Myopia management best practice: guidance for the UK & Ireland

Paper title: 2024 UK and Ireland modified Delphi consensus on myopia management in children and young people

Authors: Dahlmann-Noor, Annegret H (1,2,3,4); Ghorbani-Mojarrad, Neema (4,5,6); Williams, Katie M (2,3,4,7); Ghoneim, Ahmed (2); Allen, Peter M (4,8); Beach, Michelle L (9); Bruce, Gillian (10); Buckhurst, Hetal D (4,11); Buckhurst, Philip J (4,11); Cruickshank, Fiona E (4,12); Cufflin, Matthew P (5); Day, Mhairi D (4,13); Doyle, Lesley (4,14,15); Evans, Bruce JW (16); Flitcroft, Daniel Ian (17,18); Gray, Lyle S (13); Grewal, Indie (19); Guggenheim, Jeremy A (4,20); Hammond, Christopher J (4,7,21); Higginbotham, Jason C (22); Jawaid, Imran (23); Kearney, Stephanie (4,13); Lawrenson, John G (16); Logan, Nicola S (4,24); Loughman, James (18); Mallen, Edwards AH (5); McCullough, Sara J (4,14); Nagra, Manbir (25); Saunders, Kathryn J (4,14); Seidel, Dirk (13); Shah, Tanvi (2,26); Strang, Niall C (4,13); Webber, Kathryn J (5); Wolffsohn, James S (4,24); Young, Alexandra L (10,27)

1. NIHR Moorfields Biomedical Research Centre, London, UK.

2. Moorfields Eye Hospital NHS Foundation Trust, London, UK.
3. University College London Institute of Ophthalmology, London, UK.
4. Myopia Consortium, UK.
5. School of Optometry and Vision Science, University of Bradford, Bradford, UK.
6. Wolfson Centre for Applied Health Research, Bradford, UK.
7. King's College London, London, UK.
8. Vision and Hearing Research Centre, Anglia Ruskin University, Cambridge, UK.
9. Park Vision, Nottingham, UK.
10. Cameron Optometry, Edinburgh, UK.
11. School of Health Professions, University of Plymouth, Plymouth, UK.
12. University of Manchester, Manchester, UK.
13. Department of Vision Sciences, Glasgow Caledonian University, Glasgow, UK.
14. Centre for Optometry and Vision Science, Ulster University, Coleraine, UK.
15. Northern Ireland Clinical Research Network, Belfast, UK.
16. Department of Optometry and Visual Sciences, City St George's, University of London, London, UK.
17. Children's Health Ireland (CHI) at Temple Street, Dublin, Ireland.
18. Centre for Eye Research Ireland, Technological University of Dublin, Dublin, Ireland.
19. Leighton Opticians, St. Albans, UK.
20. School of Optometry & Vision Sciences, Cardiff University, Cardiff, UK.
21. Guys and St Thomas' NHS Foundation Trust, London, UK.
22. Myopia Focus, London, UK.
23. Queen's Medical Centre, Nottingham, UK.
24. School of Optometry, College of Life and Health Sciences, Aston University, Birmingham, UK.
25. Vision and Eye Research Institute, Anglia Ruskin University, Cambridge, UK.
26. Diopter Eye Clinic, London, UK.
27. Princess Alexandra Eye Pavilion, NHS Lothian, Edinburgh, UK.

Date: Nov 2024

References: Dahlmann-Noor AH, Ghorbani-Mojarrad N, Williams KM, Ghoneim A, Allen PM, Beach ML, Bruce G, Buckhurst HD, Buckhurst PJ, Cruickshank FE, Cufflin MP, Day MD, Doyle L, Evans BJW, Flitcroft DI, Gray LS, Grewal I, Guggenheim JA, Hammond CJ, Higginbotham JC, Jawaid I, Kearney S, Lawrenson JG, Logan NS, Loughman J, Mallen EAH, McCullough SJ, Nagra M, Saunders KJ, Seidel D, Shah T, Strang NC, Webber KJ, Wolffsohn JS, Young AL. 2024 UK and Ireland modified Delphi consensus on myopia management in children and young people. Ophthalmic Physiol Opt. 2024 Nov;44(7):1368-1391

[Link to open access paper]

Studies utilising the Delphi process are commonplace in many healthcare and research areas. They are used to gather expert opinion on specific topics and to inform and guide clinical practice decisions. 

The 2024 UK and Ireland Modified Delphi Consensus on Myopia Management in Children and Young People was established in response to the expanding field of myopia management and concerns regarding increased myopia prevalence over the past 50yrs in the UK.¹ The aim was to standardise care, combine expert opinion and identify areas within the field of myopia management which warrant further research.

Thirty-four practitioners with expertise from academia and research optometry clinics were recruited to the panel. Topics were proposed for inclusion before being reworded and refined based on multiple survey responses and a final round of voting. Final recommendations were made once a consensus was reached. 

Agreement was reached for 131 statements, with an emphasis on several key points:

Before starting myopia management

• Eyecare practitioners (ECPs) who prescribe myopia control interventions should be offered, and undertake, appropriate independent and evidence-based training.
• Early, pro-active discussions with patients and parents regarding myopia should be had as soon as possible for all children under 13yrs at risk of myopia or showing signs of progression, including myopia onset in pre-school children.
• Ocular examination prior to starting should include measurement of near point and/or amplitude of accommodation, cycloplegic auto-refraction or retinoscopy and non-cycloplegic axial length.

