Childhood-onset myopia management: Guidance for optometrists (2024)

The College supports the growing number of optometrists offering myopia management (sometimes known as myopia control) interventions to reduce myopia progression.

Provided that myopia management is within your scope of practice, you can offer this treatment. This means you must have the relevant knowledge and skills to do so, through appropriate training and experience¹.

When recommending any form of treatment or therapeutic intervention, including myopia management, you must obtain explicit consent to ensure parents and patients have made an informed decision to proceed¹. While theGuidance for Professional Practice covers consent and capacity, this guidance sets out the information on myopia management you should explain to parents and patients so they can decide if it is right for them.

Contents

1. Managing myopia
2. What to tell patients and parents
3. Managing risks associated with myopia management
4. Resources and further reading
5. References

1. Managing myopia

When providing myopia management interventions, you should:

• Keep up-to-date with the evidence about myopia management including the safety and efficacy of the treatment or interventions available and any limitations in the evidence, as the evidence base is evolving at pace. It is important for you to understand the short and long-term benefits and risks^{1, 2}.
• Consider how you will:
  • Discuss myopia management options including the available treatments, delaying treatment, conventional optical correction and no intervention,
  • Explain short- and long-term benefits and risks of each option in context,
  • Manage expectations of treatment outcomes in a clear and balanced way (see Resources for further information).
• Consider how you will measure outcomes. Axial length monitoring is the preferred method to assess stabilisation or progression of myopia¹, especially in orthokeratology. If this is not available, you should undertake cycloplegic autorefraction and keratometry to provide an estimate of axial length.³ Cycloplegic autorefraction also provides an objective and repeatable measure of refractive status at baseline and follow-up visits, but this result should not be used to prescribe optical interventions. Refractive error evaluated in isolation without axial length measures will not provide as sensitive an indication of success (or lack of success) of myopia management interventions.³
• Ensure that you understand what is involved in obtaininginformed consent.²
• Keep accurate records of the discussions leading to consent being given. You should use a written consent form as an explicit and robust record and to ensure parents and patients understand any risks and limitations associated with any intervention (along with the research evidence that shows these), to help them make an informed decision.²
• Be aware that some multi-focal contact lenses and orthokeratology lenses, while licensed as medical devices for use in the UK, do not have specific marketing authorisation for myopia management so their use in the UK would be consideredoff-label. These can be offered, provided that their use is supported by a suitable evidence, clinical rationale and where an alternative licensed product (i.e. one of the products specifically licensed in the UK for myopia management) would not meet the patient’s clinical needs.
• Have a system forreporting adverse events to track safety issues, as per your usual practice protocol. You should aim to collect data that is capable of supporting clinical audit and, if possible, that could be used (with appropriate consent) in future research. For example, axial length data collected in practice settings may provide a very valuable source of data for understanding the longer term effects of myopia management interventions.

If myopia management is not currently within your scope of practice or available in your work setting, you should make sure that you can hold a discussion with patients and their parents about the evidence, the benefits and the risks of myopia management^{1, 2}. You should also be aware of any local practitioners or services that offer myopia management, should a parent or patient require further information or request referral. This local arrangement should be agreed in advance, and where feasible you may consider offering to co-manage the patient.

2. What to tell patients and parents

• Practitioners should be able to explain to parents what myopia is and what lifestyle factors may impact myopia, the increased risks to long-term ocular health that myopia brings, and the approaches that can be used to manage myopia.^{1, 2} This includes conventional refractive correction and available treatment options intended to slow its progression.

Risk factors for myopia^{1, 4}

• Having parents with myopia.
• East Asian ethnic origin.
• Spending limited time outside and being heavily engaged in activities using near vision.⁵

There is evidence that spending increased time outside can delay the onset of myopia in some children, and may prevent it in others.^{5, 6, 7, 8} There may also be an association between increased “near work” activities (such as screen use) and myopia development and progression.⁹ You should encourage children to play/spend time outdoors and promote a healthy balance of near vision activities whether or not myopia management is offered.

Why consider myopia management?

• There is evidence that people with myopia have a relatively small increased absolute risk for ocular complications as a result of myopia. By undertaking myopia management, a reduction in the extent of myopia may provide a reduction in the risk of developing serious eye conditions later in life⁶. However, there is not yet any long-term direct evidence to confirm this, due to the duration of the research studies needed to provide such evidence.
• There is evidence that multifocal contact lens designs, orthokeratology lenses and myopia management spectacles can be used to slow the dioptric progression of myopia.^{6, 7, 10} All three options have similar levels of efficacy ranging from 40% to 60% reduction in spherical equivalent refractive error over 1-3 years compared to controls, which equates to a reduction of around 1D less myopia. These same studies also report reduction in axial elongation ranging from 30% to 50% over the same period.
• Even though existing interventions will not completely prevent myopia in the majority of patients, there may be benefits to seeking to limit the extent of the progression of myopia.^{1, 7} Lower levels of myopia offer improved uncorrected and corrected visual acuity; reduced dependence on near vision correction; and better outcomes following corneal refractive surgery. A reduced degree of myopia results in a reduction in the thickness and weight of any spectacle lens correction. This may improve spectacle wearing comfort, cosmetic appearance, increase design/style availability, and mitigate costs associated with reducing lens edge thickness and weight.There may be additional benefits for children wearing contact lenses in terms of increasing engagement in contact sports and confidence with respect to social interactions and cosmetics.
• The results of myopia management may differ from person to person and depend on factors such as:^{6, 7, 11}
  • Age of onset of myopia.
  • Age when starting myopia management.
  • Compliance with treatment.
  • Amount of near work and outdoor activity.
• Patients may not respond to an intervention as expected. This may take time to become apparent, and it may be necessary to change to a different intervention, or to try a combination of interventions if the first choice does not have the desired effect.^{1, 6, 7}
• There can be a significant time commitment as regular monitoring is necessary, and associated costs for patients and their parents should be considered, as myopia management treatments are not currently funded by UK national health systems.²

