Seeing Eye to Eye

The door is open for ODs and MDs to work together on a new myopia co-management paradigm

by Matt Herman

Myopia rates are on the march worldwide. There is, however, a growing arsenal of tools and techniques to combat the condition. Cooperation between optometrists and ophthalmologists is a perennially thorny issue, but working together might represent the best way to take advantage of the latest myopia management marvels. There is a path through the co-management morass, and three top specialists from across the globe detailed what that might look like.

If you’re engaged in the vision space, there’s no hiding from the inexorable inundation of the field by all things myopia. From an anxietyridden wave of research declaring the arrival of the myopia epidemic to the relentless churn of new products purpose-made to lay the condition low, one thing is obvious: Myopia management is unavoidable in modern eye care.

Unfortunately, there is something to the hype. On average, 30% of the world is myopic, and this number is expected to increase to a staggering 50% by 2050.1 Asia is a hotbed for the disease, with prevalences measured as high as Singapore’s 90%2 being echoed across the region.

Even in the United States, typically considered one of the more tame regions of the world for myopia, rates almost doubled in the three decades between 1971 and 2004.3 And these trends have likely taken a turn for the exponential with the reduction in time spent outdoors and increase in near work engendered by the COVID-19 pandemic.

The good news is that the world has responded. And dealing with the disease — at least in theory — has never seen more options in diagnostic and treatment modalities. Axial length can be measured, tracked, and compared against increasingly representative normative databases. Pre-myopes can be identified more quickly and accurately than ever before.

Once identified, the roster of treatments for slowing or even halting the progression of the disease is long and varied. From orthokeratology and myopia control spectacle and daily contact lenses to pharmacological interventions like atropine eye drops, doctors worldwide are seemingly spoiled for choice.

But in the real world, the diagnosis and treatment of myopia is hitting a snag despite the abundance of options. Myopia as a condition teeters precariously on the fence between the traditional domains of optometrists and ophthalmologists. Refractive error correction and screening have long been under the purview of ODs, and management of ocular disease ophthalmologists. As an ocular disease commonly treated with refractive correction, myopia can be seen as falling to both sides simultaneously. And the resulting tension is threatening to disrupt the promise of next-level outcomes for the millions suffering from myopia worldwide.

Kicking and screening

One of the more critical aspects of myopia treatment in the modern era is screening for the disease. For Dr. Sun Chen-Hsin, a consultant at the National University Hospital (NUH) in Singapore specializing in pediatric ophthalmology and progressive myopia management, this is a key area where the division of labor is critical.

“The system is already in place and we should make use of that division of labor,” he related. “In Singapore, we are trying to get more optometrists in the community involved in caring for common eye diseases like cataract, glaucoma, dry eye, myopia… things etc,” Dr. Sun continued. “The optometrist, as primary care provider, is able to screen and decide if the patient needs further treatment.”

Dr. Maria Liu, an ophthalmologistturned-optometrist and founder and chief of the prestigious Myopia Control Clinic at the University of California Berkeley, agrees. “In order to have the best [myopia] control outcomes, we need to identify the patient's risks and detect the problem as early as possible,” she said. “Early risk assessment and disease detection mostly lie with the optometrist to start collecting the patient's baseline axial growth profile.”

But while screening for refractive error is simple, identifying and isolating myopia as the cause is another beast. According to Dr. Sun, relying on simple refraction is not enough. For one, children with flatter corneas and high levels of axial elongation will go missed. “Those can be dangerous because they have a false sense of security. They may think, oh, my myopia is not too high, when in fact the eyeball is too long.”

Blaming the tools, not the carpenter

Cycloplegic refraction is one avenue, but the need for eye drops prevents it from falling under the scope of practice for optometrists in many countries. And the results themselves are not without their faults.

There is one other option that both Dr. Sun and Dr. Liu see as critical for optometrists screening for myopia development and progression risk. “In terms of collaborative care in myopia progression, one key component is a biometer to measure axial length. All the complications from myopia stem from excessive elongation of [the eyeball],” Dr. Sun shared.

