How Is Canada Addressing Myopia? Find Out From CORE’s Dr. Debbie Jones

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April 15, 2024

Following her recent studies on “Myopia in Practice” and “Myopia Prevalence in Canadian School Children,” clinical professor and scientist Debbie Jones, FCOptom, FAAO, FBCLA, shared the results of how pediatric myopia treatment is evolving in Canada, especially with the introduction of spectacle lenses to slow the progression of myopia. Learn more in this interview with Review of Myopia Management’s Editor-in-Chief John Sailer:


John Sailer, RMM Editor-in-Chief: Hello and welcome to Review of Myopia Management‘s interview series. I am John Sailer, Editor-in-Chief of Review of Myopia Management, and we are here today with Dr. Debbie Jones, clinical professor at the School of Optometry and Vision Science, and a lead clinical scientist at the Center for Ocular Research and Education, also known as CORE, at the University of Waterloo. 

In this interview sponsored by EssilorLuxottica, we will be discussing Dr. Jones’s “Myopia in Practice” study, which sought to determine how optometrists in Ontario, Canada, are managing myopic and pre-myopic pediatric patients and incorporating myopia control over time. We will also touch on her previous study, “Myopia Prevalence in Canadian School Children: A Pilot Study.” Thank you for being here, Dr. Jones.

Real-World Data on Canadian Myopia Management Since 2017
Dr. Debbie Jones, FCOptom, FAAO, FBCLA: My pleasure. Thanks, John, for having me.

RMM: In addition to my brief introduction, can you provide a more in-depth description of your “Myopia in Practice” study and your previous pilot study?


Dr. Debbie Jones

Dr. Jones: The “Myopia in Practice” study actually came out of the Fellows Doing Research program through the American Academy of Optometry, and this program supports Academy Fellows through mentoring as they develop new research ideas. We actually proposed the study in late 2019 with a scheduled meeting in 2020, which of course did not happen. But we stuck with it, and we’re a group of nine optometrists, and we have Dr. Robin Chalmers as our Fellows Doing Research mentor, who is kind of keeping us on track. We’re fortunate enough to have had funding from four industry partners, and we have database and statistical support from the Centre for Ocular Research and Education. 

The aim of the project is really to look at what’s happening in the real world and to determine how myopic and pre-myopic patients are being managed in clinical practice for the boots-on-the-ground practitioner and how this has changed over time. So, it’s a retrospective file review, and we picked specific parameters to look at. We’re looking at children aged 6 to 10 at their first visit and then comparing their management across a five-year period. So, we’re following each patient across their journey for five years or as long as they stayed with that practice. 

It’s up to five unique charts in each selected age from the years 2017 to 2021. That’s a time period where myopia control really changed, certainly in Canada and across the world. So, for example, we can look at a 6-year-old low myope and see how they were managed in 2017 and see how that changed over time. We can also look at a 6-year-old low myope in 2021 and see how that patient would be managed.

So, we have some longitudinal data, as well as kind of a snapshot as to what’s happening at a specific time point. As of early February, we’ve completed the data collection. As you can imagine, it wasn’t a small feat. We have 15 practices that we’ve either assessed their files remotely or actually gone into their practice and done a file review. We have almost 3,000 unique patients with over 8,500 visits across a five-year period. So, it’s a monster of a dataset that we’re dealing with, but with some really fabulous information in there. I’ll talk a little bit about some of the results in a moment. 

You mentioned the other study, and that was actually a paper that we published in 2018, a pilot study looking at the prevalence of myopia in two groups of children within the Kitchener/Waterloo region, which is where I’m based. We looked at 6 to 8 year olds and 11 to 13 year olds. The initial examination was performed in the school, and then if the child was found to be myopic, they were invited to a second cycloplegic examination that took place at CORE. 

At that time we saw a prevalence of about 6% in the younger group and about 30% in the older group. What was really interesting was about a third of the children had no idea that they were myopic. Not only was it interesting for us, it was also interesting for them to find out that they actually needed vision correction. 

That was just a small pilot study, and we’re really hoping to repeat the study on a much larger scale, actually Canada-wide, to cover different provinces. We have a protocol written, and we’re just looking for funding partners to see if we can really look at what’s happening across the whole of Canada on a much bigger scale.

