In the past few decades, optometrists have sought new ways to continue to evolve the practice of optometry. These evolutions include, but are not limited to, a “medical model of optometry,” dry eye centers of excellence, specialty lens clinics, and so much more. Among these new and important trends, myopia management ranks high due to the life-long risks that accompany myopia. Managing myopia can be, for some, an exciting proposition. For others, it could seem like an overwhelming responsibility.
Here, we provide something of a starter’s kit — but hopefully one that even skilled myopia management experts can benefit from.
Start With “Why”
Before you begin managing myopia, consider the topic of Simon Simek’s Ted Talk: “Start With Why.”1 Why is myopia management becoming such a big focus in the profession? The first factor to consider is that the prevalence of myopia is increasing rapidly. According to a 2016 study, in the year 2000, 22.9% of the world’s population was myopic and 2.7% were highly myopic (>5.00 D).2 The study authors predict that by 2050, 49.8% of the world will be myopic and 9.8% will be highly myopic.
Since this study was published, the COVID-19 pandemic has significantly changed visual demands. Now that everyone from adults to young children are more dependent on online communications, and the near work visual demands associated with them, these previous estimates may actually be underestimating the problem. Another study published in 2021 suggests that the prevalence of myopia in children in China “increased 1.4 to 3 times in 2020 compared with the previous 5 years.”3 This rapid shift is presumed to be the result of the home confinement that occurred during the height of the pandemic. With the increasing prevalence of myopia, our eye care system will be further challenged by the ocular complications and vision loss associated with myopia. Research published in Optometry and Vision Science reveals that “a 1 D increase in myopia is associated with a 67% increase in the prevalence of myopic maculopathy.”4 Restated, slowing myopia by 1 D should reduce the likelihood of a patient developing myopic maculopathy by 40%.4 However, myopic maculopathy is not the only concern. Myopia is also associated with increased risks for glaucoma, retinal detachments, and early onset cataracts.
Tools of Treatment
Luckily, no large initial equipment investment is required to manage myopia other than the instruments required for routine eye care. The first necessity is a corneal topographer, as topographers are essential for fitting orthokeratology (ortho-k) lenses. Two major types of topographers exist: placido disk and corneal tomography instruments. Placido disk topographers function by projecting concentric rings on the cornea. This creates light reflection off the tear film-air interface, similar to a mirror. The pattern of light reflection reveals the shape of the anterior corneal surface. Corneal tomography uses Scheimpflug imaging, which uses a rotating camera to photograph corneal cross-sections illuminated by slit beams at different angles. This allows the device to measure both the posterior and anterior surface of the cornea while providing additional data, such as corneal thickness. For most doctors, a placido disk topographer will work best for myopia management and ortho-k evaluations. Placido disc topography is cost-efficient, and it provides an option to use ortho-k fitting software. Corneal tomography, however, can be beneficial for monitoring corneal disease progression, such as keratoconus.
The next essential piece of equipment is a machine capable of measuring axial length. Axial length measurements are quickly becoming the standard of care in myopia management. Growth charts have also become a useful tool for monitoring myopia progression, and are most effective when they include refractive error and axial length data points. Can clinicians manage myopia without measuring axial length? Absolutely. However, axial length measurements may eventually become necessary to demonstrate optometric expertise. Using axial length measurement data for myopia control is analogous to using optical coherence tomography (OCT) for glaucoma management. When OCT was first introduced in the early 2000s, many doctors, myself included, relied on intraocular pressure (IOP), visual fields, and optic nerve photos to monitor glaucoma progression. While we were able to treat glaucoma without the use of OCT, most clinicians would agree that OCT has now become the standard of care in glaucoma management. Likewise, I believe that axial length will become the standard of care in myopia management.
Axial length measurements can be derived using either interferometry or ultrasound devices. Ultrasound devices are generally less expensive, but have limitations with respect to myopia management and require the use of anesthetic drops. According to 1 study, ultrasonography has a resolution of about 0.30D, whereas interferometry measurements have a resolution of around 0.03D.5
One of the most difficult parts of initiating myopia management is learning how to screen for candidates who would benefit from treatment or close observation. When I first started managing myopia in 2014, most of the patients I treated were already at -3.00 D or worse. As I became more comfortable with my expertise, and as more studies showed the benefits of early treatment, I shifted my approach. This also changed how I discuss myopia progression with parents. For a child who is not wearing glasses or is already diagnosed with myopia, we use a simple chart that we have available in each exam room (Table 1).
This chart allows optometrists and technicians to easily and quickly determine whether the child is at risk for developing progressive myopia. If a child’s eyes are less hyperopic than expected for their age and has other significant risk factors, a lifestyle change discussion is necessary. This also gives us the opportunity to stress the importance of close monitoring.
For patients with risk factors that warrant observation alone, we recommend returning to our clinic every 6 months to measure refractive error and axial length. Frequently monitoring patients that are most at risk for progression is important, as it allows us the ability to establish progression earlier than yearly exams would, thus leading to better treatment outcomes.
For a child who is already nearsighted but has not started myopia management, we use Table 2 to determine who may need to start treatment.
Having this chart easily accessible in exam rooms allows us to very quickly determine who is showing progression and would benefit from treatment initiation.
