The Myopia Guide

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MYOPIA GUIDE THE

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The latest research and how to translate it into practice

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Taking the long view on short-sightedness

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First the goalkeeper becomes blurry, then the bus number becomes hazy, and the outlines of numbers and letters lose definition on the whiteboard.

It can be easy to lose sight of the individual among the statistics that illustrate the increasing prevalence of myopia. But for each number, there is a child whose world is gradually shifting out of focus.

This guide is an acknowledgement that not only are eye care professionals in a position to correct the vision of children – they might now be able to help to

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OT supplement editor Selina Powell

OT editorial team Emily McCormick, Lucy Miller, Kimberley Young, Leah Boyle

AOP PR and media manager Serena Box

Senior designer Grant Pearce

Client engagement director Anna Vassallo

Published by Think

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minimise the progression of myopia, with the associated social, educational, and ocular health benefits that this entails.

The AOP and OT have partnered with CooperVision to bring you the latest insight on myopia management options and how these solutions can be implemented in practice. The guide is part of a broader commitment to ensure that eye care professionals have the knowledge and support they need to offer myopia management solutions for the visual and ocular health benefit of the next generation.

All rights relating to this publication are expressly reserved. No part of this publication can be reproduced.

The Myopia Guide is a paid-for partnership piece between OT and CooperVision. The financial support of a partner provides the resources for OT to produce, print and distribute the print edition of the guide, and to create and publish the guide online.

Illustrations: Getty/PCH-Vector

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Why eye care professionals should take myopia management seriously

MYOPIA RISK The evidence behind the causes of short-sightedness

THE CONTENDERS Assessing the different myopia management options and their use in practice

GETTING STARTED Tips for practices looking to establish a myopia management offering

LET’S TALK MYOPIA

Eye care professionals offer their communication advice

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THE BIG SHORT

THE ESSENTIALS Key equipment for myopia management and what’s next for the field

MEET THE PANEL Indie Grewal Optometrist and British Contact Lens Association immediate past president Location: St Albans

John Bolger Consultant ophthalmologist at My-iClinic Location: London

Sarah Farrant Optometrist at Earlam and Christopher Optometrists Location: Taunton

Dr Kate Gifford

Director of Myopia Profile and former Optometry Australia president Location: Brisbane, Australia

Dr Stephanie Kearney Lecturer in vision sciences at Glasgow Caledonian University and AOP Councillor Location: Glasgow

Dr Sara McCullough Lecturer in optometry and vision science at Ulster University Location: Coleraine

Craig McArthur Optometrist and director of Peter Ivins Eye Care Location: Glasgow

Professor Kathryn Saunders Professor of optometry and vision science at Ulster University Location: Coleraine

DID YOU KNOW? Over the past 50 years, myopia levels have more than doubled within the UK

Professor James Wolffsohn Professor of optometry and vision science at Aston University Location: Birmingham

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Eye care professionals share their views on why we need to take myopia seriously

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hy embrace myopia management? There is the lifetime risk of pathology linked to myopia, warnings that levels of short-sightedness could rise to close to five billion people by 2050, and the World Council of Optometry’s resolution urging a shift in focus from solely correcting vision to educating patients about myopia and exploring management options.

Aside from all this, for many eye care professionals (ECPs),

myopia management comes down to the patient in the chair.

“I always try to ask myself, ‘What would I do if this patient was a member of my family?’” optometrist Craig McArthur explains to OT. “I have a four-year-old son, Noah. If he develops myopia, I would immediately start him on the most appropriate myopia management strategy,” he added.

In the past, hesitancy has surrounded myopia management because of a perceived lack of

evidence supporting the different interventions that are available.

But now research exploring the mechanisms behind myopia and the different management strategies is accruing at an increasingly rapid rate.

This evidence has given regulatory authorities the confidence to approve a range of options to manage the progression of the condition.

Optometrist, Dr Kate Gifford, described myopia management as combining the best of primary eye care – correcting vision while also helping to safeguard eye health for the future.

“Given that our optical interventions for myopia management offer the ability to both correct and control myopia, with strong efficacy, it makes absolute sense for us to move from simply prescribing single vision correction to utilising options which correct and help to protect vision,” she emphasised.

For optometrist, Sarah Farrant, myopia management has the potential to transform the way that the profession practises. “It is such an exciting option given

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“We are passionate about changing the trajectory of childhood myopia” CooperVision professional services consultant, Hema Patel, on how the company is supporting ECPs to help improve the lives of their patients through myopia management

we can actively engage with, rather than passively manage, the unfolding problem,” she highlighted to OT. Farrant added that the established evidence base behind myopia management supports the view that ECPs should at least be giving patients the opportunity to make an informed decision about myopia management options.

Professor Kathryn Saunders shared her view that myopia management is a “natural progression” for optometric practice.

“We have been diagnosing and correcting myopia forever.

It is exciting now to think that we can not only correct this increasingly common condition, but influence its trajectory with the aim of keeping prescriptions as low as possible, which is more

convenient for patients as well as improving long-term ocular health outcomes,” she shared with OT. She noted the importance of ECPs ensuring that management options are supported by robust research and that the limitations of different management options are understood.

