EYECARE Myopia Management Developing Myopia as a Specialty By Mark Tosh Monday, February 10, 2020 12:30 AM RELATED CONTENT A 20-Year Journey to Perfect the Practice of Myopia Management San Francisco ECP Draws Upon Treehouse Eyes’ Resources Mentors Pass Along Key Elements of Myopia Management Orlando Practice Finds Success With a ‘Proactive’ Approach to Myopia THE Myopia Meeting Announces 2020 Schedule Click here to view a PDF of Myopia Management.Myopia is not a new vision condition, but the growing awareness of the eye health risks associated with this common ophthalmic disorder, especially among eye-care professionals, is a somewhat contemporary phenomenon. Indeed, myopia is the most common ophthalmic condition in the world, with an estimated 34 percent of the world’s population, or roughly 2.62 billion people, affected by this condition, according to recent research. This increasing awareness, while beneficial to global eye health and vision, of course, also has begun to open up fresh practice-building opportunities for ODs. A specialty such as myopia management—or any of the myriad of other areas of care that ECPs are exploring today—can open up or even deepen relationships with patients and families in a local or regional practice area. Patients often will drive hours for care that they find goes above and beyond. And because myopia is often progressive, there is concern that the condition will lead to higher and higher degrees of myopia, or high myopia. (There are an estimated 163 million people worldwide who have high myopia, usually above -6.00 diopters and worse than 20/400 uncorrected vision.) “Myopia management is white space,” said Dwight Akerman, OD, FAAO, chief medical editor of Review of Myopia Management. “To date, most eyecare professionals have not incorporated myopia management into their practices to any significant extent, primarily due to a lack of knowledge about how to integrate pediatric myopia management into a primary care optometric practice. With many treatment options available that have demonstrated efficacy, ECPs have a professional responsibility to discuss myopia management options with all parents of children at risk for progressive myopia.” Sounding the Alarm on Myopia The growing prevalence of myopia—which according to many eyecare professionals has risen to the level of a pandemic—came to the fore in 2016 in a paper published in Ophthalmology, the official journal of the American Academy of Ophthalmology, according to Akerman. “The Holden, et al, paper published in the journal Ophthalmology sounded the alarm on the global pandemic of myopia,” he said, noting that this paper projected that by 2050 there would be 50 percent of the world’s population who would be myopic. Adding to the problem, 10 percent of the population would be highly myopic. “The issue there is that highly myopic people are more prone to retinal detachment, myopic macular degeneration, glaucoma and premature cataracts, among other issues,” Akerman said. He added, “There had been a lot of papers published, but this paper was really the alarm bell for the world to say, ‘We need to take notice of this, and we need to develop treatments to slow or stop the progression of myopia.’” The economic costs of myopia are high, also, with an economic impact of uncorrected refractive error estimated at a loss of $202 billion in global GDP. While there is not universal agreement about the causes nor the best treatment options for myopia, there is increasing evidence that creeping myopia can be managed. Recently, groups such as the Global Myopia Awareness Coalition (GMAC) and the Brien Holden Vision Institute have been working to raise awareness among optometrists about the prevalence of myopia—not only in the U.S. but worldwide. And the prevalence of myopia is rising rapidly, while the age of onset is coming earlier for many children. Myopia prevalence in the 5- to 19-years-old age group of American children is 42 percent, according to recent research. Genetics play a key role in the onset of myopia, such as a family history of eyesight issues increasing the likelihood of a child’s risk of myopia. If neither parent is myopic, the chance the child will develop myopia is lower, according to recent research. But, if one parent is myopic, it increases the child’s chance of developing myopia by three times and this doubles to six times if both parents are myopic. Myopia Management in Practice What all these statistics mean is that myopia management represents an enormous opportunity for optometry, a health care profession that is appropriately positioned with clinical skills, staffing structure and professional organization and support to define and deliver the highest standards of care. According to Akerman, there are a few key principles for ODs to follow on the path to an effective myopia management program. They are: being proactive; identifying risk factors; providing information, advice and recommendations; and prescribing appropriate treatments to slow progression and avoid high