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1040-5488/16/9309-1058/0 VOL. 93, NO. 9, PP.

1058Y1060
OPTOMETRY AND VISION SCIENCE
Copyright * 2016 American Academy of Optometry

INTERNATIONAL MYOPIA CONFERENCE PROCEEDINGS: CONFERENCE PAPER

What Public Policies Should Be Developed to


Deal with the Epidemic of Myopia?
Ian G. Morgan*

ABSTRACT
Developed countries in East and Southeast Asia are now faced with a high prevalence of high myopia in young adults, and
this trend is emerging in other parts of the world. This is likely to lead to increased levels of pathological myopia. Fortunately,
several school-based clinical trials have demonstrated that interventions based on increasing the amount of time that
children spend outdoors can significantly slow the onset of myopia. I argue that it is time to implement mandatory programs
of this kind in school systems, within a framework of regular monitoring of visual acuity, so that those children who become
myopic are referred for clinical treatment as soon as possible to slow progression of their myopia towards high and po-
tentially pathological myopia.
(Optom Vis Sci 2016;93:1058Y1060)

Key Words: myopia, prevention, time outdoors, atropine, schools

E
ast Asia countries (mainland China, Hong Kong, Taiwan, confronted with a population including 700 to 800 million people
Japan, and South Korea, and Singapore in Southeast Asia) are with myopia and around 100 to 200 million with high myopia.
now faced with an epidemic of myopia, in which 80 to 90% These numbers will severely strain, if not overwhelm, Chinese
of children completing secondary education are myopic. Similar ophthalmology and optometry services. The challenges posed have
changes being documented in other parts of the world as well, but brought the issue of prevention to the center of attention, with the
not yet to the same extent.1 Most importantly, the prevalence of key aim of reducing the prevalence of high myopia.
high myopia (generally defined with a cut-off of j5D or j6D) At the end of the 14th International Myopia Conference in 2013,
has increased to over 20% in some locations.2,3 Those with high I left the meeting convinced that methods for slowing progression
myopia are at markedly increased risk of uncorrectable vision loss were now sufficiently developed that it was time for systematic
due to pathological changes in the retina, choroid, and sclera, and treatment of children at risk of progressing to high myopia. This
an increased risk of retinal detachment, cataract, and glaucoma. defined accurate prediction of those at high risk and likely to benefit
This adds enormously to the burden of disease associated with from treatment as a major research priority. Since then, the effec-
myopia because dealing with most forms of pathological myopia is tiveness of low-dose atropine (0.01%) with minimal side effects has
still difficult and also costly.4 been confirmed,7 and further evidence on orthokeratology and
Recent projections suggest that almost 50% of the world’s specialized spectacles and contact lenses has been obtained.8Y10
population will be myopic by 2050. Almost 10% will have high and Effect sizes as high as 50% reduction in progression have been
potentially pathological myopia.5 Extrapolating from the prevalence reported for the three approaches, but the results are not always
of myopia and high myopia in young adults provides another ap- consistent. Except for low-dose atropine, washout studies have not
proach to projection. This approach gives a bleak picture for some been performed, and longer-term follow-up is needed for all ap-
locations. To take China as an example, its population is expected to proaches. The clinical problem is obviously to balance the remaining
reduce to around 1 billion by 2100. Because the prevalence of uncertainties about treatments against the problems associated with
myopia in young adults is now 80 to 90% in urban areas, with the high myopia.
prevalence of high myopia around 20%,6 mainland China will be High educational pressures, including large amounts of home-
work and after-school classes,11 and spending more time indoors
during childhood,12 are important risk factors. Many other factors
*PhD
Research School of Biology, Australian National University, Canberra Australia
have been proposed.13Y15 At least some of these factors have only
and State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun small effect sizes, and some may be mediated in part by effects on
Yat-sen University, Guangzhou, China. education and time outdoors. This is an important area for future

Optometry and Vision Science, Vol. 93, No. 9, September 2016

Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.


