Roundtable focuses on treatment, education in pediatric myopia
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As the myopia epidemic continues to expand and affect children, management of the condition remains a source of discussion among ophthalmologists.
Led by Section Editor Robert S. Gold, MD, OSN Pediatrics/Strabismus Board Members discussed the importance of myopia education, treatment options and challenges at the American Association for Pediatric Ophthalmology and Strabismus meeting in Scottsdale, Arizona.
Source: Courtney L. Kraus, MD
Robert S. Gold, MD: Myopia management for pediatric ophthalmology is at the forefront of what we do each and every day in our practices. What are your standards of care? I would like to know who you are prescribing atropine to, who you are prescribing contact lenses to, what kind of contact lenses you are prescribing and who is receiving surgical management.
Roundtable Participants
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Moderator
- Robert S. Gold
- Douglas R. Fredrick
- Courtney L. Kraus
- Erin D. Stahl
- Rudolph S. Wagner
Douglas R. Fredrick, MD, FAAP: The general public is aware of the issue of the increasing prevalence of myopia, not just in the U.S. but around the world. This is not something that we have to educate our patients about. They come in already knowing the issue. This is particularly true in patients of either East Asian or South Asian background. For those of us who practice in areas where a high percentage of the population is from those racial ethnic backgrounds, the parents will come in worried about myopia because it has been a problem in East Asia and South Asia for years.
Usually, the first question parents have is, “What in the environment can they change about how their children are using their eyes?” You know this is not going to be a quick visit when they come in. In the past, refractions were the easiest thing we did, but now it becomes a long conversation.
It comes down to how I manage the question, “Who do I think is an appropriate patient for myopia control?” It starts with a history, and oftentimes there will be a family history of high myopia, with a grandparent or a parent having a history of retinal detachment or myopic macular degeneration.
Then, it is important to examine the child and determine their level of myopia and the rate of progression. It is uncommon that I will start myopia control therapy on the first visit. I will ask about the family history and the child’s habits as far as how much screen time they are having. I will reference the American Academy of Pediatrics and talk about the importance of minimizing screentime for children in the first 2 years of life. The American Academy of Pediatrics says zero screentime if the child is younger than 2 years and then limiting the amount of screentime in older children.
When I see the child for the first time, I will often get their cycloplegic refraction and axial length, which I use to monitor progression. We tell parents that children who are progressing faster than 0.5 D a year would be good candidates for myopia control therapy, especially if they have high risk factors. Then I will see them again in 6 months. If they have already progressed 0.5 D or 0.75 D, I will offer myopia control therapy, and it comes down to atropine vs. soft contact lenses. I do not recommend orthokeratology in my practice. With atropine, my protocol is to start with 0.05%, and we will see them again in 3 months after initiation of therapy for another axial length. I want to stop the progression.
Then, we see them every 6 months for as long as they are on atropine therapy. If they have been stable for two consecutive visits, I will lower the dose from 0.05% to 0.025% with the hope of getting down to 0.01%. My rationale for that is that I do not want to miss half a year or a year on low-dose therapy when they may go up another 1 D.
I usually try to reserve soft contact lenses for older children.
Erin D. Stahl, MD: Our ophthalmologists do not do anything with myopia control. We do not see any routine myopic patients, but within our optometry group, we do have two practitioners who focus on myopia control and offer a similar protocol as Dr. Fredrick.
Gold: Are you having any issues with the percentage of atropine that you are initially prescribing?
Fredrick: When I was in California where I had more East and South Asian patients with darker irises, I had no problem. Now that I am in the Northwest where there are more fair-skinned children, I do find a little more complaint, not of blur, but of photophobia. I make patients aware of it, and usually I try to have them power through it.
Gold: Does anyone else start with 0.05%?
Courtney L. Kraus, MD: I usually start at 0.01% and titrate upward, unless the patient has dark irides or is South Asian or Asian with highly myopic parents. Then I start at 0.05%, but for most of my light-eyed patients, I start at 0.01% and titrate up.
Gold: What is your follow-up?
Kraus: I see them at 6 months unless the parents strongly desire closer follow-up. Then I do a 3-month check-in. I agree that these patients require a lot of chair time. Generally, parents come to you with ideas about what types of treatment plans they may want for their child. They may have already, at least in my area, done some background reading about near time and screentime and have lots of questions about that. Sometimes they want a 3-month check-in, but most patients and I are happy with 6-month check-in.
Gold: The compounding of the medication: Is it something you are doing in-house, or are you using commercial compounding companies? Are you finding financial issues with parents in that type of situation?
