Why is it important for myopia to be recognized as a major health issue on a global level? 

Monica Jong: One of the main reasons that myopia needs to be recognized as a major health issue is due to the rising global prevalence. Global estimates show that myopia will affect all of the world in the near future, and not just Asia or the high income countries. This also means that the risk of related ocular conditions such as glaucoma, retinal detachment and myopic macular degeneration (MMD) and other sight-threatening complications will only continue to increase. MMD is already one of the leading causes of blindness in countries like China, Japan, Denmark and Netherlands (1). This will increase the associated socio-economic burden and the burden on health care systems, so comprehensive eye care services will be needed to meet this demand. 

Public health officials and policy makers need to recognize myopia as a global public health issue today, so that the treatment and care required for myopia could be integrated into countries’ health systems. For example, if policy makers recognize a health issue, they could allocate funding for training of health professionals and for treatments, and also allocate billing codes in a clinical setting such as a hospital, or even as part of a universal health system. It could also shift beyond healthcare into policy implementation in education and urban planning, to encourage more time outdoors and reduce near work intensity for children.

Gilles le Saux: Research has shown that increasing prevalence of myopia is mainly due to the change in our modes of life, with an increased demand on near vision and less time spent outdoors. But when detected early, it is possible to manage myopia—substantially reducing the risks of such long-term eye diseases and even potential vision impairment, hence it is critical for myopia to be recognized as a global health issue.

With increasing research being published on myopia, it is important for us to first gain a better understanding of the science behind myopia. If myopia is recognized as a global health issue, more governments will focus on myopia research and develop comprehensive research programs to address myopia onset and progression in children, to bring about better vision care for people with myopia. In addition, with several myopia management interventions being available today, it is important for eye care practitioners to have access to the research and education needed to identify risk factors, provide advice and recommendations and prescribe appropriate interventions to slow myopia progression and prevent high myopia. Finally, most parents today are unaware of the possible long-term risks posed by childhood myopia. That’s why it is important for myopia to be recognized as a major global health issue so that the general public are aware of the gravity of the situation. We really need to act fast, and we need to act now to be able to reduce myopia incidence and change the future, because once myopia progresses, you can’t go back in time.

What was lacking before the IMI white papers were published? 

Monica Jong: Prior to the IMI white papers, there was a significant amount of research being published on the topic of myopia which helped us understand the reasons behind why people were developing myopia, for example, due to retinal blur. There were also consistent reports from clinical trials that outdoor time could reduce new cases of myopia and that optical interventions were clinically effective in slowing down myopia progression. Though there was a wealth of information available, it was only reaching a very small proportion of practitioners globally. The majority of the eye care profession was largely still unaware of the new evidence to slow myopia progression in children, continuing to prescribe single vision spectacles and advising patients that there were no other options. Aside from reach, another issue was that given the large body of work published was highly technical, it was difficult to sort through and comprehend for all practitioners. Clear guidance was lacking and IMI was instituted to address this need. 

IMI’s mission is to advance, make aware and advocate for myopia as a public health issue. Hence, IMI’s aim was to educate practitioners by providing a series of white papers—accessible documents that they can trust to be evidence-based, as they were developed by a large group of experts to ensure that the papers were based on the latest scientific research and well-balanced by different voices within IMI. The collaborative effort of the IMI brings this information to eye care practitioners and also ensures the high quality of this information.

How can industry players help tackle the rise in myopia? Do you have a common shared vision?

The first challenge is to further improve the effectiveness of myopia management interventions in slowing down myopia progression, because the ultimate goal is to stop the progression of myopia for all children.

Gilles le Saux: To be able to address myopia and its related ocular conditions, it is important to focus on addressing two key challenges: 

• The first challenge is to further improve the effectiveness of myopia management interventions in slowing down myopia progression, because the ultimate goal is to stop the progression of myopia for all children.
   
• The second challenge is to utilize our learnings and knowledge on controlling myopia progression to apply it to the prevention of myopia. The ideal situation would be to ensure that all children remain emmetropic. 

Industry players can play a key role to develop and increase access to myopia management solutions for children. It has been more than 30 years since Essilor has started working on myopia in children towards this end, and have launched several research programs to carry out scientific studies in collaboration with leading research institutes and myopia experts and to design products. Our ultimate aim is to contribute to preventing high myopia in the future, and to effectively change the lives of millions of children across the globe. Moving forward, we will continue to study and better understand the pathways for myopia onset and progression, develop comprehensive models of myopia development in children, and advance breakthrough solutions for myopic children. 

Aside from consumer awareness efforts, together with IMI we will also help educate and equip all health care professionals on this issue. To help educate eye care practitioners, it is critical to make the latest research available for them today. IMI’s ground-breaking effort with its first series of white papers in 2019 has already seen important progress in advancing clinical knowledge and practice globally, and its upcoming series is yet another important step towards this end. But the fight against myopia is far from over, and only together can we hope to see a real impact.

Monica Jong: Ian Flitcroft has famously said that every diopter matters (2) and myopia is comparable to blood pressure— keeping it low reduces the risk of all the other serious issues. During the past few decades, research scientists have been doing remarkable work in experimental models of myopia and clinical trials, and it is important for eye care practitioners to have a comprehensive, evidence-based picture of all this work. It is also equally important for these research scientists to partner with industry players to transform their designs into spectacle and contact lenses, pharmacological treatments and medical devices. Addressing a global challenge such as myopia cannot be done alone by any one organization or research scientist, and industry players are an integral part of the solution, with a key role to play in education, developing and supporting appropriate myopia management strategies to help reduce the burden of myopia. Essilor has shown leadership in translational research and has supported initiatives to strengthen awareness of myopia across many practitioner channels. 

