Lecture: Myopia: Are We Short-sighted in Our Approach?

[Phanindra] Hello, good evening, everyone. I’m Phanindra from Vision 2020 The Right to Sight India. I welcome you to this webinar on Myopia: Are We Short-sighted in Our Approach? We will run this webinar for an hour and this webinar will provide you the comprehensive knowledge on the advocacy with regard to myopia. And the right policy for patients and also myopic children and their management of myopia.

Please take advantage of it and this will help you in relooking and revisiting your practices at your hospital and your practice and also help you to identify key gaps in whereas this provision so that you have the opportunity to improve access to services and equality that you have been working on.

I’m happy to introduce the speakers for today. We have Dr. Pavan Kumar Verkicharla. Dr. Pavan Kumar is a scientist researching in both basic and traditional aspects of myopia at the Myopia Research Lab at LV Prasad Eye Institute, Hyderabad.

Dr. Viswanath. Dr. Viswanath currently is a history professor at Elite School of Optometry and also head of the department Optometry and Optical Services. Also the chief optometrist at Myopia Management Clinic at Sankara Nethralaya.

We have two more, one with very experienced, we have Mr. Yeshwant Saoji. He’s a senior optometrist from Nagpur, having his Saoji Vision Care. And he specializes in the field of contact lenses.
We have Lakshmi Shinde. Thanks to Lakshmi for actually proposing this webinar and in no time we agreed to conduct this webinar. Lakshmi is a graduate from Elite School of Optometry Chennai. Following graduation she has worked at the contact lens department for LV Prasad Eye Institute, Hyderabad. And she’s also the CEO of Optometry Council of India, which is a self-regulatory body for optometry in India.

Thank you to all the speakers. I’m sure our partners will take advantage of this session.
[Lakshmi] Thank you to Vision 2020 and to Orbis for giving us this platform. I just take a couple of minutes to say how we’ve come together to propose a myopia white paper, which many have endorsed, many associations and organizations have endorsed. And as a group, when we came together, I guess it all started when Pavan told me that maybe this is something that OCI should take up and do. And after that, like-minded people came together and we all together came up with this myopia white paper.

Because of the current conditions in terms of a lot of online education and so on, I just proposed this talk to Mr. Phanindra and thanks to Vision 2020 greatly.
The way that the program will flow is Dr. Pavan will first give an introduction about myopia and its effect. Followed by Dr. Viswanath, we’ll talk about the spectacle intervention for myopia. And then Yeshwant Saoji will talk about the contact lens interventions for myopia. And finally, I’ll talk to you about the public health policies. Without any further delay, over to you, Pavan.
[Pavan] A very good evening, everyone. Hello to all those watching the course from India and from outside. I started putting these slide with this at a go at first: Are we really short-sighted in our approach? I spent a lot of time thinking yes, or actually no, maybe not. Then I said, let’s worry about this later and go on to the next slide.
We’ll cover the first slide when I conclude my talk.

For today, I’ll be talking about a quick overview of myopia. Keep in mind that myopia is a motion by itself. I cannot complete everything in the given time. So we’ll keep it short and I will give you a bit on the next 10 or 12 minutes or so.

I do not have any financial disclosures but I pulled the research grants from the government of India and through private industries. I’m showing this because the bulk that I’m showing here are supported by these grants.

Starting with myopia is, I do not have to go into the details, but the picture is self-explanatory. Myopia is an ocular condition where the axial elongation happens due to the way the outer coats of the eye will stretch. The problem is the ocular complications ranging from the lattice degeneration, lack of tracts, or the corneal retinopathies. Or to the more serious retinal detachment eventually leading to visual impairment. And apart from all this there is also increased risk for the development of cataract or glaucoma.

I will not bore you with this slide, you see that there will be five billion myopes by 2050, one billion by 2050 with high myopes. But I’m more interested to show you what’s happening in the Indian scenario. So this is the publication, the systematic review from the year 2020, a few months ago. If you look at these dots here, these are all the data from 1979 to about 2008. And the prevalence of myopia on its axis is about, let’s keep it 10% or less than that. Ranging from 2% to 4, 6, and the maximum you’re getting about 12%.

If you change gears and see all the data from 2009 to 2020 or 2018, you’ll see that the points push towards 25% prevalence. It’s the top two points, one published in 2016 and the other one in 2009, it gave that the prevalence of myopia in the urban school children is about 28% on average.

Now based on this, what we did is a prediction model here. We know that the prevalence of myopia is increasing in Indians that are not (mumbles). All the way from 2% based on the reports from Vision 2000, to around 35% in Hyderabad in the year 2019 or 2020. We said, okay, this is what the situation is, but let’s see how does it look like in the years to come? So this is the work that was immediately done in the Myopia Research Lab conducted by Jacinth Priscilla and the research optometrist.

