The Myopia Exchange
Dr Kate Gifford, a global authority on managing childhood myopia (short-sightedness) in clinical practice, discusses the latest myopia research and clinical techniques with experts from around the world.
The Myopia Exchange
Myopia SOS with Prof Ian Flitcroft - Episode 2 - Stride into the water
Myopia SOS! Advice from your Agony Aunt Dr Kate Gifford (optometrist), and Agony Uncle Professor Ian Flitcroft (ophthalmologist), helps you tackle the daily realities of myopia management, especially when patients don’t fit the easy mould. In part two of this six part series, Kate and Ian chat across the seas about myopia research and curly clinical cases, to help you achieve smooth sailing in practice.
What’s the cold water or pain points for you moving to the next steps in myopia management? Are you dipping your toes in by getting to know one treatment type? Kate says, for cold water swimming and myopia management – stride on in and don’t overthink it. Ian gives you the steps, and both explore a case on myopia correction versus management in a child with high astigmatism and amblyopia. Key red flags in childhood high myopia are also raised.
Yes, there may be some more oceanic references in this episode, and definitely some seagull sounds. Please share your questions and concerns with us through podcast@myopiaprofile.com.
NOTE: The new International Myopia Institute paper that Ian mentioned, on definitions of myopia correction, control and management, on which Kate was a co-author, has since been published: https://iovs.arvojournals.org/article.aspx?articleid=2803124
Welcome to the Myopia Exchange, Myopia Profile's podcast series where we talk all things myopia from research to practice. If you've joined us for the first time, a massive welcome to the community. My name is Dr. Kate Gifford and I'm an optometrist, researcher and peer educator from Australia. I co-founded Myopia Profile in 2016 alongside my PhD optometrist husband, Dr. Paul Gifford, initially as a way to share a simple communication tool that I developed to help me in my practice. Myopia Profile has grown to become the world's largest and most popular multi-platform digital suite for professional education and public awareness in childhood myopia. I've always been fascinated by how we can take the latest research and find the translation to patient care. How can we keep improving and what do we still need to learn? The information provided in this podcast is of a general educational nature, representing the opinion of Dr. Kate Gifford and does not characterize the opinion of any companies represented by our podcast guests. Examination procedures, management options, and clinical pathways for myopia management are described in this podcast on the basis of later scientific evidence. Any clinically relevant information is general in nature and intended to be globally relevant to eye care professionals who must then be individually responsible for appropriate application by practicing within the limits of their own scope and setting of practice. In addition, some of these management options may be off-label or unavailable in certain countries, and it is the responsibility of the individual eye care practitioner to be aware of regulatory requirements pertinent to their practice. Welcome back to Myopia SOS, advice from your agony aunt and uncle. This is episode two. Now, if all of this agony sounds painful to you, it's actually meant to be the opposite. An agony aunt or uncle is British vernacular for someone who gives advice to people who send in their problems, traditionally to magazines or newspapers. Please share your questions and concerns with us through podcast at myopiaprofile.com. From written to spoken word, ophthalmologist Ian Flitcroft from Ireland and myself, optometrist Kate Gifford from Australia, are here to chat across the seas about myopia research and curly clinical cases to help you achieve smooth sailing in myopia management. And yes, there may even be some more Oceania references in this episode. Uncle Ian, you've just been to Canada for the Myopia Summit. How was that?
Ian:It was great. It was a really fun place to go. And they are, as they sort of recognize in Canada, sort of utterly spoiled by their access to sort of myopia products. So pretty much everything gets into the market pretty quickly. So compared to their sort of compatriots in the southern, below their border, they're who are struggling with a single contact lens and pharmacy-made atropine, they have access to all those products. And they've really embraced that. So they're doing some really going sort of full-on myopia management and fantastic to see an enthusiastic, engaged community up in Canada. And they're really lovely people.
Kate:Of course, of course. Yes, I think Canada is top of the world when it comes to access to myopic control treatments they've just got one more spectacle lens than us in Australia and maybe one more contact lens as well yeah they're really in a really fortunate position in that respect.
Ian:Yeah that's good.
Kate:Yeah. So, here's what I'd like how I think we could approach today's episode so we have a myopia SOS question to explore from a colleague and I also I also want to explore your five steps to myopia management that you introduced to us in the previous episode. Maybe we'll do those in reverse order. We'll see. I think that might be good. So, Ian, could you introduce us to your concept of the five steps in myopia management again?
