Over the past year, I have had the opportunity to put my training in myopia development to work by helping to lead an effort to open the Myopia Control Clinic at the University of Alabama at Birmingham (UAB) School of Optometry. With the aid of several other UAB faculty and staff members, these efforts have resulted in the creation of a dedicated referral-based myopia control clinic that serves the greater Birmingham, AL area.
This article summarizes considerations for developing a myopia control clinic, including initial experiences and how we have changed course in an attempt to improve this clinic. This article is not meant to suggest a single plan for opening a myopia control clinic, but it is intended to provide guidance that practitioners can use to offer myopia control in clinical practice.
DEFINING MYOPIA AND MYOPIA CONTROL
It is important to start by defining myopia and myopia control, because these topics need to be clearly understood by patients when considering myopia control options and compliance with treatment.1 Myopia can be defined as a condition in which there is a mismatch in the eye’s optical components that results in a blurred distance image because the image is in focus in front of the retina.2 This mismatch most commonly results from the eye being too long axially.2 Or, more simply put for patients, myopia, which is also referred to as nearsightedness, is an eye condition in which a patient can see nearby objects clearly, but distant objects appear blurry without the aid of glasses. And, this blur typically results from the eye being too long compared to the rest of its parts.
In a recent study, only 66% of subjects correctly defined nearsightedness and myopia when given separate three-response multiple choice questions, while 89% of patients correctly defined nearsightedness.3 These data suggests that when speaking to patients, it may be better to use the term “nearsightedness” because patients more frequently recognize it. It is also important to clearly define the terms myopia or nearsightedness when using them to ensure that patients can more easily follow the recommendations being made.
The data also showed that being able to correctly define myopia or nearsightedness was not associated with age, income, or education, which highlights the need to avoid jargon when speaking with even more sophisticated patients.3 In fact, highly educated individuals actually prefer simple explanations with visual aids.1,4
While practitioners have been treating myopia’s visual limitations with glasses, contact lenses (CLs), or refractive surgery for many years, the vision community has only recently developed promising methods for controlling myopia progression.5 Myopia control can be defined as slowing the progression of myopia, a tactic that will hopefully result in a decrease in the treated patients’ overall adult refractive error.5
A number of strategies aimed at reducing foveal blur, such as under-correction with glasses, progressive addition spectacle lenses, and alignment-fitted GP CLs, have all been tested to determine whether they can slow myopia progression; however, they have all resulted in a non-clinically significant reduction in myopia progression (< 50% reduction in progression is considered non-clinically significant).2 Similarly, past studies have suggested that 1% atropine can be used to reduce myopia progression in a clinically meaningful way, although the side effects (e.g., cycloplegia, photophobia) have limited its application.5 Nevertheless, in 2007 and 2009, Smith et al showed that the peripheral retina is more important than the fovea is in controlling refractive error development, which has encouraged new optical treatments and an accidental finding by Chia et al in 2012 showing that 0.01% atropine can be used to reduce myopia progression with minimal side effects (treatments discussed below).6-8
COMMON MYOPIA CONTROL METHODS
Corneal Reshaping Contact Lenses Corneal reshaping CLs are worn primarily during sleep and removed each morning. According to a review conducted by Smith and colleagues, these CLs are effective at temporarily reshaping the cornea in a way that allows a person to see clearly at distance without vision correction.2 Corneal reshaping likely slows myopia progression by bending light as it enters the reshaped eye so that an image is in focus on the fovea and in front of the peripheral retina.2 Corneal reshaping CLs reduce myopia progression by about 50%.5
Soft Bifocal Contact Lenses Center-distance soft bifocal CLs are typically worn by patients who are older than 40 years of age to help with presbyopia; however, research suggests that these CLs also likely slow myopia progression by about 50% by bending light similarly to that with corneal reshaping.2
Atropine An eye drop of 1.0% atropine can be used to make the pupil bigger and to relax the eye’s ciliary muscle.2 Low-dose (0.01%) atropine was accidently found to slow myopia progression by about 60% via an unknown mechanism while having a limited impact on pupil size and visual focusing.8-10 Low-dose atropine is not commercially available, so a relationship with a compounding pharmacy is necessary to prescribe it.
