What motivates you and your patients in myopia management?

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Nowadays every conference program features some content on myopia management. Slowing the progression of myopia in childhood has become one of the hottest topics in the eye care sphere, as scientific knowledge, industry innovations, and clinical awareness in the field culminate. Only within the past 5 years have data from the clinical trials of our most effective treatments been published, covering optical, pharmacological, and novel light therapies.¹ Industry has facilitated availability of these treatments to clinicians in practice, and scientists are still exploring how best to compare treatments and set goals for management.^1,2 Underpinning the “how” of myopia control is the foundation of “why” it matters for both short-term functional and long-term eye health benefits of the patient with myopia. Understanding what motivates the practitioner, parent, and patient in commencing and continuing myopia management can be crucial in successful outcomes.

The “why” of myopia management

Although the new technologies are undoubtedly exciting, in principle and in practice it is most crucial to start with why myopia control matters. Traditionally, myopia was considered part of the continuum of refractive error, an ametropia to be corrected with optical or surgical means. It has been revealed over time, though, that myopia is not a benign state of ocular defocus, as each additional diopter increases the risk of various ocular pathologies.^3,4 Right across the refractive range, there is no safe level of myopia: every diopter increases the risk of retinal detachment by 30%, open-angle glaucoma by 20%, posterior subcapsular cataract by 21%, and most notably, myopic maculopathy by 58%. The lifetime risk of experiencing visual impairment increases by 24% to 31% for each additional diopter of myopia. The flip side of this finding is that reducing the final level of myopia by 1 D can reduce the lifelong risk of these ocular pathologies for the individual patient.⁵

Of course, it is not possible to reduce a patient’s myopia once it has manifested, but there is ample evidence for reducing progression. The younger a patient is when they become myopic, the longer they have to progress and the higher their final myopia tends to be.⁶ This means that the earlier a myopia control strategy is commenced, the greater overall impact there will be on reducing the potential final level of myopia by reducing progression.² Evidence from numerous studies has shown the capability of modern myopia control interventions to reduce the level of myopia in the treatment group by around 1 D (or the axial length equivalent) over only 2 to 3 years of a randomized controlled trial, compared with group wearing single-vision spectacles.^7-10 Data from extended studies and modeling are indicating that closer to 2 D could be “saved” by a myopia control treatment prescribed for several years across a childhood.^11,12 The compounding benefits of myopia control for long-term eye health are clearly evident and comprehensively agreed on across the field. Changing the current global trajectory away from higher frequencies and levels of myopia has benefits for each patient, and it also reduces the global burden of myopia on health expenditure, lost productivity, and quality of life.¹³

The short-term view

Although these long-term benefits of slowing myopia progression in childhood are unmistakable, understanding the short-term benefits is just as important in clinical practice. Additionally, this may be even more important in motivating parents and patients to take action.

There are simple messages on myopia correction and progression with which all eye care professionals will be familiar, yet can be powerful in clinical communication. It is vital to explain the functional impact of uncorrected or undercorrected myopia—to avoid the “wait and see” approach of a parent and counter concerns about full correction of myopia. It is a sad fact that across the world, many young myopes experience the visual impacts of undercorrection under the misguided (and long debunked) notion that it will slow myopia progression or make the eyes “weaker.”^14,15 With the escalating incidence of myopia,¹⁶ it is also common to be introducing myopia to a parent or guardian who has little personal experience of it themselves. “Healthy” individuals have been shown to mispredict the impact of chronic illness and disability compared with those with existing conditions,¹⁷ making it more difficult for the emmetropic parent to understand both short-term and long-term myopia impacts. The motivating message here is that children need their clearest possible vision to learn, develop, and participate in the world. Full myopia correction gives them their best chance and should be consistently recommended.¹⁸

Unfortunately, the progressive nature of myopia means that the fully corrected child doesn’t get to enjoy this for long: A child aged 7 to 9 years typically progresses by around 1 D in a year, on average.¹⁹ This highlights the key short-term benefit of myopia control, which is easily grasped by parents and patients—less blurred vision between eye exams and less frequent changes in prescription. As an example, the average 8-year-old who is corrected with single-vision spectacles at their eye examination will present 1 year later with 1 D of progression and around 20/60 acuity. Myopia progression is not linear, appearing to be faster in winter than in summer, but again working with averages, this could mean half the year spent with good acuity and half the year spent with declining acuity. If this same child is prescribed a myopia control treatment that slows progression by around 50% (and there are numerous such treatments available),^7-10 this progression would be only 0.50 D in the year, with presenting acuity of closer to 20/25 or 20/30. Imagine these comparative acuity levels across a year in the classroom, playing sports, and interacting with the world.

