Debbie Jones is one of the most recognizable names in the world of Myopia Management. She is a clinical professor at the University of Waterloo School of Optometry and a lead clinical scientist at the Centre for Ocular Research and Education.
In this episode, Debbie discusses the current state of the profession with regards to myopia management, what is currently being taught in optometry schools, and what the research is telling us.
This episode is the third in a four-part series of discussions sponsored by Hoya Vision Care Canada. Be sure to check out the first two interviews and stay on the lookout for the fourth episode coming soon!
Learn more about how Hoya is helping optometry fight myopia at www.hoyavision.ca
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Debbie Jones Discusses Research And Education In MYOPIA MANAGEMENT
Before we get started on this episode, I want to say a big thank you to our partner, Hoya Vision Care Canada, for supporting us with this conversation. This episode is part of a series of four interviews that we are doing on the topic of myopia management. This is the third one. Once you’re done reading this, go back and check out the 1st and the 2nd one.
There are different types of conversations that we’re having. Some of them are about an introduction to how to get started clinically. Some of them are more expert-level practice conversations and pearls. This one here with Debbie Jones is going to be clinical but also research-based education types of topics. She’s going to share what’s going on in the research world in myopia management. This is episode number three. Make sure you look out for episode number four. Once again, thank you to our partner, Hoya Vision Care Canada. Let’s go to the episode.
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Welcome back to another episode of the show, Canada’s number one optometry show. Thank you so much for taking the time to join me, to learn, and to grow. I’m so grateful that you would take the time out of your busy day to join us here. I know everybody’s got so many things that they could be doing, so the fact that you’re tuning in to this means a lot to me.
Thank you so much for all your support. It’s been a few years since I started the show. I can’t believe how much it’s grown, and it’s all because of everybody’s support, tuning in and sharing. As always, I’m going to make the same requests as I always do. Please share it and leave a review. If you haven’t known already, we had a little glitch on Apple Podcasts and all the reviews disappeared. I don’t know how to get them back. We’re asking, if you wouldn’t mind, to please leave us a review and a star rating, hopefully, five stars. That will help us get in front of more of our colleagues and share amazing conversations like this one.
This is a really special conversation. I have a very special guest with me, Debbie Jones, who is one of the most well-known names and faces in the space of myopia management in optometry in North America. I’m so glad to have her here. Dr. Jones is a Clinical Professor at the School of Optometry and Vision Science at the University of Waterloo. She’s the Lead Clinical Scientist at the Center of Ocular Research and Education, which is core at the University of Waterloo.
She was a recipient of the President’s Award from the CAO for her work in myopia. I was grateful to be there in the audience when she received that award. It was a great event. Also, she was the recipient of the Garland W. Clay Award from the Academy of Optometry for her work on the three-year data of the MiSight study. That award is given to the authors of this study which is the most cited in the previous couple of years. That tells you how much Debbie’s work has been cited, read, and shared. It’s amazing to have you here, Debbie. Thank you so much for joining me.
Thank you. That was quite the introduction.
That’s shorter. It could be a lot longer, to be honest with you.
You’re too kind.
I wanted to make sure I got at least some of the key points in there for those few people who might not know who you are. I am truly grateful to have you here. I’ve been watching from afar. I’ve seen a lot of the work that you do and I see the impact that you’re making on the industry. You certainly are one of the most impactful people in the profession. I’d love for you to share a little bit, if you don’t mind, from your perspective an introduction to Debbie Jones and who you are and what you do.
The first thing about me is I’m a clinician. I came from private practice way back when. I’ve been at the university for 25 years. I moved to the university to academia from private practice. I did some teaching in the UK, but my main role was seeing patients, particularly pediatric patients. I really had an interest and a focus on pediatric patients.
When I moved to Waterloo, I continued that. I took an active role in the pediatric clinic. That has naturally lent itself to myopia control. I’ve been fortunate enough to do my research through CORE and to be involved in some pivotal studies in the MiSight space, particularly working with children. It has grown from there.
I come at things from very much a boots-on-the-ground clinician perspective. It sometimes gives me that little bit more credibility because I am seeing patients as well as doing research on the theory behind myopia management and some of the products that we have. That’s who I am. My day-to-day job is working with students, training the next generation, seeing patients, doing research, and everything else that goes with an academic job.
