February 2023 Virtual event Presentation

Mitigation in Urban Environment for Myopia Epidemic and Promoting Public Awareness

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By Dr. Kai Yip Choi BSc (Hons) Optom, PhD, FAAO, Hong Kong & Prof. Seang-Mei Saw MBBS, MPH, PhD, FAMS, Singapore

About the presentation

The myopia epidemic has been sweeping the world in recent years, particularly in Southeast Asia. Learn how environmental exposures are critical in myopia development and get introduced to recent studies showing how outdoor environments are inhibitors for myopia development. Hear how optimal clinical care, social and environmental interventions can be alternatives that aid in alleviating the myopia epidemic, such as parent focused pediatric eyecare promotion campaign by Kai Yip Choi a Research Assistant Professor at The Hong Kong Polytechnic University School of Optometry and Seang-Mei Saw, Distinguished Wallace Foulds Professor at the Duke-NUS Medical School, Singapore, Co-Chair (Biomedical) of the NUS Institutional Review Board, and Head of the Myopia Unit at Singapore Eye Research Institute.

FAQ from the event

Is time outdoors more influential on onset of myopia or the progression of existing myopia?

The evidence we have is primarily related to onset. We can delay or prevent the onset for children for a couple of years; this is shown in a large study including 2,000 children in China. When it comes to progression of myopia, some studies have show an effect, however, the evidence is particularly strong with regard to onset.

How do you work with governmental institutions and schools to increase time spent outdoors?

We show the link between a child’s overall health from time spent outdoors, such as decreased risk of obesity and reduced risk of stress and mental health issues, and their academic performance. Showing the link between outdoor time and academic performance is something we hope to investigate further.


We actually found it quite difficult to promote more outdoor time; parents in Hong Kong are rather nervous about anything that can impact tehir children’s academic grades in a negative fashion. We therefore try to also work on how to modify the indoor environment, for example the lighting during near work, to influence the development of myopia.

How do you take into consideration the age of myopia onset and does the earlier school start in places such as Hong Kong and Singapore influence the development of myopia?

The average age of myopia onset in Singapore is 8.5 years, however, we have conducted a study showing that 10% of pre-school children are already myopic and 28% of children during the first year of school are myopic so we need interventions alrady at this age.

It is much more serious if children during their pre-school years develop myopia compared to later in life as there is a direct link between age of onset and the severity of myopia.

 

Studies in Hong Kong show that education in regular schools involves significant amounts of near work whereas education in ‘International schools’, as we call them in Hong Kong, where there is less near work time also has a lower incidence rate of myopia.

The fact that screen time is increasing, does that negate the amount of time a child may spends outdoor time?

We have not found that more outdoor time means less screen time; children who spent more time outdoors did not read or write less. In fact, children who spend significant amount of time outdoors also read and wrote a lot, and then you would have children who neither read and wrote much and also did not spend much time outdoors.

References

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Chen, M., Wu, A., Zhang, L. et al. The increasing prevalence of myopia and high myopia among high school students in Fenghua city, eastern China: a 15-year population-based survey. BMC Ophthalmol 18, 159 (2018).
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Naidoo KS, Fricke TR, Frick KD, Jong M, Naduvilath TJ, Resnikoff S, Sankaridurg P. Potential Lost Productivity Resulting from the Global Burden of Myopia: Systematic Review, Meta-analysis, and Modeling. Ophthalmology. 2019 Mar;126(3):338-346.
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Saw SM, Matsumura S, Hoang QV. Prevention and Management of Myopia and Myopic Pathology. Invest Ophthalmol Vis Sci. 2019 Feb 1;60(2):488-499.
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Wang J, Li Y, Musch DC, et al. Progression of Myopia in School-Aged Children After COVID-19 Home Confinement. JAMA Ophthalmol. 2021;139(3):293–300.
https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2774808

Read SA, Collins MJ, Vincent SJ. Light Exposure and Eye Growth in Childhood. Invest Ophthalmol Vis Sci. 2015 Oct;56(11):6779-87.
https://pubmed.ncbi.nlm.nih.gov/26567790/

Wu PC, Chen CT, Lin KK, Sun CC, Kuo CN, Huang HM, Poon YC, Yang ML, Chen CY, Huang JC, Wu PC, Yang IH, Yu HJ, Fang PC, Tsai CL, Chiou ST, Yang YH. Myopia Prevention and Outdoor Light Intensity in a School-Based Cluster Randomized Trial. Ophthalmology. 2018 Aug;125(8):1239-1250.
https://pubmed.ncbi.nlm.nih.gov/29371008/

Lanca C, Teo A, Vivagandan A, Htoon HM, Najjar RP, Spiegel DP, Pu SH, Saw SM. The Effects of Different Outdoor Environments, Sunglasses and Hats on Light Levels: Implications for Myopia Prevention. Transl Vis Sci Technol. 2019 Jul 18;8(4):7.
https://pubmed.ncbi.nlm.nih.gov/31360613/

Bhandary SK, Dhakal R, Sanghavi V, Verkicharla PK. Ambient light level varies with different locations and environmental conditions: Potential to impact myopia. PLoS One. 2021 Jul 7;16(7):e0254027.
https://pubmed.ncbi.nlm.nih.gov/34234353/

Flitcroft DI. The complex interactions of retinal, optical and environmental factors in myopia aetiology. Prog Retin Eye Res. 2012 Nov;31(6):622-60.
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Choi KY, Mok AY, Do CW, Lee PH, Chan HH. The diversified defocus profile of the near-work environment and myopia development. Ophthalmic Physiol Opt. 2020 Jul;40(4):463-471.
https://pubmed.ncbi.nlm.nih.gov/32519412/

