Addressing duty of care for myopic children - Q&A with Professor Debbie Jones

Myopia management, myopia control, however you want to term it, is considered to be standard of care in some countries² and it should be. Even if not officially the standard of care in a jurisdiction, it is our duty of care as Eye Care Professionals. Our patients deserve the best, and the best is to manage their myopia using the tools we have available. So, the younger, the better. But even if you pick up a child at an older age, it is still our duty to do the best that we can for them.

The biggest problem for some parents is the cost.^1,3 It can be a difficult, challenging conversation. It is essential to explain why you are recommending myopia control, the short-term benefits, such as better uncorrected acuity, better options, and outcomes for laser vision correction, as well as the longer-term benefits with respect to maintaining good ocular health and reducing the risk of ocular health complications that can have a permanent impact on vision later in life. It is also worth pointing out that although the initial financial outlay for a myopia control product may be more than a regular, single-vision spectacle’s correction, over a period of time, the costs may even out due to fewer changes in prescriptions, warranty options on spectacle lenses, and power changes for contact lens supplies. The parent should be encouraged to look at the bigger picture. If cost remains a factor and the parents do not choose a myopia control option for their child, be sure to have the child back to see you regularly so you can monitor for change and repeat the conversation with the parents at each visit.

While not all modalities for myopia management may be universally available, Eye Care Professionals are encouraged to actively provide and communicate to their patients the solutions that are accessible within their respective markets based on scope of practice and regulatory approval.  You should be aware of what options you have available, both on-label and off-label, and be sure to offer every myopic patient an option. 

Given the complex regulations and involvement of children in myopia management, the International Myopia Institute (IMI) recommends obtaining an informed consent. Full disclosure of treatment efficacy, risks, benefits, and any off-label use (if applicable) to parents, guardians, and patients is essential.⁴ You can refer to the IMI infographic on treatment options to understand what is available for myopia management here.
 

Spectacles are an excellent option for young myopic patients who may not be capable or willing to consider contact lenses or pharmaceutics. Parents are remarkably familiar with spectacle wear and are often more likely to accept that option for myopia control for their young children.

First, it is imperative to confirm compliance with open questions such as “How many hours a day are you able to wear your spectacles?” and some specific questions such as “Do you take them off for near work?” – this will help you decide whether or not to adjust your treatment strategy. To manage compliance, ask questions to understand why non-compliance is occurring: often, simply educating the patient is enough to improve compliance. If the patient has good compliance and you are seeing progression that you are not comfortable with, you could consider adding a treatment such as atropine in combination³ or trying a different myopia control option. Some patients will not respond as hoped to a myopia control option. The reasons can be complicated, and genetic factors may play a significant role. Of course, they may actually be getting benefits but are still changing more than you would hope - you won’t know how much they would have progressed without the intervention.

Careful monitoring of the refractive error and axial length over time will determine whether the treatment is successful or not. We expect a certain amount of axial length change as the eye grows from its infant state to its adult length, so we are looking for growth over and above that. Normative data on axial length can be very useful.⁶ If you are unable to measure axial length, then you will have to rely on careful monitoring of refraction – the IMI clinical guidelines suggest performing non-cycloplegic and cycloplegic examinations as indicated.⁴

We know from the literature that about 50% of patients will stop progressing by the age of 16, but that means that 50% are still progressing.⁷ Treatment can stop when you are confident that the axial length and refraction have been stable for some time (12 months would be a good period). If you take a child out of myopia control, you should follow them carefully and be prepared to start myopia control again if things change. If the child has no issues with what they are wearing for their myopic correction and control, I would suggest leaving them in that modality until perhaps close to 18 years of age.

More awareness of the benefits and necessity of myopia management for both the profession and the public can only be beneficial. It really is our duty of care to ensure that every patient who is at risk of developing myopia or already has myopia is offered options for myopia control. This includes lifestyle modifications for those pre-myopes all the way to optical or pharmacological interventions for myopic patients. The more informed the public and the profession is, the more likely we can make a difference and stop the prediction of 50% of the world’s population being myopia by 2050 becoming a reality! ⁸