Myopia is sweeping the world and beginning to have an impact in Australia. But there may be a way to identify it and stop it in its tracks. Insight takes a closer look and finds two eyecare professionals who have successfully prevented myopia in their own families.
Mr Jason Teh has broken the cycle.
Before the arrival of his own children, family gatherings were a sea of bobbing spectacles, a vibrant froth of frame styles, colours and lens thicknesses.
He’s seeing a few of those now as he speaks with Insight, during a visit to Vietnam with family to celebrate his father’s 80th birthday.
“In my family there’s me, my brother, my sister and our parents – all five of us are myopic,” says the Victorian optometrist , who has a special interest in myopia and dry eye disease in his In2Eyes practice in Melbourne’s Surrey Hills.
“My wife and her family circle are also highly myopic.”
Rather than stand by while two more young pairs of eyes were lost to the wave of myopia beginning to hit Australia, Teh decided prevention had to be better than management. That dealing with the possibility of pre-myopia was preferable to trying to control the eye disease after it had begun to undermine his children’s sight.
So Teh set upon a preventative path also trodden by a number of other professionals, including Sydney optometrist Dr Susan Ang, who had the same concerns for her children.
It’s a path with important waypoints, including initial work to detect the risk of pre-myopia in children, and then use of strategies to ensure the final destination is not myopia and vision loss. A path they encourage other ophthalmic colleagues to follow.
“When I had my two kids – they are 16 and 18 now – I was super focused on prevention,” says Teh.
He drew on all his experience from 24 years in independent practice, including the early years of myopia management, and the use of contact lenses and atropine.
He was swayed by growing evidence of the influence of environmental factors, and especially the promotion of outdoor time and reduced screen time, including research presented at the recent Global Orthokeratology and Myopia Control Conference in Singapore.
“There was a presenter who extrapolated all the researched data about outdoor time.
“He basically came up with a statement that in the first 10 years of your child’s age, if they got three hours of outdoor time a day, the risk of developing myopia is under 10%.”
That evidence backed up what he did with his own children, including encouraging them to put down their screens, head outside and pursue a sport.
Partly because of that, his 18-year-old son is a handy basketballer with “really good eyesight”, while his 16-year-old daughter remains a work in progress.
“She had a little bit more of an axial length risk. And then she started becoming ever so slightly myopic, so I got into the MiYOSMART D.I.M.S. [Defocus Incorporated Multiple Segments] lenses very early in the piece.
“Today, she still has a bit of astigmatism, which we’re managing, but her myopia remains extremely low and hasn’t progressed beyond -0.50D.”
Dr Ang has been similarly proactive to keep myopia at bay for her young son.
She is an optometrist with a special interest in paediatrics and special needs children, and sees patients aged between zero and 24 years old in her Sydney practice, Eyestore.
“The risk of changes in eyes usually stops about 24 and I feel that once they finish university and they’ve started work, their eyes generally stabilise and we can graduate them out of my care,” she says.
Dr Ang’s own son is far from graduating age, but at eight years old he was at risk of joining the growing global myopia alumni.
“I noticed last year that his eyes were growing a little bit, quite fast for that age group, so in July last year, I decided that although he was +1.00 D, I would put him in a pair of Essilor Plano Stellest glasses.
“He wears them during school time, homework, screen and device time, and I’ve just noticed a nice steady plateau of his eye length.”
That screen time is limited; the iPad use is only for school work and a little bit of social time at the weekend.
Dr Ang acknowledges that the lenses can be a pricy intervention for some parents, even before they face the challenge of enforcing sometimes unpopular rules around screen time and outdoor activities.
Also, this can often follow results of eye tests showing their child’s vision is good at this point.
But she insists that such actions are sometimes needed if there is a risk that eyesight might not stay that way. “We need to educate parents that seeing well is sometimes not good enough.”
That education is needed for practitioners as well.
One of the problems about heading down this particular path of pre-myopia is that it is still fresh, and the few signs along the way are vague and potentially misleading.
The path of myopia control and management is itself relatively new but at least well-trodden and understood.
