The 'Negative' Impact : tnoa Journal of Ophthalmic Science and Research

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Guest Editorial

The 'Negative' Impact

Nishanth, Shruti

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TNOA Journal of Ophthalmic Science and Research 61(1):p 4-5, Jan–Mar 2023. | DOI: 10.4103/tjosr.tjosr_132_22
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Myopia is a refractive error that has seen a resurgence in the last decade, owing to the drastic changes in children's lifestyles with the added restrictions of the COVID pandemic. In the wake of 2020, we were left reeling from the aftermath of a sudden surge of myopia in schools and clinics alike.

The average global rates of myopia were 30% in the previous decade, which is postulated to reach 50% by 2050.[1] In India, a similar trajectory has been calculated by Priscilla et al.,[2] and the evidence is seen every day in our clinics. What is alarming is the sharp rise in the prevalence of children with high myopia over the last decade.[1] Every dioptre matters—one dioptre increase in refractive error increases the risk of myopic maculopathy by 67%.[3]

Myopia or axial elongation of the eyeball is merely a response to the visual cues received by the retinal circuits. The basic pathophysiology is scleral remodelling triggered by local autonomous factors in the retina rather than central cortical control.[4] The factors promoting this scleral remodelling have been under intense study, and some proven contributory factors are peripheral hyperopic defocus,[5] retinal blur,[6] low retinal illumination,[7] and dopamine downregulation.[8]

A clinical risk profile assessment is critical for the management and follow-up of a child with myopia. The most important risk factors to document are parental myopia, younger age at onset, decreased time outdoors, and increased academic pursuits. The presence of one of these should alert the clinician to more aggressive control strategies. The clinical tests I recommend in the clinic are cycloplegic refraction and axial length measurement, preferably using an optical biometer. These parameters have to be measured every six months to track the progression. An increase of −0.5D of myopia on cycloplegic refraction with an associated rise of more than or equal to 0.2 mm axial length on biometry warrants a myopia control strategy for the child. Additional tests that can aid in choosing the proper control strategy include relative peripheral refraction and dynamic retinoscopy for accommodative lag.

Once a child has progressive myopia, the primary intervention has to begin with customised guidance on lifestyle changes. This may involve chair time, but it is the cornerstone of myopia management. I would first listen to the child's daily schedule, then work around their day to ensure 2 h of outdoor time. The other habits that may protect from myopia are restricted near work, intermittent breaks between near work, more use of natural illumination, and good sleep for 7 to 8 h.[9,10]

The interventional strategies for myopia control are dilute atropine, specialised spectacle lenses (defocus incorporated multiple segments and highly aspherical lenslet technology), progressive spectacle lenses, contact lenses, and orthokeratology. They provide a protective effect between 30% and 60%, with the most effective being dilute atropine and spectacle lens design.[11] Dilute atropine 0.01%, one drop at night for two years has proven to be effective in retarding myopia progression. At the end of two years, it is recommended to taper and stop the drug to prevent rebound. I usually prescribe dilute atropine to younger children with a history of parental myopia and aggressive progression.

Specialised spectacle lens technology has recently been introduced in India with success. They are a good alternative for children with poor compliance and poor response to atropine. They work well in the presence of relative peripheral hyperopia. In children with accommodative lag, progressive spectacle lenses may be considered. Contact lenses and orthokeratology are options now being explored with renewed vigour as they provide freedom from glasses while actively providing myopia control. An exciting therapy that I look forward to in the future is light therapy (both red and violet light are under study), where exposure to three-minute sessions of intensive colour light twice a day may retard myopia progression significantly.[12,13]

Nevertheless, beyond treatment, the time has come for active prevention strategies for myopia onset in school children. Several studies suggest that lifestyle changes have a positive role to play in preventing myopia than in retarding its progression. As a disease, I usually liken myopia to another complex disorder—diabetes mellitus. They are both lifestyle-driven and progressive and cause irreversible damage to the eye. However, the most crucial and probably unfortunate difference is that while diabetes affects the older population, myopia affects the young. These children would grow into valuable citizens of tomorrow and contribute to our economy. At the risk of sounding ominous, if we do not look at active strategies for preventing and controlling myopia, we will be looking at a generation where vision and vision-related diseases may hamper the economic drive of a country.

It is time to curate the right visual experiences for our children, to help them steer away from myopia from early childhood. An exciting study from Taiwan demonstrated the effect of a government-led policy that made 2 h of outdoor time compulsory in schools.[14] They found that it stabilised the myopia trajectory over seven years. We need effective government policies at the school level that can engage in preventive strategies for myopia. Quoting the words of Dr Bullimore, “An ounce of prevention is worth a pound of cure”.[15]

Furthermore, as ophthalmologists, we are a critical cog in this wheel. We must play an essential role in creating awareness, early identification, and proper management of this complex disorder.

We need far-sightedness to combat near-sightedness!

REFERENCES

1. Holden BA, Fricke TR, Wilson DA, Jong M, Naidoo KS, Sankaridurg P, et al Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050 Ophthalmology. 2016;123:1036–42
2. Priscilla JJ, Verkicharla PK. Time trends on the prevalence of myopia in India-A prediction model for 2050 Ophthalmic Physiol Opt. 2021;41:466–74
3. Bullimore MA, Brennan NA. Myopia control: Why each diopter matters Optom Vis Sci. 2019;96:463–5
4. Harper AR, Summers JA. The dynamic sclera: Extracellular matrix remodelling in normal ocular growth and myopia development Exp Eye Res. 2015;133:100–11
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7. Muralidharan AR, Lança C, Biswas S, Barathi VA, Wan Yu Shermaine L, et al Light and myopia: From epidemiological studies to neurobiological mechanisms Ther Adv Ophthalmol. 2021;13:25158414211059246
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9. Morgan IG, Wu PC, Ostrin LA, Tideman JWL, Yam JC, Lan W, et al IMI risk factors for myopia Invest Ophthalmol Vis Sci. 2021;62:3
10. Liu XN, Naduvilath TJ, Wang J, Xiong S, He X, Xu X, et al Sleeping late is a risk factor for myopia development amongst school-aged children in China Sci Rep. 2020;10:17194
11. Kaiti R, Shyangbo R, Sharma IP, Dahal M. Review on current concepts of myopia and its control strategies Int J Ophthalmol. 2021;14:606–15
12. Jiang Y, Zhu Z, Tan X, Kong X, Zhong H, Zhang J, et al Effect of repeated low-level red-light therapy for myopia control in children: A multicenter randomized controlled trial Ophthalmology. 2022;129:509–19
13. Torii H, Kurihara T, Seko Y, Negishi K, Ohnuma K, Inaba T, et al Violet light exposure can be a preventive strategy against myopia progression EBioMedicine. 2017;15:210–19
14. Yang YC, Hsu NW, Wang CY, Shyong MP, Tsai DC. Prevalence trend of myopia after promoting eye care in preschoolers: A serial survey in Taiwan before and during the coronavirus disease 2019 pandemic Ophthalmology. 2022;129:181–90
15. Bullimore MA, Brennan NA. Myopia: An ounce of prevention is worth a pound of cure Ophthalmic Physiol Opt. 2023;43:116–21
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