Myopia Control: What’s all the buzz?
It seems that one could scarcely throw a figurative stone in optometric circles these days without hitting someone talking about myopia control or myopia management. The industry magazines, industry journals and both international and domestic conferences alike are awash with speakers, seminars, and workshops on the very subject.
I am aware of the obvious irony in pointing this out in the introduction of a myopia management article, but it cannot be ignored that myopia management is the optometric worlds current ‘hot button issue,’ sparking debates and intrigue the length of the UK and beyond. Social media channels and video blogging have added a new 21st century dimension, offering immediacy and haste to the debate like never before.
The next contact lens revolution?
I entered the world of optics in 2003 with the industry in a similar state of flux over the introduction of another disruptive technological innovation in the form of the first generation of silicone hydrogel contact lenses. This new breed of contact lenses hit the market in 1999 with a raft of products to follow from balafilcon A,1 lotrafilcon A,2 galyfilcon A,3 lotrafilcon B,4 senofilcon A5 to comfilcon A6 and enfilcon A7 to delefilcon A8 and beyond.
These products positively changed the landscape of contact lens fitting forever, benefitting the practitioner and the public alike. But such innovations split the industry into the innovators and early adopters who are keen to embrace and exploit the benefits, and this is mirrored today in myopia management.
We have seen other seismic shifts in lens fitting practice and the creation of new lens categories within my lifetime – the advent of disposable contact lenses in the 1980s;9 the first disposable multifocal contact lenses in the late 1980s;10 the first daily disposable contact lenses in the early 1990s;11 the first daily disposable toric lenses in the early 2000s12 to name but a few.
The contact lens industry never stands still. As eye care professionals we have previously embraced such advances in lens technology, some of us more slowly it must be said, with many becoming industry standard almost immediately. Is myopia management and the use of contact lenses in the ‘treatment’ of myopia simply the next step on this journey? Does MiSight, as a soft daily disposable lens for myopia management, mark the start of the next contact lens revolution?
Instant access to information, including myopia control, is available through a huge variety of outlets
Starting a Myopia Management Clinic: My experience so far
For several years I had dabbled with orthokeratology (Ortho-K) and the off-label use of disposable multifocal soft contact lenses as a method of slowing or arresting the progression of myopia in children, having read articles about their use in industry journals. This required minimal effort, no upskilling, and no investment on my part as our practice already owned a corneal topographer for use in our specialist contact lens clinic and already fitted large numbers of patients with Ortho-K lenses and soft multifocals. The service was, during this period, only offered to children with aggressive rapidly progressing myopia or in instances driven by parental enquiry and therefore fairly low numbers.
Communication skills are vital at all appointments to create a great patient experience
What changed?
This lazy approach changed after my colleague Peter Ivins and I delivered a lecture at the inaugural 100% Optical Conference in London in 2014. We had the pleasure that evening of dinner with a longstanding friend of Peter’s and industry legend, the late great Professor Brien Holden and his colleague, Professor Kovin Naidoo.
Over a curry and a few bottles of red wine Prof Holden distilled down his immeasurable experience, intellect and understanding of the topic of myopia management, updated us on his ongoing research with the Brien Holden Institute and read me his list of myopia management clinical commandments. I left inspired and within a few weeks had setup a dedicated myopia management clinic in our practice, with Professor Holden’s words ringing in my years.
Success in myopia management: Building your toolkit
The beauty of myopia management in practice is that many of the skills required are already within the skillset of most eye care professionals. Building a toolkit of skills one can utilise during these consultations is important and can be divided into the communication toolkit, information toolkit, clinical toolkit and treatment toolkit. Each toolkit is in some way modular and can be added to over time as your experience and clinical expertise grow with regards to the subject.
Clinical and treatment toolkit
This will not be covered in detail in this article and has been covered extensively in other articles. For me this involved dusting off my prism bar, revisiting many aspects of my binocular vision assessment and practicing my dynamic retinoscopy in order to screen young myopes for esophoria, accommodative lag and elevated AC/A ratios.