If you look at these black dots here, until one, two, three, four, five, six, seven. These are seven different studies published all the way from 2000 to 2020, that’s all we have. We said, okay, let’s see how this data can be modeled. Is it looking like they’re polynomial, does it take a linear fashion? We did a lot of statistical analysis. And then said, hey, the Indian data, especially if you talk about urban population, it looks like more of a linear trend. It started a little bit something in 2020, which is about less than 5%. In three years publications are coming out that they’re indicating a linear increase compared to the other previous paper. So using this, we said let’s now look at what’s happening in 2030, 2040, 2050.

As you see here, we predicted the prevalence of myopia in Indian children who are living in urban cities is going to go up to 48%. Which means one in two may have myopia by the year 2050 if no intervention is made. Let’s say if you have, say that hey, everybody do more of an outdoor activity, given that outdoors is considered to be protective of myopia or myopia prevention. So that 48% is tending towards a drop to about 32%. Again, this is using the model that we say one out of two tend to have myopia if no intervention is made. But if you could give them some sort of intervention, how does the prevalence change?

What does this equal when we say 48% or whatever percent that you see in the first column? 2000 to 2050, this is the year. And we considered population growth rate, what’s the population in urban regions, what’s the prevalence of myopia in each decade? If you equal this 48%, we’re looking at about 64 million children who have myopia. So that’s a big problem and definitely this is a public health concern.
One bad or good thing about myopia, well, I’ll going to say it’s a bad thing about myopia, is once you’re a myope, you’re a lifetime myope. As you’ll see here, somebody with myopia on days of five, it does not go away after 15, you have to still wear your spectacles. If there’s anything, it’s only going to go worse. Given the generational effect, you can also predict that the overall prevalence of myopia is going to boom in the years to come. Not just five to 15, because today, I may be falling in the back to five to 15, but in ten years time, I will be between 15 to 25. So I’m myope and I will continue to be myope. So overall there will be a big boom of myopia.

Not just that, let’s understand there is a problem yet. How much does the children progress is a really big problem. Again, this is the work that I did with LVPEI, we got about 7,000 myopes approximately. And we found that about children aged five to 15 years progressed by about half a diopter a year. Now that’s not a problem, the problem is 17% of them tend to progress every year by about 1 diopter and this the cleanest possible data. I do not think this is data from hospital visiting. We have cleaned the data up and it’s only refractive error, no other complications. So we said that about 17% tend to have a progression which is more rapid.

And as expected, we found that children progress much faster compared to the rest. Interesting finding is here, we found that children or elderly who has higher severe myopia, tend to progress at a faster pace. If you compare the left versus the right side, the mild to moderate ones as they age, the progression is reduced. But somebody’s higher, that’s the need for us to be more adjunct in limiting some kind of anti-myopia strategy because they will move very rapid. Even if you are a child, even if you’re an adult, if you’re high or severe myope, the progression tends to be much more rapid.
The other interesting thing which also collaborates with the findings that are reported in the literature, is that somebody develops myopia at an early age, if you see on x-axis we have apparent onset of myopia, age of onset of myopia. Somebody develop before 10 years of age, when they become adult, they’ll tend to have high myopia. On x-axis is the age. Y-axis what is the refractor error when they’re adults. Adults as in here, we got about 18 or about. And then you’ll see that somebody will develop myopia before five years tend to have high myopia, this is minus eight. And somebody will develop at the age of 16 or above that, they tend to have only minor. Because as we know the progression does not happen more aggressively in the adult. So the age of onset of myopia is very important and that’s something that we have to keep in mind with our kids.

We’re talking about we are pathologic myopia scenario in India, we are no less compared to a lot of East Asians or the Caucasians. Indians also tend to develop complications with ranging from tessellation to lattice to RD and develop 4.3% of myopes.
Another point worth highlighting is that these complication does not happen only in individuals with high myopia. The notion is only if you have high myopia you might have ocular complications. That’s a myth. That’s wrong, there’s evidence to show that. And this is data from 29,000 myopes. Not just this, even before there are publications that have come up that say that. That even in mild cases of myopia, they tend to be after complications and thus careful examination including they’re on some sort of anti-myopia strategy is very precious.
Before it gets to this extent that is seen in Wuhan, where they use the physical bars to keep the material and maintain the arm distance with the reading material, I think it’s definitely time for us to act on myopia management.

