Myopia management: “I think the most exciting thing is that we have options”
OT spoke to Professor James Wolffsohn, chief scientist of the International Myopia Institute, about a new series of white papers and attitudes to myopia management
24 May 2023
The IMI white papers follow the publication of two previous series of papers in 2021 and 2019.
Recognising that it can be difficult for busy practitioners to keep up with the growing body of research around myopia, IMI released a set of video interviews which provide a “snapshot” of the key evidence around the topics explored in the white papers.
Trends in practice activity: myopiaAmongst the series of papers, the IMI global trends in myopia management attitudes and strategies in clinical practice – 2022 update provides an insight into the approaches practitioners are taking to myopia.
A global survey of more than 3000 eye care practitioners found high levels of self-reported concern about the increasing frequency of myopia in children, and that “more practitioners across the globe are practising myopia control.”
Despite the increasing levels of concern and activity in myopia management, researchers found that single vision spectacles and soft contact lenses were still the most prescribed vision correction across all continents, though this was lower than in 2019 and 2015 surveys.
Survey respondents indicated the cost to the patient as a primary hindrance to prescribing myopia interventions, and treatment availability was also identified as an issue for practitioners in Asia and South America in particular.
Researchers concluded that the growing levels of activity are translating into “the uptake of appropriate, proven, myopia control techniques at lower levels of myopia; however, there is still plenty of scope for this to be accelerated.”
They also highlighted the need for “further advocacy and collaboration” with policy makers, health regulatory bodies, and industry, to improve accessibility and affordability of treatment options.
Inside the research with Professor James Wolffsohn
As the taskforce chair of the global trends white paper, Wolffsohn also shared key findings from the survey into practitioner attitudes and activity around myopia management, and his view on developments in research.
Who would you say the white papers are for?Professor James Wolffsohn (JW): I think they are useful to read, particularly if you’re trying to get into the topic. As a busy clinician, the clinical summaries and videos are a useful starting point, and then you can dip into the white papers to find the relevant sections.
The IMI has also produced an infographic, which has just been updated with emerging treatments, and will be updated again soon with a way to understand the relative treatment efficacy of the different options available.
Did anything in the reports surprise you or particularly stand out?JW: The adult myopia white paper was very interesting [IMI–Onset and progression of myopia in young adults]. Certainly, when I started my career, there was lots of focus around adult myopia but the focus of treatments has really been around children, and we don’t know whether these treatments that have been developed for children will work as well for adults.
Another of the papers is on paediatrics, so typically very young children who get high myopia – generally from genetic causes and disease processes [IMI–Management and investigation of high myopia in infants and young children]. Again, we don’t know how effective our treatments are on those patients.
From the global trends survey, we are still progressing towards people engaging with myopia control. It is certainly getting better. The big surprises were around new spectacle lens designs for myopia control, because that just didn’t exist when we did our last survey. That’s how quickly time moves on, and suddenly this is a relatively big new modality for myopia control, and will no doubt grow.
The other stand-out part of the survey was eye care practitioners’ thinking that combination therapies work best. Arguably, the papers that we have, although limited numbers, do show that they seem to enhance the effect of either treatment on their own. But people aren’t using that yet because they don’t generally have the options of things like atropine, that they could add as an adjunct. So that might point to the future and how practitioners will use these therapies.
We are still progressing towards people engaging with myopia control
The IMI global trends in myopia management attitudes and strategies in clinical practice – 2022 update suggests the self-reported levels of concern and clinical activity are increasing. What might this indicate about the provision of myopia management in practice in 2023?JW: It looks like people are applying less single vision corrections to young progressing myopes and are engaging in peripheral blur/diffusion optic spectacles, contact lenses, and orthokeratology – those technologies that have been specifically designed [for myopia control]. But arguably, on balance, people are still not fully putting their patients in those modalities, so we’ve got a little bit of a way to go on that.
It would seem that concern is largely saturating; it is very high. Activity lags a little bit, which you would expect. It is now about choice of treatments. Cost is still a big issue for practitioners globally. That is something that needs to be considered by industry, because we don’t want this to become differentiated by wealth. If it is an important approach for us to be taking, and it seems to be, then that needs to be more universal. I can’t personally see the NHS in its current state taking this on. Therefore, it probably needs to be more of a partnership between practitioners and industry of: how do we make this more widely available?
The survey also identified accessibility as a potential barrier. Could you tell us about that?JW: It depends where you are in the world. We’re fairly fortunate in the UK, in that we do have a reasonable number of treatment options, but we don’t yet have a stable version of atropine that we can use clinically.
There will be the challenge that, invariably, it will be a prescription-only medicine, and therefore will fall to independent prescribing (IP) optometrists to do, and that is about 10% of the current optometrists. It would be interesting to see whether that changes the number of IP optometrists, because more people will want to have that ability to prescribe.
Everybody can guide their patients in terms of outdoor time. Most of the treatment options we have are fairly simple and don’t increase the risks compared to standard treatments. If you’re going to put your child in contact lenses, then putting them in a myopia control contact lens really is no extra burden. It is cost differential, rather than a new treatment that you need to train them in how to use, or that is going to put them at higher risk.
