With increasing awareness of myopia as a public health concern, more optometrists are making myopia management a core part of their practice. But how do you go from offering vision correction to proactively slowing myopia progression?
Dr. Vishakha Thakrar (pictured centre with her practice staff) has been deeply involved in myopia care for over two decades, integrating evidence-based treatments into her clinic and educating both patients and colleagues along the way. In this Q&A, she shares her journey into myopia management, how she navigates treatment choices, and the tools and strategies she finds most effective in helping children and families manage myopia.
1. Why did you decide to incorporate myopia management into your practice, and how has it evolved over time?
I found it relatively easy to transition into practicing myopia control because I had been treating patients with orthokeratology since my corneal contact lens residency over 20 years ago. Once we knew that orthokeratology could slow the progression of myopia, I began marketing my practice to patients and colleagues as a myopia control clinic. However, offering only ortho-k limited our ability to treat children whose parents were unfamiliar or uncomfortable with putting lenses in their children’s eyes. Then when the BLINK study showed that center-distance multifocal lenses could also slow myopia progression, we were able to treat more patients. Over time, a wider range of options became available, including atropine, soft myopia control daily disposable lenses, and eventually, glasses. The introduction of myopia control glasses helped more practitioners feel comfortable prescribing treatments for children. As a result, both patient and practitioner awareness has grown, driving an increase in demand for myopia control services.
2. The Canadian Association of Optometrists (CAO) recognizes myopia as a significant public health issue rather than just a vision inconvenience. How do you ensure that your practice aligns with the CAO’s recommendations on myopia management?
I began discussing myopia control management strategies almost 15 years ago. The importance of reducing the progression of myopia has already been engrained into my practice for many years. My practice subscribed very early to the impact myopia can have on ocular health. If we can positively influence the onset and progression of myopia, why wouldn’t we try?
I do follow the WCO’s myopia management standard of care guidelines. In my practice, all myopes and pre-myopes are counselled on lifestyle modifications to prevent or slow the onset of myopia. We conduct annual eye exams on children and measure axial length on myopes and pre-myopes. We use evidence-based treatments to manage myopia progression once a patient is diagnosed with myopia. In certain occasions, we have treated high risk pre-myopes with low dose atropine or plano myopia control glasses.
3. What myopia management strategies do you find most effective in your practice?
I choose my myopia management strategy based on details from the consultation including age, genetics, parental knowledge, and lifestyle of the patient. At this point, numerous studies have shown that there are many devices that reduce myopia progression considerably. However, I do not feel it is necessary to provide all of the options to the parents at once. I find if we offer too much information, parents may feel intimidated and opt not to embrace any of the myopia management strategies. Essentially, I ‘prescribe’ what I feel is best for the patient. For example, if a child is young and the parents know very little about myopia management, a familiar and highly effective choice is myopia management glasses. If a child participates in competitive sports, then I will likely recommend either orthokeratology or myopia control soft contact lenses. I no longer make my choices based on effectivity alone because many of these methods of myopia management are highly effective.
4. Early intervention is critical for slowing myopia progression. How do you educate parents and children about myopia management?
I start with the pre-myopes; these are children who have mild hyperopia or emmetropia at the age of 6 or under. I begin educating parents on the impact of outdoor time even in the winter. I have a detailed discussion on the amount of screen time and other near work. Kids don’t realize that they are on devices for 6 hours per day at school and then several hours in the evening. I often speak to them about the impact that working distance has on myopia. Lately, I also mention to parents that myopia may be inflammatory, so a healthy diet is important.
For myopes and pre-myopes, I incorporate myopia control follow-ups every 6 months instead of yearly. This is particularly important if there is a family history of myopia.
I have multiple staff trained in educating the importance of myopia management. They are familiar with all devices and protocols, so they can easily explain the processes to patients. We have put together a package on what myopia is and why we need to treat it. We also have information on our website that parents can read. For parents who want more detailed information, our team will email links of important studies.
Whenever we have push back on cost, we explain that myopia control is a therapy which is very different than simply correcting the vision. We will be monitoring the progression of the length of the eyeball, the health and the refractive error. The device used will help control progression in the future. I also address the child about how important it is for them to use/wear the device as instructed so the therapy works. Their parents have spent a fair amount of money, so it is important that they use the device as directed.
5. Technology plays a growing role in myopia management. What diagnostic tools and technologies do you use to assess and track myopia progression?
I use axial length measurements to track myopia along with refractive error. I am excited about a new biometer likely to launch in North American sometime next year which will be much more affordable than current technology. There are also some interesting apps which will allow better education and tracking for parents.
I also am excited about being able to customize myopia control even further. With the incorporation of AI, we may be able to make more customized recommendations to patients on which treatment is most effective for them based on race, genetics, environment, and lifestyle.
6. What challenges have you faced in implementing a comprehensive myopia management program, and how have you overcome them?
Before the advent of myopia control glasses to optometric practice, it was difficult at times to educate parents of young children on the importance of myopia control contact lenses and atropine. We are now at a time where myopia control has never been easier. If there is ever a price push-back on device cost, our team has to be educated on describing the importance of the therapy and how to specifically address cost concerns.
Biography:
Dr. Vishakha Thakrar is founder and director of Vaughan Vision Centre, an advanced specialty contact lens clinic that focusses on complex scleral lens fitting, myopia management, and advanced dry eye treatment. After receiving her cornea and contact lens residency, she started her career as the Director of the Contact Lens Service at the Cole Eye Institute, Cleveland Clinic. She later helped establish the Scleral Lens Clinic at the Kensington Eye Institute in Toronto. She speaks internationally and has written extensively on contact lenses, corneal disease and myopia management. She is co-founder of the Canadian Contact Lens Association and is currently co-investigator of the Myopia in Practice Study. She is a fellow of the American Academy of Optometry and the Scleral Lens Society.
