In the first article in this series, Laura Williams shared her experiences of dealing with a family with three myopic children. Although every case we will encounter is different, there were many similarities with clients I have dealt with in my own practice, and, when reading Laura’s excellent article, I expect all readers will be able to think of a patient that the circumstances and prescription reminds them of.
As such, I intend to focus more on the processes and circumstances we can encounter when practising myopia management, along with an overview of how we explain the options and a brief look at the financial implications.
Identifying who might benefit
Although we know that myopic progression might follow a familiar pattern with the children we are dealing with, the first conversation will rarely be the same. We know from the statistics that a child with two myopic parents is five to eight times more likely to become myopic than those with one or no myopic parents (figure 1).1
Delivering the news that a child with this kind of family history is short-sighted after their first refraction is not going to be particularly unexpected for the optometrist, and perhaps not that much of a surprise, although possibly still a shock, to the parents.
In my experience, these parents are often the easiest to deal with, as the explanation of how the myopia will progress as the child grows will be all too familiar to them, as they experienced it themselves, and they are most receptive to hearing about interventions that might save their child from following a similar path to the one that they took.
In stark contrast, we then have the child whose parents are emmetropic. In this scenario, it’s a whole new experience and, frankly, a lot for the parents to take in. We have all carried out refractions on a child who has been struggling to see the board at school for some time, and it is only when they try a friend’s glasses on that they realise there is a problem, at which point they tell their parents, who are not always convinced that there is really an issue, but they bring them to us for an eye exam anyway.
These clients are always more of a challenge, because they firstly need to understand what their child is experiencing. Fogging the parents’ vision with, say, a pair of +1.50DS trial lenses or reading glasses often does the trick (figure 2).
Figure 2: Demonstrating uncorrected myopia using reading glasses is a helpful way to show parents the impact of myopia on their child’s vision
With these clients making them their first pair of spectacles is the first logical step, but, having got them to digest the bad news that their child is myopic, they then need to be fed the fact that it is likely to get worse over the next few years and we need to, at the very least, make them aware there are ways of managing the process. It is not unusual, in this particular scenario, for the supply of glasses and a ‘myopia management’ leaflet (following a conversation) to be the only outcome at this stage.
This client described in the last paragraph can often become the next category of client, one who has no known family history of myopia but has demonstrated a track record of myopic progression over a period of time, often following a growth spurt (figure 3).
Figure 3: Continued myopic progression leads to a greater reliance on vision correction and the lifestyle implications that brings
Although this child’s parents will not have the personal experience of having been a myopic child themselves, a simple review of previous record cards showing how the numbers have changed over time, and just being aware of the worsening trend can be the necessary motivation required for them to allow us to intervene.
The final category includes those families who seek us out – they are frequently from out of our traditional catchment area and they have done their research or have been recommended by an optometrist in a practice that has yet to engage with myopia management, or even (and this has happened to me twice) might actually be an optometrist with a myopic child.
You would perhaps think these are the easiest group to deal with and, in some respects, they are as they have often read some of the accessible and informative material available online, published by such authorities as Kate Gifford, the Brien Holden Institute, Nick Dash and others.
However, they are also most likely to present with a barrage of challenging questions that need answering too. This can be a little daunting at first, and you can feel like you are in an exam But embrace it, be prepared for it, and you will be better for the experience.
So, what do we say to people?
I have compiled my own ‘myopia management’ leaflet (although we have CooperVision’s MiSight brochure and No 7’s Orthokeratology booklet in the practice too) and most people leave the practice with some reading matter. But before embarking on any lengthy discussion about contact lenses, it’s useful to allow the child (and the parents, if they have no contact lens experience) to physically handle a soft lens first.
People’s perceptions of what a contact lens actually is vary; I have lost count of the number of times I have been told that they had thought a contact lens was made of glass. With a child, I usually ask them to rub the lens gently between their finger and thumb and feel how smooth it is and then go on to explain that it just ‘floats on their tears’.
