The Art of Communication in Myopia ManagementWRITER Dr SooJin Nam With advancements in technolog y, research and products on myopia control making steadfast progress, primary eye care practitioners (ECPs) can certainly have more confidence in treating both pre- and progressing myopes. ECPs have a duty to distil and effectively communicate their knowledge of myopia management to both their young patients and their carers.* As SooJin Nam explains, it is the only way to really protect the future vision of young myopia patients. One of our challenges as clinical optometrists is translating huge amounts of research, clinical and product content into information that is succinct and relevant to the parents in the short times allocated for appointments. Myopia management is an investment for many families, both with time and money. We know that every dioptre matters when slowing myopia and that there really isn’t a safe level of myopia. Our job is to educate and provide solutions that best fit the child and their family. And that starts by knowing what makes a good communicator. Start by considering the communication skill set of your practice team and the journey of the patient as they travel through their eye care stages. Then consider the four key areas of myopia management: 1. Myopia risk factors. 2. The short-term and long-term goals of myopia management. 3. Myopia control treatment options based on scientific evidence. 4. Advice on improving the child's visual environment. IMPROVING COMMUNICATION SKILLS Hone Your Listening Skills A good communicator will listen carefully to the other person, consider what they have said, and then respond appropriately. Be Clear and Concise It’s best to keep things short and to the point, but also be flexible. Although some patients may want more detailed information, most want to know that they can trust their ECP to look after their visual needs. Cultivate Confidence In the consulting room and in spectacle lens dispensary, ensure the patient is confident they are seeing an expert. Remember also that communication isn’t just verbal, so body language and the way team members present themselves make a big difference to a patient’s perception. Use Empathy Myopia is a huge clinical topic and can be overwhelming. Be empathetic and try to understand the other person’s point of view. A good example is understanding how using cycloplegic eye drops could be scary for a little child and how difficult hard contact lenses may sound to parents. With this framework in mind, let’s consider how we would communicate myopia management to patients, starting from the first point of contact. BEFORE THE FIRST APPOINTMENTYour practice team will have communication touchpoints with patients at different stages of their myopia journey. A phone call to front-of-house staff will often be their first point of contact. Their knowledge and understanding about myopia treatment options will help reassure anxious parents. Don’t underestimate the value of authentic real-life examples staff have observed as a way of explaining the positive impact of myopia management.. THE FIRST CONSULTATION Once in the consultation, ensure that parents understand the concept of myopia. Parents who are not myopic will likely need more help understanding the concept of blur at distance and clearer at near. One useful tip is that non-myopic parents could be given an equivalent lens on a trial frame so they can see what their child is experiencing in the classroom. Consider using ‘myopia’ in all your communications rather than ‘nearsightedness’ or ‘short-sightedness’ so that your message is consistent. Tailor your conversation to the child in your chair. This may be a child who is appropriately hyperopic but whose parents are myopic and want to understand the risk factors. Alternatively, it might be a seven-yearold with -1.00D and their parents may not realise how quickly their prescription might change in the next few years. Once the patient has been identified as either a pre-myope or progressing myope, there are risks that could be discussed during the eye exam. For both pre-myopes and progressing myopes, consider if either or both parents are myopic. Explain that the risk factor increases three times for one parent and six times for both parents, hence the need to be vigilant about regular six-monthly eye tests.1To avoid overwhelm, only tell parents the risk factors that are relevant. If neither parent is myopic, then family history is not as important right now. Understand what the child’s current visual environment is like during history taking. Many children spend significant time on digital devices because of schoolwork or video games. Be careful not to be judgmental of how much digital time is consumed or how few outdoor activities are undertaken. Instead, focus on how much time they should spend with outdoor activities and how to practically manage near tasks. If relevant, also be mindful to communicate that Asian children progress more quickly than non-Asian children. MYOPIA PROGRESSION The rate of myopia progression also needs to be part of the discussion. Parents tend to focus on what their child’s prescription is today but have little idea how it will change. A parent may be questioning whether their child really needs glasses, or if they need to wear them all the time, as well as being concerned about whether their child’s eyesight will deteriorate. It is useful to consider using free tools such as the BHVI Myopia Calculator2or the Myopia Progression Calculator, 3to explain a child’s predicted progression, based on their risk factors. Both calculators will provide a myopia prediction to the age of 17. These tools are particularly useful for younger children as they are more likely to progress faster between the ages of seven to 12. 