For the many, not the few
Eye care practitioners explain why myopia management should be the stuff of regular practice, discuss why kids can and do wear contact lens successfully, and offer advice on how to get started with myopia control today
Myopia management may have received increased attention in 2017 in part on the back of the three-year efficacy results for the CE-approved MiSight® 1 day, CooperVision's daily disposable offering. But how to put the theory into practice?
OT and CooperVision brought together eye care practitioners (ECPs) in a roundtable to share their hands-on experiences of what myopia management means to them. The discussion explored their passion for the work, and what myopia management can achieve for patients and the practice.
Why, OT began by asking the panel, should ECPs look to actively manage myopia in clinical practice?
For BCLA president, and Leightons & Tempany Opticians branch director, Keith Tempany, myopia control had been firmly on his radar for years.
“What really pushed me was the BCLA conference in 2015. The late Professor Brien Holden summed up the morning session by saying, “We don’t know everything about myopia, but we know too much to sit back and do nothing at all.”
Optometrist and myopia management enthusiast at Rawlings Opticians, Luke Allen, explained that his myopia lightbulb moment came while at university. “I had never heard of myopia control. I stumbled across it during my dissertation and thought: ‘Why is this something we are not talking about?’”
For practices looking to take the first step in myopia management, the panel agreed that practitioners should be positive about the workload impact, and embrace the change.
Contact lens lead and optometrist at Cameron Optometry, Gillian Bruce, explained to OT that myopia management fits neatly into her practice’s commitments. “I am used to working with children and working with contact lenses, but I realise that not every practitioner does that too. While we have all got these skills, I think you actively have to take that leap to do it.”
Ms Bruce suggested that an easy first step for a practitioner looking to build up confidence working in myopia management is to get comfortable with the research.
Where is the profession at?
Asked if the panel believed that the entire profession was ready to take the leap into myopia control, the group concluded that any barriers were surmountable, the research supported the tools, and the duty of care to patient meant the profession needed to engage with myopia control today.
Senior lecturer in optometry and director of the Ophthalmic Research Group at Aston University, Dr Nicola Logan, explained that the profession should be confident in the knowledge that it now has the tools it needs to act. “I think the profession is starting to embrace the products available – such as MiSight 1 day. There are other options that ECPs could look at as well.”
She added that the research evidence is available to back up the different modalities and options available. “The evidence is being replicated in a number of studies, not just one or two. These are really good studies, in different parts of the world, offering different optical modalities and strategies for slowing the progression of myopia,” she said.
“ECPs should accept the evidence and start to implement it into their clinical practice,” Dr Logan told the group.
The panel noted that practitioners are likely to have a sense of trepidation when approaching myopia control for the first time.
Highlighting the reasons for this, Mr Allen noted: “The average practitioner probably does not read studies, and look at this stuff.” But practitioners will have many of the skills needed, he explained.
“A lot of people are probably already fitting children with contact lenses, and it is such an easy swap to get them into something that works, but they do not understand or do not have the experience to do it. The studies are there, but I think that they may not have been given the information in a way that gives them confidence to do it,” he continued.
Mr Allen also noted that clinical practice concerns are an issue too. “The way the legal side of the profession is, I think practitioners are scared of doing something that is not proven, or lacks NICE approval.”
He added that the CE approval mark for MiSight 1 day is “really important” to change that mindset.
The panel also concluded that practitioners should reject the assumption that they need to understand all that there is to know about myopia control in order to start talking to patients about management solutions.
Dr Logan explained: “Not even the researchers understand all the mechanisms behind why myopia develops in the first place, or indeed how these strategies are working and slowing it down.”
Duty to act?
OT asked the panel about practical first steps when thinking about myopia management.
Mr Tempany asserted that “it is not about fitting lenses per se,” and encouraged practitioners to think about the young “at-risk emmetrope, as well as the patient that is myopic.”
Dr Logan noted that a key consideration is how to talk about myopia management to the parents and the child, saying that it is important to stress the future risk of ocular pathology. “You need to get that point across to parents,” she said.
Mr Allen said that the practice team need to get behind the work, explaining that every optometrist at Rawlings attended a half-a-day myopia control training session. “It was done in work time – and everyone did it together at once. It was a tipping point.”
Mr Tempany advised that practices should consider locum staff. He recommended briefing locums as they arrived to make them aware it was a myopia control practice.
Supporting the point, Ms Bruce acknowledged the “massive benefit” from having all the staff behind myopia management. “Parents and kids will often have questions that they do not think of when they are in the testing room, so it important that other members of the team understand myopia management and can back up the points made,” she said.
Ms Bruce added: “Handling and hygiene sessions are one of the trickiest parts for children wearing contact lenses, so it is well worth training up other members of the team to be able to do handling sessions. If they need repeat handling, it will not take up the optometrist’s time. A whole team approach is required.”
