More needs to be done to manage myopia in children

Recently my clinic was running very low on unit vials of low dose (0.01%) atropine eyedrops, a nightly medication that is currently commonly prescribed to moderate myopia progression in children. I was informed by the pharmacist that there is a regional shortage as the demand seemed to be outstripping the supply of this eyedrops treatment for myopia in kids. The popularity of this medication is hardly surprising as it has been proven effective by multiple researches in Singapore and elsewhere, with almost no known undesirable side effects. It seems to me that the production and business side of it could see improvement, and if I were an investor I would certainly explore this.

Myopia, or short-sightedness, is a rising epidemic around the world. Recent studies showed that a trend towards increased incidence of myopia is seen everywhere, particularly in East Asian and urban areas. Many communities are anxious that more children are getting myopic and starting at a younger age, leading to more years of seeing myopia progressing, before the short-sightedness finally stabilizes at the end of adolescence.

One of 4 types of refractive errors, myopia is particularly cumbersome as it renders one to see blur for distance, with clear sight only for near. The higher the degree of myopia, the shorter the range of view becomes, thus affecting activities requiring clear vision outside this range, unless it is treated. Treatment is two-pronged: optically, to provide temporary relief by glasses or contact lenses, or if a more permanent solution is required, surgeries such as laser vision correction or lens implantation can be sought, when the degree is deemed stable. In addition, increasing focus is placed on strategies to curtail the progression of myopia in childhood, in order to keep myopia within manageable levels. Some of these include encouraging healthy visual habits such as having regular breaks during near visual tasks and spending more time outdoors.

In Singapore, huge efforts had been made both in terms of public health and education measures and in research, aiming to manage this scourge. The efforts seem to have paid off somewhat. Last year, we gave ourselves a pat on the back for seeing some signs of stabilization of myopia rates. Even so, no time should be lost in rejoicing. For many families with school-going children, regular trips to the optician’s and eye doctors’ continue in a bid to dethrone ourselves as the most myopic country in the world. To persevere with low dose atropine eyedrops therapy for children with myopia is the least we can do to control the situation, as inevitably, more and more time is spent on near work, no thanks to the increasingly wider applications on hand-held personal digital devices. Eyedrops treatment is as non-invasive as it gets, and higher concentrations sometimes being trialled for more resistant progressions, with increasing side effects as the medication becomes more powerful. Next up in the regime is contact lenses, including rigid nightwear lenses (orthokeratology), which require much more handling and strict care in hygiene, without which blinding complications may arise.

Historically, myopia is not a “new disease”. In fact, it had long existed in the Chinese, Singapore’s predominant ethnic group. As far back as during the ancient dynasties in China, scholars spent countless hours in tiny, dimly-lit study booths preparing for the imperial exams and were well known to be myopic. The soft focus rendered by their myopia apparently inspired many a funny and witty Tang poem, mirthfully enjoyed and passed down the generations, along with some myopia genes. This was the topic of a tongue-in-cheek poster I had put up for the 11th International Myopia Conference (IMC) in Singapore in 2006. The biennial IMC, currently almost in its 17^th iteration, usually never disappoints me with its interesting research from the ground-up and lack of dogma.

Indeed, all the refractive errors, myopia is the only one that has been shown in studies to be associated with psychometric intelligence, particularly of the verbal kind. Interestingly, a previous study apparently found that of a group of subjects with high IQ, a large proportion had very early onset myopia compared with a control group with normal IQ. To strengthen theories or prove alternative hypotheses, the scientific community often likes to retest similar subjects. Of course, the devil is in the details. In January this year, a scientific study (which made for an entertaining read to me) was published in the highly respectable journal Nature, titled “Refractive Error is Associated with Intracranial Volume”. The Japanese researchers went to great length studying the various volumes of the brain in more than a thousand young adults and concluded that myopia is associated with the total intracranial volume, but not the actual grey or white matter volume. As an analogy, rather like how if you are an L-size for shirts you are most probably L-size for pants too. Hence if your whole brain size is large your eyeballs would probably be large (and myopic) too, regardless of why and how the brain got to its size. Conventional wisdom would have it that both nature and nurture likely contributed to these facts and findings.

Before we rejoice in the above seemingly positive connotations of myopia, let it be known that definition of an error, in this case in refraction, still equals a state of imperfection to be improved on. Indeed myopia should be carefully minded. Not only does it make life inconvenient and certain activities difficult, if not downright dangerous without optical aids such as spectacles and contact lenses, it can be associated with and lead to a higher prevalence of other eye diseases. Some of these may be blinding, such as glaucoma and retinal detachment.

While the other errors of refraction like astigmatism, hyperopia (or long-sightedness) and presbyopia (or “old-sightedness”) are equally inconvenient, none of them is as common and impactful in the formative years of a person’s life. For instance, it may be unwieldy in certain sporting pursuits, predispose to higher incidence of injuries or mishaps, and may generally affect self-esteem or self-perception. In fact, scientific research had shown associations between myopia and personality traits of lower extroversion and behavioural patterns such as having a narrow focus of visual attention. In the more severe cases, hallucinations and paranoid tendencies had been reported to be linked to myopia.

Therein should be the impetus to reduce the incidence and severity of the plague of myopia, one of the most common causes of visual impairment in the world. In my humble opinion, simply prescribing glasses for school children is not sufficient in today’s scenario, when multiple researches have shown proven benefit of medical therapy such as using low dose atropine eyedrops in retarding myopia progression. Regular monitoring with a view to such safe and effective treatment should be highly recommended in young children and teenagers. Encouragement for more time spent outdoors in natural outdoor lighting, with the natural fluctuations in intensity that come with it, is also highly recommended, as this is what the results of several comparative studies seem to point to.

Dr. Daphne Han

Senior Consultant, Ophthalmologist

The Business Times, Sunday, 11 November 2018