Thursday, February 28, 2019

The BCLA welcomes the long-awaited publication of the International Myopia Institute (IMI) Myopia Reports – published in the latest edition of Investigative Ophthalmology and Vision Science. 
This evidence-based guidance has been compiled by 85 multi-disciplinary experts from around the world who have critically reviewed evidence to date from animals, genetics, clinical studies and randomised controlled trials to deliver guidance on several key areas.
This much-needed report will form a basis for clinical practice and future research. The report clearly advocates the need for myopia control strategies.
Leading worldwide authorities on myopia chaired seven sub-committees during the compilation of the report. 
Ian Flitcroft – Defining and Classifying Myopia. This sub-committee looked at defining and classifying myopia, providing a standardised set of terminology, definitions and thresholds of myopia and its main ocular complications.
David Troilo and Earl Smith – Experimental Models of Emmetropisation and Myopia. This sub-committee concluded that animal models continue to provide insights into the mechanisms of eye growth ‘including the identification of potential new targets for drug development and future treatments needed to stem the increasing prevalence of myopia’.
Caroline Klaver – Myopia Genetics. This sub-committee summarised the developments in gene identification for refractive error, myopia and axial length and the interaction between them.
Christine Wildsoet – Interventions for Myopia Onset and Progression. This sub-committee reviewed the evidence for the interventions currently used in myopia control; spectacles, contact lenses, pharmacological and environmental.
James Wolffsohn –  Clinical Myopia Controls and Instrumentation. This sub-committee delivered a consensus on best practice in the design of clinical trials to assess the effectiveness of treatments and their impact on patients.
Lyndon Jones – Industry Guidelines and Ethical Considerations for Myopia Control. This sub-committee reviewed the published articles and guidance documents and discussed the guidelines and ethical considerations associated with the development and prescription of treatments intended for use for myopia control.
Kate Gifford – Clinical Myopia Management Guidelines. This sub-committee delivered a report from the evidence base published within the IMI - Intervention for myopia onset and progression. It is designed to establish clinical guidelines for management of the myopic patient for the patient, the parent and, importantly, the clinician. It delivers guidance on how to manage a myopic child in practice, incorporating risk factor identification, baseline examination procedures and questions. Guidance on subjects for discussion with both patient and parent is included, covering risk benefit analysis, lifestyle and potential compliance challenges and follow-up examination processes.  

The report concludes that best practice clinical guidelines for myopia control involve an understanding of the epidemiology of myopia, risk factors, visual environment interventions, optical and pharmacological treatments, as well as skills to translate the risks and benefits of a given myopia control treatment in lay language for both the patient and their parent or caregiver. 
It details evidence-based best practice management of the pre, stable and the progressing myope, including risk factor identification, examination, selection of treatment strategies and guidelines for ongoing management. Treatment can be considered for children as young as 6 years of age and should continue at least until they are 14-16 years when myopia typically stabilises, but watch for a rebound effect. The frequency of review will depend on the treatment selected and this is outlined in the report. At all visits appropriate history taking relative to the treatment should be performed along with distance and near visual acuity, refraction (ideally objective), accommodation and binocular vision assessment and ocular health examination. Cycloplegic refraction and dilated fundus examination should be performed annually. Axial length measurement in addition is preferable, particularly with orthokeratology and pharmacological treatments. “Treatment may be stopped, switched to another form of therapy or augmented by combining with another treatment modality when myopia progression is not sufficiently controlled, in comparison to expected progression in single-vision correction and when the average efficacy of the specific treatment has been considered.”
Practitioner considerations such as informed consent, prescribing off-label treatment and guides for patient and parent communication are detailed. It is also important to discuss and document expectations of the parent and child along with clarification that there are no specific guarantees with myopia management.
The future research directions of myopia interventions and treatments are discussed, along with the provision of clinical references, resources and recommendations for continuing professional education in this growing area of clinical practice. 
The publication of the IMI Reports is a good starting point and provides us with the initial evidence we need as a profession. 

The BCLA looks forward to working with other organisations and bodies as we continue to raise awareness of myopia and its significance for both the optical profession and the general public.

The full reports are downloadable here.