Orthokeratology In Reducing Myopia: A Review Of Its Cost-effectiveness, Inclusion in Insurance, and Practitioner Training Practices Globally

INTRODUCTION

A Review of Myopia and Orthokeratology

Myopia, the scientific term for nearsightedness, is a prevalent ocular condition that impacts approximately 1.404 billion people in the world, constituting 22.9% of the world population, and it is estimated to affect 4.758 billion patients by 2050 (Yu & Liu, 2022). High myopia is defined by a spherical equivalent refractive error (SER) of ≤−6.00 D and often includes an axial length (AL) of ≥ 26 mm (Shah et al., 2024). This condition is recognized as a major cause of visual impairment, in many cases uncorrectable, and is associated with heightened risks of retinal detachment, posterior staphyloma, cataract, glaucoma, and myopic macular degeneration (Modjtahedi et al., 2021). Several genetic and environmental factors, such as race, reduced outdoor time, and educational stress, have been extensively studied as contributors to myopia (Modjtahedi et al., 2021).

A relatively recent advancement in slowing down the progression of myopia control is orthokeratology, commonly abbreviated as ortho-k. Ortho-k is an overnight therapy that uses rigid specialty contact lenses to reshape the anterior cornea and temporarily correct SER and vision (Vincent et al., 2021). The lens applies positive pressure to the central cornea and creates negative pressure at the periphery, resulting in a 'relative peripheral myopic defocus' (Efron et al., 2024).

Myopia Control Methodology Across The Globe

Myopia is a serious public health concern, and countries around the world use various methods of myopia control. In a recent contact lens study, Efron et al. (2024) collected data in 14 countries between 2019-2023, inclusive, on the proportion of four categories of rigid lens fits. To collect data, 5,000 practitioners per country every year returned a completed paper copy or electronic email form, detailing local demographics and context for the initial ten fits of contact lenses (Efron et al., 2024). Fig. 1 depicts the following proportion of rigid lens fits: corneal sphere - 30%; scleral and corneo-scleral – 28 %; myopia control/orthokeratology – 21 %; and corneal complex (including hybrid, toric, multifocal and monovision) – 16 % (Efron et al., 2024).

Figure 1. Proportion of spherical, complex (including hybrid, toric, multifocal and monovision), myopia control/orthokeratology, and scleral (including corneo-scleral) designs for rigid lens fits across 14 countries worldwide between 2019 and 2023, inclusive (n = 5,994 rigid lens fits).

Although statistically similar on average, the distribution of these contact lens prescriptions are extremely diverse when examined individually by country. A country such as Bulgaria does not use myopia control nor ortho-k at all, whereas over 50 percent of rigid lens fits in Canada and Spain model those designs. The study’s discussion does not fully translate why many Northern European countries do not strongly consider the value of myopia control and ortho-k for rigid lens fits, as well as its general value in eye care. This paper will cover possible reasons for these geographical patterns such as a cost meta-analysis, the inclusion of eye doctor care in healthcare and insurance, and different training practices for practitioners.

Meta-analysis of the Cost-effectiveness of Myopia Control and Orthokeratology

Cost-effectiveness of myopia control and orthokeratology can be understood in the context of its potential productivity loss, upfront deposits, and long-term savings from indirect healthcare costs. Although many forms of treatment for myopia are financially heavy installments, one study concluded that the ultimate cost of leaving myopia untreated is significantly more expensive than taking necessary measures for myopia control. One study by (Naidoo et al., 2019) generated mathematical calculations from data in the Global Health Estimates Technical Paper, published by the World Health Organization (WHO). Their estimation of potential productivity loss takes into account disability weight data, in relation to each individual’s level of visual impairment; labor force participation rates, categorized by age; employment rates, and GDP per capita as of 2015 (Naidoo et al., 2019). These variables correlate levels of visual impairment to lost potential productivity. Naidoo et al. (2019) identified that the global potential productivity loss as a result of uncorrected myopia and myopic macular degeneration was a total of $230 billion in the year of 2015.