That’s amazing. That’s a really important distinction to make. Not only have you had previous clinical experience but you’re in the clinic seeing patients. You are boots on the ground. It is possible to be in strictly the academic sphere and lose a little bit of touch with what’s happening in the clinic. It’s good to hear that.
We are going to be talking about myopia management here, a lot about myopia in general. One of the statements that seems to be growing in popularity or being shared more by experts in the space is that we need to make myopia management the standard of care if it isn’t already. That should be a goal of ours. If you don’t mind, why do you think that is so important?
There is no excuse for it not to be a standard of care. We have so much evidence. We know the risks of myopia. We know the long-term risks. We know the ocular health risks. We have fantastic evidence-based products that are available to us. In Canada, we are blessed that we have the whole spectrum of products. I would almost turn it around and say why would you not? You’d have to have a really good reason to not manage your myopic patients the way we know they should be managed. Canada has gone out on a limb. The CAO has stated, “Myopia management is standard of care.” They’ve followed the WCO recommendation. It would be wrong not to. It’s a no-brainer.
I would agree with that. Almost from the perspective of if we’re not doing it, we are potentially leading our patients to I don’t want to say harm, but ultimately, we know what the effects of not managing myopia are. To then choose not to do it is almost ethically incorrect at this point.
You are not doing the best for your patient. As an optometrist or as any healthcare provider, your duty is to do the best for your patient by following the evidence and doing the best that you can.
As an optometrist or any health care provider, your duty is to do the best for your patient.
There is a lot of evidence. There’s more than enough evidence hopefully to convince even the most cynical. Speaking of, let’s talk a little bit about the research side of the work that you do. This is something that the majority of us, our colleagues, don’t have a lot of experience in. I’d love to learn what that looks like for you day-to-day, what type of research work you are doing, and what’s your involvement in that area of myopia management.
I have various aspects to research that I get involved in. The main one would be in clinical trials within CORE. The MiSight study, we were a cite for that. We were the Canadian arm for that. I was the lead investigator. That was a massive study. It ended up being seven years. I was involved right from the get-go all the way through. We have other studies that are ongoing. I’m looking at other types of myopia control. Some of which I can’t mention. If they’re ongoing studies, I can’t reveal too much detail, but I have been involved with various aspects of myopia control within the research space.
I also do some survey-based research, looking at what the public thinks about various aspects of optometry. Do they understand various terminology? I’m involved in this big study looking at a retrospective file review on what clinicians are doing in practice at the moment. That’s an ongoing study. We’re about wrapping up the data collection. We had some preliminary results at the American Academy meeting not long ago.
That’s very cool. I want to put a pin in that because that’s going to be a question I want to ask you in a little bit. What are practitioners doing? What kind of goals do we want to set moving forward? That’s great that you already have some findings there that you’ll be able to share with us, hopefully. I wanted to ask you about when we are, as practitioners, evaluating, studies, data, and research that’s coming out that various companies are sharing with us, how do we evaluate that to evaluate the strength of it and the validity of it?
Objectively, you need to look at the study and the number of participants. If it’s an N of 2 or 3, you don’t have much strength there. You want a good number of participants. One of the really key things is looking at the impact on both refractive error and axial length. We know that axial length is the key to myopia control and myopia management. Reducing the axial elongation is what we’re aiming for. You want to look and make sure there’s a good correlation between axial length change and refractive error change.
We got a little bit hoodwinked earlier on with some of the atropine work where there was an impact on refractive error but not the same impact on axial length. We have almost come full circle with some of the atropine work. The jury’s out a little bit on the 0.01% atropine, but that’s a whole other episode probably to discuss that. Look at the literature and don’t take it at face value. Do a bit of a deep dive. It doesn’t mean you have to look at all the equations, all of the stats, and all of the stuff that may be complicated. Look at the actual values and the impact on both axial length and refractive error.