Ian:Yes, this is the notion that everybody from the people who think it's all witchcraft, the people who are living the IMI management dream of the massively comprehensive myopia management control practice. So step one are the people who still exist, which believe that myopia is caused by glasses and therefore they under correct or they don't correct, so I call that the naughty step - so not to be there.
Kate:Indeed!
Ian:Step two is a single vision, which is the majority of people from the IMI survey. There are five continents on the planet where single vision glasses are still the commonest - and Kate, as you know, the the only continent that doesn't predominantly describe single vision glasses is Australasia, so congratulations.
Kate:Yes! Thank you, thank you very much, it's not just me.
Ian:And I think there's some people in what's that country, that island, is it New Zealand? Aren't they beside you?
Kate:Oh yes, yes, New Zealand's pretty awesome, yes, we must give them credit!
Ian:I think we have to throw those into the bucket. So step two is the single vision glasses, I'm sure they are at this stage they know that myopia control and myopia management exists, but they're not doing anything about it. And then step three is where you just start. And I always recommend people just to, you don't need a biometer. You don't need to have access to a whole bunch of things. You just take the plunge, talk to parents about it, and start to learn the pattern. And then at some point, someone's going to jump on board and say yes. And I think that phase kind of lasts from the time of thinking about it to doing it. Just, you know, you're slowly walking into a very cold sea, but it hasn't reached your trunks yet. You're just tiptoeing in.
Kate:Just up to your knees.
Ian:Up to your knees or, you know, not to the important parts. And then, you know, maybe the first patient hasn't even come back for a six-month proper review yet.
Kate:Yeah, yep.
Ian:Or you're starting that. But, you know, you dabble. You're a dabbler. Then step four is that you say, okay, you know, we are going to actually just build out and offer that as part of our practice. So, you know, we're going to have some materials, communication stuff. We're going to be using, you know, maybe one or two things. We still haven't got a biometer, but I might be using estimation and getting a feel for axial length. And then as it builds up, as it always, as people describe it, it builds up by word of mouth and confidence. Then you can then look to embrace five, which is to bring out your management paper, read everything you could be doing and thinking, yeah, okay, we can do that. And we probably should be buying an axial length device at this point. And then you are offering fully-fledged, top-of-the-notch, gold-standard myopia management for your patients. But you can't become an Olympic swimmer every day. Every Olympic swimmer at some point was standing in two inches of cold water, waiting to get into the water.
Kate:Why has it got to be cold water? I'm just thinking we're talking about something that sounds painful. So we're getting into cold water, we're training to be an Olympic swimmer, lots of pain. Myopia management, there's lots of tools to make it not painful, right?
Ian:Yeah, but ask yourself, you know, why at this stage of the game is single vision glasses still...?
Kate:True, true.
Ian:So it is perceived as painful. So people think it's a huge amount to do, but the aim here is to say, look, whatever you're doing, I can map you on that scale. And wherever you are on that scale, unless you are at number five, there's something more you can do. So, okay you've got a myopia practice ticking along, you're number four, you're thinking really smug yeah, you're not doing axial length are you still doing gold standard? Are there cases that we could pick out where you could get caught out by not having access to axial length? You are... "single vision, I haven't got time..." Before we started the trials we used to do a lot of qualitative research, asking ECPs, academics, students, and active practice, you know, what the barriers were. That was in about 2017, 2018.
Kate:Mmm, mmm.
Ian:And it was madly broader than ever imagined. So it revolved around confidence, communication, parents not being aware of it, clearly chair time, lack of access to topography or biometry, business case justification.
Kate:Yes, yeah.
Ian:Lack of follow-up was a really interesting one, which is, going from a transactional, single visit model, doesn't really matter who you see next time. Whereas in management, it really does. If someone's mentioned it one time and they say, well, think about it and they come back the second visit and someone just goes, so how about those special glasses? What? Ah, I wouldn't bother those. All the mixed messaging can go through. But the resistance points are that if you don't tackle all of them, you know that you sit in meetings with people trying to do something innovative within an organization, and there's some smart people using every ounce of creativity to avoid doing it, rather than actually just thinking, "okay well let's see how can it work?" So yeah, I think that resistance to single vision glasses is a very human resistance to change. And once you change, it's never that hard, but it always seems hard.
Kate:Yeah, and these are all the things you're saying that are stopping our colleagues from moving from step two to three or step three to four. Hopefully, nobody listening is on the naughty step.