So again, I’m not going into the very details of it, I will keep it short. Myopia management can be two pronged. Number one, you try to prevent myopia. We saw that you understand the cause obviously, but prevention is something that we have to target at the earliest possible to ensure the prevalence of myopia does not hit 48%.

Number two, very straightforward, if you notice somebody with progression, the only way is put them on some sort of anti-myopia strategy. The next speakers will take you to the details of what are those and how they actually function. But in a nutshell, the anti-myopia strategies range from outdoor activity to pharmacology management to spectacle format or the contact lens and so on.
One point I want to highlight is that the anti-myopia strategies did not come up like that. There are double of these on the risk factors. So again, the next speakers will take you through the various spectacle and contact lens format, but I will highlight a bit on the environmental aspect.

In terms of the optical or the pharmacological management, the percentages show that about more than 50% efficacy is known in various populations. Of course we don’t have multiple data from Indian scenario. The studies are ongoing and there’s one publication that has come out recently to say that atropine is working in the Indian population too.
Coming to light exposure, why are we targeting light exposure? Obviously there’s a generational change. This picture is self-explanatory. And again, previously we all used to be outdoor, now everybody’s glued to the near work all day, mobile phones, gadgets that you want near.

So why the outdoors is protective? There’s multiple factors, there’s no single factor considered.This is the reason for why outdoors is protective. But there are few hypotheses that we can talk about. Number one, if you’re outdoors, you’re not indoors. Which means the light levels are too high in outdoors. They’re at least tenfold high. Number two, if you look at this image here, if you’re looking at a book, if you’re congregating to that, the cup, that’s far away, three diopters. But if it’s something and it’s something that’s one diopter. Whereas if you go outdoors the objects that are close to the eye are not there and you’re looking at something that’s far away. The equal adapted space, we call it. Meaning, if I’m indoors I have objects coming in from different dimensions and there’s accommodations that pull people in. From outdoors, especially in an open space, I have equal adaptive space, let’s say optical infinity, my accommodation is relaxed, not just at the center, but even in the peripheral they’re not any targets that can consider the eye to go.

If I’m outdoors, dopamine release happens in the eye that is known to inhibit the axial elongation. And the spectral composition, if I’m outdoors there’s more blue and that is known to inhibit axial elongation too.

Glass classrooms prevent in the other countries and in a few countries they’re using light trackers, much like the FitSight. Not the FitSight, much like the Fitbit, use it for burning your calories, there are these trackers that are available in the market that says you’re in the indoors by this much amount of time. It all goes by this much amount of time, sort of motivation for us to send a kid in the outdoor environment.

Again, various studies indicate that the myopia prevention can happen if you send kid in an outdoor environment. This is x-axis, number of hours spent. And y-axis is the incident or risk of incident myopia. The more time you spend in outdoor environment, the less likely that the kid might develop myopia. The studies also indicate that if it’s not just myopia prevention, but progression can also be conquered to a second extent. This is the recent evidence that’s started to come out.

This is one of the publications that we have put in the “Current Science” of Indian journal. We proposed various things that need to be considered as a public health policy such as mandatory one hour, I think Lakshmi will take you through this in video as part of the OCI initiative too.

Now coming back, are we really short-sighted? Maybe not, I think when we talk, we are managing myopia in our clinics. But if you still think that we are still short-sighted, we are not starting the treatment, we are worried, we do not have an option, I think what we need is self-belief. We need confidence. Because we have to start somewhere. Nobody becomes an expert in one shot, but you will be a beginner and then be an expert at a later stage. Confidence is contagious, catch it and spread it. I must say it’s contagious than the COVID-19, maybe. And it’s high time. Myopia is also a pandemic. If you don’t attack now, it’s going to move worse. So please be confident in managing myopia and then let’s see how we can control it.

But this is a mantra for you all who are listening today. Always hype on these four Ms. You have to be a master to see a patient or a kid with myopia. Master here is just understand that myopia is multifactorial. It’s not just because of near work, it’s not just because of algo. It’s not truly because of genetics. There’s multiple factors that play a role.

Number two, measure all the positive X factors. If you ask me what needs to be measured, I would list about 10 to 12 variables. But if you do not have all of these instruments, get whatever you have. Quantify it. And then monitor every three to four months and see if there’s real progression. Do not just put them on a strategy and eliminate them.

We do have various anti-myopia strategies, the only way is you want to give single vision lens. Look at how to control progression, a single vision lens is good if there is no progression, for sure, yes. But if there’s a progression, I always say that nobody’s vision is the same.