If we can go off on a bit of a tangent on atropine there for a moment. I’ve been doing a fair amount of atropine in our clinic, but while I was down there in New Orleans, I heard that perhaps atropine is not the best treatment option or perhaps it’s not what we thought it was. Would you mind sharing a little bit of what you were mentioning there about us coming around to understanding that better?
There are different studies that are being published. There were two at the academy that were mentioned that gave different opinions on the 0.01% atropine. One study said there was a big impact of using 0.01%, and the other said not really. There are different cohorts that they’re using in terms of the ethnicity perhaps of the participants. Maybe there is a variation there.
Certainly, it’s the 0.01%. It feels like with atropine, we’re not 100% certain. There’s fairly good evidence on the higher concentrations, so the 0.25% and the 0.5%. At the moment, until we get some really strong data, most clinicians seem to be leaning towards that slightly higher concentration and perhaps leaving the 0.01% to the sideline. Let’s wait and see.
The big controversy with atropine is it is being compounded. You sometimes maybe don’t even know what you’ve got. It may vary from one bottle to the next. There was a study presented at the academy. There was some work on what was in the bottle. Some pharmacists are diluting with saline. Some are using 1% atropine and diluting it. Some are using a powdered atropine and then adding a vehicle. We don’t really have a standardized, commercially available atropine that we can trust as being the same month over month. Until we get to that stage, we might be a little unsure of what we’re giving to our patients.
That’s a fair point. That’s understandable. From my perspective, I’ve been doing a lot of 0.05%. I know that’s on the stronger side. To not have the risk with the 0.01% being a bit of a gray area, that’s something that’s been beneficial as far as I’ve seen results from our patients. I’m curious to see about the long-term. I’m starting to hear some words on the street about rebound effects and things like that. I’m not sure if that’s about 0.01% or 0.05% as well.
The rebound was something that was talked about in the original studies and is still being looked at. I heard something at the academy say there was no rebound. I don’t know how long you can keep a patient on atropine. It is a potent drug. What impact does it have long-term? The majority of people use it as an introductory option maybe for your younger patients or use it as an adjunct initially if perhaps they have a fast progressor and then eventually look to take the atropine off. We don’t really have a standardized way of managing patients. We don’t have a formula that you plug in and say, “This is what I’ve got, so this is what I should do.”
That’s part of the difficulty. What intimidates some practitioners is that there’s no standard protocol that says, “Here are steps 1, 2, and 3 on how you should treat patients,” as we do with glaucoma, for example, or other conditions. Certainly, that is something that certain colleagues don’t want to dive into until they have that written down. They don’t want to experiment, so to speak. Hopefully, in this conversation, we can lay out a little bit of groundwork for our friends and colleagues who are tuning in.
Let’s switch gears to the education side. You mentioned there are a few different things that you’re doing in your day-to-day work with research. You’re clinical. You’re seeing patients. You’re also educating. You’re an educator. I’d love to hear what that looks like as you’re training future generations of optometrists. You’re involved at different stages along the way, second year, third year, fourth year, and so on. If you don’t mind, what does it look like? What’s your level of involvement at each step?
My main role or the majority of my teaching time is spent in the clinic with fourth-year students. I work with groups of students in the pediatric clinic. The pediatric clinic is up to about 8, 9, or 10-ish a minute. It depends on the patient. If we’ve been following a patient, they sometimes stay with us a little longer before we punt them into the main primary care clinic.
I’m working with children and students and educating them on the best management and evidence-based management of those patients. I also work in the clinical techniques lab. I’m teaching a second-year lab, so some basic clinical techniques like trial frame refraction, for example. I am making sure their retinoscopy skills are good. We’re doing cover tests and things like that.
I get the opportunity to talk about prescribing for patients and different aspects of managing patients. I try to bring it into the real world rather than, “Here’s how you do a cover test. Here’s how you do this.” I try to naturally make it relevant for them. In the winter terms, come January 2024, I’ll be teaching the pediatrics course. That’s the didactic course of pediatrics. We talk about the management of refractive error. Naturally, we talk about myopia control in that course as well. I do case examples and a lot of case-based teaching so that they can really get to grips with, “When you have this patient in the chair, what are you going to do? What are your options?”
