Early vision screening is key to slowing myopia progression in children

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More than one-third of the world’s children were myopic in 2023, with that number expected to rise to nearly 40% by 2050, according to a new report.

The study, by a group of researchers in China, showed that there has been a significant increase in the prevalence of myopia among children and adolescents in the past 3 decades—from 24% in 1990 to almost 36% in 2023—according to the paper, which was published this week in the British Journal of Ophthalmology. The researchers noted that it is anticipated that the global incidence of myopia will exceed 740 million cases by 2050.¹

Daniel Cyr, MD, a pediatric ophthalmologist at Stony Brook Medicine and an assistant professor of clinical ophthalmology atStony Brook University in New York, told Ophthalmology Times that he is seeing an increase in pediatric myopia at his clinic. “I am seeing younger and younger patients [who] are myopic compared [with] what I was seeing during training,” he said. “I am definitely seeing more myopic children over the past 10 years.”

That bears out the results of the study, which included a comprehensive analysis of 276 studies, involving a total of 5,410,945 participants from 50 countries around the world.¹

Cyr said that it is important for parents to understand the working signs, noting that children will initially present with headaches when they are doing schoolwork. Ultimately, it is either headaches or failed vision screenings at school that lead to a vision screening with an optometrist or ophthalmologist. He noted that there are several factors leading to the increase in myopia.

“Myopia is multifactorial, but in the current age that we live in, we are aware that increased near work can drive myopia,” he said, adding that less screen time and more time spent outdoors can slow myopia progression.

Moreover, Cyr said that the increasing incidence of myopia could partially be a result of genetics, as more people who are myopic have children who also are myopic. “We have more people [with myopia who] then have [myopic] offspring, but there also are environmental factors. With the increased amount of near work at school, all the children are on computers or iPads now,” he said. “All that increased near time has been shown to increase myopia."

Cyr noted today’s world increasingly has more near work required for education, and it is starting younger and younger. As a result,near work is also starting younger and younger, which Cyr added is definitely contributing to the increase in myopia witnessed today.

Cyr explained that increased screen time and less time spent outside are certainly factors in the increase of myopia worldwide. “It is thought that because of all the accommodation that the eye is doing to focus the eyes at near, it is causing an elongation of the eye, which is causing the increase in myopia,” he said. “The exact mechanism is not 100% elucidated, but it is believed [that] it is associated with the effort of accommodation.”

Cyr also noted that there are long-term health implications for children who develop myopia at an early age, pointing out that if the myopia is high enough, it can cause amblyopia. “That’s something that can occur if the myopia is very high and untreated,” he said. “If you have high myopia and you never get glasses, it’s possible that you could never see [perfectly] in the future, even with the best pair of glasses or surgery.”

Moreover, Cyr pointed out that myopia is generally associated with an increased risk of retinal detachment. “Retinal detachment can cause permanent vision loss,” he said. “It can cause glaucoma after the retinal detachment. The increased incidence of retinal detachment and the increase of amblyopia secondary to high myopia are 2 things that can be detrimental to vision in the future; that’s part of the reason why we’re trying to help treat this myopia pandemic.”

Ophthalmologists can perform orthokeratology or prescribe atropine eye drops to slow the progression of myopia. Cyr noted that when children who are nearsighted come into his office, he recommends that they reduce screen time and spend more time outside.

“The other treatments that we use—low-dose atropine, orthokeratology, and peripheral defocus contact lenses—have all been shown to reduce the progression of myopia, but it doesn’t stop it,” he said. “It can help slow it down to the point where a patient who is myopic does not become highly myopic.”

Cyr pointed out that for each diopter (D) of myopia that increases, there is an increased risk of retinal detachment and problems secondary to myopia, including degenerative myopia. “Every diopter that we can prevent—even if it’s just 1 or 2 in the children—that can help them long-term [by reducing] the risks of retinal detachment and issues with their vision,” he said.

Parents and schools are on the front line of the fight against myopia and can reduce risks for myopic children, including frequent vision screenings. Cyr said parents are instrumental in managing their child’s vision health by limiting screen time, encouraging outdoor play, and ensuring regular eye examinations.

