How to build a myopia control practice

July 12, 2019

Over the past few years the idea of prescribing myopia control has started to trickle into mainstream practice. Myopia control is often featured at clinical and scientific meetings, and patients may even be directly asking about myopia control options.

Over the past few years the idea of prescribing myopia control has started to trickle into mainstream practice. Myopia control is often featured at clinical and scientific meetings, and patients may even be directly asking about myopia control options.

ODs new to the world of prescribing myopia control or unsure about the concept may want to consider offering it to their patients for two reasons:1,2 


• Myopia control works
• Billions of myopes around the world could benefit from it

Furthermore, because myopia control is a scientifically backed treatment option for reducing myopia progression,1 it is an OD’s clinical duty to inform patients about all of their potential treatment options.

In addition, offering myopia control has the potential to generate a significant amount of revenue for a practice.

The purpose of this article is to offer readers with a framework for building their own myopia control practice while at the same time providing a scientifically backed reference, which can be used to better educate patients and allow the practitioner to make sound clinical decisions.

Related: How to control myopia progression in your practice

Patient education
Health literacy is a common problem in the United States and around the word,3 and recent data likewise suggests that a patient’s understanding of myopia is no different.4

Specifically, a study of 330 clinical subjects found that while 89 percent of subjects could correctly define “nearsightedness” when given a three-item multiple choice question, only 64 percent of subjects who were given the same three answers stems were able to correctly define “myopia,” a synonymous term. This limited ability to correctly define myopia was not associated with sex, income, or education.4

These data overall suggest that when treating a myopic patient, one should clearly define the condition to all patients.

This lack of understanding was also observed in our clinic. This deficiency caused us to create multiple patient education tools, such as a consent form, a simplified brochure that was based on the consent form, and a user-friendly website (uab.edu/eyecare/myopiacontrol), so patients could more easily comprehend their condition. This knowledge would also more likely make patients more compliant with their treatment.3,5

The below sections highlight key topics that should be covered in patient education materials along with additional information to help the practitioner with patient questions.

Related: Treating and diagnosing myopia 

Epidemiology
Myopia affects about 33 percent of the United States,6 and the prevalence of myopia may be as high as 84 percent in some Asian countries, such as Taiwan.7

The literature suggests that one’s chances of becoming myopic is tied to a complex blend of both genetic and environmental factors.8 The heritability of myopia is commonly analyzed via determining the risk of one’s offspring developing myopia.

An example of this approach is Jones and colleagues who found that a child with one and two myopic parents had a 2.08 and a 5.07, respectively, times greater chance of becoming myopic compared to a child who had no myopic parents.9

Related: Myopia and public health

Twin studies likewise suggest that up to 90 percent of myopia is explained by genetics, which also suggests that about 10 percent of myopia is linked to environmental factors.10-12

The recent increase in the prevalence of myopia is likely linked to environmental factors because genetic changes would be expected to take multiple generations to influence the prevalence of myopia.

The relatively recent increase in myopia prevalence is highlighted by a study of Alaskan Inuits.13-15 In this 1969 study, investigators found that the subjects who were 41 years or older had a myopia prevalence of 1.5 percent; however, those subjects who were 40 years old or younger (grew up with Western education) had a myopia prevalence that jumped to 44.7 percent.13

Related work suggests that this increase in myopia prevalence is likely associated with spending less time in outdoors (not near work).9,16,17

In fact, early work from Pärssinen and Lyyra found that that spending more time outside may protect against myopia,17 and more recent work from Jones and Rose who implemented better controlled studies also found more time outdoors to be protective.9,16

While there has been some debate about whether time outdoors can protect against myopia progression, a 2017 meta-analysis from Xiong determined that spending more time outdoors before developing myopia reduces one’s chances of becoming myopic, yet spending time outside after becoming myopic had no influence on myopia progression.18Related: Implementing myopia control and prevention

Comorbidities
Myopia is considered a disease by many because it is a predisposing risk factor for conditions such as myopic retinopathy, cataract, primary open-angle glaucoma, and retinal detachment.19-25 In fact, low amounts of myopia are associated with an increased risk of developing posterior subcapsular cataracts.22

Myopia also proportionally increases one’s chances of developing primary open-angle glaucoma and retinal detachments by 2.0 to 2.5 and 2.4 to 24.0 times, respectively.23,24

Thus, reducing one’s overall amount of myopia may also decrease one’s chances of developing one of these conditions. 

