“We are the custodians of people’s eye health”

Moorfields Private Eye Hospital consultant ophthalmologist, Annegret Dahlmann-Noor, provided an overview of myopia management interventions during her 100% Optical presentation Myopia management in children and young people.

Dahlmann-Noor observed that she is increasingly seeing young children with high myopia but no obvious pathology.

“Don’t be hesitant to refer children but also don’t be surprised if all our tests come back negative,” she said.

Dahlmann-Noor encouraged optometrists to refer children when they have more dioptres of myopia than their age in years, and one other feature.

Features may include a family history of retinal detachment, deafness, heart valve surgery, visual impairment or high myopia suggestive of mendellan inheritance.

Medical history features that would suggest referral in addition to high myopia include prematurity, genetic abnormalities, hearing loss and developmental delay.

Ocular exam findings that would support referral in addition to high myopia include nystagmus, retinal degeneration, imaging that suggests pathology and when the child’s red reflex is irregular.

The final set of features that Dahlmann-Noor encouraged delegates to consider relates to visual acuity. A child should be referred if they have high myopia, and their best corrected visual acuity is worse than expected or they complain of poor night vision, she said.

A global trend

Dahlmann-Noor provided an overview of increasing myopia levels internationally. She shared that in the UK, one in four young people are myopic by the age of 16.

When Dahlmann-Noor delivers presentations in schools, she will count the number of year 12 students who are wearing glasses.

“It often seems to be way more than 25%,” she said.

Dahlmann-Noor shared research showing that 53% of nine-year-olds in Singapore were myopic, while 62% of 12-year-olds in Hong Kong were also shortsighted.

“In the UK, we have a slower trend than East Asian countries, but the trend is still there,” she said.

Dahlmann-Noor highlighted that if an individual’s axial length can be kept shorter than 26mm, their lifetime risk of experiencing vision impairment as a result of myopia is 3.8%.

However, if their axial length increases beyond this threshold then the risk increases to 25%.

“If you go past 30mm, you are virtually guaranteed to suffer sight threatening complications at some point in your life,” she said.

Dahlmann-Noor emphasised the important role that eye care professionals can play in offering myopia management.

“We are the custodians of people’s eye health over their lifetimes,” she said.

Through her role as an ophthalmologist, Dahlmann-Noor has observed the effect that being myopic can have on a young person’s wellbeing.

“They can become quite anxious about the process. They feel like it is totally beyond their control – there is nothing they can do,” she said.

The effect on secondary care

Dahlmann-Noorshared with 100% Optical delegates how rising myopia levels have influenced the pathology that is seen in secondary care.

Research by Dahlmann-Noor and colleagues found that between 2016 and 2023, the proportion of retinal detachment patients older than 60 who have myopia increased from 25% to 40%.

“There is no doubt that myopia is driving complications in the retina already in the UK today,” she said.

Turning to myopia management, Dahlmann-Noor reflected on how practitioners can judge the effectiveness of a myopia management intervention.

She shared that a useful measure of success is juduging whether the patient is achievinghalf the rate of myopia progression of an age-matched control.

“Bear in mind what is achievable and keep the dialogue going with the parents,” she said.

Dahlmann-Noorexplained that there are now longer-term studies showing the effectiveness of myopia management contact lenses in limiting progression.

She observed that paediatric ophthalmologists can be hesitant to prescribe contact lenses in children, because this group of practitioners see complications associated with contact lenses.

“When we look at the overall numbers of adverse events, they are really not bad,” Dahlmann-Noor said.

She shared that children have been shown to exhibit safer contact lens habits than older age groups.

“Overall, they have been shown to be much safer than we thought they would be,” she said.

Discussing the role of atropine, Dahlmann-Noor highlightedthat this intervention is currently not licensed for use in myopia management in the UK.

In her own private practice, Dahlmann-Noor uses atropine 0.05% in children who are already using a myopia management intervention and continuing to progress at one dioptre per year.

Dahlmann-Noor expects that atropine will become licensed in the UK but predicts that it will initially be available at a lower concentration of 0.01% or 0.02%.

“I think faster progressors need 0.05% but we need more evidence from the UK,” she said.

Turning to when it is appropriate to stop a myopia management intervention, Dahlmann-Noor recommends a tailored approach.

“I don’t think we should stop after a given number of years of treatment,” she said.

“We know that the eyes are growing at least until the age of 15 and sometimes for longer. I think we need to have an individualised treatment plan,” Dahlmann-Noor observed.