How PreMO can support myopia management in practice

PreMO, a myopia management and risk stratification tool that can be used by practitioners was launched on World Sight Day in October last year.  

It is the culmination of nearly 20 years of research activity, Professor Kathryn Saunders from Ulster University shared when talking to OT ahead of Myopia Awareness Week (13–19 May).

The free-to-use browser-based tool, which is UK-CA and CE-marked, supports the prediction of myopia onset and progression. It is also registered with the MHRA as a class 1 medical device.

For Saunders a key differentiator in market for PreMO is that it allows for the longitudinal monitoring of patients, “which is so helpful in clinical decision-making,” she said.

To use PreMO, practitioners simply input the child’s age, parental history of myopia, refractive error and either axial length or k-values.

While data can be entered anonymously if clinicians prefer, Saunders emphasised that “PreMO is fully GDPR compliant.” 

Discussing the importance of myopia management, Saunders explained to OT:

“We have good evidence now that these myopia management interventions work for most children – there are still a lot of unanswered questions and our research using data gathered with the PreMO will help us answer some of them.” 

Here OT talks to Saunders about PreMO and how it is able to support practitioners providing myopia management.

Who developed PreMO and why?

PreMO has been developed by Drs Sara McCullough, Lesley Doyle and myself, at Ulster University. Using data from the Northern Ireland Childhood Errors of Refraction (NICER) study, which was funded by Ulster University and the College of Optometrists, we developed myopia risk stratification tables and normal growth curves for both refractive error and axial length. These tables and growth curves have been available online for some years. However, feedback from users suggested they would be even more useful if they provided an engaging interface to share and communicate myopia status and risk with parents and children, and if they allowed tracking of patient data over time to monitor change and evaluate the impact of interventions.

We collaborated with Professor James Wolffsohn at Aston University, a fellow optometrist and academic with experience of app development. Using sponsorship from Cylite, Hoya Vision Care, EssilorLuxottica and SightGlass, we engaged software and regulatory experts at Wolffsohn Research Ltd to convert the original risk stratification tables and growth charts we had derived from our research into a much easier to use, clinician and patient-friendly online tool. We also worked with colleagues in Hong Kong and Aston University to check that PreMO’s risk stratification was useful when applied to mixed-ethnicity cohorts in England and Chinese children living in Hong Kong.

For practices without access to biometry, PreMO includes an axial length calculator, developed by Professor Philip Morgan from the University of Manchester, which estimates axial length from k-values and refractive error.  

It has been a really collaborative project, involving academic, professional and industry partners. We are also working closely with the UK Myopia Consortium, a national group of academics and clinicians focusing on myopia research, to make the best use of the real-world data we collect using the PreMO tool.  

How do practitioners use PreMO?

PreMO is quick and simple to use. To access it, visit Myopia Onset on your internet browser and create a login profile. You can then use the tool on a patient-by-patient basis – each patient’s profile takes less than a minute to set up and you can add to it at each visit, building up a comprehensive picture of how each child’s eyes are changing over time and with treatment. 

The output is a one-page visually engaging summary on screen that can be shared with the parent and child in the test room while discussing management options. A PDF of the output can also be emailed to the parent for future reference.

How does using PreMO support practitioners using it?

The reason we developed PreMO was because we were fielding a lot of questions from colleagues and clinicians about how to target myopia management interventions and monitor how/whether they were working.

PreMO allows you to see where a myopic child’s axial length and refractive error ‘sit’ in relation to their peers, provides context from historical data on these metrics and how they have changed over time. Using these data, PreMO indicates the child’s risk for progressing at a fast rate over the coming years.

Furthermore, the implementation of a myopia management strategy can be recorded in PreMO. The impact on the child’s eye growth and refractive trajectory can then be monitored to help you understand the impact of their intervention and convey this to the parent.

We were also really keen to formalise a method by which clinicians could identify the children most at risk for future myopia because there are proven methods of pushing back myopia onset, such as increasing time outdoors. These delaying or mitigating strategies are likely to be as effective, if not more so, at reducing the final magnitude of myopia a child achieves.

While we all ‘know’ that children with myopic parents and/or low hyperopia in the early school years are more likely to develop myopia than their peers, PreMO formalises these metrics to support you in identifying the most at-risk children and communicating this risk in an engaging and easy to understand message for parents and children. This supports important conversations about the ‘mitigation’ aspect of myopia. Our conversations with parents really support the value of this evidence-based approach and clear messaging, and we are continuing to work to further hone this message. 

Practitioners can gain consent for the data they input into PreMO to be shared with your research team. How is this data used and why would you encourage this?

Talking to clinicians from across the globe, we see that there are a lot of unanswered questions about myopia management: who should I target for intervention? Will every child benefit? How long will they need to stay on the intervention? How do I know if it is working or not, etc.

The PreMO team is working with the UK Myopia Consortium, collating, and analysing data gathered through clinical use of the PreMO to address these questions and develop tools to support clinical practice. By gaining consent from the parent, we can access anonymous data for this purpose. 

So, to practitioners using PreMO, don’t forget when using it to ask parents for consent to share anonymised data with us – this can be done with a click of the button in the app. 

Is the tool suitable for those practising off the High Street?

Yes, absolutely. The patients seen in the hospital tend to be the more atypical myopes and those becoming myopic at younger ages. PreMO is most applicable to children aged six to 16 years, but if practitioners use their clinical judgement, they may still find PreMO helpful outside these ages, particularly for communication with parents.

It will also be really helpful for us as researchers looking at data input in non-primary care settings to see if and how atypical myopes respond to myopia management interventions.

The research published to date tends to have come from randomised controlled clinical trials, which don’t recruit these atypical myopes into their studies. Hence the results demonstrating efficacy may not apply to these vulnerable groups.

Through gathering more data on when/if myopia management is applied to these atypical myopes and monitoring its impact, we will know better if these interventions are suitable for these children, or not.

What would you say to encourage practitioners to download and use PreMO?

Take it from one of our early adopters, who when asked what he liked about it said, ‘Once you’ve used it, it’s a no-brainer.’ One of his favourite aspects of PreMO was the illustrations, simply showing the child and their parent how their eye size and level of myopia related to other children of their age. He noted that this independent, university-developed evidence is valued when parents are deciding whether to embrace the relatively new concept of myopia management.

Also, what have you got to lose? PreMO is quick to try, free to apply and you will be part of an exciting data-gathering ‘citizen/clinician science’ project that has the potential to rapidly escalate our understanding and improve our management of childhood myopia.

What are your three top tips for using PreMO? 

1. Keep the PreMO tab up on your desktop, laptop or mobile browser so that you can quickly add a patient or review their progress
2. Add ‘historical’ data to provide context about the trajectory of the child’s myopia over time to give context to your decision-making about follow-up and interventions
3. Obtain consent to share the data in anonymised form. Explain to the parent that by doing so they can participate in improving our understanding and management of myopia and this could directly positively impact on their child’s myopia care.