I will share a secret that can lead to complete myopia prevention in this video. It’s simple, but not many people among the general public know about it. It sounds simple, but in reality is extremely hard to achieve.

If you don’t want to watch the video, here is the transcript.

Secret to stopping myopia

Hello, this is Dr. Ding. I am an eye doctor and today I would like to tell you the secret to stopping myopia.

Myopia affects 1 in 3 people on this planet, and people with myopia have increased risks of a host of eye diseases that may lead to blindness. No, it is not merely an inconvenience of glasses or contact lenses that can be fixed by lasik surgery later. It is a fundamental change to the eyeball that permanently changes the anatomy and robustness of the eyes that no lasik can fix. Lasik may make you lose those glasses, but your eyes are nonetheless the same ones with the increased risk of macular degeneration, retinal detachment, cataract and glaucoma. These are conditions that glasses, contact lenses, or lasik can not fix.

So now you know that myopia is bad, but why is myopia so prevalent? 

We can blame some of this on our parents. Some of them have genes that make it easier for people to develop myopia. For example, if parents both have myopia, then their kids will have a much higher chance of developing myopia as well. It’s a bit like tall parents will give birth to kids who will become tall adults eventually. Unfortunately, we really don’t have a way to choose our parents or our genes at this moment. So let’s find out what else is the problem. 

For hundreds of thousands of years, humans lived as hunter gatherers and/or farmers, which means a lot of time spent outdoors. 

And up until some two thousand years ago, humans did not really read. Computers came out only in the last century, as well as ipads and smartphones. With modern education and lifestyle, it has become the norm to spend the majority of wake time reading, writing, or looking at things at an arm’s length, most often in a room. 

And this is a big problem for our eyes. Human eyes are supposed to be emmetropic or just right by stopping growing after 6-8 years of age. However, the constant near work and lack of exposure to high intensity, full-spectrum natural light keep sending signals to our eyes to continue to grow, which leads to myopia. As a result, children’s eyes develop myopia which continues to progress up till early adulthood. In fact, this high stress and demand we put on our eyes make myopia grow even in people’s 30’s and 40’s. 

The sad thing about myopia is that it is not reversible, which means that once it forms, it does not reverse. It’s just like when you grow to be 6 feet tall, you don’t just shrink to 5 feet. 

The sadder thing about myopia is that it will continue to progress if nothing is done to stop the eye from growing. 

The saddest thing about myopia is that it happens so early in life that the people who have this happen to them, AKA children, are too young to be able to make a decision to live differently to make a difference. It is up to the parents, the teachers, the school and the society to tell them, hey, this is hurting your eyes and we have to do something to stop your eyes from getting bad or worse.

So what can parents do? First, we need to know that normal growth or kids’ eyes rely on a good amount of outdoor activities daily. Numerous studies have shown that 2 hours of outdoor activities daily prevent myopia from happening in the first place, and slow down myopia progression once it starts. 

What is so special about the outside? We don’t know for sure, but most likely it’s the enormous amount of light outside vs the comparably much dimmer artificial light inside a room. For example, on a bright sunny day, the light unit outside is up to 100,000 lux, even on a cloudy day it is about 5,000 lux, whereas in a well-lit room it is typically around 1,000 lux. In addition, natural light consists of a continuous spectrum of the visible light, whereas most artificial light sources have a different light spectrum. 

Another factor could be the openness of the outside environment. Unless closed, our eyes are constantly focusing on objects and scenes. This is done automatically without you trying. So your eyes have more chances to focus on things that are much farther away outside than inside a room. 

Back to parents’ responsibility of giving kids outdoor time. This has to happen early and consistently. You don’t start bringing your kids outside when they are 6 or 7, you start doing that when they are 1 or 2. Remember it’s the bright natural light that’s beneficial and not the exercises themselves, so working out inside a gym will not help their eyes, but walking or even sitting in the sun will do.

Sure please put on sunglasses or a hat to avoid UV damage to their eyes, but even when protected by sunglasses the eye still sees much more light than inside a house.

Again it is the bright natural light that is beneficial, so taking them to the park when it’s dark or really cloudy or raining will not help. It may be good for other things but not for myopia prevention.