Dr. Liu also believes this to be a pressing need for optometrists. “At the current moment, a lot of doctors who claim to be a myopia control specialist do not even measure axial length,” she said.

So what’s keeping biometers out of the hands of the optometrists on the front lines? For Dr. Liu, the issue lies with cost and industry lag and not optometrists themselves. “The majority of optometrists are in private practice in smaller settings with smaller investments,” she lamented. “It requires the industry focusing on measuring axial length and early establishment of baseline [measurements] as important,” she said.

There are already ways cropping up to get these sorely-needed devices to optometrists who need them. Dr. Liu pointed to machines that don’t include royalty-laden IOL calculation formulae or other features beyond the bare essentials. Dr. Sun also described programs from myopia control product manufacturers that subsidize biometers in exchange for carrying that company’s wares. Dr. Liu thinks insurance companies can play a large role, too. “Once we have insurance coverage for this kind of measurement, that would motivate doctors to actually invest in a biometer,” she said.

Handoff or hands off?

Once myopes have been identified, however, is where the picture begins to muddy. The overlap between ODs and MDs starts to widen — especially for MDs in private practice — and this is where the turf wars begin to rage.

It does not need to be so. Both Dr. Sun and Dr. Liu agree that there is room for all, starting with children where myopia is already high or developing quickly. Complications in these patients can come seemingly overnight, and a timely handoff from OD to MD is critical. “[With high myopes], early referral can make sure something like a small hole does not turn into a detachment or tear,” Dr. Liu related. “Something like that requires very close collaboration between optometrists and ophthalmologists.”

Dr. Sun believes that financial interest can only cause harm in this sense. “Usually an optometrist and optician are the first point of contact. They get their first pair of glasses there, and they get followed up,” he started.

“If a child is progressing and every six months the degree increases from 200, 300, 400, 500 and the optometrist just changes their glasses and does nothing else, this is doing the patient a great disservice,” he explained. “Unfortunately, there are people who do that for fear that if they refer to the ophthalmologist, the patient may not come back to them.”

This is a worrying trend, but Dr. Sun thinks that this is where supraprofessional bodies can play a role. “These high myopia complications can almost be eradicated completely if we have stringent referral guidelines — which we don’t,” he stated flatly. “Such guidelines could mandate that any child with any degree [of myopia] higher than a certain level must be referred and started on myopia treatment,” he further recommended.

Money mayhem

In this way, a paradigm emerges where everyone wins. Optometrists use tools like biometers or cycloplegic refraction to screen myopic patients and monitor premyopes, referring them to ophthalmologists to look for retinal issues.

The next step is treatment, and this is the area where the financial conflict of interest is largest. The premium on myopia management and control products — like Ortho-K and myopia control spectacles or contact lenses — is high, and the lucre therein large, creating a tinderbox for competition and resentment.

Despite the potential for animosity, Dr. Sun and Dr. Liu believe there is massive room for collaboration, regardless of who is dispensing — and profiting. As a busy ophthalmologist in a highly regarded public healthcare system, Dr. Sun sees no reason for a break with the status quo with specialty contacts and spectacles. “Spectacle lens, and to a certain degree contact lens fitting, is definitely something optometrists do better because of the volume they do every day,” he stated.

Fertile financial ground

But that doesn’t mean that ophthalmologists need to be left out in the cold. As an optometrist, Dr. Maria Liu sees emerging treatment modalities as an opportunity for ophthalmologists as well. “ I do see ophthalmologists serving an increasingly important role in intervention as well,” she said. “Now with the availability of novel spectacles and low-dose atropine, I do see a lot of MDs being actively involved in myopia control intervention,” she continued. And with the world digesting the LAMP2 study4 results for low-dose atropine in premyopes, a host of new patients could soon be heading to the ophthalmologist for treatment as well.

