How I manage myopia in my practice

Elise Kramer

by Elise Kramer OD, FAAO, FSLS

Myopia is a serious global health concern. Today, well over 1 billion people around the world are struggling with the condition. This number is only expected to increase in the future, reaching nearly 5 billion by 2050.

Reasons for the upward trend range from increased life expectancy to decrease time spent outdoors to increased time spent staring at screens each day. To address this global epidemic, myopia management is coming to the forefront of optometry.

In my practice, I follow a specific process to manage myopia based on guidelines from the Brien Holden Vision Institute.

Consultation

When taking the patient’s medical history, I typically gear questions toward two areas: family history and the amount of near work the patient does vs. their time spent outdoors.

After conducting a complete exam, if I diagnose myopia, I perform additional tests and procedures, including corneal topography, axial length measurements, anterior segment evaluations, IOP tests, dilated fundus examinations and cycloplegic refraction.

Patient assessment

After the initial consultation, I assess the patient’s risk of myopia onset or progression. If a patient is found to be emmetropic, he or she may still be at risk for myopia based on genetic factors, lifestyle factors and demographic comparisons. For instance, if a patient’s parents (one or both) are myopic, the patient has a heightened risk of myopia onset.

Patients who do significant work in front of screens, spend limited time outdoors or show greater refractive error than individuals of a similar age group or demographic may also be at higher risk for onset.

If I diagnose a patient with myopia, I attempt to determine the risk of progression. The factors that point toward progression vary. Younger patients — typically those younger than 9 years — are at higher risk for myopia progression. Patients whose parents are myopic are also at greater risk.

Treatment strategy

If the patient is emmetropic but at increased risk for myopia, I focus on reducing risk. For example, I may advise the patient to limit screen time or spend more time outdoors.

If the patient is myopic, the equation becomes a bit more complex. There is no one-size-fits-all approach to myopia treatment. Patient suitability matters, and management strategies can vary considerably based on factors as simple as age.

Other factors will play into determining the ideal strategy as well, including the patient’s risk for progression, the degree of refractive error and the preferences of the patient or their parent or guardian. In order to choose the correct strategy, it is important to consider patient suitability, each patient’s risk of progression and their preference, the effectiveness of the strategy, and the patient’s ability to have access to it.

Correction without control includes single vision glasses and contact lenses.

There is a wide range of management methods, including contact lenses, both center-distance multifocal and extended depth of focus, orthokeratology, progressive addition spectacles, executive bifocals, peripheral defocus spectacles, low-dose atropine drops or a combination (eg, low-dose atropine and multifocal contact lenses).

Next steps

Next I focus on patient follow-up and communication. I work with the patient to schedule regular appointments. These check-ins are crucial for making sure he or she is following the management plan and to determine how well the treatment method is working.

If I prescribe contact lenses in a new wearer, I ensure the patient understands the importance of lens care and hygiene.

Typically, I schedule follow-up appointments regularly throughout the first year of treatment. The first follow-up is at 1 week, to be sure the patient is not demonstrating any negative side effects. From there, the appointment calendar includes follow-ups at the 1-month, 3-month, 6-month, 9-month and 12-month marks. Office visits may include updates to the patient’s medical history and tests for visual acuity, pupil dilation and IOP.

If myopia progression is not slowing, I evaluate the lens prescription and fit. Contact lenses may require several fittings to arrive at the most effective treatment. I also ensure the patient is following the treatment plan.

References:

Brien Holden Vision Institute. Guidelines for diagnosing and managing myopia. https://guidelines.brienholdenvision.org/. Accessed March 7, 2019.

Kinoshita N, et al. Jpn J Ophthalmol. 2018;doi:10.1007/s10384-018-0608-3.

For more information:

Elise Kramer, OD, who is residency-trained, practices at Weston Contact Lens Institute and specializes in ocular health and disease, ocular surface disease, and regular and specialty contact lens fitting. Over the last few years she has created a unique scleral lens practice.

Disclosure: Kramer reports she is a consultant for Spectrum International Group.