What factors do you think are driving the change in approaches to myopia control?JW: I think that, traditionally, eye care practitioners are perhaps a little bit conservative about changes. The information is getting better and there are more presentations, for example, on myopia control. I suspect that is beginning to swing people’s opinion.
There is also the availability of treatments. Having spectacle lens options might mean that people are perhaps more confident to apply this, such as those who don’t necessarily fit many contact lenses.
There has also been quite a lot of influencer activity. I suspect that parents are becoming more aware, and therefore seeking out treatments rather than it just being the practitioner that informs them.
I think a combination of those are swinging things, but change is always slow.
I suspect that parents are becoming more aware, and therefore seeking out treatments rather than it just being the practitioner that informs them
Do you expect we will see more parental awareness of myopia going forwards?JW: Patients are better and better informed. For parents with myopia, they know what it feels like and the issues – not necessarily the pathological ones, but certainly the inconvenience and minification, and other things that you get from myopia corrected with spectacles. I suspect that that will be quite a driving factor.
It’s an interesting one for the NHS. Journalists have talked to me about it for many years, and obviously it's becoming more widespread now, but the challenge will still be that piece around cost and availability and whether there are mechanisms to make it available at a more reasonable cost for everybody.
We are getting better at identifying which treatments are effective and are looking now at who they are most effective in. If we can get better at predicting that, then it will make it less expensive to offer these options and we would also potentially be able to offer the correct option at a young age and therefore get the maximum benefit.
Are there emerging technologies or areas of myopia control that you will be keeping an eye on?JW: The massive one is red light therapy, and light therapies in general. There are CE marked devices that are now available in the UK. Some therapies are available, but because of the way we approve medical devices in this country, they are there before we can tell whether they are going to be effective and, to me, safe.
It's also a fairly low regulatory burden to get them onto the market, so we will see lots of these products appear in a very short period of time as people repurpose other technology. That will be quite difficult, I suspect, for practitioners and researchers to keep up with. My advice at the moment is that these are emerging technologies and I would go with more established technologies until they are better understood.
What would you recommend practitioners look out for in emerging technologies, or when reviewing research?
JW: Back in 2019 when we published the first IMI reports, we looked at what a trial should have in it:
- We are looking for randomised controlled trials where a placebo treatment is used, so that you can see those biases – the placebo effects – have been taken into account
- We recommend at least two years’ worth of data to see what kind of effects we get, because we know the effect is generally greater in year one
- A washout period is also recommended to look for rebound, which we saw with high dose atropine. If we’re introducing totally new therapies, it might be something that needs to be looked at still
- Then the safety aspects need to be considered. With something like a contact lens change, it’s probably not going to have a massively increased risk and we have lots of data for contact lenses over many years – we don’t have that with some of the new therapies to-date. The challenge is that our current guidelines are around established modalities of refractive correction that have been tailored in terms of optics. If we're introducing new forms of treatment modality then the safety profile probably needs to be evaluated over a much longer period of time.
What do you hope to see in the coming years?JW: One thing would be around terminology. People are using ‘myopia management,’ ‘myopia control’ etc. While the original IMI reports defined a lot of the terminology around what is high myopia, for example, I think there is still some terminology that needs to be clearly defined so that everybody is speaking with the same language.
We've committed to updating the survey every couple of years so that will be really useful to see how those trends continue, to where we’re we going as a profession, and also to be able to benchmark ourselves to other countries and what they're doing as well.
The survey tells you what the average practitioner is doing in the UK, for example, which I think is really useful for practitioners. I think this idea of being able to benchmark your practice in myopia, but in many other areas as well, is a really important part of continuing professional development.
I think this idea of being able to benchmark your practice in myopia, but in many other areas as well, is a really important part of continuing professional development
For you personally, what is most exciting to you about myopia control at the moment?JW: I think the most exciting thing is that we have options, we know with all types of disease, that one treatment option doesn't work for all patients. I’m also excited about the predictive algorithms and ability in the future to rapidly predict which treatment is going to work best for a child because if my children were six years old, I wouldn't want to try a treatment for a couple of years and then find that they are still progressing a lot and we need to change because actually, you’ve lost a key time for reducing the amount of myopia that they're going to have.
The growth curves that we're now getting for normal development of the eye is really important, because it's a difficult conversation with a parent to say: “your son or daughter’s axial length is still progressing, but we think it's less than it would have been if we hadn't given them this treatment.”
These growth curves really help with that and we're working in a collaboration between Aston University and Ulster University to make those freely available on an app. Practitioners can put in some very basic information about a child and it will plot out those growth curves and where they are, and then they can track where they are with different treatments. That’s called the PreMo app. It is useful for practices that don’t necessarily have access to all of the technology at the moment.
I think those sorts of developments will really help in the communication with parents, but also better understanding the real world data because clinical trials are great, but they don't necessarily tell you how out in practice people are going to use these treatments, how long they're going to use them for, when they're going to stop, or when they're going to combine. Even in the trials, we’ve seen those people who are more compliant generally get a better effectiveness. We would expect that but again, we expect some people will stop early, some people will keep going for years, some people will mix and match. That's what we really need to understand in terms of its relative effectiveness.