The Myopia Enigma

Experts decode the best practices of myopia management at APMMS 2023

“Myopia is not just a vision concern. It is a chronic, progressive disease that needs comprehensive management.” These words resonated at the core of the first session of the recently held 3rd annual Asia-Pacific Myopia Management Symposium (APMMS 2023) in Taipei, Taiwan. Under the topical heading Reframing Myopia: A Disease Demanding Urgent Treatment, the morning session brought together thought leaders from around the world.

Experts from various fields within eye care presented an array of lectures, each expressing the need for a fresh perspective on a condition that has long been dismissed as a mere refractive error—easily treated and forgotten. All the session’s moderators agree that this needs to change, especially in Asia-Pacific. The diverse panel of experts had each shone a light on a different area of myopia care throughout the world, collectively spearheading efforts to make a difference in the vision and eye health of millions of children worldwide.

Myopia care highlights – from lenses to atropine

The session opened with Dr. Nicola Logan (United Kingdom), who presented a survey of global trends in treating myopia, reflecting the growing concern about the disease’s increasing prevalence in children throughout the world.

“We are all here today because we have that special interest in myopia, but are we all doing something about it in our clinical practice? Regional differences are affected by scope of practice and availability of options,” said Dr. Logan.

Her presentation identified a number of key takeaways from a global trends survey in myopia management. While contact lenses are growing in popularity, single-vision spectacles remain the most popular myopia correction method.

“We are all here today because we have that special interest in myopia, but are we all doing something about it in our clinical practice? Regional differences are affected by scope of practice and availability of options.”

— Dr. Nicola Logan

This is especially true among young myopes. Additionally, she pointed out that eye care professionals have begun to prescribe myopia management contact lenses much more frequently than soft singlevision lenses, which she said is certainly a step in the right direction.

“Single vision spectacles are still (as first option) the most frequently prescribed optical correction to young myopes [4x more often than single vision contact lenses and orthokeratology lenses; over 3.5x more than soft contact lenses and 2.5x more than spectacles for myopia management purposes],” Dr. Logan reported.

“It appears that the disparity between favoring spectacle over soft contact lenses seems to reduce when prescribed for myopia management purposes,” she explained.

Currently, according to Dr. Logan, eye care professionals consider a patient’s age to be the most important factor when deciding what intervention to use. “I would like to encourage you to consider lifestyle factors to be equally important in terms of hoosing your intervention to use in every individual child you see in your practice.

“I encourage everyone to be on board in making a difference in terms of what we are doing for young children with myopia and move away from that typical single vision correction to something that’s much more appropriate,” she concluded.

Following Dr. Logan’s lecture, Dr. Seung-Hee Baek (South Korea) spoke about the evolution of myopia treatment in South Korea in the past decade. She noted that myopia development is especially high among young Korean patients, and appears to be dvancing at a higher rate of progression in recent years.

Dr. Baek reported on the growing use of low-dose atropine as a myopia treatment, which has shown encouraging results. She presented the results of several studies involving low-dose atropine in Korean children.

“Results showed that treatment with 0.01%, 0.025% and 0.05% atropine solution inhibits myopia progression in Korean children in a dose-dependent manner,” she shared. Based on these results, it is hoped that higher low-dose atropine may soon be available, as they may prove more effective.

“The burden of myopia in Korea is substantial. Clinically, 0.01% atropine may not suffice in many cases. We are eager to have higher low-dose commercial atropine eye drops soon,” she concluded.

Early intervention is key – the axial length and genetic connection

Dr. Tzu Hsun Tsai (Taiwan) took the podium next, presenting findings from the first comprehensive study of axial length among children in Taiwan. “We established the first Taiwanese population-based percentile curves of axial length in children, which may help in assessing an individual’s health status and predicting the probability of myopia,” said Dr. Tsai.

Specifically referencing change of axial length percentile as an indicator of myopia progression, Dr. Tsai reported that these factors can be useful in charting myopia progression throughout the young population. She noted, however, that these data points are population- and timespecific, and their use may not prove useful when applied generally.

“The region-specific characteristics served as reference and helped in tailoring anti-myopia strategies,” she explained. Furthermore, Dr. Tsai added that in a cohort of orthokeratology lens users, axial length percentile change rate in addition to baseline spherical equivalent, best estimate myopia progression.

Dr. Ninomiya Sayuri (Japan) and Dr. Pei Chang Wu (Taiwan), each focused on different aspects of childhood myopia development. Dr. Sayuri focused on the pathogenesis and mechanism of the condition, while Dr. Wu’s lecture was primarily concerned with risk factors and potential preventions.

