Myopia management funding

Myopia in practice

Neil Hilton (NH): I have five independent practices within the Hakim Group family, dotted across Merseyside and Cheshire, all of which offer some, if not most, forms of myopia management.

Myopia management is something we are all very passionate about, and have been for some time. Over the past few years, we have seen the range of myopia management products available for us to offer to our patients grow rapidly.

We try our best to approach myopia management in a uniform manner, with all five practices using an online myopia tool to help screen all ‘at risk’ children and help discuss myopia and its management with their parents or guardians. These online tools are available at no cost, allowing all clinicians access to important developmental information that will help ‘at risk’ children on their journey.

Once it has been identified that a child would benefit from some form of myopia management, we can begin the treatment selection. At this point, our practices that have a topographer will take scans of the child’s eyes to gauge their suitability for orthokeratology (ortho-k). Those practices that do not have a topographer can still have a discussion around ortho-k, and can refer to one of the other practices, should this be a more suitable treatment for the child.

Suitability depends on several factors, including lifestyle, age, prescription and unfortunately, affordability. We offer both licensed and ‘off-label’ treatment options from a number of different ortho-k manufacturers. The only thing we don’t yet offer is axial length measurement. This is definitely on my priority list for 2025.

In terms of product selection, we offer most options. We have narrowed down the spectacle lens offering through a process of trial and error and feedback from patients and team members. Recently, Zeiss released MyoCare, which has made things a lot more affordable for families – a huge step in the right direction. It provides exceptional performance, with a favourable price to boot.

In terms of contact lenses, there are several options in both daily and reusable formats, and we are now able to cover most prescriptions with more bespoke options from companies such as Mark’ennovy.

As some treatments become more affordable, we are now seeing dual wear options for patients for the first time, allowing patients to switch between contact lenses and spectacles, without compromising their treatment efficacy. This is a real step in the right direction.

Dr Keyur Patel (KP): We have a fee structure, where patients pay for a myopia assessment, and then once they have had their assessment, we look at the best option, with the patient in mind. There’s no point in me offering the patient a contact lens option if they don’t want to wear contact lenses, or if their child is unable to, so we’ll have a discussion. It’s £175 for that assessment.

All our myopia management patients go onto a payment plan, where they pay a monthly installment. Within that installment, we include all of their clinical care, but also product. A patient might be a soft contact lens wearer, and it would cover that. But if they wanted to go to ortho-k, we would just switch them over, and they wouldn't have to worry about pricing structure changing.

We wanted to try and make it easy. Saying, ‘this product costs this, this product costs that,’ could influence what option people go for. They may not go for what’s necessarily best for their child, because budget becomes an issue. We took that out of their hands. We said, ‘whether you have glasses, whether you have contact lenses, this is the fee structure.’

It also makes it easier for us, because more and more products are coming out. When there was just one licensed product, it wasn’t complicated. Now you have four or five contact lens products, and three spectacle lens products. It means we’re just changing the product, and not having to go through a whole lot of admin in terms of changing the fees paid.

Myopia management is something we are all very passionate about, and have been for some time

Barriers to providing myopia management

KP: We’re a bit spoilt, in the sense that our practice is a destination practice. People tend to come looking for us. The majority of our patient base is able to fund myopia management for their children, or multiple children, in some cases. Do we get some blowback? Occasionally, when people are not used to a fee structure at all, or when they’ve been used to getting a General Ophthalmic Services (GOS) sight test and then a complete set of spectacles for minimum investment. It’s our job to educate them about why we have to charge what we do, what myopia management entails and what we’ve invested in, and how much the product costs.

NH: Two of my five practices are in areas of high unemployment, which is reflected in everything we do within them. However, the needs of the children in these areas are no different to those in the more affluent areas. The only difference is whether they or their families can afford to access the treatments and products available to them. I often leave these practices with a heavy heart, after seeing yet another child that would benefit from myopia management leave without any help.

One case in particular, of a young girl whose parents wouldn’t let her wear her spectacles for school in fear of them getting broken, sticks in my mind. She was -4.00 in both eyes. In the end we gave her a ‘school’ pair, so she could at least see the board in class.

Sadly, this is not an isolated case, with cost being the biggest barrier when it comes to myopia management uptake. If we have an eight-year-old who wants or needs ortho-k, that’s £600 per year, potentially for the next 10 years. That’s £6000. You can see why cost is a barrier.

Another common barrier is a general lack of awareness and understanding, with some parents still seeing myopia management as ‘profiteering.’ It’s difficult not to sound commercial when there’s a large price tag attached.

Fortunately, general awareness of myopia management is improving, especially now most of the major manufacturers and optical chains are getting on board with it. There are also some fantastic information resources available to patients and their families. Ocumetra has an online myopia portal where the patient, parent or guardian can view a personalised QR code, which directs them to information on their child as well as a larger suite of resources on myopia management.