While not everyone we speak to will be able to interpret a graph, my most valuable visuals are the graphs showing the mean change in refractive error over a three-year period whilst wearing Proclear vs MiSight lenses (figure 4); in particular, the graph showing the differences between the eight to nine years old group and the 10 to 12 years group is a positively compelling response to the frequently asked question, ‘isn’t my child too young for contact lenses?’
Figure 4: Change in refraction from baseline by lens type and age group.3
How do we guide clients towards the best solution for them?
Some children just do not want to wear glasses, so orthokeratology is a great choice if the prescription and corneal shape allow for it. I am also fortunate to have been among the first practitioners in the UK to be able to offer MiSight 1 day – soft daily disposable lenses for myopia control.
Parents are often more familiar with soft lenses and can be more open to exploring this option with their children. I would encourage you to register your interest in this product if you have not already at coopervision.co.uk/misight-interest-registration. We have encountered several children, however, that really like their glasses and are not keen to give them up.
In fact, two children have agreed to be fitted with lenses to manage their myopia, provided they can continue to wear glasses, with non-prescription lenses. In both cases, after wearing contact lenses for a week, they had changed their minds about wanting to still wear glasses.
Aren’t children a nightmare to teach?
Over my years in practice, I will have taught application and removal to thousands of people. I can think of many adult nightmares, but very few involving children. Children are used to learning new things. They also have smaller, more nimble fingers and thumbs than their parents. It is really important not to make unfounded assumptions (figure 5).
Figure 5: The contact lens teaching appointment; do not make assumptions that children are challenging
For example, last year, I had two children booked in for teaches on the same afternoon. James was nine years old and Katie was 12. Most would expect Katie to have been more capable, but the reality was that James was amazing – he applied and removed his lenses on the first attempt with ease, whereas Katie, who I had assumed would take to lenses more readily, took seven half-hour teach appointments before she was ready to take her lenses away.
Is it worth it financially?
I have met many colleagues who are of the opinion that contact lenses are not worth the time invested and think that their day is better spent carrying out eye exams and selling glasses. The financial argument for a child wearing, say, MiSight, is somewhat different though; let us assume a -1.50 R&L prescription, and an income of around £60 for an NHS eye exam and a voucher A.
Rightly or wrongly, we do not charge anything for a suitability appointment, where we would carry out a slit lamp exam, topography, and place a pair of lenses on their eyes. We do this because we do not want a child to miss out on this opportunity for the sake of a professional fee.
Controversially, I will not always do a fluorescein check or lid eversion at this stage – if the child is nervous, I believe that it is better to alleviate their fears by getting the lenses in situ so they can experience the comfort and vision before performing the slightly more invasive procedures on them.
At the end of this first appointment, if a decision is made to proceed further, we then charge a fee of £80 for an extended trial, at which time we will complete the full contact lens assessment and carry out an application/removal teach and supply 10 pairs of MiSight 1 day lenses. In the earlier example, James will have clearly cost us a lot less practice time than Katie.
A follow up appointment is arranged for a week later and, in most cases, parents and child are more than happy to proceed. The first three-month supply is usually purchased at that stage (we credit £40 of the trial fee towards this first order (£120 less £40 = £80 to pay) and then a £40/monthly direct debit is set up to start the following month. And, if they are 10 years old, that is going to happen every month until they are about 18 years old, and beyond if they stay in lenses.
Even if multiple teaches are required, I cannot see how this is not more financially rewarding that a voucher A and an NHS sight test fee every year; although, without myopia management, that voucher A could soon become a far more lucrative voucher B.
The level of personal satisfaction gained in the knowledge that you are helping to lower the risks of myopia associated pathology later down the line, and that you are providing that young child with the ability to see without glasses with all of the positive benefits that brings, beats any financial gain that comes as a byproduct of your efforts.
David Gould is an award-winning independent practitioner with two practices based in the North-West of England.
References
1 McCullough S. Saunders K. Childhood myopia in the 21st century. Optometry Today. Sept 2017
2 Chamberlain P, Back A, Lazon P, et al. 3 year effectiveness of a dual-focus 1 day soft contact lens for myopia control. Presented at the 40th British Contact Lens Association Clinical Conference and Exhibition; 10 June 2017; Liverpool, United Kingdom
3 With permission from CooperVision 2018