Dr. Sayuri posited that genetic components may underlie childhood myopia – pathological myopia—and that this may one day hold the key to finding a cure for the condition. Dr. Sayuri walked the audience through the three main areas for myopia control: optical, pharmacological and environmental control.

Also, she brought some good news— that MiSight® [CooperVision’s 1 day soft contact lenses for myopia control] is finally undergoing clinical trials in Japan—the first on-label trial for myopia control in the country. “So, for me, prescribing single-vision glasses to myopic kids is like giving a poisonous apple to them. I feel guilty when I know there is a better option,” shared Dr. Sayuri.

Dr. Wu spoke on the great importance of outdoor time for children as a preventative measure, as well as the correlation between other factors like physical activity and living environment, and myopia development. He also highlighted the prevalence of “quarantine myopia” during the COVID-19 pandemic, which was exacerbated by increase of screen time and lack of outdoor time.

He went far back to the concept of pre-myopia – a state of low hyperopia reserve in children—to serve a poignant reminder to the audience regarding the critical role of the environment in influencing myopia progression.

All of these speakers brought ogether one central theme—the critical importance of myopia care and prevention among young patients in order to control the condition.

“Why myopia? And why now?”

It was with these two questions that Dr. Mark Bullimore (USA) opened his lecture at the latter part of the session. Dr. Bullimore discussed the undeniable correlation between the extent of each patient’s myopia progression and their likelihood of
developing other, more critical visual impairments.

“When I was studying in England 40 years ago, we regarded myopia as a benign, refractive condition—and we would correct it with spectacles or contact lenses, and more recently, refractive surgery,” Dr. Bullimore shared. What has changed? “Well, for one, there’s an increased prevalence. Beyond that, I would say the two most important factors are that— thanks to CooperVision and other leaders—we now have the ability to do something about it, coupled with a better understanding of the role that myopia plays in ocular disease and uncorrectable visual impairment,” he explained.

Clear signs of correlation

Dr. Bullimore presented several papers supporting the relationship between myopia and advanced visual conditions. The first showcased a logarithmic interpretation of data from five unique studies of myopic patients in different global regions and their evelopment of myopic maculopathy (MM). It indicated that each additional diopter of visual impairment corresponded to a 67% greater likelihood of developing the condition.

“When I was studying in England 40 years ago, we regarded myopia as a benign, refractive condition—and we would correct it with spectacles or contact lenses, and more recently, refractive surgery.”

— Dr. Mark Bullimore

The relationship between myopia and severe comorbidities became increasingly evident as Dr. Bullimore proceeded—along with myopia, and in proportion to its extent, other ocular conditions emerged.

But what about myopia itself and the loss of vision that occurs directly as a result of the condition? Left unchecked, myopia often advances throughout a patient’s lifetime. The ongoing deformation in the eye’s axial length can frequently lead to diminished vision and, in some cases, to vision loss. While we have more preventative options for myopia than ever before, vision loss due to myopia remains irreversible. And this threat is one that needs to be understood more thoroughly.

The continuum of myopia care

To address the threat posed by myopia, Dr. Bullimore referred to what he calls the continuum of myopia care—an ongoing process wherein he encourages the profession to identify, diagnose, and treat myopia as early and as rapidly as possible—a sentiment shared by all the session’s speakers.

Key to this approach is comprehending the risks posed by myopia to young patients and sharing this understanding with their parents. “We need to start communicating that risk and really predict the future: Talking to parents early so that they are primed to understand what the future holds for their children, and understanding the fact that we have the ability to envision a different future if we intervene early,” emphasized Dr. Bullimore.

“We have the greatest opportunity to do something about it—by initiating treatment right away and not waiting for the myopia to progress,” he continued. “Of course, those treatments need to be evidencebased. And we’re here thanks to CooperVision, which offers some of the best evidence-based treatment interventions available to us,” concluded Dr. Bullimore.

Long gone are the days when corrective lenses were the beginning and the end of the story of myopia. And with our ncreased ability to treat the condition comes an increased responsibility to take the condition seriously—and to act early to protect patients’ vision.

Editor’s Note: A version of this article was first published in CAKE Magazine Issue 21.

The 3rd Annual Asia-Pacific Myopia Management Symposium (APMMS 2023) was held in Taipei, Taiwan on December 10, 2023. Reporting for this story took place during the event.