With myopia control, this same child should have clearer vision for the time between eye exams and may not even notice any visual decrement if they are reviewed every 6 months, as recommended by the International Myopia Institute.¹⁸

The long-term view

The long-term benefits of myopia control are well known to eye care practitioners: reducing the lifelong risk of eye diseases and vision impairment attendant with increasing levels of myopia.^4,5 Understanding that the complications of myopia will likely become the biggest cause of uncorrectable visual impairment in the United States in coming decades²⁰ is highly motivating for the clinician interested in preventive eye care. Key facts are that every 1 D reduction in final myopia reduces the risk of myopic maculopathy by 40% and saves predicted years of vision impairment.⁵ Although myopia is always clinically measured in diopters, there appears to be a closer link between the excessive axial eye length found in myopia and the risk of vision impairment: an axial length exceeding 26 mm is a clear delineator for elevated risk.²¹ The most significant gains for long-term eye health are made if myopia is kept below 3 D and axial length below 26 mm, whenever possible.^3,21

Understanding temporal myopia

What motivates the practitioner may not be what motivates the parent. A phenomenon called temporal myopia means that as humans, we prioritize short-term gains or immediate outcomes over long-term benefits or delayed gratification. This time-based near-sightedness makes for less logical responses to immediate gratification when it competes with potentially a better or more important outcome in the future.²² This indicates that parents and patients are more likely to identify with the short-term gains of myopia control (or be deterred by the short-term time or financial costs) than be motivated by the long-term benefits or consequences of inaction, regardless of their arguably greater seriousness. Starting with discussion of the short-term impacts and benefits of myopia control can therefore be more motivating for parents and patients, which can then be supported by the long-term benefits.

Temporal myopia can be utilized to the advantage of the proactive eye care practitioner. The clinical practice of myopia management—which includes prescribing myopia control treatments as well as providing clinical advice and long-term ocular health monitoring¹⁸—is a crucially important opportunity to improve children’s vision and eye health in the short-term and the long-term. It is also professionally rewarding, with the prospect for strong practice and professional growth. Through whatever treatments and technologies are applied, these fundamentals underpin the “why” of myopia management and the motivations to take action, for practitioner, parent, and patient alike.

References

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16. Holden BA, Fricke TR, Wilson DA, et al. Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmology. 2016;123(5):1036-1042. doi:10.1016/j.ophtha.2016.01.006

17. Ubel PA, Loewenstein G, Schwarz N, Smith D. Misimagining the unimaginable: the disability paradox and health care decision making. Health Psychol. 2005;24(4S):S57-S62. doi:10.1037/0278-6133.24.4.S57

18. Gifford KL, Richdale K, Kang P, et al. IMI – Clinical Management Guidelines Report. Invest Ophthalmol Vis Sci. 2019;60(3):M184-M203. doi:10.1167/iovs.18-25977

19. Donovan L, Sankaridurg P, Ho A, Naduvilath T, Smith EL 3rd, Holden BA. Myopia progression rates in urban children wearing single-vision spectacles. Optom Vis Sci. 2012;89(1):27-32. doi:10.1097/OPX.0b013e3182357f79

20. Bullimore MA, Brennan NA. The underestimated role of myopia in uncorrectable visual impairment in the United States. Sci Rep. 2023;13(1):15283. doi:10.1038/s41598-023-42108-y

21. Tideman JWL, Snabel MCC, Tedja MS, et al. Association of axial length with risk of uncorrectable visual impairment for Europeans with myopia. JAMA Ophthalmol. 2016;134(12):1355-1363. doi:10.1001/jamaophthalmol.2016.4009

22. Luhmann CC. Temporal decision-making: insights from cognitive neuroscience. Front Behav Neurosci. 2009;3:39. doi:10.3389/neuro.08.039.2009

23. Mella P, Pellicelli M. How myopia archetypes lead to non-sustainability. Sustainability. 2017;10(1):21-44. doi:10.3390/su10010021