That’s great. The students that are coming out of Waterloo, at least, since we can’t speak for other schools here, are they coming out with this that they’re ready to jump in on myopia management? For the most part, they should have at least a foundational level of understanding.
They should be. What’s interesting is in our 4th year, we have 1/3 of the students on-site at any one time and 2/3 are out on their clerkships. Come the fall term, I get a group back that has already been out in the spring term. Even though their knowledge is evidence-based and up-to-date, what they did in the practice they were working in isn’t necessarily the same. It’s very interesting when they come back and say, “We didn’t do myopia management. The doctor I worked with didn’t think that this was a good option so we didn’t do that.” That’s interesting.
As an intern, it’s hard to impart their influence on the practice. They’re there to do their training. Hopefully, when they graduate, even if they join another practice, they have the option then to perhaps find an area where they can impart their knowledge and share what they know that’s the current evidence with practitioners that perhaps are not quite as current.
That’s a good point. I can’t speak for everybody here, but the owner of the practice or the head of the clinic that they’re going to as part of their externship would usually be open to hearing from students in the fourth year. They know that what the students are learning is probably the most recent information.
I know that from my own experience, I had certain preceptors or owners of the clinics ask me, “What are they teaching about this? How do you use it?” I would say to students, “Feel comfortable. Feel confident.” You are mentioning it with a bit of humility. You are mentioning it to the clinic person who’s running the clinic. They might be open to hearing that.
Some clinics are. Some students are a little more confident and others are a little more reserved. They perhaps don’t feel that they can share their knowledge, although they have a lot to share.
Our office is going to be a clinical site starting in 2024. 2024 is our first year doing that. I’m getting a little nervous. I’m like, “Is my level of education or clinical skills up to what the students are going to know when they’re coming in?” I’m going to be asking them some questions, for sure.
You’ll have to give me feedback as to what you think.
They’re not from Waterloo, but I’ll still give you some input on how they are. It’s going to take us some time to get ready to see students and have them be busy, seeing the patients and getting the full clinical experience. There’s something else you said in there that I wanted to go back to. When I was in school, I remember in my first year, one of the professors posed the question, “What do you think it would be?” We might have said ophthalmoscopy or using a direct ophthalmoscope. He said, “The number one thing is retinoscopy. Bar none. No matter what. Learn retinoscopy and know it well because there’s so much information that you can get from doing good ret.” I wanted to share that with you and get your thoughts on that.
You can get me talking about this all day. Retinoscopy is so important. I’m so sad that it seems to be a lost art. When students come back, I’ll often say to them, “How much ret did you do while you were on your clerkship?” They look and go, “Not much,” or, “None.” It’s so important, particularly with young children. I’m a little bit more open to auto refraction on kiddies now than I perhaps was. I was a little bit of a dinosaur that ret is the way to go. I’m fine with using auto refraction in the right situation, but I still think retinoscopy gives you so much information. It is so valuable that it does feel like it’s becoming a lost art.
Retinoscopy gives you so much information and is so valuable that it does feel like it’s becoming a lost art.
I’m glad to hear you say that because it’s something that I certainly use every single day with not just kids. If I’m having a little trouble with refraction and things are not quite adding up, I do ret. Interestingly enough, almost always, you find something a little different than what you thought. With kids across the board, until they’re probably 17 or 18 years old, I’m doing ret on pretty much every child. It took me until I was practicing probably five years or so into my career that I realized how true that statement was and how valuable it is. When students come to my office, I’m going to make sure that they’re doing ret on as many people as they can so they’re leaving with that skill. It’s truly valuable.
Even things like lens opacities and keratoconus, you can pick them up on ret way earlier than you can pick them up on other things or at least it gives you a sense of what’s going on. It’s more than refraction. It really is something that I certainly encourage the students to do ret on everybody at least to get good at it.
On that note, the next question I was going to ask you was since we’re talking about education and students, if there are students reading this episode, is there anything that you’d like to share with them about clinical practice? Are there any pearls that you think will be helpful for them when they get out into the real world? That’s the second thing. The first thing is to do a retinoscopy.
