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Best practice in myopia control: insights and innovations for myopia prevention and control – a round table discussion
  1. Yanxian Chen1,2,
  2. Andreas Mueller3,
  3. Ian Morgan4,
  4. Frank Larkin5,
  5. Yan Wang6,
  6. Junwen Zeng7,
  7. Mingguang He1,2,7
  1. 1School of Optometry, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR
  2. 2Research Centre for SHARP Vision (RCSV), The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR
  3. 3Department of Noncommunicable Diseases, World Health Organization, Geneva, Switzerland
  4. 4Research School of Biology, Australian National University, Canberra, Australian Capital Territory, Australia
  5. 5Cornea and External Disease Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK
  6. 6Tianjin Eye Hospital & Eye Institute, Ophthalmology and Visual Development Key Laboratory, Tianjin Medical University, Tianjin, China
  7. 7State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, Guangdong, China
  1. Correspondence to Professor Mingguang He, The Hong Kong Polytechnic University, Hong Kong, Hong Kong; mingguang.he{at}polyu.edu.hk

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In August 2023, BJO and the Zhongshan Ophthalmic Center co-hosted a round table discussion on Best Practices in Myopia Control. This gathering provided a platform for the exchange of insights and discussion of evidence-based strategies to respond to the rapid increase in myopia prevalence. Participants from China, Hong Kong, the UK and Australia met in Guangzhou, China, to discuss the global status and challenges associated with myopia control (see the ‘Acknowledgements’ section for the list of panel members). The event included panel discussions on (1) prevention and public education for myopia control and (2) individualised myopia control. This report summarises the topics in myopia prevention and control discussed.

Prevention and public education for myopia control

Over the past 50 years, there has been a striking increase in the prevalence of myopia, raising questions about its causes and potential future impact.1 Early data indicate that the advent of the COVID-19 pandemic and associated lockdowns has accelerated the myopia trend.2 3 It is not clear whether a reduction in the time spent outdoors during lockdowns has led to longer-term behavioural changes favouring indoor lifestyles and hence impacted myopia prevalence.

It was noted that some countries have taken proactive measures to address the rising prevalence of myopia. Taiwan started a programme in 2010 that advocates 2 hours of daily outdoor activities at schools, yielding encouraging results.4 Singapore initiated a national myopia prevention programme that included the promotion of outdoor activities, vision screening and teacher training programmes.5 Mainland China, in recent years, has undertaken nationwide initiatives aimed at educational reform to alleviate academic pressures including homework burden.6 A press release from the National Health Commission of China announced a slight decrease of 0.9% in myopia prevalence in China following the implementation of government policies.7 Further research is necessary to evaluate the effectiveness of national policy implementation.

Reduction of the impact of myopia centres on two crucial elements: education intensity and outdoor activities. Strategies that merely broadcast knowledge about myopia have shown limited effectiveness. Singapore’s efforts, including teacher training and promoting good eye care habits in schools, yielded marginal reductions in myopia prevalence.5 Though the use of social media, such as WeChat messages, may result in some noteworthy reduction in myopia incidence,8 9 this effect may be diminished by the effect of parental myopia. Compared with children with myopic parents, online family health education was more effective in children with non-myopic parents. A more compulsive strategy to increase time outdoors may be more effective. The Taiwanese school-focused strategy allocated 2 hours of supervised time, unlike in Singapore, during which children engaged in outdoor activities. It led to a significant decrease in the prevalence of myopia4 and has generated an L-shaped decline after 10-year promotion of outdoor activities in kindergartens.10

In China, safety concerns commonly arise in the implementation of outdoor activities during school hours. For instance, from 2016 to 2018 in Shanghai, an additional 40 min of outdoor activity classes was introduced to primary schools, but teachers expressed apprehensions about potential accidents when students were outdoors. However, experiences in Australia and Taiwan have shown that, with necessary safety measures such as teacher supervision and wearing hats, the risks associated with outdoor activities at school are minimal. An alternative solution considered for schools in China is to consolidate short 10 min breaks between classes into longer periods. Based on evidence from Taiwan, a clear implementation strategy led by the government coupled with an adapted education programme is likely to be a successful implementation of outdoor activities during school time.