Myopia Management IS the Standard of Care in Canada

RMM: Very exciting. Very interesting. So, in the introduction to your “Myopia in Practice” study, you mentioned two spectacle lenses that are available to slow the progression of myopia, both of which unfortunately are not yet available in the United States. And you also discuss one soft contact lens. So those involved in myopia management throughout the world will already be familiar with these lenses, but you also mention the optometric practice reference standards of practice published by the College of Optometrists of Ontario. So, can you explain the significance of including these standards?

Dr. Jones: Whenever a professional body or a regulatory body makes a statement, we all have to sit up and listen. The optometric practice reference for Ontario acknowledges the importance of myopia control. They actually amended the section on OrthoK to include myopia control as an indication. Then in December of 2022, a section was added on myopia management. So, this really demonstrates within Ontario that the regulatory bodies are acknowledging the importance of myopia control. I think more significantly, the Canadian Association of Optometrists in January 2022 issued a position statement supporting the World Council of Optometry’s resolution regarding myopia control as being standard of care. To date, I believe we’re still the only country whose professional body has indicated that myopia control is standard of care. So, as an optometrist in Canada, we’re actually obliged to offer myopia control to our patients if we are working within the standard of care that has been basically put upon us by the Canadian Association.

RMM: Okay, go Canada! Well done. In your study, the figures that are included show the introduction of specific myopia management modalities and also a significant increase in the prescription of myopia control treatment, maybe because they’re available, but can you explain the significance of these results?

Dr. Jones: The results we presented at the Academy meeting in October last year represented just over 1,300 patient charts. So, it was preliminary data. Obviously at that point we didn’t have the full subset of data. We had seven practices completed, and the results encouragingly showed a steady increase in the number of patients being offered myopia control over that time period. So, again, we were talking about 2017 to 2021, a five-year time period. There were spikes as you mentioned, at specific times when certain myopia control products were introduced into the market. So, the first product we had was a soft contact lens, and we saw a spike there. Then a little bit later we had the introduction of spectacle lenses for myopia control, and we saw a spike then. So, it did appear as if practitioners were embracing the new technologies that were available.

Just to give you some example of the numbers, in 2017 when we looked at how many optometrists had a discussion with their patient about myopia control, even if it wasn’t implemented but they introduced the concept, it was about 10% in 2017, and this increased to almost 18% in 2021. So, still lower than we might like, and we can perhaps touch on some of the reasons for that. As we analyzed the data a little bit more closely, we looked at when was that discussion happening? Was it related to product being available, or was it related to something else? We looked at prescriptions in particular, and we saw that in 2017, a young myope had to be about a -2.50D myope before somebody said, ‘Hey, we could do something about this.’ In 2021, the level has come down to about a -2.00D myope. Again, still not what we want, but certainly showing trends in the right direction, which is very encouraging.

Myopia Management Spikes when New Treatments are Introduced

RMM: Interesting results. Good to hear there’s a spike when treatments become available. So even with these available treatments in Canada and more that are coming out, it seems single vision correction remains prominent in the study. Can you explain why this might be and what the solution could be to correct it?

Dr. Jones: Yes, John, we could observe that so many practitioners are still starting myopia management with single vision spectacles. The results we’ve presented so far just consider the initial visit for the myopes, and the 2017 numbers were around about 70% that were being put into single vision specs. In 2021, that had reduced to 62%, but still very concerning. Now this is for patients with myopia of half a diopter or more, so it is covering some of those quite low myopes as well. The data captured the initial visit, so we know that there’s kind of a bit of an enthusiasm from some practitioners to do the watch-and-wait, so they have that conversation, they start with a single vision spectacle, and then as soon as they see an increase in myopia, they then have the conversation about myopia control and put the child into a myopia control option.

We know that the watch-and-wait approach is not the right one, but I do think practitioners are doing that perhaps especially in parts of the world where spectacles are not an option. Now we don’t have that excuse here in Canada because we do have access to the myopia control spectacle lenses, but of course we didn’t when they weren’t available in 2017 and ‘18 and ‘19. So, we did have some years where we didn’t have something that perhaps we could offer easily to our low myopes or our young myopes, and I think practitioners are a little reluctant to do anything other than single vision spectacles. 

What we’re hoping when we further analyze the data is we’re actually going to look at what happens over time, so we’re going to tease out what prompts practitioners to prescribe myopia control. Is it the absolute value of the prescription? Do you have to be, for example, a minus two myope before you get offered it? Or is it progression? Is it age, or is it something else? I mean, we do feel that education remains a big part of the problem and the solution, educating our ECPs, but also educating the public. If we can get a little more education in the public domain, then perhaps parents will ask for myopia control and will be prompted to offer it sooner.

