THE CASE FOR A universal STANDARD OF MYOPIA MANAGEMENT

With a large proportion of Australian and New Zealand eyecare professionals still prescribing vision correction-only for progressing myopic children, it’s hoped a new recommended Standard of Care will provide a valuable framework for practitioners to band together to tackle this looming public health crisis.

WHAT DOES THE STANDARD OF CARE LOOK LIKE?

For the practice setting, the Child Myopia Working Group recommended the following key elements be included when managing a patient’s myopia:

1. Us e a myopia management program for patients with pre myopia or myopia based on the best available evidence.

2. Explain to patients and their parents or carers what myopia is and discuss the increased risks to long term ocular health associated with myopia.

3. Dis cuss, formulate, and implement an agreed management plan with the parent or carer and patient (child), including discussion of the evidence-based available myopia management options to mitigate axial length elongation; risks (lifestyle and family history) of myopia progression; provision of verbal and written information describing the risks and benefits of treatment, duration of treatment, review frequency, when to cease treatment and rebound effects.

4. Document a review/recall for patients with myopia that demonstrate progression.

5. Monitor the impact of treatment.

6. Recognise personal limitations and refer patients to a suitable optometrist or ophthalmologist if the required myopia management services cannot be provided.

The Australia and New Zealand Child Myopia Working Group –comprising a high-powered line-up of eyecare professionals from across the region – was established in 2018 with a clear mandate: to deliver a recommended Standard of Care for myopia management in children living in Oceania.

Why there’s a priority to implement such an initiative boils down to the fact that each year of delayed progression substantially reduces the likelihood of a myopic child developing high myopia in adulthood – a situation that could lead to potentially blinding conditions such as myopic maculopathy, glaucoma, cataract and retinal detachment.

By setting a new Standard of Care, it’s hoped a critical mass of optometrists in Australia and New Zealand will move away from mere vision correction towards a comprehensive myopia management program.

By doing this – and changing how myopia is managed with intervention starting as soon as possible – it's thought that only then can the true public health benefits of reducing its onset and impact be attainable.

In November 2022, the ANZ Myopia Working Group completed the first stage of its mission and published a recommended Standard of Care in the ‘The Australia and New Zealand Child Myopia Report 2022/23-Reducing the Risk to Vision’, which is an adjunct report to the inaugural 2018 Child Myopia Report.

At its core, the Standard of Care describes the overarching elements eyecare professionals need to implement without prescribing how or when to employ specific options or techniques. This latest report also highlights shifting trends, and awareness and understanding of myopia during the past four years.

The group recommended a shift from not only correcting vision but to also include a discussion between the eyecare practitioner and the parents and carers that explains what myopia is, lifestyle factors that may impact myopia, and the increased risks to long-term ocular health.

It also recommended discussing with caregivers the available and increasing number of approaches to manage myopia and slow its progression.

Since 2019, the profession’s peak body Optometry Australia has undertaken a review of the Entry-Level Competency Standards for Australian optometrists.

The ANZ Child Myopia Working Group report said these competency standards don’t provide management techniques or protocols of specific diseases such as myopia, as these should be available to the profession through avenues other than the Entry-Level Competency Standards. Optometry Australia recognises that best practice for myopia management, supported by the contemporary evidence base, should be followed.

Mr Jagrut Lallu is a New Zealand optometrist and founding member of the ANZ Myopia Working Group. He says for Australia and New Zealand, the forecast rate of myopia by 2050 is estimated to be 55%, with an estimated 36% of the population currently affected.

“Furthermore, Australia is expected to have 4.1 million high myopes and New Zealand over 600,000 high myopes by 2050, unless myopia management is implemented by everyone,” he says.

“These forecasts highlight the scale of the problem that is facing the profession given Australia in 2020 had an estimated 1.1 million, and New Zealand over 200,000, high myopes.”

Given the seriousness of the myopia problem, the industry-wide adoption of a Standard of Care could prove significant in this major public health problem, according to internationally-renowned paediatric ophthalmologist Professor Ian Flitcroft, who supports the ANZ Myopia Working Group’s recommended standard.

“I have long advocated for a change in the Standard of Care for myopic children away from simple refractive correction to a comprehensive program of myopia management,” Flitcroft, who practises at Children’s Health Ireland in Dublin among other positions.