 

Elise Kramer

by Elise Kramer OD, FAAO, FSLS

Myopia is a serious global health concern. Today, well over 1 billion people around the world are struggling with the condition. This number is only expected to increase in the future, reaching nearly 5 billion by 2050.

Reasons for the upward trend range from increased life expectancy to decrease time spent outdoors to increased time spent staring at screens each day. To address this global epidemic, myopia management is coming to the forefront of optometry.

In my practice, I follow a specific process to manage myopia based on guidelines from the Brien Holden Vision Institute.

Consultation

When taking the patient’s medical history, I typically gear questions toward two areas: family history and the amount of near work the patient does vs. their time spent outdoors.

After conducting a complete exam, if I diagnose myopia, I perform additional tests and procedures, including corneal topography, axial length measurements, anterior segment evaluations, IOP tests, dilated fundus examinations and cycloplegic refraction.

Patient assessment

After the initial consultation, I assess the patient’s risk of myopia onset or progression. If a patient is found to be emmetropic, he or she may still be at risk for myopia based on genetic factors, lifestyle factors and demographic comparisons. For instance, if a patient’s parents (one or both) are myopic, the patient has a heightened risk of myopia onset.

Patients who do significant work in front of screens, spend limited time outdoors or show greater refractive error than individuals of a similar age group or demographic may also be at higher risk for onset.

If I diagnose a patient with myopia, I attempt to determine the risk of progression. The factors that point toward progression vary. Younger patients — typically those younger than 9 years — are at higher risk for myopia progression. Patients whose parents are myopic are also at greater risk.

Treatment strategy

If the patient is emmetropic but at increased risk for myopia, I focus on reducing risk. For example, I may advise the patient to limit screen time or spend more time outdoors.

If the patient is myopic, the equation becomes a bit more complex. There is no one-size-fits-all approach to myopia treatment. Patient suitability matters, and management strategies can vary considerably based on factors as simple as age.

Other factors will play into determining the ideal strategy as well, including the patient’s risk for progression, the degree of refractive error and the preferences of the patient or their parent or guardian. In order to choose the correct strategy, it is important to consider patient suitability, each patient’s risk of progression and their preference, the effectiveness of the strategy, and the patient’s ability to have access to it.

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Correction without control includes single vision glasses and contact lenses.

There is a wide range of management methods, including contact lenses, both center-distance multifocal and extended depth of focus, orthokeratology, progressive addition spectacles, executive bifocals, peripheral defocus spectacles, low-dose atropine drops or a combination (eg, low-dose atropine and multifocal contact lenses).

Next steps

Next I focus on patient follow-up and communication. I work with the patient to schedule regular appointments. These check-ins are crucial for making sure he or she is following the management plan and to determine how well the treatment method is working.

If I prescribe contact lenses in a new wearer, I ensure the patient understands the importance of lens care and hygiene.

Typically, I schedule follow-up appointments regularly throughout the first year of treatment. The first follow-up is at 1 week, to be sure the patient is not demonstrating any negative side effects. From there, the appointment calendar includes follow-ups at the 1-month, 3-month, 6-month, 9-month and 12-month marks. Office visits may include updates to the patient’s medical history and tests for visual acuity, pupil dilation and IOP.

If myopia progression is not slowing, I evaluate the lens prescription and fit. Contact lenses may require several fittings to arrive at the most effective treatment. I also ensure the patient is following the treatment plan.

References:

Brien Holden Vision Institute. Guidelines for diagnosing and managing myopia. https://guidelines.brienholdenvision.org/. Accessed March 7, 2019.

Kinoshita N, et al. Jpn J Ophthalmol. 2018;doi:10.1007/s10384-018-0608-3.

For more information:

Elise Kramer, OD, who is residency-trained, practices at Weston Contact Lens Institute and specializes in ocular health and disease, ocular surface disease, and regular and specialty contact lens fitting. Over the last few years she has created a unique scleral lens practice.

Disclosure: Kramer reports she is a consultant for Spectrum International Group.