Lecture: Myopia: Dispelling Myths and Misconceptions

During this live webinar, we will be discussing the growing pandemic of myopia, some of the common myths and misconceptions – as well as providing an update on the latest advances in diagnostic imaging plus treatment options available.

Lecturers: Dr. Marcus Ang, Ophthalmologist, Singapore National Eye Center


[Marcus] My name is Marcus Ang, I am a senior consultant at the Singapore National Eye Center. I’m a cornea refractive surgeon but I’m also the clinical director of the SNEC Myopia Center which was set up two years ago to combat or to tackle the rising prevalence of myopia in Singapore.

Before I start, I thought I’d do a quick self introduction for those who don’t know me. I, as mentioned, I come from Singapore. And Singapore is famous for many things including our food, our sites, our airlines, and of course, most recently, a really famous Hollywood movie filmed in Singapore. Unfortunately, we’re also famous for myopia. Not just in our children, where we estimate that about 20% to 30% of our seven-year-olds are myopic. But in fact, as our young adults go into international service and they leave university, up to 70 to 80% of them are actually myopic as well.

And of course I’m biased because I have a wife who’s an ophthalmologist as well and I have a two-year-old and a four-year-old who are now basically reaching the age where the risk of myopia onset or incidence of myopia actually is the highest. This topic is close to my heart, not just at my job, but also at home. I think that, as eye care professionals, we all see the importance of myopia and the worrying trends around the world where myopia rates are actually increasing. But we also see a bit of a worrying trend where perhaps we’re not doing quite enough to arrest or to slow down the rising prevalence of myopia in our own societies, in our own health care settings, and in our own populations.

As I became the clinical director of the Myopia Center, I came across quite a few myths and misconceptions about myopia. Both from parents, patients, as well as policymakers. Sometimes government officials, or lay people, and even sometimes, fellow eye care professionals. I thought I’d share some of these misconceptions and myths and what we can do to basically discount them.

The thing I feel most common, unfortunately, is that myopia is a problem which is basically affecting Asia. The second most common thing I hear is that myopia affects kids, it doesn’t really affect adults. And this is really common among young teenagers or young adults who have myopia. Unfortunately, or fortunately, I think there is an understanding that myopia can be corrected with optical corrections, contact lenses, prescribed glasses, and even refractive surgery. But I think among both young adults, as well as sometimes even policymakers, there seems to be a misconception that myopia is just a refractive error that can be reversed with these interventions and it actually doesn’t cause any vision impairment.

Because of that misconception, I think this leads to the next two common myths which is basically myopia is easy to diagnose and easy to detect. And finally myopia is thus easy to prevent and easy to treat. And I think these are the most common misconceptions that I’m seeing in my capacity as clinical director of Myopia Center, both in the population and as well as among stakeholders, and I thought I’d share and elaborate on some of these misconceptions.
First and foremost, myopia is an Asian problem. I mean, there’s no doubt there. Among the east Asian cities, especially those which have high educational pressures, we are seeing that they have the highest incidence and prevalence of myopia around the world. And, of course, we are seeing a worrying trend among the children, even up to the age of 15, where basically the prevalence and incidence of myopia continues to increase in these urban cities.
But you know, myopia is beginning to increase in terms of prevalence around populations with European ancestry as well. There are emerging population-based studies in Europe, as well as around the world, where we are looking at increasing prevalence and incidence of myopia up to even 50%. And this is keeping with the long term population trends outside of Asia, where we see basically rising prevalence of spherical equivalent and axial length elongation even among the adults as they get older outside of Asia.

In fact, based on a global trend, according to birth age, in the last five to even eight decades, overall myopia prevalence has increased around the world. Based on these studies, we now project that myopia will not just affect Asia, but affect billions across the entire world. We estimate that up to five billion people will have some form of myopia and even up to one billion will have high myopia by 2050.

That’s a common misconception and I think all of here will probably notice by now that myopia is not just an Asian problem, but a global problem.
The second I hear most is that myopia affects children and not adults. This misconception usually comes from our patients and young adults who have myopia. And of course, once again, sure, myopia does affect children more. It’s pretty worrying, especially around east Asian urban cities where even up to the age of 16, teenagers and beyond, the myopia prevalence is now creeping up to almost 80-90%. But what we do know is that myopia, particularly high myopia, is associated with complications such as retinal detachment, cataract, glaucoma, as well as macular degeneration. And the incidence and the prevalence of visual loss and visual impairment actually increases with age. It doesn’t just increase with the severity of myopia, but as one gets older with myopia, the risk of visual loss actually increases. That’s something important to understand and it’s important to educate our young adults who already have moderate to high myopia, who think that this is just going to affect them when they’re young and it’s not going to affect them when they’re older.

