Most practitioners are aware that myopia prevalence is increasing worldwide, correlating with a higher risk for visual impairment with each diopter (Holden et al, 2016; Flitcroft, 2012). However, some practitioners hesitate to embrace a proactive approach to myopia management due to a perceived lack of proficiency in discussing options with families. So, what are some ways to get comfortable having the “myopia talk”?
Practice, Practice, Practice
Practice makes perfect when developing a myopia management protocol. The best way to become comfortable educating patients and families about this new frontier in eye care is through repetition. I recommend this simple, effective approach with the parents of every young myope:
- Your child’s myopia has increased.
- Myopia increases due to elongation of the eye.
- Longer eyes have increased risk of future eye disease.
- Safe treatments to slow eye elongation are available.
While some parents will want an in-depth scientific explanation, less is more for the vast majority when introducing myopia management. As you become more comfortable with this conversation, it will often take less than a minute. Note: many of the treatments discussed are off-label uses of these products.
Discussing Contact Lenses
Orthokeratology (ortho-k) and soft multifocal lenses are effective treatment strategies for slowing axial elongation (Wen et al, 2015). When discussing soft multifocals, advise parents that while these lenses differ optically from single-vision lenses, functional aspects of lens wear—such as care regimen and handling—are identical. Once this is clear, I often find soft multifocals to be the most intuitive option for parents. However, a common obstacle is the perception among parents that younger children are poor candidates for lens wear. Use this as an opportunity to educate parents that contact lenses are safe in pediatric patients when cared for properly (Bullimore, 2017). In addition, daily disposable lenses further reduce the risk for complications (Chalmers et al, 2012).
When discussing ortho-k, keep in mind that many parents are unaware of this technology, so interested families may require a more detailed explanation. Screen out poor candidates who have high myopia, internal astigmatism, or flat keratometry readings before discussing this option. If patients or parents express apprehension about lens comfort, we explain that most children adapt within about a week and that comfort is rarely an issue because the lenses are worn during sleep.
Not every child is able to wear contact lenses the first year that we discuss them. As such, it is important to be comfortable discussing pharmaceutical options for progressive myopia. I tell parents that atropine was first explored as a treatment for slowing myopia progression more than 100 years ago, although research has taken off in the last several decades (Cooper et al, 2018). Although the mechanism by which atropine slows axial elongation is not fully understood, mounting evidence suggests that it may work via a biochemical cascade rather than by an accommodative mechanism, as once thought (Arumugam and McBrien, 2012).
Parents often have questions about safety with atropine therapy. Although all concentrations affect accommodation and pupil size, most children are asymptomatic with lower concentrations such as 0.25% (Chia et al, 2016; Yam et al, 2019). I tell parents that we will start with this concentration and decrease, if necessary, at the one-month follow up. Prescribe photochromic progressive lenses to help mitigate any side effects from the atropine. Remember that systemic antimuscarinic medications can cause anhidrosis, vasodilation, constipation, and altered mental status, although no children in the above studies experienced these side effects. CLS
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