Individualised myopia control

For children already affected by myopia, the primary focus is on controlling its progression. Myopia is a condition that physically alters the shape of the eye. The concept that every dioptre of myopia matters significantly holds true; even a one-diopre increase comes with a substantial 67% higher risk of myopic macular degeneration.11 Consequently, reducing myopia by even one dioptre can be significantly beneficial. Myopia control encompasses a range of established interventions, including orthokeratology and low-dose atropine eye-drops.12 The effect on myopia of atropine is recognised to be concentration-dependent and age-dependent, which itself exemplifies the individualisation of myopia prevention and control. A history of myopia in one or both parents is known to have a significant influence on development of myopia. Is ethnicity important? Comparatively few high-quality trials have been reported outside East Asia. One of the largest such trials from the USA, in which only 11% of children were East Asian, reported no benefit of atropine 0.01% drops in low to moderate myopia compared with placebo.13

Additional emerging interventions, including defocus incorporated multiple segments spectacle lenses,14 15 high-add power multifocal contact lenses,16 spectacles with highly aspherical lenses17 and repeated low-level red light (RLRL) therapy,18 19 are showing promise. These diverse interventions offer hope for effective myopia control.

However, it is important to acknowledge that available interventions come with their own advantages and disadvantages. For instance, specially designed spectacles may have limitations related to wearing time and the patient’s age.14 15 The use of orthokeratology demands comprehensive support from both clinics and parents. RLRL, although effective with a low rate of complications, carries the potential risk of retinal damage that necessitates close monitoring. Thus, success in myopia control lies in individualisation, recognising that different parents have varying requests, capabilities and expectations. For young children or those with highly myopic parents, a more robust intervention may be advisable, such as a higher concentration of atropine drops, a greater magnitude of myopic defocus or red-light therapy.

In regions with limited resources, strategies for myopia prevention and control must be tailored to factors such as affordability and accessibility. While 0.05% atropine has shown the potential to prevent myopia onset by 50%,20 and RLRL therapy boasts a 54% reduction rate,21 the cost–benefit analysis for large-scale implementation of these interventions in myopia prevention still requires further research. Spectacle lenses, being relatively more accessible, cost-effective and effective in slowing myopia progression,15 present an alternative for low-income areas, although their effectiveness in reducing incident myopia also warrants further investigation.

In conclusion, the escalating prevalence of myopia represents a greater challenge than previously anticipated. However, there is recent clear evidence of effective myopia control on a national level in some countries taking proactive measures through interventions and educational reforms. While the effectiveness of myopia control interventions has been extensively explored, the focus must now shift towards individualised strategies in clinical practice to achieve better outcomes. Significant challenges persist, particularly concerning the large-scale implementation of myopia interventions in resource-constrained areas. These challenges remain an essential area for ongoing research and development.

Ethics statements

Patient consent for publication

Acknowledgments

The following panelists participated in the ZOC-BJO Round Table Discussion on 'Best Practices in Myopia Control' (names in alphabetical order). Andreas Mueller, WHO; Chi-ho To, The Hong Kong Polytechnic University; Frank Larkin, Moorfields Eye Hospital (chairman); Ian Morgan, Australian National University, Zhongshan Ophthalmic Center, Sun Yat-sen University

Jason Yam, The Chinese University of Hong Kong; Junwen Zeng, Zhongshan Ophthalmic Center, Sun Yat-sen University; Kathryn Rose, University of Technology Sydney; Mingguang He, The Hong Kong Polytechnic University & Zhongshan Ophthalmic Center, Sun Yat-sen University; Ningli Wang, Beijing Tongren Hospital, Chinese Medical University; Stuart Keel, WHO; Xianggui He, Shanghai Eye Disease Prevention and Treatment Center; Xiangtian Zhou, Eye Hospital, Wenzhou Medical University; Xiao Yang, Zhongshan Ophthalmic Center, Sun Yat-sen University; Yan Wang, Tianjin Eye Hospital. We are grateful to Kangying Lai and Pai Zheng, BMJ China Office for their assistance in organisation of this round table.

References

Footnotes

  • Contributors Drafting of manuscript: YC, JZ and MH. Review and revision of manuscript: AM, IM, FL and YW.

  • Funding The research was supported by PolyU - Rohto Centre of Research Excellence for Eye Care (Collaborative) (P0046333).

  • Competing interests MH is the director and shareholder in Eyerising and Eyerising International. The other authors have no proprietary interest in any aspect of this study.

  • Provenance and peer review Not commissioned; externally peer reviewed.