“We've declared myopia as the biggest eye health threat of the 21st century”

Johnson & Johnson Vision has created recommendations for the assessment and treatment of myopia in children, aiming to address what it has described as the “biggest eye health threat of the 21st century.”

Titled Managing Myopia: A Clinical Response to the Growing Epidemic, the recommendations cover how eye care professionals can assess, monitor and treat myopia in children and aim to provide a research-based rationale for providing myopia control.

Key points in the guide include the need to monitor for myopia in children and secure early treatment, with the authors describing this as “critical” to slow progression.

To identify the right treatment for a myopic child, the guide covers the various treatments available to help ECPs in conversations with patients and their parents.

The recommendations also highlight that, while myopia control efficacy has traditionally been measured by percentage, measuring axial length is preferred for monitoring myopia “due to the strong association between eye length and risk of developing complications.”

On the release of the guide, Noel Brennan, a clinical research fellow for Johnson & Johnson Vision’s Myopia Control Platform, said: “As eye care professionals, we have been concerned for the eye health of children and the trajectory of myopia on a global level, and COVID-19 has only increased our concern.

“Johnson & Johnson Vision in partnership with leaders in eye health has created this new myopia management guide as a clinical response to address the rising rates of myopia globally.”

The recommendations follow a year of collaboration with optometric organisations in America and Singapore, including the American Optometric Association (AOA), American Academy of Optometry (AAO), Association of Schools and Colleges of Optometry (ASCO) and Singapore Optometric Association (SOA).

The launch of the guide also marks the latest step in addressing myopia, following a strategic research partnership established between Johnson & Johnson Vision and the Singapore Eye Research Institute.

Robert Layman, president-elect, American Optometric Association, added that the recommendations would help professionals to “deliver individualised patient care that will support the patient throughout their childhood and into adulthood.”

OT spoke with Johnson & Johnson Vision’s Dr Noel Brennan about the myopia recommendations, changing approaches, and why practices should adopt myopia control.

How did the recommendations/guide come about?

Dr Noel Brennan: At Johnson & Johnson Vision, we've declared myopia as the biggest eye health threat of the 21st century. That's not a random claim. One study has predicted that one in 10 people in high risk areas, such as urban areas in East Asia, will face visual impairment in their lifetime, and that's principally as a result of the myopia epidemic.

We see these alarming projections over and over again, and we have a lot of faith that these are correct, but our internal research at Johnson & Johnson Vision tells us that only one in 20 eye care professionals around the world are practising myopia control.

We see that as an issue because of the great threat that myopia is, and that was what prompted us to put this guide in place. I would like to acknowledge the input of the many colleagues who contributed to the guide, and particularly my partners at Johnson & Johnson Vision, Alex Nixon and Erin Nilon.

What does the guide offer?

The guide is intended to be very practical; something that an eye care professional could refer to in their practice. It provides background information as to what the myopia epidemic is about, data and prevalence, and the risks that it involves. It also provides information about who to treat, how to assess people, and what treatments are available.

Being global in nature, and having different treatments and regulatory situations in different areas, there are no products specifically mentioned in the guide. It talks in general terms about the different categories, what they offer, and what the challenges of each of those are.

The guide also includes a table that talks about expected progression rates and axial elongation at different ages. It's a reference that you can use in practice when you have a patient to say: ‘Are they progressing too fast?’ ‘Are they within the normal band?’ Or ‘is my treatment being effective?’

The eye health threat to the population at large is quite significant

Is there anything from the guide you want optometrists to take away or an action you want optometrists to take?

I think one of the interesting things is understanding that axial elongation is a key thing that we should be looking at now.

We understand that a lot of optometrists in practice will not have biometers to measure axial length. Part of what needs to go with that is that we need to understand the limitations that monitoring myopia by refraction bring, where the general consensus is that it's axial elongation that is the key factor in bringing about eye disease.

Our ability to measure refraction, the 95% confidence intervals, in children is going to be about 0.5 dioptres. We're trying to measure half or three quarters of a diopter change, and we have that amount of error in our measurement. When we talk about change, we have that error in our initial measurement, and then in our next measurement.

I think practitioners need to be aware of these limitations. Practitioners can read more on this in our recently published paper: Efficacy in Myopia Control in Progress in Retinal Eye Research (2020).

Is it necessary to have an ocular biometer?

We appreciate that most optometry practices won't have a biometer, and if you're working with ophthalmologists who can refer patients to get biometry measurements I think that's a useful thing for young at-risk myopes. The short answer to whether it is absolutely necessary to practice myopia control is no. It is highly desirable, though.

Certainly in the future we see things going that direction. Manufacturers will address the problem of the cost of the current instruments, which really have been designed to help with getting accurate intraocular lens powers for cataract surgery. Transferring this to myopia control and understanding that there will be a very large market should help bring the cost down. It will become a standard, maybe in a decade.

