How One Optometrist Bridged Vision Therapy and Myopia Control

Share

Tweet

Share

Share

Email

sponsored content

August 15, 2023

‘In a child’s early and ongoing years, you can really make a huge impact on their education, future eye health, and quality of life. Don’t approach children as mini-adults. They grow rapidly, so be proactive in treating these little people.’

Myopia management (MM) and vision therapy (VT) may seem like two very different pediatric specialties, but for Mississippi optometrist Megan Sumrall Lott, integrating the former into her well established VT-focused office was a natural fit.

“From a vision therapy standpoint and keeping the accommodative and binocular systems in balance, I feel like kids who have convergence insufficiency progress into myopia much more rapidly,”¹ she says. 

Dr. Lott first got involved in VT when her then nine-month-old son developed a tropia. Fast forward seven years later, Dr. Lott today owns Belle Vue Specialty Eye Care in Hattiesburg and a satellite VT clinic in Jackson. Her passion and commitment to VT cemented her as the only female in Mississippi to receive a College of Optometrists in Vision Development fellowship, and she remains only one of two eye care professionals (ECPs) in the entire state to ever hold this distinction, Dr. Lott says. Additionally, her reputation in this specialty has attracted patients and their families from far as far away as Virginia, Georgia, and Florida.

Looking for something new to learn during the pandemic lockdown, Dr. Lott’s interest in MM piqued when she decided to become MiSight 1 day* certified, marking her entry into MM three years ago.

Here, Dr. Lott shares how VT and MM can be synergized into a practice, and how ECPs can turn pediatric eye examinations into a fun and rewarding experience.

Influence of Blur and Binocular Vision on Eye Growth^2-4
To date, the role of accommodation and binocular vision in the development and progression of myopia is not fully understood, although research studies continue to debate how and why the structure of a myopic eye may affect accommodative behavior, according to the International Myopia Institute.²

The Collaborative Longitudinal Evaluation of Ethnicity and Refractive Error (CLEERE) study group found a higher accommodative convergence to accommodation ratio (AC/A ratio) correlated with a greater lag of accommodation in myopic children, but this finding wasn’t associated with a faster rate of myopia progression.³

Additionally, another paper that described the long-term refractive error changes in children diagnosed with intermittent exotropia (IXT) found myopia manifested in more than 90% of patients by the time they reached 20 years of age, even for those surgically aligned during childhood.⁴

From the trenches of her day-to-day practice, Dr. Lott has witnessed a distinct overlap between the conditions.

“There are a few things I see when children are really worsening quickly in myopia. I see children who have poor binocular skills, whether it’s convergence insufficiency driving the accommodative system to make the eyes pull inward, or they have convergence excess and are overaccommodating but aren’t converging enough,” Dr. Lott explains.^1-4 “Whenever you look at something closely, there is a constant play, a constant balance of the yin and yang of the accommodative system and the binocular system, so as one focuses, one must relax. There is a constant give and take.”

From Dr. Lott’s standpoint, when one of these systems is out of balance, the other must make up the difference, she suggests. Usually, the brain will choose to see single, not double, and this may result in clear or blurry vision. 

“The brain must make a choice to see single and blurry or double and clear. Most people will choose single, but maybe it’s blurry, or over-focusing or under-focusing, and blur may drive the eye growth,”⁵ she says.

From her experience in myopia control, Dr. Lott suggests MiSight 1 day’s mechanism of action is a natural fit for ECPs who specialize in VT.

“One thing we teach in contact-lens free VT is to expand your periphery. Look hard, look soft, and be aware when you are doing this. We put a lot of emphasis on peripheral vision, which is the mechanism that drives where your eyes are. Our world is very small and very central. People walk around with their cell phones, and they’re unaware of their surroundings because they’re staring at their phones. They don’t know where they are because they get too central and lose their whereabouts,” she says.

 Dr. Lott believes MiSight 1 day compliments her VT approach and helps the eyes “look soft,” by providing myopic defocus at all viewing distances.⁶

Of note, independent MiSight 1 day studies have shown that the dual focus optical design doesn’t change the accommodative or binocular function of the eyes.^7-9

Still, children in the MiSight1 day study didn’t typically have BV issues that required VT — strabismus was an exclusion criteria. The majority of subjects in the MiSight 1 day study were orthophoric (67%) or exophoric (23%) at near compared to a small percentage presenting with esophoria (8%).⁶

Further, a separate myopia-focused investigation of unpublished data from the Northern Ireland Childhood Errors of Refraction (NICER) study, a large, nine-year evaluation of longitudinal changes in refractive error amongst white, U.K. children and young adults, found the majority who were myopic or developed myopia during the study period were orthophoric (74%) or exophoric (18%) compared to a minority who were esophoric (6%) on near cover test with correction.¹⁰

A Focus on Myopia Control
As a standard in her practice, Dr. Lott prescribes MiSight 1 day to every age-appropriate child with myopia. 

