offers accessible strategies for practitioners to work comfortably within their competency. Only with widespread uptake, will the full public health benefits of reducing the prevalence and impact of myopia be achieved. 

The Australia and New Zealand Child Myopia Working Group recommended Standard of Care for myopia management

For the practice setting, it is recommended that the following key elements should be included when managing a patient’s myopia: 

1. Use a myopia management program for patients with pre-myopia or myopia based on the best available evidence.

How: Understand the current research and literature available on myopia management to inform the chosen model of Standard of Care for your clinic and best protocol for management. Your myopia management program should support the vision and values within your practice.

2. Explain to patients and their parents or carers what myopia is and discuss the increased risks to long term ocular health associated with myopia.

How: Often visual cues such as an eye model or an online resource like the myopia vision simulator (https://www.childmyopia.com/vision-simulator-tool/) can help. Provide parents with take home educational material so they can refer to it out of the practice setting and can ask questions at the time or later.

Taking time to explain myopia carefully and address any concerns or worries will help enlist the patient and their family to support your recommended myopia management program. They need to be more than just ‘compliant,’ ideally, they are equal and active participants in the management and feel empowered in the treatment plan you have recommended.

Seek help with education resources for families of all types, (split families, for example, where parents have different views about the treatment of their child). Myopia educational material is also readily available in a range of languages.

Patient and parent education needs to include the broader impact of myopia, where increasing myopia means more than thicker glasses. It could mean more issues such as progression to high myopia and potentially serious eye health problems in the future, including myopic maculopathy, glaucoma, cataract and retinal detachment. These eye conditions can all potentially lead to reduced vision at best and blindness at worst.⁹

3. Discuss, formulate, and implement an agreed management plan with the parent or carer and patient (child), including a discussion of the evidence-based available myopia management options to mitigate axial length elongation; the risks (lifestyle and family history) of myopia progression; the provision of verbal and written information describing the risks and benefits of treatment. Consider the use of consent forms, duration of treatment, review frequency, when to cease treatment and rebound effects.

How: The following management options all have a role to combat child myopia to maintain better eye health: 

• Certain soft contact lenses featuring a special optical design which are worn during the day. 

• Orthokeratology (orthoK) contact lenses which reshape the front surface of the eye during overnight wear and are then removed during daytime. Usually, this modality corrects myopia during the day after lens removal, as well as reducing progression.

• Certain spectacle lenses featuring an optical design developed especially for myopia management. 

• Low-dose unpreserved atropine eyedrops, of varying concentrations, which are usually instilled at night before bed. 

Discuss the evidence supporting each option with the parents or carers and determine what may suit the patient best. Build in a discussion around the risks and duration of treatment and any potential rebound effects. Also address the cost of each management option as it will play a role in the decision-making process.

Adopt an approach that would entail a discussion about lifestyle with less near-work and increased time in natural light.

4. Document a review/recall for patients with myopia that demonstrate progression.

How: If axial length measurement is not available, using cycloplegic refraction to measure dioptric change over time to assess speed of myopia progression. Studies in both Caucasian and Asian populations generally define fast progression of myopia in children as more than half a dioptre (0.2 mm change in axial length) per year.^{10, 11} A recent evaluation of progression in the CLEERE study however has suggested that progression history may not be the best indicator of future progression.¹² 

Monitoring myopia progression should occur regularly, and the effectiveness of treatment evaluated at regular visits throughout the school years. Depending upon the profile of the patient (age, ethnicity, if parents are myopic etc), you may recommend three- to six-monthly visits to monitor progression.

Continue the discussion about lifestyle with less near work, increased time in natural light at every review and monitor for change. 

5. Monitor the impact of treatment.

How: If a patient’s myopia is significantly progressing, consider if the patient needs myopia management services that your practice cannot provide. Axial length measurement is the gold standard for assessing myopia progression.

Where change in axial length and refraction do not match, other causes of myopia progression or systemic causes should be considered.

Be open with patients and their family and ensure they know they can report any adverse effects of a myopia management treatment (for example glare or blur) and intervene earlier if they feel that there is a significant problem. 

6. Recognise personal limitations and refer patients to a suitable optometrist or ophthalmologist if the required myopia management services cannot be provided.

How: Write an informed referral to the optometrist or ophthalmologist as required.

To optimise patient outcome, share the following information in the referral:

• Age and ethnicity of the child

• Patient history – visual, ocular and general health history (history of retinopathy of prematurity, collagen diseases, systemic syndromes); developmental and family history; use of medications and medication allergies; visual requirements; lifestyle and hobbies

• Visual acuity and unaided vision

• Cycloplegic refraction, axial length information, if available, and change over time

• Binocular vision and accommodation examination and treatment history

• Diagnosis – for example: simple myopia, pre-myopia, degenerative myopia

• Prior myopia management history and response to treatment including adverse events

• Anterior and posterior ocular health assessment

For shared care arrangements, clear protocols should be in place and agreed to.

A myopia management Standard of Care is critical, given that each year of delay in developing myopia substantially reduces the chance of a child developing high myopia in adulthood.¹³ 

Reducing the prevalence and impact of myopia

Good vision is essential for a child’s learning and development. With 80% of classroom learning being visual,¹⁴ early detection, especially in children with a strong family history of myopia and especially a family history of high myopia, is critically important. Early detection supports not only the educational development of a child but also their social, behavioural and physical development. There is therefore an urgent need for a greater focus on preventing and managing myopia and increasing awareness of the importance of children having regular eye examinations. Only by encouraging parents and carers to establish regular and ongoing eye examinations for their children, can we identify the early signs of myopia, work to delay onset, and slow progression. 

Expected increases in myopia prevalence are likely to cause increased future public health and economic problems unless action is taken using evidence-based approaches to prevent, delay and manage the condition. 

Understanding the economic burden of vision impairment associated with myopia is therefore critical to addressing myopia as an increasingly prevalent public health problem. For example, the potential productivity loss associated with vision impairment and blindness resulting from uncorrected myopia is substantially greater than the cost of correcting myopia.¹⁵ 

Recent evidence also reveals that the prevalence of high myopia is growing at a faster rate than the prevalence of overall myopia.¹⁶ 

Advances since 2018 however should be recognised. The establishment of the Child Myopia Working Group has enabled the development of an industry-wide recommended best practice Standard of Care for managing myopia and has driven much-needed awareness among Australian and New Zealand families. Technological advances are also paving the way for more effective options for managing myopia. But work needs to continue. 

Adopting the new Standard of Care is critical to moving myopia management to a service offered by a wide range of eyecare practitioners. Only then will the full public health benefits of reducing the prevalence and impact of myopia be achievable.  

To download a copy of The Australia and New Zealand Child Myopia Report 2022/23 – Reducing the Risk to Vision, visit
www.childmyopia.com

More reading

Management of high myopia

Managing myopia with spectacle lenses

Is two better than one? Combining treatments for myopia control

References

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