“There is a growing body of evidence available to ECPs to support them in implementing myopia management strategies, including providing advice on anti-myopia lifestyle modifications, such as spending more time outdoors, for those children at risk of myopia but not yet myopic and eye growth data with which to compare and monitor patient’s eye size and their response to intervention,” Saunders observed.

DID YOU KNOW? Scientists from Hong Kong and Singapore found that the annual incidence of myopia more than doubled during the pandemic

Myopia management is one of the most exciting developments in modern optometric practice.

As eye care professionals (ECPs), we are at the forefront of this rapidly expanding industry, which offers an opportunity to enhance the lives of millions of children. At CooperVision we are passionate about changing the trajectory of childhood myopia. More than 50% of the global population is estimated to be myopic by 2050.1 Over the last 50 years, myopia has more than doubled in the UK.2 Our goal is to ensure every pre-myopic and myopic child is offered myopia management to help maintain good ocular health and reduce the risk of future visual impairment. ECPs play a pivotal role in educating and advising parents and children on myopia and myopia management strategies. Starting a child on a myopia management intervention early allows them to receive the optimal benefit of treatment.3 Commencing myopia management in an older child can still be beneficial in slowing the rate of progression.3 A paper by Mark Bullimore demonstrated that every dioptre counts when managing myopia and can help to reduce the risk of myopic maculopathy by 40%.4 Professional bodies are beginning to advocate myopia management as the standard of care, including the World Council of Optometry.5 CooperVision is supporting ECPs to embrace myopia management through its Brilliant Futures TM programme with MiSight® 1 day, which includes an accreditation course of eight modules to help ECPs get started. Upon completion, ECPs can access MiSight 1 day lenses for their patients alongside useful tools such as the Parent guide, Getting started guide, MiSight clinical decision tree and clinical summary. The CooperVision Learning Academy offers additional resources to both ECPs and support staff. www.academy.coopervision.co.uk References: 1. Holden BA, Fricke TR, Wilson DA et al. Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050. Ophthalmology. 2016 May;123(5):1036-42 2. McCullough SJ, O'Donoghue L, Saunders KJ. Six Year Refractive Change among White Children and Young Adults: Evidence for Significant Increase in Myopia among White UK Children. PLoS One. 2016 Jan 19;11(1):e0146332 3. Chamberlain P, Arumugam B, Jones D et al. Myopia Progression in Children wearing Dual-Focus Contact Lenses: 6-year findings. Optom Vis Sci. 2020;97(E-abstract):200038 4. Bullimore MA, Brennan NA. Myopia Control: Why Each Diopter Matters Optom Vis Sci. 2019; 96: 463-465 5. World Council of Optometry Resolution. The Standard of Care For Myopia Management by Optometrists. https://worldcouncilofoptometry.info/resolution-the-standard-of-care-for-myopiamanagement-by-optometrists/. Accessed 4th August 2021.

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ECPs share what drives their commitment to myopia management

INDIE GREWAL “We have a duty of care to inform parents that the myopia is likely to change or increase over time and that we have products available to help slow down the progression of myopia. It is important that we change our viewpoint to make myopia management part of our day-to-day clinic”

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DR KATE GIFFORD “I am passionate about myopia management for the individual child in my chair, for the increasing number of myopes worldwide, and for the increased scope and learning opportunities that it provides the eye care professions to benefit our patients”

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CRAIG McARTHUR “We simply need to change the way we think about myopia.

Optometrists, as gatekeepers to eye care, are ideally situated and skilled to educate patients and parents on myopia mitigation, to measure and predict children most at risk of myopia development, and prescribe myopia management strategies from our ever-growing myopia armamentarium”

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MYOPIA AND PATHOLOGY

Cataract: high myopes are 17% more likely than moderate myopes to need cataract surgery

Glaucoma: compared to those with low levels of myopia, the chance of developing glaucoma is 50% higher in moderate and high myopes

The pandemic and myopia Research published following the outbreak of the COVID-19 pandemic has illustrated the impact that rapidly altered lifestyles has had on the development of myopia in children.

In an article published in the British Journal of Ophthalmology, scientists from Hong Kong and Singapore highlighted that the annual incidence of myopia more than doubled following the pandemic.

The researchers reported that 68% of children within the study group reduced their time outdoors following COVID-19, while screen time increased 2.8-fold.

Optometrist Indie Grewal shared that during the pandemic children were using digital devices to study as well as to socialise.

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Retinal detachment: the risk of retinal detachment is five to six times higher in people with high myopia compared with those with low myopia

Myopia: a modern problem?

Ophthalmologist John Bolger argues that a shift in lifestyles has caused a rising tide of short-sightedness Myopic maculopathy: the risk of macular degeneration due to myopia rises with age and increasing myopia

Source: Williams K, Hammond C. High myopia and its risks.

