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- Do Not Do Nothing
I used to be where I imagine the vast majority of you still are. I remember the way I used to practice eye care for children and young adults, but that chapter has been closed. I never would have thought that my entire prescribing and practice philosophy could be turned end-over-end because of a 3-day continuing education event. That inflection point happened for me just a few short years ago.
Before that time, I felt how a lot of you do now about myopia control. The claims I heard at this event, presented by the American Academy of Orthokeratology and Myopia Control, of the ability to control myopic progression in the developing eye, seemed pseudo-science-y and too good to be true. But one after another, expert researchers, optometrists, and ophthalmologists from around the world took to the stage and presented mind-blowing evidence that all clicked. They presented findings indicating that myopia control was in fact possible, predictable, and, best of all, effective. I have jokingly come to call this my Holy Grail moment because for years previous, I had been dissatisfied with the status quo of eye care for children.
How frustrating is it to prescribe glasses to a child who all would agree warrants corrective lenses, only to have the parents or other caregivers not follow through with providing glasses for the child. There may be any one of a multitude of reasons: cost, poor understanding of future risks, or even the all-too-common conspiracy theories that “all eye doctors tell all kids they need glasses,” or “glasses will only make their eyes weaker.”
This is aside from the compliance nightmares that occur around children with glasses: refusal to wear them; intentional or unintentional bending, losing, or breaking them; or even the sad reality of being bullied for glasses wear, compelling the child to hide them or discontinue their use. Yes, soft contact lenses can solve some of these issues. However, children have to be mature enough in age and responsibility to safely and hygienically wear soft lenses. In addition, the risks of adverse events due to poor soft contact lens care habits make this a less-than-compelling solution in many cases—even in a heavy daily-disposable practice like my own.
My goal in this article is not to bolster the obvious point that myopia is a problem across the globe, but rather to show you how myopia control works in my practice and how it can work in yours. Myopia control is the hottest topic in eye care (sorry, dry eye disease), and there have been literally dozens of articles and studies on the subject published in the pages of optometric and ophthalmologic journals over the past 6 months. If you do not think myopia control is real, please educate yourself on one of the most profound findings in the history of our profession!
After my Holy Grail moment, here are the three biggest changes I implemented around the care of school-aged patients:
It is my (and now all of yours) ethical responsibility to educate parents, caregivers, and young children on the myopia epidemic that has taken place over the past 40 to 50 years and to tell them that now something can be done. If you do not want to practice myopia control through soft multifocal lenses, atropine therapy, or my preferred choice, orthokeratology (ortho-K), that is your choice. But please stop blaming nearsightedness on genetics alone and pretending that myopia control does not exist. You are not helping these patients, and, by neglecting to discuss this option, you run the risk of discrediting your entire practice once patients eventually find their way to doctors who practice myopia control.
I have met many parents who are furious that their previous eye care provider did not inform them of all of their options. True, myopia control is not commonplace yet. But that is not an excuse to avoid discussing it. More paths of optometrist-to-optometrist and ophthalmologist-to-optometrist referral patterns for myopia control need to open up. Do not be fearful of what you do not know or cannot offer. Refer out, as you would refractive surgery or vision therapy, and most doctors like me will coordinate care and return your patient. The fact that myopia progresses with spectacle correction must also be discussed.
This is not rocket science. All of us are aware of the process of emmetropization and the trends in refractive error as children grow and develop. Do not cut corners on preschool eye exams, and be sure to obtain good dry and wet retinoscopy results. Start asking about parental and sibling levels of nearsightedness, screen time, amount of outdoor play, etc., to help identify children at risk of developing nearsightedness—not just pathologic myopia, any myopia.
The attitude that, “well, they’re corrected to 20/20,” as we watch patients progress from -1.25 D to -2.50 D to -4.00 D needs to die. It is time to do something and explain why we should throw historical prescribing conventions to the curb. We all have nearsighted patients who have had tragic retinal tear or detachment complications that did not end well. If you could lower the risks of these types of events happening to your young patients when they are older (or your own children, nieces, and nephews), would you not?
My favorite scenario of when to act with myopia control is when patients first exhibit symptoms of refractive error that historically would lead you to prescribe their first set of glasses. I live in University of Kentucky Wildcat Country, so Coach John Calipari’s “one-and-done” philosophy is easy for parents to remember. Once a child is symptomatic, once teachers or parents begin to notice symptoms, once the child has around a -1.00 D refractive error, the timing is perfect to implement ortho-K, not only for visual correction but also for myopia control.