What can schools do to help kids prevent myopia? Let’s face it, kids spend the majority of their day time at school, when the natural light is the best. So make recess count, make every child go out to the field during recess. Better yet, increase the time of recess. Maybe teach some classes outside. Promote walking to school and not driving. Build more windows to classrooms. 

What can our society do to help children’s eyes? Educate parents, teachers and children. Let everyone know about this ‘secret’. Promote this on social media, on TV and on radio. Make policies that mandate 2 hour of daily outdoor activities for schools, preschools and daycares. Screen children for vision problems. Subsidize health plans to allow children to have free eye exams. Give working parents special time off once in a while during the day to spend time with their children outside. Foster a culture that favors activities outside as an essential part of healthy living. 

There it is, the secret. It seems so simple, yet it is so hard to do. It is in every way against our modern lifestyle and civilization, where sitting in front of a computer all day long is the mode of productivity and success. Yet we simply have to do it, because after all, what is more important than our children’s vision and health?

It is very common to see children develop myopia and get worse over time. We know that adults typically don’t have myopia progression because their eyes have fully developed and stopped growing, just like their height. However, in real life, some young people do have increased prescription numbers year after year. Researchers observed that college students continue to have increased myopia previously in Europe and the US. Now a new study [1] from Australia followed young people for 8 years (20 to 28 years of age) and confirmed this finding.

Among 516 subjects with no myopia, 14% were found to have developed myopia after 8 years. Among 698 subjects with myopia less than 6 diopters, 0.7% were found to have developed high myopia (more than 6 diopters) after 8 years. Among 691 subjects who were included in the progression analysis, 37.8% had myopic shift of 0.50 D or more. On average, the myopic progression was -0.04 D (ranging -0.03 to -0.06) per year, and axial length increase was 0.02 mm (0.014 to 0.025) per year. 

We can see that this is a small myopic shift, but it is a true shift and statistically significant.

So what kind of people are more prone to develop this myopic shift as adults? They found that East Asians were more likely than whites, females were more likely than males, those with myopic parents were more likely than those without myopic parents, and those who spend less time outdoors were more likely to develop more myopia as adults. Interestingly, they used an objective way to evaluate outdoor activities, conjunctival ultraviolet autofluorescence area, as the larger the area, the longer exposure to the sun.

These are also the risk factors of myopia progression in kids. So having myopic parents, being a female, being an East Asian, and spending less time outdoors are just not good in terms of myopia, kids or adults alike. You will notice that no one can change the first 3 risk factors, but the last one is highly modifiable. 

The take home message is that myopia progression can continue into adulthood, though at a much slower rate. And spending more time outside is always a good thing if you don’t want your glasses to get thicker.

Reference: 

[1] Lee SS, Lingham G, Sanfilippo PG, et al. Incidence and Progression of Myopia in Early Adulthood. JAMA Ophthalmol. Published online January 06, 2022. doi:10.1001/jamaophthalmol.2021.5067

https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2787671?guestAccessKey=f903daac-9b69-40d8-869f-dca0a2827933&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamaophthalmology&utm_content=olf&utm_term=010622

Many parents ask whether their children should be on both atropine and ortho K to control myopia. There were small studies, some showing better result with the combo treatment. There was also a small scale study that I talked about that showed when ortho k failed to control myopia progression, additional atropine did not help.

Now a new research that analyzed 5 clinical studies involving 341 children revealed that ortho K + low dose atropine worked better than ortho K alone in controlling myopia progression [1]. On average, using the combo treatment results in 0.25 mm axial length elongation compared to about 0.35 mm in ortho K alone after 12 months of treatment. This is a small, but statistically significant finding.  

I think having this data is helpful. When a child has sub-optimal control with ortho K alone, I can recommend adding atropine. If a child has fast progressing myopia and parents are anxious, I can recommend starting with both treatments to maximize the control.

Would you be interested in seeking both treatments together right from the beginning?

