MAYopia: an update on myopia

The day began with a session from Nicola Logan, professor of optometry and director of research for the Optometry and Vision Science Research Group, at the School of Optometry at Aston University.

Logan spoke on Myopia: putting the evidence-base into practice, reviewing research in myopia and how to evaluate studies.

Beginning the session with a poll, Logan asked attendees whether they considered myopia to be a disease, with 47% of respondents saying ‘yes’, 39% saying ‘no’ and 14% unsure.

Logan encouraged eye care professionals to consider why myopia might be considered a disease, commenting: “It is both chronic in nature, and progressive, two characteristics of a disease.”

With the long-term risks of ocular health problems, and additional impacts that myopia can have on quality of life, Logan said: “I do think that now there is broad consensus that eye care professionals do have a responsibility not only to correct refractive error but also to prescribe interventions to slow that progression of myopia.”

The risk of ocular disease doesn’t only exist for those with high levels of myopia, Logan also warned, “but we now know that all levels of myopia pose that risk.”

Logan advised practitioners on factors to look for when reviewing an evidence-base. First, she recommended looking for evidence that has been published in peer-reviewed papers, “because that has consensus ¬– not just from the researchers doing that work – but from a wider perspective.”

Within those papers, Logan recommended three things to consider: the type of study, the quality of the research, and whether the findings are relevant to the population of patients in a practice.

The hierarchy of evidence pyramid can be useful when considering the type of study. Randomised controlled trials are recognised as a “gold standard” in study design, Logan said, while meta-analyses and systematic reviews sit at the top of the pyramid.

Reviewing myopia management studies

Logan outlined the design of studies behind interventions for myopia management that have joined the UK market.

For example, the study behind Hoya’s defocus incorporated multiple segments (DIMS) technology, followed children aged between eight and 13 for two years in a randomised trial, comparing single vision lenses with the treatment lens.

Similarly, the study behind Essilor’s Stellest lens was also a prospective randomised trial over two years in children aged between eight and 13, comparing a single vision control lens and two different designs of treatment lens.

Data from both studies showed a slowing in myopia progression and the rate of axial elongation in children wearing the treatment lens.

Orthokeratology (ortho-k) has been used for decades for correcting myopia, Logan said, and a number of studies have used ortho-k to slow myopia progression, across different lens designs and populations. Logan highlighted a meta-analysis by Jun-Kang Si et al (2015) of seven studies across a two-year follow up period which indicated an average of a quarter millimetre slowing of axial length growth across studies. She explained: “What I think is really quite remarkable here, is that these are all different studies, in different parts of the world, with different populations and lens designs, and we get remarkably similar results.”

Logan reported data from a case series comparing the rate of myopia progression before and after starting treatment with an extended depth of focus (EDOF) NaturalVue lens. However, she noted that this can be difficult to quantify because progression naturally slows as children grow older. More data is likely to come out on this lens, she added.

Logan noted that parents might have read up on atropine (though not licensed in the UK) and ask about it in consultations. She explained that, while there is evidence for the use of atropine as a way of slowing myopia, the side effects outweigh the benefits currently and ongoing studies into low dose atropine in the UK are expected to provide greater insight in coming years.

CooperVision’s MiSight multi-centre study began with children aged between eight and 12 in four countries. In the first stage of the study, children were randomly sorted into a control and MiSight lens and assessed over three years. This initial study found a “clear impact in terms of both slowing rate of myopia progression and slowing the rate of axial elongation.” A further three year study looked at the impact of moving slightly older children, those who had been in the control lens, into MiSight.

A seventh year of the study found that myopia control gains were retained after treatment cessation.

Logan used data from the MiSight study to assess the key questions that need to be answered in order to fully integrate myopia control into clinical practice.

Answering the question of when to start treatment, Logan outlined that based on the indications that age of onset predicts myopia progression, and a younger onset means a patient is likely to have a faster rate of progression, treatments should be considered “as early as possible,” while adding, “it’s never too late to start that intervention.”

Concluding the session, Logan said: “It’s really important to look at the evidence base and keep up with it, but where we are now, I think we have enough evidence that we want to change our mode of practice from solely a correction of myopia into a more active management.”

Logan’s points to consider when evaluating a study

• Whether it is prospective or retrospective
• If there was a control group and what the comparison was
• Whether it was a multi-site study
• The age range of the participants
• If the participants were randomised
• If the study was masked
• The duration of the study and any follow-upMeasures. In myopia management studies, it is important not only to look at the change in refractive error, but a corresponding slowing of axial length growth.

Understanding myopia

Dr Manbir Nagra, optometrist, educator and researcher delivered a session on Myopia: the basics.

The optometrist broke down the topic of myopia into a basic overview of the current state of play for her session, to help practitioners keep up-to-date on changes in the field, and understand the theory underpinning myopia management.