Ian:I hope so.
Kate:Yes, although we know that, unfortunately, we do still have a reasonable number of colleagues around the world, a reasonable percentage - although it is decreasing over time, of eye care practitioners who do prescribe under correction as a myopia control strategy, despite it being debunked, oh, I don't know, 22 years ago.
Ian:Yeah, the O'Leary paper, yeah. Absolutely. But in this day and age, there's probably a podcast somewhere on the planet that's saying: "this is the way to go and it's all evil optical industry. Just don't believe that Kate woman. She's the Wicked Witch from the south.
Kate:Yes, I'm just out to ruin kids' eyes. When in fact, that's the exact opposite intention and that's the thing that we really want to inspire our colleagues and those of you that are listening, these enormous opportunities we have to do better for children's vision and to do better for their vision now and across their lifetime as well. So listener, you can assess for yourself. Are you on the naughty step, hopefully not? Are you just prescribing single vision spectacles? What are your pain points? What's the cold water for you in moving up through those steps? And I think that's really interesting that it doesn't seem painful to us. It doesn't seem like cold water, although cold water is therapeutic. So is there something in that analogy to explore? Cold water, actually getting into the cold water is therapeutic. Change is difficult. And that's, I guess that's what we're recognizing, right? Change is difficult, but you just have to start with one patient to move up to that step three.
Ian:And it is exactly like ocean swimming now. It's much more of an issue here cause, compared to in Australia, because the water's quite cold in Ireland. But there are a whole bunch of hardened morning sea swimmers who are complete enthusiastic zealots. But, you know, am I going to suddenly start getting up at 7am every morning to go and swim in a cold sea? Sort of, no. But, you know, from my tiptoeing thing you're tiptoeing it hasn't got your trunks. And then once you actually just get to that point where the trunks are wet, you think "ok, I'll just jump in" and then you're actually under the water and you're still thinking "oh my god that was cold". Then you're okay. And then you start doing it regularly, and then by the time you get into it. So I've never heard of anybody who's started doing active myopia management and then decided it wasn't for them, ever.
Kate:Yes. Yeah, yep absolutely, absolutely.
Ian:So in terms of it's the right thing to do, people enjoy doing it. It's an expansion of practice. And it really is absolutely a confidence issue.
Kate:Yes, yeah. And I'm very glad that you brought up cold water swimming because that the water is cold down here in Tasmania, where I'm coming from. And Paul and I have been practicing getting into the water. And I guess my way to sort of draw an analogy between my opia management and the cold water swimming is don't overthink it. This is what I've said to people when they're saying, "how can you get into that water when it's so cold!" Down here it's probably 10 to 13 degrees now, it's starting to get a little bit cooler and so I'm starting to overthink it a little bit and not get in. Getting out is harder than getting in. But I think that's probably something worth considering as well. Don't overthink it: as you said, you don't have to read the entire IMI guidelines to get started. You've got tools, you've got evidence. Don't overthink it.
Ian:Yep. Big time.
Kate:Yeah, yeah. So on the theme of correction, I've got a really interesting case. We started this series and we first talked about this series in terms of exploring curly cases and myopia SOS questions from our colleagues. So this is a really interesting one and it's about the question of myopia management versus perhaps vision correction. So let me tell you about this case. The case, the question from our colleague is, "when would you start myopia management for a patient with amblyopia?" This is a five-year-old patient and their cycloplegic refraction is -1.00, with -3.00 cyls in each eye. We won't worry too much about the exact amount of astigmatism and the axis - with the rule astigmatism. So would we assume that a myopia control spectacle lens would affect improvement of amblyopia? Should we use atropine instead? Should we start with single vision correction? What would you do in a case like this?
Ian:So how old is the kid again?
Kate:Five. -1.00 with -3.00 cyls.
Ian:Okay, and amblyopia based on bilateral ametropic amblyopia from the cyls or because of a separate BV issue?
Kate:Well, we don't know that for sure from the post. So those are interesting things to explore. And also we don't know... Yes, I'll let you talk to that, to how we proceed.
Ian:So when... This is a great case because it's kind of off the evidence, just. You know, no clinical trial is likely to be including this sort of situation. So we assume we have a five-year-old kid. And the first question is, is how unusual is his level of myopia? And the second question is, what's the most important thing I have to do first? So in terms of how unusual, that's in terms of spherical equivalent, that is, it's a pretty myopic kid in I'm assuming from a Western country?