Keep up-to-date with the evidence as much as you can. It’s really hard. I’m focused on myopia and children, which is easy for me, but I’m in a bit of a silo. When they go into practice, they’re also dealing with glaucoma, anterior seg issues, and contact lens fitting. They need to have a broad knowledge base. I’m very conscious that it’s hard to be good at everything, but at least do your best and stay as up-to-date as you can so that you are offering your patients the best that you can. The patients deserve that. They deserve to have the best treatment possible, whether it’s glaucoma, bacterial conjunctivitis, myopia, or a BV issue. They deserve the best.
Keep up to date with the evidence as much as you can.
One of the things that we put a pin in earlier was what’s happening in myopia practice. You were saying there’s some research been done and you have some preliminary information. One of the questions I like to ask experts in the space, yourself and others, that I’ve spoken to who I know are practicing myopia management at a very high level or involved in understanding the population is this. Across North America or if you want to keep it to just Canada, what percentage of practitioners are practicing myopia management?
Not enough is the first answer. This is a research study that came out of the American Academy of Optometry Fellows Doing Research. We have a group of practitioners. Apart from myself, everybody else is in clinical practice. We have a mentor. We have Robin Charmers who’s our mentor from the academy. We have a post-doc working with us who’s been doing all of the legwork on inputting the data and analyzing the data.
We looked to go into regular practices. We didn’t pre-select. They had to see the children and allow us access to their files. We’re picking 5 files from age 6, 7, 8, 9, 10, and 11 on pre-myopes and myopes over a 5-year period. We had 5 and 6-year-olds in 2017, 2018, 2019, and so on. That’s for each grade age group. It’s a massive data set. We’ve done an analysis of seven practices. It’s a snapshot. We’re looking to do 15 to 20 practices, but the preliminary analysis has been on 7.
Depressingly, 60% of myopes are being managed with single-vision spectacles across the board. That’s in general. Some practices are different. I was talking to somebody at the academy. He was adamant. He was like, “I don’t do that.” I’m like, “I get it. I understand.” When we average it out, 60% across all of those years, including up to 2021, are prescribing single-vision spectacles. About 30% are monitoring. I can understand if you’ve got a minus-half doctor myopia might monitor and wait, but there are a lot of people monitoring.
We have about 10% to 15% that are active in myopia management across all aspects of contact lenses and spectacles. We saw a really nice spike when spectacles were introduced into Ontario practices and a little bit of an uptick when contact lenses were introduced. It is trending in the right direction but still at the very bottom of the scale. It’s still a very low percentage.
We also looked at conversations. When are you having the conversation with the patient’s parents about myopia management? Encouragingly, the refractive error is going down when the conversation starts. More people are having the conversation at a lower refractive error. The other piece we looked at is the pre-myopes, which are the patients we want to encompass. Straight away, those are the young low hyperopes that are on that trajectory towards myopia.
Encouragingly, lifestyle changes are being discussed quite early on with those patients. On low refractive errors, there’s an increase in lifestyle discussions. It’s very encouraging but still disappointing. There is a lot of work to be done even to get to the 50% mark. We’re looking at 10% to 15% of those practitioners managing the myopic patients the way the evidence tells us we should be.
Ten percent may seem fairly consistent. When I asked people in the US involved in different areas of the industry, they would say maybe around 10%, which is surprisingly low. I suppose if we wanted to be optimistic or whatever about that, that means we have a lot of opportunities. There’s a lot of low-hanging fruit for us to jump on and grab on. There is a great chance for many of our colleagues to get in there as quickly as we can. We’re lucky in Canada to have spectacle options, and we have for a few years. Friends in the US don’t have sadly yet. Hopefully, they’ll get it soon.
The pre-myope conversation is interesting. When I give a lecture on myopia management, I like to do a little bit of self-promotion here. It’s called the Myopia Startup. If you ever see that listed in a lecture when you go into a conference, come check it out. It’s called the Myopia Startup for a reason because it’s entry-level. It is like, “Let’s get started. How do we get into this?”
One of the questions I ask the audience is, “Are you willing to have a conversation with a parent whose child is a plus 50 or a plus 75? Would you consider that child as being part of myopia management?” The answer should be yes. If we’ve been tracking their changes and tracking axial length and we’re seeing a trend in that direction, then certainly, that should be a child that we are looking at, at least having a conversation with. We want to get as many of our colleagues comfortable having those conversations.