I more readily conducted cycloplegic refractions on five and six-year-olds to look for outliers in emmetropization. I extensively researched treatment strategies including optical interventions in the form of progressive, bifocal and novel spectacles designs; bifocal and multifocal contact lenses (MiSight, Proclear Multifocal, Biofinity Multifocal and Mark Ennovy BluGen Multifocal) and orthokeratology contact lenses; as well as pharmacological interventions and behavioural strategies.
I have since attempted to form a treatment algorithm to select the best treatment strategy for each individual case, something I continue to tweak to this day.
Communication Toolkit: Communication is key
One of the biggest challenges in optometric practice in general is communication. This is true whether you are speaking with your team as an employer, speaking with colleagues as a fellow employee, or whether you are trying to communicate a clinical matter with a patient or parent.
The ability to adapt your use of language and tone, being mindful of your body language and being able to explain at times complex concepts to a wide demographic, from children to grandparents, of varying levels of education and from across the social spectrum is crucial to the potential success of myopia management in your practice. Success of myopia management in your practice will largely stand or fall as a result of your ability to effectively communicate the concept to your staff and more importantly your patients.
Two recent personal experiences offered excellent examples of the importance of good communication – one in practice, the other at home. Such experiences are invaluable if harnessed and, in my case, gave rise to a period of introspective, self-reflective pondering with the aim of self-improvement in my own communication skills.
Witnessing poor communication in my own consulting room
Our practice is enrolled in a programme which sees final year students from overseas visit practices including ours, as well as Messrs David Bennett and Brian Tompkins for a month to gain experience in different styles of practice in the UK. While both students visiting our practice were academically and clinically capable for their stage in training and development, one of the students was painfully woeful with regards to communication skills.
This was true both of interactions with our team and with patients alike. While being knowledgeable under scrutiny, his/her inability to integrate into our team, communicate even the most basic concept to a patient, or at times hold a normal conversation was horrendous to witness and will hinder him/her in the consulting room unless significant improvements are made. This served as a stark reminder of how things can go so badly and offered an excellent training opportunity to the rest of our team.
Being on the other side of the fence
The other recent experience, which over the course of a year, highlighted the impact of how health care professionals communicate information can extend beyond the duration of an examination and way beyond the consulting room.
My wife Jennifer (a dispensing optician) and I recently went through the life altering experience of becoming parents. This wonderful, beautiful but at times stressful experience delivered not only our first-born Noah McArthur (9lb 2oz, asking the weight seems to be the first question after the baby name, as per social convention) but also the opportunity to be ‘on the other side of the fence’ so to speak as the patient, witnessing the good, the bad and the ugly in communication skills.
The experience involved a plethora of doctors, nurses, mid-wives, and health visitor appointments. The experience with a hormonal wife during stressful appointments highlighted the importance of communication skills to the overall patient experience and general well-being of the patient.
When the doctor had a fantastic bedside manner and great communication skills we came away happy and confident, trusting what he/she had said. When a doctor had poor skills, we came away questioning the information and apprehensive. This apprehensiveness often continued until the next appointment, often several weeks later. This experience has changed how both my wife, who has just returned to work as our son approaches his first birthday, and I communicate with our patients.
Repetition breeds complacency
The repetitive nature of optometric practice can lead to communicative complacency, in my opinion, as many aspects of our day are so routine to us that after a few years we do not give them much thought. How we communicate to our patients can suffer as a result. Jennifer’s and my recent experience served as a reset button and triggered discussions between us about how and what we communicated with our patients.
Simple changes like introducing myself by name to every patient, something I had done for the first few years of my career but had grown lazy or perhaps too arrogant to remember to do every time were reinvigorated.
The experience of nameless individuals carrying out examinations on my wife had illustrated the importance of this simple gesture to us both. Terminally ill doctor Dr Kate Grange MBE had a similar experience and before her untimely death launched the #hellomynameis campaign, the aim of which is to remind healthcare staff about the importance of introductions in healthcare. This sentiment should extend to optometric practice.
The #hellomynameis campaign was created to remind healthcare staff about the importance of introductions in healthcare. Visit hellomynameis.org.uk for more information
The myopia management discussion
With regards to ‘the myopia management discussion’ one must be mindful of the delicate balance involved in explaining the problem of progressive myopia, overcoming the barriers and concerns of parents, and offering potential solutions or treatment options in an understandable manner that is scientifically accurate and morally acceptable, thus allowing patients and parents to make an informed choice about any suggested treatment plan.