Kate:Yes, this was a case from Australia.
Ian:So that's a 99.9 centile. That kid is very unusual. Has a lot of astigmatism, that level of myopia. But astigmatism should be minimal between five and six. It's bigger in little kids. It's bigger in older kids. So, first of all, a very, very unusual level of myopia. So at five, you still need to be thinking about, " could something else be going on than just conventional, normal school myopia?" So there's a bit of a red flag there about the level. Second thing is the fact that I mentioned amblyopia in somebody with the same refraction in both eyes without any mention of any sort of BV deviation suggests that they've got reduced best corrected visual acuity and then people often then just diagnose that as ametropic amblyopia. If a kid just cuts up and they've been walking around with -3.00 cyls, the parents usually haven't noticed. It's amazing that...
Kate:Yeah absolutely.
Ian:Everyone was a little bit surprised that little Johnny was is quite so awful. But I mean he's learned to cope, but his visual cortex hasn't seen much detail. So they can be sort of amblyopic. So I have a flag about the level of myopia, and the question about 'what's the most important priority' - if he has been without correction for five years and his BCVA is reduced, and he has this amblyopia, then the first pressing thing is to get him corrected, to get his visual cortex seeing some detail. It's been well established now in amblyopia management that a period of, 'don't do anything other than just correct for about six months', because you'll get an awful lot of improvement just from the correction part of it. So for example...
Kate:Oh in just six months?
Ian:Well just see where you're going. So there was a deferred intervention study, in Newcastle, whereby you either gave kids anisometropia glasses and occlusion therapy at the same time, or just deferred it for, I think they did defer it for a year, actually. And then by the time they got to 5, these all young kids - there was absolutely no difference. This was a study done at the time when all the controversy about 'does amblyopia therapy even work at all?'. So the practical adaptation now, is there's plenty of window. You just get them in correction and the great advantage is you're not trying to do too much at once and overwhelm the kid and the family. So just get them in glasses. You're going to gain, usually, a couple of lines straight out of the gate. And then by the time you start occlusion, the kid's ability to cope with it is a function of how well or badly they see when they are occluded. So if you've gained a bit, it's easy to accept. If you're starting off and a kid is barely functional when they're occluded, you've just made everyone's lives a misery. And the end result will be no better.
Kate:You're just plunging them into 'visual impairment-land'. So why would they comply?
Ian:Yeah. Whereas, you can just get them into the glasses and just sit back. And then when they come back, they will generally be, you've got a line or two for free - and you've made step two much easier. So that's kind of standard paediatric practice in our part of the world. So now that's...
Kate:Why would we pop this kid... From everything we know about myopia control spectacle lenses, and all of the data on the fact that they don't appear to influence visual function, field of view - useful field of view, peripheral motion detection; this sort of information, although those tests aren't done in five-year-old children with reasonable amounts of astigmatism, would you potentially try to tackle two things at once with myopia control spectacles and the full correction? Or do you feel single vision is the place to start with a case like this?
Ian:I can't see any downside, other than the fact that there is a cost element, which can be troubling for some markets and some parents. But no, I wouldn't be worried about adding in myopia control glasses in this kid. But, just doing that and thinking 'okay that's it, job done', this kid's... Going back to that first thing 'how unusual is this myopia?', this kid is one in a thousand at that age.
Kate:Yes.
Ian:The younger you are, the more likely you are, there may well be other factors going on, and you've got a lot of astigmatism. So I'd also be wanting to know where's that coming from, what does that cornea look like. Now I can probably guess, I mean, something that I think people don't look at enough is, because it comes off your auto refractor - is just look at the K's. If nothing else, just to look out for those steep corneas and flat corneas. So I'm looking and saying, 'is this all... does the keratometer explain that astigmatism?'. That's fine, because if it doesn't in a five-year-old, which is a very unusual amount of myopia, then you could be potentially looking at lens dislocation disorders, so, you know, homocystinuria. And I'm also looking, I would be really wanting to just run through some of the potential red flags for a syndromic disorder. So is there any developmental delay, behavioural issues going along with that, strong association of genetics with behavioural disorders. Looking for the family history, getting some sense of, how many unusual myopes are there in this family? So, is everyone -10D, are both parents absolutely fine and this kid is a complete oddball and the siblings are oddballs? Or is there another sibling? Is there a pattern of X-linked inheritance? Is there a whole bunch of super short-sighted men scattered around the family and everyone else looks fine?
