CLINICAL AND EXPERIMENTAL
Nearly 1 billion myopes at risk of myopia-related sight-threatening conditions
by 2050 –time to act now
Clin Exp Optom 2015; 98: 491–493 DOI:10.1111/cxo.12339
Brien A Holden OAM DSc PhD
Monica Jong PhD BOptom
Stephen Davis MA
David Wilson PhD BEc BA(hons)
Tim Fricke BOptom MSc FAAO
Serge Resnikoff PhD MD
Brien Holden Vision Institute, University of New South
Wales, Kensington, New South Wales, Australia
In March 2015, the World Health Organiza-
tion (WHO) and Brien Holden Vision Insti-
tute (BHVI), held the WHO-BHVI Global
Scientiﬁc Meeting on Myopia in Sydney, at
the BHVI, located on the campus of the
University of New South Wales. Key scientists,
researchers and clinical experts from around
the world, supported by the Australian
Government Vision CRC program, joined
together to address the rapidly increasing
prevalence and the visual, social and eco-
nomic impact of myopia.
It was a historic step in placing myopia on the
world health agenda. An important contribu-
tion from the meeting was the deﬁnition of my-
opia and high myopia and a description of a
potentially blinding retinal condition associated
with myopia; myopic macular degeneration
(MMD). As a result, future epidemiological sur-
veys will be able to accurately record the num-
ber of people who are blind or permanently
vision impaired from myopia.
This recognition by the WHO will hope-
fully be the catalyst for increased government
engagement with the issue, including greater
support for programs for myopia and invest-
ment in the development of solutions, en-
hancing our capacity to reach populations
with the timely interventions and treatments
this vast problem requires.
THE GROWING PREVALENCE OF
The prevalence of myopia has been growing
rapidly, particularly in urban areas of East
Asia, where some ﬁndings have been
astonishing. A study of military conscripts (19-
year-olds) in South Korea found that 97 per
cent of them were myopic.
Singapore have rates of myopia in young
adults of 70 to 80 per cent.
In Western coun-
tries, the prevalence is also increasing, rising
from 25 to 42 per cent among 12 to 54-year-
olds in the United States over the last
while a recent study in Australia
found 31 per cent of 17-year-olds to be
We conducted a comprehensive meta-
analysis on prevalence of myopia, in which
we projected the change in prevalence over
the next 35years. We estimated that in 2010,
there were almost two billion people with
myopia but if current trends continue, ﬁve
billion people will be myopic by 2050 (half
the 2050 world population). Of these, almost
one billion people will be highly myopic (5.00
D or more) and at a signiﬁcantly increased
risk from sight-threatening conditions asso-
ciated with high myopia, such as retinal
damage, cataract and glaucoma.
The good news is that several promising
approaches to control myopia offer hope that
we can signiﬁcantly reduce the number of
people progressing to high myopia and elim-
inate the increased risk of blindness associ-
ated with the condition. What is absolutely
necessary is substantial backing from govern-
ments, health-care systems, education systems
and private funders to support the research
and public health programs, which need to
be implemented to counter this threat.
High myopia (5.00 D or more) signiﬁcantly
increases the risk of sight-threatening condi-
tions and is now being recognised as a major
cause of blindness. High myopia increases
the risk of glaucoma (14.4 times for 6.00 D
or more of myopia),
(7.8 times for 8.00 D or more)
(3.3 times for 6.00 D or more of myopia).
The risk of visual impairment is increased
3.4 times with myopia between 6.00 D and
10.00 D and 22 times when above 10.00 D.
Our projections indicate that if current
trends continue, over 900 million people will
have high myopia (5.00 D or more) by 2050 –
up from around 200 million in 2010. In Singa-
pore, for example, we estimate that nearly
half the population will have high myopia by
MYOPIC MACULAR DEGENERATION
Myopic macular degeneration is the cause of
6.3 to 26.1 per cent of cases of blindness in
population studies across the world, being
ranked either the ﬁrst, second or third most
frequent cause of blindness in studies con-
ducted on Asian populations and the second
to ﬁfth most frequent cause of blindness in
In the general popu-
lation, visual impairment due to myopic
macular degeneration occurs in one to ten
people per 100,000 annually.
Myopic macular degeneration is the lead-
ing cause of monocular blindness in Tajimi,
and the leading cause of new cases
of blindness in Shanghai, China.
glaucoma, age-related macular degeneration
and corneal opacity.
The fact that myopic macular degene-
ration is one of the most common causes of
blindness in people with high myopia, re-
mains relatively unknown. Signs of myopic
macular degeneration include atrophic reti-
nal macular changes or subfoveal choroidal
neovascularisation leading to atrophy, in the
presence of high myopia.
