June 15, 2021
By Jeffrey Krohn, OD, FAAO, Diplomate (ABO and AAO); Fig Garden Optometry, Fresno, CA
By explaining the folly of simply making the correction (single-power glasses or contact lenses) stronger year after year, I hope to frame the difference between putting fuel on the fire and attempting to fight the fire.
I believe it is accurate to say that eye care practitioners have always been “managing” myopia; however, until recently, we have been managing it inappropriately. Though my career in optometry began in the late 1980s, it wasn’t until around 2013 when the realization of my “mismanagement” hit me square between the eyes. I was at the American Academy of Optometry’s Scientific Program when I realized that what I had been doing – prescribing single power spectacles or contact lenses – was feeding the fire of myopic degeneration and axial elongation.
Now, with a comprehensive array of treatments, an abundance of resources, and the right tools under my belt, I’m able to use what I’ve learned to educate patients and their parents and provide the best myopia management care.
Creating a Treatment Plan
Each myopia patient is different, and finding the right course of treatment – especially with children – is unique to their individual needs. Based on conversations with the patients and their parents, we determine what kind of optical correction they are most suited to. For those not interested in a contact lens approach, we recommend lined bifocal spectacles with nightly low-dose atropine. If they are interested in contact lenses as a correction, we present a contact lens that is worn during the day to see with (soft design) versus a contact lens that is worn overnight and removed in the morning to see without (OrthoK). Typically, presenting those two alternatives side-by-side will elicit a positive response. The patient’s lifestyle can also come into play when choosing a treatment option, as we usually will recommend OrthoK first for kids who are active in water sports, such as swimming or diving.
When it comes to combination treatments, I determine those on a case-by-case basis. When young children present with higher axial length measurements, we regularly utilize low-dose atropine with an optical approach. We are anxious to see continuing research on the efficacy of a combined treatment approach, but we feel the benefits far outweigh any potential downside to implementing an aggressive treatment protocol.
What Are the Treatment Options?
When we began the shift to offering a more comprehensive array of services and focusing on myopia management, we felt comfortable and competent in our orthokeratology fitting process. The most significant difference was retooling the presentation of OrthoK to our patients; rather than a “no more glasses” approach, we emphasize how OrthoK works to manage myopia. We currently utilize Art Optical’s MOONLENS and other OrthoK designs from Paragon (CRT) and GP Specialists. We also started utilizing center-distance annular multifocal contact lenses more aggressively. Our primary options for prescribing these types of lenses are the Biofinity Multifocal “D” design and CooperVision’s MiSight 1 day contact lenses. We have also started using the Synergeyes “iD” lens with an enhanced field of depth design when the patient’s prescription falls outside other available parameters.
It was also fairly straightforward to implement the lined-bifocal designed lenses for those patients not amenable to contact lenses. Our use of low-dose atropine was a little slower to get off the ground, but it has taken off once we identified a pharmacy that provided the products and services we were looking for.
Instrumentation is also an essential component of myopia management. The most important addition to our office was the Topcon Aladdin-M, which is a combination topographer, pupilometer, and biometer. Measuring axial length allows us to monitor patients’ myopia progression more closely, and having this tool has been beneficial for all of our younger patients. We’ve started taking axial length measurements on all patients under the age of 18 and have incorporated conversations with parents about axial length into all pediatric exams.
The Role of Parent Education
Educating parents about myopia management, including the risks, the benefits of treatment, and how we can leave lasting positive impacts on their children’s eye health, is an important part of the puzzle. My professional journey with myopia management as a practitioner offers me a unique perspective to begin the education process with parents. I try to humbly present my experience managing myopia incorrectly for the first 20 years of my career. By explaining the folly of simply making the correction (single-power glasses or contact lenses) stronger year after year, I hope to frame the difference between putting fuel on the fire and attempting to fight the fire.
We also share materials and resources with parents from leading experts in the myopia management field to help them better understand why we’re starting these treatments. We created a brochure that we give to each myopia management parent that outlines the most commonly asked questions and what this process will look like from a time and cost perspective. The educational materials from CooperVision/Paragon have also been helpful in the exam room when going over lens-related therapies, as has the app CooperVision created for patients and their parents using the MiSight 1 day lenses. We’ve gotten great feedback about the app from those who have used it in our office along with the other resources that are available through the Brilliant Futures program. The BHVI Myopia Calculator, which can show patients and their parents what eyesight will look like down the road, has been another great tool when talking with parents. We also just started using resources from Myopia Care.
Additionally, we’ve done a lot of work in social media and establishing a solid online presence. We’ve created videos on our website that explain to prospective patients what myopia is, who our doctors are, and what they can expect from our practice. The videos have been helpful for several reasons, but it’s also helped our doctors in the exam room because the preparation process forced us to articulate our message about myopia management protocol to be as concise and informative as possible. Since posting them about six months ago, we’ve seen a notable uptick in our referrals from other optometric providers and new patients who found us due to our online presence. When talking with patients, mentioning and referencing specific videos and offerings on our website has been helpful. However, I would venture to say that most new patients who find us may have visited our posts online, but they are typically sent there by another satisfied patient or parent. In other words, our social media presence or website becomes the business card that patients hand out to other friends and family members.
Looking to the Future
While adopting any new treatment modality comes with challenges, the resistance and lack of collaboration from pediatricians and ophthalmologists have been the most significant source of frustration in myopia management. We hope that positive responses within our patient population and the dissemination of studies demonstrating the efficacy of the intervention will break down this resistance. We know what these treatments can do for children’s long-term eye health, and getting all health care providers on board will lead to even better outcomes.
Dr. Jeffrey Krohn is one of the managing partners in Family Practice Optometry in Fresno, Calif., where he has served families with complete eye and vision care for over 30 years. After graduating from the Southern California College of Optometry, he served on the faculty of that institution. He is a Fellow of the American Academy of Optometry, achieving the highest level of certification as a “Diplomate” in the Academy’s section on “Cornea, Contact Lenses and Refractive Technology,” currently serving as the Chair of that Section. He is also a board-certified “Diplomate” with The American Board of Optometry. He has lectured to other optometrists in local, state-wide, and national gatherings. He serves as an “Administrator” for the Vision Source network – representing the Central California offices. He has also engaged in clinical research for the contact lens and pharmaceutical industry.