Kate:Can I ask you a question on syndromic myopia? I remember before this was immortalised in the IMI paper on paediatric high myopia, of which you were the lead author in 2023. Is that correct? Is it 21 or 2023?
Ian:Yeah, should be.
Kate:Yes. So before that, I remember you endowing us with this fantastically useful rule of thumb that if the diopters exceeds the candles on the birthday cake, that we're concerned about syndromic myopia. With this child there, -1.00 with -3.00 cyls, five years of age; best sphere's about -2.50. Is it the astigmatism that's raising a more of a red flag for you there, or is it because the level of myopia itself is relatively low?
Ian:So this falls in between. This is... someone turns up at 7 [years old] with, -1.50 you know, that bulk - that's vanilla ice cream until proven otherwise. The birthday cake one is that, somebody with those those high ones is almost certainly genetic.
Kate:Yes, ok.
Ian:And then the ones in between - at least think about it, otherwise you'll forget. So between some of the cases I was presenting in Toronto, maybe in the future you might dig a few of those out. A good few of those had been put in myopia control things for a good few years before, and they were actually referred on to me for sort of atropine treatment, not to question the thought about whether this is. So for this kid, I certainly want to look at those those K's, make sure that there's no abnormal cornea. And as I said, a lot of astigmatism without a corneal change in a young kid with a lot of myopia is a red flag for the Marfan [syndrome], homocystinuria- type disorders. Family history is just as important. In that paper there's an infographic which looks at some of those red flags. So a couple of the things: he has three on the basis with no other history at all, which is centile based. You know, he's one in a thousand, unusually high that spherical equivalent, for a five-year-old. He's got a lot of astigmatism - again, unusual for that refraction and he's been described as having amblyopia. Which implies a reduced best corrected visual acuity. There's another paper looking at the electrophysiology and that ametropia - both hyperopia and myopia, and a specific association of astigmatism with inherited retinal disorders.
Kate:Okay.
Ian:So inherited retinal disorders have, they're much more likely to be ametropic, but they're much more likely to have astigmatism.
Kate:Oh, okay.
Ian:So we looked at... in Moorfields, the risk factors for having abnormal electrophysiology and that combination of being myopic and astigmatism. So the assumption here is that it's amblyopia. But this combination of an unusual myopia and that age definitely raises the risk that this could be an inherited retinal disorder. So that's where the family history comes in. One of the screening questions is night vision. Now you don't ask 'does the kid see at night', you just ask age-specific behavioural questions. Which is, e.g. 'when he was when he was a baby, could he get out of his bed and navigate to the parents bed with the lights off?'. Or... every kid often has a night light, but is it a night light, or do you wake up in the morning and find every light in the house on? Which is the typical story of a kid navigating. So those three factors: I want corneas, I want to know retina, and the other super simple screening thing in that flags list is looking for signs of hypermobility for connective tissue disorders. Very easy to do the 'pinky test': put your hand flat on the desk, bend up the pinky. If that goes beyond 90 degrees, don't break bones.
Kate:Don't snap it.
Ian:Kids are bendy. Just get used to doing that. When you put your thumb across your palm, does it reach the other side?
Kate:Yes, I'm doing that now.
Ian:Actually, I always do that when I'm demonstrating to parents with my left hand. My left hand actually now, my left thumb actually has become hypermobile over the last few years.
Kate:Ha ha, too much stretching.
Ian:My right thumb just can't do it at all. It's normal. But my left thumb actually is ever bent...
Kate:Side effect of clinical communication! Ha ha ha.
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Kate:So can I throw something else into the mix with this child? You mentioned topography, wanting to understand even just looking at Ks. Now, this was actually a case that had some discussion in the Myopia Profile Facebook group. And the original poster said that they had no chance of getting this child near a topographer because they had ADHD and ASD. So attention deficit hyperactivity disorder (ADHD) and autistic spectrum disorder (ASD). So in the context, we've talked about inherited retinal dystrophies. Obviously, that would be a concern if we... say we corrected single vision to start with and then didn't see acuity improve? Perhaps that's something you're suspicious of right off the bat, as you've been talking about. But what if we can't get those K readings? And what about this potential relationship, I guess, with autistic spectrum disorder?