Time Outdoors In 2007, Jones et al reported in a longitudinal study that children who spend more time on “sports and outdoor activity” are less likely to become myopic.11 More recent work has since found that the primary factor associated with reducing myopia development is spending time outdoors rather than exercise.12
The mechanism leading to reduced myopia development is not currently known, although it has been theorized to be related to increases in retinal dopamine or increases in systemic vitamin D levels.13-17
It is important to note that a recent meta-analysis has found that spending more time outdoors is only helpful for preventing myopia development, not slowing the progression of myopia.12 Therefore, the clinical recommendation of additional time outdoors is for myopia prevention purposes and perhaps only for patients who are at high risk of developing myopia (e.g., patients who have two myopic parents).11
Control Method Selection Considerations Atropine can be used by a wider range of patients because practitioners do not need to worry as much about patients’ age/maturity (as opposed to with CL handling and compliance with a CL care regimen) and because commercially available CLs come in a limited number of parameters.18 Conversely, some patients are not interested in using a medication to control myopia progression when its mechanism is unknown.2
Patients who are treated with atropine also still need refractive error correction (with glasses or contact lenses). It is currently unclear whether using multiple control methods simultaneously is beneficial.5 It is also important to let patients know that all of these treatments are simply slowing eye growth, not reversing the amount of myopia present. Therefore, patients will always need to wear glasses or CLs to correct their vision unless they undergo refractive surgery following myopia stabilization.
KEY PATIENT EDUCATION TOPICS
After defining myopia and educating patients (and their parents in the case of pediatric patients) about the potential myopia control options, it is important to teach patients the other beneficial effects of long-term myopia control. The following are key topics to discuss during an initial myopia control consultations.
It is important to convey each of these topics to patients verbally and to provide written descriptions of the topics and myopia control options with a comprehensive informed consent process. All patients should be allowed adequate time to review and sign the consent form (both patients and parents sign the consent form) before treatment is commenced. It is important to develop a consent form for patients written at a fourth-grade reading level.4 UAB’s Myopia Control Consent form can be found at http://bit.ly/2sgccE7 .
What causes myopia? The scientific community currently has a basic understanding of the underlying mechanisms that cause myopia. Twin studies show that ~90% of myopia inheritance is explained by genetics, which is further supported by the fact that having one myopic parent results in a 2.08 times increased chance of becoming myopic and having two myopic parents results in a 5.07 times increased chance of becoming myopic compared to having no myopic parents. These facts suggests that myopia has a strong underlying genetic component.11,19
Who becomes myopic? Patients of all races and ethnicities can be affected by myopia, although patients of Asian descent as well as those who live in developed countries are more likely to become myopic.23 Furthermore, the prevalence of myopia in Australia, Western Europe, the United States, and Taiwan has been estimated to be 16%, 27%, 33%, and 85%, respectively, and the prevalence of myopia is likely on the rise.23-26 This increase in myopia prevalence is unlikely to be related to genetics, as the prevalence of myopia has only recently increased; it is more likely that the prevalence of myopia has increased because of an environmental factor, such as patients spending less time outside.23
Why control myopia progression? While correcting myopia with glasses, CLs, or refractive surgery can reduce the visual symptoms associated with being myopic, none of these options reduce the long-term pathological consequences associated with myopia.27 Specifically, there is a strong positive association between having higher levels of myopia and having higher odds of developing myopic maculopathy, primary open angle glaucoma, retinal detachments, and posterior subcapsular cataracts.28 Therefore, reducing the overall amount of myopia could significantly decrease the likelihood of developing a visually threatening condition while at the same time could reduce reliance on vision-correction devices.28
Who should undergo myopia control? The ideal myopia control patient is someone getting his or her first pair of glasses (who is ~ –0.75D); however, myopia control can be offered to anyone still progressing. This group may include patients in their late teens or early 20s. During informed consent, it is important to educate patients that this age group has not been included in myopia control studies and that they may benefit less compared to someone younger. As some myopes progress into the mid- or even late-20s, patients should initiate a myopia control method that will be used until the mid-teens or even longer, although there are currently no data suggesting when patients should discontinue myopia control treatments.5,29
How safe are myopia control treatments? Research suggests that children (8- to 12-year-olds) and teens (13- to 17-year-olds) are at equally low risk of being noncompliant with their CLs or developing a CL complication.30 Furthermore, children and teens who wear CLs have indicated that wearing the lenses has improved their appearance, social acceptance, ability to play sports, and their overall satisfaction with their vision correction.31,32
Low-dose atropine (0.01%) is also considered safe because it also has a minimal effect on accommodation and light sensitivity.8 Nevertheless, if a patient complains of these symptoms (which happens in ~6% of patients), glasses can be prescribed with a near add to help mitigate symptoms.8
With that said, none of these treatments have been approved by the U.S. Food and Drug Administration (FDA) specifically for myopia control even though they are approved for other uses, and we recommend that you make your patients aware of this during the informed consent process.5
It is recommended that all patients who are scheduled in a myopia control clinic to have had a recent comprehensive examination to ensure ocular health prior to the visit and to keep examination billing simple. All myopia control evaluations should start with comprehensive patient education that includes a review of informed consent, myopia control options, and professional fees.
