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Have lockdowns and screen time escalated Australia’s myopia problem?

The term ‘quarantine myopia’ has been coined to describe what appears to be a worsening of the condition in many paediatric patients due to lockdowns across the world. RHIANNON BOWMAN asks whether Australian optometrists and parents should be worried.

Children across the world including Australia were plunged into home learning arrangements in 2020, spending several hours a day in front of computer screens as governments fought to stop the spread of the coronavirus.

It immediately placed pressure on parents who were required to adapt to home-schooling while also performing their own jobs from home, leaving some children a free pass on video games, social media and television.

One survey in the US of more than 3,000 parents found the average time spent online doubled for kids during the crisis. Nearly 50% of survey respondents’ kids were spending more than six hours a day – compared to 8% of kids before the pandemic – on online platforms.

Australian eyecare practitioners also turned to screens, gathering in online forums to share their concerns about the uncharacteristic changes in the progression of myopia in their young school-aged patients. One local practitioner noted that a child’s myopia progression over six months is what she would have normally expected over the course of a year.

Their fears were partially confirmed when the results of a six-year study on the progression of childhood myopia in China shot to prominence in January revealing that myopia prevalence in young school-children rose significantly during the COVID-19 pandemic.

It drew on data from approximately 123,000 Chinese children and found home confinement during the pandemic in 2020 appeared to be associated with a substantial myopic shift – approximately -0.3 diopters – for children aged six to eight years.

The study, published in JAMA Ophthalmology, noted the prevalence of myopia appeared to be approximately three times higher in 2020 than in 2015 to 2019 for children aged six, two times higher for seven-year-olds, and 1.4 times higher for those aged eight.

The study, which made headlines in Australia, sparked the new term ‘quarantine myopia’.

Recently, Professor Mingguang He and Professor Paul Baird, both professors at the University of Melbourne and Centre for Eye Research Australia, were co-authors of a comprehensive global research review of myopia published in Nature Reviews Disease Primers in December 2020, outlining a growing global crisis among young people.

They cite the prevalence of myopia in 12-year-old children shows major differences in some Asian regions, with 53.1% in Hong Kong, compared with 20% in the US, and 11.9% in Australia. In Australia, they claim one in four people (six million) have myopia and this is likely to double by 2050. But could these rates accelerate due to new habits brought about by the pandemic?

Practitioner’s perspective

A Sydney practitioner with a clinical interest in myopia control has noticed myopia progression accelerating amongst her predominantly Asian patient base.

Independent optometrist and ProVision member, Ms Susan Ang, owns Eyestore with practices in Bankstown and Kiama, south of Wollongong. “Bankstown is the epicentre of Sydney’s Asian and Vietnamese community, so there’s a pool of myopic people in the community.”

Susan Ang, Eyestore

Ang is working towards making her practice an exclusive myopia clinic in 2022 and is an active member of a private forum on Facebook, a companion to the Australian-created myopia control and management website, Myopia Profile.

“There has been discussion on the forum and thoughts shared on how practitioners fared last year in myopia management,” Ang says.

Specifically, forum participants have raised concerns about the rate of diopter change among myopic patients, the rise of the ‘quarantine myopia’ phenomenon, and the unique combination last year of winter, lockdowns, shut playgrounds, and parental anxiety about coronavirus.

Ang established her Bankstown practice in 2002, and says she noticed an increase in myopia when new technology such as iPads became widespread.

“Technology has accelerated myopia,” she says. “Last year NSW had six weeks of school lockdown. In term 3 – July – 50% of students went back to school, while the other 50% kept learning from home because parents were still working from home, on devices up to 10 hours a day, and kids followed suite,” she says.

Ang immediately noticed an acceleration in myopia progression among her existing patients, and she began identifying new cases with kids complaining of blurry vision.

“I saw a child in February [2020] before the practice was closed during lockdown. We re-opened in May and the child came in for their three-month review. The increase in diopters I would normally see over the course of a year, I saw in six months [in that child],” she says.

At Ang’s Bankstown practice, kids that were following a myopia management treatment plan did better during and after lockdown than those opting for single-vision correction or no correction.

“For the patients under my care, those on atropine 0.05% fared the best in combination with orthokeratology, bifocal, or multifocal vision correction. It has fortified my view that some treatment is better than none,” she says.

