Dec. 3, 2019
By Calah Ray, OD
As a -12.00 diopter myope, the mom of a five-year-old -1.00 diopter myope, and an optometrist who has focused her career on pediatrics, I have more than a passing interest in myopia management. I began prescribing low-dose atropine over three years ago. Treatment acceptance was low at first but quickly began to increase as I gained confidence in the safety and efficacy of low-dose atropine. Recently, I have started to fit daily disposable distance center multifocal contact lenses. Similarly, acceptance was initially low; now, many of my myopic patients are wearing this lens.
Prior to embarking on the myopia management journey, each practitioner must consider several factors. Will this benefit my patients? Will this benefit my practice? Am I comfortable with these procedures? And, perhaps most importantly, is it the right thing to do? In other words, do we have an ethical responsibility to offer myopia management to our patients?
The American Optometric Association Code of Ethics instructs us “to keep [our] patients’ eye, vision, and general health paramount at all time; to respect the right and dignity of patients regarding their health care decisions; and to advance [our] professional knowledge and proficiency to maintain and expand competence to benefit [our] patients.” How do we apply these principles to the rapidly expanding field of myopia management?
“To Keep [Our] Patients’ Eye, Vision, and General Health Paramount at all Time”
It is widely accepted that myopia is a risk factor for comorbidities such as glaucoma, cataracts, myopic macular degeneration, and retinal detachment. Managing myopia does more than preventing the patient from having thick glasses lenses; it reduces the risk of the patient developing one of the diseases associated with high myopia. The World Health Organization is predicting almost 50% of the population will be myopic by 2020. It is our duty as healthcare providers to work to minimize myopia progression and therefore minimize the burden associated with treating the comorbidities.
“To Respect the Right and Dignity of Patients Regarding Their Health Care Decisions”
Perhaps the most crucial aspect of myopia management is obtaining informed consent from the patient and parents. Many parents of my patients are discouraged by the term “off-label.” We must have an often lengthy discussion involving the definition of that term, myopia treatment options, and the supporting research. I utilize a “Myopia Control Agreement Form” that lists my preferred treatment options, their statistical success rates, any fees involved, and a statement acknowledging many of these treatments are “off-label.” Once we determine the treatment course, the parent signs the form and receives a copy of it. If the parent is hesitant, I encourage them to take the form home, discuss it with their family, and let me know what they decide. I will also send home a printout from the Brien Holden Vision Institute Myopia Calculator specific to the patient’s age, refractive error, and recommended treatment modality. This calculator uses peer-reviewed data to predict myopia progression with and without treatment. It provides an excellent visual aid for the patient and parents. If, after this discussion, the patient or parent decides to decline treatment, that is entirely within their rights.
“To Advance [Our] Professional Knowledge and Proficiency”
It is our responsibility to keep up with current research and pass that along to our patients. How will they know if we do not tell them? We discuss various options for dry eye therapy; similarly, we should be able to discuss options for myopia management. After all, both are conditions that affect ocular health.
Marketing Myopia Management
Myopia control options have become a natural part of my patient education. As I explain the need for glasses due to myopia, we discuss its expected progression and the options to slow that progression. In my opinion, myopia management should be initiated along with refractive treatment. For children under age 6, I encourage reducing screen-time and increasing time outdoors. For patients ages six to eighteen, I prescribe low-dose atropine or distance center multifocal contact lenses.
I am fortunate that my Vision Source practice is located in a very close-knit community where word travels quickly. It is very common for new patients to come to our office because a friend, family member, or social media post recommended our practice. We strive to provide the highest level of care to our patients by utilizing the newest diagnostic and therapeutic technologies, including those related to myopia management. Patient to patient referrals drive many myopic patients into my office. As a result of these referrals, I fit five children from three families in daily disposable multifocal contact lenses this summer. As one child was successful, the other children were motivated to try as well.
My least favorite part of myopia management education is the discussion of the associated fees. Myopia control contact lens fittings are priced according to the lens selected. Patients are charged for myopia control follow-up visits. These visits occur every three to six months, and the frequency is determined by the treatment modality and the patient’s response to treatment. These fees are detailed in our Myopia Control Agreement Form and are explained by our office staff.
It is our ethical responsibility to offer myopia management to our patients. When we present the options along with the research to support them, we enable our patients to make well-informed decisions regarding their healthcare. When we are honest in our patient education, and patients experience treatment success, patient to patient referrals are a natural result. When we set reasonable exam fees and clearly communicate them to our patients, we can profit from myopia management while still upholding our ethics and core values.