Getting Started in Myopia Management in Canada

Myopia is a growing public health concern, with increasing prevalence worldwide and significant long-term ocular health risks. For Canadian Optometrists, implementing myopia management involves assessing risk factors, selecting appropriate interventions, and adhering to evidence-based guidelines. This article provides a step-by-step guide for practitioners looking to integrate myopia management into their clinical practice while aligning with the Canadian Association of Optometrist’s (CAO) position statement and best practices from the latest clinical research.

Why Myopia Management Matters

The prevalence of myopia in Canada is increasing, with a 2018 pilot study showing a myopia prevalence of 29% in children aged 11-13.¹ Given that the World Health Organization (WHO) has classified myopia as a significant public health concern,² and the World Council of Optometry has set out the standard of care for Optometrists, it is imperative to engage in proactive myopia management rather than simply correcting refractive errors.

The CAO advocates for early intervention, recommending that Optometrists assess myopia risk factors, discuss preventive measures with parents, and offer evidence-based management strategies.³ These measures can significantly reduce the risk of myopic progression, with studies showing that saving 1 dioptre from a patient’s potential final level of myopia (achievable with just 2 to 3 years of treatment with of currently available strategies) can decrease a patient’s lifelong risk of myopic maculopathy by 58%, retinal detachment by 30%, and glaucoma by 20%.⁴ Additionally, early intervention can help prevent long-term dependence on strong corrective lenses, improving both visual quality and overall quality-of-life for patients. Taking proactive steps in childhood ensures that long-term ocular health risks are minimized, helping individuals maintain good vision and functional independence later in life.⁴

A structured approach to myopia management allows practitioners to offer clear and consistent recommendations to their patients. Educating parents and caregivers about the importance of early detection and intervention ensures better adherence to prescribed treatments and lifestyle modifications.

To read more about communicating the myopia message to parents, read more in the article Keys to Communication in Myopia Management on MyopiaProfile.com.

What are the steps to getting started?

Myopia management can be introduced with any pediatric patient by incorporating key steps into routine practice. Here’s how Optometrists can begin:

1. Identify at-risk patients
2. Perform essential clinical tests
3. Determine available treatment options
4. Integrate myopia management into the practice

The following sections will explore each of these steps in more detail, providing guidance on how to effectively incorporate myopia management into clinical practice.

Step 1: Identifying at-risk patients

Proactive myopia management begins before a child becomes myopic, by identification of risk factors. The following risk factors are also related to myopia progression, as detailed below.

• Refractive Status: This is the most significant  risk factor for myopia onset. Children with low hyperopia for their age (e.g., ≤ +0.75D at 6 years) are at greater risk of early-onset myopia.⁵ Watch younger children for loss of their age-normal hyperopia to identify pre-myopia.
• Current Age: This is the most significant risk factor for myopia progression. Younger children progress most quickly, especially those aged up to 10 years who can progress on average around 1 diopter per year.⁶ At least half of children are still progressing at age 16,⁷ indicating that myopia treatment should be proactively prescribed at least until this age and continued throughout childhood.
• Family History: Children with one or both myopic parents have a higher risk of myopia development and progression. One parent increases the risk by 2-3 times, where two myopic parents increase the risk by 3 to 5.5 times.⁸
• Environmental Factors: Prolonged near work and excessive screen time increase myopia risk,⁹ while outdoor activity delays onset.¹⁰ Outdoor activity appears to have less influence on progression after myopia onset. It is important to discuss the importance of balanced visual habits with parents, including breaks from screen use and outdoor play. Read more on specific guidance for parents in the Myopia Profile article The visual environment in myopia.
• Binocular vision – Children with high accommodative convergence (AC/A) ratios, often linked to esophoria, have a 20-fold increased risk of developing myopia within a year.¹¹ Accommodative lag may also contribute, though evidence is mixed.¹² Additionally, intermittent exotropia has been associated with myopia onset and progression.¹³ After myopia onset, there is no clear relationship between management of binocular vision disorders and the direct impact on myopia progression.¹⁴

Routine eye exams for children are crucial to detect early refractive changes and assess myopia progression risk. Encouraging parents to monitor their child’s visual behavior—such as excessive squinting, complaints about blurry vision, or difficulties with distance vision—can help in early detection. The CAO recommends annual eye examinations for school-aged children aged 6 to 19 years old;¹⁴ for myopes and pre-myopes, 6 monthly eye examinations are recommended.¹⁵

Step 2: Perform essential clinical tests

A comprehensive clinical evaluation is essential to assess refractive and ocular health status, status to guide management decisions. These tests are:

1. Refractive Error and Cycloplegic Refraction

Accurately measuring myopia progression is crucial for both clinical decision-making and helping parents understand its impact.

• Both subjective and objective refraction are useful in assessing refractive status and determining the extent of progression.
• The CAO recommends cycloplegic retinoscopy for the initial assessment of school-aged children to help identify those with significant refractive error, strabismus, amblyopia or anisometropia.¹⁴

2. Axial Length Measurement

Axial length measurement is valuable both as a standalone indicator of the risk of myopia-related eye diseases (along with posterior eye health examination) and as a tool for tracking the effectiveness of myopia management over time. Optical biometry devices such as the IOL Master or AL Scan are up to 10 times more accurate than refraction or ultrasound measurement in detecting changes in axial length. Myopia-specific instruments including the Myopia Master or MYAH combine several diagnostic measurements and tracking software.