Community Eye Health. 2019;32(105):5-6. PMID: 31409941

“WE CAN NOT ONLY CORRECT THIS INCREASINGLY COMMON CONDITION, BUT INFLUENCE ITS TRAJECTORY WITH THE AIM OF KEEPING PRESCRIPTIONS AS LOW AS POSSIBLE” Professor Kathryn Saunders “We have seen a lot of children who haven’t been myopic previously becoming myopic. We have seen changes in children who are in myopia management strategies that were perhaps larger than we would have expected,” he said.

Professor James Wolffsohn noted that nine recently

published studies have so far identified an increase in myopia progression during the pandemic.

“One study found this myopic progression was reversed partially after lockdown, suggesting that both accommodative spasm and structural changes contributed to this accelerated rate.”

Most of the 4.9 billion people who will be myopic in 2050 have not yet been born. When they arrive in this world they will come with a perfect eye growth algorithm that for millions of generations has produced emmetropia. But as soon they arrive in the modern urbanised world, this algorithm is corrupted by unnatural environmental inputs which causes the eye to continue to elongate.

Have you ever wondered when looking at the skulls of human ancestors in a museum why they all had perfect teeth? It is the modern processed, sugared and softened diet of today that gives us the need for dentists and orthodontists. And our ancestors had perfect vision too: even low myopes would not have been able to feed themselves or avoid predators to reproduce. The challenge is to produce an environment for this imminent future generation that allows their eyes to develop naturally.

I believe we know enough now to allow this to happen. In my view the two major causes of this pandemic of myopia are, firstly, the levels of lighting that we habitually occupy and, secondly, the unnatural prolonged close work that is part of modern life.

Our ancestors used accommodation only briefly to check whether a berry was edible and immediately were looking in the distance for the next berry and to ensure there were no predators nearby. Prolonged uninterrupted close work had no survival value. It is not a question of finding a “cure” for myopia, it is a question of allowing our future children to live in an environment that is natural and allows natural development. In the meantime we need to help those of us who are already myopic and progressing.

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NEAR WORK

The Big Picture

Some researchers suggest that prolonged time on near work could be connected to the development of myopia, but no interventions exploring this link have been validated in controlled trials.

Unravelling the puzzle of what causes short-sightedness

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he starting point for treating any condition is to understand what is causing it to develop in the first place. Although much research has accrued on the topic, there are still unanswered questions about what causes myopia. As Professor Kathryn Saunders notes: “With every new piece of information gained through research, we create more questions that are yet to be resolved.”

ECPs can use tools like the Predicting Myopia Onset risk indicator (see below) to assess a child’s likelihood of becoming myopic. Saunders highlights that myopia is not simply a genetic condition.

Research during the past three decades has supported the idea that the environment a child grows up in has a strong influence on how a child’s eyes grow.

“For example, light exposure appears to influence eye growth

and therefore there are strong links between childhood myopia and spending less time outdoors where light levels are higher.”

Studies have also found a link between additional years in education and levels of myopia.

As a result, some researchers hypothesise there may be a link between near work and myopia.

However, Saunders notes that this could also be explained by the large amounts of time spent indoors that studying involves.

She added that there is emerging evidence suggesting that poor sleep quality and/or disrupted circadian rhythms could influence refractive outcomes and potentially promote myopic growth.

“It is easy to see how our modern lifestyles and environments don’t exactly promote healthy circadian rhythms – perhaps this is also contributing to the rapid increase in prevalence of earlier onset myopia in modern children.”

EDUCATION Children who study for a longer duration and at a higher intensity are more likely to develop myopia.

However, exactly what causes this trend is the subject of debate.

SLEEP AND CIRCADIAN RHYTHMS

Investigating what causes myopia in children

Researchers have reported an association between sleep, circadian rhythms and myopia levels. But current evidence is not consistent enough.

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Spending time outdoors appears to have a protective effect against the development of myopia.

School-based studies have shown that increased time outdoors of 40 to 80 minutes per day produced significant reductions in the number of children becoming myopic.

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DIGITAL DEVICES The International Myopia Institute has concluded that the current evidence linking the use of digital devices to myopia levels is “sparse and far from consistent.”

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FAMILY HISTORY A child who has two myopic parents is eight times more likely to be myopic by the age of 12 than a child without a family history of myopia.

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i p Dr Sara McCullough on… the Predicting Myopia Onset risk indicator We developed the Predicting Myopia Onset (PreMO) risk indicator to help optometrists determine a child’s risk of developing myopia, and if the child becomes myopic, their risk of myopic progression using a traffic light

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system: red (high risk) to green (little/no risk).

We know ECPs already have conversations with children and their parents about healthy lifestyles for their eyes, but we hope this will be a helpful visual aid to really push home the messages for those children most at risk.

Identifying children before they even become myopic is important and early implementation

of lifestyle changes to try to delay myopia onset, even by a few years when the eye growth slows down, can make a big impact.

Once a child becomes myopic the risk indicator can be used to talk to parents and children about progression and whether myopia management is needed. The resource can be accessed online: bit.ly/38T8ym3

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From soft contact lenses to ortho-k and spectacle lenses, OT examines the evidence behind different myopia management options

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nce a practice has committed to offering myopia management, it can be a daunting task to choose which solution or range of solutions best meet the needs of a practice, taking into account its unique needs and patient base.