Related: Considering myopia control

Myopia control options
The literature suggests that 0.01 percent atropine, center-distance multifocal contact lenses, and orthokeratology all have a clinically meaningful effect on reducing myopia progression.26-33

In fact, a 2015 review by Smith and Walline indicates that atropine, soft bifocal contact lenses, and orthokeratology reduce myopia progression by on average 77 percent, 48 percent, and 77 percent, respectively.1

A more recent soft bifocal contact lens study found that over 81 percent of subject had complete halting of their myopic progression.34

Given this data, UAB Eye Care educates patients that all three options are about equally effective at reducing myopia progression.

Related: Essilor forms task force to combat rise of myopia

Orthokeratology and soft bifocal contact lenses are thought to optically reduce myopia progression by decreasing peripheral hyperopic defocus (considered a growth stop signal from animal studies) while also correcting foveal myopic defocus to allow for clear distance vision.35

The community currently believes that soft bifocal contact lenses (~4 cases/10,000 wearers/years) and orthokeratology (~20 cases/10,000 wearers/years) are no more likely to induce microbial keratitis when used for myopia control compared to using them for myopia correction.36

Data from the Contact Lens Assessment in Youth (CLAY) study group also suggest that children who are 8 to 14 years old (prime population of interest for myopia control) are less likely to develop adverse events compared to 15- to 25-year-old subjects who are commonly fit with contact lenses.37

Related: Examining 7 options to control myopia 

Data from the Bifocal Lenses In Nearsighted Kids (BLINK) study group also suggests that children who wear multifocal contact lenses have visual acuity comparable to their spectacles.38

The underlying mechanism by which 0.01% atropine reduces myopia progression is unknown, though 0.01% atropine is thought to have minimal side effects-the Atropine in the Treatment of Myopia (ATOM) study group found that accommodative amplitudes were reduced to 11.3 D with only a 1 mm increase in pupil size.31

The mechanism is likely to be different than the optically-based options because a 2018 study by Kinoshita  found that atropine in combination with orthokeratology results in additive myopia control effects.39

The full safety profile of long-term use of 0.01% atropine is unknown; however, data from the amblyopia literature suggest that 1.0% atropine (100 time stronger) is safe to use in children.40Related: How hyperopes differ from myopes 

Patient selection
The ideal myopia control patient is one who was recently diagnosed with myopia (e.g., first pair of glasses). Younger patients likewise are more likely to benefit from myopia control than older patients because younger patients have the potential to progress more than older patients.41 With that said, a patient of any age who is progressing may benefit from myopia control. Because all three myopia control methods are about equally efficacious,1,34 it may be best to select a correction method that best suits the patient’s lifestyle. 

Atropine can be used on the youngest patients because the patient simply needs to apply one drop of atropine in each eye before bed. These drops can be administered by the child’s caregiver. Some patients may not elect atropine because they dislike that atropine’s mechanism for controlling myopia is unknown. They may also dislike that they will still be dependent on spectacles.

The most commonly used contact lens-based myopia control options are spherical daily disposable or daily wear contact lenses, which have the ability to correct minimal amounts of astigmatism.34,38

Although not part of controlled studies, other contact lens options, such as multifocal bitoric gas permeable and custom soft multifocal toric contact lenses have the potential to control myopia progression in astigmatic patients. If one of these latter methods are selected, the patients should be made aware that they have not been clinically tested.

