During this live, interactive webinar, we will explore the growing prevalence of myopia around the world while highlighting the recent findings and leading articles in this field. The clinical causes of vision loss from myopia, beyond refractive error, will be briefly discussed including diseases of the posterior segment like retinal detachment and neovascularization. The majority of this webinar will then focus on the current approaches and treatments that are available now, as well as in the development pipeline, to prevent myopia and curb this public health concern.
Lecturer: Dr. Nathan Congdon, Ophthalmologist, Queen’s U Belfast, United Kingdom
>> Fantastic. I’m delighted to have been invited by Orbis and our sponsors to speak to all of you today about a question that I think all of us involved in vision care are aware of and that’s the global epidemic of myopia. In particular, I will talk today about how Orbis and our partners are responding to the global myopia epidemic. We will begin by outlining the nature of the problem, the reasons for the problem, but most importantly, I will spend a lot of time today talking about approaches to the problem that we think are most effective. I’m going to begin by introducing myself. My name is Nathan Congdon, I’m a professor at Queen’s University in Belfast and I’ve been in Northern Ireland for 8 years now. I’ve been honored to serve as director of research with Orbis. I’m a visiting professor at the Ophthalmic Center, the largest eye hospital in Guangzhou, China. My work in China for 40 years gives me a kind of unique perspective on the concept of myopia in the world. China is the world leader in that area. Today’s talk is designed to address three major questions. What is the myopia epidemic? What is causing it? Why should we be concerned about an epidemic of myopia? We just give folks glasses, right? It’s not a big deal. And perhaps most importantly what is being done by Orbis and our partners to try to solve this problem. This will not just be talking about problems but also solutions to problems. I’m going to begin with the polling questions that we have here. It’s kind of a pretest to give you to get a sense, really, of what you know now and what you learned from this talk. What are some compelling reasons for programs to prevent as well as treat myopia? These reasons include, A, prevention is proven to be more coast effective. B, treating myopia with glasses does not address many of the problems associated with high myopia. C, there’s strong resistance to treatment with glasses in many settings. D, wear of glasses in children is shown to weaken the eyes by worsening myopia. E, all of the above. And F, B and C. So a little bit of complexity there. You will have to give some thoughts to how that all fits together. Good. You can give some thought to that. And we can move on, I think we’ll come back to these at the end. Got one more set of questions here. Which of the following statements about self-refraction is or are true. Don’t worry if you never heard about self refraction before, you will get an ear full of it today. A, several studies have suggested that resulting in visual acuity with self-refraction maybe similar to conventional refraction. Self-refraction is particularly accurate in assessing cylinder compared to spherical power. C, a concern of self-refraction compared to cycloplegia refraction is the potential for over minus-ing myopia power that is too high. D, self-refraction is only appropriate for adults. E, all of the above. And F, A and C only. We will come back to all of these again at the end. And I’ll reveal the true answers. But until then you can be thinking about these questions as we move through the rest of the lecture content today. So our first section is what is the myopia epidemic and what is causing it? Why do we say there is a myopia epidemic? That’s a good place to start. 80 percent of all or more of all poor vision in kids globally is caused by the lack of a pair of glasses. We’re starting out at this point in time in 2023, with the fact that myopia is a big problem for children’s vision. There is evidence from population studies and school programs and military fitness screening and all sorts of stuff, all of this suggests that myopia rates are climbing rapidly in recent decades and this slide is meant to show that. Some of this is predictions into the future but we can see a very rapid rate of increase going from around 1 billion people in 2000 to a predicted 5 billion people in 2050. Nearly an additional billion people with myopia every decade. High myopia, and we’ll talk about that more in the future, down in the orange, is also growing at a pretty high rate. We’re talking about a billion people with high myopia by 2050. In urban parts of east Asia — by the time they complete secondary school. 