February 2023 Virtual event Presentation

The Science of Compliance - The Importance of a Flexible Approach to Managing Myopia in Children

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By Indie Grewal BSc (Hons) MCOptom DipTp (IP) Prof Cert Glau FBDO FBCLA

About the presentation

Children are likely to be in a myopia management treatment plan for a number of years – what might make sense at first, may need regular and constant review as that child gets older in order to maximise the treatment effectivenss With the increasing availability of myopia management interventions, we are now able to fit the child to a product rather than the product to the child.

Three case records of children on a myopia management plan will be shared to help illustrate the importance of recruiting the whole family on a myopia journey to reinforce the need of strict compliance. The cases describe 3 individual children, their journey into myopia management and the outcomes during followup that led to a change in approach to ensure that each child was able to benefit the most effectively from their individualised treatment plan to suit their lifestyle and life-stage.

FAQ from the event

Have you measured any correlation between children who have high contact lens adherence and children who spend more time outdoors? How are you currently measuring time spent outdoors for the typical patient?

It is my impression that children wearing contact lenses are more active, but I do not have any data-based evidence to supporting this.

Is a progressive lens in spectacles effective for myopia management?

It has been shown to have an effect but not to the same degree as on-label products. I personally would not prescribe varifocal or multifocal spectacle lenses to a child today. For my colleagues in countries that do not have the same treatment options at their disposal as I do, I would of course go with whatever option is best for the child within the options available to me - and read up on what is to come.

Is adherence to a prescribed treatment is an issue equally across treatments e.g. ortho-k, soft lenses and so on? And does this influence how you make your treatment recommendation?

Ortho-k does have an element of discomfort which then requires the parent to continiously reinforce that "It will get better"; but we all know that children who experience something to be uncomfortable will probably not want to wear it. However, for a while ortho-k was my only option. Nowadays, I tend to find children more compliant with soft contact lenses, particularly with daily disposable lenses. When it comes to spectacles, it is very difficult to monitor compliance because they can easily take them off. Spectacles probably has the least observable compliance. This is where ortho-k is really good, the parents see the lenses put in in the evening and taken out again in the morning.

Why do you think the compliance is better with MiSIght 1-day contact lenses than with Ortho-K?

In general, my experience is that compliance is better with MiSIght 1-day contact lenses than ortho-k lenses. Whilst parents may have the best intentions, they tend not to do all that you tell them to do; a classic example is deproteinizing the lenses, we ask them to deproteinize the lenses twice a month and when you speak to them, they are probably not doing it quite as often. Whereas with MiSight contact lenses, it is quite easy for a child to apply and remove the lenses and the parent can see it is being done.

We know there is evidence confirming that myopia control improves with increased wear. is there anything you do in your practice to encourage full-time wear?

We have started to send an email one month after the consultation and then three months after to stress the importance of full-time wear to parents. With contact lenses, whether it be ortho-k or soft contact lenses, we also have a face-to-face interaction after six months as parents are obliged to bring their child in for an update of their lenses and pick up a new supply of lenses; as they are asked to bring in any unused lenses, the number of lenses they bring back to us is a great indication of compliance. We don't have this same opportunity with spectacles.

Would you ever prescribe anything to a pre-myope?

I think that is a really interesting part of myopia management; at the moment, the only thing I can prescribe is outdoor time and reduced near vision digital device use. It would be great if I could prescribe something like atropine to a low hyperope and keep them hyperopic until their early teenage years.

Some practitioners believe combination treatments is a preferred approach in myopia management. Do you ever prescribe a combination of treatments to a child undergoing myopia management?

The only combination approach I tend to offer is if a child would like a day off from their soft contact lenses, for example, contact lenses during the week and spectacles during the weekend. I will then suggest myopia management spectacles in line with their contact lenses; ortho-k is slightly different as you are either all in or out, so to speak. It is not often that we do combination treatments as they typically off-label and icome at an additional cost.