It is important to not be overly gloomy with regards to the increased risk of glaucoma, maculopathy, retinal detachments, etc and have parents, and more importantly children, leaving the practice frightened for what the future may hold. It is also important not to oversell the benefits of our interventions.
However, providing enough accurate information about the very small risks associated with contact lens wear, versus the longer-term risks of myopia associated diseases in a balanced manner is crucial. I always like to remain upbeat throughout, stressing that we have been given an opportunity to influence proceedings and always like to end on a positive note of how lucky we are to have options available to us unlike previous generations.
To do this effectively, for me this involved swatting up on the topic with regards to myopia statistics, myopia associated diseases and the mechanisms of myopia development.
Having such information on the tip of my tongue for inquisitive parents and at my fingertips to send in an easy to understand format was important, whether in the form of a leaflet or email. As mentioned by David Gould in part two of this series, our friends ‘down under’ in the form of the Brien Holden Institute and optometrists Paul and Kate Gifford, and closer to home optometrists Nick Dash and Pascal Blaser have done an excellent job of bringing a lot of this statistical data to the fore for the jobbing, non-academic optometrists among us.
Such publications allow anyone new to myopia management or in need of a refresher to quickly access statistics and clinical papers, thus keeping us abreast of the latest clinical research available.
Dealing with difficult parents
One of the keys to communicating the concept of myopia management effectively is to be able to tailor your communication to your audience. This can be done in various ways, and if done correctly will allow you to engage with patients and parents quickly and with the optimum results. A one size fits all philosophy simply does not work.
There are many personality and communication preference models in existence (Insights, Myers Briggs) and in our practice we often use a modified version of the Herrmann Brain Dominance Instrument (HBDI) concept in hiring staff.13 But we also apply some of the principles to how we communicate with our patients.
The HBDI categorises people into blue, green, red and yellow sub-types, each with their own personality traits and we can exploit how best to communicate with each group. This technique can be applied to any conversation in practice whether explaining the benefits of one contact lens over another, the benefits of varifocals or the risk in an upcoming cataract surgery. Unlike a full HBDI assessment involving a lengthy questionnaire, our system is based on assumptions made during conversation. Often the individuals’ job will offer some clues too.
In my experience convincing children of the benefits of contact lenses is comparatively easy, meaning it is mostly likely the parents, particularly non-myopic or emmetropic parents, who will pose the biggest barrier. Most patients or parents can be loosely subdivided into different personality types – analytical (blue), structured (green), expressive (red), and the driver (yellow).
Analytical (Blue – Logical, technical and financial)
This group make decisions based on logical thinking rather than emotions. They expect facts and figures, requiring a deeper knowledge and understanding of a subject before making a decision. Being information-oriented and with an eye for detail they will likely respond best to use of a qualitative and statistical data. They will also quiz the financial implications of each option at length.
In a word think: Fact
As a profession think: Engineer
How to handle: Disease prediction tools backed up with clinical papers and good explanations of the aetiology and progression of myopia will be useful. Be ready for many questions and be patient as this group are slow decision makers. Know your pricing, as you will be quizzed.
Structured (Green – Organised, detailed and structured)
This group will base decisions on how well you have built credibility during your interactions and based largely on how well they trust you as a professional and the message you are delivering. They can be difficult to read, do not openly express their emotions and will not say much unless specifically asked. The are also perfectionists and will crave detail in your explanations.
In a word think: Form
As a profession think: Project manager
How to handle: This group require detail and structure. Use of animations such as those provided by Optimed in the Captiv8 software system may be useful. Providing a written treatment plan and expected time frame for each treatment option discussed is beneficial. Allowing them time to digest the information with a follow-up appointment to discuss things works well.
The Expressive (Red – Emotional, sensory and people)
This group are sociable, respectful, and trustworthy. They are often long-term, loyal patients of your practice. Unlike the analytical group they care more about building rapport and forming a relationship with you. They may openly exhibit an emotional response to the news of their child’s progressive myopia.