I had a patient who just came in last week, she’s -15 diopters in both eyes before LASIK, which was done 20 years ago. And she came to my clinic because basically her optometrist referred her for increasing myopia up to five diopters in both eyes, even though she had LASIK done. On clinical examination, actually essentially she has a normal examination, which was confirmed with scans to exclude acacia, cataract, as well as macular degeneration or dome shaped macula. Essentially what this patient has is regression of her LASIK, or basically progressive myopia beyond 15 diopters as she reaches the age of 40.
And we’re seeing that becoming more and more common in a clinical practice. And what we’re trying to educate our patients is basically to correct this misconception that myopia affects you only when you’re young. But actually, visual impairment related to myopia actually affects you even as you get older and even as you become, reach your 50s or 60s.

But what I think what’s troubling is that high myopia affects adults really at their prime. At the age of 40, we see a bimodal distribution of high myopes. This is a doctor who came, who’s one of my patients, who struggles, basically, because she’s turns out there’s a bass line. She alternates between wearing RGPs and glasses, depending on what kind of activity she’s doing at work, and during her exercise. And now she’s come in with 30 diopters of myopia in both eyes, really unable to function, and really affecting her quality of life. And we know that basically high myopia begins to affect productivity in adults at their peak, at their prime. And this is something which we’re trying to educate our patients, as well as stakeholders or policymakers, that myopia doesn’t just affect children but it really starts to impact adults at their prime. And, of course, leading on to further complications as they get older.
Now myopia is, without a doubt, one of the major causes, or major problems of uncorrected refractive error around the world. This is from the World Report on Vision and we know that my myopia doesn’t just cause vision impairment through uncorrected refractive error, but also it can affect education, opportunities, and function beyond just visual function. And that’s worrying, because myopia is now not just a refractive error, when uncorrected has huge global impact or burden on societies. Unfortunately, uncorrected myopia affects societies in unequal or disproportionate ways. We find that in rural areas, compared to urban areas, uncorrected myopia is a much bigger problem.

And unfortunately, around certain regions around the world such as Asia, uncorrected myopia affects us more. In our own population area studies, we know that the cost of myopia is huge. Not just from a population-based perspective but also from a healthcare setting point of view. And we’ve already mentioned that as myopia severity increases as the population ages, the risks from visual loss from myopia actually increases as well.
Eventually, what we’re really worried about is pathologic myopia which affects 2 to 5% of the population with high myopia. And we now estimate that 3% of the entire world actually suffer from visual impairment from pathologic myopia, which is irreversible. There are many retinal features, but the main hallmark is thinning of the choroid, thinning of the sclera, and staphyloma formation. But visual loss really comes from myopia-associated optic neuropathy, as well as myopia-associated macular degeneration.

Myopia is not just a refractive error. When uncorrected it leads to population public Health burden, loss of education and opportunities, especially around rural and Asian regions of the world. And when it does lead to complications such as pathologic myopia it can cause irreversible vision impairment. So this is something that we’re trying very hard to educate both the public, our patients, as well as policymakers. As I already mentioned before, because of the first few misconceptions, somehow people think that myopia is easy to diagnose and its complications are easy to diagnose. But to start with, there’s a huge problem in defining myopia. And so it’s hard to solve a problem, or diagnose a problem, when we can’t agree on how to define it.
If we look at prevalence of myopia based on studies around the world, both from east Asia, Asia, as well as Europe, we find that, well of course, there are varying degrees and varying prevalences of myopia. But it also depends on how myopia was defined. And when we are reporting myopia as a diagnosis, it does depend on how myopia was measured. So if you’re looking at school health based screenings, especially around Asia and China, poor unaided visual acuity is the most commonly used screening tool. And if we use that as the benchmark, we’re looking at about 10 to 15% in this study, for example, among 6-year-olds. But if we look at non-cycloplegic refraction, that value or that prevalence drops to about 10%. And if you actually conduct cycloplegic refraction, that prevalence of myopia is actually 2 to 5%.