“Some parents take a ‘wait and see’ approach and see what happens. There’s still a stigma or belief among the Asian population that glasses make a child’s eyes worse. Technically, there is some truth in that – wearing single-vision lenses can make eyesight worse. To clarify, those under my care with some form of myopia management treatment strategy fared the best, while those without a strategy, accelerated.”

Ang says she prescribes a range of treatment options, including orthokeratology, bifocals, multifocals, and soft multifocal contact lenses such as CooperVision’s MiSight 1day.

“I started prescribing Hoya Vision’s MiyoSmart lenses in December but haven’t seen patients for review yet – that will happen in the next three to six months,” she said in January.

Despite a lack of clinical evidence in Australia on par with China’s latest data, Ang says the effects of lockdown on myopia progression among her Bankstown patients is “palpable”.

“Conversely, myopia hasn’t increased in patients at the Eyestore practice in Kiama, where the population is predominantly Caucasian, and the lifestyle is more focused outdoors as it’s near the beach. There are only five myopia cases in the Kiama practice’s database.”

Optometrist Mr Jenkin Yau, practice partner and founder of Sanctuary Lakes Eyecare in Melbourne’s West, says he has seen a spike in myopia progression in some of his young patients.

“Some patients myopia prescription – which has been well-controlled for a number of years – has now increased for the first time,” Yau, a ProVision member, says.

Jenkin Yau, Sanctuary Lakes Eyecare

“It’s [ostensibly] from a combination of more screen time and less outdoor time [in lockdown] than they would normally experience attending school.”

Despite the “unusual year”, Yau says many of his patients’ myopia has remained well-controlled, due in part to the range of treatment options available.

“I’ve prescribed a lot of Hoya’s MiyoSmart spectacle lenses since October [2020], as I’ve found them to be a good option for kids who aren’t ready for contact lenses. I also prescribe CooperVision’s MiSight daily disposable contact lenses, and orthokeratology lenses,” he explains.

Sanctuary Lakes Eyecare has a mix of Caucasian, Asian and Indian patients and Yau has seen some younger kids more often during the pandemic, as well as new patients referred via family and friends of existing patients.

“I’m hopeful we don’t have another outbreak, but nonetheless, our environment is changing normal patterns of behaviour. Parents have been more lenient with computer use over the past 12 months – it’s our role to provide education and advice about screen time and eye health,” Yau says.

Aussie quarantine myopia ‘anecdotal’ at present

Dr Kate Gifford is well-known as a thought-leader in myopia management here and abroad, with one of her most notable contributions being the Myopia Profile platform she co-founded with husband Dr Paul Gifford.

Kate and Paul Gifford, Myopia Profile

Today, it’s an internationally renowned go-to resource on clinical myopia management for eyecare professionals.

Gifford believes it’s too early to say if Australia has a ‘quarantine myopia’ problem, citing opposing observations in China and the US.

She says the Chinese study is a valuable data set but points out there is significant variability in home-based learning between China and Australia, with the former adopting a more structured approach.

And recent information from the US highlights conflicting opinions from clinicians and scientists on whether myopia seems to be better or worse due to home confinement.

In an article titled ‘What Has the Pandemic Done to Our Eyes?’, published in New York Magazine in January, Californian optometrist Dr Thomas Aller said he was concerned about what effect the pandemic would have on his myopic patients.

He suspected his school-age patients would experience “excess myopia progression” due to remote learning and living in a world where going outside is generally discouraged.

He conducted a survey of 65 of his myopia patients, all of whom were children and were being actively treated for myopia. Comparing their progression before and after the pandemic hit, Aller said: “I concluded that either these kids were very well protected during the remote learning and lockdown with their various myopia treatments, or remote learning was somehow less likely to trigger myopia progression than conventional schooling.”

Gifford says Aller’s survey results, which run counter to the Chinese study, could be partly due to less structured home-schooling, or the product of a less built-up Californian environment.

“Aller’s patients may have had more time outdoors versus students in hard lockdown who can’t leave the house, or have no accessible outdoor space, such as a backyard or courtyard,” she says.

“Right now, in Australia, ‘quarantine myopia’ is hypothetical or anecdotal, rather than based on systemic observation. In clinical science, there are levels of evidence, like a pyramid: anecdotal or observational evidence is at the bottom, and a randomised, controlled clinical trial is at the top of the pyramid. The virtue of the Chinese study showing myopia progression in lockdown is that it is a large scale, longitudinal data set, whereas Aller’s anecdotal or observational evidence demonstrates he is not seeing myopia progression accelerating.”