90 percent. Half the world’s population is going to be myopic by 2050. Nearly 5 billion people. This gives you a good sense of what the nature of the epidemic is. Something that is affecting more than half of the world’s people I think is fair to describe as something being epidemic. What seems to be causing it? There are things that are inherently good that are causing myopia and things that are maybe not so the good causing myopia. The good is more kids are attending school than ever before. That is deliberate. The sustainable development goal, No. 4, has set out the goal that every child should have access to a good education. UNESCO and world governments have made lot of progress towards achieving that school. The bad is there is minister time spent reading and less time-out doors. These are both proven to drive myopia rates higher. Reading is a good thing but if that reading happens too early in life, that is before the school years as often happens in parts of Asia where kid are going to nursery schools and learning the alphabet at age 2, 3, or 4, that reaches the point in terms of diminishing returns in terms of education and drives myopia. As kids spend more time reading, they spend less time-out doors. Outdoor time is protective against myopia. In the countries of east Asia, like Taiwan, Vietnam, China, Korea, Japan, Singapore are subjecting high proportions of the population to long days of near work and low outdoor time that is leading in these countries in east Asia to high rates of myopia. That is exacerbated by afternoon and evening cram schools. That time after school when kids would normally go outside, they spend time or more near work and more education. There is good research to suggest that is a problem that’s independently contributing to this issue of myopia. A lot of people naturally assume that video games and smartphones are playing a big role here. We don’t have a lot of evidence for that. If you look back at the chart that I showed you before, you will see those values and numbers for myopia growth took off 25 years ago before smartphones were ubiquitous. Before we had video games. It’s not clear that video games and smartphones are playing a massive role but they’re probably not helping. In large part they’re not helping because kids playing video games are not going outside. The myopic phenomenon is likely to become ever more global. We’re going to find that myopia continues to rise just like that curve that I showed you. Maybe I’ve convinced you there is a lot of myopia. But so what? Why should we care? I think a lot of eye care professionals would think of myopia as being send them a pair of glass, no big deal. Let’s talk about why we care about this epidemic of myopia. When I began my career, we didn’t even count poor vision due to unconstructed errors of refraction problem. The need for glasses wasn’t seen as being a real vision issue. If you’re in a poor country with poor access to glasses, then it’s a big problem for you. Not having glasses making you just as visually impaired as glaucoma or cataracts or anything else if you’re not going to get glasses. We know that 80 percent of kids that need glasses in underserved areas like rural western China and India and most parts of Africa don’t have them. And there is strong trial evidence that proves that lack of glasses greatly impedes academic process. We care about myopia, one reason is because many, many children in the world don’t have the glasses they need to correct myopia and those kids are at a major disadvantage in school as they can’t see the Blackboard. The second reason, though, perhaps even worse is that prevalence of high myopia, more than 6 diopters of myopia is rising rapidly. That can be associated with problems like cataract, glaucoma, retinal detachment, myopic macular degeneration. We don’t have great treatments for myopic macular degeneration. The problem of high myopia becomes a very significant complicated vision problem. It’s estimated to affect about a billion people globally by 2050 which sounded a long time in the future when we first wrote that but it’s only 25 years away at this point. Importantly, with respect to high myopia. Correction with glasses does not address that problem. It’s a problem of an overly long eye. We can correct that eye to see better before problems like myopic macular degeneration occur but we can’t head off those problems just by giving glasses. So let’s talk about what’s being done to manage the epidemic of myopia. Broadly, we have two approaches and I’m going to divide the rest of my talk into two to talk about these separately. The first approach is to treat myopia with glasses. I already said that doesn’t halt high myopia, doesn’t fully solve the problem. But we have billions of people in the world now including hundreds of million of children who need glasses now in order to do better in school. We haven’t successfully prevented those kids from having myopia so we have to do something to treat those kids with glasses now. Treating myopia, I’m going to start with that, that’s immediate. That is something that has to be happening now. Preventing myopia, there are a variety of different strategies including increased time-out doors and other strategies, we’ll talk about those. Broadly, I would say this is not a neither nor. This is not either we’re going to do myopia treatment with glasses or we’re going to prevent myopia. We have to be doing both. We need to be starting this now for these problems. We’ll talk about them separately. We’re going to start with treating myopia with glasses. So what does it take to deliver glasses. We’re going to talk about several things that are needed. We have hundreds of millions, probably over a billion kids that need glasses. Glasses are cheap. They cost 5 