Feature, Report

Tools, training, time: The pillars to myopia care

With an expanding patient group, effective interventions and a strong research-base, the conditions are ripe for optometrists to make myopia management a serious part of their practice. RHIANNON BOWMAN finds out what it takes. 

The impending myopia epidemic is one eyecare professionals are contemplating with an equal level of trepidation and enthusiasm.

On the one hand, governments and the eyecare sector are bracing for potentially one of the largest modern-day public health problems that is predicted to impact half of the world’s population by 2050.

On the other, a greater understanding of the condition coupled with an expanding suite of effective treatments means optometrists are now better equipped to manage Australia’s 6.3 million myopes and prevent more serious problems later in adulthood.

As a result, an increasing number of eyecare professionals are considering how they can turn this opportunity into a clinical and business success for their practice.

However, a recent survey in Australia suggests there could be some way to go. In that study, the majority of local practitioners stated they often prescribed single‐vision distance spectacles for myopia correction in school‐aged children, despite an awareness of the potential effectiveness of contact lens interventions and atropine. In other findings, 20% of respondents considered the need to purchase additional clinical equipment as a key barrier to practising the subspecialty.

In light of these developments, established myopia practitioners explain the necessary treatments, equipment, training, and patient and practice management systems in order to effectively practise myopia control.

Pursuit of clinical excellence

At his practice, Harmony Vision Care on the Gold Coast (ProVision), optometrist Mr Paul Graham says as many as 70% of patients are under the age of 17. It is a paediatric practice by default, not design, due to the nature of its services.

He has been interested in myopia control from the outset of his professional career. At the time of starting the practice in 2003, he did so intentionally with a corneal topographer in order to prescribe orthokeratology (orthoK) and complex contact lens fittings.

“We were then one of the first practices to start trialling MiSight lenses from CooperVision,” he says.

For Graham, establishing a myopia clinic has always been less about a business decision, and more about the pursuit of clinical excellence. However, he notes with the removal of the Medicare fee cap, optometrists now have the autonomy to set their own fees for their expertise.

“I would encourage optometrists considering incorporating myopia management – or any area of expertise – to change their model of care to move away from a high-turnover retail focussed model and put greater emphasis on counselling and managing patients’ expectations over a number of years.

“That means explaining their condition, and making sure they understand, explaining their options and underlining why we are doing all this. Part of the secret to successfully incorporating myopia management in your practice is to give patients your time.”

For professionals considering myopia, Graham says they need to make a “solid decision to develop their expertise”. This may include completing relevant courses, attending conferences, and reading up on the subject.

Expertise with contact lens fitting broadens the scope of what a practice can offer.

“Don’t just rely on others’ interpretation. You need to form an opinion guided by your own interpretation of evidence-based research,” he says. “You need to invest in your own education and professional development because there’s two sides to understanding myopia: why it has developed, and how to manage its progression.

“If you’re confident in your expertise and your depth of knowledge, your patients will trust you and continue to seek your skills to treat and manage their condition.”

Graham says most practices are well-equipped to do some form of myopia management. The level of investment in equipment depends on the extent to which the professional wants to practise it.

For example, improving one’s knowledge and expertise with contact lens fitting increases the scope of what a practice can offer its patients.

“In my experience, a corneal topographer is a ‘must-have’ for managing myopia patients if you want to offer a full scope of services. An ocular biometer [to measure axial length] is a ‘nice-to-have’.

“I’ve been successfully managing myopia control in my patients without measuring axial length, but this piece of equipment will become more prevalent in optometry practices as it becomes less cost prohibitive. We recently added an OCT that does ocular biometry.”

When Graham diagnoses a new myopia patient, he informs them of the treatment options in detail and their long-term prognosis. He is not therapeutically endorsed, but still discusses atropine.

“The research on atropine dosages is not completely clear on the longer-term advantages over the results for managing myopia with orthoK and multifocal soft contact lenses. I refer our patients for atropine management based on a combination of the patient’s wishes and need.”

Make a start but give it time

It’s no secret effective myopia control can become an expensive undertaking for families. That’s why having a transparent conversation can help avoid future complications with patients and their parents.

“Letting patients know from the outset that there will be an out-of-pocket cost helps manage expectations,” Dr Pauline Kang, senior lecturer at the UNSW School of Optometry and Vision Science and coordinator of the Myopia Control Clinic, says.

“Optometrists can also utilise the Medicare Benefits Schedule where applicable, when the case meets the requirements of ‘progressive disorder’, as per MBS item number 10914.”