How do we diagnose and define myopia? Should it be based on uncorrected visual acuity, which is what a lot of population-based studies are using in children? Should it be based on refraction, should it be refraction, altered refraction, cycloplegic refraction or non-cycloplegic refraction? There are many groups around the world advocating for axial length measurements now being used as to the definition or diagnosis of myopia because it’s objective. But do these really correlate well with function and are there enough studies in enough data to show that axial length actually correlates closely with visual acuity and finally visual impairment in myopes and high myopes? There are a lot of questions about the diagnosis of myopia still.

But beyond that, once we’re dealing with myopia the challenge really is to diagnose its complications. Because its complications is what causes the visual impairment in the end. But the problem is, the optical aberrations associated with myopia and high myopia, even axial length measurement as I mentioned before, is challenging in eyes with abnormal or irregular axial elongation, especially in staphylomas. And the irregular structures of the eye make it very difficult to measure, for example, choroidal thickness, or even retinal thickness in highly myopic eyes.

Fundus photography, for example, is probably one of the most common tools that we use to diagnose myopia as well as its complications. We know the limitations of fundus photography, as it captures a very small area within the fundus, or the retina. And in eyes with staphyloma, the structure of the staphyloma and the eye is not fully captured with fundus photography. MRIs give us the holistic evaluation of the structure of the eye. But we know that this is expensive and not widely available. It’s impossible to MRI all our eyes, all our patients with staphylomatous eyes. Recently, wide field imaging has emerged as a potential adjunct to basically diagnosing myopia and its potential detection of complications with a field that’s up to 7 to 10 times the original size. And this might be useful to diagnose myopia and its complications in staphylomatous eyes and to look out for features such as ischemia or fundus changes in the periphery of the retina.

Essentially, what we really need is an imaging modality that is accessible. OCTs are very useful and provide high definition, but they’re not widely available and may be expensive to perform. Another issue with diagnosing myopia and its complications is evaluating the optic nerve. As we all know, myopia affects the optic nerve structure as well as shape, and it’s very difficult to diagnose myopia-associated optic neuropathy or damage to the optic nerve or even glaucoma in highly myopic eyes. We try and use multimodal imaging or multiple modes of assessments such as visual field, OCT, on top of clinical evaluation to diagnose myopia-associated optic neuropathy. But still this is extremely challenging. Detecting myopia and its complications or causes of visual loss becomes extremely challenging.

Last, but not least, measuring the axial length, as I already mentioned, is extremely difficult. There are multiple ways of doing this using multiple biometric compilations. But as we know, as the axial length of the eye increases, the accuracy of this decreases and the variability increases as well. And this is important for us to manage patients with high myopia and suffer from complications such as cataracts, which unfortunately can happen at a much younger age compared to non-myopes or low myopes.

And because myopia is challenging to diagnose sometimes and its complications are difficult to detect, it makes the management of myopia extremely challenging. The management of myopia essentially involves two aspects. One, we’re trying to prevent myopia from progressing so that myopes don’t become high myopes, which essentially have a higher risk of developing complications as well as developing pathologic myopia. And two, can we actually prevent visual impairment from occurring in eyes with high myopia and pathologic myopia?

Fortunately, recently in the last five to 10 years there have been a lot of new and emerging interventions for myopia control in children. And basically these can be divided into environmental public health interventions, optical interventions, as well as pharmacological interventions. However, even though the evidence that’s emerging for outdoor time, for example, is getting stronger and stronger from randomized trials, as a public health intervention, this is extremely difficult. We know that there’s a dose-response relationship for incident myopia from quite a few studies around the world. And what we’re trying to do is to encourage one to two hours of outdoor time for our children in schools, even though we know that it may not have any, or minimal effect on myopia progression once the onset myopia occurs, especially in our five to six-year-old children.

The relationship between outdoor time and near work is also complex. The evidence for near work is closely intertwined with outdoor time. And it’s very difficult to separate which one is more important. But we do know that outdoor time seems to be the more important factor in preventing myopia onset and certainly when it comes to the debate about screen time. In Asia, we do know that myopia has been rapidly increasing, even before screens were invented. So we still advocate outdoor time as a more important public health intervention. But this is extremely challenging, especially as I mentioned before, in east Asian cities where the educational pressures are extremely high and basically putting one to two hours of outdoor time into regular curriculum in the schools has been an extreme challenge from an interventional point of view.