Patients considering contact lenses need to be mature enough to wear them-a characteristic that most care providers can judge by evaluating the patient’s in-office behavior.42

Combination therapy is a possibility (atropine plus a contact lens option), though it may be best to try one method and add a second method if clinically meaningful progression is detected.39 Patients fit in contact lenses should be monitored as typical of the modality, and all myopia control patients should be monitored at least every six months to evaluate myopic progression.

Related: Know the legal aspects of myopia control 

Exam flow

Begin the exam by reviewing the informed consent with the patient. The patient should be given ample time to consider his options because myopia control is a long-term treatment.

If the patient is interested, his visual needs and demands should be investigated to determine the best myopia control option for his lifestyle. Visual acuity at distance and near, cover test at distance and near, accommodative amplitudes, pupils, and an anterior segment exam should be performed to monitor safety. Obtain topography for contact lens fitting purposes, and perform autorefraction and non-contact axial length measurements to track myopic progression. 

Marketing
Marketing a myopia control practice may be more or less difficult based upon your community’s general understanding of myopia and myopia control. 

Start with internal marketing by introducing it to patients in your practice.

Related: Patching, atropine may suit moderate or severe amblyopia

Once systems are in place, start marking via methods that have worked for your practice, such as newsletters, lectures, and networking within your community. Radio or television advertising might also work to spread awareness.

Be sure to update digital materials such as practice website and email newsletter with myopia control practice offerings.

Conclusion
The scientific community generally believes that myopia control is safe and efficacious.1 Myopia control is also gaining acceptance within the clinical community; therefore, if you have not already started  offering myopia control, it is time for you to develop your own plan-or at least develop a relationship with a practitioner who does offer it.

By offering myopia control, your patients can have the opportunity to reduce their visual burden and their risk of developing an associated vision-threatening conditions.19-25
 

About the author
Dr. Pucker
earned his OD, MS, and PhD degrees from The Ohio State University. He is the principal investigator of a National Eye Institute-funded project related to myopia development, and he manages other projects related to refractive error, dry eye, and contact lenses. Dr. Pucker has received research funding from National Eye Institute, Alcon, Bausch & Lomb, Euclid, and Contamac, and he has consulted for the Optikal Care Inc. over the past three years. In his free time, he enjoys homebrewing, traveling, and spending time with his family.
apucker@uab.edu

References:

