Roundtable: Myopia management brought into focus
Optician recently brought together a group of parents and professionals to talk about myopia and its management. Chris Bennett reports
Author: Chris Bennett
Reams of research, hours of education and a clutch of contact lens launches have been dedicated to myopia management, but what are the levels of understanding and how keen are the profession and the public to get involved?
Optician and VTI convened a roundtable to delve into levels of understanding and attitudes towards myopia and myopia control and to gather real-life experiences of the patient journey from both perspectives.
Sarah Sanders is parent of two children, the older one of which is using VTI NaturalVue lens to control his myopia. Sanders wore contact lenses from the age of 16 but now wears spectacles to correct her -8.00 myopia. Her son had been wearing spectacles but wanted contact lenses to play sport.
Kate Souper started wearing glasses at 14 and later contact lenses for her -2.00 of myopia. Her daughter has had her vision monitored since the age of two, as her father is a high myope (-10.00), has been wearing spectacles since the age of three and has been on NaturalVue for 18 months.
Delegate Kieran Minshull is a contact lens optician and a director of LK Leon Optician London for over 30 years.
David Bennett, optometrist at Brooks and Wardman Optometrists and Contact Lens Practitioners, Nottingham, has also been in independent practice for 30 years. ‘I’ve been practising myopia control for the same amount of time,’ he said.
Indie Grewal, independent optometrist in St Albans, is also a 30-year veteran of optics and is currently president of the British Contact Lens Association.
Starting at the basic level, the chair asked the parents how comfortable they were with the word myopia, what it was and who might have it. Having had the advantage of training as a doctor, Souper said she knew what myopia was but admitted: ‘It’s a weird word and I would always talk about being short sighted.’
Sanders said she has an awareness of the word myopia but did not express any view on who might be at risk or what the reasons behind myopia might be. She said it was the advice of the eye care practitioner (ECP) that counted to her.
‘I knew that it could be hereditary,’ said Souper. ‘Both of my parents had it but my sister didn’t.’ She said her partner was very myopic [-10.00] so they made sure their kids were checked out. She had also heard about the role of daylight and the
developing eyeball and that types of light had been linked to worsening children’s eyesight. She had been told this was not true but had read further suggesting it could be correct. ‘We did try to encourage her [myopic daughter] to spend more time outdoors but it’s not her natural environment, she’s a bit of a bookworm.’ While her knowledge had led to her encouraging more outdoor time she pointed out her husband had spent hours and hours playing football outside as a child. ‘He still ended up as -10.00.’ She asked the other delegates if reading was a factor in eyesight, concluding: ‘I don’t know, I’m not an expert.’
The chair pointed out that on the NHS website it suggested reading and computer use were contributing factors to myopia and invited Grewal to offer a point of clarification. ‘It’s about keeping up [with the latest research],’ he suggested. ‘You are right Kate; outdoor time is important but what element of outdoor time helps kick the can down the road and stops them [kids] becoming myopic, we’re not sure.’ He suggested UV, the intensity of light and vitamin D could all be factors but he concluded: ‘There’s not an absolute reason.’ Reading and computer and tablet use have not been linked to myopia either, said Grewal. ‘What we do know is that lots of time at very short distances is a factor.’ He concluded that encouraging outdoor time for kids was good for a variety of reasons.
Bennett drew the delegates’ attention to the myopia profile website (www.myopiaprofile.com), which he said was a great resource for parents and professionals. He highlighted a recent paper by Professor Ian Flitcroft that showed how large amounts of myopic defocus across the visual field during outdoor time compared with hyperopic defocus when indoors could delay the onset of myopia but evidence that that slows progression is very limited. Equally, the latest papers on myopia are inconclusive about the role of computer, tablet and smartphone screen in the onset of myopia.
Virtual panelists, clockwise from top left, Kieran Minshull, Chris Bennett, Sarah Sanders, Kate Souper, Indie Grewal and David Bennett
The chair said arguments using such terminology might prove problematic for parents to process and asked how ECPs approach the topic with their patients. ‘It’s a difficult balance,’ said Minshull, ‘It’s trying to get the message across quickly without complicating the issue so they get the take home message.’ Grewal said it was important to stress that implementing such changes was putting off myopia, not necessarily slowing it down. ‘You are kicking the can down the road, but the further you can kick the can the better ultimately.’
However, there are clearly mixed messages going out to parents. Sanders said she had been advised to encourage her children to get more time outdoors but she said real-life does not always enable that. ‘When you have got a 14-year-old boy they are either on the PlayStation or the laptop or they could be running around playing rugby. You go from one extreme to another.’ She said she did try to encourage outside time but was left thinking myopia might just be down to genetics. ‘Is there that much we can do?’