Ian:Again, it's common enough, but you are more likely to get a genetic basis if you have, myopia with any behavioural condition. I presume at this stage obviously, the kid has had a proper neuro-developmental review.
Kate:Well, you have to presume that, yeah.
Ian:I hope so. So going back to this single vision versus myopia glasses, getting a kid with that combination into glasses can also be challenging. So that's the sensory issues associated with that. And without that, I would be bunging the kid into myopia control glasses with the proviso to the parents that we haven't got much evidence, and that we haven't tested that type of product with that thing. But anyways, it's a good place to start. And also I'd be investigating that kid just for these other issues. But a good reason for starting with single vision glasses in a kid with that background is they're probably going to trash multiple pairs of glasses, or they may not even wear them. Going back to the first question of 'what's the most important thing', the most important thing in this kid is to correct that myopia and correct that cyl, to get them actually functioning at a higher level. Kids with autistic spectrum disorder, when you get them vision correction, has a profoundly sort of accelerating benefit in terms of their development. In that paediatric paper you referred to before, we discussed this issue at quite some length, so there's this concept of visual autism, where kids can have delay issues, they have visual impairment, and they can be diagnosed with autism. Obviously one of the features of that is being able to understand emotions and faces, and react appropriately. But that kid, outside corneal disease, no five-year-old with a -3.00 cyl has just developed it. Astigmatism, he was born with that - and it may have reduced.
Kate:Yeah, of course.
Ian:So his ability to see faces in detail, and certainly any micro expressions - is deeply impaired. So his ability to learn and navigate a world of adults and parents and siblings based on their facial expressions is going to be impaired. So that accelerates and emphasises any other underlying ASD issues. And sometimes, it can literally be a mimic of visual impairment. So getting this kid into glasses absolutely is a priority. It can be really hard when they have these sort of sensory issues too, so working with the parents and trying to work out... and this is a situation where frame design is critical. Comfort, anything that feels abnormal, and how do you start this off? I always say to people it's that parents vary in terms of either; they'll just try once and give up, or they'll be tyrannical and torment the child to the point of one story of involving duct tape and glasses and children, which is not to be recommended.
Kate:Wow, that's next level stuff. How do you take the duct tape off? You mean around the child's head? How do they shower? They don't shower...? Yes, a lot to unpack there, not recommended.
Ian:Getting kids into vision is just, you try, you stop.... you take a break, you try again. The television Thomas the Tank Engine 'remote control trick' is, you sit there, put the favourite on for everyone, you have remote control. You take the glasses off, you press stop. Then put the glasses back on, you press play... and they can't even see you have the remote control, but they kind of go, 'oh, it moves when I put my glasses on', trying to clean them up. So for this kid, I would certainly explain the importance of it, but then also encourage the parents and support them in terms of how to get these glasses on. And acknowledge that this might be a really tough challenge in this scenario; getting the kids seeing in glasses. If those glasses are going to be trashed, then I would actually be experimenting with single vision. Wait till he's comfortable not breaking glasses before you go for the expensive lenses.
Kate:So this is a really interesting case in terms of your five steps of myopia management. We've stopped on step two there; of single vision correction, but for very good reason, because as the case has been explored and further illuminated, we've got elements to this patient management aside from their refraction, aside from their level of myopia, even aside from those syndromic possibilities or retinal health possibilities you talked about, just in terms of compliance, in terms of them getting their correction. And this speaks a little bit to myopia management also encompassing myopia correction, right? So sometimes myopia correction is where we're starting from or where we really have to work hard in initial phases of treatment, as is the case for this patient.
Ian:Yeah, and thanks for bringing up that myopia correction thing, because that notion that myopia correction is something separate, and then myopia management and myopia control is in a different bottle. So with the IMI, we're going to be producing a paper, of which you are an author, so you know about this too.
Kate:Yes, I know about this.
Ian:The world doesn't yet, but I'll give a sneak preview if you want to. So it's the notion that defining myopia management its absolutely broadest contexts. So myopia management is actively managing myopia in all its aspects: including prevention, education, and including complications, because we're trying to push it to be a lifelong activity. But in the middle of this diagram of myopia management, there are three overlapping balls within that. Myopia correction is one of them; myopia control is the second one; and then monitoring - which is a really key component of myopia management sort of overlaps both of those. But the first thing you have to do is the correction; it is part of myopia management, but the phrase we use is that it's not, in isolation, adequate management. Absolutely, you start there and don't forget some myopia control things, as you mentioned - also include correction. So you can correct and control at the same time. Sometimes if you're using atropine, whatever preferred flavour or concentration, then you still have to do the correction part of it. And that's still part of your, ' what's the appropriate correction...'.
