Take a more consultative approach to myopia

Issue: April 2018

ByMichael D. DePaolis, OD, FAAO

I recently had the privilege of presenting at our institution’s 63rd annual ophthalmic conference. A regional meeting with a rich history of exceptional continuing education, I knew this year would be no different. With a world-renowned faculty and topics running the gamut from OCT in neurodegenerative disease to manipulating corneal refractive index in refractive surgery to gene therapy in inherited retinal disease, I pondered how I could complement such a robust program. After much consideration – and some consternation – I decided on a topic. Myopia.

You may ask: What was he thinking? Few things in eye care are as cut-and-dry as myopia. It’s one of the first conditions we master in the early days of training. With defined symptoms, typical examination findings and prescribing habits that haven’t changed in a millennium, what more is there to say? Fully acknowledging the mundane nature of myopia, I entitled the presentation, “Should we be less myopic ... with respect to myopia?”

With more than 1.5 billion myopes globally, it is estimated this number will skyrocket to 5 billion in the next 30 years (Holden et al.). In the U.S. alone, the prevalence of adults with myopia has just about doubled over the past 30 years (Vitale et al.). And the cost to society in direct patient care as well as indirect loss of productivity in the U.S. is a staggering $200 billion a year (Fricke et al.). But most alarming is the sight-threatening impact of myopia, especially in those with higher levels of refractive error. Given myopia’s predisposition to peripheral retinal disease, early cataract, glaucoma and myopic macular degeneration, the risks are noteworthy, especially when one considers that each generation brings not only more myopes, but an ever-increasing prevalence of high myopia.

Our colleague, Noel A. Brennan, PhD, estimates that if we slow myopia’s progression by one-third, we could potentially reduce the number of high myopes by 73%. The obvious question is: How? As daunting of a task this might seem, taking a little less myopic view of myopia is undoubtedly the first step. Rather than merely pile on the minus year after year, perhaps it’s time we take a more consultative approach. We do it effectively with so many ocular disease states, why not with myopia? The challenge lies in scripting the perfect message for patients and parents.

While we don’t have all the answers, we still have plenty to offer. Discussing the importance of natural lighting and time outdoors is a good place to start. Likewise, providing guidance on digital device time and proper reading distance can be of benefit. With respect to spectacles, a progressive addition lens is a reasonable recommendation for the young myope with accommodative lag and esophoria. And overnight corneal reshaping gas-permeable lenses and center distance annular design multifocal soft lenses are compelling options for managing progression. Finally, atropine provides an attractive pharmacologic option. Granted, we’re still learning how to prioritize treatments, but we can initiate discussion and provide much-needed direction.

Optometry’s primary care role, geographic distribution and broad knowledge base make us a logical profession for taking the lead in many initiatives, such as annual diabetic eye exams and dry eye management. In this same vein, myopia progression management plays well to our professional strengths. Diagnosing, prescribing, managing progression and monitoring myopia’s ocular health sequelae are at the heart of what we do. While we won’t eradicate myopia, our efforts in slowing its progression are anything but mundane.

References:
Brennan NA. Contact Lens & Anterior Eye. 2012;doi.org/10.1016/j.clae.2012.08.046.
Fricke TR, et al. Bull World Health Organ. 2012;doi:10.2471/BLT.12.104034.
Holden BA, et al. Ophthalmology. 2016;doi:https://doi.org/10.1016/j.ophtha.2016.01.006.
Vitale S, et al. Arch Ophthalmology. 2009;doi:10.1001/archophthalmol.2009.303.