Myopia: What can we learn from the experience of developed World?

India is also home to around 9 million blinds out of which one third has preventable blindness. Later means that we can treat it if we have capabilities and intention to treat. NPCB has done a great job of containing the problem of preventable blindness in India.

Changing the glasses is not enough. Newer research shows that we can slow the myopia progression rather than being the mute spectators.

Your son is having difficulty in seeing the blackboard and is taken to the doctor. He says your son needs glasses. Sorry, your son has myopia. He comes back with spectacles on his nose and you with the guilt of what went wrong on your part that he got this disease.

The story remains the same, only the character and the locations are different when it plays out in any part of the world. The only good news (if it can actually be called one) is that if you are living in India, your children are slightly lucky as the prevalence of myopia here is less than what we have in South East Asia, and Europe, US, and Canada. A better statement would be to say we do not have the correct data for the Indian population to actually compare. What we do have is the advantage of knowing what is going on there and to an extent why is it happening and if possible learn a lesson or two.

why do we have myopia?

A recent report from Canada says that nearly 30 percent of their population is myopic. Not only are rates rising but it’s appearing in younger children. In a  study, reported from the UK, a scientist has found strong evidence that more your child time spends reading books, more is he/she at risk of developing myopia. It also said that the early start of schooling increases the length of time over which myopia can become severe. The researcher has reported an association between the amount of time a child spends outside playing, with their likelihood of developing myopia. They could not explain why is this happening but there is some evidence that sunlight itself has a beneficial effect on the eye and that the child’s effort to focus on a variety of objects near and far is also helpful in preventing myopia.

Genes

A genetic study, from New York, done  160,420 individuals of European or Asian ancestry,  to study the role of genes in causing myopia. It says that environmental and lifestyle factors have a role in myopia, but there is also evidence that genetic factors also play their role. The researcher has attempted to look for potential genetic factors in individuals from European populations and from a population in East Asia, where myopia is particularly common. The authors reported, “Our genetic observations add credence to the current notion that refractive errors are caused by a retina-to-sclera signaling cascade that induces scleral remodeling in response to light stimuli,”. That means that the pattern of the light eye receives while reading books or computer screens induces certain changes in the eye structure that results in myopia. The authors further added that their study   “provides a large number of new molecular candidates for this cascade and clearly implicates a wide range of neuronal cell types in the retina, the [retinal pigment epithelium], the vascular endothelium, and components of the extracellular matrix.”

Schooling

We all are aware of the public perception that people who wear glasses are usually studious. The recent reports say that this is not entirely unfounded. A study published in BMJ says that more time the children spent in education, is a causal risk factor to develop myopia. Importantly, it also adds that more years in education one has, more likely one has the risk of having myopia.  Myopic children have a problem in doing the kind of jobs that require better distance vision like driving and outdoor games, but have better near vision so it actually gives them an educational advantage.

The problem of myopia in China and Southeast Asia is more concerning, making it an important public health issue. Shanghai’s Health and Family Planning Commission report from China says that 47.2 percent of primary school students, 75.8 percent of middle school students, and 89.3 percent of high school students suffer from myopia. The number of those affected grows as children get older. It is the lack of outdoor activity, very strong pressure from family for academic achievements and widespread long-duration use of mobile screens are the major reasons cited for why the incidence of myopia is so high in China.

Studies also report that children who spend less time in outdoor activities like playing consistently reports higher incidence of myopia. This difference is noticed in the incidence of myopia reported from countries like China and Singapore where the incidence of myopia is high as compared to countries like  Australia or the United States.  Children from developed East and South-East Asian countries are found to spend less time outdoors than their counterparts in Australia or the US. So there is enough scientific evidence to suggest that time spent outdoors during childhood protects against the development of myopia. 