“I am finding in my clinic that more parents today are aware of this and are urging their children to spend less time on screens and encouraging them to spend more time outside,” Cyr said. “Having children’s eyes screened by their pediatrician with their photoscreeners that take pictures of the eyes and can catch refractive errors at a much younger age [will help us to] start treating them at a much younger age.”

With schools and pediatricians screening for vision, Cyr said it ensures that the child can be referred to an ophthalmologist for treatment when an issue is detected. “That is one of the biggest things that can be done to help prevent the progression of myopia in the future, just monitoring children’s vision and making sure they are going to their well-child visits,” he said. “If they do have a failed vision screening, it should be taken seriously.”

Even if a child doesn’t complain of blurry vision, the results of the test should be followed up on. “I recommend all kids should at least have 1 examination with an ophthalmologist or an optometrist before starting school,” Cyr said. “But I recommend screening for all patients when they are being seen by their pediatricians and a photoscreening tool.”

Cyr noted that myopic children younger than 10 years are at greater risk for becoming highly myopic, or having myopia of more than 6 D. “That’s the critical age, because if those children get treated, it can slow down their myopia progression,” he said. “We can prevent them from [developing high myopia].”

Cyr also noted that it is important to catch myopia early to ensure it doesn’t progress to amblyopia, which can typically only be treated up to the age of 8 or 9 years.

Once a child is diagnosed with myopia, Cyr will discuss the condition and myopia progression with their parents. “I will talk to them about initial steps to hopefully reduce myopia progression right at that first visit, [including] the environmental factors that we can have some control over, such as reducing screen time and [increasing] time outside,” he said. “That’s typically the first visit, but if I find that they’re very highly myopic already at that first visit, [then] I will also often get an axial length so I can monitor for axial lengthening progression.”

Children whom Cyr observes as being highly myopic will also be scheduled for a follow-up visit in 6 months, and he will review their eyes with an overrefraction and another axial length scan. “The children are just mildly myopic at a young age. I will typically bring them back in 1 year, and if that shows progression of 1 D or greater, then I start [conversations about] atropine or the peripheral defocus contact lenses,” he said.

In addition to myopia, Cyr said he does see cases of amblyopia, and with the improved photoscreeners available, ophthalmologists can catch it earlier.

Looking ahead, Cyr said there are advancements in pediatric eye care looming on the horizon that could help manage or prevent the rise of myopia and children. He noted that atropine drops are compounded and have a short shelf life, but lower doses are being developed that are not compounded and that will have a longer shelf life and be more affordable. “The peripheral defocus contact lenses are a big thing,” Cyr said. “I have seen that they are showing promising results for slowing myopia progression.”

Virtual reality (VR) headsets for the treatment of amblyopia are also emerging as an effective option for ophthalmologists to consider for their young patients. In a recent discussion with Ophthalmology Times, Scott Xiao, cofounder and CEO of Luminopia, talked about the Patients Using Prescription Luminopia (PUPiL) Registry and how the VR treatment for children with amblyopia works and can revolutionize treatment for this condition.

“We’ve developed the first FDA-approved binocular treatment for amblyopia, which is the leading cause of vision loss in young children,” Xiao said. “Despite its prevalence, it’s a space that hasn’t had innovation in a long time.”

Xiao noted that the standard-of-care treatments up to this point have been glasses, followed by eye patches and atropine drops for some patients. Adherence to these treatments is often very poor and, even in patients who are adherent, many of the young patients are left with residual vision loss.

“We set out on this mission about 7 years ago to create a more engaging and a more effective way of treating amblyopia,” Xiao said. “The technology that we developed, we like to say, allows kids to watch their favorite TV show as treatment instead of having to wear a patch. You can imagine [adherence] gets a little easier if the kids get to watch SpongeBob [SquarePants] as treatment.”

Cyr agreed that adherence can be an issue for young patients diagnosed with amblyopia, and he noted that VR headsets could shift the paradigm in amblyopia treatment.

Reference

1. Liang J, Pu Y, Chen J, et al. Global prevalence, trend and projection of myopia in children and adolescents from 1990 to 2050: a comprehensive systematic review and meta-analysis. Br J Ophthalmol. Published online September 24, 2024. doi:10.1136/bjo-2024-325427