We have to rely on other interventions which can help children prevent myopia progression. Outdoor time may reduce incident myopia, but what we need is basically optical interventions. And fortunately there have been more and more designs emerging with evidence from randomized trials that show a moderate effect on reducing myopia progression. And as well, as orthokeratology, which also has shown to reduce axial length elongation.

Orthokeratology has been around for a long time. And the debate still goes on about efficacy versus safety, as there are concerns in replicating clinical trial results in the real world. And the safety that can be replicated in trials. We watch our trial subjects very closely for complications, we spend the time educating parents and children who are involved in randomized trials. But we do know, based on real world studies and real world experience, for example, that reported in China 10 years ago where there was a spike in infections with orthokeratology use. And so the concern with overnight contact lens wear, especially in our children, still remains a concern.

The recent emergence of data that support multifocal designs where basically these are daytime wear, are much welcome in the community at the moment. I think there is enough evidence from trials that suggest that there is a significant mild to moderate reduction in spherical equivalent progression in children with contact lens wear. And we are waiting for more long term results to emerge.

We summarized the optical interventions that we can use in combination with public health interventions. I think that these are basically promising. But there are still a lot of challenges with treating myopia or preventing myopia progression from a public health perspective as well as from optical intervention perspective.

Pharmacological interventions have been around for a long time as well. Atropine being the most common. And even until today we don’t exactly understand the mechanism of action. But what we do know is that it does work, both in the high dose as well in the low dose forms, just about the balance between the side effects as well as the efficacy. Without a doubt, pharmacological interventions do work and it adds to another option to treat our children to prevent myopia progression.

Given, even then, there are its many challenges, even though we have so many options at the moment. I think a lot of questions still remain. As mentioned before, even for atropine or orthokeratology, can we actually replicate such good results in the real world setting? Is the safety more of a concern in a real world setting? And are we educating our parents and children and patients enough to prevent complications from happening? We do not know a lot about initiation, when do we escalate treatment, when do we stop treatment? These are not well-defined based on the clinical trials. And really while there are a lot of promising clinical trials, published results, long term data beyond five years is really lacking. And what we really need is more trials and studies and results coming out from other parts of the world other than Asia.

I think that even though it’s promising that there are more options for us to treat and prevent myopia progression in our children, there are still a lot of challenges in terms of treating and managing myopia.

Taking one step forward, though, what we really are trying to do is prevent visual impairment from high myopia. What we’re hoping to do is, the children don’t get such severe progression to high myopia which puts them at higher risk of the complications associated with high myopia and the development of pathologic myopia. Because once pathologic myopia occurs in adults, then the management of pathologic myopia becomes very challenging. Fortunately with, for example, myopic CNV, we see the anti-VEGF treatments are actually quite effective and there are surgical interventions that can be used to great myopic traction maculopathy. But the treatment of myopia-associated optic neuropathy or end stage myopic macular degeneration are still really ineffective for preventing end stage visual loss at the moment.

We also don’t really understand enough about pathologic myopia. Because it’s really multifactorial. We assume that axial length elongation leads to the complications associated with pathologic myopia. But in reality, we know that basically staphyloma formation, for example, does not always correlate well with axial length elongation or the risk of progression of myopia in children. We also know that corneal retinal atrophy or basically end stage myopic macular degeneration, does not always occur in eyes with long axial lengths. So there’s a lot that we don’t know surrounding the mechanisms of development of pathologic myopia. And if you don’t understand it, it’s extremely difficult to treat. And because the genetics of pathologic myopia development’s also so complex, it’s extremely difficult to try to detect individuals who are higher risk of developing pathologic myopia.

In summary, we don’t know how to effectively prevent pathologic myopia. We assume the axial length elongation and prevention would reduce the complications associated with pathologic myopia and staphyloma formation, but that really isn’t proven at the moment based on evidence. We also don’t have sufficient evidence to suggest that preventing axial length elongation and myopia progression reduces the risk of staphyloma formation or visual loss, because pathologic myopia development really is multifactorial.

