This month, we dive deep into the topic of myopia management with Dr. Monica Jong, Executive Director of the International Myopia Institute (IMI). The IMI is the global expert body focused on advancing myopia research, education, and management to prevent future vision impairment and blindness from high myopia related complications.
Dr. Jong’s research interests include refractive error, understanding myopia and high myopia risk factors, myopia control, and the public health impacts.
Myopia has become an important topic in recent years. How did you become interested in the issue?
MJ: When I was 10 years old, I got my first pair of eyeglasses with -0.50 D and -0.75 D of myopia. That became the driver of my work in myopia as an optometrist, a researcher, and an advocate. I remember I felt so down about being diagnosed with myopia, as my parents had always warned me to look after my eyes, avoid TV, avoid too much reading, and go outside. There was a stigma with wearing spectacles, so I only wore them to look at the board. I realise now that not wearing my glasses impacted me because I spent my days outside looking through a blur and not participating as best as I could. When you cannot see properly, that also affects your confidence.
My myopia kept progressing, and every time I came back from my optometrist, I felt down because there was nothing I could do. One of my eyes even became highly myopic. My parents were also very worried about myopia, and if we knew then what we know now, they would have done what they could to make sure I would not progress as much as I did. If parents can understand that myopia is not a normal state of the eye and opens up the risk for future complications, why would they not do something about it for their child?
As a mother now, I will be doing all I can to prevent myopia in my child.
With myopia projected to affect 50% of the world’s population by 2050, there’s a fear that it could become the most common cause of irreversible blindness worldwide. How are environmental factors, exacerbating a problem that was not seen to this extent in previous generations?
MJ: A number of studies have looked at the association between myopia and screen time, and the findings suggest that increased screen time and near-work is associated with an increased risk of myopia. However, the evidence that near-work and screen time increases myopia progression is not strong at this stage. Having said that, myopia development is based on a number of different environmental factors, including outdoor time and near-work intensity. Someone doing a lot of near-work who also frequently goes outdoors may not be at as high of a risk as someone who does a lot of near-work and spends little time outdoors.
The prevalence of myopia was high in parts of East Asia before the advent of screens. It is now also increasing in many parts of the developed world, most likely for environmental reasons. Working on screens has always been considered near-work in terms of accommodative demand. The difference now is that social media and many apps on smart devices are designed to be highly addictive, and designed to keep you viewing for longer periods of time, and that is increasing the intensity and duration of near-work, and reducing the time outdoors. I think that is really worrying in terms of increasing the risk of myopia.
In the past, we could just close our books and stop reading, but now we are always primed to keep waiting for the next notification on WhatsApp or Facebook.
Pediatricians and school nurses are often the first to see a vision problem in children. How can we ensure that they have the best skills on myopia management?
MJ: I think advocacy about myopia, and why it is important to try to prevent and manage it in children, is critical. The IMI is producing white papers and clinical summaries in this area, which will be useful for clinicians to share with local pediatricians and school nurses. At the same time, at the association level, we should be engaging with pediatricians and school nurses, the allied health networks.
How can education systems and parents be a part of the solution to this issue?
MJ: We really all need to think holistically about myopia. We know that the environment plays a big role in myopia development, that near-work is a risk factor and being outdoors can prevent myopia. There are also areas we can target such as light levels, classroom design, and activities that deliver education using different visual tasks. Experimental studies in animals and in humans show that eye length changes minutely over the course of the day. This is called diurnal variation which are like changes in our natural body rhythms.
Perhaps in the future, there may even be a “safer” time of day to do intensive near-work and then have physical education classes at other parts of the day. It may also tell us when to use a particular myopia control treatment on the eye.
There’s no “one size fits all approach” to myopia management. Eyeglasses are a tool to manage the symptoms of myopia. What else is available to manage the problem?
