1040-5488/16/9309-1058/0 VOL. 93, NO. 9, PP.

1058Y1060
OPTOMETRY AND VISION SCIENCE
Copyright * 2016 American Academy of Optometry

INTERNATIONAL MYOPIA CONFERENCE PROCEEDINGS: CONFERENCE PAPER

What Public Policies Should Be Developed to

Deal with the Epidemic of Myopia?
Ian G. Morgan*

ABSTRACT
Developed countries in East and Southeast Asia are now faced with a high prevalence of high myopia in young adults, and
this trend is emerging in other parts of the world. This is likely to lead to increased levels of pathological myopia. Fortunately,
several school-based clinical trials have demonstrated that interventions based on increasing the amount of time that
children spend outdoors can significantly slow the onset of myopia. I argue that it is time to implement mandatory programs
of this kind in school systems, within a framework of regular monitoring of visual acuity, so that those children who become
myopic are referred for clinical treatment as soon as possible to slow progression of their myopia towards high and po-
tentially pathological myopia.
(Optom Vis Sci 2016;93:1058Y1060)

Key Words: myopia, prevention, time outdoors, atropine, schools

E
ast Asia countries (mainland China, Hong Kong, Taiwan,
Japan, and South Korea, and Singapore in Southeast Asia) are
now faced with an epidemic of myopia, in which 80 to 90%
of children completing secondary education are myopic. Similar
changes being documented in other parts of the world as well, but
not yet to the same extent.1 Most importantly, the prevalence of
high myopia (generally defined with a cut-off of j5D or j6D)
has increased to over 20% in some locations.2,3 Those with high
myopia are at markedly increased risk of uncorrectable vision loss
due to pathological changes in the retina, choroid, and sclera, and
an increased risk of retinal detachment, cataract, and glaucoma.
This adds enormously to the burden of disease associated with
myopia because dealing with most forms of pathological myopia is
still difficult and also costly.4
Recent projections suggest that almost 50% of the world’s
population will be myopic by 2050. Almost 10% will have high and
potentially pathological myopia.5 Extrapolating from the prevalence
of myopia and high myopia in young adults provides another ap-
proach to projection. This approach gives a bleak picture for some
locations. To take China as an example, its population is expected to
reduce to around 1 billion by 2100. Because the prevalence of
myopia in young adults is now 80 to 90% in urban areas, with the
prevalence of high myopia around 20%,6 mainland China will be
*PhD
Research School of Biology, Australian National University, Canberra Australia
and State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun
Yat-sen University, Guangzhou, China.
confronted with a population including 700 to 800 million people
with myopia and around 100 to 200 million with high myopia.
These numbers will severely strain, if not overwhelm, Chinese
ophthalmology and optometry services. The challenges posed have
brought the issue of prevention to the center of attention, with the
key aim of reducing the prevalence of high myopia.
At the end of the 14th International Myopia Conference in 2013,
I left the meeting convinced that methods for slowing progression
were now sufficiently developed that it was time for systematic
treatment of children at risk of progressing to high myopia. This
defined accurate prediction of those at high risk and likely to benefit
from treatment as a major research priority. Since then, the effec-
tiveness of low-dose atropine (0.01%) with minimal side effects has
been confirmed,7 and further evidence on orthokeratology and
specialized spectacles and contact lenses has been obtained.8Y10
Effect sizes as high as 50% reduction in progression have been
reported for the three approaches, but the results are not always
consistent. Except for low-dose atropine, washout studies have not
been performed, and longer-term follow-up is needed for all ap-
proaches. The clinical problem is obviously to balance the remaining
uncertainties about treatments against the problems associated with
high myopia.
High educational pressures, including large amounts of home-
work and after-school classes,11 and spending more time indoors
during childhood,12 are important risk factors. Many other factors
have been proposed.13Y15 At least some of these factors have only
small effect sizes, and some may be mediated in part by effects on
education and time outdoors. This is an important area for future

Optometry and Vision Science, Vol. 93, No. 9, September 2016

Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.