The range of options available to eye care professionals (ECPs) has proliferated as scientists and industry have turned their focus to addressing rising levels of myopia internationally.

“When you look at myopia from the prism of the technology adoption lifecycle, we have moved from the innovators, through the early adopters that comprise the early market for myopia management,” optometrist Craig McArthur shared.

“We have now jumped the chasm and are moving towards the mainstream,” he added.

For optometrist, Indie Grewal, it is an exciting time to be practising in the field.

“We have more products now than we ever have done. We are able to fit a lot of myopes that we see now with CE marked options licensed specifically for myopia management,” he said.

During this time of rapidly expanding options, Grewal emphasised the need to take an

evidence-based approach to the management solutions ECPs offer.

“It is important that ECPs read up on the products and the research behind the products so that they are fully informed,” he highlighted.

To help with this task, OT summarises clinical guidance from the International Myopia Institute (IMI) on the range of myopia management interventions that are available to ECPs.

Lifestyle measures Research has found that time spent outdoors can have a protective effect against myopia onset, with school-based interventions showing that an increase in outdoor time of 40 to 80 minutes per day produces a significant decrease in the incidence of myopia.

The IMI advises that encouraging children to spend more time outdoors has the

potential to decrease the incidence of myopia. The evidence shows that a higher prevalence and degree of myopia is linked to the intensity and duration of education but the IMI notes that the mechanism involved is unclear.

When to start management?

For children who have pre-myopia or low myopia (<-0.50D), the IMI highlights that a refractive correction would not be suitable so the patient and parent or caregiver should be advised on the need for regular eye examinations.

When the degree of myopia is equal to or greater than -0.50D, then the ECP should consider

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the management options available in consultation with the child’s caregiver. The rate of myopia progression should also be considered before initiating treatment.

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Orthokeratology This management option can be used from -0.50 to -4.00D. Orthokeratology (ortho-k) can be used with optical correction worn during the day for higher myopia (>6.00D).

A benefit of this option is that children are free from refractive correction during the day.

However, it requires overnight contact lens wear with its associated, though rare, risk of complications. The most severe complication is microbial keratitis.

Soft contact lenses Soft myopia control dualfocus contact lenses with up to six years of clinical trial data demonstrating safety and

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efficacy are now commercially available. These lenses are available in a range of powers and daily disposable options carry a lower risk of potential complications than ortho-k.

MiSight® 1 day soft dual focus contact lenses designed specifically for myopia control has been clinically shown to slow the progression of myopia in children and was the first FDA-approved contact lens for myopia control.

McArthur shared that his practice was one of the first in the UK to offer MiSight 1 day contact lenses to patients.

“It remains my first-choice product in large part due to the quality of the ongoing study monitoring its efficacy,” he said.

Ophthalmologist John Bolger has been running a myopia control clinic for the past three years.

Within the clinic, ECPs use contact lenses (soft or overnight ortho-k) as the primary management option.

Myopia control spectacle lenses Spectacle lenses for myopia management are now commercially available, backed by up to three years of clinical trials.

Defocus Incorporated Multiple Segments (DIMS) spectacle lenses significantly slowed myopia progression and axial elongation in Chinese children between the ages of eight and 13.

McArthur described the MiyoSmart spectacle lens,

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“EACH TIME NEW OPTIONS APPEAR WE TRY TO GAIN THE APPROPRIATE EDUCATION AND ADD IT TO OUR PRACTICE ARMOURY”

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incorporating DIMS technology, as an “exciting addition” to his practice’s myopia management offering. “Some families and some children are just not ready for contact lenses initially. Previously I would stand by and watch their myopia rapidly progress until I could finally convince them to try a contact lens. Now with MiyoSmart we have an immediate alternative or an adjunctive therapy for days off from contact lenses,” he highlighted.

Other manufacturers have also developed myopia control spectacles, including Essilor’s Stellest lens.

Atropine The most effective dose of atropine has not yet been determined, but research so far suggests it is between 0.01% to 0.05%.

Atropine is not approved for use in the UK although a multi-centre study is exploring the effectiveness of 0.01% atropine drops in managing myopia. The CHAMP-

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The IMI in a nutshell UK study is monitoring children between the ages of six and 12 who are asked to instil either a placebo or atropine drop in each eye, each day, for two years. CHAMP-UK Ulster University lead, Professor Kathryn Saunders, highlighted that if atropine is approved for use in the UK, it could be a useful management option for patients who are not suitable for ortho-k, soft contact lenses or myopia control spectacle lenses.

Saunders notes that soft contact lenses and spectacle lenses require wearing times of at least 10 hours a day to be effective in modifying eye growth. She added that children with low levels of myopia are often those who do not wear glasses fulltime as they can see reasonably well without them.

“Using atropine rather than expecting children to comply with full-time spectacle or contact lens wear may be a better option,” Saunders shared.

She observed that ECPs in primary care are well-placed to offer atropine if approved by the Medicines and Healthcare products Regulatory Agency.

