Subtheme: ECP awareness and sources of knowledge

ECPs had good awareness of the data showing increased myopia prevalence. They also reported a rise in children with myopia attending their clinics, although some theorised this observation may be due to an increased frequency of eye examinations. ECPs reported a general decrease in the age of myopia onset, as well as faster progression rates. They also percieved an increased prevalence of myopia among young adults, with progression continuing into the third or fourth decade. Generally, ECPs viewed myopia in the UK as a trivial concern compared to East Asia, but believed it was likely to become a considerable future problem. Most ECPs regarded low myopia with little concern, however, there were concerns about high myopia-associated pathology in adulthood and impact on the National Health Service (NHS) in the future, as well as its impact on the individual.

"Myopia is not seen as a gross, huge disease, or a problem, or something that we have to be concerned about now." (Group 6, pre-registration optometrist)

ECPs typically felt that there was a sufficient amount of educational material available for clinicians regarding myopia management, but were sceptical over some of its quality and possible bias. ECPs expressed concern over exaggerated claims of efficacy in materials produced by manufacturers and the possibility of this misinformation being conveyed to parents. ECPs regarded peer-reviewed research and researcher-led resources as more trustworthy, however, doubt was still cast over their true independence from commercial influence. Some concerns were raised about researchers being out of touch with day-to-day practice. ECPs suggested more emphasis was needed on the practical elements of myopia management as part of degree and training programmes.

ECPs reported difficulties keeping up to date with new advancements in the field. They suggested that regularly updated (e.g., annually) and accessible scientific educational material would be useful. There was a preference for this to be produced by unbiased sources, such as relevant professional bodies.

"[Manufacturer representatives] are very, very pushy on this and make claims that aren’t really supported, and that’s a little bit dangerous." (Group 4, optometrist)

Subtheme: ECP engagement

ECPs felt that the current provision of myopia management was a ‘postcode lottery’, believing that England had fallen behind the devolved nations, with the UK as a whole lagging behind other countries who are more proactive in paediatric eyecare. Ophthalmologists felt that they were lacking clarity over their role within myopia management, believing it outside their scope of practice.

ECPs reported a few reasons for reduced engagement. One was a lack of confidence in using their clinical knowledge to manage a progressing myope, especially where there is a lack of consensus over certain decisions, for example, the time to cease treatment. Some reported a lack of confidence in answering parents’ questions, for example, about treatment efficacy, or recommendations on the amount of time spent outdoors and/or doing close work. Some ECPs also believed desensitisation to myopia was a problem. As low myopia is seen commonly, they believed ECPs often view it simply as a refraction, rather than an eye condition with potential associated risks. A few ECPs expressed scepticism over the efficacy of available treatment options, with ECPs reporting a lack of strong evidence from UK studies. ECPs highlighted concern about making recommendations to parents without solid evidence, with a few drawing comparisons with contentious areas of optometry, such as Irlen lenses and ‘blue light’ lens coatings.

"You can get marmite with optometrists - that some believe in it, some don’t believe in it." (Group 5, contact lens optician)

Subtheme: common obstacles affecting ECP communication

A few ECPs reported not discussing the risk of myopia-associated pathology with parents—some were concerned about worrying parents who could not afford myopia management, while others did not want to appear to use this concern to ‘push’ treatment. ECPs also expressed frustration at the lack of time available for a fully informed discussion with parents, sometimes having to omit details, especially in busy clinics with short appointment times.

"You guys work in practice, you don’t always have the time, right? It’s not even 20 minutes." (Group 5, optometrist)

Affordability was the greatest communication issue, especially with parents from lower socioeconomic backgrounds and/or with multiple children. ECPs expressed discomfort recommending high-cost options and were concerned about being perceived as profiteering. A small proportion of ECPs reported that they occasionally chose not to discuss myopia management if the parent appeared disengaged or were perceived as unable to afford treatment. Concern was raised about the lack of NHS funding towards myopia management in the General Ophthalmic Services (GOS) system. This is further explored in theme 4. Only a small number of ECPs advised that their patients were not concerned about cost, and typically these were ECPs who worked in independent practice.