“Is it too early to say if myopia progression is accelerating as a result of lockdown? There is not a simple answer.”

Gifford says the Chinese study, including data from over 120,000 school students, demonstrates the average refractive error in children aged 6-8 years was similar between 2015 and 2019, but appeared to jump by a mean of -0.30D in 2020.

“In looking at the data, there was a small trend towards more mean myopia with time in these age groups. There’s no doubt that a larger jump in 2020 was evident. The jump is significant, but small and within the range of error of measurement. Nevertheless, is this jump due to COVID, or is this an acceleration of a trend which was already occurring?” she asks.

“The research team in China have been running that same testing every year for six years, so the timing of COVID presented an important data-collection opportunity.”

She believes the Chinese study results provide practitioners with an opportunity to discuss the visual environment with parents and young patients, including good screen habits, visual fatigue, and ultimately build greater awareness.

To assist parent-practitioner discussion, the Giffords created My Kids Vision, a free online tool that helps parents assess and manage myopia risks for their kids. A bi-product of Myopia Profile, it includes “how to” video guides on maintaining a healthy visual environment for children during COVID pandemic restrictions, which eyecare practitioners are freely able to share to their own websites and social media platforms. It also provides information on treating myopia, an area where new products are entering the market in rapid succession.

Spectacles to become new stepping-stone

Her husband and research optometrist, Dr Paul Gifford, says the market for treating myopia is on the verge of cracking wide open.

He points to CooperVision’s MiSight daily disposable contact lenses as having shown significant efficacy for managing myopia and been wellaccepted since launching in the Australian market, and now Hoya and Essilor are shaking up the myopia spectacle lens segment.

“Spectacle lenses – such as Hoya’s MiyoSmart and Essilor’s Stellest – with efficacy as good as contact lenses is going to revolutionise myopia management,” he says.

In the latest available information, Essilor has claimed after one year children wearing its Stellest lens saved more than half a diopter of myopia degree, on average, corresponding to a more than 60% slowdown in myopia progression compared with a control group wearing single vision lenses. Trials have concluded children wearing Hoya’s defocus lens had 60% less myopia progression compared with those wearing single-vision lenses.

Dr Paul Gifford explains: “Especially for very young children, spectacle lens options offer an opportunity for even earlier adoption of effective myopia control strategies, and can even act as a stepping-stone to contact lenses. These new spectacle lenses have the potential to revolutionise spectacle and contact lens sales. At the moment the step is often too high to go straight to contact lenses for effective myopia control, and single-vision lenses are not effective in slowing progression. Hoya and Essilor’s new myopia controlling spectacle lens options bring in an easier step and a lower barrier to jump into myopia management, for both practitioners and parents.”

He continues: “If I had a crystal ball, I would predict that these spectacle lenses will become more and more mainstream and be considered the normal mode of correction for myopes – making it easier for parents to accept and understand the importance of myopia management.”

The Giffords agree it will remain anecdotal whether ‘quarantine myopia’ in Australia is fact or fallacy but in China time will tell.

“The gradually increasing prevalence of myopia [in China] might account for the observation in this recent publication. This Chinese study has accumulated large volumes of data, with the same testing repeated annually for six years. Will the same study reveal a similar trajectory next year or was COVID-19 just a blip?,” Paul Gifford says.

Long-term implications could be ‘catastrophic’

Professor Padmaja Sankaridurg is head of the myopia program at the Brien Holden Vision Institute (BHVI) and conjoint professor at the School of Optometry and Vision Science at the University of New South Wales.

Padmaja Sankaridurg, BHVI

She has been managing the myopia program since its inception in 2003, and over the years BHVI has seen successful translation of its technology into myopia control products, namely peripheral defocus technology incorporated into MyoVision, and its extended depth of focus (EDOF) technology incorporated into a regulatory-approved myopia control contact lens manufactured by mark’ennovy (Mylo). It also recently penned a deal with Bausch + Lomb to develop a myopia contact lens.

And in 2019, BHVI signed a licensing agreement allowing its algorithms for tracking and estimating refractive error to be incorporated into Oculus’s world-first instrument for myopia management (Myopia Master).

Sankaridurg acknowledges the quarantine measures to manage the COVID outbreak saw schools shut and children confined indoors with their normal activities significantly curtailed.

