16 Aug MANAGING MYOPIA: EVOLUTION OF A NEW STANDARD OF CARE
Since the 13th century when spectacles were invented as a replacement for reading stones, the management of myopia has been almost entirely symptom-oriented, designed to alleviate the characteristic complaint of blurred distance vision among those affected. While new ways to correct refractive error have come into existence, including contact lenses (19th century) and refractive surgery (20th century), these too have evolved as means to manage the symptoms rather than the causes of progressive myopia.
Eyecare practitioners have been very much aware of the potential risks of high (previously known as “pathological”) myopia, and various techniques such as under-correction were used to try limit progression. The primary clinical concern has until very recently, been to ensure that children and adults have an optimal refractive correction, with myopia control just a peripheral priority (for most practitioners).
Times are changing, however! There is increased awareness that myopia prevalence is rising fast and that myopia-related eye disease is now a leading global cause of vision impairment and blindness among the working age population. Additionally, it is now accepted that there is no safe level of myopia and that the risk of complications is dose-dependent, i.e. more myopia progression leads to increased risk of disease development.
We have reached a stage where progressive myopia is no
longer just a refractive state, but is now considered a modifiable risk factor for the development of eye disease and associated vision loss.
Crucially, scientific and industrial innovators have responded to the threat posed by myopia. We now have a rapidly increasing range of treatments available which have been shown to delay myopia onset, reduce or eliminate the progression of myopia in some children and which may thereby reduce the risk of long term damage. Consequently, we have reached a stage where progressive myopia is no longer just a refractive state, but is now considered a modifiable risk factor for the development of eye disease and associated vision loss.
Myopia management has become one of the most dynamic and fast-changing areas of ophthalmic clinical practice. The question now arises as to what exactly is the standard of care for myopia management. The release of Myopia Management Guidance for Optometrists from the UK College of Optometrists, somewhat controversially stated that “the evidence is not sufficient to recommend the wide-scale roll out of any myopia control intervention”. This has undoubtedly contributed to the general indecisiveness among some practitioners about making the transition from passive to active myopia management. More recent developments, however, are likely to resolve any lingering reluctance to engage and should fast track the transition to proactive rather than reactive myopia care.
What do we mean by “Standard of Care”?
According to the New England Journal of Medicine (2004), Standard of Care is defined as “a diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance”. As clinicians, however, we also need to be cognisant of its legal as well as clinical meaning, because the standard of care is critical in terms of establishing medical malpractice/negligence. From a legal perspective, standard of care does not mean perfection in practice but instead requires that a practitioner should exercise the degree of skill, care and learning possessed by others in the same profession.
Scientifically robust clinical practice guidelines can be used to define the standard of care, but they do not necessarily set the legal standard. One important consideration is that customary practice, i.e. what is commonly done, may not be considered enough. So although it has been customary to simply correct myopia with traditional methods, this may not provide protection in any legal action. Practitioners should instead be seen to take all “reasonable” measures in the care they provide for their patients.*
World Council of Optometry Resolution: The Standard of Care for Myopia Management by Optometrists
In April 2021, the World Council of Optometry (1) called for a new evidence-based standard of care for myopia management by optometrists, comprising three main components, the 3 M’s:
- Mitigation – as optometrists, we should appropriately educate and counsel parents and children, discuss risk factors and provide lifestyle/behavioural guidance during early and regular eye exams. Such measures allow us to contribute to the prevention/delayed onset of myopia or facilitate early detection and therapeutic intervention.
- Measurement – optometrists should comprehensively evaluate the status of a patient during regular vision and eye health exams including refractive error and axial length measurement (whenever possible).
- Management – optometrists should address patients’ needs of today by correcting myopia while also providing evidence-based interventions (e.g. contact lenses, spectacles, pharmaceuticals, behavioural guidance) that slow the progression of myopia, for improved quality of life and better eye health today and into the future.
This resolution recognises the pivotal role optometry can play as a profession, specifically targeting the continued reluctance of some optometrists to integrate the increasing scientific evidence relating to myopia control into their clinical practice. Importantly, the resolution states that the lack of an appropriate standard of care for myopia management is a disservice to the optometry profession, our patients and public health.
