THE IMPACT OF MYOPIA

IMPACT OF INCREASING
AND HIGH MYOPIA
PREVALENCEOF MYOPIA
AND HIGH MYOPIA Report of the Joint
World Health Organization–Brien Holden Vision Institute
Report of the Joint World Health
Global Organization–Brien
Scientific Holden
Meeting on Myopia
Vision Institute Global Scientific Meeting on Myopia

University of New South Wales, Sydney, Australia

16–18 March 2015

The impact of myopia and high myopia a

THE IMPACT OF MYOPIA
AND HIGH MYOPIA
Report of the Joint
World Health Organization–Brien Holden Vision Institute
Global Scientific Meeting on Myopia

University of New South Wales, Sydney, Australia

16–18 March 2015
The impact of myopia and high myopia: report of the Joint World Health Organization–Brien Holden Vision Institute
Global Scientific Meeting on Myopia, University of New South Wales, Sydney, Australia, 16–18 March 2015
ISBN 978-92-4-151119-3
© World Health Organization 2017
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Contents

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

1. Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.3 Agreed conclusions and recommendations . . . . . . . . . . . . . . . . . 1
1.4 Specific conclusions and recommendations . . . . . . . . . . . . . . . . . 2

2. Background and purpose of the consultation . . . . . . . . . . . . . . . . . 4

3. Global prevalence of myopia . . . . . . . . . . . . . . . . . . . . . . . . . . 5

4. Myopia as a cause of vision impairment and blindness . . . . . . . . . . . . 7

5. Terminology and classification . . . . . . . . . . . . . . . . . . . . . . . . . 8

5.1 Myopia, high myopia and pathologic myopia . . . . . . . . . . . . . . . . . 8

5.2 Myopic macular degeneration . . . . . . . . . . . . . . . . . . . . . . . . 8

6. Impact of myopia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

7. Evidence for causes of myopia . . . . . . . . . . . . . . . . . . . . . . . .11

7.1 Optical and environmental influences . . . . . . . . . . . . . . . . . . . . 11

7.2 Genetics and parental history . . . . . . . . . . . . . . . . . . . . . . . . 12

8. Control of myopia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

8.1 Optical control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

8.2 Time spent outdoors and behavioural influences . . . . . . . . . . . . . . 15
8.3 Pharmacological and therapeutic control . . . . . . . . . . . . . . . . . . 15
 9. Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

9.1 Epidemiology of myopia . . . . . . . . . . . . . . . . . . . . . . . . . . .17

9.2 Myopigenesis, environmental, optical and therapeutic factors . . . . . . . .17
9.3 Risk factors and individual heterogeneity . . . . . . . . . . . . . . . . . . .18
9.4 High myopia, pathologic myopia and comorbid conditions . . . . . . . . . 18
9.5 Eye examinations in myopia . . . . . . . . . . . . . . . . . . . . . . . . .18

10. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Annex 1. Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

Annex 2. Programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Annex 3. Regions defined in the WHO Global Burden

of Disease programme . . . . . . . . . . . . . . . . . . . . . . . . .29

For more information, please contact:

iv The impact of myopia and high myopia

IMPACT OF INCREASING
Acknowledgements
PREVALENCEOF MYOPIA
AND HIGH MYOPIA
Thanks go to the authors of this report: Brien A. Holden, the Chair of the meeting;
Silvio P. Mariotti, Ivo Kocur, Serge Resnikoff and Mingguang He, the Chairs of the individual
sessions; Kovin Naidoo, the Rapporteur; Monica Jong, the scientific secretary; and the
participants listed in Annex 1. Thanks are likewise due to the Australian Government, WHO,
Report
the Brien of the Joint
Holden Vision World
Institute,Health Organization–Brien
the Vision Cooperative ResearchHolden
Centre and scientists and
Vision Institute Global Scientific Meeting on Myopia
professionals who supported this meeting, and the staff of the Brien Holden Vision Institute and
WHO who organized the meeting.

The impact of myopia and high myopia v

For more information, please contact:

vi The impact of myopia and high myopia

1. Executive summary
1.1 Introduction
The prevalence of myopia and high myopia are increasing globally at an alarming rate, with
significant increases in the risks for vision impairment from pathologic conditions associated
with high myopia, including retinal damage, cataract and glaucoma. The impact of myopia is
difficult to determine, because there are no standard definitions of myopia and high myopia,
and recognition that myopia can lead to vision impairment is limited by the absence of a
defined category of myopic retinal disease that causes permanent vision impairment. A further
impediment to progress in this area is insufficient evidence of the efficacy of various methods
for controlling myopia.

In view of concern about the current and future impact of myopia, the Minister of Health for
Australia, the Right Honourable Mr Peter Dutton, contacted the Director-General of WHO, Dr
Margaret Chan, to request the involvement of WHO in an international scientific meeting on
myopia to be held by the Brien Holden Vision Institute (BHVI). As a result, a three-day joint

IMPACT OF INCREASING
WHO–BHVI meeting was convened on 16–18 March 2015 at the University of New South
Wales in Sydney, Australia.

PREVALENCEOF MYOPIA
1.2 Summary
Scientific and clinical experts in myopia were invited from all six WHO regions (see Annex 1).

