Ernie Bowling, OD, FAAO

is in practice in Rome, GA, and is past chair of the American Academy of Optometry’s Comprehensive Eye Care Section

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The desire to control myopia progression in children has been around for quite a long time. For good reason: the prevalence of myopia is increasing and many visual and pathological complications come from high myopia. There are many interventions designed to inhibit myopia progression. But of the therapies at our disposal, are some better than others? It is an important question to answer for both ourselves and our patients.

Related: Unlock the potential of refractive surgery

A recent study published in BMC Ophthalmology addressed that very question.1 Researchers from Greece and the United Kingdom performed a synthesis of systematic reviews and meta-analyses of published literature investigating the efficacy and safety of multiple myopia interventions vs control conditions. Their target was myopic children and adolescents less than 18 years of age without ocular comorbidities, including strabismus and amblyopia.

Primary outcome measures regarded myopia progression as a mean change in refractive error measured in diopters and axial elongation measured in millimeters. The outcomes assessed included change in refractive error and change in axial length from baseline to one year and from baseline to two years.

Forty-four unique primary studies contained in 18 eligible reviews published between 2002 and 2017 involving 6400 children were included in the analysis. Of the 18 studies, four studies investigated atropine, four analyzed orthokeratology, two focused on outdoors exposure, one examined the efficacy of acupuncture, and two investigated the use of multifocal lenses. The remaining five examined multiple interventions for myopia control.

Related: 10 things I wish I knew earlier about vision therapy

The findings of this study suggests atropine eyedrops appear to be more effective for myopia control compared to spectacles or contact lenses. Their findings mirror the consensus published by the World Society of Pediatric Ophthalmology and Strabismus (WSPOS), which reported that atropine is the most beneficial intervention for myopia progression control.2 The findings from this study showed no dose dependence and no difference in the efficacy of atropine across different doses in the range of 0.01% to 1%. However, the five-year results from the Atropine in the Treatment Of Myopia (ATOM2) study supported binocular daily application of 0.01% atropine as the safest and most effective concentration for restricting myopia.3

Related: How to differentiate CTK from DLK in post-surgical patients

Orthokeratology also demonstrated effectiveness in retarding myopia development compared to other types of lenses, but orthokeratology side effects have resulted in this treatment presenting higher dropout rates compared to other myopia interventions.4 Peripheral add multifocal contact lenses also appear to be effective, showing no refractive changes in a year and has a low reported risk for infectious keratitis.

Increased outdoor exposure is yet another myopia-controlling intervention for which the mechanism of action has not been clarified. A systematic review and meta-analysis analyzing up-to-date evidence showed outdoor exposure appears to provide protection from myopia onset in non-myopes but does not result in restriction of myopia progression in already myopic individuals, according to one study.5

On the other hand, a randomized controlled trial reported a beneficial effect of outdoor exposure in both nonmyopic and myopic individuals.6

Related: Refractive surgery in 2020: From minimally invasive LASIK to light adjustable lenses

Under correcting the full refractive error has been used with debatable results. One study showed that full correction reduces progression of myopia compared to under correction over a two-year period of treatment.7 But a more recent study on 121 Chinese children proposed that no correction at all was effective in slowing myopic progression and axial elongation compared to prescribing the full correction.8

Related: Comanaging intraocular lens power calculations

The data from this review suggests atropine followed by orthokeratology and multifocal soft contact lenses demonstrate efficacy in controlling myopic progression. It remains unclear if atropine or orthokeratology could lead to a permanent longterm effect on myopia control. Possible rebound effects upon treatment cessation also need to be assessed.

This review can give practicing optometrists insight in treating patients seeking myopia progression control. The topic is going to gain even more attention in the future, so it is in everyone’s best interests to be aware of available therapies.

More by Dr. Bowling: Dr. Ernie Bowling discusses dry eye in the digital age

Articles

Meta-analysis investigates multiple myopa management interventions vs control conditions.

Safety and efficacy of myopia progression therapies in children

Looking at studies shows that contact lens wearers continue to abuse lens wear by not following wear recommendations, care regimens, or replacement times. Even with advances in contact lens science, such non-compliance remains a significant problem. Reinforcing education and training plus prescribing daily disposables may help improve compliance.

 wearers as “the junkies of eye care.” I mean, these patients have a tendency to abuse just about every aspect of contact lens wear-care regimens, replacement schedules, wearing time. You name it, they ignore it.

And for that same amount of time I have blamed myself for these patients’ failings. Perhaps I am not explaining the importance of compliance, I thought, or perhaps I am not emphasizing how serious the complications of abusing their contacts could be.