Dr Trusit Dave, an optometrist, practice owner and director of Optimed, spoke about the importance of communication and understanding in his session, Myopia management: a patient-centred approach.

Patient-centred approaches are now the standard of care in healthcare, Dave said, encouraging active collaboration and shared decision-making between the patient and practitioner, to design a comprehensive and customised care plan.

Addressing the question of when to begin treatment, Dave said this begins with talking about the risks of myopia and qualifying the patient – identifying those patients who are myopic or pre-myopic.

His approach is to take a cycloplegic refraction for new patients between the ages of six and 10. His initial exam will also involve ocular biometry, ocular motor balance and accommodative lag, to help him decide on the best treatment options.

Sharing treatment options

When talking to patients about treatment options, Dave recommended discussing efficacy, and sharing the message that: “With modern treatments you can expect around a 50% reduction in eye growth, or a slowing down of their prescription. The key point is to always give the time period, which is two to three years.”

He advocated using the Brien Holden Vision Institute myopia calculator with the patient, to illustrate the myopia progression effect of treatments over time.

A patient-centred approach to the discussion around treatment options should allow children and parents to make the decision based on the clinical evidence and observations provided by the optometrist, as well as patient factors, such as lifestyles.

Dave highlighted the importance of having a sensitive and repeatable mechanism of measurement for follow-ups, recommending optical biometers.

Patient understanding and consent

In discussing myopia management options, patient consent needs to be obtained. Dave outlined five legal aspects relating to consent: information disclosure, competence, voluntariness, comprehension, and consent.

In the past, cases were judged by the ‘Bolam test’ – acting as other practitioners would – but following the landmark Montgomery High Court case in the UK in 2015, Dave said: “We have to tell them about risks, choices, options, and what happens if they don’t have a particular treatment.”

“You have to allow the patient and their parent to make an informed decision. If you’re not offering myopia management, you ought to be discussing this and referring to somebody who does if the patient decides they want to go down this route,” he said.

“The crux of this is patient education and understanding,” Dave said, but added: “Comprehension and patient understanding is one area we spend a lot of time on in the consulting room, and that patients forget once they’ve left.”

He illustrated how animations produced by his company, OptiMed, aim to make the conversations easier to understand, and allow the patient to retain the understanding after the consultation.

“There are four key areas when thinking about a patient-centred approach; the when, what, why, and where,” Dave concluded. “Just remember, it’s about empowering patients and their parents to make the best decision in terms of myopia management.”

Communicating with pre-myopic children

1.  Ask about behaviours, near work, outdoor activity, and what distance they hold things at to read
2. Advise the family by referring to studies that suggest the risk of developing myopia can be reduced by around 50% with two hours spent outdoors a day, reading at longer distances, or setting some restrictions around the use of digital devices
3. Plant the seed that, if and when the child becomes myopic, there are treatments to slow the progression
4. Schedule a six-month visit and use growth curves.

Obtaining consent in myopia management

The AOP has produced a myopia management consent form for use in practice. Here, Dr Peter Hampson, the AOP’s clinical director and an optometrist, shared his advice on using the form.

Scientist, speaker and educator, Professor Mark Bullimore, led attendees through the research into myopia management options, in his session on Myopia control: the evolution of spectacle lens technology.

Comparing myopia management to treating dry eye, Bullimore explained: “We perhaps didn’t talk to patients about dry eye a lot 20 years ago, because we didn’t have a lot of viable methods to deal with it. Now, we have a range of pharmaceuticals and instruments.

“Myopia is going through the same phase. We now have the ability to offer them viable options that can slow the progression of myopia and make an impact on future life and vision,” he said.

Focusing on spectacles as a method for managing myopia, Bullimore first reminded practitioners that “under-minusing makes it worse” sharing two randomised controlled studies in different parts of the world (Kahmeng Chung et al, 2002, and Daniel Adler and Michel Millodot, 2006) that both concluded that under-corrected children progress faster than fully corrected.

The research journey

Outlining the development of research in the field, Bullimore shared that the first studies that began to indicate that myopia was a relevant area to explore were held in the 1950s, first looking at whether bifocals would have an effect on myopia progression, with mixed results across a number of different studies over time.

The JT Leung study in 1999 from Hong Kong looked into progressive addition lenses (PAL) and inspired a number of further studies, such as the Correction of Myopia Evaluation Trial in 2003, and Edwards et al study in 2002.

The latter studies found a treatment effect of less than a quarter of a dioptre, Bullimore shared, commenting: “I would argue that this a clinically meaningless benefit when slowing myopia – we can do better with modern therapies.”

He highlighted the importance of the periphery for myopia management, noting that “most of the things we’ve found that work for myopia are elements that put some plus power into the periphery.”