In summary, I’ve talked about five very common misconceptions from the public, parents, and patients, but also from sometimes fellow eye care professionals, policymakers about myopia. Common things I hear is myopia is more prevalent in Asia. It’s true, but it’s mainly an Asian problem which is not a global problem. But now we know that basically myopia is set to affect the entire world in a very disproportionate way, but it’s set to affect the world on a global scale. Many patients and parents and young adults think that myopia is something which affects them only when they’re young, but we now know that’s not true. As myopia progresses and leads to a lot of complications and affects quality of life and visual functioning, especially as they become productive in their 40s, through 50s, and eventually leading to visual impairment, potential vision impairment from potential complications, as these patients become elderly.
Myopia is a big problem from a public health perspective as a form of uncorrected refractive error which affects rural areas more than urban areas and Asia more than the rest of the world. But beyond that, myopia can lead to pathologic myopia, which has an irreversible vision impairment from mainly optic neuropathy and myopic macular degeneration. And because myopia is difficult to define around the world, policymakers sometimes struggle to understand the full burden of this disease. And because it’s not easy to diagnose and its complications are not easy to detect based on conditions which actually lead to visual impairment, myopia is actually very difficult to treat and prevent. Because children, which we’re trying to basically prevent myopic progression or even incident of myopia from developing, can be challenging because of how we find it difficult to implement public health measures.

But also the myopia control interventions, which are now available where this optical/pharmacological, have their own set of risk-benefit ratio with a lack of evidence surrounding treatment protocols, when to treat, when to escalate, when to stop. So these are basically the challenges in treating myopia, preventing myopia from occuring in our children. And so doing, even if we do prevent myopia from progression, there’s a lot of lack of evidence in terms of how to prevent pathologic myopia and visual impairment from occurring in our adults.

Surrounding all these problems, I think that as eye care professionals, we really need to come together to collaborate, to bring together all our resources, to basically dispel these myths among our patients. And also engage other stakeholders such as policymakers to basically gather more resources to deal with myopia. A good start would basically be international engagement of stakeholders. We do this often with Orbis, with IAPB, we do this often with the WHO. And basically, to have what I call the public-patient-parent education to make them understand that myopia is not just a refractive error. Because, basically, eye care professionals around the world know that the patients come in as the first point of entry because they require optical corrections. And so that’s a good opportunity for us to take that opportunity and educate them that myopia is beyond just correction of using contact lenses or glasses or spectacles. But also something that they need to be aware of, even if they go into their adulthood and elderly life, that they need to manage and watch and look out for potential complications.

A lot of investment and effort also needs to come from us, eye care professionals, to try to detect early onset of complications that can lead to vision impairment because early detection and early treatment can prevent visual loss. And last but not least, a lot more resources probably need to come in for us to answer those unanswered questions. In terms of using research and development using resources, engaging industry to invest in more clinical trials for us to answer those clinical questions for us to basically manage and treat myopia in a more effective way.

I thank you for your time and attention on this topic. Obviously it’s a topic that’s close to my heart. I think some of the things that I shared may not be new to you, as eye care professionals, but certainly is something which I face commonly in my clinic, in my practice, when I’m talking to patients, parents. So I feel that still more can be done in terms of education, awareness, international engagement of stakeholders. I’m really glad that you’ve joined me through this Orbis/Cybersight platform.

I’d like to thank Orbis, once again, for this opportunity to talk and chat about this topic which is big. I hope you’ll believe me now that it’s big, not just in Asia, but around the world. Wherever you are dialing in from, I hope that you have some questions or some topics that we can discuss for the next 20 minutes or so about myopia.

The first question coming in is basically to talk about the usefulness of atropine and which age groups do we typically prescribe this in. Atropine is something that, as I mentioned before, that has been prescribed in our children around Asia, especially Singapore, for the past few decades. It’s not actually widely available as yet because it is still considered off-label. Sometimes, in some countries, there are commercially available formulations of atropine. But essentially what we are advocating for the moment, is basically low dose atropine. In Singapore the most common concentration that we use is 0.01%, but there are 0.02% and 0.025% available, both commercially and also clinically being used.

Typically we use these eye drops once a day in children who have rapid progression of myopia. Typically more than one diopter a year, but again, this is subjective based on the clinical practice. And the context, really, is about the risk of myopia progression, whether the child is rapidly progressing at a younger age and whether they have risk factors such as a family history of high myopia or even parental high myopia.