Fredrick: We are an eye institute and we do not compound, so we use licensed compounding pharmacies. They are reasonable in price. People who want to engage with myopic control do not seem to have any issue with paying for the medication. Our issue more is our provider’s license and the ability of an out-of-state pharmacy to dispense within our state.
Like Dr. Stahl said, once we initiate myopic control, it is all in the hands of the optometrist. For example, in Oregon, the most reliable pharmacy provider in the Northwest is in Washington. So, we have all of our optometrists licensed in Washington so that they can do the prescribing, and we do not have to cosign their prescriptions. When we were in New York, we used a company that was in Virginia. There is also a reliable pharmacy in Hawaii that provides excellent service, but they may not be allowed to dispense in your state.
It took a lot of effort to get everybody to sign off on [a myopia management package]. An example is the code for the A-scan. Normally you get an A-scan, and there is a professional technical component, and it is not a small number. So, we got our coding/finance people to create a separate code, and it is at lower price. That is baked into the whole package deal. We trained our orthoptists to do axial length measurements, so our photographers and ultrasonographers who normally do the IOL calculations do not have to be involved.
Rudolph S. Wagner, MD: I agree with Dr. Fredrick’s management as far as who I want to treat and how I want to treat. I like the idea of having protocols because it is important for caregivers to understand the therapy. Most of the people who I treat come to inquire about reducing the progression of myopia.
For dosing, I was starting at 0.01% and then I had a mother come in who was educated on this treatment and say, “Do you think you should start with 0.05%?” I agreed in this case.
I have had a few patients with compulsive parents who I am sure are getting those drops in every day who have complained about light sensitivity and a couple who I have had to reduce the prescription because of overdilation of the pupils and blurred vision at near. I do not think that the cost is as much of an issue for this group of patients either because they know what they want, and they understand the treatment. I have not gone out and tried to recruit people who did not bring it up initially. I think that is an interesting idea because that would be where you would have to finesse this a little bit more and have this information available so they can make a decision on it and whether they want to go for the cost of that. Protocols would be useful in these situations.
Have any of you had that experience where you were the first one to bring it up to a person who never heard anything about it and then wanted to explore it?
Gold: A lot of times, we are the first doctor to tell the patients and their families about this. I would estimate 25% come in with a predisposed opinion. They have heard it, they have read about it, they have read about the contacts — more the contacts than the drops in my practice.
I do something similar to Dr. Fredrick, in which my first visit with them is to try to start educating them with the family history. If they have come in and they have glasses already and they have started to progress 0.5 D in a year, I am not going to wait a year. I am going to see them again in 6 months. We possibly can use eye drops at that point.
I then start to mention contact lenses based on their age, but I do think it is an education process. In my practice, I do not like to say on the first visit, “Here’s your prescription to the compounding pharmacy for atropine. I’ll see you in 3 to 6 months.”
I have come around to be more aggressive to start discussing it more, and I think it is intriguing as a business practice to come up with a protocol with this type of package. In our area in Florida, the optometrists have a package that costs a lot of money that I suspect many cannot afford. We have not done that yet in our practice, but it is an intriguing idea.
I have not personally tried multifocal contacts, but I do know that is also on the armamentarium.
When I tell the parents that their children are going to have to be on eye drops for that long a period of time, their eyes open up so wide. Then they are looking at the child, and the child looks at you and says, “I don’t want eye drops every day for the next several years.” The compliance issue is certainly real.
Fredrick: One more comment about the stronger dose. I have used atropine for a long time. Before low doses came around, I was using 1% with photochromic and progressive lenses, so I know 1% worked. When somebody comes in complaining about photophobia, I say, “I’m glad you’re noticing the difference because that means the medicine is working.” If they cannot tolerate a higher percentage, I definitely drop it down, but a lot of time, with a little encouragement, they will get used to it. In Portland, Oregon, it is gray from October until April, so it is not going to be as big a problem as it is in Florida where you have blue skies year-round.
- For more information:
- Douglas R. Fredrick, MD, can be reached at Casey Eye Institute/Oregon Health & Science University, 545 SW Campus Drive, Portland, OR 97239; email: fredricd@ohsu.edu.
- Robert S. Gold, MD, can be reached at 790 Concourse Parkway South, Suite 200, Maitland, FL 32751; email: rsgeye@gmail.com.
- Courtney L. Kraus, MD, can be reached at Wilmer Eye Institute, 615 N. Wolfe St., Wilmer 230, Baltimore, MD 21205 email: ckraus6@jhmi.edu.
- Erin D. Stahl, MD, can be reached at Children’s Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64108; email: edstahl@cmh.edu.
- Rudolph S. Wagner, MD, can be reached at Doctors Office Center, Suite 6100, P.O. Box 1709, Newark, NJ 07101; email: wagdoc@comcast.net.
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