Selecting an option: Clinical Decision Trees in myopia management


Originally published: June 26, 2018
Most recently updated: September 21, 2021

There is no one-size-fits-all with myopia management, so which option should you choose for your individual patient? Here we are going to ask you to consider three key clinical questions in selecting an option for myopia management. Your responses to these questions will direct you through the clinical decision trees. Let's get started.

Here’s our first question - spectacles or contact lenses? You have to correct the myopia so it makes sense to prescribe a first line treatment which both corrects and controls myopia. Contact lenses are the most widely available effective treatment to primary eye care practitioners (ECPs) at this stage. Our newest generation of myopia controlling spectacles appear to show similar efficacy to our best contact lens options, but are not yet widely available. Atropine will feature a little later on. So, this means the initial decision tree is as follows.

Clinical decision trees Q1_crop

That’s the reasonable first decision, and there’s more information on selecting the spectacle lens type below in Q3. So if the answer is YES to Q1, and the child is suitable and willing to wear contact lenses, which should you select? The next decision tree looks something like this. In Q2, 'MCCL' is a myopia controlling contact lens - a soft contact lens which has research evidence for myopia control, which includes multifocal, dual focus and extended depth of focus designs. The term 'MFCL' is used for a multifocal contact lens, specifically toric MFCLs which are available for presbyopia but have only been researched for myopia control in their spherical forms. Read more about this in Which multifocal contact lens? Refraction and safety. 

Clinical Decision Trees Q2_crop_NEW

The next level up in customising your treatment choice is then including binocular vision status. For Q3 we are now going to combine Q1 on contact lens suitability with information on binocular vision status. If you want to learn more about the four reasons why binocular vision matters in myopia management, or want to expand your clinical skills in binocular vision, follow the relevant links. If you feel confident in binocular vision diagnosis and management, read on.

Clinical Decision Trees Q3_crop_NEW

Now we can see each of our options for the initial treatment choice, and how we may come to select them. You’ll notice low-concentration atropine is mentioned here as a first line treatment if the equivalent optical treatments are available or suitable - based on the current evidence that our best intervention of each category, being atropine (0.05%), orthokeratology, dual-focus soft contact lenses and the new generation of myopia controlling spectacles have similar efficacy. You may consider including atropine as a first line combination therapy with a contact lens option if we have a child at risk of faster progression, although there is only research evidence for combining atropine with orthokeratology at this stage.

So now you've got an idea of which treatment option to suggest, how should you explain that to the patient and their parents? Take the next steps by reading Keys to communication in myopia management.

If you're not too confident in binocular vision, our comprehensive, self-paced online course Binocular Vision Fundamentals is specifically designed to help you increase your skills and clinical scope in binocular vision management. This course is relevant to management of patients of all ages, not just myopes, and you can try the first two lessons for free. There's also free resources to help you upskill in binocular vision on our YouTube channel:

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About Kate

Dr Kate Gifford is a clinical optometrist, researcher, peer educator and professional leader from Brisbane, Australia, and a co-founder of Myopia Profile.

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