“My rule is that every child who is a contact lens candidate starts in MiSight 1 day.* I won’t fit a child in a spherical lens first, and six months later, have them return to try MiSight 1 day.”

MiSight 1 day is the only myopia treatment option Dr. Lott prescribes. From a functional vision standpoint, low dose atropine (off-label MM in the US) was never an option for her since a child wouldn’t be able to perform an accommodative activity the same if the cycloplegic effects of atropine are still present, Dr. Lott says.

“I need to know the child’s focusing and binocular systems are working hand-in-hand, and whenever you take focus out of the equation, it offsets the balance,” Dr. Lott explains.

If indicated, Dr. Lott will suggest VT exercises to strengthen their binocular system, and in turn, teach them how to pull their eyes inward without using their accommodative system.

Three years into MM, a majority of her patients’ myopia levels have not worsened at all, with only two children experiencing a modest -0.25D change. 

“The lens is easy to fit, and I became more comfortable talking to parents about myopia control based on the consistent results I’m getting.”^†6,11

When it comes to pricing the lenses, Dr. Lott adopts the same universal structure to myopia control that she uses for her VT patients.

“When suggesting treatment, I tell parents that it’s going to be a long journey. With VT, we present the package and then tell parents how many follow-up visits will be included. I have the same approach with MiSight 1 day. I tell parents, ‘This is how much it will cost, and I’ll see you back in two months and then in six months, and if you need anything between those times, call me.’”

A Forward Thinker
Dr. Lott, who is one of the highest MiSight 1 day prescribers in her area, strongly encourages other ECPs to get involved in MM if they haven’t done so yet.

“With MiSight 1 day, there’s no special equipment needed, it’s as easy to fit as a spherical daily disposable contact lens with no additional chair-time required compared to my single vision contact lens patients, so there’s no reason why ECPs shouldn’t be fitting this lens,” she says.

Top Pearls for Pediatric Eye Examinations
Dr. Lott’s practice is known for its five-star reviews and Southern hospitality.

“We do things differently in the South. We hug, we ask about family, your grandma, and your neighbors. Our patients really become our family, and they know we are invested in them over the next 18 years.”

In addition to her trademark handwritten thank you cards to patients who provide positive reviews and referrals, Dr. Lott and her staff offer the following tips on how every pediatric examination can be a positive experience for both the child and the practice.

• Recognize children’s eyes are unique. “Children grow and develop, and for the most part, aren’t miniature adults. You can still influence their prescription and visual growth and development through contact lenses and therapy, which will impact them for the rest of their lives,” Dr. Lott says. “In a child’s early and ongoing years, you can really make a huge impact on their education, future eye health, and quality of life.¹² Don’t approach children as mini-adults. They grow rapidly, so be proactive in treating these little people.” 
• Use What You Already Have in Your Office: Even though Dr. Lott specializes in pediatrics, she describes her office as not being equipped like a “McDonald’s Funhouse.” Instead, her practice is decorated in soft, muted colors to make patients comfortable and relaxed.    
• Make visits fun and engaging. Know your movies, TV shows, and characters, Dr. Lott suggests. “Be silly, tell corny jokes, and make funny noises. Children love it. I’ll snap my fingers and turn the room lights on and off too.” Dr. Lott also uses stuffed animals and puppets to connect with children and put them at ease.
• Don’t be intimidated. “Don’t be scared of little people,” Dr. Lott says. If an ECP isn’t comfortable fitting contact lenses in a child who is eight years old, then refer the patient to an ECP who is, she says. “In my area, some ECPs tell patients they can’t wear contact lenses until they are 12, but that can be too late for some young myopes,” she continues.
• Fine-tune your exam when needed. Dr. Lott suggests raising the child’s chair in the examination room, so they are positioned slightly higher than the ECP. Additionally, don’t feel like you need to give the typical application guidance to children. “I teach parents how to apply the lenses, she says. “Over time, the child will get comfortable and can do it themselves.” 