Souper said despite her husband’s -10.00 correction she was not given any advice to encourage her daughter to spend time outside. ‘When I first brought up spending more time outdoors, [with her ECP] because I had read something about it I was told it was a load of rubbish,’ she said.
Bennett highlighted the need for education and said that was not something that should be confined to discussion with parents. He said he always makes the child the centre of the discussion. ‘The profession has a communication problem with parents,’ continued Bennett. ‘How to talk to them about myopia in the first place let alone myopia control because that’s a whole separate concept.’ He said if the profession can’t get the concept of short sightedness and why it happens across to patients it’s missing a big trick.’
The chair drew the panel’s attention to advice on the NHS’s website that suggested myopia ran in families but was exacerbated by screens and reading. ‘That’s wrong,’ interjected Bennett: ‘But it doesn’t surprise me about the NHS because they are generally a little bit behind the curve. Sites like www.myopiaprofile.com are right on the ball, bang, smack, up to date.’
Minshull suggested a lot of parents were aware of the genetic element but took little action. He gave an example of a child brought in during the summer, the parents had no concerns about the child’s vision but on refraction she was -4.00. The mother and father both had corrections around -8.00. ‘The alarm bells should have started to sound a lot earlier and we were quite flabbergasted when we found out the prescription. Others may be in denial.’ He used the example of a child whose correction was increasing rapidly, reaching -3.25, when the practice suggested he absolutely needed to be corrected. The parent’s reaction was ‘does he really?’
Grewal said he had experienced a similar issue. He had spoken to a parent about being ready for myopia. The first time the parent brought the child in he was examined and was already -3.00. The parent was ‘absolutely mortified.’ He said the profession should present myopia as it is classified, as a disease. ‘That way we may have more success in getting parents to bring their children in for a full assessment.’ None of the parents present realised that myopia was classified as a disease. Both Bennett and Souper took issue with the classification. Souper asked what the process was for the disease while Bennett did not think ECPs should be telling parents their kids have a disease because it suggested that it could be cured.
Returning to patient stories, Bennett said he found myopic parents the easier ones to deal with because they understood what it meant to be myopic whereas the children themselves often do not. He added that a child sees what it sees and it does not surprise him when they come in at -3.00 and do not complain. Children are great at covering up for myopia and if they can read they may not know there is anything amiss. Although it is ridiculous, parents often blame themselves. ‘The harder ones to deal with are parents who don’t wear glasses,’ Bennett said. He puts the parent in the chair and mimics the child’s vision to show them what it’s like. ‘Then they realise what the situation is and we can have the conversation about myopia.’
The chair then asked about the emotional impact of myopia. Sanders said her son was 14 when he first had to wear glasses and was quite relaxed about it. ‘I can’t remember him getting upset or concerned, he was probably happy that he could see.’ Souper joked as a -2.00 she laid the blame squarely at her -10.00 partner’s door. Her child had been tested since the age of two. ‘She’s worn glasses all her conscious life.’ As she now wears contact lenses six days of the week it’s nice to have a break. As she gets older that may change, said Souper but: ‘So many more kids wear them nowadays.’
Bennett said while there is definitely an ‘excitement to see’ from newly-corrected kids it does not always go well. ‘I’ve had a couple of kids just breakdown, outside the consulting room, saying “I’ve gotta wear glasses.” That’s a whole different conversation with mum and dad and an empathy line that it’s not their fault and if they can see better then that’s really good.’ The spectacle wearing experience is also transformed since the old NHS 524s, there’s so much more choice. Grewal agreed that there had been a generational shift. Technology had transformed contact lenses which were now a viable option for most patients today, including children. ‘That is so much so that we will offer contact lenses over spectacles as the first correction.’
Minshull agreed that it was now no longer a big deal for children to be prescribed glasses because it is such a cool thing. He has had children trying to fake an eye exam so they can be prescribed glasses: ‘my daughter is one of them.’
But that is not to say parental guilt has completely gone away said Grewal. He explained that in cases where neither parent is myopic and their child is, the first question they will ask is ‘why?’. ‘You try to placate their guilt a little bit by saying it’s not them but they want the answer to the question.’ That is when you have to start the conversation about outdoor time and the use of mobile devices. ‘You have to hint at something, but parents can feel really guilty about their child’s inadequacies, if you want to call it that.’
The dangers of high myopia are well known by the profession but neither of the parents seemed aware of the risks. ‘I’m a -8.00 so I guess I’m getting there,’ said Sanders. She had an expectation that her son’s myopia would progress but is hopeful it can be maintained around -2.00. ‘It’s not at my level, let’s hope he has his dad’s genes and not mine.’ Sanders said she only had that first conversation with her ECP when her son started myopia control. She already has floaters so appreciated the later dangers. ‘I was then aware that if we could keep it low it would be better for him in the long term.’