AND HIGH MYOPIA

Keynote presentations, working groups and plenary sessions were held to review the evidence
on the major issues in myopia. The results of these deliberations were reported to plenary for
discussion, and agreement was reached on a series of statements, definitions and priorities for
research.
Report of the Joint World Health Organization–Brien Holden
Vision Institute Global Scientific Meeting on Myopia
1.3 Agreed conclusions and recommendations
• The group agreed on definitions of myopia and high myopia and on a category for and
description of the pathologic consequences of myopia.
• The epidemiological surveys currently used to measure the status of vision (e.g. the WHO
protocol and Rapid Assessment of Avoidable Blindness) do not allow the definition of high
myopia as a possible cause of vision impairment, partly because these surveys do not include
a description of this condition or any measurement of refractive error. The group agreed that
action should be taken to include myopia and high myopia among the attributable causes of
vision impairment in the surveys currently used.
• Measures for the detection and management of myopia should be an integral part of plans
for the provision of eye-care services. They should be part of general health care for vision
impairment due to (i) the uncorrected refractive error associated with (the increased prevalence
of) myopia; and (ii) the pathologic consequences of myopia.
• The term “myopic macular degeneration” (MMD) should be used clinically and in research
to categorize the blinding retinal diseases associated with high myopia. Currently, a number
of terms are used, including MMD, myopic maculopathy, myopic retinopathy and myopic
choroidal neovascularization.

The impact of myopia and high myopia 1

• Epidemiological data are lacking on the prevalence of myopia, high myopia and vision
impairment associated with high myopia in Africa, Central America, South America and
Oceania. These areas should be priorities for future research.

1.4 Specific conclusions and recommendations

Definitions of myopia and high myopia
• The definition of myopia is “a condition in which the spherical equivalent objective refractive
error is ≤ –0.50 diopter (–0.50 D) in either eye”.
• The definition of high myopia is “a condition in which the spherical equivalent objective
refractive error is ≤ –5.00 D in either eye”.

Clinical definition of myopic macular degeneration

• The clinical definition of myopic macular degeneration (MMD) is “a vision-threatening condition
in people with myopia, usually high myopia, which comprises diffuse, patchy macular atrophy
with or without lacquer cracks, choroidal neovascularization and Fuchs spot”.
• It was agreed that the direct ophthalmoscope lens power wheel should be used in rapid
assessments of avoidable blindness and other surveys to record the power at which the
fundus is clearest, to ensure that possible cases of high myopia are recorded.

Clinical and epidemiological research on myopia

• A cycloplegic agent should be used in clinical or epidemiological studies of children under
the age of 18 years.
• In surveys and studies, the continuous distribution of age and refractive errors should be
reported for people up to the age of 25 years.
• The ocular history of individuals should include interventions such as refractive surgery and
other procedures to reduce refractive error, but not necessarily the consequences of axial
eye elongation.
• The use of cycloplegic investigation and its inclusion in survey protocols for both young adults
and adults should be investigated further.

Attributing vision loss to high myopia or MMD in blindness surveys

(rapid assessment of avoidable blindness, WHO survey protocol and others)
• It was agreed that the term “myopic macular degeneration” (MMD) should be used to define
the retinal condition that causes vision impairment in myopia, because it is clearly defined and
easily categorized for rapid assessment of avoidable blindness, in the WHO survey protocol
and others.

Definition of MMD for the purposes of epidemiological surveys

• The definition of MMD for the purposes of epidemiological surveys (e.g. rapid assessment
of avoidable blindness, WHO survey protocol) with limited resources and in remote settings
was agreed to be:

“vision
For impairment
more information, and
please visual acuity that are not improved by pinhole and cannot be attributed
contact:
to other causes, and direct ophthalmoscopy records a supplementary lens:
≤ –5.00 D and changes such as “patchy atrophy” in the retina, or ≤ –10.00 D”.

2 The impact of myopia and high myopia

Myopia correction
• Access to correction for myopia is essential to avoid vision impairment. All people with myopia
should have access to appropriate, accurate refractive correction.

Myopia control
• Although there is a widely held clinical view that undercorrection of myopia is beneficial in
preventing its progression, the available evidence does not support this idea. Recent reports
show that undercorrection is associated with a higher rate of progression of myopia.
• Some initial published evidence indicates that time spent outdoors can delay the onset and
perhaps reduce the progression of myopia, although more research is required, as it is also
potentially a risk factor. If the evidence is proved correct, it will add beneficial eye care to the
list of other health-promoting outdoor activities (e.g. reduction of childhood obesity through
exercise, exposure to sunlight for vitamin D production, games for socialization).
• There is published evidence that excessive near work increases the risk of myopia.
• There is published evidence that multifocal spectacles can slightly reduce the rate of progress
of myopia; executive bifocal lenses are associated with substantially larger reductions.

IMPACT OF INCREASING
• Specially designed contact lenses that reduce peripheral hyperopia and/or create significant
myopic defocus can slow the progress of myopia. It is important that contact lenses are
appropriately cared for in order to avoid adverse effects.

PREVALENCEOF MYOPIA
• Orthokeratology can slow the progress of myopia, but overnight wear of contact lenses is
associated with risks.

AND HIGH MYOPIA

• Low-dose atropine has been shown to be effective in reducing the progression of myopia but
not in slowing the rate of increase of axial length. A dose of 0.01% has few side-effects, but
more research is required to determine the optimal regimen.
Report
• of thehave
Other agents Jointbeen
World HealthforOrganization–Brien
suggested the control of myopia, Holden
such as 7-methylxanthine;
Vision Institute
however, Global
larger clinical Scientific
trials Meeting
are needed on their
to establish Myopia
safety and efficacy.

Pathological consequences of myopia (pathologic myopia)

• High myopia can cause serious, sight-threatening retinal damage. Hence, the following
recommendations were agreed for the care and management of pathologic myopia.
• Patients with complications from pathologic myopia should have access to a full range of
eye-care services.
• Myopic choroidal neovascularization is one of the consequences of high myopia that causes
vision impairment; agents against vascular endothelial growth factor may be beneficial in the
treatment of this condition, but the long-term prognosis for vision is unknown.
• Myopia increases the risk of glaucoma; glaucomatous optic neuropathy should be investigated
in patients with high myopia.
• Myopia increases the risk of retinal detachment and cataract; a fundus and anterior segment
examination is essential for people with high myopia.
• People with vision impairment that cannot be corrected to a level of vision that they find
acceptable should have access to comprehensive eye-care services, including vision
rehabilitation and appropriate devices and surgery if necessary.