bucks a pair in China. They can be delivered cheaply when you have good quality, efficient service delivery models. Why don’t we do it? What do we need to do in order to deliver glasses to all the kids that need them? Well, we need refraction capacity. Specially-trained refractionists don’t exist in many countries like Vietnam or China. China is beginning to build it up. That doesn’t yet exist in large numbers. Vietnam only has two schools to train optometrists right now. Together they have probably trained fewer than a hundred folks. There is quite a lag in many countries that are most affected by myopia in terms of the ability to deliver glasses to those folks by trained specialists. Orbis and our partners and other NGOs like Brian vision institute have been working on training centers to create pathways for licensure. All of that is needed and takes time and investment and takes collaboration and buy in from existing professionals like ophthalmologists. In my own country, the United States, that has not always been there. Countries in which Orbis have been active in these arias is Mongolia, and Vietnam, China and bang la dash. There can be challenges. There can be conflicts with other vision workers, in particular ophthalmologists not always friendly to the creation of optometrists. They see them as competition. Lack of financial opportunities. There has to be a clear opportunity to make money from a career as a refractionist. There may be absent or inadequate regulatory apparatus. It may not be viewed as a medical activity. In some countries refractionists are regulated by the same laws that regulate beauticians, people doing hair and nails and there is problems with that because in many ways myopia is a medical problem that requires a medical solution. So what else is needed in order to deliver glasses. We need school vision screening. The idea is that we want to go where the kids are in the same way that Willie Sutton was once asked why to you rob banks, well, that’s where the money is. We need to go to schools to deal with this problem of the need for glasses. That is where the kids are. And that’s where the biggest impact is, the strongest reason, to help children learn better. Orbis has delivered the largest school vision screening program in the world. Our REACH project has screened 2.5 million children across India. The largest study of glasses compliance done within REACH, shows that REACH has the highest rates of wear, 70 percent of any such program. The children most likely to wear glass are those in the greatest need. Rural kids. Kids going to government schools. Kids living in poor areas that never had glasses before. The ability is there. Models exist for the cost effective delivery of glasses but there is important questions that remain. There is some important questions about what works best. For example, where should refraction to measure glasses power be done. Should it be done in schools? That’s a great idea, right. Very few kids get missed. The problem is and there’s there, they’re a captive audience. They’re there and you bring them the glasses, unlikely to lose those kids to follow up. The problem is the resources don’t exist to scale this model nationally in most countries. Think of India with more children than any other country in the world. A refractionist would have to be spending every minute of his or her day going to different schools in order to deliver refraction services in every school in India. There probably still wouldn’t be enough. So how about the alternative. Instead of having the refraction services occur in the school, how about a vision screening in the schools, the teachers help with that. And we refer the kids that fail the vision screening to nearby centers. That approach is more sustainable and scalable. The optometrist can remain in their institutions and wait for referral. Kids and families to those facilities. The problem is that many families fail to take up these referrals and that blunts program impact. Orbis has completed a prison trial in India that shows that fewer than 10 percent of families showed up when referred. In other settings we find the same results particularly in Africa, Mongolia, low population density and problematic transportation infrastructure. It’s hard for families to make that journey to a referral center. There is things we need to do to try to make sure we make it easier and make it more manageable to many families do show up and take advantage of the offer of refraction services whether free or for a fee. I mentioned Orbis and the prison trial in India, refraction in schools is more cost effective. Becaus90 percent of kids fail to complete the process and fail to benefit. This is a common problem, loss to referrals. We need randomized trials and other studies to test and prove strategies to enhance referral uptake. We have to get more kids, more families to be willing to accept the referral to get refractive services once they are found to fail vision screening at school. So what else works in terms of delivering refraction services. Even referring kids for refraction at nearby facilities may be impractical ..