Related: Know the hidden links among glaucoma, contact lenses, and the cornea

So, to help clear up my angst about this situation I decided to do some quick online research.

The first study I found was among a group of young, university-based contact lens users in South India.

 wearers with an age range of 18 to 22 years were questioned regarding their compliance with soft contact lens care with a focus on contact lens wearing habits, cleaning and disinfecting procedures, and maintenance of lens care accessories.

Only 34 percent of the subjects maintained a satisfactory level of compliance. Twenty-three percent of those who participated in this study reported that they wore their lenses longer than the recommended daily wearing time. Some 5.6 percent of the contact lens wearers studied admitted they slept overnight with their contact lenses against the prescriber’s recommendations.

This mirrors the results of another study conducted around the same time in which 24 percent of wearers reported overwear of their contact lenses.

 It has long been recognized sleeping in contact lenses carries a five times greater risk of microbial keratitis compared with daily wear of lenses.

Related: How to succeed with multifocal contact lenses

These studies were five years old. Surely things have improved since then.

The most current numbers I found were from a study conducted in Ohio,

 and the results were not much different. Of 297 subjects participating in this study, non-compliance with replacement schedule was reported in 38.7 percent of subjects. Non-compliance with prescribed overnight wear was reported in 23.9 percent of subjects in the report.

Related: How the blink affects contact lens wear

In yet another study, a total of 40 percent to 74 percent of contact lens wearers did not replace reusable contact lenses on time and in recommendation with the manufacturer’s recommended replacement frequency. In that same report approximately 6 percent of patients reported intentional overnight 

 wear in lenses that were not designed or approved for extended wear.

I find these results amazing because eyecare professionals know the disease load is reduced by 60 percent to 70 percent by simply avoiding overnight lens use.

To add insult to injury, subjects who were non-compliant with lens replacement were more likely to be non-compliant with overnight wear. Daily replacement wearers were most likely to be compliant with contact lens replacement, but all subjects, including daily replacement wearers, had similar overnight wear non-compliance.

There is also a disconnect between what the patient sees as acceptable compliance with 

 wear and care and what the practitioner sees as acceptable behavior. In both of the 2014 studies, survey respondents considered themselves to be compliant.

Related: Corneo-scleral topography allows for precise fitting

I have figured out that patients’ non-compliance with 

Related: Laser vision correction: Look backward to move forward

Although the industry has seen remarkable advances in contact lens science, noncompliance with lens-wearing schedules, replacement schedules, and lens care regimens remains a significant problem. Noncompliance is present across demographic groups and patient types.

 Because it is obviously impossible to convince all contact lens wearers to replace their lenses according to manufacturer recommendations, it is up to the contact lens practitioner to find some way to reduce the risks of 

The first step is proper patient education and training. As the studies show what we feel is acceptable is quite different than what the patient believes and subsequently what the patient actually does. Constant reinforcement at the time of exam and at all follow-up visits is the first step. Asking the patient to demonstrate how he cares for his lenses often reveals care errors.

Consider switching non-compliant patients to a daily disposable lens. The 2019 Ohio Study

 showed daily replacement wearers were more compliant than two-week and monthly replacement wearers with prescribed lens replacement.

Combine this with the fact daily disposable lenses are associated with a 12.5x lower risk of corneal infiltrative events compared with reusable lenses,

 and it seems the first step is to get patients to a daily modality.

More by Dr. Bowling: Experts offer advice to ODs starting dry eye subspecialty

1. Noushad B, Saoji Y, Bhakat P, Thomas J. Contact lens compliance among a group of young, university-based lens users in South India. Australas Med J. 2012;5(3):168-174.

2. Gyawali R, Nestha Mohamed F, Bist J, Kandel H, Marasini S, Khadka J. Compliance and hygiene behaviour among soft contact lens wearer in the Maldives. Clin Exp Optom 2014 Jan;97(1):43-47.

3. Reuff EM, Wolfe J, Bailey MD. A study of contact lens compliance in a non-clinical setting. Cont Lens Anterior Eye 2019 Oct;42(5): 557-561.

4. Ramamoorthy P, Nichols JJ. Compliance factors associated with contact lens-related dry eye. Eye Contact Lens 2014 Jan;40(1):17-22.

5. Stapleton F, Carnt N. Contact lens-related microbial keratitis: how have epidemiology and genetics helped
	us with pathogenesis and prophylaxis. Eye (Lond). 2012 Feb;26(2):185-93.

6. Yeung KK, orister JF, Forister EF, Chung MY, Han S, Weissman BA. Compliance with soft contact lens replacement
	schedules and associated contact lens-related ocular complications: the UCLA contact lens study. Optometry. 2010
	Nov;81(11):598-607.