To conclude myopia prevalence is on rise and is considered as a 21st century’s problem with 48% headed towards myopia. A fact in India, I would say there’s an Indian myopic boom that we’re going to head towards. Myopia progression also happens in India. Do not say that Indian children do not progress, about 17% are progressing more rapidly. And as rapid as one diopter. Keep in mind earlier the onset, greater is the risk of developing high myopia. Pathologic myopia, again, in Indian scenario we are no less in terms of pathologic regions. And irrespective of age, irrespective of the refractive error, pathological to do work on.

Conclusion is that beyond the single vision correction, the next speakers will take you there. But keep in mind the myopia mantra: master, measure, monitor, and manage. The experts say nearly one billion myopes at risk of myopia-related sight-threatening conditions by 2050. It is definitely time to act now. That’s a big man sign. I want to end my talk by saying that in India, if it’s not now, then it will be too late. If it’s not now, then when? Thanks for your attention.

[Lakshmi] Next is Dr. Viswanath who will talk to us about spectacle intervention.

[Viswanath] Thanks, Lakshmi, and I would like to thank Vision 2020 for giving me this opportunity to present on spectacle management of myopia.
Why spectacle lenses for myopia management? No complications compared to contact lenses like redness or dryness. No side effects compared to atropine like blurred vision or photophobia. And young children can easily be fitted with these spectacles.

Is it full correction or under correction? With Cheng et all in 2002, gave full correction to 47 myopic children and he undercorrected to another set of 47 myopic children by plus points on diopters. And what they found was undercorrection produced more rapid myopia progression and axial elongation. And in the recent meta analysis comprising six studies with 69 different subjects, what they found was myopic eyes which are fully corrected are more prone for myopia progression when compared to people who are undercorrected. So what is loud and clear here is undercorrection may do more harm than good.
What are the myopia controlled spectacle options available? Until 2010, traditional progressive addition lenses and bifocals were tried and after 2010, special design lenses have been tried. COMET study was one of the largest study conducted on 469 children. They gave progressive addition lenses with plus two addition to 235 children and single vision lenses to 234 children and they followed up for three years.

A similar study was conducted in 2008 on 92 Japanese children. They gave progressive addition lenses with plus one point for addition. And after 18 months, they crossover and they followed these children for three years. And what they presented was progressive addition lenses slowed myopia progression but the treatment effect was very small.
Moving on to the bifocal lenses. Cheng et all in 2010 and in 2014 gave executive bifocal to 48 children and executive bifocal with three prism basin to 46 children. And after three years, what they found was significant reduction in spherical equivalence and axial elongation. But unfortunately, because of the conspicuous line which runs across and because it’s not cosmetically appealing, these lenses were not considered further.

Until 2010, whatever traditional lenses that we’ve been trying, have been tried, were based on accommodative lactery and following 2010 were developed were based on Professor Earl Smith’s animal experiments based on peripheral hyperopic theory. Where we correct myopia with traditional lenses, the central part of the retina is only corrected leaving the periphery with a significant hyperopic defocus. And what is believed is that these peripheral hyperopic area stimulates the eyeball to grow further. And the lenses that have been developed following 2010 are based on this concept that it will reduce the peripheral hyperopic defocus or to induce a myopia defocus.

Based on this three novel spectacle designs were developed to reduce peripheral hyperopic defocus and the first one had 20mm central clear optic zone with plus 1 diopter relative peripheral power. And the second one had 14mm center clear optic zone with plus two diopter, clear relative peripheral power. And the third one was an asymmetric design with plus 1.9 diopter relative peripheral power. And the fourth one was a conventional single vision design. And when they gave these randomly to 210 children, what they found was unfortunately there was not much of an effect in terms of no control of myopia progression, except in the third design where they found a moderate control in myopia progression in terms of spherical equivalence and axial length.

Moving on to the next generation of the special designs by Hoya and Essilor. Hoya’s Miyosmart lenses were based on defocus incorporated multiple segment technology, which was developed with the Hong Kong Polytechnic University. Where these lenses had a central clear optic zone surrounded by treatment zone and these multiple treatment zones had myopia defocus of plus 3.5 diopters. And these lenses were tried on 183 children. And what they found was these lenses significantly retarded myopia progression and axial elongation. And these results also demonstrated that simultaneous clear vision with constant myopia defocus would slow myopia progression.

And the Stellest lens by Essilor was based on this HALT technology, which is highly aspherical lenslet target, where these aspherical lenslet induced myopic defocus and these were tried on 167 children. Again, these lenses had good reduction in spherical equivalence and axial elongation as well.