(audio blipped).. such as Africa.We’re steaming along and in good shape here on time. Even referring kids for refraction at nearby facilities may be impractical in Africa where population density is low. Allowing kids to self-refract, that is a lot of them to suggest the optimal power in each eye with dials or other mechanisms. Let me quickly show you a couple of these. Here are a couple of models of what self-refraction glasses look like. Here on the top, a kid pulls a little dial there and basically brings the vision into focus by injecting fluid into the glass there which makes it thicker and creates more power. Here a similar kind of dial, slides a kind of lens bar up and down presenting different powers in front of the eye. Basically, it’s the same thing. Imagine the kid is turning a dial and bringing the world into focus. There has been a lot of studies done, Orbis has sponsored a lot of them and they all suggest the same thing, these approaches do quite a good job and can get probably 90 percent of kids to see quite well. Maybe not quite as well as gold standard refractionists but they’re good. We have these fluid filled designs and bars. These are the two most common designs that exist now. So there’s been 10 years of research on self-refraction. A lot of which has been done by our teams and it’s shown that results are comparable to conventional refraction regarding the vision obtained, the accuracy of the power, and the willingness of kids to wear the glasses. Those are the big three. And self-refraction has proven to work pretty well. Some limitations are still there. Astigmatism cannot be corrected. Some designs are not appealing to kids. The glued-filled ones tend to have large round frames and rims that kids don’t like. Self-refraction without a vision professional present isn’t allowed in some countries. Those are regulatory and other barriers. Nonetheless, I would say this is an approach that has a lot of research behind it and can be appropriate in some settings. Orbis is currently using self-refraction to deliver glasses in rural Mongolia. If there is any place where it’s hard to get conventional refractive services together with a kid, it’s Mongolia. The distances can be hundreds of kilometers and it’s not reasonable to fly a kid to a central place to get a pair of glasses. The results are thousands of children that were enrolled in that program show that vision outcomes are not statistically different from conventional refraction by an ophthalmologist. Data suggesting that self-refraction can do quite a good job in terms of delivering glasses to kids. One of the concerns about self-refraction has been the idea of under training. What Orbis believes is we should train refractionists at the same time we’re doing self-refraction to deliver services now. Those two things, conventional service capacity building and self-refraction are in no way in opposition to each other. So another big problem about the issue of delivering glasses to kids is getting children to wear their glasses. The question is, what works? Studies in rural China and Tanzania and other places are shown that providing glasses for free increases rates of wear compared to just giving prescriptions. There is real benefit in giving kids free glasses. Rates of wear of free glasses in many settings remain low, sometimes less than 20 percent. That’s a big issue. Orbis was very gratified to see and reach that 70 percent of kids were wearing their glasses. That is great. It’s one of the highest rates that’s been seen. 70 percent is still not 100% and we would obviously like to see it even higher. Reasons that kids don’t wear their glasses include a fear that glasses will weaken the eyes. That is not true. We’ll talk about that I think a little later. But in case I don’t have a slide here, we have done a couple of randomized trials that show that wearing glasses does not weaken the eyes. Nonetheless, the average family in rural China does not read the British medical journal unfortunately and so there’s still a very widespread concern that wearing glasses will weaken the eyes in China, Africa, a number of settings. Will is cosmetic concerns. Kids get teased. Don’t like the way they look. Parents may feel the kids don’t look good. They may not be marriageable if wearing glasses: Inconvenience in sports. Various strategies have been profunda posed including providing a wide choice of designs for kids to choose. That is one of the key things is to give a lot of different designs so kids can choose something they like and appreciate. That sense of choice is very important. One of the few strategies that has been proven and studied in an RCT was teacher incentives. And Orbis helped us support this study among urban migrant schools in Shanghai, China about ten years ago. Teachers were offered a small gift if when we came back and did an unannounced check through the school window, basically, if we found that greater than 80 percent of kids were wearing the glasses that were supposed to have glasses, the teachers would get a small Chinese-made — for charging the battery. Something to charge their smartphone batteries. This approach of giving little gifts can be sustained by tying this to teacher salaries and that is being done in part of China where spectacle wear by kids only if it’s high do teachers receive the full salary which includes this modest bonus. That works very, very well in a setting like China where teachers are highly respected. We