7. Chalmers RL, Keay L, McNally J, Kern J. Multicenter casecontrol study of the role of lens materials and care products
	on the development of corneal infiltrates. Optom Vis Sci. 2012 Mar;89(3):316-25

Doctors should not blame themselves but look to better patient education and daily disposability.

How ODs should handle non-compliance with contact lens replacement

Four dry eye experts offer their suggestions to ODs who are interested in adding a dry eye clinic to their practices. Their suggestions include having a passion for dry eye instead of following the masses, creating a dry eye protocol, honing needed clinical skills, and incorporating patient questionnaires.

 information available to ODs by a variety of channels. Lectures, articles, workshops-all for us to improve our dry eye diagnosis and treatment skills.

But how do you get started? Often the first steps in any process are the hardest.

Related: Your glaucoma patients also have ocular surface disease

I had the good fortune to discuss just this with four leaders in the dry eye field:

– Whitney Hauser, OD; director of clinical affairs at Keplr Vision, founder of Dry Eye Coach and Signal Ophthalmic Consulting

– Scott G. Hauswirth, OD, FAAO; assistant professor, department of ophthalmology at the University of Colorado School of Medicine – Tracy Swartz, OD, FAAO; in group practice in Madison, AL

– Crystal Brimer, OD, FAAO; in private practice in Wilmington, NC 

To each of them I posed one question: What advice would you give to an OD wanting to start a 

A passion for the topic was mentioned by both Dr. Hauser and Dr. Swartz.

“Don’t treat dry eye because everyone else is,” offers Dr. Hauser. “Don’t be peer pressured into it. Have an interest in 

 and want to pursue it, otherwise you’ll quit.”

“You have to have a passion for dry eye,” adds Dr. Swartz.”You sincerely have to want to make the patient better.”

Related: New guidelines in OSD evaluation before surgery

Related: Minimize symptoms of dry eye disease in refractive surgery patients

Every person in the practice needs to be on board with adding 

“Commitment takes a team effort,” says Dr. Hauser. “You need staff buy-in to the project. What are you going to do internally?”

Dr. Hauswirth suggests that ODs first train themselves to be an observant clinician before fully jumping into treating dry eye.

, and then there are a lot of masqueraders,” he says. “You have to become a good problem-solver.”

Dr. Brimer made an interesting point: “What one thing am I going to do that is so easy I can’t say no to it? Create a space and time for it,” she says. 

Related: Treat dry eye disease first, address comfort next

Several ODs suggested that the first step in starting with dry eye testing is developing an office protocol.

Dr. Hauswirth recommends ODs interested in treating dry eye should begin with improving skills.

“Use your vital dyes, use your eyes, and perhaps invest in one or two things to get started. Don’t invest a ton of money into diagnostics until you get good at the basics,” he says.

Dr. Hauser agrees. “Spending money isn’t hard,” she says, “but don’t do that at first.”

“I use staining patterns, InflammaDry (Quidel), Standard Patient Evaluation of Eye Dryness (SPEED) scores, topography, and meibomography,” adds Dr. Swartz.

Related: Do ODs take chronic inflammation seriously?

The docs also recommended the use of a patient questionnaire to track symptoms.

Says Dr. Swartz: “I use the SPEED survey, but the important point is to make use of a patient survey,” Dr. Schwartz says.

Related: Amniotic membrane grafts help ocular surface disease

“The majority of offices do not make use of surveys,” adds Dr. Brimer.

Dr. Hauswirth suggests that ODs become familiar with gland expression and closely examining lids, glands, and the ocular surface in general.

“Understand what environmental stressors contribute,” he says. “Evaporative stress may be different in Colorado than in South Florida, for example.”

Related: Why OAB should be considered before cataract removal

The doctors agree that screening patients is a great way to get started in treating 

“Play in your own sandbox before seeking referrals,” says Dr. Hauser. “Primary-care patients have dry eye. Don’t let your normal patient flow camouflage the dry eye patients in front of you.”

Dr Brimer agrees that most practices have untreated dry eye patients already there. “Doctors and staff have to realize how prevalent dry eye is in their offices,” she says.

“Doctors have no idea how many people are suffering from dry eye in their practices. A lot of dry eye patients are missed because the patient isn’t complaining. A consistent screening process of every patient will identify those patients.”

Dr. Brimer recommends that ODs screen every patient for dry eye.

Related: Modern-day techniques for diagnosing dry eye disease

Dr. Hauswirth agrees: “You have to look for 

,” he says. “Optometry-like most of medicine-is a reactive profession. To treat dry eye well, ODs have to be looking for changes before the patient has symptoms.”