At the UNSW clinic, Kang says patients are provided with an information sheet informing them they’ll be charged for their appointment. For example, an orthoK lens fitting costs approximately $1300-$1400, depending on the lens design, she says, adding the clinic does not include an MBS rebate.

“We charge $150 annual myopia control fee. If the patient requires more frequent visits, to receive atropine drops for example, we charge an additional fee. A fee structure that is similar to an orthokeratology fitting annual fee may be suitable for general practice.”

According to Kang, myopia control management is a personalised service, with the patients seen more regularly – typically on a six-monthly basis to monitor progression.

“There is a shift towards prescribing soft multifocal contact lenses to treat myopia, but atropine is also a common treatment prescribed by therapeutically-endorsed optometrists,” Kang says.

“Not all treatments will work for all patients, you can’t predict what will work, it can be trial and error, so it’s important to manage patient expectations, and in difficult cases or for patients who are not responding to treatment, refer to an optometrist with more experience.”

The Zeiss IOLMaster is considered the gold standard biometer for axial length measurements in myopia patients.

To successfully incorporate myopia management into a practice, Kang agrees eyecare professionals need a strong knowledge base and understanding of current evidence-based treatment.

She says practitioners should be across current hypothesis of treatment options – and how they work – so they are well-placed to discuss treatment options and gaps in research, while remaining transparent with patients.

“For example, atropine is a popular treatment in practice, however, current clinical studies typically investigate treatment over a two-year period only, so we need research to support longer term treatment. The most effective concentration of atropine for myopia control is yet to be determined.”

Myopia research is continually evolving, she says, and it’s important for practitioners in the field to stay updated with current literature, including peer-reviewed published research, attending conferences and seminars and participating in online courses.

Investment in equipment is another integral element to effective myopia management. However, the cost of acquiring devices shouldn’t necessarily be considered a deal-breaker.

For example, Kang says an ocular biometer is a beneficial, but not essential, piece of equipment. “It is not enough just to measure refractive error of a myopia patient – which is why an ocular biometer is beneficial because it can measure the axial length of the eye.”

She adds: “They are expensive to purchase, typically upwards of $70,000. The gold-standard is the Zeiss IOLMaster but there are other more affordable products on the market.

“If you don’t have an ocular biometer, you can refer your patients to an ophthalmologist or clinics such as ours at UNSW for the axial measurements.”

Kang says a corneal topographer is a vital, yet versatile, piece of equipment for prescribing orthoK lenses and contact lenses in general.

“There’s a lot of corneal topographers on the market – you can purchase a stand-alone model but if you have limited space in your practice, you can buy a model that clips onto your slit lamp.”

Calculating Myopia

Clear communication about the importance of myopia management is arguably one of the most important aspects following a diagnosis.

To aid this process, BHVI has developed a myopia calculator to help eyecare professionals demonstrate the difference between treatment and non-treatment to patients and their parents.

“I am not exaggerating when I say it is the most widely used tool in myopia management in the world,” BHVI director of professional services Ms Pamela Capaldi says. “Thousands of eyecare professionals access this online-estimator each month to demonstrate to their patients and parents why myopia management is critical.

“The calculator provides a quick visual estimator for eyecare professionals and their staff to help explain to patients and parents the urgency for myopia management.”

While public awareness of myopia continues to trend in the right direction, Capaldi – who is based in the US – has identified a discrepancy in knowledge-base among practitioners.

To bridge this gap, BHVI launched its online Myopia Education Program, which is designed to provide the overarching knowledge necessary for aspiring myopia practitioners. More than 4,000 optometrists around the world have completed the program thus far.

The first single-module online course on managing myopia was introduced in 2017 and has since expanded to become a three-module program, with a fourth on staff training beginning last month.

The BHVI Myopia Calculator is said to be one of the most widely used tools for practitioners when communicating with patients.

“As more eyecare professionals recognise the growing need to service their increasing patient populations, they are seeking ways to gain knowledge to immediately incorporate their learnings into their daily practice,” Capaldi says.

“This can be a challenge when everyone is already so busy. As well, many have voiced the fact that they cannot find sequential, methodical courses that flow from A to Z to learn what is needed to get started.”

Capaldi says the full education program serves up six hours in each module and can be taken over a year’s time at the practitioner’s own pace.

“We are told often that one of the key advantages of online learning is that there is no need to pay conference fees, airfares, hotel and other expenses that come along when one travels for education.”

According to Capaldi, the first module, Managing Myopia, has been well received, with 98% of participants saying they immediately incorporated their learnings into practice. There is also a course dedicated to complex cases.