While highly beneficial, axial length is not essential for providing myopia management. Myopia progression can still be effectively monitored using refraction alone.¹⁵

Read more about using both refraction and axial length data in the Myopia Profile article Gauging Success in Myopia Management.

3. Corneal Topography & Keratometry

Corneal Topography is essential when contact lenses, especially orthokeratology, are part of the management plan. Understanding corneal shape is important for contact lens fitting and treatment choices. It is also highly useful for ensuring that any noted myopia progression is not due to corneal changes or ectasia and is hence a recommended clinical test – when available or indicated – in the International Myopia Institute Clinical Management Guidelines.¹⁵

Along with corneal topography and keratometry, a thorough examination of the anterior eye using a slit lamp biomicroscopy is also recommended.¹³

4. Binocular Vision Assessment

Specific binocular vision disorders can be  linked to earlier onset, faster progression, and varying treatment outcomes in myopia.14 There are numerous binocular vision tests possible, as detailed in the IMI Clinical Management Guidelines.13 While there is no specifically described  standard assessment, the CAO guidelines indicate that binocular vision testing is an essential component of pediatric vision assessment,¹² and should therefore be included in your myopia examinations. Read more in the Myopia Profile article Four reasons why binocular vision matters in myopia management.

Step 3: Consider available treatment options

Once a patient has been identified as at-risk for myopia progression, and clinical testing has been completed, the next step is selecting an appropriate evidence-based treatment strategy. In Canada, Optometrists have access to a wide range of treatment options. These include:

• Myopia control spectacle lenses: These lenses slow myopia progression by incorporating a peripheral treatment zone while maintaining a clear central zone for sharp vision. Available options include DIMS (Hoya MiYOSMART®), H.A.L.T. (Essilor® Stellest®), CARE (Zeiss MyoCare®), and MiSight® (DOT^TM) spectacle lenses, each using different optical strategies such as myopic defocus or contrast modulation to slow myopia progression.
• Myopia control soft contact lenses: These daily disposable lenses correct vision while introducing peripheral myopic defocus to slow myopia progression. Options available in Canada include MiSight® 1 day, Acuvue® Abiliti™ 1-Day, and NaturalVue® Multifocal 1 Day.
• Orthokeratology: Ortho-k lenses are worn overnight to temporarily reshape the cornea, providing clear vision throughout the day without the need for glasses or contact lenses. This treatment is effective in slowing myopia progression and has the widest body of evidence supporting its use in combination with 0.01% atropine.
• Low-dose atropine: Low-dose atropine (0.01%–0.05%) is the only pharmacological intervention currently available and can be prescribed alone or in combination with optical treatments for enhanced myopia control.

To read more about all the treatment options available, you can read the article Myopia Treatment Options and Pathways in Canada.

Step 4: Implement myopia management in your practice

Successfully integrating myopia management into clinical practice involves clear patient education, effective communication, and structured follow-up protocols:

• Educate Parents: Providing printed educational materials and digital resources such as MyKidsVision.org and MyMyopia.ca [LINK to YOUR PUBLIC FACING WEBSITE] can help enhance adherence and reinforce the importance of management. Standardized communication scripts ensure that every patient receives clear, consistent information about myopia control. The free-to-download Managing Myopia Guidelines Infographics and Patient Brochure provide support for clinical communication.
• Establish Follow-Up Protocols: Establishing structured tracking and follow-up protocols allows for more effective management and treatment adjustments. Scheduling regular review appointments helps assess changes and optimize care, while clear guidelines for addressing patient concerns and adherence strengthen long-term management success. The Managing Myopia Guidelines Infographics provide support for review schedules and gauging success in myopia treatments.
• Train Your Team: Educating staff on myopia management is essential for delivering consistent messaging and seamless patient care. Training staff on myopia risk factors, available treatments, and follow-up schedules ensures that every patient interaction—whether booking appointments, answering questions, or providing educational materials—fosters patient confidence and reinforces the practice’s commitment to evidence-based myopia management. The world-first course Myopia Management for the Practice Team, accessible through a free-to-create Myopia Profile Practice Account, provides practical learning in a micro-lesson format for staff.

How you can get started in myopia management

By following evidence-based protocols, considering available treatments, establishing management pathways, and educating patients and parents, Optometrists can play a crucial role in addressing this growing epidemic. Myopia management requires a proactive approach, regular monitoring, and ongoing patient education to ensure success. Staying up-to-date with the latest advancements in optical and pharmaceutical treatments and management strategies is key for best possible patient outcomes, and keeping your practice at the cutting edge. With strong support from organizations like the CAO and WCO, and wide availability of effective treatments, Canadian Optometrists are well-positioned to adopt myopia management as a standard of care, improving long-term ocular health outcomes for their patients.

References

1. Yang M, Luensmann D, Fonn D, Woods J, Jones D, Gordon K, Jones L. Myopia prevalence in Canadian school children: a pilot study. Eye (Lond). 2018 Jun;32(6):1042-1047.

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