The methods used in this study have been previously explained in detail.4,5 Shortly, a questionnaire in eight languages (i.e., Chinese, English, French, German, Italian, Portuguese, Russian and Spanish) was distributed via the Internet using SurveyMonkey software (Palo Alto, California, USA), through various professional bodies to reach eye care professionals across the world (opticians, optometrists, ophthalmologists, and others). In Spain, the questionnaire was disseminated by email to all registered Optician-Optometrists in the country through the Spanish General Council of Spanish Optician-Optometrists. The questionnaire comprised the following nine questions:

• 1.

  Level of concern about the increase in the incidence of paediatric myopia in clinical practice (quantified between “not at all” and “extremely” concerned on a 10-point scale).

• 2.

  Perceived effectiveness, defined as the expected level of reduction in the progression of paediatric myopia of several clinical options for myopia control (quantified as a percentage from 0 to 100%).

• 3.

  How activate they would consider their clinical practice in the area of myopia control (quantified between “not at all” and “completely” on a 10-point scale)

• 4.

  Frequency with which different methods of myopia correction are prescribed to young/progressive myopic patients on an average month.

• 5.

  Minimum patient age to consider the prescription of a myopia control method (assuming that the management skills and motivation of the child/parent are sufficient).

• 6.

  Minimum level of myopia that would need to be present to consider prescribing a myopia control method (specified in 0.50D steps)

• 7.

  Minimum level of myopia progression (dioptres/year) that would prompt a practitioner to specifically adopt a myopia control approach (specified in 0.25D steps).

• 8.

  Frequency with which single-vison under-correction is being prescribed as a strategy to slow the progression of myopia (stated as “no”, “sometimes” or “always”).

• 9.

  -If they had only ever fitted single-vision spectacles/contact lenses to myopic patients, what had prevented them from prescribing alternative refractive correction methods? The options (multiple options could be selected) consisted of:

  • •

    They don't believe that these are any more effective

  • •

    The outcome is not predictable

  • •

    Safety concerns

  • •

    Cost to the patient makes them uneconomical

  • •

    Additional chair time required

  • •

    Inadequate information/knowledge

  • •

    Benefit/risk ratio

  • •

    Other

Although voluntary participation in the survey was anonymous, respondents were asked to provide basic demographic information about themselves, such as years of being qualified (grouped in six categories: 0, 0–5, 6–10, 11–20, 21–30, ≥31 years) and everyday working environment (i.e., clinical practice, academia, industry or other). The results obtained were grouped into five large regions (i.e., Asia, Australasia, Europe [without Spain], North America and South America) for analysis and comparison with Spain. The data was collected between October 2018 and April 2019.

Statistical analyses were performed with SPSS 25.0 software (SPSS Inc., Chicago, Illinois, USA). The Shapiro Wilk normality test was used to assess whether the study variables were normally distributed. Subsequently, the Kruskal-Wallis and Mann–Whitney U tests were used for data analysis of non-normally distributed variables, whereas one-way analysis of variance and unpaired t-test were used for normally distributed data. To evaluate statistical significance, a threshold of p ≥ 0.05 was used.

Responses were obtained from 1,336 eye care practitioners, of whom 13 were from Africa (not included in the analysis), 202 from Asia, 79 from Australasia, 717 from Europe, 5 from the Middle East (not included in the analysis), 147 from North America, and 173 from South America. Of the 717 questionnaires obtained from European practitioners, 173 provided data from Spain. Seventy-two percentage of all the questionnaires obtained globally were provided by optometrists, 20% by ophthalmologists, and the remaining 8% by other eye health professionals. All questionnaires obtained from Spain were completed by optician-optometrists (referred thereafter as “Spanish optometrists”, “Spanish practitioners” or the like). Most of the professionals who participated in this study overall as well as in Spain work in clinical practice - either in an optometry or refractive surgery setting (92% and 91%, respectively). Worldwide and Spanish practitioners reported being registered to practice for the 11−20 year and 21–30 year categories, respectively.

The concern about the increase in paediatric myopia reported by eye care practitioners worldwide was very similar (8.5 ± 2.1) to that reported by Spanish practitioners (8.4 ± 1.9) (p > 0.05). Spanish practitioners were more concerned than Australasian (p = 0.025) and European practitioners (p = 0.007); and similarly concerned to Asian, South American and North American practitioners (p > 0.05). If European countries alone are taken into consideration,5 Spanish practitioners were more concerned than those from Germany (p = 0.000) and The Netherlands (p = 0.007), and similarly concerned than those from Italy, Portugal, Russia and the United Kingdom/EIRE (p > 0.05). In Spain, as in the other regions, no significant differences were found between the years of experience and the level of concern (p > 0.05).