“It would be helpful if practices were equipped with a biometer so that robust measures of axial length are made to accurately determine the need for and efficacy of treatments,” Saunders highlighted.

For ECPs without access to a biometer, tools are available (Ulster University has developed a table to estimate axial length from average corneal curvature and spherical equivalent refraction measures: bit.ly/38T8ym3).

Combined and sequential treatment The IMI highlights that combined therapy using pharmacological treatments such as atropine in addition to optical treatments seems to be more effective than a single management approach.

The effectiveness of current management options appear to decrease with time.

However, as different treatment modalities have different mechanisms of action, it may be possible to use a range of options in a sequence with greater cumulative effect.

“THE BENEFITS ARE CLEAR: LESS DETERIORATION OF VISUAL ACUITY BETWEEN EYE EXAMINATIONS IN THE SHORT-TERM, AND POTENTIALLY LESS LIFELONG RISK OF EYE DISEASE AND VISION IMPAIRMENT IN THE LONG-TERM” Dr Kate Gifford

Research is underway in this field, with full outcomes to be published at a later date. For optometrist, Sarah Farrant, having a range of different myopia management options on offer is key. “Each time new options appear we try to gain the appropriate education and add it to our practice armoury. The more solutions you can offer the more inclusive you can be for your patients,” she shared.

Limitations While there is strong evidence to support a range of myopia management interventions, there are still unknowns within this developing field. Optometrist, Dr Kate Gifford, highlighted that robust data supports a variety of interventions that provide similar efficacy – including the newest generation myopia control spectacles, ortho-k, dual-focus contact lenses, and 0.025 to 0.05% atropine.

“The benefits are clear: less deterioration of visual acuity between eye examinations in the short-term, and potentially less

The International Myopia Institute (IMI) is a global group of experts who come together to develop the latest evidence-based recommendations in myopia classification, patient management and research.

These are published as the IMI white papers: www.myopiainstitute.org/ imi-white-papers

lifelong risk of eye disease and vision impairment in the longterm,” she said.

However, Gifford added that there are limitations to the current evidence that supports different management options.

Most myopia control studies recruit participants between the ages of six and 14, who are between 1 and 5D myopic. “This means we have less or a minimal evidence base for younger and older children, and higher myopes – requiring us to be cautious in setting expectations and informed consent,” Gifford observed.

Optometrist and lecturer, Dr Stephanie Kearney, highlighted that although research suggests that the effects of myopia control contact lenses and spectacle lenses are significant, results can be variable. She added that there is no guarantee that every child will respond to treatment.

“We don’t yet know why this variability exists and how to predict which child will benefit the most,” she shared.

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Guide, 7

Getting

started How to navigate through the range of management options and evolving research when starting out on the myopia management journey

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nowing where to begin with myopia management can be a challenging task for practices that are new to the field.

There is a diverse range of treatment options and myopia management is also an area of practice where research is rapidly evolving.

The International Myopia Institute (IMI) Yearly Digest for 2021 notes that 1000 articles on myopia were published between 2019 and mid-2020.

Optometrist Craig McArthur told OT that he recommends practices starting out in myopia management pick a product, complete the accreditation process (if applicable) and begin fitting.

He emphasised the importance of avoiding

becoming overwhelmed with the range of options on offer.

“You need three things to get started: a slit-lamp, a booster seat to ensure children can reach your slit lamp, and something essential in managing children in practice – enthusiasm. The rest can come later once your experience grows,” McArthur shared with OT. “You already have the basic skillset required for starting a myopia clinic – the ability to fit contact lenses and the ability to produce a pair of spectacles with accurate optical centres,” he added.

McArthur shared that because there has been a growing interest in myopia over the past eight years, there is an abundance of resources available to the eye care professional (ECP) including

CooperVision resources

Learning Academy Brilliant Futures programme with MiSight® 1 day accreditation Brilliant Futures digital resources Brilliant Futures occluder Parent Guide Getting Started Guide MiSight 1 day Myopia Management Clinical Decision Tree Clinical Summary MiSight 1 day Product Summary Myopia Vision Simulator Axial Length Estimator.

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The international standard

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The three ‘M’s of the World Council of Optometry’s standard of care for myopia management

MITIGATION: Educating and counselling parents and children, during early and regular eye exams, on lifestyle and other factors to prevent or delay the onset of myopia.

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MEASUREMENT: Evaluating the status of a patient during regular comprehensive vision and eye health exams, such as measuring refractive error and axial length whenever possible.

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Addressing the current needs of patients by correcting myopia, while also providing evidence-based interventions that slow the progression of myopia, for improved quality of life and better eye health today and into the future.

Read the full standard online: www.worldcouncilofoptometry. info/resolution-the-standard-of-care-for-myopiamanagement-by-optometrists/

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lectures, websites and social media groups updated with the latest research in the field.

“The manufacturers have some excellent resources the ECP can dip in to,” he observed to OT. Optometrist Sarah Farrant also highlighted the availability of high-quality online resources, including the British Contact Lens Association’s myopia management course (bit.ly/3tIQeWn).