It doesn’t stop there either, according to Dr. Liu. Further down the line, the increase in myopia presents indirect opportunities for ophthalmologists. “Refractive surgeons are becoming more and more supportive of myopia control because doing this makes patients a better candidate for refractive surgery,” she stated.

“The higher the prescription after myopia has stabilized, the more tissue needs to be removed in refractive surgery. If they ended up being a minus four, instead of, say, minus eight, for the same corneal thickness, they're more likely to be corrected without as many complications,” she explained.

In the end, though, despite the potential for symbiotic collaboration, there is still money involved in the private sphere, and there will still be the inevitable vitriol between ODs and MDs. Dr. Sun thinks, though, that keeping things in perspective is critical.

“Singapore is an extreme example — A vast majority of our population is myopic”, he reflected. “There’s no shortage of people who can benefit from myopia treatment. No matter how many thousands that we are seeing in our government hospital, we are really just scratching the surface,” he continued. “There’s a huge market out there and no one should fear that patients are being taken away from them.”

Building bridges

As beneficial as the era of myopia control can be for both patients and doctors from both sides of the divide, there will always be work to be done to smooth this relationship. Some of this load can be borne at the top. Dr. Sun’s proposal for referral guidelines is one way to ensure cooperation is taking place at critical phases of disease progression.

Standardization of optometric education and certification is another oft-mentioned pathway for instilling more confidence in ophthalmologists with reservations about working with optometrists. Dr. Sun has called for more standardized postgraduate opportunities for ODs. “At the moment, there is no university level or even postgraduate level training available in Singapore, so they have to go overseas,” he said. “When they get more training, they come back and those are the ones who have closer relationships with ophthalmologists in working together to provide care,” he related.

Inclusion in academic conferences for such highly-trained individuals is one way to ensure communication and consistency of message for myopia treatments for Dr. Liu. “In interprofessional and scholarly exchanges, we could have more vision scientists and clinician-scientists on the optometry side with more podium time to talk about what is changing in terms of clinical evidence and animal models,” she proposed.

Dr. Glenda Aleman-Moheeputh, an optometrist and myopia specialist, believes strongly in the potential for our shared humanity to undergird strong professional relationships in myopia care. Even in the battleground of her native Florida, where legislation to remove the title of doctor from optometrists was recently introduced (and defeated), she sees the relationship as being stronger and more critical than ever.

“You need to drop the card, invite them to lunch, invite them to your office,” she suggested. “Let’s focus on building bridges. If you go in and break the ice and build a relationship with an ophthalmologist, they can be your biggest advocate,” she said.

And that’s exactly what Dr. Aleman-Moheeputh is doing with the nascent professional organization Women in Eyecare. She believes that uniting ODs and MDs along the axis of their shared humanity — and in this case, femininity — is one of the most potent ways for advancing patient outcomes through cooperation. “If we unite together, we can do bigger — and better — things,” she proclaimed. And for the growing multitudes of children worldwide at risk of, or already developing, myopia, this level of cooperation is the key to a future of clear sight.

Contributing Doctors

Dr. Maria Liu is an associate professor at the UC Berkeley School of Optometry, and the founder and chief of the Myopia Control Clinic of UC Berkeley Eye Center. She received her bachelor's degree in clinical medicine from Peking University, her OD from Pacific University, and her PhD and MPH from UC Berkeley. She is a world-renowned clinical researcher in the field of myopia and her expertise focuses on the impact of complex multifocal environments on emmetropization and myopia development, as well as novel optical and pharmaceutical treatments in myopia retardation marialiu75@berkeley.edu. cfssch@nus.edu.sg

Dr. Sun Chen-Hsin is a clinicianengineer. He graduated from Johns Hopkins University in 2008 with a Bachelor of Biomedical Engineering and a Master of Science in Electrical and Computer Engineering in 2009. In 2013, he received a Doctor of Medicine (MD) from Duke-NUS Graduate Medical School. After completing his ophthalmology residency clinician-scientist training in 2019, he was accredited by the Specialists Accreditation Board as a specialist in ophthalmology by the Ministry of Health of Singapore. As he has special interests in managing progressive myopia in children and developing pediatric Ophthalmology medical devices, he developed a wearable device to track outdoor time and near reading. These are both important factors in determining myopia progression. He is also developing an ambulatory biometer to measure the elongation of eyeballs in children. This will allow precise monitoring of the myopia progression of children, optimizing their course of treatment.