In a word think: Feelings
As a profession think: Teacher / Nurse
How to handle: Make yourself likeable by creating a good impression and recognising their presence. Asking questions that show you are interested in their opinion and including them in the decision-making process works well. Encourage discussions including personal experiences and use examples of how myopia management has helped other families helps this group connect with the concept. They tend to make decision quickly under the right circumstances.
The Driver (Yellow – risk taker, intuitive and big picture)
Individuals with this personality can be self-centred, opinionated and may dominate the conversation. They are goal-orientated and demand immediate answers and solutions. However, they value both your expertise and competence. Building your credibility is important. Drivers are fast decision-makers, so expect a yes or a no within the first conversation.
In a word: Future
As a profession: Entrepreneur
How to handle: Get straight to the point when explaining myopia management. Mentioning irrelevant or unnecessary information will be waste of your time and more importantly theirs, so be careful to mention only what is required in their child’s case. Be direct without compromising clarity and quality of your message. Provide succinct facts and evidence to help them easily understand your message and make quick decisions.
Conclusion
MiSight has lowered the point of entry for many considering the use of a myopia management strategy due to the relatively low risks associated with daily disposable wear when compared to the perceived risks with soft monthly lenses and orthokeratology. It has also lowered the entry point with regards to the technology required and the clinical skillset in contact lens fitting, thus opening the opportunity to potentially more practitioners.
The success of myopia management in your practice will rely largely on your ability to effectively communicate the concept to your patients and their parents. As a one size fits all philosophy is unlikely to work, it is important that we tailor the information we offer to each individual family. For the first time we may be able to proactively influence the development of myopia rather than cleaning up what nature has thrown at us, I personally find this opportunity exciting and one to be embraced as our understanding improves.
References
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2 Alvord, Larry, et al. “Oxygen permeability of a new type of high Dk soft contact lens material.” Optometry and vision science: official publication of the American Academy of Optometry 75.1 (1998): 30-36.
3 Kodjikian, Laurent, et al. “Bacterial adhesion to conventional hydrogel and new silicone-hydrogel contact lens materials.” Graefe’s Archive for Clinical and Experimental Ophthalmology 246.2 (2008): 267-273.
4 Dillehay, Sally M., and Marian B. Miller. “Performance of Lotrafilcon B silicone hydrogel contact lenses in experienced low-Dk/t daily lens wearers.” Eye & contact lens 33.6, Part 1 of 2 (2007): 272-277.
5 Riley, Colleen, Graeme Young, and Robin Chalmers. “Prevalence of ocular surface symptoms, signs, and uncomfortable hours of wear in contact lens wearers: the effect of refitting with daily-wear silicone hydrogel lenses (senofilcon a).” Eye & contact lens 32.6 (2006): 281-286.
6 Lakkis, Carol, and Kate Weidemann. “Clinical Evaluation of a New Non–Surface Treated Silicone Hydrogel Lens During Continuous Wear.” Investigative Ophthalmology & Visual Science 47.13 (2006): 2395-2395.
7 Szczotka-Flynn, Loretta. “Looking at silicone hydrogels across generations.” Optom Manag 43.5 (2008): 68-71.
8 Hill, Gregory A., et al. “Comparative measurement of coefficient of friction of contact lenses: the need for an industry standard.” Contact Lens and Anterior Eye 35 (2012): e10.
9 Woods, Craig A. “Acuvue in independent practice.” The Journal of the British Contact Lens Association 12 (1989): 33-36.
10 Saunders, Brenda D. “The optical performance of bifocal contact lenses ‘in vivo’.” Journal of The British Contact Lens Association 12 (1989): 71-74.
11 House, Harry O., et al. “Contact lens daily cleaner efficacy: Multipurpose versus single-purpose products.” International Contact Lens Clinic 18.11-12 (1991): 238-245.
12 FDA, Alcon Affiliate Receives. “CIBA Simplifies Contact Lens Selection for Astigmats.” Optometry and Vision Science 80.11 (2003).
13 Bunderson, C. Victor. “The validity of the Herrmann Brain dominance instrument.” The creative brain (1989): 337-379.