It also begs the question as to why you wouldn’t have that conversation. You know there’s a risk factor, parental myopia in particular. We know that a low amount of hyperopia in young children is indicative. Why not have the conversation? The conversation is simple. It’s what parents want you to say. It’s more time outside, less time on screens. How many times a week do parents say to me, “Doctor, can you tell him that he needs to stop playing on his iPad?” I’m like, “I’ll be the parent here.” You sit them down and say, “You’ve got to start.” They’re like, “He likes to play on it all day.” I’m like, “Okay.” You need to have that conversation.
In some of my lectures, I certainly talk to the students about how every child is on the myopia platform. If we think about a train station, every child is on the platform. Some children get on the myopia train and some children stay on the platform. The goal is to keep them on the platform as long as possible. When they get on the train, some are on the slow train and some are on the bullet train. We want to keep them on the slow train. Once they’re on that train, they’re not getting off. Once they’re a half up to myope, they’re not getting back on the platform. They’re not a pre-myope anymore, but let’s slow it down as much as we possibly can. It’s what we should be doing. We have so much evidence that we have no excuse.
You mentioned axial length change. That’s a whole different conversation. That has not become the standard of care yet. I’m not sure when it will. You have very active practitioners. I was talking to this one particular practitioner who said to me, “That’s not what I do. I manage all my myopes,” but he didn’t measure axial length. He doesn’t have an option to measure axial length. It doesn’t mean he is not managing his patients well, but he perhaps is missing some of the subtleties in those pre-myopes where the axial length shift changes before the refraction.
If we were creating a menu of things that you should be doing, the axial length of all children might be there. We’re not there yet. I don’t know that we ever will be. It’s perhaps until we get something portable and easy and cheap to measure axial length. It would be very interesting to monitor axial length change alongside refractive error even in those pre-myopes.
First of all, I love that analogy. The platform and the train is a really great analogy. It’s very cool. The fact that there are slow-moving trains and fast trains as well, that’s great. On the point of axial length, that was going to be one of the next questions I wanted to ask you. The idea of having a portable device or something small like a small footprint that is easy to use is a good point. I’m wondering if there are any companies out there racing to bring that out because that will be a successful product to have. For the practitioners who are early in the game here getting started in myopia management, do you think axial length is imperative on day one, or should they work towards that and maybe add that into their arsenal at some point down the road?
It’s ideal, but it’s not imperative. Nobody should hold back from managing myopic patients if they can’t measure axial length. If they can get somebody else to measure the axial length, that’s great. I know clinicians who have local ophthalmologists who will happily measure the axial length for their patients. We’re circling back to one of the very first things we talked about. If you are looking at the evidence where there’s a good correlation between axial length change and refractive error change, then you can trust the data. You trust that somebody else did all the hard work. They saw all of the participants and took all the measurements.
Nobody should hold back from managing myopic patients.
If the correlation is there for that particular product, you can probably be confident. It comes back to if there’s a new product on the market. If somebody comes to you and says, “This is the one you need to be using,” make sure there are good correlations. Go ahead and start even without being able to measure axial length.
To your question about a portable device, there is one that’s being launched in early 2024. It’s a company out of the UK. I’ve seen pictures of it. I haven’t touched it. I’m desperate to get hold of one. I’m really hoping that they’re going to send me one. It’s going to be at a price point that’s going to be manageable. With that said, some of the other instruments, the multifunction instruments, at a higher price point can give you so much value when you are able to do other things. You might be able to do auto refraction with one.
There are contact lens fitting options, topography, keratometry, and printouts that parents get. Parents love to get reports for their kids. You can see if they are monitoring over time and see if they are still on that same percentile or whether they’ve dropped down to a different percentile. There’s value in those multifunction instruments. If somebody’s looking to invest in their practice, perhaps that’s where they want to look so that they get a small footprint and they’re getting multiple options from that particular piece of instrumentation.