Overall, eye care practitioners worldwide perceived orthokeratology as the most effective method of myopia control (51.3% [Confidence intervals {CI}: 49.7–52.8]), followed by pharmaceutical approaches (46.5% [CI: 45.0–48.1]) and approved myopia control soft contact lenses (42.7% [CI: 41.2–44.2]). In Spain, orthokeratology (63.5% [CI: 59.6–67.4]), followed by approved myopia control soft contact lenses (54.4% [CI: 50.2–58.4]) and time outdoors (48.5% [CI: 43.6–53.4]) were perceived as the most effective myopia control methods. This difference in perceived efficacy between the world's average and Spain was significant (p < 0.001) (Fig. 1). Significant differences were found between Spain and some of the other regions assessed in the efficacy of single-vision under-correction spectacles, single-vision (full correction) spectacles, bifocal spectacles, rigid gas-permeable contact lenses, single-vision soft contact lenses, specific myopia control soft contact lenses, orthokeratology, progressive addition spectacles and increased time spent outdoors (Table 1). However, no significant differences were found between Spain and the other regions assessed in the efficacy of standard multifocal soft contact lenses, pharmaceuticals and refractive surgery (p < 0.05). In Spain, practitioners reported higher levels of efficacy for orthokeratology, approved myopia control soft contact lenses and time spent outdoors the fewer the years of experience (p < 0.05). In contrast, in North America, the more years of practitioner experience the greater the perceived efficacy of orthokeratology (p < 0.05). If results from optometrists surveyed globally are considered alone (since Spanish optometrists cannot prescribe drugs like atropine), it was found that Asian optometrists (54.4 ± 23.6) reported a higher perceived efficacy of pharmaceutical approaches than Spanish optometrists (45.2 ± 28.5) (p < 0.05), but no significant differences were found between Spanish optometrists and optometrists from the other regions of the world (p < 0.05).

Figure 1.

-Perceived efficacy of the different myopia control methods. RGP, rigid gaspermeable contact lenses; SCL, soft contact lenses; MC SCL, soft contact lens approved for myopia control; Ortho-K, overnight orthokeratology; RS, refractive surgery. Error bars represent one standard deviation.

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RGP, rigid gas-permeable contact lenses; SCL, soft contact lenses; MC SCL, soft contact lens approved for myopia control; Ortho-K, overnight orthokeratology; =, Similar levels of efficacy reported by Spanish practitioners; >, Spanish practitioners reported significantly higher levels of efficacy; <, Spanish practitioners reported significantly lower levels of efficacy.

Spanish practitioners reported a similar level of perceived clinical activity in the field of myopia control (6.9 ± 2.6) in comparison with practitioners worldwide (7.0 ± 3.6) (p < 0.05) (Fig. 2). In Spain, as in North America and the rest of European countries, significant differences were found between the different age ranges of professional experience in the perceived level of clinical activity in the field of myopia control (p < 0.05), with increasing years of professional qualification typically showing an increase in the perceived level of clinical activity in the field of myopia control.

Figure 2.

Perceived level of clinical activity in the field of myopia control reported by practitioners located in Spain and in other regions of the world. Box = 1 standard deviation, line = median, whiskers = 95% confidence interval, n= number of responses and o = extreme values.

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Single-vision (full correction) spectacles were, by far, the most widely prescribed option to progressing/young myopes, representing 31.2% (CI: 26.4–36.0) and 47.7% (CI: 43.7–51.6%) of all prescriptions reported overall in the world and in Spain, respectively (Fig. 3). In contrast, orthokeratology were prescribed to 13.2% (CI: 12.0–14.5) and 9.5% (CI: 7.2–12.4) of progressing/young myopes by practitioners worldwide and Spanish practitioners, respectively. Significant differences were found between Spain and the other regions assessed in the prescription frequency of single--vision spectacles, singlevision soft contact lenses, approved myopia control soft contact lenses and pharmaceuticals. However, no significant differences were found between Spain and the other regions in the prescription frequency of bifocal spectacles, progressive addition spectacles, rigid gas-permeable contact lenses, standard multifocal soft contact lenses, orthokeratology and refractive surgery (p < 0.005). Significant differences between the different age ranges of professional qualification were found in the prescription frequency of approved soft contact lenses for myopia control (p = 0.036), with increasing years of professional qualification typically showing a lower prescription frequency of such lenses. No significant differences were found between Spanish practitioners’ years of experience and the prescription frequency for the remaining myopia control strategies (p < 0.005).

Figure 3.

Prescribing frequency of different myopia correction options to progressing/young myopes in a typical month. RGP, rigid gas-permeable contact lenses; SCL, soft contact lenses; MC SCL, soft contact lens approved for myopia control; Ortho-K, overnight orthokeratology; RS, refractive surgery. Error bars represent one standard deviation.