1. Smith MJ, Walline JJ. Controlling myopia progression in children and adolescents. Adolesc Health Med Ther. 2015 Aug 13;6:133-140.
2. Holden BA, Fricke TR, Wilson DA, Jong M, Naidoo KS, Sankaridurg P, Wong TY, Naduvilath TJ, Resnikoff S. Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050. Ophthalmology. 2016 May;123(5):1036-1042.
3. Williams MV, Parker RM, Baker DW, Parikh NS, Pitkin K, Coates WC, Nurss JR. Inadequate functional health literacy among patients at two public hospitals. JAMA. 1995 Dec 6;274(21):1677-82.
4. Pucker AD, McBride R, Cox S. Patient Understanding of Nearsightedness. Academy 2017 Chicago 2017;Poster 45.
5. McMonnies CW. Improving contact lens compliance by explaining the benefits of compliant procedures. Cont Lens Anterior Eye. 2011 Oct;34(5):249-252.
6. Vitale S, Ellwein L, Cotch MF, Ferris FL, 3rd, Sperduto R. Prevalence of refractive error in the United States, 1999-2004. Arch Ophthalmol. 2008 Aug;126(8):1111-1119.
7. Lin LL, Shih YF, Hsiao CK, Chen CJ. Prevalence of myopia in Taiwanese schoolchildren: 1983 to 2000. Ann Acad Med Singapore. 2004 Jan;33(1):27-33.
8. Goldschmidt E, Jacobsen N. Genetic and environmental effects on myopia development and progression. Eye (Lond). 2014 Feb;28(2):126-133.
9. Jones LA, Sinnott LT, Mutti DO, Mitchell GL, Moeschberger ML, Zadnik K. Parental history of myopia, sports and outdoor activities, and future myopia. Invest Ophthalmol Vis Sci. 2007 Aug;48(8):3524-3532.
10. Lyhne N, Sjolie AK, Kyvik KO, Green A. The importance of genes and environment for ocular refraction and its determiners: a population based study among 20-45 year old twins. Br J Ophthalmol. 2001 Dec;85(12):1470-1476.
11. Dirani M, Chamberlain M, Shekar SN, Islam AF, Garoufalis P, Chen CY, Guymer RH, Baird PN. Heritability of refractive error and ocular biometrics: the Genes in Myopia (GEM) twin study. Invest Ophthalmol Vis Sci. 2006 Nov;47(11):4756-4761.
12. Hammond CJ, Snieder H, Gilbert CE, Spector TD. Genes and environment in refractive error: the twin eye study. Invest Ophthalmol Vis Sci. 2001 May;42(6):1232-1236.
13. Young FA, Leary GA, Baldwin WR, et al. The transmission of refractive errors within eskimo families. Am J Optom Arch Am Acad Optom. 1969 Sept;46(9):676-685.
14. Morgan RW, Speakman JS, Grimshaw SE. Inuit myopia: an environmentally induced “epidemic”? Can Med Assoc J. 1975 Mar 8;112(5):575-577.
15. Sorsby A, Young FA. Transmission of refractive errors within Eskimo families. Am J Optom Arch Am Acad Optom. 1970 Mar;47(3):244-249.
16. Rose KA, Morgan IG, Ip J, Kifley A, Huynh S, Smith W, Mitchell P. Outdoor activity reduces the prevalence of myopia in children. Ophthalmology. 2008 Aug;115(8):1279-1285.
17. Parssinen O, Lyyra AL. Myopia and myopic progression among schoolchildren: a three-year follow-up study. Invest Ophthalmol Vis Sci. 1993 Aug;34(9):2794-2802.
18. Xiong S, Sankaridurg P, Naduvilath T, Zang J, Zou H, Zhu J, Lv M, He X, Xu X. Time spent in outdoor activities in relation to myopia prevention and control: a meta-analysis and systematic review. Acta Ophthalmol. 2017 Sep;95(6):551-566.
19. Vongphanit J, Mitchell P, Wang JJ. Prevalence and progression of myopic retinopathy in an older population. Ophthalmology. 2002 Apr;109 (4):704-711.
20. Lim R, Mitchell P, Cumming RG. Refractive associations with cataract: the Blue Mountains Eye Study. Invest Ophthalmol Vis Sci. 1999 Nov;40(12):3021-3026.
21. Younan C, Mitchell P, Cumming RG, Rochtchina E, Wang JJ. Myopia and incident cataract and cataract surgery: the blue mountains eye study. Invest Ophthalmol Vis Sci. 2002;43(12):3625-3632.
22. Chang MA, Congdon NG, Bykhovskaya I, Munoz B, West SK. The association between myopia and various subtypes of lens opacity: SEE (Salisbury Eye Evaluation) project. Ophthalmology. 2005 Aug;112(8):1395-1401.
