Authors Sarah L Morgan, BSc (Hons), MCOptom, MPhil, FAAO, FBCLA

Reference Helping parents understand their child’s myopia: a ‘dual purpose’ approach by Sarah L Morgan BSc (Hons), MCOptom, MPhil, FAAO, FBCLA. Originally published in Optometry Today, 10 October 2020

Introduction

Diagnosing myopia in a child is a normal part of everyday practice, and this article discusses key elements of how eye care professionals (ECPs) can optimise their interaction with parents and children. ECPs themselves are extremely familiar with myopia, and this is perhaps the greatest distinction between them and the parents of the newly diagnosed myopic child – context.  Where one parent may have some sense of refractive error running in families, another may not make the link.  A simple understanding of myopia, let alone the relationship between the various optical components of the eye (e.g. corneal curvature and axial length), remains largely unknown by parents,1 so the education gap is wide.  Parents deserve to be informed about the likelihood of their child requiring vision correction, as well as the key milestones in their growth and development where optometric examination is both diagnostic and prognostic in helping to predict the future refractive status and needs of their child.

Myopia – the first diagnosis

A child may be brought for an eye examination for a variety of reasons. When one or both parents require vision correction, eye examinations are part of their regular healthcare checks, which may lead them to consider having their child examined.  In contrast, emmetropic parents may not recognise the importance of regular eye examinations for their children.  In some instances, a child’s vision problem may be picked up via a school vision screening programme or from concerns expressed by an observant teacher.  These scenarios are examples of the possibilities an ECP might encounter when examining a child for the first time.  Specifically, when myopia is the refractive outcome, it is useful to consider the existing knowledge and experience of the parent(s) when delivering the conclusions of the eye examination and discussing next steps.

Tabell 1

Tabell 2

Background facts

Conducting an eye examination of a child is routine for ECPs, and the regular history and symptoms form part of the initial discussions including reason for visit.  When myopia is suspected, or the child has been identified as having the potential to become myopic, the usual questions are asked in addition to those which focus on gaining more detail for the myopia risk profile of the child.  Open questions at the start of the consultation allow the ECP to gain vital insight into the child’s everyday life experience, and the current level of awareness of myopia (and the long-term visual experience of living with myopia) with one or both parents.  This knowledge at the beginning of the eye examination, and well in advance of its conclusion, gives the ECP the time to consider how best to communicate the recommendations, in addition to being able to ask further questions to help discuss and educate the parents and the child about the future implications of myopia as the child grows.

Tabell 3

Knowledge pathway – discussing next steps

When formulating where to start with professional advice on myopia for an individual child, the ECP can consider the Knowledge Pathway framework (Figure 1).  This helps to consider where to begin in terms of both educating the parents (and child), taking into account the current experience of the parents and child.

The Knowledge Pathway – Images CooperVision

1) What is myopia?
This is the first step on the pathway when the parent(s) are not themselves myopic.  They first need to appreciate how their child is currently functioning visually. The CooperVision Vision Simulator  (https://coopervision.co.uk/practitioner/clinical-resources/myopia-in-children/myopia-simulator) is a great tool covering a wide range of educational settings from age five through to age 16, where it is possible to show the parent the visual impact of uncorrected myopia in a variety of school environments (Figure 2).  Using plus trial lenses, or ready readers, can help to show an emmetropic parent how their child currently sees without spectacles or contact lenses.

child’s myopiaImages CooperVision

2) Myopia forecast
Parents with myopia, may also have personally experienced how their refractive error advanced over time.  For other parents, they may not be aware of the way myopia can increase as their child grows.  The Vision Simulator offers the potential to demonstrate not only how the child may see on first presentation, but also how this might change with progressing myopia.  This gives parents some context for the immediate needs as well as their child’s future requirements and demonstrates the importance of regular eye examinations.  For ECPs, the reference is dioptric change, this in itself is a meaningless number to a layperson. Showing them the visual impact of uncorrected myopia facilitates their understanding and appreciation.

3) Vision correction options
Where parents are themselves emmetropic, the need for vision correction, in whatever form, may be unfamiliar.  Parents need to appreciate that there is no cure for myopia.  The word ‘correction’ when used with ‘vision correction’ can be misconstrued by the lay person as ‘curing’ vision in some way and should be avoided in dialogue with patients.

Parents will be well aware that some children need to wear spectacles, but they may not know that contact lenses, in addition to spectacles, can be successfully fitted and worn by children.2,3 Sharing the impact contact lens wear can have on a child based on the results from the ACHIEVE study in particular provides good evidence of this, with children who participated in the study described feeling more competent when taking part in sports or activities, feeling better about their appearance, and feeling better about fitting in with friends – all positive outcomes that parents would find desirable for their child.