myopia. The communication approach with parents and children also plays a critical role in a myopia management method. Akerman recommended using language that parents can easily understand and creating a package of written material that explains the eye health risks of myopia and treatment options in plain language. The materials might include peer-reviewed articles, but not too many, he said, and it’s also important to explain to parents that myopia care, similar to orthodontia, may not be covered by insurance. It’s also important that any educational materials are designed to improve parental and patient understanding and adherence to prescribed treatments. Research indicates that each diopter in treatment regimens matters, and that slowing myopia by 1 diopter should reduce the likelihood of a patient developing myopic maculopathy by 40 percent. Additionally, this treatment benefit accrues regardless of the level of myopia, the research notes. Akerman noted that this myopia pandemic is global and increasingly affects children in the U.S., as well. A journal paper published two years ago that looked at the prevalence of myopia among teenagers found that rate at 42 percent. (This paper in its research looked at 60,000 teenagers between the ages of 5 and 19 years old, who represented a mix of Caucasians, Chinese, African-Americans and other ethnicities. “This is not just an East Asian problem, it’s a global problem and it is affecting the U.S. practitioners as well,” Akerman said. “So slowly but surely, U.S. practitioners are realizing that ‘Ok, I am seeing these patients in my practice and perhaps I should do something.’” The First FDA Approved Treatment Before Nov. 15, 2019, the date the Food and Drug Administration approved the CooperVision MiSight 1 day lens, the treatments for myopia in the U.S. were considered off-label prescribing. So, whether an ECP wanted to prescribe orthokeratology, or myopia control soft lenses or even low-dose atropine, it had to be done in an off-label process, which requires a signed consent form. The ECP is, in effect, saying “In my best medical judgment, I am recommending this treatment to you.” “Practitioners are hesitant to pull out these informed consent forms and ask the parents to sign it,” Akerman noted. “I think this has been a little bit of an issue [for optometrists], but MDs do off-label all the time.” This has slowed the progress and uptake of myopia control. “Most practitioners today in the U.S. are taking a kind of wait and see attitude, but [awareness] is growing,” he said. “And now that CooperVision has FDA approval for the MiSight lens, I think that will go a long way toward getting practitioners behind myopia control and proactively prescribing.” He added, “The big buzz words right now are, ‘Let’s get proactive.’ We now have a product, a specific product that has been well-tested and approved by the FDA with a specific labeling indication for myopia control. Now we have something.” Treatments on the Horizon There are several other products for the treatment of myopia that are seeking regulatory approval. These include three topical low-dose atropine products that are in clinical trials in their efforts to gain a labeling indication for myopia management. Once any of these three topical products are commercially available with a labeling indication that will support the effort to increase myopia awareness. In addition, Visioneering Technologies Inc. has developed a one-day multifocal contact lens that has been shown to slow the progression of myopia. This lens has a “CE” mark—which means it is a medical device made to meet the requirements of the Medical Devices Directive (MDD)— but it does not have an approved FDA indication for myopia. An often-used approach to treating myopia in the U.S. is the specialty rigid lenses that have been shown to lessen progression in children. Orthokeratology (ortho-k) lenses are worn at night and change the corneal topography to correct low to moderate amounts of myopia. Also, Hoya, Essilor and Zeiss are all actively conducting research on whether spectacle lenses can be used to treat myopia. Hoya has licensed technology that it calls MyoSmart spectacle lens. This lens (with Defocus Incorporated Multiple Segments, or DIMS) has been shown in a randomized clinical trial (conducted in Hong Kong) to slow progression of myopia by about 60 percent, according to Akerman. “People are really excited about this,” he added, noting that the lens is commercially available in China and Hong Kong now. Time spent outdoors has been shown to be protective against myopia, also, potentially due to light stimulation of retinal dopamine. Still, it appears that public health interventions are going to be needed if the growing myopia epidemic is to be managed. To better understand how individual ODs are working to build a myopia management specialty in their practices, Vision Monday talked to a few doctors who have a range of different experience in this specialty area. Their stories are presented on the following pages.