Clockwise from left: Iain Johnson, Craig McArthur and Alex Smith
Business building
Iain Johnson, optometrist director at Cheshire-based Johnson and Leatherbarrow, says that myopia management has become a big part of the practice business. ‘If priced correctly, it can help build the business, whilst also being extremely gratifying at the same time.
Anyone who is on the fence as to whether to start offering one form or another, I would say to go for it. With the right training it is possible for anyone to get involved,’ he says.
Johnson’s case study patient is a 13 year old male who engages in lots of sport including football and swimming. The patient’s parents heard about orthokeratology treatment through a friend and approached the practice as they were concerned that their son’s prescription had increased at each visit and they were both myopic too.
Johnson performed a new eye examination, including corneal topography and then discussed the myopia control options, including spectacle lenses (Miyosmart), orthokeratology and soft contact lenses (MiSight and NaturalVue).
‘We discussed the pros and cons of each design and decided to go with the orthokeratology option because it allowed the patient to do all activities, including swimming,’ says Johnson.
For Johnson, having multiple myopia control options is key: ‘There really isn’t one size fits all for managing myopia. In this case, the patient decided to stick with their original plan, which was the right choice for their lifestyle,’ he says.
The practice operates an appointment schedule to ensure ortho-k patients are seen regularly in practice. ‘As expected, the patient had minor improvements after their first nights’ wear. They had no issues with insertion or removal, and their sleep was uninterrupted.
'At week one, they were achieving great vision and were delighted at being able to see clearly without any spectacles. At four weeks, they had consistent vision throughout the day with no issues whatsoever,’ says Johnson.
The patient’s initial prescription was RE -3.25 / -0.50 x 115 LE -3.50 and after the first night it was RE -2.25 / -0.25 x 115 LE -2.50. After a week, the prescription had adjusted to RE -1.50 LE -0.50 and after three weeks, RE 0.00 LE 0.00.
Patients are invited to return at any time if they have any issues, using the practice’s booking system to schedule follow-up emails at set intervals. ‘The automation implementations have been a great way for us to get patients back in early when they are having any difficulties, and avoid larger complications,’ says Johnson.
The patient displayed no changes when he returned this September for his three-month review and he has a further review scheduled at six months.
‘The patient is already achieving excellent vision and I would expect minor improvements over time. We would also expect they continue to find ways of making orthokeratology part of their day-to-day routine,’ he says.
Best fit
Craig McArthur, optometrist director at Glasgow-based Peter Ivins Eye Care, says his patient first attended with her parents as an 11-year-old after noticing a change in her right eye. She was wearing frames made in 2016 with the prescription R: -1.00 / +0.50 x 175 L: -0.50 / +0.25 x 100.
The patient had an eye examination in the summer of 2017 in Singapore just before moving to the UK with the prescription R: -2.50 / +0.50 x 180 L: -0.50 / +0.25 x 100.
Both her parents are myopic, she is a keen reader, she plays hockey at school and attends Chinese school at the weekend, therefore spending most of the time on close, indoor work.
A cycloplegic refraction revealed a prescription slightly less than that prescribed in Singapore - R: -2.00 / +0.25 x 5 L: -0.25 / +0.25 x96. ‘This shows the importance of cycloplegic refractions in managing young myopes, as ‘over-minusing’ can be easy.
Despite her anisometropia, her binocular function was good. There was no sign of amblyopia, normal stereo, normal AC/A ratio, no esophoria, and no obvious accommodative lag,’ says McArthur.
Given the asymmetric nature of the patient’s refractive error, McArthur decided that contact lenses would be the preferred method of correcting her asymmetric refractive error and slowing down her myopic progression.
The patient and her parents were comfortable with the idea of daily disposable lenses and so they selected MiSight, starting treatment in December 2017.
‘I reviewed the patient three months later, then approximately every six months thereafter. Amazingly, after almost five years of MiSight-wear in the right eye, her myopia hasn’t progressed,’ says McArthur.
‘Over the last two years her axial length change has been 0.08mm in both eyes, with an annual growth of 0.05mm/a. This represents a resounding success of our combined efforts to reduce her myopia progression,’ he adds.
At age 17, the patient is happy with the vision and comfort provided by MiSight. ‘Even though the likelihood of further axial elongation and myopic progression is likely to be low, the patient and her parents are happy to continue wearing the single MiSight lens and to re-evaluate cessation of wear once she graduates from university,’ he says.