KP: Ophthalmology can’t offer myopia management in the way we can offer it, so we’ve really got to embrace it. Ultimately, we’re trying to do the best for our patients in whichever way we can. Sometimes, optometrists are guilty of being afraid to offer a product or a treatment because we’re worried about the patient’s wallet. That shouldn't be what stops us discussing all available options. We should discuss it, and then the patient gets to make an informed decision about what they would like to do.

It’s our job to educate them about why we have to charge what we do, what myopia management entails and what we’ve invested in, and how much the product costs

Problems and potential in myopia management funding

NH: If we could offer all our patients in need of help access to some form of myopia management treatment, that would be groundbreaking. To remove all barriers to myopia management could not only help millions of children, but could save the NHS millions of pounds in future ophthalmic treatments caused by myopia.

KP: I think in a perfect world, it would be funded. In the real world, the NHS can’t afford it. Anything available product-wise would need National Institute of Clinical Excellence (NICE) guidance. Ultimately, NICE guidance involves a cost-benefit analysis. I don’t think they would think there was enough data to warrant the investment.

Recently, at the International Myopia Conference in China, one of the questions was, ‘does having myopia guarantee that there will be ocular disease?’ The consultant basically said, ‘no, there is no guarantee that you will get eye disease with myopia.’

We see people who are high myopes, and don’t have any problems. The NHS has got to balance it out. How do you treat cancer patients, and cataract patients, and broken limbs patients, if your budget is going on speculative potential treatment further down the line?

Until there’s more data, or more solid evidence, I think the NHS will struggle to justify the budget. If they did invest in it, I think they will have very strict protocols about who they do it for. I think it would potentially just be younger children, with certain levels of myopia.

NICE would have to do a big research project, to figure out where treatment starts, and who you don’t treat. You then start to get into the realms of discrimination, postcode lotteries – all things that, unfortunately, affect healthcare at the moment.

Everything costs something, and you have to get that balance right now. There are still people who think myopia management is not necessary. Ultimately, only time will tell. We’re only going to know when we get there.

Means testing myopia management

KP: For anyone who is getting a level of funding, there is a benefit. It doesn’t matter whether you are super rich or struggling, if you can get help from the NHS to contribute towards the cost, you will take it.

My patients are not necessarily rich, but they manage to find a way to pay for treatment. Myopia management is going to cost one of our patients about £400 pounds a year. It’s not small money, for most people. If the government says, ‘we're going to give you £50,’ that is more than 10%. Most people would take that discount.

But from the government's perspective, how many sets of £50 can you give out? The BBC just ran something where they said one in three children, now, is myopic. If you run the calculations, we’re talking millions.

NH: I would love to see myopia management being one of the qualifying criteria for help towards treatment for all those children at risk of myopia progression.

In my opinion, this should be based purely on the child’s risk of developing myopia-related ocular disease, rather than being means tested. This is the only fair way to allow access to treatment for ‘at risk’ children, and focuses on the child’s needs rather than the income of the family. If a child is at risk of developing a level of myopia greater than say -3.00 and is 18 or under, they could be granted a voucher towards, or covering the cost of, myopia management.

Removing means testing would take away barriers to treatment and keep children and their ocular health as our sole focus. No one can be just above or just below the agreed income level, and affordability would no longer be a concern. It puts the decision in the hands of the clinician. We need all children to be treated the same, irrespective of background or familial affluence.

KP: You could means-test it. But say someone is 16: they’ve just become a -0.50, and their parents are really struggling financially. They’d be entitled to this benefit. Then you’ve got a 12-year-old who is already –4.00, and the parents are making enough money to not qualify for means testing – but the difference in what they’re earning is £2. They’ve got a 12-year-old who is –4.00, who probably needs it more, but they’re not going to be able to fund it.

That's when it starts to become complicated, so I don't know if they would ever make it means tested. I think it might be more a case of need. Younger children, with higher levels of myopia, probably should have more access to it, as they progress more quickly.

It is so complicated, and ultimately, money talks. If you’ve got to pay nurses and doctors for all the hard work they do, and you can’t afford to pay them, where will any government come up with £10 or £20 million for the kids who need glasses?

Also, it’s more than just providing a product. If we talk about provision of care, and if you look at the value that is put on a GOS sight test, it’s a nominal sum. These children, particularly progressing myopes, are going to need to be seen more frequently. If you talk about gold standard assessment, they need axial length measurement, which for most optometrists means investment in new kit. That kit is not cheap, so who is going to cover those costs? It really starts to get into big numbers.

I think any optometrist who is interested in myopia would love all their myopic children to have access to this product, but I think the real-world nature of it means we are unable to provide that. It is heart-breaking sometimes. But an independent business owner is often also supporting a family. They also have people who need to be looked after. We can’t get caught up in giving away services because we feel guilty, otherwise everything would collapse.