That’s a great point. For our colleagues here in BC, and I’m not sure how it is across the country, our association, the BCDO, has done an incredible job, and I always want to give them kudos whenever I can, to negotiate a new agreement with the government to get new billing for us through our provincial government. They’ve come up with a new billing code for axial length actually. There’s a little bit of a gray area or honor system on that, but if we do axial length, we can bill a certain number of dollars on that. That’s going to help encourage more colleagues here in BC to get into it and start investing in the device. You’ll be able to make that money back whether you’re billing the government or you come up with your own consultation fees. Hopefully, that will help us get more into it.
We don’t have that luxury in Ontario, but we do bill the patients. Parents will pay that little bit extra. When you explain why it’s important, they will pay for that service.
I’ve spoken to a couple of other colleagues who do a full suite of tests. It’s a great idea. They have the consultation fee, whatever that number is, for topography, axial length, cyclo, and even maybe wide-field imaging from the Optum app or something like that to get that in there. That’s all a great idea.
I’ve heard the same thing. It’s a fixed fee, and for that, you get all of these clinical techniques done. You get the clinical testing and the results. The practitioner and the patient have a good sense of where they are and certainly where they’re starting from.
That’s great. You touched on this briefly earlier when we were talking about atropine, but the idea of doing an adjunct or a combination of therapies. I know there’s a gray area and we don’t have a protocol set, but is there at least an idea of when doing a combination might be a good idea, let’s say spectacle plus atropine? Is there a lot of data showing it’s useful?
There is not a lot of data. There is some data, but it’s not that strong. There seems to be more of an impact in the first six months or so. If you introduce atropine as an adjunct therapy early on perhaps is a little bit more of an impact. With atropine, it doesn’t really matter how it acts, but it acts in a slightly different way. There could be an argument that you’re hitting things from two aspects.
The other thing for me is particularly for those spectacle wearers, you’ve got coverage at all times. Spectacle wearers are not necessarily the most compliant with their spectacles. The low myopes, we really struggle with. If you are a 0.75% myope and you’re 7, there is no incentive for you to wear your spectacles at all. You might put them on when you get to school. As soon as they come off for recess or when you have gym class or something that they’re off, chances are they’re in the backpack and they don’t go back on.
If you’ve got an adjunct therapy, at least you’ve got coverage on both sides. You could say, “Why don’t you just do atropine and not spectacles?” If they need a vision correction, why not put them in a myopia control spectacle? There’s no reason not to. This 60% putting in single-vision spectacles is, quite frankly, ridiculous because we have spectacles from different manufacturers that work and that children tolerate. They’re cosmetically fine. There are no issues with them cosmetically. Kids wear them and they can see. It’s a no-brainer. Why wouldn’t you do that?
Adjunct therapy is for spectacle wearers. Some people I know, when they see the progression that they perhaps think is a little higher than they might expect, will add in an adjunct therapy. There is no good evidence, but you’re doing no harm. You could potentially be doing some good. We need a lot more data. All of these studies need to be long-term, minimum of two years of data. We’re seeing more things being published, but we’ve got a long way to go until we see the data hitting the journals and can be able to pull it apart and really see what’s going on with those adjunct therapies.
Those of us who are into it have to watch closely over the next couple of years. We’ll start to get a lot of that information.
I agree.
The last question I have for you is we did a little bit of advice for students. I’d love it if you could share some advice for practitioners on how to get started, whether it’s speaking to parents, bringing products into their practice, or however you might think is a good way for our colleagues to get into this.
For those who are not doing anything, you need to familiarize yourself with why you should be doing it, what’s available, and what the options are. There are lots of great resources out there. There are podcasts. What a great resource that is. There are things like Myopia Profile, which is a very clinician-friendly website out of Australia. You’ve got the Review of Myopia Management. You’ve got the International Myopia Institute papers. You can pitch it however scientific or more grassroots that you want, but there is a lot of information. It’s in every CE meeting, so you’d have to have your head in the sand if you’re not able to access some information.
Do it. Take the plunge. We have products available. We have contact lenses. We have spectacles. If you’re not sure about atropine because maybe you’re not sure about the compounding pharmacy that’s closest to you or you’re not really sure about that, that’s fine. You don’t have to do that. You don’t have to do ortho-k. You don’t have to be able to do everything to manage your patients.
