About a decade ago, I was fortunate to attend a CET lecture by Professor Ed Mallen who outlined the many significant breakthroughs in our understanding of the mechanisms that drove myopic progression. He explained how a relative, under-corrected defocus in the retinal periphery could reduce to stimulus to axial elongation (figure 1, above). As a myope married to a myope and with two myopic daughters, I was curious about the potential for this breakthrough to evolve into mainstream optometry.
Developing Practice
While there had been some experimental intervention around the use bifocal soft contact lenses to manage myopia prior to that period, I could not help feeling that our recent, heightened understanding of the peripheral defocus mechanism could be the catalyst to a real breakthrough in mainstream clinical practice. Of course, the ability to place a relative under-correction in the periphery always leaned towards a contact lens intervention as the most obvious mode of delivery, I did not consider at that time that a spectacle lens could be designed to produce the same effect. We now know this is an option.
It was only after that lecture I really started to ruminate upon the significant health benefits of reduction in myopia to reduce the risks of glaucoma, myopic macular degeneration and of course retinal detachment (figure 2). In a family of myopes, I am never far away from someone concerned about floaters and flashes; there is a psychological price as well as tangible risk factors we myopes carry as a result of our elongated eyeballs.
Figure 2: Retinal detachment; an ever-present concern for myopes
Fast forward to 2017 and the BCLA conference in Liverpool and I was in the audience when the initial findings of a three-year study on the efficacy of CooperVision MiSight for reducing myopia progression were presented. This was starting to feel real; the data was compelling. Further data emerged showing that the benefits appeared to be ‘locked in’ and the suggestion that there was no ‘rebound’ after discontinuation of wear was enlightening. And all of this was being published against a backdrop of increasing concerns about what has been described as a global pandemic of myopia.
Professor Brien Holden’s team had, in 2016, set out the global challenge we all faced by publishing a prediction that 50% of the world’s population will be myopic by 2050. It felt like an alignment of unmet need and effective, proactive intervention was taking place.
Future Practice
And here we are in 2023. We have a seven-year MiSight study to demonstrate the efficacy of that product and we even have a number of spectacle lens interventions at our disposal (figure 3). It feels like myopia management has become mainstream.
Figure 3: Spectacle options are now available for myopia management
So, how do I think this will impact upon my role as clinical consultant to the Optical Consumer Complaints Service, and what would be my insights from nine years in that role that we can apply to this emerging area of practice?
At the time of writing, we have not yet had a case relating to the new generation of myopia management products, but we know one will be coming our way. Historically, we have seen a number of complaints relating to orthokeratology, and these have been useful for us to help shape our thinking and what advice to offer eye care professionals concerning expectation management and how to define what good looks like.
I would categorise the complaint risks into two possibilities:
- ‘I am disappointed with the result!’ This, I would term as a risk of commission.
- ‘Why didn’t you tell me about this?’ This I would call a risk of omission.
Risk of Commission
If I take the first, I think a well articulated and balanced outline of the latest data and the use of point-of-sale materials, combined with a direction to online resources for further reading, can form the basis of a cogent and reasonable description. This allows parents to make an informed choice about whether to pursue a myopia management intervention. Write down the advice given and do not prejudge affordability. Disappointment in any outcome can thus be avoided.
What we must avoid is over-promising, and we should adopt the habit of checking understanding with parents and children. Be clear about what myopia management is and also what it is not. Management is a touch on the brakes, a slowing down; it is not myopia cessation, nor is it myopia eradication.
When people are buying into a dream, there may be a propensity not to listen terribly well so we must make sure that we are sensitised to that risk. A simple consent form, in addition to good record-keeping, when commencing myopia management is an excellent way to ensure understanding and commitment by the parents to the process. And, of course, we should combine any optical appliance intervention with advice about increased outdoor activity as part of a more holistic approach to advice.
Risk of Omission
This is the area, I believe, that could prove much more difficult to defend in the future. Whether mum or dad agree to proceed with myopia management for their potentially progressively myopic child is their decision. However, I believe that any failure to have made them aware of myopia management options could be hard to defend in years to come (figure 4). As an evidence-based clinical profession, how can we fail to share the ever-growing data regarding the efficacy of these interventions?
Figure 4: Failure to mention all correction options, including myopia management contact lenses, to parents of young patients with potential for progressive myopia is likely to be hard to defend in future
This a now a fast-moving area of optometry. We need to be up to speed with the rapidly emerging research that aids our understanding of how and when to intervene. It is increasingly clear that the earlier we intervene, the better; that compliance with wearing schedules is key; that full-time wear appears to be more effective than part-time wear in slowing myopic progression in young myopes; the list goes on. How can we project ourselves as trusted eye health professionals and not be at the vanguard of this new technology.
I genuinely believe that we are now at the point where saying nothing is simply not an option.
Top Tips
- Soak up CPD in this area to keep yourself appraised of the rapid developments in myopia management.
- Enable parents to make an informed choice. Record your advice and consider the use of a simple consent document.
- Consciously develop your own ‘phraseology toolkit’ to inform effectively.
- Richard Edwards is an optometrist and clinical consultant to the Optical Consumer Complaints Service (OCCS).
- Look out for a more comprehensive discussion of this topic by this author in a CPD article to be published in Optician later this year.