Recently Novel DOT design from SightGlasses were developed based on retinal contrast signals. And their hypothesis was high retinal contrast signals would lead to high myopia. And these lenses were tried on these myopic kids in one eye. And the standard lenses were given in the other eye. And after three months, what they found was the axial growth was drastically reduced in the eye which had these DOT lenses. And after three months they swapped the lenses and what they observed was in the eye which had good reduction started growing. And in the other eye, which had good control, virtually stopped growing. These results, the initial results are very promising.

This is a graph depicting spherical equivalent reduction and the axial elongation reduction. If you look at the graph on the right side, is a clear winner.
And moving on to the strategical deliberation of spectacle management. The next question is when do we start prescribing these lenses? We all know that younger ages are associated with greater progression, so it is better to start early. And it is also better to wear this through the waking hours. And when do we call these patients for follow up? And it is better to call them frequently at least half yearly or at least once yearly to monitor the progression. When we fix these lenses, monocular PD and height are to be measured and if it’s based on that. The take home message is do not stop with single vision lenses, especially when we observe progression, consider myopia control strategy. Thank you.

[Lakshmi] Thanks, Vishwanath. The next speaker is Yeshwant. He’ll be talking about contact lens strategies for myopia.

[Yeshwant] Hello, everyone. Now that Pavan has told us everything about myopia and Viswanath has told us about spectacle options for controlling myopia, let’s talk a little bit about contact lenses.
When we talk about contact lenses and myopia control, the first thing that comes to mind is orthokeratology. And that is the buzzword in India today, everybody wants to get into practice in orthokeratology. And I don’t think I need to elaborate more about what ortho-K lenses are, but I would rather talk more about the other options. You have the daytime ortho-K lenses, this is not very, very common. This is technically not an ortho-K lens but a regular RGP lens with a plus four ring on the front surface of the lens. When we talk of contact lenses, any contact lens which is for myopia control would always have a plus ring on the front surface or a regenerator plus ring on the cornea. Similarly in cases of soft ortho-K, these are regular soft contact lenses, which is again, got a plus four ring on front surface. And these lens are the regular daywear RGP ortho-K and soft ortho-K. They’re supposed to be worn during the daytime.
Yes, Lakshmi?

[Lakshmi] Have you changed the first slide or?

[Yeshwant] No, I haven’t. I haven’t. And if we are a little bit unlucky if we don’t have access to these speciality products then we have our own very faithful soft multifocal contact lens in the Indian market for sure. And the only difference being if possible go in for a center distance design with the highest possible add, that also helps in controlling myopia.
Let’s talk a little bit about orthokeratology. The moment you mention the word orthokeratology, many cringe. And it’s because of the bad experiences people have had in the past. But those designs were different, those conditions were different, the kind of practitioners did not understand orthokeratology so well, they were not trained properly. And they would indiscriminately dispense to the patients over the counter. As a result, many of the patients did have some complications and some of them were serious, as well. And because of this, ortho-K lenses were banned in some countries and especially in China. But understanding the importance of getting into myopia control, now the Chinese government is actually helping to propagate orthokeratology in China. And I believe the same is happening with Russia. And other countries like Singapore, Vietnam, UK, US, Australia are where ortho-K lenses are very, very widely used.

One example I would like to quote is of Vietnam. Vietnam got into orthokeratology just four years back and they are way ahead of India. They understood the importance of practicing these lenses and the amount of lenses being ordered by Vietnam today is amazing. So this is where India has to reach very soon.

Orthokeratology are night wear lenses, so you’re supposed to be wearing these lenses when you go to bed. And they create thickness differences across the cornea. So in the center they have a positive pressure which compresses the epithelium. Now the lenses are not very creating the corneal epithelium, but always remember there is a tear film between the lens and the cornea, which is what we should counsel the patients. Otherwise the patients feel that they’re irritating the cornea and it could be risky. If you have a tear film, then the staining will not happen. The positive pressure in the center and negative pressure in the midperiphery will cause central flattening and in the midperiphery there’ll be expansion of epithelial cells and this is what will correct the myopia and also control the myopia. We will see that in the next slide.

The four points, it’s safe and very effective option for myopia control, it’s very, very effective if the lenses are designed very well, the results are really good.
Myopia correction by orthokeratology lenses have been US FDA approved up to minus six diopters of spherical with minus 1.75 diopters of cylinder. So rarely you may encounter a kid who’s beyond this correctable range. If you do have kids like that and you still want to implement myopia control, please remember partial correction up to minus six is equally effective as complete correction. Children adapt faster because children lead a disciplined life where eight o’clock is breakfast time, 12 o’clock is lunchtime, four o’clock is your brunch time. When a person is wearing orthokeratology lenses, they need to have some discipline and they need to sleep well at least for six to eight hours for the lenses to correct the cornea properly.
When we talk about sleeping with the contact lens, the first question which anybody, optometrist, ophthalmologists, parents, patients, everybody would ask us, “What about the complications?” The complications are exactly the same as your daywear soft contact lenses. Now today when we prescribe daywear soft contact lenses, we don’t think twice about complications. Orthokeratology, if the lenses are fitted well, it’s the same rate of complications.