Dr Logan added that reception staff should be trained too. “If parents make that initial phone call, it is important that reception staff understand what it is that the practice can offer for their kids,” she said.
If the research is clear, and the tools are available, the panel were asked if they believed practitioners have a duty to act.
Mr Allen supported the assertion, observing: “I think that you are not fulfilling your full duty of care as a practitioner if you do not discuss the options. You do not have to fit it yourself; you can just tell the patient that the research is there.”
Ms Bruce agreed: “As more ECPs fit the lenses, and as word spreads and more patients ask about it, you will become more uneasy if you are not discussing these sorts of options with patients. There will be more motivation.”
Dr Logan challenged a perception held among practitioners that myopia management is a specialised area for the few not the many. “I think it should become normal correction of a child with myopia. It should be the first port of call. And that conversation would start before the child becomes myopic.”
Dr Logan explained: “You do not need any specialised equipment – if you are doing ortho-k you have got a topographer anyway – but what else do you need other than a slit lamp? You don’t need to measure the axial length as you will see from the refractive error change.”
Ms Bruce added: “We have got the skills and equipment we need. It is about having the confidence to deal with children in contact lenses, and the age the child is.”
"We have got the skills and equipment we need. It is about having the confidence to deal with children in contact lenses"
Hurdles to leap
The panel were asked to consider other potential barriers to myopia management uptake.
Issues around cost were key for the group. To mitigate these concerns, Mr Tempany said that, in his practice, he made sure that both the parent and child were in the consulting room when introducing contact lenses to manage myopia. “We give all of the options, sow the seed, and are readily available for a follow up chat,” he said.
Another potential barrier identified by the panel emanated from the UK’s commitment to offer free correction for children.
Ms Bruce elaborated: ‘There may be a barrier perceived by optometrists about how to start talking about the associated costs with families. Do I tell them about something that they can’t afford – but they know now what they are missing out on? I think it is a difficulty.”
She added that is important to remember there must be a balance when communicating the risks. “Parents may not be able to afford contact lenses, and are not able to handle contact lenses. For them, it should not be seen as a complete and utter disaster if the child doesn’t end up having contact lenses. On the other hand, if you don’t mention something that could help the patient because you assume they won’t want it, you are doing your patient a disservice.”
The panel were asked to reflect on the concept of ‘high risk’ in the context of myopia management.
For Dr Logan, the focus should be on the risk before a child becomes myopic. “It is all about the level of hyperopia at younger age groups, parental level of myopia, what environment they are in, what tasks they tend to do, how much time they tend to spend outdoors – and looking at all of that as indicators as to what you can do and modify that to see if that reduces your risk of becoming myopic before they come back and see us,” she explained.
The task of communication to parents and children was recognised as a top priority by the panel.
Dr Logan asserted that it is important to set expectations at an early stage. “We can’t predict what is going to happen for an individual, so we can’t be certain that they are definitely going to have that ocular pathology – but we can say the risk is greater. Likewise, if we implement a myopia management strategy, we don’t know if that is going to 100% work for everyone,” she added.
Reflecting on the tools the panel use when talking to families about myopia management, a range of resources were highlighted.
Ms Bruce said that a myopia projection calculator is her go-to resource. The tool, she explained, allowed her to put forward the evidence in a clear way. “It gives parents confidence to know myopia management is established.”
Ms Bruce added that, when communicating to parents, she believes that it is important to address eye health issues head-on. “As soon as your prescription gets to -1.00D you are twice as likely to have a retinal detachment – and I do not shy away from saying that. Be prepared to consider a shorter recall period to revisit the conversation if necessary, especially if there is concern that myopia may progress.”
“A lot of parents are myopic so are aware of these points anyway,” she added.
Dr Logan shared that she used pictures to show the changes at the back of the eye and what the different ocular pathologies might be.
Exciting and new
While progress in myopia management has moved at pace, Dr Logan told the group that, for any practitioner who wants to get involved in this area, there is a need to acknowledge there will be more to learn. “It is an evolving process, and you have got to continue engaging in the literature and the research just to keep up to date,” she concluded.
For the panel, the success of myopia control came back to communication.
For Mr Tempany, working with children is “not a walk in the park. It does stretch our communication skills, but most practitioners are pretty good communicators.”
And the panel agreed that the fact that the science behind myopia control is evolving can be positioned as a positive rather than a risk.
Ms Bruce commented: “If you have a parent in front of you who was -6.00D as a child, they are likely to think, ‘where was this lens when I was becoming myopic?’ It is a really positive story.”
Mr Allen agreed: “I think parents like the fact that we don’t know everything. We are at the forefront, we have not waited for all the answers, and we are doing something that is new and exciting.”