"I’ve had mums, they are in tears because they’ve got three children and they cannot afford any of this." (Group 7, ophthalmologist)

Subtheme: effective communication strategies

ECPs suggested that, while it is important to provide enough detail for informed decision-making at the earliest opportunity, inundating parents with information and promoting immediate treatment can be counterproductive. Multiple ECPs reported that ‘planting the seed’ at the initial consultation, then following up with another appointment or at the next eye examination gives the parent time to digest information and reduces scepticism.

"They don’t always take it in at the first appointment, but when you see them after six months, they might have gone onto Google, or done some of their own research, and then they’re more intrigued about it the next time around." (Group 2, optometrist)

ECPs reported more successful implementation of myopia management when all patient-facing staff work as a team to provide the service. Dispensing opticians and contact lens opticians reported frustration when optometrists had not informed patients about myopia management during the eye examination.

"I’m a contact lens optician, so my big problem is that I can’t go in and talk about a huge amount of this if the optom hasn’t already started talking about it." (Group 3, contact lens optician)

Optometrists highlighted the importance of being able to hand the discussion over to a well-trained staff member after their consultation. This allows parents to seek clarification to queries, as well as reducing time pressures in the consulting room. ECPs expressed concern over practices with large teams, or high staff turnover, where training is harder to regulate.

"If the people on the shop floor are involved in it as well, it’s a much easier conversation that can be carried on through." (Group 1, optometrist)

Subtheme: lack of consensus on best practice

ECPs were uncertain about identifying suitable myopia management candidates, with different ECPs suggesting different criteria. There was debate over fitting at the earliest opportunity (i.e., at first myopia diagnosis) for maximal effect, versus waiting for evidence of progression. This was from both an ethical and financial standpoint. Other ECPs recommended a patient-dependent approach, tailoring to their specific risk, but that ultimately the decision of when to initiate treatment should be left with the patient and parent. ECPs displayed similar uncertainty on when to cease treatment.

"Once they’re minus, you just crack on… the earlier you start, the more time you have to manage it." (Group 6, contact lens optician)

There was greater uncertainty about management of progressing adult myopes and children with pre-myopia. ECPs expressed concern about prescribing for children with pre-myopia, both over initiating a potentially unwarranted treatment, and about having possibly superfluous discussions with parents and shortening recalls unnecessarily. A few ECPs reported instances where progressing adults were seeking treatment, but they were unsure whether to prescribe ‘off-label’ in the absence of evidence of treatment efficacy.

"I feel that an adult would benefit from some kind of myopia control." (Group 4, dispensing optician)

Subtheme: guidance versus guidelines

ECPs had mixed awareness of available guidance, such as those from the IMI, and professional bodies such as the College of Optometrists or the Association of British Dispensing Opticians (ABDO). Several ECPs indicated they were not aware of any formal guidance. ECPs who were aware of guidance generally regarded it as outdated, given the rapidly expanding evidence base, and questioned their utility for clinical decision-making. Ophthalmologists commented on the need for up-to-date guidance from the Royal College of Ophthalmologists. Some perceived a lack of commitment from the professional bodies to advocate myopia management within the profession. Others acknowledged the available guidance as an appropriate, unbiased view from the current evidence base.

There were varied expectations of guidance. Some called for specific prescribing guidelines, while others believed such strictness was not appropriate or helpful, and should be patient dependent. This view was often taken by those with more myopia management experience. Some suggested basic guidance that could be supplemented with an individualised approach. They stressed the importance of guidance being harmonised between the relevant professional bodies, ensuring consistent messaging to all ECPs, and believed this would provide more confidence in their patient management.