found in our studies it raised glasses wearing from 20 percent to over 70 percent. There are some approaches to this that are very effective. In terms of sustaining a program of glasses distribution what works. So we’ve shown in our CTs and other studies that giving free glasses increases wear compared to charging for them. Nonetheless, cost recovery from glasses sales can be crucial to keeping the programs going in the real world. Orbis carried out a trial called PRICE that was done in China and it showed that as many as 40 percent of families would pay for upgraded glasses with more attractive frames and scratch free lenses even when free ones were offered. Giving free glasses and also charging for glasses as a way of keeping a program sustained, keeping the program moving forward by paying for itself, these two things are not in opposition. It can occur together at the same time in some projects. So we talked already about approaches to delivery of glasses. I’m going to finish today’s talk by focusing on approaches to the prevention of myopia and we’ll talk about that. It’s an important area. It’s getting more and more attention all the time. Let’s start with this, why do we need to prevent myopia? We just gave glasses to every child on earth who needed them, wouldn’t that solve the myopia problem by itself? It’s hard to get glasses to every kid on earth as we just saw. But nonetheless, even if we could, it wouldn’t be enough for the reasons that we mentioned. High myopia, that is greater than 6 diopters of myopia is predicted to be present in some 10 percent of the world’s population. Some billion people by 2050. Because high myopia has an associated very long eye, this causes a lot of problems, many of which are much more difficult to manage than refractive error and that cannot be prevented with glasses. They include retinal detachments, glaucoma, cataract, myopic macular degeneration. We don’t have good treatments of any kind for that now. Only preventing myopia can prevent these problems. Giving glasses as important as it is can never be the whole solution. We also need other approaches to prevention. Let’s talk about some of the different approaches to prevention. Let’s start with some technical approaches. This has been a very exciting area of innovation in recent decades. There are contact lenses and glasses which prevent myopia by preventing out of focus light from striking the peripheral retina. A signal for the eye to lengthen. As this drawing shows, these lenses focus light coming from a variety of different directions so they all fall towards the center of the eye, prevents the light from defocused light from falling over the periphery here. Our sponsors for today, our collaborators have been leaders in this area. And I believe the picture I’m showing here depicts their product income this area. It’s an important area moving forward, an important part of the solution to the prevention of myopia. There is medications like atropine that can prevent the elongation of the eye and prevent myopic prevention when used in low doses. And the low doses generally avoid side effects. There is a number of exciting trials in Singapore and Hong Kong and other areas. An overnight treatment with very tight contact lenses to flatten the cornea. Called Ortho-K. All three are proven to be effective but their use is somewhat limited to relatively small numbers of families generally more, better educated and more affluent families and especially in big cities, Shanghai, Beijing, Hong Kong, Singapore because of a variety of reasons. But basically, boiling down to three things. Expense with respect to the contact lenses and glasses. They are on the expensive side compared to conventional glasses. Risk of complications. Ortho-K while it works well to slow down the progression of myopia by flattening the surface of the eye, wearing tight contact lenses over night can lead to serious infections of the eye. And finally because some of these are relatively invasive, the idea of putting eye drops into the eye gives someone invasive — in a lot of settings. Has to be done by a physician. Parents generally are allowed to do it but it would be very difficult, for example, to do this in schools which is really where programs are needed. So for these reasons, a combination of these reasons, these three important areas, areas of innovation have been somewhat limited in their impact. I would argue that the benefit all kids in society and not just children who are lucky enough to have relatively affluent or more educated parents. What we need is low-cost safe approaches that are usable and suit suitable for use in schools. We started saying we need to work in schools because that is where kids are. It is an easy and efficient and cost-effective place to find large numbers of kids and because we’re interested in an impact in school. We want to see kids seeing better to learn better. So increased time outdoors, there is a school-based solution with some strong evidence behind it. There’s been a first trial in JAMA in 2015 that showed an additional hour per day of time outside reduced myopia progression by 23 percent. And a study has shown this is a scalable solution. There’s a long standing national program like Taiwan’s daily 120. Which means 120 minutes a day, two hours a day