23. Marcus MW, de Vries MM, Junoy Montolio FG, Jansonius NM. Myopia as a risk factor for open-angle glaucoma: a systematic review and meta-analysis. Ophthalmology. 2011 Oct;118(10):1989-1994 e1982.
24. Ogawa A, Tanaka M. The relationship between refractive errors and retinal detachment--analysis of 1,166 retinal detachment cases. Jpn J Ophthalmol. 1988;32(3):310-315.
25. Risk factors for idiopathic rhegmatogenous retinal detachment. The Eye Disease Case-Control Study Group. Am J Epidemiol. 1993 Apr 1;137(7):749-757.
26. Aller T, Wildsoet C. Optical control of myopia has come of age: or has it? Optom Vis Sci. 2013 May;90(5):e135-137.
27. Cho P, Cheung SW, Edwards M. The longitudinal orthokeratology research in children (LORIC) in Hong Kong: a pilot study on refractive changes and myopic control. Curr Eye Res. 2005 Jan;30(1):71-80.
28. Walline JJ, Jones LA, Sinnott LT. Corneal reshaping and myopia progression. Br J Ophthalmol. 2009 Sep;93(9):1181-1185.
29. Walline JJ, Greiner KL, McVey ME, Jones-Jordan LA. Multifocal contact lens myopia control. Optom Vis Sci. 2013 Nov;90(11):1207-1214.
30. Anstice NS, Phillips JR. Effect of dual-focus soft contact lens wear on axial myopia progression in children. Ophthalmology. 2011 Jun;118(6):1152-1161.
31. Chia A, Chua WH, Cheung YB, Wong WL, Lingham A, Fong A, Tan D. Atropine for the treatment of childhood myopia: safety and efficacy of 0.5%, 0.1%, and 0.01% doses (Atropine for the Treatment of Myopia 2). Ophthalmology. 2012 Feb;119(2):347-354.
32. Chia A, Chua WH, Wen L, Fong A, Goon YY, Tan D. Atropine for the treatment of childhood myopia: changes after stopping atropine 0.01%, 0.1% and 0.5%. Am J Ophthalmol. 2014 Feb;157(2):451-457 e1.
33. Chia A, Lu QS, Tan D. Five-Year Clinical Trial on Atropine for the Treatment of Myopia 2: Myopia Control with Atropine 0.01% Eyedrops. Ophthalmology. 2016 Feb;123(2):391-399.
34. Cooper J, O'Connor B, Watanabe R, Fuerst R, Berger S, Eisenberg N, Dillehay SM. Case Series Analysis of Myopic Progression Control With a Unique Extended Depth of Focus Multifocal Contact Lens. Eye Contact Lens. 2018 Sep;44(5):e16-e24.
35. Smith EL, 3rd, Hung LF, Huang J. Relative peripheral hyperopic defocus alters central refractive development in infant monkeys. Vision Res. 2009 Sep;49(19):2386-2392.
36. Stapleton F, Keay L, Edwards K, Holden B. The epidemiology of microbial keratitis with silicone hydrogel contact lenses. Eye Contact Lens. 2013 Jan;39(1):79-85.
37. Wagner H, Richdale K, Mitchell GL, Lam DY, Jansen ME, Kinoshita BT, Sorbara L, Chalmers RL; CLAY Study Group. Age, behavior, environment, and health factors in the soft contact lens risk survey. Optom Vis Sci. 2014 Mar;91(3):252-261.
38. Schulle KL, Berntsen DA, Sinnott LT, Bickle KM, Gostovic AT, Pierce GE, Jones-Jordan LA, Mutti DO, Walline JJ; Bifocal Lenses in Nearsighted Kids (BLINK) Study Group. Visual Acuity and Over-refraction in Myopic Children Fitted with Soft Multifocal Contact Lenses. Optom Vis Sci. 2018 Apr;95(4):292-298.
39. Kinoshita N, Konno Y, Hamada N, Kanda Y, Shimmura-Tomita M, Kakehashi A. Additive effects of orthokeratology and atropine 0.01% ophthalmic solution in slowing axial elongation in children with myopia: first year results. Jpn J Ophthalmol. 2018 Aug;62(5):544-553.
40. Li T, Shotton K. Conventional occlusion versus pharmacologic penalization for amblyopia. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD006460.
41. COMET Group. Myopia stabilization and associated factors among participants in the Correction of Myopia Evaluation Trial (COMET). Invest Ophthalmol Vis Sci. 2013 Dec 3;54(13):7871-7884.
42. Walline JJ, Jones LA, Rah MJ, Manny RE, Bernsten DA, Chitkara M, Kim A, Quinn N; CLIP Study Group. Contact Lenses in Pediatrics (CLIP) Study: chair time and ocular health. Optom Vis Sci. 2007 Sep;84(9):896-902.