Higher levels of myopia are also associated
with other retinal abnormalities such as
chorioretinal atrophy, lattice degeneration,
lacquer cracks, posterior staphyloma, Fuchs’
spot, retinal breaks, retinal detachment, reti-
noschisis and posterior vitreous detachment.
The risk of visual loss signiﬁcantly increases
with these changes.
The prominent role myopia has in blind-
ness is yet to be ofﬁcially recognised by major
© 2015 Optometry Australia Clinical and Experimental Optometry 98.6 November 2015
bodies such as the WHO, International
Agency for the Prevention of Blindness or
the National Eye Institute in the US. It is
hoped that the recent WHO meeting in Syd-
ney will see this change in attitude toward
CURRENT INTERVENTIONS FOR
CONTROL OF MYOPIA
Several optical, pharmacological and behav-
ioural interventions have shown promise in
controlling myopia but generally require fur-
ther investigation, clinical evaluation and/or
improvement in performance.
Spectacle interventions tested include ex-
ecutive bifocal lenses, progressive addition
lenses and lenses designed to reduce periph-
eral retinal hyperopic defocus. The most suc-
cessful of these has been executive bifocals
with near prism providing a 51 per cent re-
duction in the rate of progress of refractive
error and 34 per cent for axial length.
other option is orthokeratology, which has
also shown promise at 40 to 50 per cent re-
duction in axial length growth,
one long-term (ﬁve years) study observed a
decrease in control of myopia over time
(years four and ﬁve), averaging a 30 per cent
reduction over the ﬁve years.
Pharmacological agents that have demon-
strated an ability to slow myopic progression
clinically include: pirenzepine
both of which have reported side ef-
fects. The higher concentrations of atropine
such as 0.5% and 1.0% produce side-effects,
such as ﬁxed pupils, loss of accommodation
and potentially allergic reactions, with a re-
bound effect observed after cessation of treat-
Low-dose atropine (0.01%) is
proving to be the most effective and com-
monly prescribed in Asia, with a 49 per cent
reduction in myopic progression
side-effects, although the lack of effect on ax-
ial elongation is puzzling. Tablets containing
7-methylxanthine have been reported to re-
duce progression by 66 per cent, by causing
scleral collagen thickening and proliferation
but longer-term studies are needed.
have found that in-
creased time outdoors (light exposure) is pro-
tective against myopia and is being widely
tested. Further to this, it appears progression
is slower during summer months, suggesting
that light may play a role.
At the moment, the best approach may be
a combination of interventions, but evidence
is needed on interventions that work
What is heartening, is that a model based
on the data of Vitale, Sperduto and Ferris
and assuming a 50% reduction in the rate of
progression of myopia (commencing treat-
ment at the age of seven years) would result
in almost 90% per cent fewer high myopes
(5.00 D or more).
This would substantially
reduce the risks of sight-threatening compli-
cations of myopia later in life.
LAUNCH OF THE ‘MYOPIA INSTITUTE’
What we do know is that we need to ring the
alarm bell now and co-ordinate our efforts
and resources to bring this issue to the atten-
tion of the world. Outside of Asia, myopia is
not generally regarded as a public health issue.
To build on the momentum generated by
the WHO-BHVI Global ScientiﬁcMeetingon
Myopia, we are launching ‘The Myopia Insti-
tute’in the near future –aglobalcollaboration
of researchers, public health specialists, op-
tometrists and ophthalmologists, to deliver
the knowledge and information needed to
inform the world about the global challenge
of myopia (http://www.optometry.org.au/
This ‘virtual organisation’will investigate
and report on evidence-based strategies for
reducing visual impairment and blindness
caused by myopia. It will provide evidence
for governments, professionals, teachers, chil-
dren and society in general, on the nature of
the potential adverse inﬂuence of myopia on
health, education, social and economic wel-
fare and vision.
WHAT ROLE FOR OPTOMETRY?
Optometry should be on the frontline of this
battle. It not only has a responsibility to pro-
vide the best care to patients but to remain in-
formed about epidemiological trends and
understand the latest range of treatment op-
tions for progressive myopia. Optometry
should also be assuming a leading advocacy
role in raising awareness about this threat, de-
signing broad-based programs and assuming
the position as the profession that can
provide the solutions. We have professional
bodies, non-government organisations and
research and educational institutions to un-
dertake much of the formal advocacy work
and we need to engage with and contribute
to these. Control of myopia brings a broader,
therapeutic commitment to controlling re-
fractive errors and thereby better serves the
eye-care needs of all people, especially
children. Myopia brings a threat but at the
same time, an inspiring challenge that we
can meet at the individual level.
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