Parents are beginning to ask. I have patients that come in and straight away, they know what they want. Parents are becoming more interested and informed. It doesn’t take much for one parent to tell another. If you are not doing it, they’re going to go somewhere else. You are going to lose your patients. I’m circling back to what I’ve said before. Your patients deserve it. You should be doing the best for them. We know that is the best option. Take the plunge. Get some products in. Get used to fitting those spectacles. Get used to offering them.
Practitioners sometimes say, “I don’t know how to have a conversation with the parent.” It’s easy. You tell them that by slowing down the rate of progression, you are going to keep those eyes as healthy as possible for as long as possible. What I also say is better-uncorrected acuity. If they’re in the swimming pool first thing in the morning, a minus 2 myope can manage much better than a minus 4. I also say better options for laser vision correction. That one resonates with parents. There are better options for laser vision correction later on.
Those are my three reasons, and then you give them the options. If the only option you have is a spectacle option, then that’s what you recommend. If you have spectacles and contact lenses, then you give them the choice and explain the differences. If you have all the options, you can discuss all the options. It isn’t difficult. You don’t have to go into the complexities of the optics of contact lenses or spectacles.
I say, “There’s a special type of spectacle lens that has been shown to slow down the progression of myopia. There’s a particular type of contact lens that has been shown to slow down the progression. There are drops that have been and it’s the same message every time.” They came to you for their child’s care for a reason. It’s because they trust you. They’re going to trust your recommendation. Otherwise, they wouldn’t be in the chair to start with. People don’t take their children to people they don’t trust.
That’s a good point.
You are the caregiver. You are providing optometric care to that patient. They want the best option for their child.
That’s great advice. Thank you very much. If I could add something to what you’re saying about how sometimes, colleagues or practitioners may not feel so confident in offering. They don’t know what to offer or whether it’s going to work. A guest that I had on my show early in the journey here was a football player. He was talking about how you get confidence in something or in anything, whether it’s playing football or practicing optometry. The only way to get confidence is by doing it, and then you get the feedback. You get the proof that it works. That’s the confidence that you have to go further. You have to start. That’s the only way.
You do see the results. When the patient comes back 3 or 6 months later and you see that there has been no change, because the parents sit on the edge of the chair and they’re desperate and waiting, when you say there’s no change, it’s like a hallelujah moment for the parent. For you, it is like, “That’s great. I’ll see you in six months. Off you go.”
Do it. See the results in the same way as when you first started treating glaucoma or anterior uveitis. You did what you were told to do and then you had the patient back. It is like, “Look at that. The pressure is lower. It’s cleared up.” We treat things, and this is treating myopia. This is slowing down progression using a treatment modality. You will see the results.
Thank you so much. I really appreciate having you on the show. There’s so much value in this. If you have time, go back and read some of the things that Debbie was sharing here because there’s going to be a lot in there for you to digest. This is great information, whether you’re looking at it from the research perspective or getting started practice-wise. Thank you so much for sharing all of that information. Do you have any final words you want to share before we wrap up?
Just do it.
Thank you very much, Debbie.
You’re welcome.
I want to say thank you to Hoya Vision Care Canada for sponsoring this episode. This is 1 of 4 episodes in a series of myopia management that we are producing here on the show. Thank you to Hoya Vision Care Canada for their support in that. Thank you to everybody who’s tuning in and supporting the show. This is Canada’s number one optometry show. I will see you guys in the next episode.
Important Links
- Debbie Jones
- EPISODE 121 – FINDING LEVERAGE POINTS IN YOUR BUSINESS – ANKIT PATEL, MY BUSINESS CARE TEAM
- EPISODE 122 – NEUROLENS IS TRANSFORMING EYECARE – DR. KIRAN RAMESH AND DR. TREVOR MIRANDA
- Apple Podcasts – The 20/20 Podcast
- Myopia Profile
- Review of Myopia Management
- Hoya Vision Care Canada
About Debbie Jones
Deborah Jones, BSc(Hons) FCOptom FAAO FBCLA
Clinical Professor – School of Optometry & Vision Science
Lead Clinical Scientist – Centre for Ocular Research & Education