For optometrist, Indie Grewal, it is important for ECPs to involve the whole family in myopia management.

The level of involvement will vary according to the child’s age and confidence, he added.

“But as children become older and more accomplished, parents may step back because they have seen their child do it 100 times and they are happy that their child has good habit,” Grewal highlighted.

He emphasised that myopia management is not just about fitting contact lenses or fitting a pair of spectacles. “Myopia management starts before a

child becomes myopic. What we are looking at is ‘how hyperopic are they at the age of six or seven? Do they fit into some of the risk factors that we have for myopia – do they have parents who are myopic, are they spending a lot of time indoors on digital devices, do they have limited outdoor time?’ You have to take all of that into account,” Grewal said.

Parents should be advised if there is potential for their child to become myopic and what the significance of this is for the child and family.

“The ECP needs to set up regular screening of that child with regular eye examinations so they can be monitored carefully,” Grewal observed.

“MYOPIA MANAGEMENT STARTS BEFORE A CHILD BECOMES MYOPIC” Indie Grewal

DID YOU KNOW? 1000 articles on myopia were published between 2019 and mid-2020

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let’s talk myopia

Eye care professionals share their communication tips – from raising awareness of myopia management to addressing concerns and breaking down misconceptions

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common thread runs through establishing a successful myopia management offering, from practices starting out in the field to early adopters with extensive experience.

It is not the latest equipment or the largest investment but the way that eye care professionals (ECPs) talk with patients about myopia management.

Optometrist, Craig McArthur, shared with OT that one of the key challenges in introducing myopia management is patient and parent awareness.

“As myopia management is not even yet mainstream within optometric practice, it is far from being mainstream with regards to the public,” he emphasised.

“Communication is key. The success of myopia management within your practice will largely stand or fall on your ability to communicate this fast

moving and, to the layperson, complicated process,” McArthur added. Turning to his tips for engaging with patients and their families on myopia management, McArthur highlighted the need for an individualised approach to communication.

“A one-size fits all approach to communicating myopia simply won’t work. Similar to explaining the benefits and virtues of one varifocal over another, some families will require minute details, clinical studies and ray diagrams. Others simply want the headlines and will make quick decisions,” he said.

There will be families who require more emotional support, while others will simply want the optometrist’s recommendation as an expert.

McArthur recommends that optometrists consider the patient before them and adapt their message accordingly.

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AOP clinical director, Dr Peter Hampson, shares how the association is supporting members as they navigate myopia management

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The AOP has produced guidance that members can provide to patients which explains the risks associated with myopia, management options, and the risks associated with those options.

It is really important when talking to patients about myopia management that a fair and balanced view is given and that the latest good quality evidence is conveyed. That means avoiding both scare mongering or over promising, and making sure that patients don’t feel pressured into making a decision.

As this is still an emerging and rapidly progressing area of practice it is important that members stay up to date and follow good practice, including making sure that they understand the limitations of the treatment option they have chosen.

Looking forward, as the evidence base continues to build, we will see a far greater understanding of which interventions work best and for which patients.

I expect that we will increasingly hear calls for myopia management to be available on the NHS and that will be essential if we are to close the current inequality between those who are in a position to afford treatment and those who can’t. Unfortunately, that won’t be an easy argument to make in the current climate and success will require time and a very robust evidence base.

The AOP has developed a consent form to help members explain myopia and potential management options: www.aop.org.uk/myopia-management-consent

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“Having the ability to tailor the information and the language to each family is a great skill to develop. Overall, keep things simple and avoid jargon and acronyms,” he shared.

Optometrist Dr Kate Gifford recommends starting a conversation about myopia by explaining its typical childhood progression, its impact on function in the short term, and the increased lifelong risk of eye disease that comes with any level of myopia.

She noted that providing advice on visual environment is good practice when seeing all children – and especially for children who are at risk of myopia.

“Parents are frequently desperate for advice about managing screen time, and you can provide them the good news message that increasing time spent outdoors can help to

balance the impact of near work time on their children’s vision – and has other general health benefits too,” Gifford shared.

For optometrist, Sarah Farrant, having informative leaflets on hand and useful information on the practice website to allow families to do research at home is also helpful.

Her advice on communicating about myopia management is straightforward: “Simply engage with every appropriate patient and their families every time.”

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“THE SUCCESS OF MYOPIA MANAGEMENT WITHIN YOUR PRACTICE WILL LARGELY STAND OR FALL ON YOUR ABILITY TO COMMUNICATE” Craig McArthur

Optometrist, Indie Grewal, noted that he prefers to frame conversations about myopia management around the health of the eye rather than focusing on potential pathology.

“It is about maintaining good health now, into adulthood and later life,” Grewal observed.

“A lot of ECPs may not do myopia management because they don’t want to have that negative conversation with parents. I think that is absolutely fair,” he shared.

CooperVision’s Hema Patel shares her top tips on myopia management communication

LIFESTYLE: Children at risk of developing myopia should be advised about the benefits of behavioural and lifestyle changes. For example, spending more time outdoors, taking regular breaks from near work and encouraging the child to keep near tasks at an arm’s length.