Whereas, not a great deal is known about pre-myopia, how to detect its risk and the guidelines for ensuring it does not become its debilitating older brother.
That means optometrists and other eyecare professionals can find themselves on shaky ground.
The International Myopia Institute (IMI) has a little guidance on evaluation of pre-myopia.
It defines the condition as “a refractive state of an eye of ≤+0.75 D and >−0.50 D in children where a combination of baseline refraction, age and other quantifiable risk factors provide a sufficient likelihood of the future development of myopia to merit preventative interventions.
“It is likely that the other quantifiable risk factors include hereditary/genetic influences and lifestyle,” it says.
Using that definition, a recent study of almost 24,000 children in Taiwan aged five to six years found that the prevalence of pre-myopia could be 52%. Another study, in Shanghai, put the number at 21.9%.
Beyond this definition, there is little else to help eyecare professionals reach definitive conclusions on which they can build a case for clinical intervention, including potentially expensive glasses and significant behavioural change that might not actually be needed.
A child with a refractive result of ≤+0.75 D and >−0.50 D will not necessarily become myopic.
What that means in Australia is that practitioners like Teh and Dr Ang must go beyond simply measuring that refractive range and the axial length of a young child’s eye to determine if they are pre-myopic and at risk of myopia.
For Teh, “if you’re at age six and your cycloplegic refraction is around ± 0.50 D then that’s a risk factor.
“And then the axial length, anything over 23.5 millimetres, is definitely a risk factor.”
For him, other factors include whether one or both parents are myopic, whether the child spends less than 90 minutes outdoors each day, and how much near work the child does.
Ethnic background is another consideration for both practitioners.
Myopia is particularly prevalent in Asian cultures.
“When I first opened the practice, I didn’t realise that I was going to get such a following of Malaysians and Singaporeans and people from Hong Kong, so definitely about 80% of my client base is Asian or of Asian origin.”
That means he sees plenty of myopia.
“Growing up, we were always indoors and education is a huge thing,” he says.
That includes plenty of near-work and intense study on languages, music and other subjects, which raises the risk of myopia.
Dr Ang also likes to test a child’s hyperopic reserve, which is another recent focus for the IMI and an indication of how effective the child’s distance vision is.
“Hyperopic reserve can be eroded through too much device use,” she says.
“As a six-year-old, my expectation is that your child should have a hyperopic reserve or a plus figure that sits about +1.50 to +1.00 D. And then I’ll do my testing and say, ‘Look, your child sits at +0.50 D, and it’s a little bit low for this age group’.”
That intense education and a growing reliance on laptops and tablets in schools may be myopia risk factors for some, but Dr Rohan Hughes believes more education about pre-myopia may actually help to provide one path to preventing it in the first place.
The Postdoctoral Research Fellow in the Queensland University of Technology (QUT) Centre for Vision and Eye Research has secured significant overseas funding to investigate the early warning signs of myopia in Australian children.
The research, funded through the American Academy of Optometry Foundation, will be the first of its kind in Australia to investigate pre-myopia.
Dr Hughes knows myopia well. He sees plenty of it in the QUT Myopia Control Clinic, where he works as one of the supervising optometrists.
“It’s the kids that are pre-myopic that have always interested me because we know that they’re already on the pathway to myopia, so the logical question is always whether we can try and stop the process.”
It’s already too late for Dr Hughes.
“I’m myopic, but I find it interesting because I grew up in North Queensland and you tend to spend a fair bit of time outdoors,” he says.
“But I was also a pretty avid reader, and I feel like I had the two most well-established risk factors sort of working against each other, but I’ve still ended up being myopic.
“So that has certainly piqued my interest in research.”
He too believes that preventing myopia in the first place would be better than having to rely on various ways of managing it.
“We know that if we can delay or prevent myopia progression, then we have better outcomes long term with respect to the ultimate level of myopia and the risk of myopia-related eye disease.
“If we can actually stop them from becoming myopic in the first place, if we’re able to identify factors that can predict the kids that will become myopic, it gives us the opportunity, clinically, to intervene a bit earlier with myopia control treatments that might actually prevent or at least delay the onset.”