The impact of myopia and high myopia 3

2. Background and purpose of the
consultation
It is estimated that over 285 million people in the world have vision impairment and that 42% of
this is due to uncorrected refractive errors (1). Published estimates based on epidemiological
studies indicate that myopia affects 1.89 billion people worldwide, and, if the current prevalence
rates do not change, projections show that it will affect 2.56  billion people by 2020 (2).
Uncorrected myopia is the leading cause of vision impairment, and MMD in higher myopia was
reported as the major cause of new cases of blindness in Tajimi, Japan (3) and in Shanghai,
China (4, 5). In the Beijing Eye Study, it was found that the major cause of vision impairment is
cataract in older adults but pathologic myopia in the younger cohort (6). Myopia causes vision
impairment not only by direct retinal damage (7) but also by increasing the risks for cataract (8)
and the onset of glaucoma (9).

The meeting was called because the increasing prevalence of myopia and high myopia and the
issue of vision impairment associated with myopia receive insufficient attention from a public
health perspective in terms of assessment of prevalence, preventive interventions and possible
treatment. Currently, there is no consensus on the thresholds for classifying myopia or high
myopia. The terminology, classification and methods to be used in epidemiological studies
should be defined in order to assess the extent and contribution of myopia to vision impairment.

A three-day joint WHO–BHVI global scientific meeting on myopia was convened on 16–18
March 2015 at the premises of the Institute, University of New South Wales, Sydney, Australia,
in response to a communication from the then Minister of Health for Australia, Mr Peter Dutton,
to the Director-General of WHO, Dr Margaret Chan, on the growing concern about myopia and
the commitment of the Australian Government to discuss ways of addressing it. The participants
were experts in myopia research (see Annex 1) drawn from all six WHO regions. The agenda
included keynote presentations and working group sessions to share the most recent results
from conclusive research on the core issues discussed, reviewing the published evidence,
analysing and agreeing on definitions on the basis of scientific evidence and current medical
practice, reviewing epidemiological data on morbidity and discussing the social and economic
consequences for children, the elderly and society (for the programme of the meeting, see
Annex 2). Particular attention was paid to the evidence on strategies for reducing the assessed
and projected increase in myopia prevalence and their applicability in public health beyond
research settings.

At the end of the meeting, the definitions and terminology were made available for consideration,
in the framework of the 11th revision of the International Classification of Diseases (10),and
the conclusions for evidence-based public health policies and recommendations for additional
research were presented as a contribution to World Health Assembly resolution WHA66.4 on a
global action plan on universal eye health for 2014–2019 (11).

Professor Brien Holden was elected Chairperson of the meeting, and Professor Kovin Naidoo
was elected Rapporteur. The draft agenda was adopted (for the programme of the meeting,
see Annex 2).

For more information, please contact:

4 The impact of myopia and high myopia

3. Global prevalence of myopia
Myopia and high myopia were estimated to affect 27% (1893 million) and 2.8% (170 million)
of the world population, respectively, in 2010. According to published studies, the prevalence
of myopia is highest in east Asia, where China, Japan, the Republic of Korea and Singapore
have a prevalence of approximately 50%, and lower in Australia, Europe and north and south
America (2).

Preliminary projections based on these prevalence data and the corresponding United Nations
population figures (12), and accounting for the effects of age and time, indicate that myopia and
high myopia will affect 52% (4949 million) and 10.0% (925 million), respectively, of the world’s
population by 2050 (2) (Figs. 1 and 2).

Fig. 1. Numbers of cases (blue) and prevalence (red) of myopia worldwide between
2000 and 2050

Results: Myopia - Now and in 2050

IMPACT OF INCREASING Numbers of Myopes Myopia prevalence (%)

PREVALENCEOF MYOPIA
5000 52% 60

Myopia prevalence (%)

Numbers of myopes (Millions)

4500 46%
4000 50

AND HIGH MYOPIA

40%
3500 40
3000 33% 4949
28% 4156 30
2500
2000 22% 3337
Report of the Joint World Health2584
Organization–Brien Holden 20
1500
Vision
1000 Institute Global Scientific
1914 Meeting on Myopia
10
500 1343
0 0
2000 2010 2020 2030 2040 2050
Year
BrienHoldenVisonlnstitute Adapted from Holden et al. 2016 Ophthalmology

The impact of myopia and high myopia 5

Fig. 2. Numbers of people worldwide with high myopia (blue) and prevalence (red)
between 2000 and 2050

Results: High Myopia - Now and in 2050

Numbers of Myopes Myopia prevalence (%)
1000 12
Numbers of high myopia (Millions)

high myopia prevalence (%)

10.0%
900
800 10
7.0%
700 8
600 925
500 5.0% 6
4.0% 635
400
300 3.0% 4
2.2%
200 432 2
100 136 300
205
0 0
2000 2010 2020 2030 2040 2050
Year
BrienHoldenVisonlnstitute Adapted from Holden et al. 2016 Ophthalmology

Countries were grouped according to the 21 regions of the WHO Global Burden of Disease
programme (13) (see Annex 3) to determine regional differences in the prevalence of myopia
and high myopia in smaller geographical areas than the large administrative and political WHO
regions. The WHO regional structure will, however, be important for policy implementation. The
model used to make projections (2) gave the results described below.
• In 2000, the prevalence of myopia did not exceed 50% in any of the regions but, by 2050,
the prevalence will be ≥ 50% in 57% of the countries, if current trends continue.
• Countries in which the prevalence of myopia has been estimated and measured as low in the
past (e.g. India) will have major increases by 2050.
• In 2050, the prevalence of myopia will be much higher in high-income regions of the Asia-
Pacific, in east Asia and in south-east Asia, and the prevalence in high-income north America,
southern Latin America, all of Europe, north Africa, the Middle East and about 30% of Africa
will be similar to that in Asia today. The prevalence of high myopia is predicted to increase to
24% in all the Global Burden of Disease regions and in high-income Asia-Pacific countries
by 2050.
• According to Global Burden of Disease estimates, uncorrected distance refractive error is
the second largest cause of blindness and the leading cause of moderate and severe vision
impairment (53%) (1). The estimated cost of uncorrected refractive error in terms of direct and
indirect loss of world productivity is 269 billion international dollars (I$) (14) (US$ 202 billion
(15)), and the estimated cost of addressing the problem is US$ 28 billion over 5 years (15).
On the basis of current estimates and demographic trends, myopia is the main cause of
distance refractive error and will probably continue to be so in the future.
• Reducing the rate of myopia progression by 50% could reduce the prevalence of high myopia
Forby upinformation,
more to 90%.please contact:

6 The impact of myopia and high myopia

4. Myopia as a cause of vision
impairment and blindness
Uncorrected refractive error has been reported to be the first cause of vision impairment in
the world (1), and undercorrected myopia is the most common cause of vision impairment, as
judged by presentation for poor visual acuity.

MMD is the most common cause of visual impairment in patients with myopia, as 10% of
people with pathologic myopia develop MMD (due to choroidal neovascularization), which is
bilateral in 30% of cases (16).

Myopia is associated with higher risks of glaucoma and cataract but may be protective against
age-related macular degeneration and diabetic retinopathy.

Approximately 1% of whites and 1–3% of Asians have pathologic myopia (high myopia with
signs of retinal atrophic changes) (5). Pathologic myopia causes more vision impairment or

IMPACT OF INCREASING
blindness in Asians (0.2–1.4%) than in Caucasians (0.1–0.5%). Overall vision impairment due
to pathologic myopia occurs in 5–10 Asian people per 100,000 annually (Table  1). In this
study, cut-offs according to the best-corrected visual acuity classification were used, based

PREVALENCEOF MYOPIA
on WHO or United States criteria for vision impairment and blindness. Currently, choroidal
neovascularization in MMD is managed by treatment with antivascular endothelial growth factor
agents, but many questions remain regarding treatment regimens, monitoring, follow-up and

AND HIGH MYOPIA

long-term outcomes.

Table 1. Prevalence of blindness in pathologic myopia

Report of the Joint
Disease stage
World Health Organization–Brien
Parameter
Holden
Outcome Reference
Vision
pathologicInstitute
myopia Global Scientific Meeting on Myopia
Prevalence in the general adult population
White 1% 17
Asian 1–3% 18, 19, 20, 21
Estimated prevalence of vision impairment due to pathologic myopia
European 1–5 per 1000 22, 23, 24
Asian 2–15 per 1000 3, 6, 25, 26, 27
Other populations 28, 29
Annual incidence of blindness due to pathologic myopia 28, 30
White 1–5 per 100 000 28, 31
Asian 5–10 per 100 000 4
Myopic choroidal Prevalence of choroidal neovascularization
neovascularization
General population 0.05% 17, 21
Patients with pathologic myopia 5–10% 31, 32, 33
Incidence of choroidal neovascularization in 10% 16
pathologic myopia over 10 years
Bilateral myopic Prevalence of bilateral choroidal neovascularization 15–30% 16, 31, 34
choroidal secondary to pathologic myopia
neovascularization

Source: Wong et al. (5).

The impact of myopia and high myopia 7

5. Terminology and classification
5.1 Myopia, high myopia and pathologic myopia
There is currently no internationally agreed threshold for myopia or for high myopia. An operational
definition for high myopia is necessary so that the results of population-based studies can be
conducted with the same criteria in different countries, to determine the prevalence of high
myopia, the prevalence of vision impairment and/or blindness attributable to high myopia and
to determine whether high myopia progresses to pathological myopia in a similar way and in
the same proportion in different countries, ethnic groups and socioeconomic environments.
Longitudinal studies of high myopia and pathologic myopia should be conducted to quantify
the risk for sight-threatening conditions due to high myopia.

Currently, the definition of high myopia varies by study; it has been defined as: < –5.00 D
myopia, ≤ –5.00 D myopia, < –6.00 D myopia, ≤ –6.00 D myopia and ≤ –8.00 D myopia. High
myopia has also been defined on the basis of an axial length > 26 mm. Axial length, however,
can be an inaccurate criterion because it can vary even in normal eyes. Overall eye power is
derived from a combination of the lens, cornea and axial length, and some eyes with longer
or shorter axial length have no refractive error. Furthermore, measurements using different
instruments may vary.

The participants agreed that a classification of high myopia as ≤ –5.00 D is the best definition,
as a person who has –5.00 D uncorrected myopia has a visual acuity of 6/172 (10), which is
much worse than the threshold for blindness (< 3/60 in the better eye) (35).

Pathologic myopia is also not well defined, with different descriptions across studies of vision-
threatening changes in the retina or the presence of posterior staphyloma,1 and various criteria
for axial length and spherical equivalents refractive error. Pathologic myopia has been reported
as high myopia with myopia-related fundus abnormalities such as MMD and glaucoma.

5.2 Myopic macular degeneration

MMD is a major cause of vision impairment in high myopia. A number of terms are used, including
MMD, myopic maculopathy, myopic retinopathy and myopic choroidal neovascularization.
Although other features of pathologic myopia can cause vision impairment, the same term
should be used in all studies and in clinical practice to ensure unequivocal classification and
assessment of vision impairment due to high myopia.

MMD includes signs of diffuse chorioretinal atrophy, patchy chorioretinal atrophy, lacquer
cracks, choroidal neovascularization and related macular atrophy in the presence of higher
myopia (Fig. 3).

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1 An outpouching of the wall of the eye with a radius of curvature that is less than that of the surrounding curvature of the wall
of the eye; associated with a higher risk for degenerative changes in the retina.