This is how ortho-k is believed to work, for example, or multizone contact lenses, and the same applies for spectacle lenses designed for myopia management.

Focusing on spectacles

Bullimore assessed studies that looked at spectacle lens designs for myopia management.

The study involving Hoya’s DIMS, marketed as Miyosmart, found “a very robust treatment effect… but perhaps more importantly, a slowing of axial elongation.”

Essilor has also recently joined this arena, developing the highly aspheric lenslet (HAL) technology behind its Stellest lens. The results of a randomised controlled trial of almost 200 children wearing single vision, HAL, or slightly aspheric lenslet (SAL) technology found the HAL had a “dramatic” slowing of myopia progression and axial elongation.

Positioning the spectacle lens results onto a graph comparing the efficacy of various myopia management modalities, Bullimore said: “We can see that spectacle lens technologies are very effective when compared to alternatives, such as ortho-k.”

The studies also revealed that compliance is important, Bullimore shared. In the second year data of the Stellest lens trial, researchers found a greater treatment effect in children who wore their lenses at least 12 hours a day compared to those who wore theirs for less time.

SightGlass Vision represents another potential for myopia management spectacle technology in the future. The lens doesn’t have an optical defocus component, but a technology to reduce contrast in the periphery. A multicentre study is currently underway in the US, with over 250 myopes and 24-month interim data presented at the Association for Research in Vision and Ophthalmology (ARVO) 2022 suggested “encouraging” results.

Rounding off the day, dispensing optician and optometrist, Indie Grewal, delivered a presentation on Effective communication of myopia management from the consulting room.

Introducing the session, Grewal shared: “Parents expect optometrists and eye care professionals to advise them on all eye care options to reduce the progression of myopia in their children, and they are increasingly becoming aware that interventions to slow myopia, or the worsening of their child’s vision, are becoming available.”

Grewal outlined research into parental understanding of myopia which found that, of 329 parents of children with myopia, 46% considered myopia to have an association with the long-term optical health of their children. 

Myopia was regarded as an optical inconvenience, which could be corrected with contact lenses, glasses or laser refractive surgery, by 46% of those surveyed.

“As nearly half of those surveyed were unaware of the association between myopia and long-term health, we have an obligation to start a conversation from our consulting rooms,” Grewal said.

Parents can sometimes feel disappointed or saddened that their child has become myopic and the conversation needs to be handled sensitively, Grewal shared. Graphs can be used in the consultation, to present the potential of myopia progression and treatment options to parents.

Illustrating the progression of myopia

Grewal recommended using the CooperVision Axial Length Estimator, available to any practitioner accredited for the MiSight One Day, which can then be entered into a centile chart. He explained: “Every parent understands a centile chart. In this case, it allows us to show where that child is on that prediction for myopia.”

Another resource recommended by Grewal was the predicting myopia onset and progression indicator (PReMO), an evidence-based and open-access resource from University of Ulster.

The tool has two parts, the first a myopia indicator that provides advice and guidance for children and parents on the likelihood of future myopia, and a structure to discuss strategies to delay the onset of myopia. The second part can be used with professional judgement to select evidence-based management approaches for myopia children.

Grewal demonstrated how he has used these tools in practice, with a case study of two sisters. Sharing the data and graphs used to indicate the potential future progression of myopia, and how this informed their treatment plans, Grewal said: “This was building a picture that educated their mum, and brings about the significance of coming in for regular eye examinations, as well as the importance of having a thorough baseline to confirm whether or not that child is likely to become myopic.”

Walking the tightrope

When outlining treatment options with parents, Grewal emphasised: “Parents want to know why we’re choosing a particular strategy, or what the benefits or differences of a myopia management strategy are over ordinary spectacles and contact lenses”

Discussing studies with parents, including length, outcome and any limitations, helps them to make an informed choice, he said, but he also stressed the importance of acknowledging that “no myopia management option will halt the progression of myopia. Starting at a young age, we are beginning to slow the worsening of that prescription.”

Grewal also proposed taking the word ‘risk’ out of conversations around the potential for a child to become myopic, as children may think they are at fault. In his practice, the optometrist said: “We say their child may become myopic, and the considerations of this.”

Concluding the session, and the day’s agenda, Grewal shared: “I know at the beginning, talking about myopia management can be a bit like walking a really tight tightrope. If you do this day-in, day-out and talk to every parent about lifestyle changes and the possibility of progressive myopia, you will be on a much thicker tightrope that will be easier for you to walk and you’ll be able to do it more confidently.”

Myopia management: Grewal’s top tools

• World Council of Optometry’s three ‘M’s’
• AOP resources
• CooperVision Axial Length Estimator and Visual Simulator
• PReMO.

For more advice, top tips, and tools for myopia management, check out OT’s Myopia guide, in partnership with CooperVision and the AOP.