Kate:Important part of the picture.
Ian:And for this kid, for a kid with difficulty wearing glasses, some of you might have to spend a good while getting them to cross that line into comfortable glasses wear.
Kate:Correction, in the first instance.
Ian:Yeah. The thing is in, with autism spectrum disorder, it's hard to change anything, but then once you've changed them, then they're great at it. So once they're wearing a pair of glasses, that's okay, 'we've won that battle, let's look at the next one.'
Kate:Next step, next step, fantastic.
Ian:In terms of those steps, if you're at single vision and never ever do myopia control; that's kind of step two. To move on to step three, choose a nice, simple, middle-of-the-road, vanilla ice cream-type kid.
Kate:Yeah maybe not this one for your first patient.
Ian:E.g. mum's -3.00, dad's -3.00; kid rocks up at 10 [years old], in a -1.00. Yeah, off you go.
Kate:That's our vanilla myope. Get started there.
Ian:And you've got two parents who are totally on board. They kind of get it. That little kid's almost certainly going to end up worse than both parents and just easy stuff. But if you're thinking, you're sitting there with your feet chilling in the edge of the icy ocean.
Kate:Cold, Irish waters...
Ian:...the pebbles starting to push into your soles...
Kate:-we've got sand here.
Ian:And you're thinking, I'm going to do my first case. And you come across one like this. Just that first question, how unusual is this myopia? Is this... birthday candles straight off to a tertiary...
Kate:-straight off to Ian.
Ian:...hospital, wherever they happen to be. When you see that kind of case, you probably need to ask somebody who's on step five, just for a bit of advice. Almost certainly, in your area, you're probably inspired to try to move on from two to three by hearing somebody in that situation.
Kate:That's good advice.
Ian:Like all of us... so just reach out and ask; that guidance and mentoring and approach is an incredibly valuable thing to be doing. I think most people who are enthusiastic in this area are more than delighted to offer that advice.
Kate:Absolutely.
Ian:There are odd dimensions and I don't want to scare people off at all, but part of going up the staircase to get to five is understanding some of these nuances. And the weirder they are, the more it's worth asking for advice about them. When you start to unpack what looks like a super simple case...
Kate:-there's a little more to it!
Ian:There could be; that's that's the point. There may not be. This is a kid where it's not so extreme that the risk of a genetic thing is super super high, like the birthday candles one. But it's like diagnosing anything, if you never even think of the possibility, you're never going to make that diagnosis. Every missed diagnosis and every kid on the planet, about general health or eyes; is that somebody who could have made the diagnosis has almost certainly seen that kid and it never occurred to them.
Kate:I think that's a good place to finish up, to say ask for advice, to think about these sorts of cases. When we're talking about step two as we have here, we have an awareness of the other steps. We're also thinking about moving from step two to step three, with a vanilla myope. A simpler case than this one, but a most fascinating case nonetheless. Thank you so much Ian.
Ian:Pleasure.
Kate:Stay tuned for the next podcast in the series when Uncle Ian and I will be chatting more about myopia cases, research and helping you with your burning myopia questions. I would like to thank Ocumetra for sponsoring this episode of the Myopia Exchange. Ocumetra provide a range of software products to simplify myopia management in clinical practice. To learn more, head to Ocumetra.com. And thank you for tuning into the Myopia Exchange, learning about myopia research, innovations and the translation to clinical practice. I trust you've found some useful pointers for your next patient and you've enjoyed the nerdy goodness. Please stay tuned for more episodes. And in the meantime, make sure to check out the numerous resources, courses, cases and more available to help you on myopiaprofile.com. Together, we can improve children's vision care worldwide. The information provided in this podcast is of a general educational nature, representing the opinion of Dr. Kate Gifford and does not characterize the opinion of any companies represented by our podcast guests. Examination procedures, management options, and clinical pathways for myopia management are described in this podcast on the basis of later scientific evidence. Any clinically relevant information is general in nature and intended to be globally relevant to eye care professionals who must then be individually responsible for appropriate application by practicing within the limits of their own scope and setting of practice. In addition some of these management options may be off-label or unavailable in certain countries and it is the responsibility of the individual eye care practitioner to be aware of regulatory requirements pertinent to their practice.