September 15, 2020
By Kevin Chan, OD, MS, FAAO
“Refer your patients to me for specialty care, and I will send them back to you for primary care and glasses,” said almost no optometrist ever. Unlike the symbiotic relationship between dentists and orthodontists, optometrists historically have not developed referral and co-management networks effectively for specialty eye care service. The ‘do-it-all’ approach adopted by most eye care professionals (ECPs) stems from concerns about losing patients or being seen as not clinically adept. In essence, co-management networks in optometry have seldom been used. Over the last few years, I have seen the rise of specialized eye care platforms such as dry eye, vision therapy, sports vision, and specialty contact lens fitting, all of which are finally breaking down some of these legacy barriers. As the senior clinical director for Treehouse Eyes, I have developed a unique perspective on co-managing patients for myopia treatment, which I believe applies to many of these other specialty fields as well. I have had referrals from over 170 doctors’ offices to our Tysons Corner, Virginia, location and successfully co-managed children in myopia treatment with over 75 of those practices.
Myopia is a disease that is growing in prevalence, with an estimated 15 million children in the U.S. already myopic. Myopia represents more than optical inconvenience alone; it also significantly increases a child’s lifetime risk of serious eye diseases such as myopic maculopathy1,2 and glaucoma3-5, so early intervention is critical. Fortunately, we now have treatments that are proven to treat myopia in children, not just compensate for the symptom of blurry distance vision. Given the magnitude of the challenge, all ECPs need to work together, along with allied health care professionals such as pediatricians, to educate parents about myopia and provide interventions for children with myopia progression.
Myopia management is still perceived as a novel specialty in our eye care industry. The training we go through in optometry school did not prepare us with all of the skills needed to treat myopia effectively, and, in most practices, there is no access to appropriate optical biometry for axial length measurement, a critical tool in pediatric myopia management. Fortunately, there is now a plethora of continuing education courses and resources available to educate optometrists on myopia management. Despite that, effectively managing myopia in children is not for every practice. It can be more time and labor-intensive to do additional clinical testing, educate parents, and customize a treatment plan for each child. So, I believe co-management is a great solution to ensure all children have access to myopia management, even if their primary eye doctor does not provide this service.
The first step to setting up a co-management relationship for myopia management is to ensure you have the clinical expertise and are equipped to excel in this field. Referrals generally stem from the recognition and trust of your stellar expertise and service provided for patients. Other ECPs will not send you patients for myopia treatment unless they are fully confident that you will take great care of their patients. A great way to establish this expertise is to host CE events for other ECPs in your area. I have done “back-to-school” and “summer fun” CE seminars periodically for local ECPs and vision therapy practitioners. Before COVID-19, we held weekend events at our Treehouse Eyes office or dinner meetings. In addition, I have also been invited to present CE lectures sponsored by refractive surgeons as part of their outreach efforts to optometry. Since COVID-19, we have moved to conduct CE webinars using a Zoom platform. Sharing the latest research on myopia, relevant clinical papers, and case studies is helpful in raising demand for other doctors to ensure they develop a better understanding of myopia treatments we offer and align expectations for their patients.
With your expertise established in your area, I advise that you reach out to other optometric practices and assess whether they want to provide this service at their offices. For those who do not, it is an excellent opportunity to discuss co-management service for their patients. The key to success is establishing that you provide myopia management solely, while the other optometrist remains their primary care provider. Focus on what your expertise does for patients’ myopia needs, and let the ECP continue with providing optical services to patients. We have a reasonably turnkey system at Treehouse Eyes that we use to make it easy for other practices to co-manage with us. When that practice sees a child for a primary care exam, they provide them our patient brochure and send us a co-management form for further evaluation if the child is considered a candidate. Once evaluation for myopia treatment is completed, and when parents opt to proceed with treatment for their child, we send a summary report to their ECP and initiate appropriate myopia treatment. We also advocate parents to continue primary eye care service with their referring doctor periodically.
Our office provides a complimentary myopia consultation for families to reduce the barrier to a visit. It is a win-win both for us and the co-managing practice as there is no risk to their patient of a consultation. I often find that parents may not be ready to start myopia treatment right away but later come back once their child’s prescription has gotten worse and are ready to start treatment because they are better educated.
Like co-management in refractive surgery, once a patient starts myopia treatment at Treehouse Eyes, we make the co-management payment to the other practice. In addition to providing the history of the patient, the primary care practice also sees the patient for a six-month follow up and sends those findings back to our practice. This helps both keep the relationship with the primary care practice and enables us to follow up with the patient if I have any concerns about those six-month findings. I find by using the example of orthodontic braces, where the dentist provides primary care and the orthodontist only focuses on braces, it helps parents understand the role of each provider.
We all share the goal to help more myopic children have better vision now and reduce their risk of more serious eye diseases associated with myopia. Setting up a co-management model is a win-win-win: patients get the best possible care from a specialist, the primary eye care doctor ensures their patient is treated, and the myopia management practice develops a relationship with area practices. I often refer outpatients we see at Treehouse Eyes who may have issues other than myopia or need a primary eye care provider for routine care and glasses. I hope all optometrists embrace this model, and we can work together to treat the 15 million-plus children with myopia in the U.S.
Kevin Chan, OD, MS, FAAO, is senior clinical director at Treehouse Eyes. This article is published in cooperation with the Global Myopia Awareness Coalition campaign.
- Xiao O, Guo X, Wang D, et al. Distribution and Severity of Myopic Maculopathy among Highly Myopic Eyes. Invest Ophthal Vis Sci 2018;59:4880-5.
- Hayashi K, Ohno-Matsui K, Shimada N, et al. Long-Term Pattern of Progression of Myopic Maculopathy: A Natural History Study. Ophthalmology 2010;117:1595-611, 611 e1-4.
- Shim, S. H. et al. The Prevalence of Open-Angle Glaucoma by Age in Myopia: The Korea National Health and Nutrition Examination Survey. Curr Eye Res 42, 65–71 (2017).
- Marcus, M. W., De Vries, M. M., Junoy Montolio, F. G. & Jansonius, N. M. Myopia as a risk factor for open-angle glaucoma: A systematic review and meta-analysis. Ophthalmology 118, 1989-1994.e2 (2011).
- Tan, N. Y., Sng, C. C., Jonas, J. B., Wong, T. Y., Jansonius, N. M., & Ang, M. (2019). Glaucoma in myopia: diagnostic dilemmas. British Journal of Ophthalmology, bjophthalmol-2018.