Considering the wealth of experience, you have with myopia management and compliance, what would you have done differently in the past?

I would communicate more often. Keep your patients and their parents close and continue to constantly reiterate treatment advice and the importance of compliance in different ways using new research and so on. The pandemic really taught us that we cannot leave these children drifting nor can we afford to not be in contact with their parents.

Have you measured any correlation between children who have high contact lens adherence and children who spend more time outdoors? How are you currently measuring time spent outdoors for the typical patient?

It is my impression that children wearing contact lenses are more active, but I do not have any data-based evidence to supporting this.

Is a progressive lens in spectacles effective for myopia management?

It has been shown to have an effect but not to the same degree as on-label products. I personally would not prescribe varifocal or multifocal spectacle lenses to a child today. For my colleagues in countries that do not have the same treatment options at their disposal as I do, I would of course go with whatever option is best for the child within the options available to me - and read up on what is to come.

Is adherence to a prescribed treatment is an issue equally across treatments e.g. ortho-k, soft lenses and so on? And does this influence how you make your treatment recommendation?

Ortho-k does have an element of discomfort which then requires the parent to continiously reinforce that "It will get better"; but we all know that children who experience something to be uncomfortable will probably not want to wear it. However, for a while ortho-k was my only option. Nowadays, I tend to find children more compliant with soft contact lenses, particularly with daily disposable lenses. When it comes to spectacles, it is very difficult to monitor compliance because they can easily take them off. Spectacles probably has the least observable compliance. This is where ortho-k is really good, the parents see the lenses put in in the evening and taken out again in the morning.

Why do you think the compliance is better with MiSIght 1-day contact lenses than with Ortho-K?

In general, my experience is that compliance is better with MiSIght 1-day contact lenses than ortho-k lenses. Whilst parents may have the best intentions, they tend not to do all that you tell them to do; a classic example is deproteinizing the lenses, we ask them to deproteinize the lenses twice a month and when you speak to them, they are probably not doing it quite as often. Whereas with MiSight contact lenses, it is quite easy for a child to apply and remove the lenses and the parent can see it is being done.

We know there is evidence confirming that myopia control improves with increased wear. is there anything you do in your practice to encourage full-time wear?

We have started to send an email one month after the consultation and then three months after to stress the importance of full-time wear to parents. With contact lenses, whether it be ortho-k or soft contact lenses, we also have a face-to-face interaction after six months as parents are obliged to bring their child in for an update of their lenses and pick up a new supply of lenses; as they are asked to bring in any unused lenses, the number of lenses they bring back to us is a great indication of compliance. We don't have this same opportunity with spectacles.

Would you ever prescribe anything to a pre-myope?

I think that is a really interesting part of myopia management; at the moment, the only thing I can prescribe is outdoor time and reduced near vision digital device use. It would be great if I could prescribe something like atropine to a low hyperope and keep them hyperopic until their early teenage years.

Some practitioners believe combination treatments is a preferred approach in myopia management. Do you ever prescribe a combination of treatments to a child undergoing myopia management?

The only combination approach I tend to offer is if a child would like a day off from their soft contact lenses, for example, contact lenses during the week and spectacles during the weekend. I will then suggest myopia management spectacles in line with their contact lenses; ortho-k is slightly different as you are either all in or out, so to speak. It is not often that we do combination treatments as they typically off-label and icome at an additional cost.

Considering the wealth of experience, you have with myopia management and compliance, what would you have done differently in the past?

I would communicate more often. Keep your patients and their parents close and continue to constantly reiterate treatment advice and the importance of compliance in different ways using new research and so on. The pandemic really taught us that we cannot leave these children drifting nor can we afford to not be in contact with their parents.