References

1. Holden BA, Fricke TR, Wilson DA, et al. Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050. Ophthalmology. 2016;123(5):1036-1042.

2. Quek TP, Chua CG, Chong CS, et al. Prevalence of refractive errors in teenage high school students in Singapore. Ophthalmic Physiol Opt. 2004;24(1):47-55.

3. Vitale S, Sperduto RD, Ferris FL. Increased prevalence of myopia in the United States between 1971-1972 and 1999-2004. Arch Ophthalmol. 2009;127(12):1632-1639

4. Yam JC, Zhang XJ, Zhang Y, et al. Effect of Low-Concentration Atropine Eyedrops vs Placebo on Myopia Incidence in Children: The LAMP2 Randomized Clinical Trial. JAMA. 2023;329(6):472-481.

Dr. Glenda Aleman-Moheeputh , OD, received her Bachelor of Science degree in Vision Science and Doctor of Optometry from Nova Southeastern University (NSU). She has held the role of clinical liaison for Walmart Health Optometry in Florida from 2019-present. She currently serves as a Johnson and Johnson myopia management professional affairs consultant (PAC). She is an active advisor in the advisor committee AAOMC and is an advisor for Nevakar myopia specialists. She is the founder and CEO of iSmart Vision Care, located in Miami, Florida. In her practice, she specializes in providing multiple solutions for myopia management. And in her mission to fight the myopia epidemic, Dr. Aleman-Moheeputh has recently launched her new venture, OK Love Myopia Control Experts. Beyond myopia management and educating patients, OK Love also offers consulting designed to educate fellow optometrists on various methods of implementing myopia control practices. She has lectured extensively nationally and internationally to contribute to educating others in the field of orthokeratology and myopia management in hopes of mitigating the myopia epidemic.

Drglenda.m@gmail.com

by Brooke Herron

WCO’s Dr. Sandra Block addresses today’s growing need to elevate the standard of care in myopia management

The alarming rise of pediatric myopia is a global and multifaceted problem — and to help control the impending epidemic, optometrists need to know (and follow) the most current and effective management and treatment strategies. Dr. Sandra Block, World Council of Optometry presidentelect, addressed the latest in mitigation, management, and treatment of pediatric myopia at a recent WCO Virtual Event, Myopia Management: Advancing the Standard of Care.

Before retiring, Dr. Sandra Block dedicated her career to pediatric optometry. Today, as the president-elect of the World Council of Optometry (WCO), she’s bringing her invaluable expertise to a global stage to help elevate the standard of care in myopia management.

According to Dr. Block, we need to recognize that myopia is not only a refractive state — but rather, a disease entity — that can cause vision loss through a number of different pathologies associated with moderate and high myopia. This includes posterior segment conditions like tilted disc, tessellated fundus, posterior staphyloma, thin choroid, macular degeneration, peripheral retinal degeneration, and vitreoretinal interface disease.

“Since we are now aware of the association of moderate and high myopia with these relatively common pathologies, it becomes more important for optometrists to look at myopia as a disease entity and consider myopia management to reduce the risk of developing these vision-threatening pathologies,” she said.

Keeping up with the latest evidence-based strategies

In addition, the continued increase of myopia prevalence in younger children further contributes to the urgent need for eye care practitioners to get on the same page when it comes to management strategies.

“The profession is learning that the epidemic (almost pandemic) of myopia is continuing to grow,” said Dr. Block. “And it’s clear that there are many researchers providing evidence on how to address myopia management — and it’s imperative for eye care providers to stay on top of current research and how it impacts practice patterns.”