RESOURCES: Myopic children and their parents should be made aware of the benefits of myopia management as well as the management options available to them. It is important to include the child in the conversation. If they can understand your explanation of myopia and the options to manage it, the parent will understand too. Provide parents with literature to take away about myopia, such as a copy of the parent guide, which can be accessed following MiSight® 1 day accreditation.

STARTING OUT: We recommend starting your journey through the Brilliant Futures accreditation process available on the CooperVision website via the Learning Academy: www.academy.coopervision.co.uk

Myth busting with

Professor James Wolffsohn ìSome ECPs think there is not enough evidence to support “Some myopia management and are worried about the risks of fitting children with contact lenses.

YPZRZ VM ƒ[[PUN JOPSKYLU ^P[O JVU[HJ[ SLUZLZ However, there is much more evidence for the efficacy of myopia control modalities, [OL L➪JHJ` VM T`VWPH JVU[YVS TVKHSP[PLZ including multiple top-level evidence randomised controlled trials, than there are for most common everyday optometric practices. While contact lenses do carry risks, it is known they are low if worn compliantly and young children are very compliant. There are now also myopia controlling spectacle designs becoming available, giving ECPs a wide range of options to select from.”

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Eye care professionals share their go-to tools and their hopes for the future of myopia management

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hat forms the cornerstone of a practice’s myopia management offering?

Equipment complements the eye care professional’s (ECP’s) skills and knowledge. OT asked ECPs for the myopia management tools that they treasure in practice.

especially useful for children who are corrected by orthokeratology (ortho-k). The anterior segment module of our OCT allows mapping of epithelial thickness so that it is possible to confirm that the ortho-k is well centred. Our Sirius from CSO permits us to monitor tear film as well as pupil size.

Luke Allen

MY GO-TO KIT John Bolger

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Top tip

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In running a myopia control clinic, we have found corneal mapping a very useful tool. It is

For me, the most important part of providing myopia management is being able to effectively communicate to parents the need, the expectations and predicted

For ECPs who do not have access to ocular biometry, Ulster University’s NICER Study has tools to estimate baseline axial length. Explore ECP resources online: bit.ly/38T8ym3

Further reading Brilliant Futures™ with MiSight® 1 day https://coopervision.co.uk/practitioner/misight Bullimore, The Safety of Soft Contact Lenses in Children. DOI: 10.1097/OPX.0000000000001078 Bullimore and Richdale, Myopia Control 2020: Where are we and where are we heading?

DOI: 10.1111/opo.12686 Chamberlain P et al. A 3-year Randomized Clinical Trial of MiSight Lenses for Myopia Control DOI: 10.1097/OPX.0000000000001410 CHAMP Study, Childhood Atropine for Myopia Progression in the United Kingdom, https://aru. ac.uk/science-and-engineering/research/institutes-and-groups/vision-and-hearing-sciences/ champ-study/ Accessed 6th September 2021 Chang et al. Comparison of Myopic Progression before, during, and after COVID-19 Lockdown, DOI: 10.1016/j.ophtha.2021.03.029 Flitcroft, The complex interactions of retinal, optical and environmental factors in myopia aetiology, DOI: 10.1016/j.preteyeres.2012.06.004 Holden et al. Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050 DOI: 10.1016/j.ophtha.2016.01.006 Huang PC et al. Protective behaviours of near work and time outdoors in myopia prevalence and progression in myopic children: a 2-year prospective population study, DOI: 10.1136/bjophthalmol-2019-314101 Jong M et al. IMI 2021 Yearly Digest, DOI: 10.1167/iovs.62.5.7 Lam et al. Defocus Incorporated Multiple Segments (DIMS) spectacle lenses slow myopia progression: a 2-year randomised clinical trial, DOI: 10.1136/bjophthalmol-2018-313739 Mountjoy E et al. Education and myopia: assessing the direction of causality by mendelian randomisation, DOI: 10.1136/bmj.k2022 McCullough et al. Axial growth and refractive change in white European children and young adults:

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outcomes. For some parents who are not myopic or only mildly myopic, a demonstration of the effects of myopia can be helpful.

I find CooperVision’s myopia simulator an easy to access and effective tool for demonstrating worsening myopia, and the positive outcomes of managing myopia.

This also puts them in the right place to access more information on myopia management should they wish to read about it.

Dr Kate Gifford

MyopiaProfile.com includes numerous free tools, including our free-to-download Managing Myopia Guidelines Infographics and parent brochures – and our parent educational website MyKidsVision.org – to support your communication in practice. In addition to these clinical resources, MyopiaProfile.com is an extremely useful tool for ECPs as it also provides answers to clinical questions based on the available evidence, and presents case studies and latest science.

My wish list for the future…

Luke Allen I would like to see a wider range of products, including high minus prescriptions and astigmatism offerings in daily disposable contact lenses and spectacles at an affordable price, with sensible GOS vouchers available for this.

Dr Stephanie Kearney I am excited that atropine will hopefully become a licensed treatment strategy in the not-too-distant future.