Agyekum et al. (2023) conducted a similar study, comparing the cost-effectiveness of ortho-k and other methods of myopia control to that of single-vision lenses, the standard treatment of myopia. Their measure of cost-effectiveness assumes direct and indirect costs. Direct costs consider factors such as consultation and follow-up appointments, optometric services, contact lens solution products, and medications; indirect costs consider “adverse events” and a guardian’s productivity loss, including time spent and income deficits in transportation to appointments (Agyekum et al., 2023). Ortho-k has the highest estimated total cost ($15,347) on children aged ten years old, set over a 5-year period, compared to the following other relatively effective myopia control methods: daily disposable contact lenses (MiSight; CooperVision), red light therapy, atropine eye drops, and progression additional lenses (Agyekum et al., 2023). In terms of axial length (AL), a common measurement linked to myopia, Agyekum et al. (2023) concluded that the incremental cost-effectiveness ratio (ICER) of ortho-k across 12 other methods was a great $2376/AL reduction, with atropine eye drops next in descending order at an ICER of $428/AL reduction. In this study, despite a high initial cost, orthokeratology proved to be one of three most cost-effective methods of myopia control.

Insurance Policies of Eye Doctor Care in Healthcare

Orthokeratology is often assumed to be a cosmetic measure rather than a form of necessary medical treatment. In the United States, the subset of contact lenses in optometric costs are not generally covered by standard insurance plans (VanderVeen et al., 2019). Countries such as Taiwan likewise do not insure ortho-k (Wu et al., 2022). In Southeast Europe, the sovereign country Bosnia and Herzegovina does not support private insurance; citizens are mandated to use public health insurance or fall back on the alternative of paying full price for optometric services, not deemed of high medical urgency, at private clinics (Erickson et al., 2020). These recurrent costs to maintain this method of eye doctor care is the major, strong deterrent to adopting ortho-k.

Training Practices Vary Internationally

Training practices, ones that focus on myopia control and other optometric services, are scarce in the majority of countries internationally. Erickson et al. (2020) highlights that only approximately 200 ophthalmologists work in Bosnia and Herzegovina, with no domestic optometric training programs and no specialized corneal and ocular disease units (Erickson et al., 2020).

One online survey, distributed to a total of 534 Spanish optometrists, questioned respondents about their knowledge of myopia and current training and clinical practices (Di Pierdomenico et al., 2023). Di Pierdomenico et al. (2023) discovered that only 11.4% of the participants reported “working where pharmacological management of myopia progression is applied”. When questioned about key barriers to myopia management practices, 29.6% of respondents for each barrier identified the additional purchase of clinical equipment and limited hours of optometric practice, and 50% deemed lack of workplace support as important or very important. Other barriers included lack of experience (42.6%) and lack of time for professional training (40.7%). When asked to identify deterrents from using alternative methods to single-vision glasses, or conducting myopia control, most respondents identified cost to the patient (51.9%) and lack of information (40.7%) (Di Pierdomenico et al., 2023).

However, taking a look at training practices in Africa, Ouzzani et al. (2021) found that Algeria does have some practitioners who specifically work with orthokeratology, most of whom work in contact lens centers of referral. Ortho-k has existed in Algeria for over a decade, but its practice is not otherwise very well documented and is looked upon by many in the study to continue its expansion and prevalence in North Africa.

Discussion

Given the trends of current methods of myopia control in these countries, to have the biggest positive outcome quality of life I expect increasing hours of practitioner education with ortho-k, reducing in patient fees for ortho-k technology through insurance, and releasing public health communication campaigns. Ortho-k, despite extensive research, is still not a very globalized use of slowing down the progression of myopia. Presenting myopia control as a necessary medical option may allow health insurance companies to cover this sect of optometry and ophthalmology care in their insurance. Increased exposure of the efficacy of orthokeratology can be realized through the endorsement of the aforementioned public health campaigns, amplifying societal support. Myopia is an increasingly more dangerous medical condition that has found severe cases in virtually every country and should be taken more seriously.

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