McArthur references another patient who opted for Miyosmart ophthalmic lenses. In 2017, and at age six, the patient attended a routine examination and was found to be pre-myopic with a prescription of R: -0.25 / +0.25 x 120 L: -0.50 / +0.50 x 75.
His parents were myopic but the patient’s binocular function was normal, there were no accommodative or convergence issues and he had full stereo at distance and near. It was therefore decided that the patient didn’t need any intervention but to review him every six months.
In early 2020, pre-Covid there was a -0.50 change in the right eye, however no symptoms. McArthur advised the parents to consider MiSight contact lenses to slow the likely myopia progression at an early age, but they declined.
By June 2021, there was a dramatic change, from -0.50 to -2.00 in the left eye, attributed to the amount of time on close work on an iPad and socialising with friends on gaming devices.
Following a discussion about the various myopia management options and shortly before his 11th birthday, the patient started wearing Miyosmart in June 2022. The patient’s axial length dropped after starting treatment and McArthur says his axial length and refractive error have been flat since, with the right growing by R: 0.03mm/and the left eye actually reducing by -0.03mm/a.
‘This represents a success in the myopia management interventions slowing both the change in axial length and refractive error since starting treatment.
'The patient is happy to continue with his glasses full-time for now, and in the last three months he has started wearing Mylo Toric contact lenses three to four days per week for his football training and matches to ensure 100% of his day is spent in a myopia management product,’ says McArthur.
Duty of care
Alex Smith, an optometrist at Newcastle-based Michael Offord Optometrist thinks there is now too much research about the importance of managing myopia to not be offering myopia advice to patients.
‘If myopia management isn’t available in your practice, I feel we still have a duty of care to inform patients and their parents about the options, so they are able to make an informed decision,’ she says.
Since completing the post-graduate CPD module in myopia management at Glasgow Caledonian University, Smith says: ‘I feel I am able to confidently discuss lifestyle and risk factors, like family history, time spent outdoors and age of onset, and non-optical methods of reducing risk and progression of myopia.’
As part of the myopia treatment discussions, the practice will always cover the three options, namely MiSight contact lenses, No 7’s Eye Dream orthokeratology lens and Miyosmart spectacle lenses: ‘I feel it is important to be able to offer a range of different treatments to ensure the patient is fitted with the option that best fits their needs and lifestyle,’ says Smith.
Smith’s patient has been under the practice’s care since 2011 and up until 2017, she had normal vision, healthy eyes and no prescription. In 2017, she complained about reduced vision and difficulties when looking at the board in school.
‘We found a small myopic prescription causing slightly reduced vision (-0.75D R&L). We began discussions around myopia control at that time, but her parents decided against treatment, and single vision glasses were dispensed,’ says Smith. At her routine review appointment at the end of 2018, the patient’s prescription had increased again, now to -1.50D R&L.
After discussing myopia management again with the patient and her parents, it was obvious that ortho-k was the best treatment option: ‘The patient was keen to try contact lenses as she is very active, doesn’t like wearing glasses and didn’t want to wear them full time,’ says Smith.
At that time, it wasn’t possible to measure the patient’s axial length, so Smith used her vision and over-refraction to monitor progression. The patient was able to achieve great vision with ortho-k very quickly. Her first morning prescription reduced to RE -0.50D LE -0.25D and she was very pleased with her unaided vision - RE 6/7.6 LE 6/7.6.
By her week one appointment, the patient’s vision had further improved to RE 6/7.6 LE 6/6, and her prescription was RE -0.25D LE plano. ‘We continued to monitor her closely, reviewing her again at one month, three months and now every six months. This is our general rule; however, we will see patients more frequently if we feel it is clinically necessary,’ says Smith.
During the first few years of wearing ortho-k, Smith says that the patient’s results were stable and there was no obvious myopia progression.
‘We now have a Myah in our practice, so we use this to measure axial length to allow us to better monitor for changes in all myopia treatments, especially ortho-k. The graphs are an excellent tool for showing patients their results and the effect of their chosen myopia treatment,’ she says.
Since 2019, the practice has made very small changes to the patient’s lenses. In 2022, the lens diameter was increased and in 2023 the base curves were slightly adjusted.
'This is when being able to measure axial length is amazing, as the patient’s measurements are stable, giving me confidence that the treatment is still working and her myopia is stable. The patient loves her ortho-k lenses. Her dad wishes it was something he had done rather than laser eye surgery,’ she adds.