Prescribing considerations

• There was strong evidence for the efficacy of first-line interventions such as myopia control diffusion-optics and peripheral-plus spectacle and dual focus and orthokeratology contact lenses, although no one method has demonstrated superiority. 
• There was also support for ECPs to use their discretion in prescribing off-label alternatives which do not carry CE or UKCA labelling. 
• There was a consensus on the evidence for the efficacy and use of low-concentration atropine. This included using low-dose atropine as a combination therapy, when authorisation and funding allows.
• When deciding on an intervention, the discussion should involve the ECP, patient and parent. It should be a holistic, child-centred approach which considers the child’s preference alongside lifestyle and environmental factors.
• Although there was agreement that 2hrs outdoors daily may help protect against myopia onset, there was no consensus on how much outdoor time guarded against progression. There was also little agreement on how beneficial holding books or screens further from the eyes was for slowing progression.
• There was strong consensus for public funding of myopia control interventions to improve accessibility, particularly for those at risk of fast progression or high myopia.

Ongoing management, monitoring treatment success and when to stop

• If growth percentile charts are not available in a practice, an indicator of improvement is for no more than 0.15mm (0.25D) progression over 1yr period for a child under 13yrs.
• For children over 13yrs who progress more slowly, no more than 0.08mm progression over 1yr period could be deemed successful. 
• If an improvement is not seen over 1yr despite patient compliance, then another intervention could be considered
• There was strong agreement that axial length is important in assessing progression and should be measured at 6-monthly intervals. Cycloplegic auto-refraction and/or retinoscopy should be performed where axial length measuring is not possible. However, progression cannot be reliably assessed by refraction changes alone. 
• Myopia may not stabilise until early adulthood and myopia management may be required until that stage. Further progression after ceasing wear may signify a need to resume interventions.
  
  

The Delphi study made recommendations where there was a strong consensus from the panel on best practice. Eyecare practitioners can adopt these opinions from experienced clinicians and researchers into their practice and use them to develop their skills and guide their decision-making.

Key take-away points from this review are that:

• Children should be offered myopia management interventions as soon as their risk of myopia development or progression is apparent
• Our advice should be personalised to the child, to consider their interests and lifestyle
• Myopia control spectacle and contact lenses are our first choice, based on sound evidence
• We have evidence-based guidance on how to monitor progression and how to assess the end-point for treatment.
• We should be proactive and keep ourselves up to date on new strategies
• Public health funding should be considered as a way of removing barriers to available products

Following consensus updates as they are released will help provide standardised myopia management approaches in the UK and Ireland, and keep practitioners informed of regulatory changes and emerging technologies.

Areas with less agreement in the study reflected current concerns over areas in myopia management which need further research or clarification. These include:

• Long-term safety and optimal dosing of atropine, how it may be used in combination with other currently available therapies and how gradually reduced dose may help limit rebound effects when ceasing use.
• How near work can influence myopia development and progression 
• Epidemiological research and socio-economic impact assessments could inform public health policies and on the cost-effectiveness of myopia management.

The consensus also discussed that although myopia screening programmes were not needed, there was a need to involve other healthcare professionals in myopia management awareness schemes.

A limitation of this Delphi study is that although there were many areas of strong agreement, it cannot provide advice on specific practice scenarios and cannot be used as sole guidance.

Children under 16 years fall under a protected dispensing category within the Opticians Act and the study acknowledged that although Dispensing Opticians were not represented on this consensus panel, they would ideally be included in future updates.

Title: 2024 UK and Ireland modified Delphi consensus on myopia management in children and young people

Authors: Annegret H Dahlmann-Noor, Neema Ghorbani-Mojarrad, Katie M Williams, Ahmed Ghoneim, Peter M Allen, Michelle L Beach, Gillian Bruce, Hetal D Buckhurst, Phillip J Buckhurst, Fiona E Cruickshank, Matthew P Cufflin, Mhairi D Day, Lesley Doyle, Bruce J W Evans, Daniel Ian Flitcroft, Lyle S Gray, Indie Grewal, Jeremy A Guggenheim, Christopher J Hammond, Jason C Higginbotham, Imran Jawaid, Stephanie Kearney, John G Lawrenson, Nicola S Logan, James Loughman, Edward A H Mallen, Sara J McCullough, Manbir Nagra, Kathryn J Saunders, Dirk Seidel, Tanvi Shah, Niall C Strang, Kathryn J Webber, James S Wolffsohn, Alexandra L Young

Purpose: This work aimed to establish the largest UK and Ireland consensus on myopia management in children and young people (CYP).

Methods: A modified Delphi consensus was conducted with a panel of 34 optometrists and ophthalmologists with expertise in myopia management.

 Results: Two rounds of voting took place and 131 statements were agreed, including that interventions should be discussed with parents/carers of all CYP who develop myopia before the age of 13 years, a recommendation for interventions to be publicly funded for those at risk of fast progression and high myopia, that intervention selection should take into account the CYP's hobbies and lifestyle and that additional training for eye care professionals should be available from non-commercial sources. Topics for which published evidence is limited or lacking were areas of weaker or no consensus. Modern myopia management contact and spectacles are suitable first-line treatments. The role and provision of low-concentration atropine needs to be reviewed once marketing authorisations and funding decisions are in place. There is some evidence that a combination of low-concentration atropine with an optical intervention can have an additive effect; further research is needed. Once an intervention is started, best practice is to monitor non-cycloplegic axial length 6 monthly.

Conclusions: Research is needed to identify those at risk of progression, the long-term effectiveness of individual and combined interventions, and when to discontinue treatment when myopia has stabilised. As further evidence continues to emerge, this consensus work will be repeated to ensure it remains relevant.

[Link to open access paper]