“The challenge of the extended lockdown stretching into months has seen a shift to increased time spent online on digital devices,” she notes.

“This prompted a concern that the increased time spent indoors and on digital devices may have resulted in an increased progression of myopia or a myopic shift in refractive error.”

Sankaridurg points to the Chinese study which found an increased prevalence of myopia in children aged six to eight years in the year 2020 compared to previous years.

“As this study indicated, it appears that younger children, six to eight years of age who are in the critical stages of eye growth and development may be more prone to such environmental influences,” she says.

Sankaridurg says the potential long-term implications of accelerated myopia progression could be catastrophic for young patients.

“Increased and accelerated progression of myopia results in the eye reaching higher levels of myopia; -5.0D and above. This is particularly important if the myopia is observed in young children; the rate of progression of myopia is faster in younger children and since they are likely to spend a greater number of years in the progression phase, they are likely to reach higher levels of myopia. High myopia is significantly associated with a risk of complications particularly in adult life. Such complications may be associated with loss of vision and may be progressive, such as myopic maculopathy, for example,” she says.

Fortunately, Sankaridurg notes there is clear evidence that both the onset as well as progression of myopia can be better controlled with many optical, pharmaceutical and environmental strategies.

“Many of these strategies have been adopted by practitioners as off-label treatments – for example, use of multifocal soft contact lenses for myopia control – but more recently there have been products that have been specifically designed and available for myopia control. The uptake of such treatments has been steadily improving,” she says.

While having multiple treatment options is beneficial, Sankaridurg cautions that patient management is multidimensional.

“In addition to efficacy of a given product, many patient related factors such as age, motivation, lifestyle, product related factors such as affordability, availability as well as cultural factors and expertise of practitioners, influences the choice of a treatment strategy,” she says.

“For example, in young children with myopia, spectacles may be considered to be more convenient than contact lenses whereas in older children, contact lens may provide other benefits. Thus, having multiple options is desirable; they balance the individual’s circumstance and the desired outcome for myopia control.”

Sankaridurg’s colleagues Dr Kathleen Watt and Dr Pauline Kang, coheads of the Myopia Clinic at UNSW’s Optometry Clinic, have recently collated myopia progression data of children who attend their clinic, to evaluate if there was any impact of COVID lockdown on their myopia progression.

Results aren’t yet available, but it could provide the first true insight into whether Australia has avoided or succumbed to ‘quarantine myopia’.

Smart solution catalyst for change in myopia management

A myopia control spectacle lens that launched in Australia last year is proving popular among a new and unexpected cluster of optometrists.

Hoya introduced MiyoSmart with D.I.M.S. Technology here last October. The non-invasive method was developed on the back of a two-year double-blind randomised clinical trial in Hong Kong that showed wearing defocus spectacle lenses daily significantly slows progression and axial elongation in myopic children aged 8 to 13.

A peer-reviewed study found myopia progression slowed (SER) by 59% and axial elongation decreased by 60% compared with those wearing single vision lenses*.

Mr Ulli Hentschel, national training and development manager at Hoya Lens Australia, says uptake in Australia has been incredible, “especially among optometrists that have not yet begun myopia management services in their practice”.

Ulli Hentschel, Hoya Lens Australia

“This is very exciting because it seems that the introduction of MiyoSmart in the market has been the catalyst of change for many optometrists to start on this journey of myopia management. If we can help grow the number of practices that are treating myopia, we can help more children than ever before from progressing,” he says.

As the latest innovation in myopia management solutions, he says MiyoSmart is fast becoming a preferred first line option for eyecare professionals and their young myopic patients.

“As a spectacle lens that is highly effective, safe, easy to prescribe and use, MiyoSmart is a game-changer in terms of increasing the amount of children that have access to a myopia management option.”

In terms of the variety of children commonly being prescribed MiyoSmart, Hentschel says: “The majority would be young children that have either not had any myopia control treatment yet or less effective spectacle lenses, as well as children that have previously been wearing contact lenses and either didn’t want to continue or wanted an alternate option to contact lenses.”

*Lam CSY, Tang WC, Tse DY, Lee RPK, Chun RKM, Hasegawa K, Qi H, Hatanaka T, To CH. Defocus Incorporated Multiple Segments (DIMS) spectacle lenses slow myopia progression: a 2-year randomised clinical trial. British Journal of Ophthalmology. Published Online First: 29 May 2019. doi: 10.1136/bjophthalmol-2018-313739