Once the foundation is laid, the Business of Myopia module is “a quick learn” that covers patient flow, communication, marketing and management. The fourth module, a four-hour myopia management training program for staff, was launched at the Vision Expo East in New York City on 25 March.

“One of the costs that is not normally thought of initially is that of training staff to be part of your myopia management team,” Capaldi explains.

“This can be a time-drain on a practice so we recommend self-instruction and then group discussion over staff training sessions.

“The Staff Training Course equips the team with a broad base to say and do the right things when parents and patients ask questions.”

From a business perspective, Capaldi says there are many ways eyecare practitioners can promote myopia management services to their community. Educating the practice’s patient base is a good starting point.

“Written newsletters, posts on your website and additional information to send home with parents and caregivers will open the discussion,” she says.

“Outreach to school nurses, childcare centres and other child-oriented service providers – again with an educational intent – will start to grow the word that there are new management methods to slow the progression of myopia.”

She adds: “The hope is that with patient awareness growing about the increasing incidence and risks of high myopia that patients will actually arrive to the practice asking for information on the latest management modalities for myopia management.

“The most important thing is to get started now. Take the next 10 myopes that sit behind your phoropter and begin offering to manage their progressive myopia on a proactive basis. There are many tools to get you started.”

Build your reputation

With about 10-15% of her patients being myopic children, Associate Professor Ann Webber, of Clarity Optometrists (ProVision), has a well-established clinical interest in paediatric optometry and has pursued extensive post-graduate qualifications and research in this field.

“With the accumulating evidence about treatment to slow myopia progression in children, we started to actively manage myopia in clinical practice about seven to eight years ago, including orthoK, low-dose atropine, and dual focus soft contact lenses,” she says.

“We’re a practice that aims to provide full-scope advice based on best evidence. The intent of offering treatment modalities was not to grow the practice but to prescribe to current evidence what would be in the patient’s best interests.”

According to Webber, myopia management builds the reputation of the practice. “There’s recognition of the expertise and knowledge of the practitioners in the practice, that then helps to build something that’s distinct about our practice compared to our commercial competitors.”

In terms of practice management, Webber says eyecare professionals need to be mindful of time management and patient flow.

“Cycloplegic [drops] as part of the refractive error determination is important in both myopic and hyperopic children, so you need to think about how you’re going to schedule patients so that you can incorporate including cycloplegic [drops] as part of your consultation.

“Good retinoscopy skills, and binocular vision assessment skills on children are essential. An ocular biometer [to measure axial length] is an incredibly useful piece of equipment and really establishes to the patient’s parent that myopia is related to structure, and helps in the education of parents about what the underlying aetiology is of myopia.

“It helps parents to understand the optics of the visual system that we’re correcting with glasses or contact lenses.”

Practitioners also need to be aware there are significant costs for families with all the treatment modalities.

“For patients from low socio-economic families who can’t afford the cost of contact lenses or atropine drops, bifocal lenses are a cost-effective solution,” Webber says, adding that a new spectacle lens designs are in the pipeline.

“For practitioners, aim to keep abreast of the emerging literature in this rapidly evolving area, and consider how to translate that into practice for your patients, but be pragmatic. Your patient wants your professional advice regarding which treatment option would best suit their individual presentation and risk for progression.”

Positive impact

Bayside Eyecare in Melbourne which is also part of ProVision, was also one of the first to trial CooperVision’s MiSight lens when it was released in Australia in November 2016.

Practice owner Ms Rebecca Jamieson was also part of BHVI’s pilot myopia management course in 2017.

“The course was a brilliant entry into understanding myopia management. In the not-too-distant future, this will be the gold-standardof care,” she says.

“It is our duty of care as optometrists to offer our patients best practice care for all eye conditions. There is extensive evidence from research that shows that myopia control strategies slow myopic progression and so we should be offering this to our young myopes”.

For Jamieson, as a behavioural optometrist, myopia management has always been an ideal fit. “Namely, preventive eyecare management, and providing patients remediation.”

However, like other eyecare professionals in the field, it is the positive impact of her work that she finds most rewarding. 

“I had a nine-year-old South East Asian myopia patient in last week, and both his parents are myopic.

“It’s satisfying seeing a child who could potentially follow in their parent’s footsteps down the path of myopia progression and the risks associated with that including risk of retinal detachment, not progressing, and parents are happy. It’s rewarding, and the impact on your patient’s lives as they grow into adults – you’re positively impacting on their lives.”