As mentioned before, the real challenge is that a lot of these prescribing patterns are not well-defined based on clinical protocols. And do vary widely based on the clinical practice whether you’re looking at Singapore, Hong Kong, China, or even Australia, and the rest of Asia-Pacific. It would be very difficult for me to basically pin down how we would be able to prescribe atropine based on an individual child or an individual patient. But what I can share is based on randomized trials that are replicated in Singapore and Hong Kong and many parts of the world now based on low dose atropine. We are seeing 30% to 50% reduction in myopia progression compared to placebo, which is basically eyes which are not receiving any atropine, just normal saline eye drops. And that is quite promising from a clinical perspective.

Right. So the next question is basically about floaters in highly myopic eyes. Is this something which is normal or is it something which is a complication that we do need to manage? Floaters is, of course as we all know, something which is very common even in low myopes or even non-myopes. What it reflects really, is the vitreous syneresis, or vitreous detachment that occurs with age. Leading to, basically, a more pronounced realization and visualization of the vitreous gel within the eye. Posterior vitreous detachment does occur at a slightly younger age sometimes in highly myopic eyes. And actually, interestingly, we published a paper recently using very high resolution OCT to look at the vitreous attachments. Because basically now with high resolution OCT, we now are able to visualize, not just the retina and the retina layers, but also the attachments of the vitreous to various points of the retina.

And what we found is that vitreous attachments play a very big role in the development of myopic traction maculopathy, such as epiretinal membrane, basically vitreous syneresis, and also retinoschisis associated with myopic macular degeneration. What we think is the vitreous is actually an important part, or plays an important role in myopia degeneration. But we’re only starting to understand its role, at the moment, with advancements in imaging technology that allow us to actually image the vitreous. I think we will see, in the future, more and more studies emerging about vitreous and the role of the vitreous, in high myopia and myopia progression.

Another question is about atropine again and this question is for cost. In some countries 0.01% can be more expensive than 1% atropine and is there any explanation for this strange phenomenon? I think this question is highly relevant. It is obviously country-specific. What I can share is that 1% atropine has actually been around for a long time. We use it, for example, to provide cycloplegia in uveitis, for example, we also use it to treat certain conditions. And basically what happened is that when atropine first emerged as a potential treatment for myopia progression, we actually used 1%. You must understand that this is commercially available, widely available, and made by many companies already preexisting 10 to 20 years ago.

The problem is that diluting and making 0.01% probably requires more companies to come on board and basically get them to change their manufacturing process to include this as part of their pharmacy. And if they don’t have that cost-benefit numbers to make sense, they probably would carry on just telling the 1%, which is what they’ve been selling for the past 20 to 30 years. The good news is there are a lot of commercial companies around the world now and pharmacological companies that are beginning to make low dose atropine best part as a commercial product. So as I mentioned before, they are already commercially available at 0.01%, 0.02%, and 0.025% available. And we will see the cost of these eye drops come down over the next few years, I believe, as more and more commercial companies start to manufacture this.

Another question is related to atropine and it’s about low dose atropine. For low dose atropine, how long does the cycloplegic effects last in a day? Does it affect accommodation during the daytime and do we advise patients to use progressive lenses along with atropine? This is actually a very good question. And we saw this a lot more in terms of side effects when we were using 1% atropine in our children. And of course as you would expect, the higher proportion of children suffered from cycloplegic side effects when using 1%. And pupil dilation sometimes can cause a lot of glare in the daytime and the patients actually had to wear progressive glasses to counter the cycloplegic effects.

What we’re seeing though is that with low dose atropine, especially just once daily, the cycloplegic side effects are a lot less. I would say 0% but it’s a lot, lot less. It really, again, depends on which trials that you’re looking at and how compliant the children are with the eye drops. But in our clinical practice, this is really uncommon and now we find that low dose atropine is actually quite well tolerated by children if they’re compliant in our clinical practice.
Another question that’s come on that is very, very interesting and this was a topic that was hotly debated at our meeting in 2019 before the COVID pandemic actually set in. And we hosted, in Singapore National Eye Center Myopia Center, a collaboration between IBB, we had representatives from Orbis. What we did was we brought together stakeholders, eye care professionals, optometrist from the World Council of Optometry, opthamologists, epidemiologist, policymakers from around Asia-Pacific. And what we wanted to do was talk about certain, wanted to debate about certain controversial topics surrounding myopia and its management. In fact, we published the results of that debate in the British Journal of Ophthalmology last year.