outside. The evidence from the recent paper in 2020 is that this national program is scaled up national program has led to myopia reductions on a population basis. There is an inflection point in myopia. The rates are coming down a bit thanks to national programs about outdoor activity in Taiwan. Spending time outdoors can decrease obesity. There are some limitations though. A number of countries including China and Singapore have enacted policies requiring daily time of 1 to 2 hours of outside time during school but they have been unable to follow through. Where the myopia prevalence is highest, the cultural resistance to adding outdoor time is the greatest. Parents and schools are concerned that children’s academic performance may be affected by having them spend more time outdoors. There are other novel approaches. Novel classroom designs to create light levels in the classroom similar to those outdoors. They have been appealing for teaches and children and trials of these designs are on going in China. If we can’t get the kids outdoors, bring the outdoors to the kids. These have some challenges in terms of managing heat build up. But generally, as you see from these kids here, these have been implemented in some settings. There are other approaches to classroom lighting, delivering light levels or wavelengths that resemble outdoor light. They are being tested in China. Different lighting including red light. A variety of different things. We haven’t yet converged on the idea of the approach to school lighting but it’s an area of strong interest. I would say from my perspective, perhaps the most exciting technology that appears to be out there now is repeated low light red therapy. I think this is of interest for a variety of reasons. This device was described originally by collaborators in China and Australia. Designed for amblyopia treatment but it’s been shown by those investigators in a recent randomized control trial in ophthalmology to reduce myopia progression by 65 percent. And among kids with good compliance, the kids that looked in this device every day, 85 percent reduction. Very impressive. How this thing works, here is a picture of it. It looks like Wall-e. A sad little face. It’s a table top device that requires a kid to view a red light of brightness approximately equipment to a bright laptop screen for six minutes a day. Two uses a day of 3 minutes each. This is of interest because a device like this potentially could be used in school. You can envision a scenario where kids, since it’s only used three minutes at a time, kids could go through a treatment room on their way between classes. The impact on glass time would be significantly less than the two hours that is required for outdoor therapy. There is potential to use this at home. It can still be a school-based approach. We can do the screening to identify the kids who need treatment in the schools. That gives us access to a full set of all the kids in society who need help. And then potential to treat can be delivered at home. We’re looking now at studies in China, Singapore, Hong Kong, a variety of settings using a school-based approach. And I think this offers good promise for society-wide impact in terms of reducing myopia prevalence. A lot still to be figured out in terms of safety. We can talk more about that if there is questions about it. Let’s talk about the role of research and delivering better global solutions for childhood myopia. Implementation research is necessary. When I talk about research, I’m the director of research at Orbis. Orbis has invested a lot of time and money in trying to answer these questions. Research to answer the questions on how to better deliver glasses in school and ensure high rates of wear. Make sure the kids are wearing the glasses. Impact research. Showing how glasses change lives to convince governments and others to invest. Orbis has done a trial showing that giving glasses to kids had a significant impact in improving educational outcomes and the impact was greater than for any other healthcare intervention that was done in school. Greater than vitamins and greater than deworming. Orbis is getting ready to start a study called SWISH which looks at the idea of whether providing free glasses can increase the proportion of children that go onto attend high school. It’s less than 50 percent in many parts of China. This impact research is important. Strong evidence that improved educational outcomes come from delivery of glasses. We’ve seen that mostly in China and the U.S. There’s evidence needed from other areas like India and Africa and part of an ongoing trial in Sierra Leone as a way to deliver glasses in educational outcomes in an Africa setting and Orbis is helping to support that network. Testing and proving novel approaches to prevention. Particularly those that are low cost and noninvasive and thus appropriate for use in schools is an important area for future research. Whether it’s novel classroom designs or repeated low dose red light therapy. So that is the end of what I wanted to talk to you about today. I’ve outlined some of the important things we need to work on in the future. I would like to come back in and repeat these questions that we asked at the beginning. Compelling reasons for, sorry, I’m going to move this out of