4Figure 1. Communication protocols for front-of-house staff. It is also important to explain that, unlike other refractive errors, myopia is progressive, can be associated with other ocular risk factors, and will likely get worse. At this stage, specify that myopic prescriptions in children and young adults require both correcting myopia and slowing its progression. The myopia progression calculator is a useful clinical tool when explaining the long-term ocular health risks to parents and, hence, long-term benefits of myopia control. The message here is simple to communicate. In the case of a six-year-old Asian child, we can show that the child’s myopia is predicted to be -7.00 by the time they are 17-years-old. High myopia pathology increases in incidence from -6.00. If myopia progression is slowed to -4.00 by the age of 17, their lifetime risk of myopia pathology is also reduced.5Remember that the child is usually in the room as this information is being conveyed. When explaining a sensitive topic, such as the long-term risk of eye diseases and blindness in I’m not suggesting we sugar-coat facts, but our faces and tone should be positive as we convey our management plan.“ Remember also that communication isn’t just verbal... body language and the way team members present themselves make a big difference to a patient’s perception Figure 2. The increased risk in ocular pathology with increased myopia.6Figure 3. The best treatments can be described as “slowing progression by about 60%”. The next best treatments can be described as "slowing progression by about a third". Treatment options with small efficacy minimally slow myopia progression (but may be clinically the best option for now). Figure 4. The efficacy for atropine usage can be simplified to 60% (for 0.05%), 30% (0.025%) and minimal (0.01%) for the different compounded concentrations.8high myopia, consider your language and avoid trigger words like ‘blind’, and ‘disease’, especially if the child or parent (or both) seem anxious. Also, remember that just because they did not ask any questions doesn’t mean there aren’t any. Consider asking open-ended questions such as “How do you feel about this treatment?”. Developing open communication can assist in building trust between us and the parent as well as with the child. COMMUNICATE TREATMENT OPTIONSParents appreciate being provided with information on the treatment options available for myopia, their effect, and how the management options can impact the myopia timeline. As every child is unique, consider the best optical options for them based on your clinical findings and their personal need. Outline the reasons for your recommendation. Is it due to their current prescription, lifestyle, age, binocular vision findings, visual task requirements or another clinical reason? The treatment that works best is the one that best fits the child and family needs, and maximises compliance. The International Myopia Institute (IMI) has a comprehensive review of the optical intervention’s efficacy,7but it can be difficult to describe the efficacy of each option. The BHVI myopia calculator 2has a control percentage for each myopia management option. However, for the purposes of explaining treatment efficacy to parents, consider a simplified version using approximate percentages ( Figure 3). The same type of simplified graph can be used to explain the efficacy of atropine usage (Figure 4). If atropine is the myopia treatment of choice, then have a discussion around the possible side effects and expected intervals for eye test reviews to monitor for symptoms and progression. ADVISE ON VISUAL ENVIRONMENTMyopia management is not just about the optical correction. Parents also appreciate advice on a child’s visual environment. A common question that is raised by parents is, “How much time should my child spend on the computer or other electronic device?” According to health.act.gov.au, the recommended recreational screen time limits (watching TV, using computers, and playing electronic games) are: • Children younger than two years – none. • Children two to five years – no more than one hour per day. • Children five to 17 years – no more than two hours per day. Practical advice to parents can include: • Screen time and near work – close reading distance <20cm and duration >45 minutes increases myopia risk.9• Outdoor time – increased outdoor time can help prevent onset of myopia10and may reduce progression of myopia. 11Aim for 90 minutes a day outdoors. • Physical activity – indoor sports don't help to prevent myopia. However, myopia prevalence is associated with a sedentary lifestyle.12Changing a child’s habits can be challenging. Ask parents to focus on just one or two practical things. It is often more productive to consider how their child can spend more time outside, for example, than focussing on how much time they are on electronic devices. TAKE ADVANTAGE OF REGULAR REVIEWSThe information covering myopia management is extensive, so consider the flow of information to the family and align it to the child’s regular reviews. You don’t need to cover all the points about myopia management in one appointment. Consider that the first six-month review is to assess adaptation, compliance, and suitability of the treatment rather than focus on myopia progression. The