Today’s lenses are made with slightly different technology, we’ve got complicated lids, complex lids which actually have precision production of orthokeratology lenses. These are called accelerated ortho-K lenses. Earlier times you needed to change one or two pairs. But now with proper assessment of the patient and proper trial fitting, the first pair that you give works for myopia correction as well as for myopia control. That’s the same pair that the patient wears it for the period of one year or little bit more.

Custom design versus ready stock, the advantage in custom design is everything is under your control. You look at the pupil diameter, you look at the HVID and then you design the lens for best possible results. No doubt about that, that these lenses provide the best myopia control. The mid peripheral plus can be controlled. I will show you in the subsequent slide that for every diopter of myopia corrected, there is power generated in the mid peripheral region. For myopia to be controlled very well, we need at least plus four to plus 4.5 diopters of plus in the mid peripheral region. Let’s say that you have a patient who’s got minus one diopter of myopia and comes in for myopia control. When you correct this patient with a regular ortho-K lens, a ready stock ortho-K lens, the plus that will be generated is about plus one. Plus one to plus 1.25. Whereas if you customize this lens, you can generate up to 4.5, 5, or even beyond that.

As opposed to custom design lenses, let’s talk about ready stock lenses. The advantage is everything is right there in front of you. If the lens is not fitting, if the diameter is not working properly, you’ve got another diameter. If the peripheral curves or the lift is not properly fit, you can just remove the lens, put another one in, and reach it, then your job is done. You don’t have to wait for the lab to design the lens and send it to your office, no. So it’s much faster. The only slight disadvantage is initially you have to invest in trial sets. On the right side is my little collection of ortho-K lenses in my practice.

A few tips that I would like to share with respect to ortho-K. Just one second here. The number one and number two lens, the Paragon CRT and the Context lenses, most often I use these lenses for myopia correction rather than myopia control. Other contacts does have myopia control lenses also, the EX lens. And most often because when it comes to lenses when it comes to myopia control. Now the treatment zone, the average treatment zone varies between 2.8 to about 4.5 millimeters. It depends upon the myopia being corrected. Lower myopia corrections will give you larger treatment zones and higher myopia corrections will give you smaller treatment zones.

So let’s assume that the average treatment zone is about 3.5 millimeters and for myopia control to be best, we need some amount of this peripheral plus to fall in the pupillary area. So let’s talk about 1.5 to 2 millimeter ring inside the pupil. Which means we need to have a diameter pupil, diameter of five millimeters at least, to have the best myopia control. If that is not achieved and the patient’s pupil is small, then you’ll have to customize the lens wherein you can reduce the treatment zone’s size and get effective myopia control.
The contact lens care regimen has to be up to the marker as with any contact lens, the solutions have to be good, the care and maintenance has to be good. The patient needs to understand when to come for follow up, what are the warning signs, and how to wear, what to do if the lens gets stuck in the eye. All of those things you have to train the patient very well.
I’m sorry, I’m going a bit faster. This slide I’ve already covered. Plus one diopter of plus power is generated for every one diopter of myopia is corrected. And plus 4.5 is required for best myopia control. Now this can only be achieved by customizing the lens on a soft pair where an asphericity is generated on the back surface to add additional plus.
If you see in the diagram, this is the positive pressure that was applied to correct the myopia and this power was shifted here and it became plus. So this power, let’s say, was minus five, this becomes plus five.

Now let’s talk a bit about complications. I just want you to pay attention to three points on this slide. Point number two, daily wear soft contact lens have got microbial keratosis risk factor at 0.12% and ortho-K has 0.14%. So it’s practically the same as your regular soft contact lenses. Now what you need to inform the patient, and remember is, a minus five or beyond minus 5 diopters of myope is four times more likely to develop myopia-related complications than microbial keratitis. We as parents, we as practitioners, we worry about contact lens-related complications which possibly will never happen. But there is a four times or five times more likelihood of myopia-related complications happening in this patient’s eyes. So worry more about that and counsel the patients accordingly.
Regular RGP contact lenses, as I said in the beginning slide, if your power is exceeding beyond, (timer beeping) one second, that’s 10 minutes up. It’s exceeding beyond minus six, which is the possible limit, then you can have the customized RGP contact lens with a plus four, plus 4.5 ring on different surface.