RMM: Okay. So those who are familiar with myopia management also know that the available treatments are not the only solution to slowing both the onset and the progression of myopia. Lifestyle changes were also discussed in your study. Can you explain any impact this aspect of the study has had?

Dr. Jones: We have good evidence about things that can delay the onset of myopia, so lifestyle changes such as more time outside and perhaps less time on digital devices, particularly for those younger patients. We know that the younger the patient starts on their myopia journey, the more likely they are to have that higher final prescription. So, delaying the onset is key with our younger patients. 

Now, lifestyle change recommendations in our data, again, it was also a little disappointing in 2017, we were seeing about 2% of patients that in the chart had recorded that lifestyle changes were recommended. This increased quite dramatically to 18% in 2021. So, we are seeing the discussion happening with increased frequency, but of course we could only report what was written in the chart. Personally, I give lifestyle advice to all parents of young children, whether they’re myopic or have a risk or family history of myopia, for example. Does it always get noted in the chart? I would love to say that my charts are perfect, and I write everything down that I say, but of course we know that doesn’t really happen, and some of the discussions that practitioners are having don’t always get noted. So again, with increased knowledge about those lifestyle recommendations that we can give to our pre-myopes, in particular, hopefully those discussions are happening certainly in the chair even if they’re not being written in the file.

RMM: Okay, good. What further results related to myopia management have you observed, if any, since the conclusion of these studies and any ongoing studies?

Dr. Jones: As I mentioned, the preliminary data we had at Academy last year, we’ll be presenting at ARVO in May, and we have abstracts going in for the Academy meeting and the International Myopia Conference, and those abstracts will cover the whole dataset. So, at that point, we’re hoping to really show how the behavior changed over the time for a much larger set of patients. We really want to know what makes an ECP initiate treatment or change treatment? Is it progression? Is it prescription? Is it age? So, we’re really looking forward to seeing what makes the practitioner tick with myopia control. What is it that really encourages them to make that leap into myopia control or make the change? So, we’re looking forward to plowing through the data and having some more results later in the year. Perhaps you and I can have a conversation when we have all of the results in front of us.

RMM: Alright, we’ll do that. So, now for my last question, a more broad question: Ultimately, what conclusions have you reached already and what are you looking toward for the future of myopia management in Canada from your perspective, and also globally, as you participate in conferences throughout the world on the topic?

Dr. Jones: The main conclusion is there is so much more that we can do and that we need to do. We need more education on appropriate ways to manage our myopic patients and indeed the pre-myopic patients. This is really going to be a big focus of attention at meetings for the next few years, is what do we do about those patients to stop them becoming myopic, or stop would be lovely, but at least delay as much as we can. And we need to educate the public. We need early intervention even on the basics of the need for routine eye care for children. It still seems to be being missed, and people I talk to around the world, not just in Canada, parents are very quick to take their children to the dentist but not so quick to take them to an optometrist.

So, we really need to educate other health care providers, family physicians, pediatricians. We need to educate teachers and make sure that everybody is giving the message to the parents that routine eye care is essential. And then we can find those pre-myopes, find those young myopes, and really intervene early. 

I think globally as more myopia control products get regulatory approval, we should see a global increase in myopia control. You’ve already mentioned in the U.S. there are no myopia control spectacles yet. And certainly in Canada we found that to be a game changer, to have that option really opened up lots of opportunities for people who perhaps were less comfortable with contact lenses or pharmaceuticals, really gave them the option to be able to offer something to their patients. 

So hopefully we see worldwide availability of all myopia control products. Ultimately, our patients deserve it. And even if it’s not officially the standard of care in the jurisdiction that you are in, it certainly is our duty of care to offer the best to those patients. It’s just what we have to do. It’s plain and simple.

RMM: Good to know. And something hopeful to look forward to.

Dr. Jones: There’s going to be a lot more as we move forward, and it’s a really exciting time. I think there’s so much that’s available and so much we can do. We’ve heard the prediction that by 2050, 50% of the world population will be myopic. We have the opportunity, perhaps not to change the 50%, but to change that 10% that’ll have high myopia. I think we have the opportunity to really make sure that that prediction doesn’t come true.

RMM: Well done. Thank you very much, Dr. Jones, for your insights into myopia management.

Dr. Jones: You’re very welcome. It’s my pleasure to talk to you.

RMM: And we would also like to thank EssilorLuxottica for sponsoring this interview, and thank you for listening.

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