How to Have “The Talk”
When we determine that a child has a high risk of myopia or needs treatment for progressive myopia, we then need to communicate this concern to their parents. Unfortunately, doctors have led the public to believe that myopia is not only normal, but that progression is normal as well. This message, which has been consistent for decades, needs to change immediately.
When I discuss myopia or myopia management with a parent, I start by explaining it as a disorder involving blurred vision at a distance. I then discuss some solutions for their child’s symptoms such as traditional eyeglasses, contact lenses, and the potential for future refractive surgery. I make it a point to explain the anatomical changes that occur within the eyeball as a result of axial lengthening over time. I believe it is critical to stress that as their child’s eye continues to lengthen, there is additional strain on the eye structures, such as the retina.
I often apply principles from the book, Secrets of Question Based Selling by Tom Freese to better convey the importance of myopia management. The book emphasizes human motivation for achieving a particular task. For example, the author states that some people run their fastest to win gold medals (desire to obtain positive rewards), while others run at top speed only when chased by German Shepherds (fear of negative consequences).6 It is important to ask each parent basic questions pertaining to their child’s worsening myopia to determine their motivation for treatment. Clinicians must also convey the importance of treating the condition, not just the symptom, of blurred vision.
I always begin myopia conversations by asking the parent’s permission to discuss myopia management. This is important, as it lets them control the conversation. Once permission is given, I ask if they would like their child to have the option to function without glasses, or if they would consider refractive surgery, such as LASIK, in the future. I then discuss the risk of significant eye disease associated with worsening myopia. I find it beneficial to state some specific repercussions of myopic progression including retinal detachment, glaucoma, and myopic macular degeneration, to convey the long-term consequences of myopia. By asking specific questions, I am able to determine if the parents are driven by positive rewards (freedom for LASIK correction), or if they are more motivated by negative consequences (increased disease risk). If you can determine parental motivation, you can specifically discuss how myopia management will benefit what matters most to that parent.
Choosing A Treatment
Once you have a parent who elects to manage their child’s myopia, how do you decide which treatment to start with? I start by considering each of the available treatments in the US (orthokeratology, soft multifocals, and low dose atropine) and assessing each child based on refractive error, age, maturity, and parental goals.
Ortho-k is my first choice if the patient’s prescription falls between -2.00 to -6.00 D, with less than 1.00 D of astigmatism, and they do not have unusually flat corneas. I have had success with orthokeratology patients as young as 6 years when they have proven to be mature with highly motivated parents. The reason for choosing ortho-k first is twofold. It allows the clinician to customize the amount of hyperopic defocus in the periphery and also provides the visual benefit of eliminating dependence upon glasses and contact lenses.
If a patient has flat corneas, or fails to meet the previously mentioned prescription parameters, I opt for soft multifocal contacts. There are 2 daily disposable options with center distance and peripheral plus/near optics: MiSight® (CooperVision) has FDA approval up to -6.00 D for children ages 8 to 12 years, and Naturalvue® (Visioneering Technologies, Inc.) is available up to -20.00 D.
The third treatment option for myopia management is low dose atropine. I generally use this for children who are too young or unwilling to wear contacts, or those with high astigmatism. Low dose atropine must be made at a compounding pharmacy. The most commonly accepted dosages are 0.01%, 0.025%, and 0.05%. I have used all 3 doses in my career, but based on the 3-year data from the LAMP Study, I prefer starting with 0.05% especially on younger children or rapidly progressing patients.7
Begin Myopia Management Today
A potential future option will involve spectacle lenses specially designed to curb progression. This technology is not yet available in practice, but the research around these tools is exciting and could offer a noninvasive approach to halting the disease early.
As those new devices and approaches become available, they will further clarify what optometrists already know: The era of accepting myopia as a condition that patients simply must live with has come to a close. Patients should not have to navigate myopia’s effect on their vision or their quality of life. Optometry has more to offer patients, especially children, than refractive correction. To practice at that level, optometrists must take advantage of the technological developments and the opportunities they provide.
1. Sinek S. Start with why–how great leaders inspire action. [Video]. YouTube. https://www.youtube.com/watch?v=u4ZoJKF_VuA. Published September 28, 2009. Accessed April 27, 2022.
2. Holden BA, Fricke TR, Wilson DA, et al. Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmol. 2016;123(5):1036-1042. doi:10.1016/j.ophtha.2016.01.006
3. Wang J, Li Y, Musch DC, et al. Progression of myopia in school-aged children after COVID-19 home confinement. JAMA Ophthalmol. 2021;139(3):293-300. doi:10.1001/jamaophthalmol.2020.6239
4. Bullimore MA, Brennan NA. Myopia control: why each diopter matters. Optom Vis Sci. 2019;96(6):463-465. doi:10.1097/OPX.0000000000001367
5. Wolffsohn JS, Kollbaum PS, Berntsen DA, et al. IMI – Clinical myopia control trials and instrumentation report. Invest Ophthalmol Vis Sci. 2019;60(3):M132-M160. doi:10.1167/iovs.18-25955
6. Freese T. Secrets of question based selling: how the most powerful tool in business can double your sales results. Sourcebooks;2013.7. Yam JC, Jiang Y, Tang S-M, et al. 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. Ophthalmol. 2019;126(1):113-124. doi:10.1016/j.ophtha.2018.05.029