Similarly, in cases of soft contact lenses, the results are good but they may not be as good as your regular RGP ortho-K lenses. But for cases wherein you may not want to fit an ortho-K RGP, or the lenses are not available, then you can fit these lenses. And the lenses are decent.

Presently what is available in India is the ortho-K, OK Vision Miracle lens, which is made by OK Vision Russia. And you’ve got soft ortho-K lenses made by GOV USA. And I’ve deliberately put MiSight One Day, although it is not available in the Indian market yet, it is the first lens that is approved for myopia control by the US FDA.
Multifocal soft contact lenses are where nothing is available, definitely for these lenses make sure there are center distance lenses and prescribe the highest add as possible. You may have to refract to get the proper distance vision because sometimes these patients are slightly higher minus in the center.

And that’s about it, I think last slides were rushed, but I personally believe that it’s a team work. Myopia control is a team work and the team is the patient’s parents, the patient, you as an optometrist, and an ophthalmologist. All four people need to get together to do what is best in the patient’s interest. And unfortunately what I’m seeing in the Indian scenario is when the optometrist cannot prescribe atropine, he is preferring more of ortho-K. And when the ophthalmologist cannot prescribe ortho-K he is going more in favor of atropine, that should not be the case. You assess the patient and then decide what modality would be best for that particular patient. An optometrist definitely needs to get themselves trained in myopia management. And publications, especially with respect to corneal ortho-K, need to increase so that the ophthalmologists, the parents, and everybody is convinced that these lenses are not risky when it is worn on overnight basis.
Thank you very much, over to you, Lakshmi.

[Lakshmi] I will be talking about public health policies and myopia control. I’d like to thank Paula Mukherjee, who was my colleague, as well as Dr. Dharani who have helped me in the presentation. And before I proceed, I’d like to name all the people who are part of the Myopia Task Force in OCI. Of course, the speakers here, that is Dr. Pavan, Dr. Viswanath, Yeshwant, and we also have two more people. One is Dr. Anuradha, who heads the Elite School of Optometry, as well as Dr. Raswana, who’s a Myopia Control Specialist as well, she, as well as myself. So we all form a part of the Myopia Task Force as well as OCI is concerned. And as far as the Myopia white papers is concerned as well. And we plan to make a couple of other task forces when it comes to implementation of the same.
Just a summary of what everybody has spoken. More close work contributes to an increase in myopia which is very clearly spoken by Pavan. He also alluded to outdoor activities reducing the incidence and prevalence of myopia. And to a certain extent, maybe, progression. And for people who are already myopic, we need to look at how we reduce the progression of myopia because the progression leads to more and more complications in the eye. The health policy that we would look at needs to be holistic in its approach and should cover all the above points mentioned.

Just to look at some of the countries which already have health policies in place, we have Singapore, Hong Kong, China and Taiwan. The paper is here an example of how Singapore has gone ahead in its health policy towards myopia. So they have a National Myopia Prevention Program which was started in 2001. This is basically a complete approach in terms of providing brochures, assisting the parents, involving the teachers in schools, and many other ways in which they’re trying to control myopia as an epidemic.

One of them is this FitSight watch which is similar to Fitbit, which Pavan did speak about. It has a light sensor and it’s connected to an app. At the end of the day you can see the amount of time the kid has spent outdoors. And the feedback goes to both the person who’s wearing it, that’s the kid, as well as the parent. And the garment has given certain norms in terms of how many hours. And if they fall short during the week, then the parents are encouraged to try and make up for the same amount of time outdoors during the weekends as well.

As far as the ministry’s common approach is concerned, they have a lot of health promotion talks, brochures and they have a lot of information in their websites as well. And they also arrange outdoor activities in terms of with visiting national parks and so on during the weekends. And the location is done on a rotation basis so that the kids do not get bored.
As far as China is concerned, they have a lot of ministries which are working in collaboration. The Education Ministry, the National Health Commission and many other departments, which have come together. And they basically tell parents that the kids need to spend time more outdoors and also in their educational policy, they try and give very less kind of pertinent work for small kids like Pre-Kg and Kg and the first and second standard kids. They try and give less and less of writing homework so that near work is reduced and the parents are also advised to refrain from any kind of gadgets for their kids.