And one of the questions at one of the debates is actually posted by one of our listeners today and it’s about insurance reimbursement for conditions associated with myopia. Insurance companies, in general, do not reimburse conditions associated with refractive errors such as myopia, but what about pathologic myopia and its associated complications? And what about other countries? What countries are looking to do this? And we debated this with policymakers from Singapore and around Asia, together with Health Services Research, or HSR experts from Australia and Singapore, to talk about the pros and cons of insurance reimbursement for myopia-associated complications. And really the conclusion from the debate might answer your question. I think it’s very difficult for us clinicians to accept that our patients, we’re watching patients with high myopia, that patient I presented earlier on who’s a 40-year-old with 30 diopters of myopia, unable to function and really affecting her quality of life. And she’s a doctor who was very productive and also very active in her work and outside of work. And for us to say that look, that patient in a poorly resource setting, would not be able to seek financial support to treat her myopia and its associated complications, seems to be a bit of a travesty. Compared to, for example, an individual with cataracts or an individual who has glaucoma, or retinal degeneration, or retina requires some form of treatment.

I think that we definitely need have a cause for debate and I think this brings me to my message from the lecture which is basically I think what we need to do is really engage policymakers, including insurance companies, government officials, stakeholders, on the international level, for everyone to understand a little bit more about myopia that it’s not just a refractive error in certain individuals. It can lead to loss of function and loss of quality of life in certain individuals. And for those individuals we should consider having more support from healthcare policy and insurance policy point of view. I hope that answers your question in terms of what people believe in and I think that the way forward is basically to have more engagement and awareness about this.
Another question is about atropine again and what’s the earliest age? In general, low dose atropine based on the evidence in the trial so far, have been to treat myopia progression. We are doing a randomized trial at the moment to look at onset of myopia or preventing low myopia from occurring, however that trial is not completed. So there really is no evidence to treat low myopia or incident myopia so we’re only reserving it for high myopia or moderate myopia, preventing for more myopia from becoming high myopia in our children. And for that reason we actually don’t start them at such a young age. So it really depends on their myopia and how fast it’s progressing. But in general, safety studies are not available for ages which are too young, less than six to eight years old, so we’re really looking at the school-going age where myopia is rapidly progressing.

The next question is about diagnosing myopia. I love this question because that really highlights my fourth point, which is myopia is easy to diagnose. Everybody understands the concept of myopia and how to diagnose it. This question was quite specific. Do we use spherical equivalent to diagnose myopia? For example, if a child comes in with hyperoptic that means she’s plus one or +0.75, but has very high astigmatism, -4 diopters of astigmatism. This patient spherical equivalent is actually myopic. But really is this child or is this person myopic? That is a really good question. If we look at epidemiological definitions, if we look at public health definitions based on spherical equivalent, absolutely. This patient based on spherical equivalent is, by definition, myopia.

But if we were to group this child or this eye together with our typical -2 eye, for example, in a seven-year-old, we do know that the disease or the condition is completely different. And that’s what we struggle with both as epidemiologists or researchers, as healthcare professionals or clinicians, as government officials. So what we really need is a common definition and then that is not easy. And should we be using axial length then since that’s a lot more objective, or should we be just using basically the sphere instead? So the debate goes on.
And so what I would recommend is really look at the definition carefully based on the patient sitting in front of you, versus, and differentiate it from booking at research studies or data that’s coming up from prevalent data around the world or from WHO and know the difference. If you’re a clinician and you are a practitioner, eye care professional, make sure you diagnose myopia and manage the myopia based on the child or the patient sitting in front of you. Define the myopia well, monitor the patient, and progression well, and know what we’re treating. I’ll be a lot more concerned that a seven-year-old has -4 degrees of astigmatism and look out for any corneal conditions or amblyopia, and worry about more than the actual definition of myopia. Yes, you could debate but in reality, clinically, diagnosing myopia in this individual is probably not as important. But of course, once you’ve excluded corneal conditions, once you’ve excluded amblyopia, then watch or advise this child to be monitored closely as he or she becomes an adult, to look for other signs of myopia progression and other potential complications as they get older.