With her daughter’s prescription at -6.00 Souper said she had not had discussions about controlling myopia progression until she heard about the NaturalVue lens. ‘In my mind I always expected her to get to about -10.00. That was pre having these special lenses because that has virtually stopped it [myopia] in its tracks.’
Grewal said pathology had to be discussed but not dwelt upon. ‘We know that the younger a child becomes myopic it’s inevitable that they are going to progress.’ Once it has developed to a high level retinal detachment, glaucoma and myopic maculopathy and cataract are all possible complications.
‘If we know we are looking at children who are progressing at a young age we can have a discussion with the parents about what we can do to slow down this progression and talk about the alternatives,’ added Minshull. He said it is important to get all parties to engage and to explain the importance of intervening. This will seem like light years away for the kids but the parents will get the importance. Avoiding pathology cannot be the be all and end all, but it is down the list.
Grewal said he asks all his patients if they have children and start to plant the seed of myopia management before the child has set foot in the practice. ‘There’s a desperate lack of
awareness in the general public around myopia control, particularly orthokeratology,’ said Minshull. Patients are constantly surprised that they had never heard of orthokeratology and ask why there is not ‘some great body’ spreading the word. ‘They ask why could they not have started two years ago to stop little Johnny’s prescription from changing.’ But, asked Minshull: ‘Where is that information going to come from? Should it be government lead, should it be NHS lead. There needs to be so much more done in terms of educating the population.’
Grewal said the optical bodies needed to catch up. ‘Our problem is that the governing bodies haven’t properly recognised that it’s a significant problem and that the solution is there to slowing myopia, so the profession hasn’t taken it up as quickly as they could.’
Neither of the parents present were aware of orthokeratology and had not been aware of soft lens options for myopia management until their children took up NaturalVue. Souper said the idea of her child wearing hard lenses had been discussed but her own experiences with discomfort had put her off. Sanders said she was unsure how the whole arrangement of wearing a lens overnight might work and the effect on her child’s eyesight but it had not been discussed anyway. Minshull said one aspect of orthokeratology was that parents remained in control, application and removal was all conducted at home, which some parents liked.
Providing some points of information, Grewal explained to the parents that while orthokeratology had been the choice of lens available for potentially controlling myopia , soft lens options, which use a multifocal type of design, had been employed more recently.
Having been brought up to speed on the options to control myopia the chair asked the parents how they felt about the information they had been given. Sanders said it was only because of her son’s sport that the idea of contact lenses arose. ‘The optician said you can have some normal contact lenses or there’s these myopic lenses that might help slow his
progression down. When he was in glasses I can’t remember any conversation other than general advice.’ The only advice given had been: ‘not to let him wear his glasses too much.’
Sanders suggested she might not have had conversations about high myopia problems later in life because her son’s correction is still quite low, despite being a -8.00 herself. Bennett said the profession was not very good at understanding how myopia might progress. ‘What has happened in the past is not a good predictor of what might happen in the future.’ Given that the NHS’s website does not mention myopia control is it any wonder that there are not hordes of patients demanding it? ‘That’s not happening because it’s not out into the wider psyche. Hardly any parents mention contact lenses when they come for an eye exam, let alone myopia control contact lenses, they are just thinking of specs. The profession is pretty bad at promoting lenses and they’ve been around for yonks. I’ve been fitting orthokeratology lenses for nearly 30 years.’
Grewal said he had seen a surge in people seeking myopia management because they had become aware of other children using it from his clinic. ‘They have sought us out to ask why their child is becoming more myopic.’
Sanders said since adopting the lens she had tried to spread the word and has mentioned it to other parents.’ People have asked and we explain about the lenses but I don’t think many people know.’ Souper agreed that parents will wait until the push for myopia management comes from their eye care professional. ‘I do talk about it and everyone has said, “wow that’s amazing”, so it’s not like they already know.’
Turning to the professionals, the chair asked if the time had come when not offering myopia management was unacceptable. ‘We are responsible for our patients and we have a duty of care to inform them of the risks of myopia, but also that there are contact lenses and spectacle lenses out there that can help slow it down,’ said Grewal. The College of Optometrists advises that even if a practice does not offer myopia control it has a duty of care to talk about the risks of myopia and the risks and benefits of myopia management. ‘If you don’t do it you should be referring them on to someone who can,’ he concluded.
‘It’s absolutely essential,’ said Bennett. ‘If you’re not doing myopia control yourself and you don’t mention it to people you’re not doing your job properly.
He recognised that education was a slow burn process and the understanding of myopia control was getting out into the community very, very slowly. ‘It’s a bit like presbyopia lenses, we had a big push on them 20 years ago and they are just becoming more mainstream.’