This is something that Pavan already alluded to, in terms of the distance to be maintained in schools. They’ve also gone ahead of late, to look at more of sunlight exposure in classrooms. So they have something called a sunroof, which now you can see many houses also, that they have sunroofs to bring in sunlight. Similar kinds of classrooms have been designed in China, as well.
And they also have a device that’s clipped onto the spectacle frame of the children, which measures what distance they use their reading material. Whether they’re spending more and more time in gadgets and if it is a gadget, what kind and what kind of phones and so on. It gives a lot of information to assess the nature of their near work, the kid’s near work. And once that is done, then that data goes to the eye care practitioner.

Now coming to the Indian scenario. We have a lot of these teaching apps now which are on gadgets, unfortunately. And more and more are being used now because of Covid. We also are now shifting from outdoor sports to these sports coming into these gadgets, which is actually a bad sign as far as myopia is concerned. Where we are advocating the kids to go out and play more and more. Now all these apps are coming onto these gadgets, which is making them even more addictive as far as the sports is concerned with the gadgets.
Just to share some data, in 2019, the number of international schools were around 708. I think by now, they’ve also increased. The reason I put that data is because compared to normal schools, international schools use more gadget-related educational material. So everything comes on the phone and so on. Now, of course, because of Covid, all the schools have moved to this scenario, which is quite alarming as far as myopia is concerned. The picture says it all here. Basically because of Covid, all of us have moved to more and more online education.
Just a few activities that OCI has done until now, we’ve covered 410 government schools where we’ve presented with posters and information around nine different languages, Indian languages, in government schools. And we said that each class would be responsible for one poster so that it doesn’t get damaged. And also presentation to educate both the students as well as the teachers, with regards to myopia and other eye conditions.

And during the pandemic we did do some awareness initiatives. But all of this is such a miniscule when you look at the huge, huge problem that we have. So definitely, advocacy of this problem is the key and we need to look at health policy changes as far as eye care towards myopia is concerned. So we need to involve eye care providers, governments, parents, teachers, and as a team. As Yeshwant said, it’s a whole team that needs to work if we need to really reduce the percentages that Pavan was talking about.

I do get people asking, do you mean that if classrooms are outdoors we’ll be going back to our old school of thought of good school and all of that. And why do we have technology nowadays? I try and say that nobody’s stopping technology being used underneath a tree when we have outdoor classrooms. You need to take best of both worlds and then bring them together so there’s nothing wrong in holding a few classes outdoors if the school has that kind of premises. We can always say that few classes can be held outdoors in sunlight as well.
As OCI, we did come up just for a start, as I said, this is such a miniscule effort compared to the huge problem that we have in front of us. We came up with this white paper document and it’s been drafted by the people that I mentioned. And we were very, very thankful that so many organizations, local associations, and international organizations did endorse our efforts. Recently WCO’s also coming up with a resolution in terms of how to manage myopia and OCI being a member of WCO we would also be signing such a resolution shortly, in terms of advocacy of myopia management among the eye care professions itself.

So what does the white paper consist of? It consists of recommendations for schools, for eye examination, in terms of health care policies, and some other recommendations as well.
For the schools, we are saying they have one compulsory outdoor activity. They should have a little bit of spacious playgrounds. And the new upcoming schools, when they’re constructing, they should have windows, and they should be constructed in such a way that it allows ample amount of sunlight to enter into the class. And for small kids, try and do more activity-based education rather than books or some near work-related activities.

As far as eye examination goes, we have said that people who are wearing spectacles need eye examination every six months in kids. Parents that are myopic, which is definitely a precursor for the kid to develop myopia, then the teachers should recommend eye examination for those kind of children. And the other children who do not wear spectacles or who are not myopic, they should be examined every year as well. And in case of online classes, that is there now, after every year give a slight break so that the kid gets away from near work and looks at something distant according to the 20-20-20 rule.
Recommendations for the education point of view is more of awareness among the parents of the importance of myopia and what myopia progression can do as far as eye health is concerned. Involving the teachers as key stakeholders because they’re in constant communication with the students and also giving the schools, as well as the students, some kind of awareness material.

Other recommendations is for the entire holistic development of all these that have been mentioned, you need to have some kind of a special interest group working with the government as well as the education ministry, to come up with all these policies and implementation of the same. As well as have some kind of community activity, maybe over the weekends, for all the children in small communities where we can get outdoor activities so that they’re exposed to sunlight.

This, in a nutshell, is what we have recommended and we have sent this document to the government officials as well and we hope to work with them in regards to this in the near future as well.
That comes to the end of the talk.

[Phanindra] Thank you so much, all the speakers, Dr. Pavan, Dr. Viswanath, Yeshwant, and Lakshmi, for a very excellent presentation. And thanks to all the participants who really made part of this discussion with very good questions, really relevant. Thank you everybody, thanks so much.
[Speakers] Thank you.