8 The impact of myopia and high myopia

Fig. 3. Myopic macular degeneration

IMPACT OF INCREASING
PREVALENCEOF MYOPIA
Source: Hayashi et al. (33), presented by K. Ohno-Matsui during the meeting.

MMD develops in the presence of high myopia, with initial early retinal changes leading to a
tessellated fundus, which may then develop into diffuse atrophy or lacquer cracks, patchy

AND HIGH MYOPIA

atrophy or choroidal neovascularization and finally MMD (Fig. 4).

Fig. 4. Progression of myopic macular degeneration in a group of people with high

myopia (≤ –8.00 D)
Report of the Joint World Health Organization–Brien Holden
Vision Institute Global Scientific Meeting on Myopia

Source: presented by K. Ohno-Matsui during the meeting, from a retrospective study of a group of Japanese people with
myopia ≤ –8.00 D.

The impact of myopia and high myopia 9

Table 2. A proposed international photographic classification and grading system
for myopic macular degeneration

Category Myopic maculopathy Additional lesions

0 No macular lesions
1 Tesselated fundus Lacquer cracks
2 Diffuse chorioretinal atrophy Choroidal neovascularization
3 Patchy chorioretinal atrophy Fuchs spot
4 Macular atrophy

Source: presented by K. Ohno-Matsui during the meeting.

No universal grading system for MMD is in use clinically. An international photographic grad-
ing system was proposed during the meeting (Table 2). It was noted, however, that the system
is too complex for classifying vision impairment due to MMD in population-based surveys con-
ducted by technicians and nurses.

6. Impact of myopia
Uncorrected distance refractive error was estimated in 2013 to affect 108 million people globally
(1). It is the leading cause of moderate and severe vision impairment (42%) and a major cause
of blindness (3%) (1). Uncorrected myopia as low as –1.50  D will result in moderate vision
impairment, and uncorrected myopia of –4.00 D is sufficient refractive error to be classified as
blindness (36). Most distance refractive error is caused by myopia; the global prevalence of
myopia is expected to increase from 27% of the world’s population in 2010 to 52% by 2050
(2). In raw numbers, this would correspond to a 2.6-fold increase in the number of people with
myopia, allowing for the predicted increase in the global population. If the increasing prevalence
of myopia is not addressed, a similar increase in uncorrected refractive error can be expected.
These projections are based on conservative assumptions and, given the published relationship
between level of education and myopia, increased provision of education could markedly
increase these trends. Furthermore, uncorrected distance refractive error has been estimated
to result in a global loss of productivity of I$ 269 billion (14) (US$ 202 billion (15)), which will also
increase if there is a significant increase in uncorrected myopia.

The cost of care is also likely to increase significantly, and will be exacerbated by an even
greater increase in the prevalence of high myopia, from 2.8% (190 million people) to 9.7%
(924 million people) by 2050 (2), representing a 4.9-fold increase in high myopia. In some
populations of young adults in Asia, the prevalence of high myopia has already reached 38%
(37). The annual direct cost of optical correction of myopia for Singaporean adults has been
estimated at US$  755  million. SM Saw, in a presentation shared at the meeting, estimated
that, if the available data were extrapolated to all cities in Asia in which the prevalence of
myopia is approximately equal to the rates in Singapore, the estimated direct cost would be
US$ 328 billion. Lim et al. (38) estimates that the direct cost of myopia in Singaporean children
was US$ 148 per child per year.
For more information, please contact:
The impact of myopia is not only financial; it also affects quality of life and personal development.
A study of Singaporean adolescents found that those with vision impairment, measured in

10 The impact of myopia and high myopia

terms of presenting vision (i.e. wearing their habitual correction), had statistically significantly
lower scores for total quality of life (P = 0.03), psychosocial functioning (P = 0.03) and school
functioning (P = 0.02) (39). Another study indicates that correction of refractive errors by
the provision of spectacles in low socioeconomic areas in China would markedly improve
educational outcomes since the major medium of instruction is the blackboard (40). The
increase in the prevalence of high myopia will eventually lead to an increase in pathologic
myopia and hence blindness and permanent vision impairment, with an associated increased
pressure on ophthalmological and low-vision services.

The participants agreed on the basis of the evidence that myopia warrants national and
international synergistic efforts, as the costs and public health implications are huge and
often underestimated.2

7. Evidence for causes of myopia

7.1 Optical and environmental influences
IMPACT OF INCREASING
Several optical and environmental factors have been identified as possible causes of the onset
and progression of myopia, acting either individually or in combination.

PREVALENCEOF MYOPIA
Peripheral hyperopic defocus in a corrected myopic eye (41):3 According to Smith et al. (42),
experimentally imposed hyperopic defocus, which is common in corrected myopic eyes, can

AND HIGH MYOPIA

increase ocular growth; whereas myopic defocus, especially when it is imposed over a large
area of the retina, can slow axial elongation (Fig. 5).

Fig. 5. Association between central and peripheral refraction

Report of the Joint World Health Organization–Brien Holden
Vision InstituteAdults
Global Scientific Meeting on Myopia Children
myope 1.5
Relative Peripheral Refraction (D)

5
Refractive error (D)

Millodot, 1981 1.0

Central vs. 30 deg Nasal
4
Hyperopia

3 0.5

emmetrope Mutti et al., 2000

2 0.0

1 -0.5
hyperope
0 -1.0
Myopia

-1 -1.5

0 20 40 60 Myope Emmetrope Hyperope

Temporal Eccentricity

Source: presented by EL Smith III during the meeting.

2 SM Saw, presentation to the meeting.

3 EL Smith III, presentation to the meeting.

The impact of myopia and high myopia 11

 The pattern of peripheral refraction varies with central refraction. People with myopia typically
have relative hyperopia in the periphery, whereas those with hyperopia have relative myopia in
the periphery (43,44).

