Myopia on Spotlight at AOS Virtual 2022

The 5th meeting of the ASEAN Ophthalmology Society (AOS) opened on Saturday March 26, 2022 with a myriad of scintillating sessions over the weekend.

While the COVID-19 pandemic is still raging regionally, it didn’t dampen spirits as delegates gathered online to attend the virtual two-day congress.

“We were supposed to have the 5th congress in Manila, the Philippines in 2021 (last year), but we couldn’t make it because of the COVID-19 pandemic. We have the 5th Congress here today, as a virtual meeting. We are fortunate to have many guest speakers and many interesting topics,” Dr. Paisan Ruamviboonsuk, AOS secretary general, said in his opening remarks.

The AOS was incorporated in 2013 in Bangkok, Thailand, during the Summit of Ophthalmological Societies hosted by the Royal College of Ophthalmologists of Thailand. It consists of 10 member countries: Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand and Vietnam.

While delegates have become accustomed to the easy access of online forums — the new normal in congresses during the pandemic — this comes with its own set of pros and cons.

“What’s not good about online meetings is that we miss traveling, the culture and the climate of countries. Online meetings are less personal,” said the chair of the society’s scientific committee Dr. Doric Wong from the Singapore Society of Ophthalmology.

“What’s good about online meetings? Travel may not be necessary. I can sit in my office on my own and be able to connect with you all during this meeting. It certainly costs less money and time. We don’t have jet lag to deal with. In the long-term, you’ve got to think about the environmental impact of traveling all the time to meet each other. Now content is quite accessible, we can jump from room to room. Quite often the proceedings are recorded, and we can review them later. And being less personal may be less daunting for some of the introverts among us,” he added.

“As ophthalmologists, we value the connection we have with each other, the sheer proximity of our countries with each other. If we think of our own country as our nucleus family, ASEAN is our extended family.”

Future Treatments Ahead As Myopia Rises

More outdoor time and less time spent indoors has been found to slow myopia onset and progression, Dr. Audrey Chia, head of pediatric ophthalmology at the Singapore National Eye Center, said in her AOS Keynote Lecture where she talked about Management of Myopia: Current and Beyond.

Future treatments in the pipeline for myopia could include high light intensity, with increased sun exposure, and red light. There is also promising animal study data for new pharmaceuticals. Current treatments available for myopia include atropine eye drops, orthokeratology lenses, multizonal contact lenses, and DIMS and HALT glasses.

“The interest in myopia in the 1980s began with the myopia epidemic, which resulted in myopia rates increasing from about 30 to 40% in the 1970s, to about 80% in the 1990s in countries such as Hong Kong, Taiwan, Singapore and South Korea,” she said.

“A lot of this change was attributed to a change in lifestyle, namely the increase in academic pressures and a shift toward more urban living where there was less outdoor activity and a lot more indoor activity. Genetics also played a role, and we do know that myopic parents are more likely to have myopic children,” emphasized Dr. Chia. 

In Singapore, some 28% of 7-year-olds, 63% of 12-year-olds, 80% of 18-year-olds, are myopic, with up to 20% being highly myopic, she said. This is a trend that is rapidly increasing over the rest of Asia and the world.

The Socio-Economic Burden of Increasing Myopia Rates

The fear is that with increasing rates of myopia, increased visual impairment secondary to myopia complications will also be seen over time, and that this might pose a social economic burden on communities. The challenge is in preventing and delaying the onset of myopia or to control its progression. It is best to prevent high myopia, associated with a range of myopia complications, such as early cataracts, retinal detachment, optic neuropathy and macular degeneration.

A study in 2009 comparing 12-year-old Chinese Australian children to Singaporean children found that the rates of myopia in Australia were very low, around 30%, compared to 60% in Singapore. Australian children spend about 14 hours per week outdoors, compared to only four hours in Singapore. More outdoor time was shown to be protective against myopia, regardless of how much indoor activity was performed.

Hence, it was recommended that children should spend at least two hours per day outdoors. Some technologies have been developed to monitor and control children’s outdoor activity, such as watches that show when children are exposed to bright light. Some phone apps developed also encourage them to spend less time on their phones and more time outdoors, and these are linked to reward systems.

Genetics and Myopia

Genetics also plays a role. East Asian people are at higher risk of developing myopia. Having two parents with myopia increased the risk of a child having myopia by two to five times.

Over the years, a number of treatments have emerged in order to manage myopia better. High-dose atropine eye drops are relatively cheap and have up to an 80% efficacy rate, although 10% may respond poorly. Low-dose atropine on the other hand, has up to a 65% efficacy rate. Orthokeratology lenses are contact lenses that are worn at night, and work by remodeling the surface of the cornea, so that glasses and contact lenses are not needed during the day. Studies suggest that these lenses can slow myopia by up to 30 to 50% over three to five years, although 10% may have a poor response.

Rebound can also occur when these lenses are stopped in children under 14-years-old. These are best used for children with low to moderate myopia and no astigmatism. Because of the recurrent and overnight use, users need to be careful about infection or infective keratitis. They are less suited for those with poor hygiene and allergies.

Other Specialized Lenses for Myopia

In the 2010s, the focus turned to peripheral defocus content glasses, multifocal or multizonal contact lenses. Studies suggest that multifocal or multizonal lenses can slow myopia by 30 to 50%. However, 10 to 20% may have a poor response.

More recently, there are the DIMS or HALT glasses, available in two brands: the Hoya Miyo-Smart-DIMS glasses and the Essiolor Stellest-HALT. Studies in older children aged 8- to 13-years-old show that these lenses can slow myopia progression by up to 60% over one to two years, but 13% may have a poor response.

There is some suggestion that they may be less effective in younger children under the age of 9. The effect is also unknown in children with higher myopia, astigmatism or strabismus.

“Moving into the future, there is now great interest in light combinations and new medications. In terms of light therapies, the interest is in high light intensity therapies or red light therapies,” noted Dr. Chia.

“However, there are still some questions on what is the best intensity, chromaticity and duration, and whether there are any long-term safety issues. In terms of combinations, people are combining optical and medical treatments. We do know that not all treatments work well for all children,” she added. 

Editor’s Note: The 5^th AOS Congress was held virtually on March 26-27, 2022. Reporting for this story took place during the event.