my way here. For programs to prevents as well as treat myopia, include, A, prevention is proven to be more cost effective. We don’t have that proof that convention is more cost effective. I saw a number of you answered that but the glasses are cheap. B, treating myopia with glasses does not address many of the problems associated with high myopia. That is correct as hopefully you have seen by now. Giving glasses is great. It improves kids learning and educational outcomes but it does not prevent high myopia. So programs to prevent myopia are also needed because of reason B. Reason C, is also correct. There’s a strong resistance to treatment with glasses in many settings. So there’s a need to try to prevent myopia as well. Treatment by itself may not be enough. D, wear of glasses is shown to weaken the eyes. That is not true. So the correct answer is F, which is B and C. Both B and C are true. I’m just trying to see — we had, looks like 30 percent. Yes, 30 percent. The majority of you got that answer. That is great, fantastic. And let’s go to No. 2. Not the majority but the plurality. No. 2, which of the following statements about self-refraction is or are true? A, several studies have suggested that resulting visual acuity with self-refraction is similar to conventional refraction. A is true. We’ve had a lot of studies show that we can get over 90 percent good vision from self-refraction and from conventional refraction. B, self-refraction is particularly accurate in assessing cylinder compared to spherical power. That is not true. I mentioned briefly that astigmatism and cylinder power is something that self-refraction can’t manage. Basically, all of these glasses that can change their power can only correct spherical power. They can’t correct astigmatism. B is not true. A concern of self-refraction compared to gold standard reaction is the potential for over minus-ing myopic power that is too high. C is correct. That is also true. Self-refraction is only appropriate for adults. That is not true. It’s been shown to be effective for kids as young as the age of 6. E is not correct. Not all of the above. F is correct. It is A and C that are correct. We got 51 percent that got that right. We got the majority that got that right. I don’t remember what it looked like at the beginning but I’m sure your performance improved over time. Are there any questions? Happy to chat with you. Usually I put my email here. Let me just do that. If you have any questions and you would like to reach out, you can do so. I think Lawrence and Andy are going to help moderate the Q&A session. We have a good ten minutes. Do we have any questions that have come up on the chat yet? >> Yes. We have 14 questions so far. >> See, there, Q&A. I can run down, shall I run down these? I can see them actually. >> That would be great. >> I’m going to take them in the order they seem to have come in. How do we slow down myopia with new advancements? There are a number of ways to do this. It’s important to get children outdoors more. I think that’s something that is probably more acceptable in India. In China there is a lot of worry that kids won’t learn as well. There is a more healthy approach to children going outdoors in India. That is part of the answer. Getting kids outdoors is important. The other thing that is important is as a society is to reduce academic pressure on children. In China it’s illegal to give homework to children before the age of 9. You can do that in India are. Schools aren’t allowed lowed to give homework before the age of nine. Cram schools in China are restricting the amount of money they charge so they’re not profitable. That is something you can do in India. More time outdoors for kids and less academic pressure, especially less early academic pressure, like 3, 4, 5. The later that academic pressure starts, the better. The more time kids spend outdoors the better. Those are my main suggestions. What about family history and genetic background. That is important, yes. Genetics does appear to play an important role in myopia. How do we know that genetics isn’t the only thing. We saw a curve that showed the prevalence of myopia increasing fiver fold over 20 years. If this was largely genetic, I think the human genome has changed fivefold in 20 years: Clearly there may be a genetic role. But the answer is there are clearly strong environmental interactions with the genome or purely environmental effects because only those can explain the rapid changes we’ve seen in myopic prevalence. Anonymous has asked, do you think the new reasons behind increased myopia would increase the myopia complications. No, I don’t believe the evidence suggests that myopia is being caused mostly by the cornea, I think the evidence is pretty good that increased axial length is still a strong issue in many kids with myopia. We see a lot of retinal detachments. We see myopic macular degeneration. Those things are largely driven by having a long axial length. I would say the mechanism has not changed a lot. I don’t believe we have strong evidence for the idea that the mechanism has changed. And the complications as — to answer the first part of your question, are still the same. How much does dose of atropine reduce the effects of myopia. Atropine briefly in high doses may have an effect. In low