Intensive near work (45,46): Ghosh et al. (45) suggested that the mechanism by which near
work increases axial length is the combined influence of biomechanical factors (i.e. extraocular
muscle forces, ciliary muscle contraction) associated with near tasks in downward gaze.

Time spent outdoors (47): I. Morgan informed the meeting that the epidemic of myopia in East
Asia is primarily due to changes in environmental (social) factors, specifically intensive education
and less time spent outdoors (Fig. 6). Observed seasonal variation in the progression of myopia
adds weight to the argument that time spent outdoors slows the progression of myopia.

Fig. 6. Five-year risk of incident myopia among six-year-old Australian children

Odds Ratios of Incident Myopia

16
14
12

10
8

6 Low

4
Moderate Outdoors
2
High
0
High Moderate Low

Near Work
Source: French et al., 2013 (37).

Successive and simultaneous hyperopic defocus: As indoor scenes have highly heterogeneous
dioptric topography, eyes are more likely to experience hyperopic defocus, which has been
shown to be a strong stimulus for myopic growth in laboratory animals (49).

7.2 Genetics and parental history

Genetics and the environment play a role in the development and progression of myopia, but
the genetic contribution is considered small, and there is consensus that genes may determine
susceptibility to environmental factors (50).

Genes for myopia and high myopia development have been identified in familial studies and twin
studies and by linkage analysis. Large-scale genome association studies have been conducted
on single nucleotide polymorphisms. Two of the largest studies are that of the Consortium for
Refractive
For Error please
more information, and Myopia
contact: (CREAM), with almost 46 000 participants (51), and the 23andME
study, with over 59  000 participants, which found genes associated with myopia and high
myopia (52).

12 The impact of myopia and high myopia

As M. He reported during the meeting, twin studies have shown that genetics can explain
60–80% of variance in spherical equivalent refractive error and axial length. Other studies,
however, have indicated that the genetic contribution is far less and does not explain the majority
of cases of high myopia (53). Studies of the genetic contribution should include evaluation
of environmental aspects, as factors such as time spent outdoors time and near work vary
by family. The rapid increase in the prevalence of myopia seen over a short time in east Asia
(54, 55, 56) cannot be explained by genetics, thus indicating that environmental factors
associated with more widespread education and urbanization play a larger role. Furthermore,
the higher prevalence of myopia is not limited to a single race: it is higher in people of
Chinese, Indian and Malay origin in Singapore (56) than in Indians in India (57) and rural Chinese
in China (54).

In the twin study by He et al., reported during the meeting, baseline refraction and parental
myopia were found to be risk factors, while near work intensity and outdoor exposure were
possible risk factors. Other studies have found that the children of myopic parents have a higher
prevalence of myopia, but the relative risk varies and is lower where the prevalence of myopia
is high, as in east Asia (58, 59, 60, 61).

IMPACT
8. Control ofOF INCREASING
myopia
PREVALENCEOF
8.1 Optical control
MYOPIA
AND HIGH MYOPIA
Various optical approaches to the control of myopia progression have been evaluated over the
past few decades. These are based on different hypotheses of myopia progression, such as
accommodative lag associated with myopia and peripheral defocus. The spectacle methods
Report
evaluatedof the Joint
include World Health
undercorrection, Organization–Brien
progressive Holdenbifocals, peripheral
addition lenses, executive
Vision
defocus Institute Global
correction and Scientific
peripheral defocusMeeting on Myopia
plus a bifocal aid. Contact lens methods include rigid
gas-permeable lenses, bifocal contact lenses, peripheral plus contact lenses, orthokeratology
and extended depth-of-focus lenses. Executive bifocal spectacles, orthokeratology and
peripheral plus contact lenses appear to be the most effective, reducing the rate of myopia
progression by 57% (62), 45% (63) and 50% (64), respectively. Extended depth-of-focus lenses
are a promising means of myopia control, but longer-term studies are required. The details of
these optical methods are outlined below.

8.1.1 Spectacle methods

Leaving myopia uncorrected did not reduce the rate of progression in comparison with full
correction or undercorrection in a 12-month prospective, randomized study in children aged
9–12 years (65). Undercorrection has been shown to increase myopia progression; it has
been suggested that this is due to peripheral and central blur, stimulating axial length growth
(66). Undercorrection is therefore not advocated (67). Progressive addition lenses have been
shown to have a small, statistically significant but not clinically significant effect, although
clinical significance was found in subgroups, such as people with excess convergence or
accommodative lag (68). The reduction in the rate of myopia progression was correlated with
the degree of relative myopia produced in the superior retina by near addition (69).

Executive bifocals with a +1.50 addition and 3 D base-in prism reduced the rate of myopia
progression by 57% after three years (62). These lenses are thought to reduce the stimulus for

The impact of myopia and high myopia 13

axial elongation, either by reducing the accommodative lag in myopia (although this association
has not yet been demonstrated) or by imposing myopic focus in the superior peripheral
retina. Spectacle lenses with peripheral plus that are intended to reduce the degree of relative
peripheral hyperopic defocus in people with myopia were investigated in a 12-month trial. The
reduction in myopia progression was not statistically significant. In a subgroup of children with
myopic parents, the rate of myopic progression was 30% less than in controls (–0.68 ± 0.48 D
vs –0.97± 0.48 D, P = 0.033) (70). A lens with peripheral plus and a progressive addition lens-
like near addition resulted in a small but statistically significant reduction in myopia progression,
which was similar to that observed with spectacles with peripheral plus (71). This study showed
that executive bifocals provide good clinical myopia control and that other forms of spectacle
correction have limited or no effect on myopia progression.

The factors that may limit the success of spectacle myopia control methods are eye movements
behind the lens (which affect the position of the optical treatment zone relative to the visual axis),
compliance, the maintenance of a large non-treatment zone in order to minimize effects on
central vision, and “swim” produced by eccentricity-dependent variations in magnification that
can be produced by either eye or head movements (71).