Industry players are an integral part of the solution, with a key role to play in education, developing and supporting appropriate myopia management strategies to help reduce the burden of myopia.

What key areas do the white papers cover and what are the key outcomes of the white papers so far?

Monica Jong: The first series of white papers aimed to address the areas of most urgent need and some included recommendations to unify the definitions of myopia and high myopia, and to agree on a separate definition for pathologic myopia. More than 400 different definitions for myopia and high myopia are in use today, which is often a source of confusion and conflict for practitioners. To be able to manage a condition requires a standardized and clinically relevant definition. For the first time ever, the definition of ‘pre-myopia’ was proposed, which was, “A refractive state of an eye close to emmetropia in children where a combination of baseline refraction, age, and other quantifiable risk factors provide a sufficient likelihood of the future development of myopia to merit preventative interventions” (3). Such clinically relevant definitions will also better serve future research in studying and managing myopia in large cohorts of people.

The first series of the IMI white papers consisted of: Definitions and Classifications; Experimental Models; Interventions; Genetics; Clinical Trial Guidelines; Clinical Management Guidelines; and Industry and Ethical Guidelines. The major outcome of the IMI white papers is that moving forward, this allows for harmonization in research and also in clinical management, which will help advance both research and patient outcomes. The white papers have been one of the most widely downloaded and cited papers published in their first year in the IOVS journal (4), and peak health bodies have also referenced them, for example in the WHO Vision Report (5) and the International Agency for the Prevention of Blindness (IAPB). This puts myopia on the radar of policy makers, which is critical if myopia is to be recognised as a serious health issue.  

What are the areas of myopia that are still missing or still need to be addressed as part of this continuing collaborative effort?  

Monica Jong: There is still a lot to do in bringing the knowledge to practitioners. The next series of white papers in 2021 will tackle the areas of myopia that have not been addressed yet, and have been identified as critical. Taskforces have been established with taskforce members selected based on their expertise, geographical representation, and chaired by experts invited by the IMI advisory board. It is a lengthy process to ensure that there is discussion and agreement across all the taskforce members, and this takes place mostly virtually as IMI members are located worldwide. To ensure the highest quality the white paper then undergoes a wider IMI member review process, prior to submission to the peer-reviewed journal. Due to COVID-19, several task forces have been delayed, but the good news is that the white papers have undergone the wider review and are pending journal peer-review process. The new series of white papers is still on track to be published in early 2021. 

How can we continue synergistic efforts in the fight against myopia?

An important aspect is to reinforce long term research activities in order to better understand the basic mechanisms of myopia onset and development.

Gilles le Saux: An important aspect is to reinforce long term research activities in order to better understand the basic mechanisms of myopia onset and development. This includes better understanding the visual specificities of myopic children to be able to determine the causes of myopia, exploring the risk factors that can help predict if and when a child becomes myopic and also understanding how to further improve our solutions in slowing down myopia progression. 

Finally, beyond the healthcare community, patients, particularly the parents really need to get involved in understanding what myopia is, what opportunities exist for their child and why these opportunities are so important to take advantage of. It starts with recognizing to turn the focus beyond correction to management of myopia. The sooner a child's myopia gets detected, the earlier the child will gain access to myopia management interventions and proper vision care. It is important for the eye care industry to continue to rally and strengthen awareness of myopia with one global voice.

Monica Jong: The first thing is to ensure availability and access of interventions for myopia management to every child worldwide – universal health coverage; where myopia management should be considered as part of essential eye care. To achieve this requires a synergistic effort in research to develop technology that makes it simple to manage myopia, treatments that are easy, effective, affordable and safe for long-term use. The second aspect is to educate the healthcare community, public policy makers and the general public about the long-term consequences posed by myopia. The first step in this process is to have myopia management education become widespread in all optometry, ophthalmology and other medical education programs, to ensure that practitioners and other allied health care professionals are well-educated and are making the commitment to change their mindset. A step further would be to ensure a unified curriculum in myopia management which is adapted for each profession and region. Eye care practitioners keeping up with the current evidence by reading the IMI publications in the form of the white papers or the clinical translations, being aware of research advances and communicating with their colleagues, can be a real catalyst for change.  

(1) Fricke TR, Jong M, Naidoo KS, Sankaridurg P, Naduvilath TJ, Ho SM, et al. Global prevalence of visual impairment associated with myopic macular degeneration and temporal trends from 2000 through 2050: systematic review, meta-analysis and modelling. Br J Ophthalmol. 2018;102(7):855-62.
(2) Flitcroft D. I. (2012). The complex interactions of retinal, optical and environmental factors in myopia aetiology. Progress in retinal and eye research, 31(6), 622–660. https://doi.org/10.1016/j.preteyeres.2012.06.004
(3) Flitcroft DI, He M, Jonas JB, et al. IMI – Defining and Classifying Myopia: A Proposed Set of Standards for Clinical and Epidemiologic Studies. Invest Ophthalmol Vis Sci 2019; 60(3): M20-M30. doi:10.1167/iovs.18-25957.
(4) Investigative Ophthalmology & Visual Science February 2019, Vol.60, Issue 3
(5) World report on vision. Geneva: World Health Organization; 2019. License: CC BY-NC-SA 3.0 IGO.