Reference:

[1]https://journals.lww.com/claojournal/Fulltext/2021/02000/The_Efficacy_of_Atropine_Combined_With.7.aspx

We know that low dose atropine has been used to control myopia progression for a number of years now. It is still not approved by the US or Chinese FDA partially because long-term safety data are lacking. Previous studies demonstrated 2 years of using to be safe and effective. But myopia control is a long-term thing, maybe up to 10 years if a child starts to develop myopia from an early age (6- 8 years of age). 

Well now there is a study in Taiwan following children using low dose atropine for 10 years. This is a cohort study, no controls, and with only 23 subjects. Every child (that had myopia) was on low dose atropine for the entire 10 years and monitored every 2-4 months to check their refraction and axial length. It is certainly not a controlled or randomised study, and with a low sample size. However, I think it gives us a lot of information in a clinical setting on what to expect once a child is on low dose atropine for myopia control long term.

They also adopted a commonly used clinical approach, stepwise increase in treatment dosage if the treatment effect is not enough. For example, every myopic child started with 0.05% atropine. If a child did well on this, they continued this dosage throughout the 10 year period. If however their myopia continued to progress more than 0.50 D every 6 months, then they were switched to higher concentrations of 0.1%, 0.25%, and until 0.5%. A high concentration of 1% was not used.

In my clinic (and perhaps many others), I usually start with even lower concentration, 0.01%, which has been clinically proven to be effective in myopia control and with the least side effects including pupil dilation, light sensitivity and blurry near vision. I would go up to 0.02% and 0.05% if myopia control is not achieved, and I seldom go higher than 0.05% because at this point the side effect is noticeable and may interfere with normal study and life of a child. Eye doctors in Taiwan are more aggressive in myopia control in terms of using atropine and I thank them for the study. I always wonder whether I should ramp it up, and if higher concentrations are effective, then maybe it’s worth the side effects (and potentially risks of using this for 10 years).

This study answered my question to some degree. First of all, 65% patients were only using 0.05% atropine throughout the study, which means 35% patients did not respond well to the initial low dose. This is a high number. Remember 0.05% is already a higher concentration than the most commonly prescribed 0.01%, and still ⅓ of children do poorly on it. When we encounter children like this (and we will), do we further increase the dosage? In their study they did, and what they discovered was that for those who did not do well in the initial low concentration of atropine, despite the stepwise increase in the atropine concentration, their myopia control was still worse than the kids who responded to the initial low dose atropine. There were vast inter-individual differences, but the mean numbers look like this: the responding kids started with -1.5 D and progressed to -4.7 D after 10 years, whereas the poorly responding kids started with -0.9 D and progressed to -6.6 D. Their study did not have a control, but based on natural history of myopia progression in their population, they predicted about -7.7 D if no myopia control was done at all. So for those that respond to atropine, a reduction of 3 D of myopia over 10 years is quite good, especially it prevents these kids from developing high myopia (more than -6.0 D), which is associated with more retinal related complications. On the other hand, 10 years of high dose atropine in children who were poor responders resulted in only 1 D of myopia reduction, it seemed less worthwhile, considering the burden of using drops daily for 10 years and the side effects associated with dilation. Of course, this is purely based on a mean value, and individuals can be quite different, and for some, maybe 1 D reduction is still something that helps. 

But the lesson here is that if a child responds poorly to low dose atropine, merely increasing the concentration may not be the answer. They may be better off with additional or alternative control methods, such as ortho K lenses or multifocal soft contact lenses. 

Another outcome is that they did not find significant side effects with 10 year use of low dose atropine drops. The study also claimed that the children were not prescribed PALs. That is interesting, considering that atropine at concentration of 0.1% or above will have significant dilation and cycloplegic effects. Given that they used higher concentrations, it can be assumed that 0.01% atropine can also be used without significant side effects for up to 10 years.

So the take home message is that long term use of low dose atropine (10 years) may be safe and effective, but if a child responds poorly to low dose atropine, then they may benefit more from other methods of control. But keep in mind that this is a limited study with small number of patients. We still wait for larger scale and better controlled study.

The study cited in this article:

Chuang, MN., Fang, PC. & Wu, PC. Stepwise low concentration atropine for myopic control: a 10-year cohort study. Sci Rep 11, 17344 (2021). https://doi.org/10.1038/s41598-021-96698-6