8.1.2 Contact lens methods

Standard rigid gas-permeable lenses do not reduce the rate of myopic axial elongation and can
lead to some corneal flattening (72).

Bifocal contact lenses significantly reduce the rate of myopia progression, in terms of both
the spherical equivalent of refractive error and axial length. It has been suggested that bifocal
contact lenses act by reducing accommodative lag (73); however, it is more likely that they act
by reducing peripheral hyperopic defocus or imposing myopic defocus (74). Peripheral defocus
correction by peripheral-plus contact lenses results in a 50% reduction in the rate of myopic
progression, in terms of both spherical equivalent and axial length (75).

A dual-focus contact lens with multiple rings of plus power that produce relative myopic defocus
over a large part of the retina resulted in a 36% reduction in the progression of myopia and a 49%
reduction in the rate of change in axial length: however, long-term studies are still required (41).

Orthokeratology involves wearing rigid gas-permeable lenses overnight to flatten the cornea.
Use of these lenses led to a consistent reduction in myopia progression of approximately 45%
over a two-year period and 30% over five years, when measured in terms of axial length (63).

Extended depth-of-focus lenses support the myopic defocus hypothesis by reducing the signals
that are thought to increase axial growth (76). Preliminary results showed a 35% reduction in the
rate of progression of the spherical equivalent of refractive error and a reduction of up to 45%
in the rate of progression in axial length.

For more information, please contact:

14 The impact of myopia and high myopia

8.2 Time spent outdoors and behavioural influences
A number of studies have been conducted to determine the effects of the amount of time spent
outdoors and behavioural changes on myopia progression in children (77, 78, 79). Evidence
is emerging that spending more time outdoors can protect against the onset of myopia, the
effect of near work and the effect of parental myopia and possibly slow the rate of progression
of myopia.

It was reported that, when children spend sufficient time outdoors (more than two hours/day),
the risk of myopia was reduced, even when they had two myopic parents and continued to
perform near work (77). The total time spent outdoors appeared to be the important factor,
rather than time playing sports, because time spent indoors playing sports was not beneficial.
Thus, the nature of the outdoor activities does not seem to be critical (77).

Wu et al. (79) reported that the incidence of new cases of myopia over one year was significantly
reduced, by approximately 50%, when the time spent outdoors was increased by an additional
80 minutes/day, compared with a control group (8.4% versus 17.6%). The rate of progression of
myopia in the children who spent additional time outdoors was also significantly reduced (0.25 D

IMPACT OF INCREASING
versus 0.38 D). In the Guangzhou outdoor activity longitudinal study (80), a 23% reduction in
the number of cases of incident myopia was found after an additional 40 minutes/day outdoors
for three years. A small, statistically significant reduction in the spherical equivalent refractive

PREVALENCEOF MYOPIA
error was found but no statistically significant reduction in the rate of axial length elongation.

The mechanism of action of time spent outdoors remains unknown and requires further

AND HIGH MYOPIA

investigation. Rose et al. (77) hypothesized that the brighter light outdoors stimulates the release
of dopamine from the retina, which is reported to inhibit axial elongation in animal models of
form deprivation myopia (81, 82). Seasonal differences in the rates of myopic progression,
which are faster in winter and slower in summer, support this hypothesis (83).
Report of the Joint World Health Organization–Brien Holden
Vision Institute
Increasing children’sGlobal Scientific
time outdoors Meeting
may be difficult, on Myopia
particularly during school time, because of
a cultural commitment to educational success in many parts of the world, as well as weather
conditions.4 Outdoor activity could be made part of obesity reduction campaigns for children,
and schoolchildren in particular.

Further studies should be conducted on the effect of time spent outdoors, with better, simpler
survey methods. Work is also needed to address the social, cultural and educational barriers
to spending more time outdoors. For example, children in Guangzhou and their parents are
committed to intense, lengthy extracurricular study with a daily two-hour afternoon nap, and
they often do not leave their classrooms during school hours.5

8.3 Pharmacological and therapeutic control

A number of therapeutic interventions for myopia control have been investigated. Use of 0.01%
atropine is the most common treatment regimen for the management of myopia in children in a
number of Asian countries, such as Singapore and Taiwan, China. One experimental intervention
that is being tested in Denmark is 7-methylxanthine; it shows promise, but its long-term safety
still needs to be studied.

4 SM Saw, presentation to the meeting.

5 I Morgan, presentation to the meeting.

The impact of myopia and high myopia 15

8.3.1 Atropine
Atropine eye-drops are antimuscarinics, blocking the muscarinic receptors from stimulation by
the neurotransmitter acetylcholine. These receptors are found in the central nervous system
and in many parts of the eye, where they can, for example, cause pupil dilatation and block
accommodation (84). Atropine reduces myopia progression in children in a dose-related
manner, but a rebound effect (“catch-up”) occurs with higher doses (85).

Atropine eye-drops are generally considered to be safe, although a high percentage of products
have substantial side-effects, such as allergic reactions, fixed dilated pupils requiring sunglasses
to be worn, accommodative paralysis necessitating bifocal spectacles, papillary conjunctivitis
and, in some cases, nausea and vomiting. Lower doses, such as 0.01% (as opposed to the
usual clinical concentration of 1.0%), reduce the common side-effects observed with the higher
dose, including pupil dilatation, loss of accommodation and reduced near vision. Atropine at
0.01% resulted in a 59% reduction in the rate of progress of myopia, with minimal adverse
effects; however, controversially, it had no effect on axial elongation (85). During a seven-year
observation period after treatment for two years, atropine at 0.01% slowed myopia progression
by 50% in children aged 6–9 years, with no apparent effect on axial elongation rates.6

Clinical guidelines are needed on who should be treated, when treatment should begin and
cessation and the duration of treatment. Table 3 lists potential clinical guidelines based on the
ATOM2 study.