success of myopia efficacy can be considered after 12 months, taking into account refractive status and/or axial length changes during treatment. If their efficacy is satisfactory, then continue. If not, then communicate the alternative options available. Patients and parents may ask when the treatment can stop. While there is no firm consensus, it is important to communicate that myopia typically progresses throughout childhood and the teenage years. The findings from the COMET study1can help us prepare for these conversations: • 50% of myopes stop progressing by age 15, • 77% of myopes stop progressing by age 18, • 90% of myopes stop progressing by age 21, and • 96% of myopes stop progressing by age 24. The key message, then, is that myopia control treatments should ideally continue until the child or young adult shows stability of their myopia. PUTTING IT TOGETHERIn summary, effective communication of myopia management involves your entire practice team, uses useful tools and resources such as the myopia calculator, and makes sure that parents receive timely information in a way that is easy to understand. Your team needs to share information ethically and responsibly to gain and retain patient trust. Eye care practitioners need to convey myopia education and treatment plans clearly, accessibly and empathetically so that our patients receive optimal care. Useful Resources For Myopia Communication My Kids Vision https://www.mykidsvision.org/en-us/ Home/HowToGuides These short video guides provide tips and tricks for managing children’s vision and fitting contact lenses in a busy myopia management optometry practice. Make Your Eye Moves Toolkit! https://bhvi.org/myopia-calculatorresources/myopia-awarenessweek-2022/ The BHVI campaign toolkit provides myopia facts, graphics and videos to promote broader awareness of myopia. Use the toolkit as a guide to spread awareness of myopia in your sphere of influence. Myopia Profile https://www.myopiaprofile.com/ product/myopia-management-inpractice-infographic/ This site offers parent-facing infographics and brochures designed to help you communicate your myopia management message including tiles on environmental advice, explaining efficacy of myopia management options, contact lens safety and benefits for children, and why myopia management is important. Myappia by Thomas Aller https://www.myopia.care/public_ myappia Effective communication is generally important in everyday life. How much more for us working in healthcare, where a patient’s long-term quality of life may depend on our next move? Empathy is an underestimated skill, and the adage that “patients don't care how much you know, until they know how much you care” still holds true. Parents want to be reassured that their child is in good hands, and it is our job, apart from providing superior clinical care, to let them know they are. Dr SooJin Nam MOptom BOptom MBA (exec) is a part-owner of six Eyecare Plus optometry practices in Sydney and has a strong interest in three main areas: binocular vision dysfunctions, myopia control and orthokeratology. She graduated in 2000 from UNSW (BOptom) and also completed post-graduate studies; MBA (exec), MOptom and Optometric Extension Program (OEP). She was previously a director for both Optometry NSW/ ACT and Eyecare Plus and is a current director of the Australian Optometric Panel. She is a regular contributor to the optometry industry as a key opinion leader. * For conciseness, the term ‘parent’ or ‘parents’ is used when referring to any adult who is the primary carer of the child and who is responsible for the decision making in their myopia management. References 1. Morgan IG, Wu P.C, Ostrin LA, et al. IMI Risk factors for myopia. Invest Ophthalmol Vis Sci. 2021;62(5):3. https:// doi.org/10.1167/iovs.62.5.3 2. https://bhvi.org/myopia-calculator-resources/ 3.https://www.myopia.care/public_myappia 4. Jones-Jordan L, Sinnott LT, Chu RH, et al. Myopia Progression as a Function of Sex, Age, and Ethnicity. Invest Ophthalmol Vis Sci. 2021 Aug;62:36. 5. Bullimore MA, Brennan NA. Myopia Control: Why Each Diopter Matters. Optom Vis Sci. 2019 Jun;96(6):463-465. doi: 10.1097/OPX.0000000000001367. PMID: 31116165. 6. https://www.myopiaprofile.com/the-why-ofmyopia-control/7. Christine F. Wildsoet, CF, et al. IMI – Interventions for Controlling Myopia Onset and Progression Report. Invest. Ophthalmol. Vis. Sci. 2019;60(3):M106-M131. Doi:10.1167/ iovs.18-25958. 8. 15 Yam, J. C. et al. Low-Concentration Atropine for Myopia Progression (LAMP) Study: A Randomized, Double-Blinded, Placebo-Controlled Trial of 0.05%, 0.025%, and 0.01% Atropine Eye Drops in Myopia Control. Ophthalmology 126, 113-124, doi:10.1016/j. ophtha.2018.05.029 (2019) 9. Huang HM, Chang DS, Wu PC. The Association between Near Work Activities and Myopia in Children-A Systematic Review and Meta-Analysis. PLoS One. 2015 Oct 20;10(10):e0140419. doi: 10.1371/journal.pone.0140419. PMID: 26485393; PMCID: PMC4618477. 10. Wu PC, et al. Outdoor activity during class recess reduces myopia onset and progression in school children. Ophthalmology. 2013 May;120(5):1080-5. doi: 10.1016/j.ophtha.2012.11.009. Epub 2013 Feb 22. PMID: 23462271 20 11. Xiong S, et al. Time spent in outdoor activities in relation to myopia prevention and control: a meta-analysis and systematic review. Acta Ophth 12. Bull FC, et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med. 2020 Dec;54(24):1451-1462. doi: 10.1136/bjsports-2020-102955. PMID: 33239350; PMCID: PMC7719906.
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