What are the longer-term implications for the myopia epidemic? How do you feel the COVID-19 pandemic could have an impact?

NB: In a paper published with Professor Mark Bullimore, we estimate that each increased dioptre of myopia leads to a 67% increase in risk of myopic macular degeneration. This is across the spectrum – you see this increase even in low amounts of myopia. There is no safe level.

The eye health threat to the population at large is quite significant, and that's putting it mildly. It is not just the Asian world that is in trouble, the Western world is also at risk. In a submission we've put in for The Association for Research in Vision and Ophthalmology (ARVO), Professor Bullimore and I estimate that in 2050, approximately 30% of the vision impairment in the United States will be directly attributable to myopia. That’s a stunning figure when you consider that when people were looking at vision impairment even 10 or 20 years ago, the complications of myopia did not have a separate category. The major risk factors were age-related macular degeneration, cataract, glaucoma and diabetic retinopathy. The complications of myopia are now sitting squarely as one of the major causes of vision impairment. Already in some of the Southeast Asian countries, we're beginning to see this – it is the major cause of new blindness, according to one study in China.

COVID-19 is an interesting feature. Though the pandemic has only been around for a year, there have been a number of reports on the impacts. One good example is a paper by Dr Jiaxing Wang in JAMA ophthalmology (Progression of Myopia in School-Aged Children After COVID-19 Home Confinement). The researchers gathered prevalence data for myopia between 2015 and 2019. In six year olds it is about 5% consistently over that period of time. In 2020, it was over 20%. That is dramatic. We attribute that principally to more time spent indoors, we know the outdoors is protective against myopia development and the logical conclusion is to attribute it to that greatest amount of time spent indoors.

Are there any barriers to providing myopia control that you hope to address?

A paper by James Wolffsohn and co-workers looked at global trends in myopia management in practice, asking what the main barriers are. One of the key answers was that practitioners felt they were not yet well informed enough to enter myopia control in their practice. Other answers touched on uncertainty around the efficacy, or safety. These are all about education, and this guide is intended to address a lot of that.

Myopia control should be the standard of practice. This guide is intended to accelerate that process to make it the standard. I think there are very few good reasons not to be going down that path, and a lot of good reasons to.

One of the other barriers to myopia control is that some practitioners are hesitant because they are not seeing any complications from myopia in their practices. They're actually right, we're not seeing the complications of myopia in huge numbers yet. The reason for that is that the children of the epidemic of myopia were largely born after 1970. In 2020, they're just beginning to get to the 50 year old age group when their complications become manifest.

Myopia control should be the standard of practice… I think there are very few good reasons not to be going down that path, and a lot of good reasons to

So those practitioners are right, they're not seeing a rise in complications, but it's coming. There's no doubt about that, we're going to see an escalation of myopia associated disease in the future. That's why practitioners need to be there to protect the long term health of their patient's eyes.

We've seen a near doubling of myopia from the year 2000 to 2020. In myopia prevalence around the world, it is going to nearly double again by 2050. But the rates of high myopia are going to go up a lot more than that. Similarly, we're going to see that the expected increase in prevalence in myopia is going to be vastly outnumbered by the increasing prevalence of the diseases as time goes on.

An example of that was from a recent study in Japan by Ueda et al, published in Investigative Ophthalmology in 2019 (Trends in the Prevalence of Myopia and Myopic Maculopathy in a Japanese Population: The Hisayama Study). They followed a group of people in a population-based study over 40 years of age across time. In 2005, the rate of myopia was around 38%. In 2017, it was 46%. We expect that because the younger people being more myopic are getting older, we see this generational increase. But the rate of high myopia and the rate of myopia associated disease more than doubled, even though we only went from 38% to 46% of myopia. That is a great example of the manifestation of how these relatively modest increases in myopia are going to cause great increases in disease and in high myopia prevalence.

How are approaches to myopia control changing?

We are seeing a change in mentality. There's more interest, more information coming out, and more organisation behind it with different companies getting involved. There is a great deal of interest from practitioners, but it's not necessarily always translating into practice.

I think the days of having a young myope come in, who's perhaps minus one and giving them a pair of glasses that have a minus one prescription, should be over. In the past, practitioners might have given them a pair of progressive addition lenses if they're worried about myopia progression, and we know they have minimal impact on arresting progression rates. In those circumstances, there's no question that more needs to be done for those patients. It is shifting, but slowly.

A study has suggested that it takes on average about 17 years for a new technology to become fully invested in clinical practice in healthcare. We've got to shorten that time span for myopia. That requires making a lot of noise, and we need education. The American Academy of Ophthalmology has become interested in myopia now and we're hoping that will create a shift in practitioners' mentality, but also in the public's mentality and in how the authorities approach this.