research, but fortunately the suggestion by Rahi et al.15 that
prospects for prevention are likely to remain limited until this
complexity is understood does not appear to be correct.
In countries with a strong cultural commitment to high edu-
cational outcomes, changing the education system is likely to be
difficult. However, the central government in China has recently
moved to reduce homework hours in primary schools, which
could have a considerable impact on the onset of myopia, pro-
vided that it is combined with measures to get children outdoors,
rather than spending their spare time on television or computer
games, and backed by controls on private provision of out-of-
school classes.
Considerable evidence that children who spend more time out-
doors during daylight hours are less likely to be or become myopic
has also been presented.16 Reductions in incident cases of myopia of
around 25% (with an additional 40 minutes per day of time out-
doors) to 50% (with an estimated 80 minutes per day) have been
reported in trials carried out in Guangzhou17 and Kaohsiung,
Taiwan.18 The magnitude of these effects is consistent with epi-
demiological evidence that 2 to 3 hours per day outdoors outside of
school hours largely blocks the additional risk of myopia associated
with large amounts of nearwork12 and parental myopia.19
The clinical trial in Taiwan increased time outdoors by locking
students out of their classrooms during school recesses, given that
children in East Asia often spend their recess time in their classroom.
But this solution cannot be applied to schools in mainland China,
where schools have a 150-minute lunch break, during which chil-
dren often sleepVa widespread practice in China. Therefore, op-
tions such as bright classrooms and bright desk lamps for school or
homework will need to be trialed. They may also be useful in parts of
the world where variations in natural lighting mean that for a sig-
nificant part of the year, maximum natural daylight exposures may
be insufficient to protect from myopia.
There is obviously a need for further clinical trials. One trial
from China has reported that roughly doubling the light intensity
in the classrooms markedly reduced incident cases of myopia.20
This result does not fit with the light intensities needed to prevent
myopia in experimental models, or those that distinguish indoor
from outdoor environments, and this trial was flawed by a very
low rate of cycloplegia. It urgently needs to be repeated because if
such a simple intervention is confirmed, then it could be very
widely and rapidly implemented.
The role of screen time with computers, and particularly tablet
computers and smart phones, in the myopia epidemic has received
a lot of attention recently, and Taiwan has put limits on their use
by preschool-age children. These devices were clearly not the cause
of the initial epidemic of myopia because the prevalence of myopia
was already high in high school graduates in Taiwan in surveys
carried out in 1983,2 when tablet computers and smart phones
had not been invented, and computers were not in common use.
The World Wide Web, which triggered the computer age, was not
available until 1993, so these devices cannot have had a causal role.
It is possible that their increasingly widespread use may make it
harder to turn the epidemic around, if they provide further reasons
for children to spend less time outdoors.
One issue that needs resolution is whether increased time outdoors
slows progression of myopia and delaying onset. Epidemiological
work has not detected any significant effect of time outdoors on
Optometry and Vision Science, Vol. 93, No. 9, September 2016
Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.
Myopia and Public PolicyVMorgan 1059
progression,21,22 but marked seasonal effects on progression, which
suggest active regulation by environmental factors, have been
reported.23 Because onset and progression both depend on axial
elongation, it would not be surprising if both proved to be regulated
by time outdoors, but more detailed analysis of this speculation is
clearly required.
There is no agreement yet on the mechanisms involved. The
competing theories are that bright light outdoors increase dopa-
mine release from the retina, and that increased dopamine release
inhibits eye growth,12 the hypothesis that increased UV exposures
outdoors are the key factor,24 and that eye growth is controlled by
the balance of exposure to myopic and hyperopic defocus, with
outdoors characterized by greater uniformity in dioptric space.25
The evidence for and against these hypotheses is discussed in other
papers in this issue.26,27 The mechanism is not particularly crucial
for prevention because there is general agreement that time out-
doors does protect. The UV hypothesis seems to have been ex-
cluded as inconsistent with the evidence that UV-free lights block
experimental form-deprivation myopia, and with more detailed
epidemiological data.28 This is important because it means that
myopia prevention is likely to be compatible with protection from
UV damage.
Despite the many unresolved issues, increased time outdoors
can now be used to prevent the onset of myopia. Clinical rec-
ommendations for increasing time outdoors might be useful for
children at risk of myopia, such as those with myopic parents or
siblings of early-onset myopes. But the potential for school-based
interventions shifts the emphasis from clinical considerations to
public health myopia prevention.
Here, there are two approaches. One, used in Singapore, is to
educate parents about the benefits of time outdoors, but there is no
evidence that this approach has had much effect. The other is to
embed increased time outdoors in the school program, particularly
at primary school level, as part of the mandatory school day. This
approach has been adopted in Taiwan, which now has 2 hours per
day outside at the core of its school-based myopia prevention
program. In our clinical trial in Guangzhou,14 we found that a
parental education campaign had no effect, reinforcing the need for
mandatory school-based programs.
There is a strong argument for embedding prevention of in-
cident myopia in a traditional framework of school-based mon-
itoring of visual acuity and referral of problems to clinicians.
Annual screening would enable children who became myopic,
despite the preventive programs, to be referred for control of
progression as early as possible. Early and prompt intervention is
important because in East Asia, annual myopia progression rates
in early-onset myopes can be of the order of j1D per year,29
leading to high myopia from the age of 11 to 13 on. But even for
countries where the epidemic is less developed, such a regime
would facilitate monitoring changes in prevalence and provide a
framework for public health action in relation to specific groups of
children at greater risk of becoming myopic, such as children of
East Asian ancestry growing up in Australia.22
Measures of this kind will not completely prevent myopia
because myopia is an etiologically heterogeneous condition that
includes forms of genetically determined myopia in a small pro-
portion of the population.30 The emergence of the epidemic of
environmentally driven myopia does seem to depend on a few key
1060 Myopia and Public PolicyVMorgan
social changes in schooling and lifestyle, which can be countered
by increasing the amount of time that children spend outdoors.
Preventing high myopia is the key challenge for the future.
Taiwan seems to be leading the way with school-based interven-
tion programs. The results, which can be expected over the next
few years, will tell us whether this approach is as effective as the
current evidence suggests it should be.
Received March 18, 2016; accepted June 30, 2016.
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Ian G. Morgan
Research School of Biology
Australian National University
Canberra, ACT 2601
Australia
e-mail: ian.morgan@anu.edu.au