The impact of the pandemic highlights the urgent need for myopia guidelines: The clinicians’ role

Even before the COVID-19 pandemic, the number of people with myopia in 2020 was estimated to be 2.6 billion globally, and it was expected to rise up to 4.9 billion by 2050, unless preventive actions and interventions were taken. ¹ Myopia is an important health-care problem due to its well-known complications and the natural course of high myopia; myopia is already one of the most common causes for irreversible vision impairment including blindness.^1,2 Without setting guidelines and the prompt establishment of national reforms, the existing large number of myopes is bound to rise considerably.

The children population is the most crucial one, as myopia is increasing the greatest among the young generation. Recent studies found that a) in Hungary, the prevalence of myopia was three times higher (57%-61%) in younger age groups (18–35y) than in older ones ³ ; b) in France, the highest prevalence of myopia was also found in the age groups between 10–39y, with a similarly high peak (52.4%) in those aged 20–29y ⁴ ; and c) the European Eye Epidemiology Consortium found the highest rates of myopia (around 40%) in younger age groups. ⁵

Preventing myopia and its progression became all the more important, since home confinement during the COVID-19 pandemic has exacerbated the worldwide burden of myopia. ⁶ Studies exhibited an 1.4 to 3.6 times increase in myopia progression during the COVID-19 lockdown,^7–10 especially in younger children,^6,10,11 even in children under low-dose (0.05% or 0.025%) atropine therapy. ¹¹ Studies showed that the statistically most important risk factors for an increased myopia progression were the increased digital device screen time of children (in association with a significant increase in e-learning using smartphones, tablets or computers) and the decreased time spent on outdoor activities (and reduced sunlight exposure) due to home confinement.^6,7,9–14 The digital screen time of children increased 1.3 to 7.8 times during the COVID-19 lockdown as compared to the pre-COVID time^7,11–14 while the outdoor activities decreased by 48.6% to 62.8%.^7,8,11,14

The COVID-19 epidemic presented an unwelcome chance to test the impact of behavioral changes and myopia in the real world. ¹³ Based on these new findings, it is critical to address the environmental risk factors for myopia, even in children undergoing therapy to slow down myopic progression. ¹¹ As children's physical activity during the first COVID-19 UK lockdown was significantly reduced, ¹⁵ promoting safe physical outdoors exercises for all children is critical not only for myopia control but also for the children's overall health and development.^12,15,16

There is a wealth of evidence-based knowledge on myopia, including its onset, progression, risk factors, screening and detection, follow-up, and interventions for myopia control.^2,17 The significant increase in the number of articles published about myopia in general is not matched with information and discussion about the roles and responsibilities of specialists in the prevention of myopia and reduction of its progression. This article provides an overview of the required action.

1. Primary prevention refers to procedures used to prevent the onset of a disease, in this instance myopia. The highest level of evidence supports the need for children to spend more time outdoors and do less near vison activities (level I. evidences, Elsevier) to prevent or at least delay the onset of myopia.^6–14,18,19 Strong evidence (level III. evidences, Elsevier) has shown the major preventive nature of increased reading distance (more than 20–30 cm), ²⁰ limitation of continuous reading (less than 30–45 min), ²¹ and use of incandescent or fluorescent light bulbs (instead of LED lamps). ²² Using natural light or extremely bright light bulbs (over 3000 Lux) indoors is beneficial for myopia prevention. ²⁰ Children who used television and projectors for online or e-learning had significantly less myopic shift than those who used tablets and mobile phones, suggesting that television and projectors may be superior options for online learning. ¹⁴

Preventing the onset of myopia requires health promotion. Medical experts have a dual role. There is a need to present current information and necessary interventions in a manner that would encourage decision makers and politicians to undertake actions and decisions that accomplish environmental changes. To modify the environmental factors surrounding education necessitates action from the Ministries of Education, including the provision of evidence-based facts about myopia to children and parents as well as to those in charge of initiating and achieving lifestyle changes among children. Eye care specialists should play a key role in information dissemination and advocacy since they are more familiar with the epidemiological and scientific facts about the myopia epidemics and feasible preventative methods.

Further concrete actions of clinicians might be:

Regular teaching of nurses and social services

Secondary prevention needs active screening and follow-up programs. The task of eye care personnel is to submit evidence on unmet needs and appropriate ways of such screening campaigns to decision makers/politicians so that the Ministries of Health and Education can develop mass screening programs for preschool children. There is also a need to raise public awareness by disseminating information through various media (news, radio, television, online, etc). Eye care and medical professionals need to prepare appropriate messages for the public and to be prepared to undertake screening, follow-up, and interventions for pre-myopes.

Further concrete actions of a clinician might be:

Regular teaching of nurses and social services who perform the vision screening

Tertiary prevention to avoid progression to high myopia necessitates active work by eye care professionals. There is an urgent need to advocate the appropriate assessment procedures as well as potential myopia control interventions. Campaigning for proper funding of necessary myopia examinations, follow-up examinations, interventions, optical equipment, and eye drops in the healthcare budget is required by all stakeholders.

Concrete actions of clinicians might be:

Organizing training courses for eye care specialist on the application of myopia control methods suggested by the latest literature

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