Related: How to address the three aspects of dry eye disease

The ODs recommend starting small initially.

“Don’t overthink it,” recommends Dr. Brimer, “and don’t be overwhelmed, either.”

Dr. Hauswirth suggests ODs attempt to learn from every single case in order to become a dry eye expert.

“Learn to keep an open mind when approaching a patient,” he says. “

 is a puzzle, and you have to get good at problem solving.”

Dr. Swartz says ODs needs to really listen when talking with patients.

“Plus, eyecare practitioners are constantly changing what they think about dry eye. You have to be willing to adapt,” she says.

Remember that what works for one practice may not work for another, according to Dr. Hauser.

“Figure out what fits into your practice, then make it work,” she says.

More by Dr. Bowling: Remember the basics as dry eye treatments expand

From developing an office protocol to screening all patients, read these supportive tips.

Experts offer advice to ODs starting dry eye subspecialty

 is a topic eliciting much discussion among our colleagues. Many of us dive headlong into the topic. There has been an explosion of information about the condition in the last decade, every continuing education meeting has several presentations on the subject, and a cottage industry has sprung up concerning diagnosis and management of the disease. For good reason. What was once considered an afterthought in our 

 has been shown to be ubiquitous and has become an inevitable public health problem.

Dry eye is one of the most common ophthalmic conditions, affecting hundreds of millions of people worldwide. 

affects five percent to 30 percent of the world population 50 years and older, with women representing approximately two-thirds of those affected.

 The disease is increasing in younger patients.

Dry eye has a significant impact on quality of life due to chronic symptoms of ocular pain and discomfort in addition to functional vision impairment. Dry eye can impact functional vision, interfering with everyday activities such as driving, reading, computer usage, watching television, and work performance.

 Dry eye negatively impacts mental health as dry eye patients report higher rates of anxiety and depression.

Dry eye disease is among the most common reasons for visiting eye care practitioners and represents a substantial health and cost burden. Financially, dry eye is estimated to cost $3.84 billion per year to the healthcare system with an average annual cost of $783 per patient for treatment.

So, it is obvious that a lot of patients are suffering with dry eye. Dry eye is everywhere, going undiagnosed/underdiagnosed/undertreated, and our patients need our help. It is in our patients’ best interests to properly recognize and treat the condition.

Still, with the abundance of information available, it is easy for one to be overwhelmed with the data available. Where to start? How do I start? Do I really need all the bells and whistles available in the marketplace to properly diagnose and treat dry eye?

Which is where this project comes in. Over the course of this coming year, we will explore developing a dry eye subspecialty within optometric practices.

We will cover the nuts and bolts of starting a dry eye clinic, using the knowledge from experienced practitioners who have done just that in their practices. We aim to provide information on where to start, how to start, and some of the pitfalls and missteps along the way so you can avoid those stumbles.

 is a great practice builder. It is an excellent entry point into medical optometric care. You can spend as much or as little as you like, based on your budget and desire, to develop your 

Even more importantly, you’ll be providing a much-needed service to the scores of patients in 

 who are suffering from dry eye overtly or in silence. Your patients will thank you for recognizing their problem and addressing their needs.

And who knows? You may have fun along the journey.

Related: Common systemic conditions associated with dry eye disease

1. Stapleton F, Alves M, Bunya VY, Jalbert, Lekhanont K, Malet F, Na KS, Schaumberg D, Uchino M, Vehof J, Viso E, Vitale S,
	Jones L. TFOS DEWS II Epidemiology Report. Ocul Surf. 2017 Jul;15(3):334-365.
	2. MiljanoviÄ B, Dana R, Sullivan DA, Schaumberg DA. Impact of dry eye syndrome on vision-related quality of life. Am J Ophthalmol. 2007 Mar;143(3):409 15.
	3. Li M, Gong L, Sun X, Chapin WJ. Anxiety and depression in patients with dry eye syndrome. Curr Eye Res. 2011 Jan;36(1):1-7.
	4. McDonald M, Patel DA, Keith MS, Snedecor SJ. Economic and humanistic burden of dry eye disease in Europe, North America, and Asia: a systematic literature review. Ocul Surf. 2016 Apr;14(2):144-167.

Because of its prevalence, it’s more important than ever that ODs are well versed in DED.

Author | Ernie Bowling, OD, FAAO

Articles

Safety and efficacy of myopia progression therapies in children

How ODs should handle non-compliance with contact lens replacement

Experts offer advice to ODs starting dry eye subspecialty

Remember the basics as dry eye treatments expand