See how Dr. Lott does an InfantSEE exam here.

Dr. Megan Sumrall Lott is a functional optometrist who practices in Hattiesburg, MS, and she is a 2006 graduate of Southern College of Optometry. In 2016, Dr. Lott opened Belle Vue Specialty Eye Care in Hattiesburg, MS, and in 2019, she became the first female in Mississippi to receive Fellowship status in the College of Visual Development in Mississippi. She is a member of the College of Visual Development, Neuro-optometric Rehabilitation Association, International Sports Vision Association, American Optometric Association, and Mississippi Optometric Association. Dr. Lott has served as Vice-President for the Mississippi Vision Foundation, she was awarded the Young OD of the Year in 2009 and 2015, and she was awarded the Community Service Award in 2017 and 2019. In 2016, Dr. Lott was awarded the Mississippi Business Journal’s prestigious award, Top 50 under 40, and the Mississippi Healthcare Heroes in 2017.

 

References

*Indications for Use: MiSight (omafilcon A) daily wear single use Soft Contact Lenses are indicated for the correction of myopic ametropia and for slowing the progression of myopia in children with non-diseased eyes, who at the initiation of treatment are 8-12 years of age and have a refraction of -0.75 to -4.00 diopters (spherical equivalent) with ≤ 0.75 diopters of astigmatism. The lens is to be discarded after each removal.

†Initial CL BVP selection and observation of fit follows same fitting protocol for single vision CLs; fit success rate same with MiSight 1 day and Proclear 1 day  

The views expressed in this article are those of the author who was compensated by CooperVision, Inc. to share her experience. 

1. Meng Q, Wang L, Zhao M, Wu X, Guo L. Comparing myopic error in patients with basic and convergence insufficiency intermittent exotropia in China. BMC Ophthalmol. 2023 Jun 26;23(1):290. 
2. Logan NS, Radhakrishnan H, Cruickshank FE, et al. IMI accommodation and binocular vision in myopia development and progression. Invest Ophthalmol Vis Sci.  2021 Apr 28;62(5):4.
3. Mutti DO, Mitchell GL, Jones-Jordan LA, et al. The response AC/A ratio before and after the onset of myopia. Invest Ophthalmol Vis Sci. 2017 Mar 1;58(3): 594-1602.
4. Ekdawi NS, Nusz KJ, Diehl NN, Mohney BG. The development of myopia among children with intermittent exotropia. Am J Ophthalmol. 2010 Mar;149(3):503-7.
5. Sankaridurg P, Berntsen DA, Bullimore MA, Cho P, Flitcroft I, Gawne TJ, Gifford KL, Jong M, Kang P, Ostrin LA, Santodomingo-Rubido J, Wildsoet C, Wolffsohn JS. IMI 2023 Digest. Invest Ophthalmol Vis Sci. 2023 May 1;64(6):7. 
6. Chamberlain P, Peixoto-de-Matos SC, Logan NS, et al. A 3-year randomized clinical trial of MiSight Lenses for myopia control. Optom Vis Sci. 96(8):556-567.
7. Ruiz-Pomeda A, Pérez-Sánchez B,, Cañadas P, et al. Binocular and accommodative function in the controlled randomized clinical trial MiSight Assessment Study Spain (MASS). Graefes Arch Clin Exp Ophthalmol. 2019 Jan;257(1):207-215.
8. Gifford KL, Schmid KL, Collins J, Maher C, Makan R, Nguyen TKP, et al. Accommodative responses of young adult myopes wearing multifocal contact lenses. Invest Ophthalmol Vis Sci. 2019;60(9):6376.
9. Schmid KL, Gifford KL, Chan P, Christie B, Crouther S, Nahuysen O, Sechenova K, Sevil L, Youssef M, Atchison DA. The effects of aspheric and concentric multifocal soft contact lenses on visual quality, vergence and accommodation function in young adult myopes. Invest. Ophthalmol. Vis. Sci. 2019;60(9):3893.
10. McCullough SJ, Adamson G, Doyle L, et al Latent growth modelling of refractive error development in white children & young adults. Invest Ophthalmol Vis Scine. 2018 60:5841 (meeting abstract)
11. CVI data on file 2018
12. Dudovitz RN, Izadpanah N, Chung PJ, Slusser W. Parent, Teacher, and Student Perspectives on How Corrective Lenses Improve Child Wellbeing and School Function. Matern Child Health J. 2016 May;20(5):974-83.