4) Contact lenses for myopia
If either parent is myopic with experience of wearing contact lenses, they will be familiar with the clear benefits of spectacle-free vision.  It is possible that even with this knowledge, they may not be aware that children can successfully wear contact lenses.  When there is no contact lens wear experience in either parent, it is important for the ECP to discuss the everyday benefits of contact lens wear which applies in equal measure to children.

5) Myopia matters
An additional area that has the potential to be discussed is the longer-term risk of myopic pathology.  In order to appreciate the ocular changes that might ensue due to myopia, the parents must have a basic understanding that myopia usually comes from the eye overshooting its optimal size.

6) Contact lenses for myopia management
Once the parent(s) is familiar with the overall concept and benefits of contact lens wear, and that children can successfully wear contact lenses, it is then a small step in knowledge to discuss myopia management options using lenses, such as daily disposable lenses or orthokeratology, which have been approved and specifically designed for myopic children that may help reduce the longer term risk of myopic pathology.

7) Professional advice and expertise
It is useful to share case histories with both the parents and the child, so they have some insight into how myopia management can also benefit them.  Support staff can also give information about the expertise of the ECP in advance of appointments, which helps to instil confidence ahead of the consultation.

Clearly there are many elements to consider when discussing childhood myopia with a parent, which makes it so important to take essential background history from the parents to inform and help steer conversations appropriately and in the context that they will personally understand.  Discussing our professional motivation to reduce the risk of myopia pathology without the context of what comes before is likely to be too much of a leap for most parents to take on board.

Communication – key words and phrases

Explaining the difference between a single vision daily disposable contact lens, and the more complex optics of a myopia management contact lens, such as MiSight® 1 day, to parents has the potential to lead to much bewilderment.  A more simple approach can be to describe a myopia management contact lens as being ‘dual purpose’ – the primary function of the lens is to give the child clear spectacle-free vision (i.e. the spectacle prescription is incorporated into the lens), and the secondary function is to help manage the myopia with specially designed optics which research has shown may slow down the progression of the myopia leading to a lower overall final prescription – a lower prescription is always better result for everyone (better cosmetically, better practically, and better for the long term health of the eye).

In a child where there is no known family history of myopia, it may be better to curtail this relatively complex discussion to saying ‘myopia can have long-term eye health implications (e.g. an increased risk of retinal detachment), which is why we are so keen to limit the rapid growth of the eye’.

Case scenarios – experience and success

Consider the presentation of the following two cases.  Review the history and think about the additional information required to begin discussing the child’s myopia with the parents.  It will be useful to reflect on where these two cases would sit on the Knowledge Pathway and how this might inform the first steps in the communication strategy in each scenario.

Case 1: Meet Lukas
Lukas

Case 2: Meet Sofia
Soifa

Conclusions

A child identified as being at risk of developing myopia, attends for their first examination accompanied by one or both parents with a wide range of possible background family history in relation to the diagnosis of and prescribing for myopia.  An earlier article by the same author (OT August 2020) discussed the benefits of pre-handling what the future holds by discussing ‘pre-myopia’ with both the parents and child.4  To facilitate this, the child must be seen on or around their 6th birthday to best align with this key milestone in ocular growth and development according to extensive research data on children who develop myopia.3

Of course, there is some joy when prescribing for a myopic child in saving them from their currently blurry world.  There is also the opportunity to discuss their options beyond spectacles including contact lenses for myopia management.  When contact lenses are positively considered by the parents and the child, there is great opportunity to prescribe a dual-purpose contact lens that not only corrects the myopia (offering the child a spectacle-free visual experience) but also to offer the additional possibility to slow down the progression of their myopia.

The role of the ECP requires the assimilation of the examination evidence to date coupled with a comprehensive understanding of the family unit in relation to both myopia and experience of vision correction per se to considerately guide the recommendations following the consultation.

No parent wants their child to miss out on anything that may benefit them, but without proactive advice and direction, they may remain ignorant.  Children deserve the opportunity to ‘see the best they can see’ so that they can ‘be the best they can be’ during their early years’ education right through to high school and beyond.

Sarah Morgan is an optometrist and staff development consultant. At The University of Manchester, she lectures and leads clinical sessions where she holds the post of Vision Sciences Fellow.

This article was supported by a grant from CooperVision.

References

  1. CooperVision data on file. GMAC data – parents – 2019
  2. Walline J, et al. Randomized trial of the effect of contact lens wear on self-perception in children. Optom Vis Sci. 2009 Mar;86(3):222-32.
  3. Chamberlain P, et al. A 3-year Randomized Clinical Trial of MiSight Lenses for Myopia Control. Optom Vis Sci. 2019 Aug;96(8):556-567.
  4. Morgan SL. Age six – the refractive error milestone? 2020 Optometry Today 60:08 60-63
  5. Zadnik K et al. Prediction of Juvenile-Onset Myopia. JAMA Ophthalmology, April 2015 DOI: 10.1001/jamaophthalmol.2015.0471