Collaborative care in myopia management

Myopia management is just one of many responsibilities in patient eye care. In some parts of the world such as North America, Australia, and New Zealand, in addition to providing vision care, optometrists play a crucial role in identifying, managing, and treating eye conditions. Primary eye care practitioners can face challenges to practice including limited time and resources, legal and regulatory barriers, access to training, and limitations in scope of practice. This raises the need for referral and/or co-management between optometry and ophthalmology.

The clinical needs of the patient may overlap with other professionals, who may be better equipped to deal with certain aspects of management. This may include other optometrists, ophthalmologists, orthoptists, paediatricians and other medical subspecialties. These situations provide opportunities for collaborative care and co-management, allowing you to provide best-practice patient care, greater access to care, more efficient use of resources, and enhanced patient education.

Young, high myopes are best suited to the collaborative care model. High myopia in children is a challenging demographic to manage for several reasons. Depending on the part of the world, vision screening programmes may not begin until a child reaches school age. Primary eye care practitioners are often the first line of defence in recognising previously undetected myopia and the presence of syndromic forms of myopia. Uncorrected high myopia can compound behavioural issues, and high myopia is often accompanied by other pathological findings; ultimately leading to ophthalmological referrals.¹

High refractive error can result from environmental factors (mainly pre-term birth) and genetic factors. A large proportion of high myopia in children is associated with other ocular and systemic complications.¹ A retrospective hospital-based study of children under 10 years of age with myopia ≤ 6.00 D showed only 8% had ‘simple high myopia’ without other ocular or systemic associations, while 54% of children had an underlying systemic condition.⁷ High refractive error can be an accompanying feature of inherited retinal diseases (e.g. retinitis pigmentosa), metabolic disorders (e.g. Gyrate atrophy), connective tissue disorders (e.g. Marfan syndrome), and neuro-developmental disorders (e.g. Down syndrome).

The presence of high myopia in a young child can be recognised as a child whose dioptres of myopia exceeds their years of age. Coupled with one or more other suspicious features, such as patient medical or family history, or ocular findings, this may warrant further investigation and referral. The high incidence of underlying ocular, genetic, and systemic problems suggests that all children with high myopia should strongly be considered for ophthalmological opinion.⁷ The diagram below from the IMI details these features.

For primary eye care practitioners, prescribing optical correction and myopia management are clear clinical priorities to ensure normal visual development and prevent amblyopia. Tackling visual problems is only a small part of the overall management for a child who may require multidisciplinary care. Co-management of patients with diabetes, for example, requires close cooperation between optometrists and medical practitioners such as GPs and/or endocrinologists. Children who have visual development abnormalities – mainly amblyopia and strabismus, could benefit from orthoptic co-management to assist visual rehabilitation. Children who have ‘simple’ high myopia are at a greatly elevated risk of acquired myopic pathology into adulthood, and regular ocular health follow-up with optometry or ophthalmology are appropriate measures to mitigate that risk. 

Visual impairment associated with myopia can adversely impact a child’s behaviour, learning, and personal development. What should not be underestimated, is the importance of raising awareness about myopia to the child’s teachers and parents, and educating them directly about myopia as a public health issue. As eye care practitioners, we certainly understand the clinical implications of not being able to see the board at school, or a visual environment leaning heavily towards near activities. The substantial role that teachers and parents have towards a child’s development can be leveraged to recognise eye problems sooner. For example, looking for the ‘three S’s’:

• Sitting closer to the front of class/TV at home

• Squinting to see further away

• Schoolwork performance is declining or unexplained changes in behaviour at school

Detecting myopia can provide valuable insight into other co-existing ocular, systemic, and developmental issues in children by prompting referral for further investigation. Accurate and early diagnosis facilitates educational planning, hastens genetic counselling, and provides the patient and their family with an understanding of the condition and its consequences. In other cases, it could prove to be the opposite scenario: the child may present with an already established medical diagnosis, allowing us to determine the best approach to ophthalmic care. The referral pathway serves as a network for patients to receive a higher standard of care by distributing patient care requirements to the most appropriate professionals.

• Many patients will require multidisciplinary care that exceeds a primary eye care practitioner’s typical scope of practice.

• Appropriate referrals and co-management between health professionals allows efficient distribution of knowledge and skills, for patients to receive the best possible care.

• Clinical management of high myopia requires a careful approach in addressing both vision needs and ocular complication risk. In young patients with high myopia, systemic health associations must be investigated, and co-management between optometry and ophthalmology can be required.