The Childhood Atropine for Myopia Progression (CHAMPUK) is a multi-centre trial that is working towards obtaining atropine as a licensed myopia management option in the UK. Sarah Farrant I look forward to the increasing range of options we will be able to offer, meaning the solution is accessible to even more patients. I also look forward to seeing the long-term outcomes for my patients and being able to track their progress.

predictive factors for myopia DOI: 10.1038/s41598-020-72240-y McCullough et al. Six Year Refractive Change among White Children and Young Adults: Evidence for Significant Increase in Myopia among White UK Children, DOI: 10.1371/journal.pone.0146332 Morgan et al. IMI Risk Factors for Myopia, DOI: 10.1167/iovs.62.5.3 O’Donoghue et al. Risk Factors for Childhood Myopia: Findings From the NICER Study, DOI: 10.1167/iovs.14-15549 Read SA et al. Light exposure and eye growth in childhood. DOI: 10.1167/iovs.14-15978 Tideman et al. Association of axial length with risk of uncorrectable visual impairment for Europeans with myopia, DOI: 10.1001/jamaophthalmol.2016.4009 Yam et al. Two-Year Clinical Trial of the Low-Concentration Atropine for Myopia Progression (LAMP) Study: Phase 2 Report. Ophthalmology. DOI: 10.1016/j.ophtha.2019.12.011 Wang et al, Progression of Myopia in School-Aged Children After COVID-19 Home Confinement, DOI: 10.1001/jamaophthalmol.2020.6239 Williams et al. High Myopia and its Risks, PMID: 31409941 Wolffsohn JS et al. IMI 2021 Reports and Digest – Reflections on the implications for clinical practice, DOI: 10.1167/iovs.62.5.1 Woods et al. Ocular health of children wearing daily disposable contact lenses over a 6-year period, DOI: 10.1016/j.clae.2020.11.011 World Council of Optometry Resolution, The Standard of Care For Myopia Management by Optometrists, https://worldcouncilofoptometry.info/resolution-the-standard-of-care-for-myopiamanagement-by-optometrists/. Accessed 4th August 2021 Wu et al. Outdoor activity during class recess reduces myopia onset and progression in school children, DOI: 0.1016/j.ophtha.2012.11.009 Zhang et al. Myopia incidence and lifestyle changes among school children during the COVID-19 pandemic, DOI: 10.1136/bjophthalmol-2021-319307.

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Something getting you down?

Talk it through with someone who wants to listen Our Peer Support Line volunteers are waiting. Call them in confidence on

0800 870 8401

The Peer Support Line is free, confidential and for anyone in optics, you don't have to be an AOP member to call.

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Ready to take on myopia Slowing myopia progression can help to significantly reduce the risk of myopia-related complications, such as retinal detachment, myopic maculopathy and vision loss later in life.1

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MiSight® 1 day is a daily disposable soft contact lens specifically designed for myopic children.2§ MiSight® 1 day with ActivControl® Technology slow both axial length increase and myopia progression while correcting refractive error.2

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Treatment zones creating myopic defocus ART

Correction zones

Artist’s rendering

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The MiSight® 1 day clinical study is the longest continuous soft contact lens study for myopia management with 6 years of data.2,3 Among MiSight® 1 day wearers (fitted between the ages of 8-12):

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41% had no meaningful progression of myopia at 3 years4*† 23% had no meaningful progression of myopia at 6 years.4*† Over a 3 year period, MiSight® 1 day reduced myopia progression by an average of 59% and axial elongation by 52%2* Over a 6 year period, children wearing MiSight® 1 day progressed less than -1.00D4, and less than 0.5mm on average in axial length4.

Introducing MiSight® 1 day at the earliest opportunity may result in the most significant impact in the reduction of myopic progression5.

Register for the MiSight® 1 day accreditation programme at coopervision.co.uk *Compared with a standard single-vision one-day lens over a three-year period. † 0.25D or less of change. ‡ Age 8 and 9. § >95% of children were successfully fit with MiSight® 1 day or Proclear® 1 day.

References: 1. Flitcroft DI. The complex interactions of retinal, optical and environmental factors in myopia aetiology. Prog Retin Eye Res. 2012;31(6):622660.

2. Chamberlain P, et al. A 3-year Randomized clinical trial of MiSight® lenses for myopia control. Optom Vis Sci. 2019;96:556–567. 3. CVI Data on File 2021.

4. Chamberlain P, Arumugam B, Jones D et al. Myopia Progression in Children wearing Dual-Focus Contact Lenses: 6-year findings. Optom Vis Sci 2020;97(E-abstract): 200038. 5. Arumugam B, Chamberlain P, Bradley A et al. The Effects of Age on Myopia Progression with Dual-Focus and Single Vision Daily Disposable Contact Lenses.

Optom Vis Sci 2020;97(E-abstract):205340, AAO 2020 Poster © 2021 CooperVision. CooperVision®, ActivControl®, MiSight® and Proclear® are registered trademarks of The Cooper Companies, Inc. and its subsidiaries.

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