doses like .01 percent, or potentially lower, we get a very good reduction in myopia. Without some of the complications that atropine causes. We don’t have problems of kids being bothered by bright light. We don’t have problems with blurring and near vision. There is a variety of concentrations that work well but around 0.1 percent seems to work well. The challenge is this is medicalization. It means a medical therapy being presented, being delivered to kids. That may be very difficult to do in schools. You can’t do it in schools, I think it’s ever going to be a society-wide approach. Some patients think that some ocular exercises help with the reduction of predictions. Are there studies to say that eye exercises help? With respect to No. 1. I can’t say they don’t work. With respect to No. 2, I would say no, there is not strong evidence that I have seen to suggest that eye exercises reduce the power or prevent myopia. I would not say that. If you’re a parent that wanted to prevent myopia in your kids, I strongly suggest you send them outdoors rather than doing exercises. >> Does atropine treatment have any side effects? The potential side effects, someone is going to come in and ask me a question in one second. Side effects that we worry about are not side effects that are dangerous side effects: But often they cause kids to be aware of light being too bright which can be problematic and it can blur vision making it difficult for kids to read. Those problems are largely avoided by using low-dose atropine. Often here under correction enhances myopic progression. Slight significance shown by some studies and others don’t. I have heard a lot of people suggest that under-correction prevents myopic progression. Here is my view, I’ve done two large randomized control trials on this in China both of which involved 20,000 kids. We did not only not find that failure to deliver any — that is the ultimate under correction. We found it did not help and did not prevent myopia progression in these kids. The kids that got the glasses, their vision did a little better. I’m talking about their uncorrected vision. Uncorrected vision was not worse in kids that did not get glasses. No evidence that under correction help, no evidence that getting kids glasses they need hurts. That is what I would say. What are your views on patching therapy for someone who is amblyopic. Patching is proven effective. Not proven for myopia per se. It is proven for amblyopia. If the kid happens to be myopic, I would treat the myopia but you can also do patching therapy to prevent amblyopia in those kids. Given the emerging red-light therapy, is there evidence for a protective effect. Yes, there is compelling evidence. There is a high quality randomized control trial showing 65 to 85 percent reduction in progression of myopia. There is strong evidence it works. I heard a lot about blue light as well. I’m not a physiologist. I’m not a basic scientist. I can’t tell you the fundamental underlying reason for red versus blue. What I can say is yes, there is strong evidence for the protective effect of repeated low-dose red light therapy and I would suggest that more studies need to be done. This is a very encouraging and exciting new area. We have someone who said their own name and then we have how does the tabletop device help. We don’t really know. The available evidence suggests that it prevents myopia by causing, may work by causing thickening of the choroid. As the choroid thickens, it pushes the macula forward causing effectively shorter eye optically. Less myopia. I think there’s a lot we still need to know about mechanism. The important question to ask is how long will this persist. There is evidence this persists for at least a year. There is some evidence of rebound effect, that is one of the problems with atropine. You stop and the myopia comes back. This is something we still need to figure out, one of the key areas where more research is needed around red light therapy is this question about how long it needs to be continued. Staphlommas are fairly common in high myopic patients. It’s one of many problems. Is blue light really harmful for eyes especially for myopia? The jury is out on that. Contact lens makers would like to tell you we need blue blocker therapy. We need IOLs with blue blocking. I don’t think the evidence is particularly harm of the modest amounts of blue light that we encounter day to day. There is a lot that still isn’t known about the color of light. I would say that repeated low dose red light therapy does appear to be effective in preventing myopia. Exactly why it works we’re still working on. I see there is more questions and some of these are repeating the same things about under correction. I have come to the end of our time together. For my other questions, you have my email. Feel free to shoot them along. We had over 80 attendees today. People from India and Pakistan and Bangladesh. Great stuff. I have worked in all of those countries and I’m delighted to have so many of you showing up today. I hope I have the opportunity to work with you and collaborate with you in research in the future. Thank you so much for your attention today. Thanks to Orbis for the opportunity to speak to you and thanks for Hoya for their support of these series. Talk to you soon, bye.