"As a pre-reg, I live for guidelines… it just reassures me that I’m doing the right thing. And that also I know things are getting more litigious, and that’s always on my mind as well." (Group 2, pre-registration optometrist)

ECPs expressed worry over future negligence claims if patients were not informed about, or offered, myopia management when indicated. Some ECPs were unsure whether they were expected to refer a patient if their practice did not offer myopia management or offer the best option for that particular patient. Some reported feeling a conflict of interest between duty of care versus the risk of losing business for the practice. A few ECPs also reported not knowing where to refer myopia management patients within their local area. They emphasised that clear guidance on expectations regarding duty of care would make them feel more protected.

"It is our duty to refer to colleagues, not competitors, but colleagues … if it is offered in your local area." (Group 1, optometrist)

Subtheme: public awareness and attitudes towards eyecare

While parental receptivity varies, ECPs generally felt that parents are desensitised to myopia, possibly because it is increasingly commonplace. ECPs felt parents were generally unaware of potential associated pathological implications and were more concerned with their child’s dependency on spectacles or the appearance of thicker lenses. When discussing myopia management with parents, ECPs reported frequent scepticism regarding the need for treatment or whether it would be effective, particularly when costs were discussed.

ECPs felt that the eyecare profession is undervalued in the UK compared with other healthcare services, such as dentistry, or compared with how the profession is perceived in other countries, for example, the Netherlands. ECPs felt that the public view optometric practices primarily as retail orientated, thus reducing optometry’s credibility as a healthcare profession. There was a belief that the UK public are accustomed to having free NHS examinations for children and help towards their spectacles, and as such they are reluctant to spend money.

"I think we apologise as an industry for the costs that we charge…. dentists have no problem charging their charges for what they do." (Group 5, contact lens optician)

ECPs highlighted the need to educate the public about the value of eye health and eye examinations early in life, as well as specifically educating about myopia. ECPs suggested a national public health initiative on myopia management, believing the onus is on the professional bodies and government to instigate this. They suggested education might be more successful through schools and nurseries and emphasised the need to reach children from all backgrounds.

"Perhaps the role of the GOC [General Optical Council] and the College [of Optometrists] is to educate the government, to educate the NHS." (Group 5, optometrist)

Subtheme: incompatibility with current eyecare models

ECPs expressed concern about the compatibility of myopia management with business models which rely on high patient volume per day and are dominated by sales targets, rather than emphasising clinical quality. ECPs felt some practice owners did not believe myopia management to be lucrative enough to incorporate it successfully into this type of business model. Several ECPs felt limited by a lack of relevant equipment in practice, such as topographers or biometers, which can be a costly investment. ECPs also reported difficulties following up patients, especially as a locum, or in stores with high numbers of patients and staff. Some ECPs alluded to a general lack of emphasis on paediatric eyecare in primary practice, possibly as paediatric appointments are viewed as less lucrative. A few ECPs suggested that myopia management may be best suited as a specialist service, possibly with an accreditation scheme, as per glaucoma management.

"I personally would like to see that kind of, almost sub-specialisation, particularly when it comes to something like myopia management, which I think has a kind of complexity to it that you need to have some specialist knowledge and training to do." (Group 2, optometrist)

ECPs frequently discussed the incompatibility of myopia management with the GOS system, with many expressing concern over making accidental false claims. For example, they felt unsure about claiming for low, asymptomatic myopes who may not traditionally be prescribed a single-vision correction, but who may benefit from myopia management. The question over the potential for NHS funding specifically for myopia management was also raised. ECPs desired a higher-value NHS optical voucher to be introduced for myopia management, to provide increased help towards treatment cost. Some suggested they would like fully funded management options through the NHS, because of the current financially biased accessibility to care. While ophthalmologists agreed that NHS provision of myopia management would be ideal, they were firm in their wish for myopia management to remain within primary eyecare, while continuing to accept referrals for possible syndromic or pathological myopia.

"I’m not going to receive any referrals from community opticians whose parents want a consultant conversation about their child’s myopia [management] treatment, because I don’t provide that. I’m not trained to do that." (Group 7, ophthalmologist)