Myopia and Public PolicyVMorgan 1059

research, but fortunately the suggestion by Rahi et al.15 that progression,21,22 but marked seasonal effects on progression, which
prospects for prevention are likely to remain limited until this suggest active regulation by environmental factors, have been
complexity is understood does not appear to be correct. reported.23 Because onset and progression both depend on axial
In countries with a strong cultural commitment to high edu- elongation, it would not be surprising if both proved to be regulated
cational outcomes, changing the education system is likely to be by time outdoors, but more detailed analysis of this speculation is
difficult. However, the central government in China has recently clearly required.
moved to reduce homework hours in primary schools, which There is no agreement yet on the mechanisms involved. The
could have a considerable impact on the onset of myopia, pro- competing theories are that bright light outdoors increase dopa-
vided that it is combined with measures to get children outdoors, mine release from the retina, and that increased dopamine release
rather than spending their spare time on television or computer inhibits eye growth,12 the hypothesis that increased UV exposures
games, and backed by controls on private provision of out-of- outdoors are the key factor,24 and that eye growth is controlled by
school classes. the balance of exposure to myopic and hyperopic defocus, with
Considerable evidence that children who spend more time out- outdoors characterized by greater uniformity in dioptric space.25
doors during daylight hours are less likely to be or become myopic The evidence for and against these hypotheses is discussed in other
has also been presented.16 Reductions in incident cases of myopia of papers in this issue.26,27 The mechanism is not particularly crucial
around 25% (with an additional 40 minutes per day of time out- for prevention because there is general agreement that time out-
doors) to 50% (with an estimated 80 minutes per day) have been doors does protect. The UV hypothesis seems to have been ex-
reported in trials carried out in Guangzhou17 and Kaohsiung, cluded as inconsistent with the evidence that UV-free lights block
Taiwan.18 The magnitude of these effects is consistent with epi- experimental form-deprivation myopia, and with more detailed
demiological evidence that 2 to 3 hours per day outdoors outside of epidemiological data.28 This is important because it means that
school hours largely blocks the additional risk of myopia associated myopia prevention is likely to be compatible with protection from
with large amounts of nearwork12 and parental myopia.19 UV damage.
The clinical trial in Taiwan increased time outdoors by locking Despite the many unresolved issues, increased time outdoors
students out of their classrooms during school recesses, given that can now be used to prevent the onset of myopia. Clinical rec-
children in East Asia often spend their recess time in their classroom. ommendations for increasing time outdoors might be useful for
But this solution cannot be applied to schools in mainland China, children at risk of myopia, such as those with myopic parents or
where schools have a 150-minute lunch break, during which chil- siblings of early-onset myopes. But the potential for school-based
dren often sleepVa widespread practice in China. Therefore, op- interventions shifts the emphasis from clinical considerations to
tions such as bright classrooms and bright desk lamps for school or public health myopia prevention.
homework will need to be trialed. They may also be useful in parts of Here, there are two approaches. One, used in Singapore, is to
the world where variations in natural lighting mean that for a sig- educate parents about the benefits of time outdoors, but there is no
nificant part of the year, maximum natural daylight exposures may evidence that this approach has had much effect. The other is to
be insufficient to protect from myopia. embed increased time outdoors in the school program, particularly
There is obviously a need for further clinical trials. One trial at primary school level, as part of the mandatory school day. This
from China has reported that roughly doubling the light intensity approach has been adopted in Taiwan, which now has 2 hours per
in the classrooms markedly reduced incident cases of myopia.20 day outside at the core of its school-based myopia prevention
This result does not fit with the light intensities needed to prevent program. In our clinical trial in Guangzhou,14 we found that a
myopia in experimental models, or those that distinguish indoor parental education campaign had no effect, reinforcing the need for
from outdoor environments, and this trial was flawed by a very mandatory school-based programs.
low rate of cycloplegia. It urgently needs to be repeated because if There is a strong argument for embedding prevention of in-
such a simple intervention is confirmed, then it could be very cident myopia in a traditional framework of school-based mon-
widely and rapidly implemented. itoring of visual acuity and referral of problems to clinicians.
The role of screen time with computers, and particularly tablet Annual screening would enable children who became myopic,
computers and smart phones, in the myopia epidemic has received despite the preventive programs, to be referred for control of
a lot of attention recently, and Taiwan has put limits on their use progression as early as possible. Early and prompt intervention is
by preschool-age children. These devices were clearly not the cause important because in East Asia, annual myopia progression rates
of the initial epidemic of myopia because the prevalence of myopia in early-onset myopes can be of the order of j1D per year,29
was already high in high school graduates in Taiwan in surveys leading to high myopia from the age of 11 to 13 on. But even for
carried out in 1983,2 when tablet computers and smart phones countries where the epidemic is less developed, such a regime
had not been invented, and computers were not in common use. would facilitate monitoring changes in prevalence and provide a
The World Wide Web, which triggered the computer age, was not framework for public health action in relation to specific groups of
available until 1993, so these devices cannot have had a causal role. children at greater risk of becoming myopic, such as children of
It is possible that their increasingly widespread use may make it East Asian ancestry growing up in Australia.22
harder to turn the epidemic around, if they provide further reasons Measures of this kind will not completely prevent myopia
for children to spend less time outdoors. because myopia is an etiologically heterogeneous condition that
One issue that needs resolution is whether increased time outdoors includes forms of genetically determined myopia in a small pro-
slows progression of myopia and delaying onset. Epidemiological portion of the population.30 The emergence of the epidemic of
work has not detected any significant effect of time outdoors on environmentally driven myopia does seem to depend on a few key

Optometry and Vision Science, Vol. 93, No. 9, September 2016

Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.


1060 Myopia and Public PolicyVMorgan

social changes in schooling and lifestyle, which can be countered 15. Rahi JS, Cumberland PM, Peckham CS. Myopia over the lifecourse:
by increasing the amount of time that children spend outdoors. prevalence and early life influences in the 1958 British birth cohort.
Preventing high myopia is the key challenge for the future. Ophthalmology 2011;118:797Y804.
Taiwan seems to be leading the way with school-based interven- 16. French AN, Ashby RS, Morgan IG, Rose KA. Time outdoors and the
tion programs. The results, which can be expected over the next prevention of myopia. Exp Eye Res 2013;114:58Y68.
few years, will tell us whether this approach is as effective as the 17. He M, Xiang F, Zeng Y, Mai J, Chen Q, Zhang J, Smith W, Rose K,
current evidence suggests it should be. Morgan IG. Effect of time spent outdoors at school on the devel-
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Received March 18, 2016; accepted June 30, 2016. trial. JAMA 2015;314:1142Y8.
18. Wu PC, Tsai CL, Wu HL, Yang YH, Kuo HK. Outdoor activity
during class recess reduces myopia onset and progression in school
children. Ophthalmology 2013;120:1080Y5.
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Optometry and Vision Science, Vol. 93, No. 9, September 2016

Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.