One way for optometrists around the world to stay up-to-date with the everevolving research is to participate in webinars, like the recent one held by WCO. During these informative events, optometrists can glean clinical pearls that can be integrated into daily practice — all backed by experts and their personal experience.

“The WCO has realized that we, as global leaders for the optometric profession, need to communicate this research and rethink how we regard myopia,” explained Dr. Block. And it’s not just the optometric societies that are answering the call to halt myopia progression — the industry is also stepping up in areas of research and development, as well as in supporting education.

For example, the WCO, along with CooperVision, created their “Standard of Care Guidelines for Myopia Management” in 2021 to serve as an important resource for optometrists. This includes information on new tools developed for myopia mitigation, measurement, and management, supported by welldesigned studies that demonstrate successful methods to slow down the progression of the disease.

Embracing change through education

According to Dr. Block, although eye care providers are slow to integrate change in their practices, it is happening — and the WCO is ready to support these efforts through education.

“From my perspective, change will occur faster as schools and colleges of optometry teach myopia management within the core curriculum,” said Dr. Block. “In addition, the number of webinars and articles that focus on the changing preferred practice guidelines, along with the education of the public from groups such as the Global Myopia Awareness Coalition (GMAC), will drive change at the level of patient care. Educational programs will need to continue to be offered to help optometrists maintain the highest level of knowledge and skills to best treat their patients,” she continued.

Dr. Block hopes that viewers of the WCO Virtual Event were convinced to at least update their perspective of myopia — and that’s away from the dated idea that myopia is a refractive error that can be corrected with simple optical lenses … to the reality that myopia is a disease entity that needs early detection, treatment, and follow-up.

“It’s our responsibility to educate patients and parents about lifestyle changes that can help lessen the impact, along with new and emerging tools to improve outcomes,” she said, adding that when it comes to pediatric eye care, parent involvement and awareness are imperative.

For example, parents should know what risk factors can be modified and which cannot, like genetics. “If a parent has myopia, that immediately increases the risk and that cannot be changed,” said Dr. Block. However, lifestyle changes can be made to help lower this risk, such as spending more time (at least 90 minutes per day) outdoors and less time on devices or doing other close work.

Eye exams also play a crucial role: Starting at age three and throughout school age, children should undergo multiple comprehensive eye exams. “We know that the eyes are still developing, and vision can change up to the age of 20,” she added.

“We need to ensure that our patients are offered the most effective and current treatments that could help maintain a lifetime of good vision,” concluded Dr. Block. “Optometry is core to the diagnosis and treatment of myopia and I envision that the profession will step up to the call to action.”

For more information about myopia or to register for an upcoming webinar, visit https://myopia. worldcouncilofoptometry.info.

Contributing Doctor

Dr. Sandra S. Block , OD, MEd, MPH, FAAO, FCOVD, is a Professor Emeritus at Illinois College of Optometry, Global Clinical Advisor and consultant to the Special Olympics Lions Clubs International Opening Eyes program, and cochair of the National Center for Children’s Vision and Eye Health. Dr. Block received her OD degree in 1981 and Pediatric Residency in 1982 at the Illinois College of Optometry, where she is a faculty member. She completed her Master of Education at the National Louis University and her Master of Public Health from the University of Illinois, School of Public Health. She is a diplomate in Public Health and Environmental Vision at the American Academy of Optometry and a Distinguished Fellow of the National Academy of Practice. She sits on the Prevent Blindness Board of Trustees and recently joined the VISION 2020 Board of Directors. Dr. Block has been a consultant to the Special Olympics Lions Clubs International Opening Eyes program since 1995 and has been instrumental in developing the vision program globally. Her interests lie in primary care for children and persons with disabilities, as well as diagnosis and treatment of visually related learning problems as well as public health issues facing the equity and quality of eye care delivery. She has authored numerous publications and conducted presentations worldwide. In November 2021, she was elected as the WCO President-Elect. Prior to this, Dr. Block served on WCO’s Board of Directors as the Public Health Committee Chair.