As part of the study, Dr Hughes and colleagues Dr Emily Woodman-Pieterse, Professor Steve Vincent and Professor Scott Read, intend to first conduct vision screenings of more than 1,000 children at schools across Brisbane, to identify the prevalence of myopia, pre-myopia and other refractive errors in Australian school children.
The second part of the project will be a 12-month longitudinal study of those children identified as pre-myopic.
“We’ll be measuring eye growth and refractive error, and capturing images of a range of eye structures, and seeing if there’s anything that we can measure in a clinical setting that might predict a kid who’s going to progress towards myopia development.”
The researchers will also look at a range of environmental factors, from the oft-mentioned near-work and outdoor time to different variables such as diet and sleep.
“Diet and sleep have been loosely linked with myopia in the past, but there’s not a lot of solid evidence behind either of them,” says Dr Hughes.
That’s one of the challenges of approaching pre-myopia.
Many eyecare professionals like Dr Ang and Teh are doing good work, but pre-myopia and its treatment is understudied.
However, research is rapidly emerging, says Dr Hughes.
“The definition for pre-myopia was only established in 2019 from the original IMI white papers,” he says.
“Until now, most people have identified that myopia is a problem and that we should try to slow progression, and clinicians have certainly been offering advice regarding lifestyle modifications with the hope of preventing myopia development or delaying onset.
“But now, with this definition, I think the focus has shifted in the last couple of years to trying to identify what we can actively do to prevent or at least delay myopia from developing using our current myopia control treatments.”
The sector was already grappling with the building wave of myopia.
“The added concept of pre-myopia may be adding complexity to clinical myopia management, but pre-myopia and myopia are essentially part of the same process, so we can always be doing work to understand and manage both aspects.”
Ms Jeanne Saw, manager of professional affairs and relationships at Myopia Profile, doesn’t believe that a focus on myopia management should come at the expense of work to prevent the eye disease in the first place.
“Pre-myopia is a natural extension of myopia management, so I think that in order to reduce the overall impact of myopia, naturally it’s important to also focus on pre-myopia.”
Myopia Profile, founded by Brisbane optometrists Dr Kate Gifford and Dr Paul Gifford almost a decade ago, is now one of the world’s premier sources of support and assistance for eyecare professionals, practices and parents.
It has some pre-myopia guides and resources on its online platforms.
“Our Managing Myopia Guidelines Infographics, which are freely available on the Myopia Profile website, has a section for risk factors on the practitioner chairside reference side. This details all of the different risk factors to look out for,” says Saw. “And it also details what to discuss with patients and parents on the parent-facing side.”
She agrees that while it may be ideal to focus on prevention and not just management, research on pre-myopia is currently sparse and limited, and there are plenty of knowledge gaps for eyecare professionals, parents and young patients.
Dr Hughes and his team plan to publish their findings in about two years.
He hopes that these will reveal scientifically backed predictive factors that have direct clinical applications for practices and patients.
“If we find something significant that you could actually measure clinically that then indicated, or ideally predicted, that a particular child was about to undergo a really rapid rate of eye growth and then most likely go on to develop myopia, it would allow us to identify and intervene with those children and start applying myopia control treatments to either prevent, delay or slow it.”
Dr Ang and Teh will be keen to see those results and the tools that flow from them.
But they are not hanging around.
Research and data might be limited, but all agree that environmental factors such as outdoor time, near-work and screen use, among others, are helping to fuel the rise of myopia and are possibly key to preventing it in the first place.
“I just said to a young parent, ‘If you’re going to a dentist appointment or optometrist appointment, bring your child a toy, a water bottle, fidget toys, and let them go for it,” says Dr Ang.
“You don’t need to hand them the phone at three years old – that’s the social norm because it’s a whole social anxiety about how their kids have to be online, catching up with their social life through Tik Tok and what have you.
“We’ve engineered myopia into our lives.”
Now it’s time to find the tools to prevent it.
More reading
US-backed study of Aussie kids will provide insights on pre-myopia
Survey exposes how little parents know about their child’s myopia
Playing it safe: integrating UV safety with myopia control