Patients should be encouraged to ask questions and to take as much time as needed to consider myopia control because it is a long-term treatment. In addition, patients (and their parents) need to be invested in the process from the onset to help ensure compliance.
Following this, a myopia control evaluation is completed, which includes baseline distance and near visual acuities, pupil testing, cover test, accommodative testing, and a slit lamp biomicroscope examination for safety and binocular vision monitoring purposes. It has also been shown that patients who have large pupils may benefit more from corneal reshaping CLs compared with patients who have small pupils, so pupil testing can also guide a practitioner’s myopia control selection.33 Next, perform corneal topography to help guide CL selection (Figure 1), measure axial length with non-contact biometry, and measure refractive error with cycloplegic auto-refraction.
After the initial evaluation, present the findings to patients and suggest suitable myopia control options. If a patient selects a CL recommendation, it is important to follow the manufacturer’s recommended fitting guide. If a patient elects to use atropine, it is important to call the patient/parent approximately two weeks later to make sure the medication has been received and is being well tolerated.
Regardless of the myopia control treatment that is chosen, all patients are scheduled for a six-month follow-up examination to monitor myopia progression with autorefraction (applicable for atropine and multifocal contact lenses) and axial length measurements (applicable for all three options) and compliance.
It is recommended that eyecare practitioners bundle a separate myopia control fee (non-itemized) that is in addition to standard professional fees for corneal reshaping CLs, multifocal CLs, and atropine; usually, it is comparable to the fee associated with a medical eye examination and also includes the cost of a six-month follow-up visit. This fee is for myopia control expertise and the extra time associated with prescribing myopia control.
All fees should be outlined and presented to patients on an agreement form, and patients should also be given a brochure that includes an estimated cost of each treatment including the indirect costs associated with selecting each treatment (e.g., CL solutions, atropine cost). Interestingly, our experience indicates that multifocal CLs are the least expensive option, followed by atropine and corneal reshaping CLs.
Originally, we also charged interested patients for a consultation examination, but we found that this initial visit fee inhibited patient recruitment. We have since determined that it is better to provide a free initial consultation (patient education and myopia control evaluation). So, we now charge patients after they complete this consultation and select a treatment recommendation. The need for this practice may vary by market.
The UAB Myopia Control Clinic initially started recruiting patients via internal referrals. Once the clinic had developed its systems, external marketing began. We started by presenting to local groups of eyecare providers, generating newsletters for the local medical community, raising awareness of myopia control through local news, and developing a clinic-specific webpage (www.uab.edu/optometry/home/eye-care-services/myopia-control-clinic ), which is especially important for the target demographic. It is important for a practice to also develop a myopia control clinic-specific recall system. That will help practitioners better ensure patient retention.
Staff education is essential to running a successful myopia control practice because staff members are typically the first people who interact with patients. Properly educating staff will help ensure that patients are receiving consistent information about myopia and myopia control. In addition, empowering staff will also allow them to act as myopia control advocates. Staff education should include a discussion of all of the topics described above. You may also want to consider having staff members shadow you while you are working with myopia control patients so that they are more easily able to field patient questions and concerns.
While long-term myopia control has not been fully evaluated by the scientific community or approved by the FDA, it is time to act because predictions indicate that there will be about 5 billion myopes in the world by the year 2050.23 Each of the above control methods has shown promise in well-designed clinical trials, with generally safe profiles.5 Therefore, it is time to prescribe myopia control, or to at least refer patients to a clinician who does prescribe myopia control, so that we can provide patients with an opportunity to reduce their overall refractive error, which can not only improve their visual quality of life, but also potentially reduce other vision-threatening conditions.28 CLS
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- Smith MJ, Walline JJ. Controlling myopia progression in children and adolescents. Adolesc Health Med Ther. 2015 Aug 13;6:133-140.
- Pucker AD, McBride R, Cox S. Patient Understanding of Nearsightedness. Poster presented at the American Academy of Optometry Meeting, Chicago. 2017 Oct. 11-14;Poster 45.
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- Smith EL 3rd, Hung LF, Huang J. Relative peripheral hyperopic defocus alters central refractive development in infant monkeys. Vision Res. 2009 Sep;49:2386-2392.
- Smith EL 3rd, Ramamirtham R, Qiao-Grider Y, et al. Effects of foveal ablation on emmetropization and form-deprivation myopia. Invest Ophthalmol Vis Sci. 2007 Sep;48:3914-3922.
- Chia A, Chua WH, Cheung YB, et al. 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;119:347-354.
- 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;157:451-457.e1.
- 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;123:391-399.
- 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;48:3524-3532.
- Xiong S, Sankaridurg P, Naduvilath T, et al. Time spent in outdoor activities in relation to myopia prevention and control: a meta-analysis and systematic review. Acta Ophthalmol. 2017 Sep;95:551-566.
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