From the parents’ perspective, their child’s daytime activities go virtually undisturbed by the wear of an ortho-K lens, which is placed on the child’s eye after brushing their teeth before bed and removed first thing in the morning upon wakening. There are no concerns with purchasing expensive glasses, keeping track of the glasses, worrying whether the child is wearing the correction during the school day, or replacing them once they become damaged or lost. The need for separate pairs of corrective eyewear such as sports goggles, prescription sunglasses, or even swim or ski goggles evaporates.
It requires parents to invest in a lifestyle vision correction option, similar to refractive surgery, for their child to enjoy activities such as outdoor play, sports, and swimming without the limitations of eyewear (or soft contact lenses for older children). But it is also an investment that pays even bigger dividends when they return for progress checks, as, visit after visit, the child’s refractive error remains unchanged or ever so slightly progressed.
ORTHO-K PATIENT STUDY
by Trulee Gilkison
From the children’s perspective, they get to do the coolest thing to their eyes among their classmates and teammates, and they never stop telling people about their magic contact lenses!
A second scenario of when to act is for children who each year are rapidly progressing in their level of myopia. I think of my now 14-year-old patient who at age 11 was -1.25 D in each eye (OU), by age 12 had progressed to -2.75 D OU, and at 13 was -4.25 D OU. On her exam at age 14 she was -7.25 D: I repeat, -7.25 D!
(A famous quote comes to mind here: “The definition of insanity is doing the same thing over and over again, but expecting different results.”)
This patient has been successfully treated with ortho-K. Hers is the highest refractive error I have corrected with ortho-K. For 18 months now, we have witnessed no progression in her nearsightedness.
Myopia control and ortho-K are something special. It is something magical to experience for the parents, the patient, and the practitioner, and it is something you just cannot appreciate until you dive in and experience it for yourself.
Now, in my practice, recommendations around refractive error have been turned upside down from what most colleagues in my area recommend. I do not rush to throw -0.50 D OU glasses on a child who is asymptomatic and has appropriate visual acuity for his or her age just to sell a pair of glasses or because the child did not see 20/20 perfectly. I am now conservative with my spectacle-prescribing habits, and I my patients and I have become aware of the benefits to this strategy.
I heavily educate on the first exam about the reality of the myopia epidemic, and I advise changes in behavior such as limiting screen time and encouraging outdoor play to help reduce the onset and speed of myopia progression. Once that has been done, parents are much more engaged in the overall problem that myopia truly is. I review their child’s progression at annual or biannual visits based on their risk factors, always reminding them of when is the best time to intervene with a myopia control treatment strategy. When the time is right, nine out of 10 parents understand and go for it.
This is the epitome of medical eye care that we can provide to our youngest patients. Do not fear learning a myopia control strategy or make lame excuses that your patients will not be able to wear “hard” ortho-K lenses or their parents will not be able to afford it. Excuses suck.
I have become one of the leading fitters of ortho-K lenses in the nation in just a little more than 2 years, in a rural Kentucky town of 9,000 residents with a median household income of around $40,000 per year. If I can practice this way here, you can where you are as well. Patients rely on us and trust us to offer what is best for their eyes or their children’s eyes, so it is time to step up to the plate and help myopia control become the standard of care that it should be.
CONCLUSION AND A GUEST AUTHOR
As a last note, professionally and personally, ortho-K and myopia control have reinvigorated in me a passion for what I do that was starting to wane with the burdens of dealing with vision plans, competing with the ever-evolving online options, and hearing patients tell me how to run my practice. Ortho-K inspired me to be something bigger, something grander.
One result of my adoption of ortho-K came in the form of a request from one of my smartest ortho-K patients to spend part of her summer voluntarily studying aspects of my ortho-K practice for a research project. I was so impressed by her dedication and results that I asked her to author a portion of this piece by presenting a brief study of her own case. Allow me to introduce Trulee Gilkison (see Ortho-K Patient Study). Ortho-K has taught me to embrace outside-the-box thinking, and by doing so, I hope to continue to inspire others like her. n
Jeffrey A. Klosterman, OD
• President of Klosterman Eye Associates in Harrodsburg, Kentucky
• (859) 734-2020; email@example.com
• Financial interest: none acknowledged