AT THE 2023 Global Specialty Lens Symposium (GSLS), I presented a lecture alongside pediatric ophthalmologist Ian Flitcroft, MA, DPhil (oxon), FRCOphth, from Ireland. Our lecture for GSLS explored collaborative care in myopia management from both the optometry and ophthalmology points of view. The opportunities in collaboration are obvious in improving patient care and education and best use of health resources. A central challenge is that myopia management looks different across the world, especially in primary eye care where access to atropine treatment and axial length measurement varies enormously.

We posed key questions in how our professional roles and collaboration could look. Which profession should be taking the lead and how might first-line treatment choices differ? On the latter, there is a clear optometry preference for optical treatments (World Council of Optometry, 2021) and ophthalmology for atropine (World Society of Paediatric Ophthalmology and Strabismus, 2016), which is logical from both sides. Who should take the lead, though, ultimately depends on the patient presentation.

To demonstrate this, we offered four case studies. In each, the patient presented initially to one profession but ended up requiring the involvement or even lead management of the other profession. Two cases started with optometry and then presented red flags for ophthalmological involvement.

First was a 3-year-old child who had borderline high myopia. Live polling indicated that the primary concern of the audience was myopia management. Professor Flitcroft highlighted, though, that for myopic children in which “the diopters exceeds the birthday candles,” there is a high risk of a genetic syndrome or systemic health issue that has the potential to be life threatening, such as Marfan and Stickler syndromes (Marr et al, 2001).

Red flags for these cases are the presence of more diopters than a child’s age, along with at least one other clinical feature such as reduced best-corrected visual acuity; ocular exam abnormalities such as nystagmus, color vision defect, or irregular red reflex; a medical history including prematurity, hearing loss, or developmental delay; or a family history of high myopia, visual impairment, or related general health conditions.

The second case was a 13-year-old who had progressive myopia and astigmatism, flagging the potential for keratoconus. While the spherical component of refraction is expected to progress at a certain rate in myopic children, progressive astigmatism is not typical. In fact, population studies in Europe (O’Donoghue et al, 2015) and Asia (Tong et al, 2004) indicate that progression of 0.50DC or more over three years is unusual and should precipitate corneal investigation to rule out ectasia. These cases illustrated key red flags for optometrists in managing progressing myopes.

The next two cases—which presented to ophthalmology but ultimately saw optometry taking the management lead–were a 9-year-old low myope who had family history and a young adult showing mild progression with requirement for retinal health monitoring.

Collaborative care between optometry and ophthalmology supports the best possible patient outcomes. There are models in place for other conditions such as glaucoma and strabismus—global, evidence-based perspectives that then require local interpretation. The same will come for myopia management. CLS

References

1. World Council of Optometry (WCO). WCO Resolution: The Standard of Care For Myopia Management by Optometrists. 2021. Available at worldcouncilofoptometry.info/resolution-the-standard-of-care-for-myopia-management-by-optometrists . Accessed Feb. 3, 2023.
2. World Society of Paediatric Ophthalmology and Strabismus (WSPOS). WSPOS Myopia Consensus Statement. 2016. Available from wspos.org/wspos-myopia-consensus-statement . Accessed Feb. 3, 2023.
3. Marr JE, Halliwell-Ewen J, Fisher B, Soler L, Ainsworth JR. Associations of high myopia in childhood. Eye (Lond). 2001 Feb;15:70-74.
4. O’Donoghue L, Breslin KM, Saunders KJ. The Changing Profile of Astigmatism in Childhood: The NICER Study. Invest Ophthalmol Vis Sci. 2015 May;56:2917-2925.
5. Tong L, Saw S-M, Lin Y, Chia K-S, Koh D, Tan D. Incidence and Progression of Astigmatism in Singaporean Children. Invest Ophthalmol Vis Sci. 2004 Nov;45:3914-3918.