References

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https://dictionary.apa.org/compliance

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https://pubmed.ncbi.nlm.nih.gov/25837970/

Twelker JD et al. Children’s Ocular Components and Age, Gender, and Ethnicity Optom Vis Sci. 2009 August ; 86(8): 918–935.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2901932/

Chang LC et al. Trajectories of myopia control and orthokeratology compliance among parents with myopic children CLAE 44 (2021) 101360
https://pubmed.ncbi.nlm.nih.gov/33023822/

Sankaridurg P et al. Myopia control with novel central and peripheral plus contact lenses and extended depth of focus contact lenses: 2 year results from a randomised clinical trial Ophthalmic Physiol Opt 2019; 39: 294–307
https://pubmed.ncbi.nlm.nih.gov/31180155/

Xiong S et al. Time spent in outdoor activities in relation to myopia prevention and control: a meta-analysis and systematic review Acta Ophthalmol. 2017: 95: 551–566
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Chang LC et al. Trajectories of myopia control and orthokeratology compliance among parents with myopic children CLAE 44 (2021) 101360
https://pubmed.ncbi.nlm.nih.gov/33023822/

Routhier J et al. We hear and we forget. We see and we remember. How effective is an electronic reminder when it comes to our patient’s contact lens compliance? BCLA ABSTRACT| VOLUME 35, SUPPLEMENT 1, E47, DECEMBER 01, 2012
https://www.contactlensjournal.com/article/S1367-0484(12)00258-5/fulltext

Dalal DM, Jethani J. Compliance in usage of low-dose atropine for prevention of progression of myopia in Indian children. Indian J Ophthalmol 2021;69:2230-1
https://pubmed.ncbi.nlm.nih.gov/34304219/

Azuara-Blanco A, Logan N, Strang N, et al. Low-dose (0.01%) atropine eye-drops to reduce progression of myopia in children: a multicentre placebo-controlled randomised trial in the UK (CHAMP-UK)—study protocol Br J Ophthalmol 2020;104:950–955
https://pubmed.ncbi.nlm.nih.gov/31653669/

Wu PC et al. Increased Time Outdoors Is Followed by Reversal of the Long-Term Trend to Reduced Visual Acuity in Taiwan Primary School Students Ophthalmology 2020;127:1462-1469
https://pubmed.ncbi.nlm.nih.gov/32197911/

Costello I, Wong CK, Nunn AJ A literature review to identify interventions to improve the use of medicines in children Child: Care health & development Nov 2004 30:6 525-532
https://pubmed.ncbi.nlm.nih.gov/15527475/

Wolffsohn JS et al. History and symptom taking in contact lens fitting and aftercare CLAE 2015
https://pubmed.ncbi.nlm.nih.gov/25819266/

Wang J, He XG, Xu X. The measurement of time spent outdoors in child myopia research: a systematic review. Int J Ophthalmol 2018;11(6):1045-1052
https://pubmed.ncbi.nlm.nih.gov/29977821/

El-Rachidi, S et al. Pharmacists and Pediatric Medication Adherence: Bridging the Gap Hosp Pharm 2017;52(2):124–131.
https://pubmed.ncbi.nlm.nih.gov/28321139/

Sankaridurg, P The Importance of Patient Compliance, Review of Myopia Management August 29, 2019
https://reviewofmm.com/the-importance-of-patient-compliance/

Okeke, C. O. et al. Adherence with Topical Glaucoma Medication Monitored Electronically: The Travatan Dosing Aid Study. Ophthalmology 2009. 116, 191-199
https://pubmed.ncbi.nlm.nih.gov/19084273/

Boland MV et al. Electronic Monitoring to Assess Adherence With Once-Daily Glaucoma Medications and Risk Factors for Nonadherence The Automated Dosing Reminder Study JAMA Ophthalmol. 2014;132(7):838-844.
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Prepared by the World Council of Optometry Myopia Management Resource Committee 2023.
The World Council of Optometry Myopia Management Standard of Care initiative is a collaborative partnership between World Council of Optometry and CooperVision.