3. Managing risks associated with myopia management

Myopia management contact lenses and Orthokeratology^{1, 7, 12, 13}

• Contact lenses and orthokeratology lenses are a safe and predictable method of myopia management treatment in children with a low incidence of serious adverse effects. Complications may be mitigated by following advice on good hand hygiene and contact lens cleaning compliance. This means the change from standard contact lenses to specially designed myopia management contact lenses or orthokeratology lenses is unlikely to introduce any significant additional risk of corneal infections in children beyond that of any patient increasing their standard contact lens wearing times.
• There is no increased risk from wearing myopia management contact lenses during the day compared with wearing conventional contact lenses.
• There could be a small increased risk of corneal infections in children and young adults, associated with wearing lenses for longer periods and overnight wear, or for an individual moving from spectacle wear only to contact lenses wear. However, the risk of corneal infection can be significantly reduced with proper instruction and advice on handling these lenses and hand hygiene.
• Children can manage contact lens wear safely, provided they are able to handle them hygienically, so they need a full contact lens fitting evaluation and patient instruction on lens wear and care. The incidence of corneal infiltrative events in children is no higher than in adults, and in the youngest age range of 8 to 11 years, it may be markedly lower.¹²
• The long-term success and safety of orthokeratology requires a combination of accurate lens fitting, rigorous compliance to lens care and follow-up recommendations, and timely treatment of any complications.

Myopia management spectacles^{6, 7}

• Spectacles lenses for myopia management treatment have no known increased risks compared to wearing spectacles with standard correction lenses.

4. Resources and further reading

• Consent - College of Optometrists (college-optometrists.org)
• PreMO-risk-indicator-for-website.pdf (ulster.ac.uk)
• Northern Ireland Childhood Errors of Refraction Study - Six Year Refractive Change among White Children and Young Adults: Evidence for Significant Increase in Myopia among White UK Children
• Flanagan SC, Saunders KJ. The optometric management of childhood myopia. Optometry in Practice 2019; 20(4):1-11.
• Axial growth and refractive change in white European children and young adults: predictive factors for myopia - PMC (nih.gov)
• International Myopia Institute

5. References

1. Gifford, Kate L., et al. "IMI–clinical management guidelines report."Investigative ophthalmology & visual science60.3 (2019): M184-M203.
2. Jones, Lyndon, et al. "IMI–industry guidelines and ethical considerations for myopia control report."Investigative Ophthalmology & Visual Science60.3 (2019): M161-M183.
3. Morgan, P. B., McCullough, S. J., & Saunders, K. J. (2020). Estimation of ocular axial length from conventional optometric measures.Contact Lens and Anterior Eye,43(1), 18-20.
4. Han, X., Liu, C., Chen, Y., & He, M. (2022). Myopia prediction: a systematic review.Eye,36(5), 921-929.
5. Jonas, Jost B., et al. "IMI prevention of myopia and its progression."Investigative ophthalmology & visual science62.5 (2021): 6-6.
6. Wildsoet, C. F., Chia, A., Cho, P., Guggenheim, J. A., Polling, J. R., Read, S., ... & Wolffsohn, J. S. (2019). IMI–interventions for controlling myopia onset and progression report.Investigative ophthalmology & visual science,60(3), M106-M131.
7. Németh, J., Tapasztó, B., Aclimandos, W. A., Kestelyn, P., Jonas, J. B., De Faber, J. T. H., ... & Resnikoff, S. (2021). Update and guidance on management of myopia. European Society of Ophthalmology in cooperation with International Myopia Institute.European Journal of Ophthalmology,31(3), 853-883.
8. Bullimore M, Brennan N. Final Level of Myopia versus Age of Onset: Effect of Race and Age at Final Refraction. Invest Ophthalmol Vis Sci 2022;63:4244.
9. Foreman, J., Salim, A. T., Praveen, A., Fonseka, D., Ting, D. S. W., He, M. G., ... & Dirani, M. (2021). Association between digital smart device use and myopia: a systematic review and meta-analysis.The Lancet Digital Health,3(12), e806-e818.
10. Walline, J. J., Lindsley, K. B., Vedula, S. S., Cotter, S. A., Mutti, D. O., Ng, S. M., & Twelker, J. D. (2020). Interventions to slow progression of myopia in children.Cochrane Database of Systematic Reviews, (1).
11. Gajjar, S., & Ostrin, L. A. (2022). A systematic review of near work and myopia: measurement, relationships, mechanisms and clinical corollaries.Acta Ophthalmologica,100(4), 376-387.
12. Bullimore, M. A. (2017). The safety of soft contact lenses in children.Optometry and Vision Science,94(6), 638.
13. Liu, Y. M., & Xie, P. (2016). The safety of orthokeratology—a systematic review.Eye & contact lens,42(1), 35.