Choi KY, Chan HH. Extrinsic and Intrinsic Factors Regulating Juvenile Refractive Development and Eye Growth. Invest Ophthalmol Vis Sci. 2021 Nov 1;62(14):21.
https://pubmed.ncbi.nlm.nih.gov/34797905/

Hess RF, Schmid KL, Dumoulin SO, Field DJ, Brinkworth DR. What image properties regulate eye growth? Curr Biol. 2006 Apr 4;16(7):687-91.
https://pubmed.ncbi.nlm.nih.gov/16581514/

Baird PN, Saw SM, Lanca C, Guggenheim JA, Smith Iii EL, Zhou X, Matsui KO, Wu PC, Sankaridurg P, Chia A, Rosman M, Lamoureux EL, Man R, He M. Myopia. Nat Rev Dis Primers. 2020 Dec 17;6(1):99.
https://pubmed.ncbi.nlm.nih.gov/33328468/

Zhou X, Pardue MT, Iuvone PM, Qu J. Dopamine signaling and myopia development: What are the key challenges. Prog Retin Eye Res. 2017 Nov;61:60-71.
https://pubmed.ncbi.nlm.nih.gov/28602573/

Wu PC, Chen CT, Lin KK, Sun CC, Kuo CN, Huang HM, Poon YC, Yang ML, Chen CY, Huang JC, Wu PC, Yang IH, Yu HJ, Fang PC, Tsai CL, Chiou ST, Yang YH. Myopia Prevention and Outdoor Light Intensity in a School-Based Cluster Randomized Trial. Ophthalmology. 2018 Aug;125(8):1239-1250.
https://pubmed.ncbi.nlm.nih.gov/29371008/

Jin JX, Hua WJ, Jiang X, Wu XY, Yang JW, Gao GP, Fang Y, Pei CL, Wang S, Zhang JZ, Tao LM, Tao FB. Effect of outdoor activity on myopia onset and progression in school-aged children in northeast China: the Sujiatun Eye Care Study. BMC Ophthalmol. 2015 Jul 9;15:73.
https://pubmed.ncbi.nlm.nih.gov/26152123/

He M, Xiang F, Zeng Y, Mai J, Chen Q, Zhang J, Smith W, Rose K, Morgan IG. Effect of Time Spent Outdoors at School on the Development of Myopia Among Children in China: A Randomized Clinical Trial. JAMA. 2015 Sep 15;314(11):1142-8.
https://pubmed.ncbi.nlm.nih.gov/26372583/

Mijie Li, Carla Lanca, Chuen- Seng Tan,Li- Lian Foo,Chen- Hsin Sun,Fabian Yap,Raymond P Najjar,Charumathi Sabanayagam, Seang- Mei Saw. Association of time outdoors and patterns of light exposure with myopia in children Br J Ophthalmol
https://pubmed.ncbi.nlm.nih.gov/33858839/

Read SA, Vincent SJ, Tan CS, Ngo C, Collins MJ, Saw SM. Patterns of Daily Outdoor Light Exposure in Australian and Singaporean Children. Transl Vis Sci Technol. 2018 May 29;7(3):8.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5976264/

Zhang MZ, Saw SM et al. Refractive errors in Singapore and Xiamen, A comparative study in school children aged 6 to 7 years. Optom Vis Sci 2000;77:302-8.
https://pubmed.ncbi.nlm.nih.gov/10879787/

Systematic Review and Meta-Analysis on the Impact of COVID-19 Pandemic-Related Lifestyle on Myopia. Li M, Xu L, Tan CS, Lanca C, Foo LL, Sabanayagam C, Saw SM. Asia Pac J Ophthalmol (Phila). 2022 Sep 1;11(5):470-480. 
https://pubmed.ncbi.nlm.nih.gov/36179338/

Ngo CS, Pan CW, Finkelstein EA, Lee CF, Wong IB, Ong J, Ang M, Wong TY, Saw SM. A cluster randomised controlled trial evaluating an incentive-based outdoor physical activity programme to increase outdoor time and prevent myopia in children. Ophthalmic Physiol Opt.2014;34:362-8.
https://pubmed.ncbi.nlm.nih.gov/24460536/

Lanca C, Saw SM. The association between digital screen time and myopia: A systematic review. Ophthalmic Physiol Opt. 2020 Mar;40(2):216-229.
https://pubmed.ncbi.nlm.nih.gov/31943280/

Paul N Baird, Seang-Mei Saw, Carla Lanca, Jeremy A Guggenheim, Earl L Smith Iii, Xiangtian Zhou, Kyoko-Ohno Matsui, Pei-Chang Wu, Padmaja Sankaridurg, Audrey Chia, Mohamad Rosman, Ecosse L Lamoureux, Ryan Man, Mingguang He Myopia Nat Rev Dis Primers. 2020 Dec 17;6(1):99. https://pubmed.ncbi.nlm.nih.gov/33328468/

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Mitigation
Measurement
Management

Prepared by the World Council of Optometry Myopia Management Resource Committee 2023.
The World Council of Optometry Myopia Management Standard of Care initiative is a collaborative partnership between World Council of Optometry and CooperVision.

Soft Dual Focus or Multifocal Contact Lenses

Spectacle Lenses for Myopia Control

Orthokeratology

Atropine

When to wear it

Children who are physically active
Ideal for very young wearers
Children disliking glasses and/or inclined to not wearing them full-time

Considerations

Shown to improve confidence and ability to participate in activities.

Typically more availability for astigmats.

No wearing time during waking hours.

Optical correction is still needed.

* Excluding children frequently engaged in water sports.