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Significant differences between regions were found in the minimum age at which a myopia control method would be prescribed (p < 0.001) (Fig. 4). Overall, eye care practitioners from all regions recommend prescribing a myopia control treatment at an older age (10.1 ± 5.8 years [CI:10.0–10.2]) than Spanish practitioners (7.8 ± 3.5 years [CI: 7.6–8.0]) (p < 0.001). Spanish practitioners recommend the prescription of single-vision spectacles, rigid gas-permeable contact lenses and pharmaceutical agents at a younger age in comparison with the other regions assessed (p < 0.001). No significant differences were found between regions in the age at which a patient would be prescribed any of the other myopia control options assessed (p < 0.05). Of interest is that Spanish practitioners recommend the prescription of approved myopia control soft contact lenses at a younger age than soft contact lenses (p < 0.001). No significant differences between the different age ranges of professional experience were found in the mean minimum age at which a patient would be prescribed a myopia control method for any of the regions assessed (all p > 0.05).

Figure 4.

Minimum age (years) at which practitioners from the different regions would recommend myopia control treatments to patients. RGP, rigid gas-permeable contact lenses; SCL, soft contact lenses; MC SCL, soft contact lens approved for myopia control; Ortho-K, overnight orthokeratology; RS, refractive surgery. Error bars represent one standard deviation.

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Spanish eye care practitioners recommend prescribing a myopia control method to patients with a slightly higher level of myopia (-1.6 ± 1.4D [CI: -1.7 to -1.5]) than that of the average of all the other regions (-1.5 ± 1.3D [CI: -1.6 to -1.5]) (p = 0.03). Significant differences between regions were found in the minimum degree at which the different myopia control methods would be prescribed (p < 0.001) (Table 2-). Spanish practitioners, as it was typically the case for practitioners from the other regions as well, reported prescribing single-vision spectacles and single-vision soft contact lenses for lower levels of myopia (mean -1.2 ± 0.4D and -1.40±0.8D, respectively), whereas rigid gas-permeable contact lenses and refractive surgery would be prescribed for higher levels of myopia (mean -2.7 ± 2.0D and -3.8 ± 2.1D, respectively). No significant differences between the different age ranges of professional experience were found in the minimum degree of myopia at which a myopia control method would be prescribed for any of the regions assessed (all p > 0.05).

SCL, soft contact lenses; RGP, rigid gas-permeable contact lenses; MC SCL, soft contact lens approved for myopia control; Ortho-K, overnight orthokeratology; RS, refractive surgery; =, Similar rates; >, Spanish practitioners reported significantly higher degree of myopia to consider myopia control options; <, Spanish practitioners reported significantly lower degree of myopia to consider myopia control options.

Spanish as well as Australasian and European practitioners would recommend a myopia control intervention to patients with a lower annual myopia progression (0.50–0.75D/year) than those from the other regions (p < 0.001) (Table 3). If European countries alone are taken into consideration, practitioners in Spain recommend a myopia control intervention for patients with a higher annual progression of myopia than those from Germany, Ireland, Italy, Norway, Portugal, Switzerland and the United Kingdom (p < 0.001); and for patients with a lower annual progression of myopia than those from Austria, France and The Netherlands (p < 0.001). No significant differences were found overall for all regions in the minimum range of annual myopia progression to offer a myopia control option based on the number of years of professional experience (p > 0.05).

Globally, 78.2% of all eye care practitioners that participated in this survey did not consider distance, single-vision under-correction to be an effective strategy for slowing myopia; 17.4% practitioners reported prescribing it sometimes; and 4.1% reported always recommending this strategy (Table 4). These figures were slightly different in Spain (p < 0.001), where single-vision under-correction was never, sometimes or always recommended by 69.4%, 30.2% and 0.6% of practitioners, respectively. Spain and South America are the regions where practitioners most commonly prescribe single-vision under-correction as a method for slowing myopia progression (p < 0.05), whereas Australasian practitioners the least (p < 0.001). No significant differences between the different age ranges of professional qualification were found in the prescription of single-vision under-correction neither for Spanish practitioners (p > 0.05) nor overall for practitioners globally (p > 0.05) .

Significant differences were found between Spain and the rest of the world's average in factors preventing the prescription of a myopia control approach (p < 0.05). Worldwide, as well as in Spain, the main reasons why myopia control methods are not prescribed are their high cost followed by inadequate information (p < 0.05). Additionally, in Spain, South America and Asia, unpredictable results and lack of efficacy are also important factors preventing practitioners the prescription of myopia control approaches (p < 0.05). Other reasons commented in the free text section preventing Spanish practitioners the prescription of myopia control approaches included the need for dissemination of better scientific information on these methods to improve practitioner training. In contrast, practitioners globally identified other factors preventing the prescription of myopia control approaches, which included lack of availability of treatments and instruments required to prescribe them, as well as the need for informative material and consistent regulation for the approval and prescription of these methods.