BLOG: Myopia management reimagined
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There has been a lot of buzz recently around the new optometry subspecialty of myopia management.
I consulted my good friend and highly respected clinician, Jeff Kegarise, OD, and together we have a few thoughts — and perhaps a reality check — on this topic.
Although eye care providers have noted a trend in the stabilization of myopia with hard lenses, the use of bifocals in children and even the use of atropine, the rationale for myopia control has been largely anecdotal. The first evidence-based study was not until 2002, and that small study found no effect from bifocals, soft lenses or atropine (Wolffsohn et al).
Around this time, I started using Paragon CRT lenses after the lens system received FDA approval for overnight wear in June 2002. Although I did not initially fit these lenses for myopia control, several well-designed studies showed that overnight orthokeratology was effective in reducing the progression of myopia (Chen et al). Much of this work was done in Asia, and many Asian parents brought their young children to see me for myopia control.
The financial model was fairly simple: We charged a healthy initial fitting fee, the lenses were reasonably priced and we monitored patients over time with annual follow-up fees and periodic lens replacements.
The complexity of the fitting and patient management for ortho-K limited the use of these lenses to those of us who fit specialty gas-permeable contacts.
In subsequent years, many reports confirmed the efficacy of overnight GP lens wear, pharmacologic atropine in various concentrations and center-distance soft multifocal contact lenses in slowing axial elongation and reducing myopic progression (Cooper et al).
A change in the ‘playing field’
In 2019, CooperVision received FDA approval for the MiSight lens, which the agency described as the “first contact lens indicated to slow the progression of myopia (nearsightedness) in children between the ages of 8 and 12 years old at the initiation of treatment.” This changed the playing field. This single-use, daily disposable lens could be prescribed by anybody licensed to fit soft contact lenses. Unlike ortho-K lenses that are only worn during sleep, MiSight treatment requires the patient to wear the lenses for all waking hours. Families will incur the costs of daily disposable lenses as well as annual fitting and follow-up fees during the child’s growth years.
A child who is diagnosed as a myope at age 8 years will need to wear these specialized daily disposable soft lenses full time until they are roughly aged 21 years, or when the provider feels that eye growth has stopped. The per-lens cost is about 50% higher than a comparable soft daily disposable lens, and at the end of the treatment, the child is still myopic and must then wear contacts or glasses.
Dr. Kegarise and I discussed this experience and the variability of myopia control programs in the eye care marketplace. He noted, “Many practitioners confuse the MiSight lens with myopia control, when in reality, it is just one tool in a complex treatment program.”
Consider individual patient, all treatment options
A comprehensive myopia control approach involves a customized strategy between practitioner and patient. The doctor must consider the patient’s habits and lifestyle and then consider all known potential treatment options with a selection of the most appropriate method. The patient must be willing to limit screen time and reading and agree to spend more time outdoors, exposing the visual system to distance objects. In some cases, combinations of therapies are found to be more effective.
Myopia is a disease characterized by increased axial length. The risk for associated morbidities, particularly retinal disorders, increases with longer axial length. Therefore, biometry is essential when managing and making determinations of “stability” or “reduced progression.”
Thus, the most effective program is to train optometrists in all aspects of myopia progression. This would include the theory of myopia progression based on genetics and abnormal axial lengthening from overfocused light on the peripheral retina. Optometrists can then be trained on all effective modalities to limit the myopic correction to the central retina and monitor patients using axial length and topography.
They may use the MiSight lens option, soft monthly disposable center-distance soft lenses, ortho-K lenses, low-dose atropine or even new spectacle lens options. Follow-up visit frequency would be determined by the complexity of the case and axial growth monitoring. This type of therapeutic program would parallel the method that optometrists use in managing glaucoma cases by taking into account all structural and functional measurements and not just looking at eye pressure.
The annual myopia management encounter would, at a minimum, include axial length measurements and topography in addition to a review and update of current treatment and consideration of other options. This program can be billed for a treatment period and could include refractive surgical treatment considerations at the end of the growth cycle. The treatment modality — contacts, eye drops or spectacles — could be charged separately or included in the annual program fee.
This new approach would place the success and effectiveness of the treatment on the optometrist, rather than on the modality of treatment. By including the final refractive procedure in the package, the comprehensive treatment program would end with the elimination of the refractive error while minimizing pathological axial length growth during developmental years.
Optometrists need to strive for continuous improvement and lifelong learning and use technology as a tool rather than letting technology drive the profession.
Editor’s note: On Sept. 9, 2024, this article was updated to specify that center-distance soft multifocal contact lenses are one technology used for myopia management. Healio regrets the error.
References:
- Chen C, et al. Invest Ophthalmol Vis Sci. 2013;doi:10.1167/iovs.13-12527.
- Cooper J, et al. Eye Contact Lens. 2018;doi:10.1097/ICL.0000000000000499.
- FDA approves first contact lens indicated to slow the progression of nearsightedness in children. https://www.fda.gov/news-events/press-announcements/fda-approves-first-contact-lens-indicated-slow-progression-nearsightedness-children. Published Nov. 15, 2019.
- Wolffsohn JS, et al. Invest Ophthalmol Vis Sci. 2019;doi:10.1167/iovs.18-25980.
For more information:
Scott A. Edmonds, OD, FAAO, specializes in vision-based neurorehabilitation at Edmonds Eye Associates in Philadelphia. He can be reached at scott@edmondsgroup.com.
Jeffrey Kegarise, OD, is president and chief operating officer at The Center for Professional Development and president of Cool Springs Eye Care and Donelson Eye Care in Tennessee.
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