Other scientists have correlated lower light exposure with high myopia risk, and it is possible that those who spend more years in education spending most of their time indoor have had less exposure to natural light. The progression of myopia is also reported to be faster in winter months, which further gives credence to this theory. Later is also the reason why countries like China and Singapore have started the concept of  “bright light classrooms” which is supposed to protect against myopia. To what extent this strategy is useful will be seen later. With the available evidence, what can be best recommended is for children to spend more time outside.

What nations are doing about it?

The pace with which the prevalence of the myopia is increasing, is definitely alarming. Though the complaint of blurred vision is redressed with the wearing of glasses, it is neither the cure of the disease, nor it stops its progression.

Awareness

In Australia, the health organisations have started awareness programs to change the public perception, especially how it can be prevented and its long term consequences. Australia has started observing Myopia Awareness Week,  from 14 – 18 May, and china observes 6 June as national Sight Day.

In Australia, Brien Holden Vision Institute (BHVI) Academy. organizes Program, which is directed to educate the ophthalmic practitioners to change the way they manage myopia It is a self-paced program that gives participants the opportunity to connect with global leaders in myopia control, through a live webinar. It helps the profession to make an essential shift in myopia management strategies.

Outdoor activity

In China, the government is making a database of the status of myopia in children by ensuring the regular eye checkup.  Doctors argue that over two-hours of outdoor activity every day can drop the risk of development of myopia in children so the time allotted for outdoor activity in schools is been prolonged. As the ambient light is supposed to play a role in the development of myopia, the local government is renovating lighting to make their classrooms brighter.

Apps

As the unnecessary mobile and another similar device usage as also been implicated in the  development of myopia, a company named  AntzWorkz has launched an application named Plano at an event at Singapore in October 2017. The company claims that Plano is the world’s first parental health management app which will help parents and teachers   to constantly  monitor the use of these devices by children

Newer lens

There are also efforts to develop better spectacles for myopic children as these are something they have to use anyways. A team of researchers from the Hong Kong Polytechnic University (PolyU) has claimed to have developed a lens that may slow down the progress of myopia in children. It is a Defocus Incorporated Multiple Segments (DIMS) Spectacle Lens that is claimed to correct myopia and astigmatism.  The DIMS Spectacle Lenses has a central optical zone surrounded by multiple segments of constant myopic defocus, thereby using a homeostatic mechanism known as emmetropization, whereby the eyeball adapts to receive focused images. Again the benefits of this new technology are to be seen in the future.

Corneal cross-linking

Another new technology is in the development phase at Columbia University in New York that is not only non-invasive but also claims to correct myopia permanently.  According to Columbia University, the critical component of this new technology is low-density plasma which ionizes water molecules within the cornea resulting in cross-links. Later will induce changes in the mechanical properties of the treated corneal tissue. If carefully tailored, it can induce the required refractive changes in the eye. It offers advantages over the conventional laser treatment as the latter is invasive techniques, and is known to be associated with corneal thinning and other complications.

Now the question is what we can learn from their experience?

where do we Indians stand?

The 2016 Annual States of Education Report (ASER) survey in India shows that over 25% of children in grades I to VIII were absent from school on the day a team visited the school. It raises a bigger question of whether we should actually be worried about myopia when it is difficult for the government to keep the children in the schools. I would argue that we should be worried about both the issue. The development of a registry that documents various health parameters of children (including myopia) and the regular health assessment should be the government’s priority. Myopia can also be included in various health awareness programs organized by governmental and non-governmental organizations. Parents should be made aware of the adverse effects of excessive mobile phone use by children and lack of outdoor activities. Doctors should start prescribing the modern spectacle lens having the potential to reduce the progression of myopia. Parents should appreciate that outdoor games are just as important for children as getting good marks in exams. The access to mobile devices and similar screen-based devices, to the children, should be seriously monitored.

Currently, our spending on education stands at 3.4 percent of the GDP which lows by standards of developed countries. we hope that this spending will go up in days to come.  All schools will have classrooms,  and hopefully bright light ones.

Indian children will show the myopia trends similar to what some of the southeast Asian countries are showing. Share your views on how we should address this issue in the comments below.