“I therefore sincerely hope that the Australia and New Zealand Child Myopia Working Group’s recommended Standard of Care for myopia management will be embraced by the region. If so, it will help bring about more informed discussions in the practice setting with parents or carers, helping them to consider the available options that can be used to manage myopia and what may work best for their child.

“Most importantly, setting a new Standard of Care is critical to moving myopia management from a service offered by a minority of eyecare practitioners to being universally available. Only then will the full public health benefits of reducing the prevalence and impact of myopia be achievable. Now is the time for optometrists, ophthalmologists, parents and carers, educators and other healthcare professionals to collaborate effectively on behalf of the children for whom we have the privilege to care.”

In its report, the ANZ Myopia Working Group highlights the importance of children having regular eye exams as part of a child’s regular health checks, akin to dental visits. The group wants to encourage all parents and carers across Australia and New Zealand to have their children’s eyes examined by an optometrist before starting school and regularly thereafter.

“By doing so, this will enable every child diagnosed with myopia to be managed with the recommended Standard of Care,” NSW-based paediatric ophthalmologist and ANZ Myopia Working Group member Dr Loren Rose says.

“A myopia management Standard of Care is critical, given that each year of delay in developing myopia substantially reduces the chance of a child developing high myopia in adulthood.”

Mr Joe Tanner is the professional services manager for CooperVision ANZ which supported the ANZ Myopia Working Group and its report.

“It is time to change how myopia is managed with intervention starting as soon as possible. We call on the profession to adopt the recommended Standard of Care to ensure myopia management is universally practised and available to every child,” he says.

WHAT’S CHANGED SINCE 2018

As Flitcroft explains, there has been progress during the past four years in terms of raising much-needed awareness of myopia and how to manage it.

The optometry profession’s understanding of myopia also continues to advance, he says, with the latest evidence and data continually informing best practice.

“However, the coronavirus pandemic has had a significant impact on the

AUSTRALIA AND NEW ZEALAND CHILD MYOPIA WORKING GROUP MEMBERS:

• Dr Rasha Alt aie , Ophthalmologist, Vice President of the Cornea and Contact Lens Society of New Zealand, Auckland, New Zealand.

• Luke Arundel , Optometrist, Chief Clinical Officer, Optometry Australia, Melbourne, Australia.

• J agrut Lallu , Optometrist, Past President of the Cornea and Contact Lens Society of New Zealand, Hamilton, New Zealand.

• Mar garet Lam , Optometrist, National President, Optometry Australia and National President of the Cornea and Contact Lens Society of Australia, Sydney, Australia.

• Dr L oren Rose , Paediatric Ophthalmologist, Senior Clinical Lecturer Macquarie University, Sydney and Canberra, Australia.

• Andr ew Sangster , Optometrist, Board Member of The Orthokeratology Society of Oceania, Wellington, New Zealand.

• Chair –Scientia Professor Fiona Stapleton , Head, Eye Research Group, School of Optometry and Vision Science UNSW, Sydney, Australia.

progression of child myopia in those populations who endured extended lockdowns, bringing the issue of myopia to the attention of a wider audience than ever before,” he says.

To demonstrate this, the report highlights a large Chinese study that found myopia prevalence rose significantly in young school children during the COVID-19 pandemic. It reported an almost 400% increase in six-year-olds, a substantial myopic shift (approximately −0.30 dioptres) that hasn’t been seen in any other year-to-year comparison.

The evidence of the protective effect of time outdoors also continues to expand and Optometry Australia now recommends children spend at least 90 minutes per day outside to help prevent myopic development and progression.

Ethnic and geographical differences in terms of myopia prevalence also need to be acknowledged as influencing factors, as does the urban or rural environment in which an individual resides, the report states.

For example, myopia prevalence differences exist between people living in south Asia (which includes Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan and, more recently, Afghanistan), compared to south Asian populations living outside the region. Myopia rates for Indians living in Singapore are more aligned with rates for the Singaporean Chinese population than for Indians in India. Similarly, south Asian children living in Australia and England are approximately five times more likely to be myopic than their counterparts living in Nepal or India.

“At age 15, around 40% of migrant south Asians develop myopia, compared to 9% of indigenous south Asians,” the report says.

“It is estimated that children living in predominantly urban environments have 2.6 times greater chance of developing myopia than those living in rural environments. Regions that have undergone rapid economic transition, south and east Asia for example, have also experienced a rapid rise in rates of myopia.”

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