This WCO resolution means that a comprehensive monitoring and management plan should now be adopted as the standard of care for myopia management by optometrists.
European Society of Ophthalmology in Co-operation with the International Myopia Institute (2021): Update and Guidance on Management of Myopia
Ophthalmology has also seen fit to respond to the growing threat of myopia, with new clinical guidance recently issued (March 2021) by the European Society of Ophthalmology. In a comprehensive position paper published in the European Journal of Ophthalmology (2), several important recommendations were made to improve the detection and management of myopia. These included specific targeting of pre-myopes (children who are less hyperopic than expected for their age, combined with other relevant risk factors which together indicate a likelihood of progressing to myopia) for close observation and preventative intervention (such as recommending higher risk children spend more time outdoors).
An evidence-based approach to myopia management, according to the European Society of Ophthalmology, must start with a cycloplegic refraction to avoid misclassification and should include a binocular vision work up as pre-myopes may exhibit specific binocular vision disorders [higher accommodative lag, high AC/A ratio (esophoria at near) and reduced accommodative flexibility]. Monitoring of axial length changes is recommended as the primary target for myopia management. Centile growth charts are suggested as a tool to identify the risk of future myopia and to monitor growth trajectories with or without anti-myopia intervention. The decision to treat a child should be based on the age of onset, axial length or refraction at a given age, along with knowledge of their individual rate of progression and overall risk profile.
Treatments should be comprehensive, including lifestyle advice, provision of full refractive correction for full-time use, along with an available form of myopia control therapy to reduce or eliminate further progression. Combination therapies should be considered in children who continue to progress despite treatment. The report acknowledges that the available information is constantly evolving, so it is recognised that practitioners must stay abreast of new developments in the peer-reviewed literature.
International Myopia Institute – Clinical Management Guidelines Report (2019 & 2021)
The International Myopia Institute (IMI) was established to support the advancement of myopia research and education to prevent future blindness. As part of this mandate, the IMI has produced the IMI White Paper series (3), first published (Series One) in 2019 and recently updated (Series Two). The contents of these papers are too extensive to cover here, but for clinicians at the coalface of myopia management, these papers represent a valuable resource detailing current evidence-based best practice for myopia management, including risk factor identification, the examination process, selection of treatment strategies and guidelines for ongoing management.
This landmark paper series is a must-read educational piece for any clinician working to proactively manage myopia in children. Additional useful clinical information, including Supplementary Digital Content (4) with helpful links and resources, is also available on Myopia Profile.
Providing an updated spectacle or contact lens prescription to a child with progressive myopia remains a necessary component of clinical care, but should no longer be considered as the treatment for a myopia, but representative of a treatment failure to prevent myopia progression.
It has now become clear that correcting refractive error alone is not enough and the new clinical management guidelines for optometrists provide the impetus for a shift to comprehensive risk-based management. The mitigation, measurement and management principles defined in the WCO resolution outline an evolved minimum standard of evidence-based care appropriate to modern eye health needs.
Passive alleviation of blurred vision symptoms is inappropriate. Providing an updated spectacle or contact lens prescription to a child with progressive myopia remains a necessary component of clinical care but should no longer be considered as the treatment for myopia, but representative of a treatment failure to prevent myopia progression.
Supported by new practice guidelines, increasing educational resources and emerging myopia control options to suit every child, practitioners are now better positioned to introduce myopia control into their practice. Of course, some barriers still exist, but the WCO resolution captures the need for clinical practice evolution perfectly when it states, “simply correcting the refractive error is no longer sufficient, and myopia management should not be optional, and rather be an obligation of optometrists”. Failure to adopt this standard of care may soon be considered negligent, so let’s embrace this evolution and the opportunity to better serve our patients, our professions and wider society.
*NOTE: Individual jurisdictions will have different legal systems and interpretations and is beyond the scope of this article.
James Loughman is the Clinical Research Director for Ocuco Ltd. An Optometrist with more than 20 years of clinical, academic, research and management experience, James is also presently the Director of the Centre for Eye Research Ireland, a research facility based in Technological University Dublin, the same university where he received his PhD in 1997. James oversees a portfolio of research including technology development and big data analytics projects alongside various clinical trials for the control of myopia, glaucoma and other blinding conditions.