MJ: Today, we really can think more broadly about myopia beyond correcting vision with a pair of spectacles because we need to also consider it is an ocular condition and not only as a refractive condition. We need to think of the patient’s age, lifestyle, preferences, and level of myopia and risk of progression. Then we can consider the best option for our patient. And it is great to see that practitioners have many options today that offer comparable slowing of myopia and the opportunity to personalize patient management.
The better-performing spectacle options we have today are the executive bifocals and defocus incorporated multiple segments (DIMS) based on the latest clinical data. In the contact lens-based options, we have orthokeratology lenses. We also have a number of soft contact lens designs such as the simultaneous defocus, which is the FDA approved Misight lens, enhanced depth of focus, and distance-centred designs. These optical interventions correct vision and slow myopia progression. We also have low-dose atropine drops that are effective. Evidence is also starting to suggest that combination therapy provides better myopia control.
For practitioners, this area is growing, with new options and research to provide better evidence-based management.
The IMI published a landmark series of papers in 2019 on the topic. Why are these papers important and how did this research shed additional light on the topic?
MJ: Prior to the publication of the first series of IMI white papers, there was a lot of work being done in this area, most of which was not being translated into clinical practice, partly because the evidence was not reaching the majority of the practitioners. Professors Brien Holden, Serge Resnikoff, Earl L. Smith and Kovin Naidoo recognized that greater awareness was needed to address the public health issue of myopia and high myopia, and to reduce the future increase in vision impairment. I worked with them to help found IMI in 2015, and the task forces were formed to develop white papers on definitions, interventions, and management guidelines.
For the first time, we had all the experts come together and review all the evidence. This is very important in an area where there is so much information from diverse sources. Practitioners need to know and trust what they are reading to be able to provide the best care.
Where are the gaps in research when it comes to myopia?
MJ: When it comes to myopia management, the 2016 WHO report on the impact of myopia and high myopia states that we need to prevent or slow myopia because of the increased risks of ocular complications and vision impairment in the future, and that there is evidence to support the use of interventions clinically. As with any condition, there are things we still do not know and need to research, such as the optimum concentration of atropine, the best time of day to use a treatment, how long a treatment be applied, and what patient factors make one person respond best to a particular treatment.
The IMI is tackling these topics by bringing together all the global experts to examine, discuss and develop evidence-based guidance for practitioners and policymakers.
What’s next for the IMI?
MJ: Our work has been referenced by the WHO and professional associations, and used by the eye care education sector, which is a momentous achievement. At the same time, we have produced clinical summaries of the initial seven IMI white papers and translated them into 12 languages. We recognize there are areas that still require work. A second series of IMI white papers on topics such as the impact of myopia, pathologic myopia, accommodation and binocular vision in myopia, environmental risk factors, and a yearly digest update will be published in early 2021. We will continue to engage eye care practitioners via dissemination of the white papers online, speaking at meetings, and sharing with health bodies and professional networks.
Our main aims are to produce evidence-based resources that are based upon experts coming together and keeping myopia on the agenda as a public health issue, and to advance myopia management, research, and education. The work is still not done because in many parts of the world, myopia management remains unknown, and myopia is increasing everywhere. Based on the Holden et al. estimates, by 2050 half the world will be myopic. We still have a lot of work to do to get the message out that increasing levels of myopia are a serious global problem and not just an “Asian problem.” We need to communicate better with our own colleagues and other key professions working with children and start educating everyone about the need to manage myopia.
What do you see as the impact of the COVID-19 pandemic on myopia?
MJ: It is hard to predict, as we do not know how long this pandemic will last. What would be heart breaking during this time is if children could not access eye care, including vision correction or have their myopia managed. Their myopia may progress faster and, as a result, their vision and eye health may be compromised. At the same time, children may be indoors a lot more and on devices longer if they are doing home schooling during the pandemic. We know that near work and reduced time outdoors is associated with myopia.
Eye care practitioners should consider how they can provide their services at this time through telehealth, home visits if it is safe, and by keeping in touch with parents and educating their patients about ocular health and lifestyle advice.