I have another question which is about contact lenses, and we seem to be moving on to contact lenses now which is nice. There are a lot of questions about atropine, which I’ll try to go through. But we do have about five minutes left so I’ll try to move through quickly. What do I think about multifocal soft contact lenses? So I did mention it as one of the options in my talk earlier on. Because I only had a short amount of time I couldn’t elaborate more. But essentially there are clinical trials now emerging that multifocal soft lenses of various designs, may reduce myopia progression by up to 30 to even 50%. There are multiple designs available now. I won’t mention company names in this lecture, but if you look at them online based on evidence, there are at least two and I know of one that is just emerging now that will be available to clinicians to prescribe. I think that the fact that we have more options available is promising and I think that it’s useful, as clinicians, to be able to offer multiple or various types of treatment of myopia progression prevention interventions to our children. Because basically our children and our patients are very different and they have different beliefs or different habits. A parent may not be so comfortable with prescribing orthokeratology versus somebody who is not comfortable wearing daytime contact lenses based on their lifestyle and their school going activities. Having a night time wear contact lens versus a day time contact lens, clearly it’s only beneficial and good for children.

What I would say though is that contact lens wear for children, prescribed by eye care professionals for myopia control, would require collaborative care, especially in Singapore that’s what we’re trying to encourage. So what we’re trying to say is what we want to see is, basically, eye care professionals coming together, whether you’re an ophthalmologist or an optometrist or an optician, to basically come together to manage the patient together. To ensure accurate prescriptions, accurate diagnosis or myopia monitoring so that there’s enough cycloplegic refraction to know it actually is working. So that we know when to stop, when to start, when to move on to other interventions. Multimodal imaging, like axial length measurements as well, so that we know that what we’re doing is actually effective, and so that we can monitor complications. Especially before, 10 years ago, very bad experience in China has led to strict regulation of ortho-k prescriptions in China. And what we want to see is basically not that happening elsewhere in the world. That’s what I would say about contact lenses.
As a corneal surgeon, I try not to be biased but, of course, in my practice I’ve had to manage quite a few and even do perform transplants quite a few young, 12 to 16-year-old children who had severe keratitis leading to irreversible scarring from ortho-k an contact lens use. But I do understand that the incidents of these complications are low if they are managed properly with proper patient and parent education. But, unfortunately, that does not happen in all clinical practices. So I think as eye care professionals, as education platforms such as Orbis, what we want to do is to engage all eye care professionals to practice responsibly and to include education and parent education and engagement as part of their practice, and not just prescribing.

We’re going on to a lot more interesting questions. Now I’ve got three minutes left or two minutes left. Unfortunately, I cannot answer all of them. All of them are really good. Some of them are very specific to basically prescribing or prescription practices. What I will do now is to quickly go through all of the questions the last two minutes based on the answers but I’m already described. So number one, when will we prescribe atropine or contact lenses? As I mentioned before, practice guidelines are not well-defined at the moment. But what I would really recommend is to attend a course or to attend an online resource that helps discuss this from a clinical perspective. Because they’re supposed to be specific to certain patients. Talking about prescribing patterns, without context, can be very challenging.

One question here is very interesting about glaucoma. Is myopia glaucoma related? That’s a controversy of its own. We published two papers in BJO and in Current Opinion which I flashed just now. Email me, I can share the papers with you.

What is the best myopia control methods for adult myopia? That’s a great question. I talked about it in my fifth myth and misconception. There aren’t any and it’s really difficult at the moment based on evidence to try and prevent high myopia and pathologic myopia from occurring in adults so more R&D’s required.
I did answer the pre-myopia question. We are conducting a randomized trial now for atropine to see its role in pre-myopia or incident myopia or low myopia. At the moment there really isn’t enough evidence. What I do, based on evidence at the moment, is any child, my own children included who are two and four, for the only evidence at the moment that seems to suggest prevention of incident myopia really is outdoor time. One to three hours of outdoor time for our children a day, which is extremely challenging. As a parent, I understand that, but that’s what we can do, basically, to prevent low myopia or incident myopia from developing.

And finally, I think that the last question is about artificial intelligence. And yes, there is a lot of research on artificial intelligence in myopia now. Singapore National Eye Center published a paper recently in Advanced Digital Health. Please look it up, it’s open access. Talking about using AI to diagnose MMD based on fundus photos. So based on fundus photos, you don’t need to know how to read it. Basically the AI is able to detect MMD and its potential sight-threatening complications. So AI is here to stay. We are doing a lot of research in AI to help prevent or detect myopia complications. And in the near future, I’m sure there will be more and more work to use AI to help us manage myopia.

My time is up. I’d like to thank all the audience who have attended today with all of your questions and all the questions were really useful. And I thank you for joining me for this Orbis/Cybersight session.


July 6, 2021

Last Updated: October 31, 2022

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