Obstacles in the road
So, is lack of confidence, confusion over techniques or chair time stopping ECPs from recommending myopia control? ‘It’s a combo of all three,’ said Bennett. There is a time constraint in the high street plus teaching and education must be factored in. There are also limitations to be considered. Souper said at -6.00 her child was too myopic for ortho-k, but could wear NaturalVue when it became available. Minshull said most high myopic youngsters are picked up early but there are occasions when a child of -6.00 or -7.00 comes into practice. ‘We all know there is only one direction that this is going to go and that’s upwards.’ It is technically possible to try orthokeratology but it is at the limit. MiSight goes up to -6.00 but for even higher corrections NarturalVue has become available for corrections up to -12.00. NaturalVue offered ‘another tool in the box’. He said the lens had worked really well and he had transferred patients from orthokeratology to it for a range of reasons.
With the tools in place and ECPs increasingly interested the chair asked if parents are enthusiastic when they find out about myopia control? Grewal said he has had parents happy to leave their myopic children in spectacles and then only start considering myopia control when the level has already progressed.’ However, he said ECPs must be respectful that some parents do not want to have that additional concern of their children wearing contact lenses. Others may assume their child cannot handle their lenses or is not mature enough.
For some parents there will be limitations, said Souper. ‘Having just paid for another set of 60 pairs for some parents it’s just not going to be financially doable. You need to be up front about that and some parents will feel awful that they are not going to be able to afford x hundred pounds a year because that would mean the family can’t go on holiday.’
Minshull suggested involving children in the discussion. ‘They are all too well-aware of the implications of wearing glasses and could well be over the moon about wearing contact lenses or having myopic correction.’ He said if the parents see how enthusiastic they are about myopia control it could make them think in a different way. That conversation can continue at home.
Delving into the emotional impact of controlling or not controlling myopia the chair asked if parents might be left feeling guilty? ‘Certainly not in my practice,’ said Grewal, ‘because that conversation starts as early as possible.’ Looking at Souper’s situation he suggested her child at -6.00 would have seen ECPs when action could have been taken earlier. Souper said she could not be certain about waht she had been offered but would have seen myopia control as something positive. ‘If they had said: “If she has these [lenses] it will almost definitely slow it down”, I would have done it. As soon as it [myopia control] was mentioned we said: “Right we are doing this”,’ she added.
‘There’s enough parental guilt as it is, no matter what you do,’ joked Sanders. She had gone in to practice with her son for contact lenses to play sport not for myopia control. ‘They said you can have these lenses or you pay twice as much and these lenses will help control short-sightedness. We were in a financial position to do it, so it wasn’t really up for discussion, we just got the better lenses.’ She was hopeful, but open-minded, about controlling myopia. ‘You talk as if it’s going to [control myopia] but you are still taking a chance. If the science is there it should help,’ she concluded.
The chair asked if ECPs ran the risk of angering parents if they did not talk about myopia control. Grewal said he had seen parents unhappy they had not been told, but it was still a new topic for the profession. Bennett said awareness was growing and from a CET point of view there was lots of information, but perhaps the profession was going about this the wrong way. ‘Perhaps we should be looking at influencers on Facebook or Twitter. We aren’t looking at them, but the kids are.’ Souper suggested Mumsnet was the kind of place that might hit the mark.
Minshull said the key was monitoring all young patients, not just for myopia but levels of hyperopia. Monitoring it and letting them know when we need to intervene. Managing parental expectations was also crucial.
Some young patients have been on orthokeratology for 15 years or more and there can be situations where a child goes from -2.00 to -3.00 and the parent has asked why the treatment has not stopped the myopia. ‘It’s not meant to stop myopia, it’s going to slow the progression. It’s a bit of a ticking time bomb. If you look at a child who was -1.00 last year and is -2.50 this year and you know for sure next year he is going to be -3.50; are you going to sit and wait and not do anything or are going to intervene and do something at least to slow it down? Even if it’s only 20 or 30% [effective] it’s better than doing nothing at all. If you do nothing it’s only going one way.’
Closing the discussion, the chair asked the parents if they were glad they have opted for myopia control.
Sanders had no qualms and her son’s myopia was now stable. ‘Just wanting contact lenses for sport, that’s how our journey began. He took to it like a duck to water. Getting the lenses in and out and that is what, I think, a lot of the parents are going to be worried about. He just got on with it.’
Some practicalities, such as dry hands, can be a factor in how the lenses fitted into everyday life but Souper found it a positive experience. ‘It’s had a really dramatic effect on my daughter. She went through a period when we had to get her in [for an eye exam] quite regularly and her numbers were just going up and up. In the first six months it [myopia control] just stopped it dead. They’ve been incredible, it really helped.’