Atropine eye-drops were recently approved by the United States Food and Drug Administration
for long-term amblyopia therapy in children. There is currently no regulatory approval for the use
of atropine to slow myopia progression.

Table 3. Clinical guidelines for children aged 6–10 years with myopia > 1.0 D and
documented myopia progression > 0.5 D per year
Treat children with Atropine 0.01% for 2 years
Good response: almost no Moderate response: myopic Poor response: myopic progression
myopic progression progression of 0.5 D to 1.0 D >1.0 D over second year
(<0.5 D over second year) over second year
Taper and stop Atropine Continue Atropine 0.01% for a May be a non-responder. Consider
further 1–2 years, then taper and taper and stop Atropine
stop Atropine
Follow subject for a year post stopping Atropine
Recommence Atropine if significant rebound and continue review

Source: modified from the ATOM2 study (85).

8.3.2 7–methylxanthine
7-methylxanthine is a non-selective adenosine antagonist that affects the release of
neurotransmitters such as dopamine, norepinephrine, acetylcholine, glutamate and serotonin
(86). It is a metabolite of caffeine and theobromine, and its half-life after oral ingestion is
3.5 hours. 7-methylxanthine is thought to penetrate the blood–brain barrier only minimally and
to be relatively non-toxic; it is excreted predominantly through the kidneys.

For more information, please contact:

6 TY Wong, presentation to the meeting.

16 The impact of myopia and high myopia

During eight years of follow-up of 750 myopic Danish children who were treated with various
systemic dosages of 7-methylxanthine, no side-effects were reported. The dose of 400  mg
twice a day reduced myopia progression and excessive eye elongation by 60% (70).

9. Research
There is a large body of research on myopia, but the epidemiology, myopigenesis, myopia
control, risk factors and pathophysiology of the condition require further research to improve
evidence-based management. Areas where further research is required are detailed below.

9.1 Epidemiology of myopia

Epidemiological studies are essential for defining priorities in planning and targeting resources
for eye care. Management of myopia and prevention of vision impairment from uncorrected
myopia must be optimized in view of the projected increases in the global prevalence of the

IMPACT OF INCREASING
condition. Participants agreed that MMD should be included in epidemiological studies on
the prevalence and causes of vision impairment, including rapid assessments of avoidable
blindness and WHO surveys on vision impairment and causes.

PREVALENCEOF MYOPIA
Few data are available on the prevalence of vision impairment due to conditions associated with
high myopia, such as cataracts, glaucoma and MMD. Higher-quality data should be produced

AND HIGH MYOPIA

on the prevalence of myopia in various countries, especially developing countries in Africa, the
Americas and the WHO Western Pacific Region.

9.2 Myopigenesis,
Report environmental,
of the Joint World optical and
Health Organization–Brien therapeutic
Holden
factors
Vision Institute Global Scientific Meeting on Myopia
9.2.1 Environmental factors
Strategies should be devised to increase the amount of time children spend outdoors, particularly
in preschool and primary school.

Although it is clear that increased time outdoors reduces the risk of myopia, the aspect that
imparts a protective effect is unknown. The potential roles of ambient lighting and differences
in the spectral composition of light, dioptric topography and spatial scale should be clarified to
optimize any therapeutic benefit. Controlled parametric studies involving experimental animal
models of myopia would be useful.

Randomized clinical trials with at least three years of follow-up should be conducted to determine
the optimum time required to control the development and progression of myopia.

9.2.2 Optical and pharmaceutical approaches

A variety of interventions, from spectacles to contact lenses to pharmaceuticals, appear to be
effective in reducing the progression of myopia in children. Best-practice clinical trials (randomized
trials that are blinded when appropriate, with adequate power and use of cycloplegic agents,
for a minimum of 12 months and preferably longer) should be conducted to optimize strategies.

The impact of myopia and high myopia 17

Clinical trials should include an intention-to-treat analysis, assessment and analysis of the effect
of compliance and documentation of any adverse events.

9.2.3 Near work

It is widely recognized that near work in formal education is associated with myopia. Studies
should be conducted to identify and characterize the components of near work and formal
education, e.g. contrast and spatial components, that could cause myopia.

9.2.4 Combination therapy

The effect of combining the various types of preventive and control strategies is unknown.
Knowing how the different therapies and strategies work together is important, as patients are
unlikely to use one method in isolation.

9.3 Risk factors and individual heterogeneity

Individual differences in susceptibility and behaviour are likely to play a role in determining
the occurrence of myopia and, probably, the ultimate degree of myopia. There are significant
gaps in understanding of refractive development from approximately two years of age until
the start of formal education and between the end of secondary education and middle age
(approximately 40 years). Studies on refractive development and the prevalence of refractive
errors from approximately two years of age up to and including 25 years are encouraged. These
would benefit from methods for documenting behaviour quantitatively, such as validation of
questionnaires and objective measurement of exposure to light.

9.4 High myopia, pathologic myopia and comorbid

conditions
It is not understood whether high myopia develops into pathologic myopia or whether they are
two conditions with different underlying causes. Retrospective case-control studies, population-
based studies or meta-analyses are needed to determine whether and what proportion of
people with high myopia develop pathological myopia. The natural history, including age at
onset of pathologic myopia, and the risk factors and factors associated with vision impairment
should be studied. The causes of high myopia and pathologic myopia must be identified,
including genetics and the environment, near work and time spent outdoors.

The proportion of people with myopia who will develop ocular complications is not known,
nor the age or level of myopia at which complications typically develop. Research is required
to understand the causes of the comorbid conditions associated with myopia and their risk
factors.

9.5 Eye examinations in myopia

The use of cycloplegic agents in eye examinations should be standardized, as there are no
guidelines on use of these agents in myopia. Studies show that the measured level of refractive
error in people with myopia differs when cycloplegics are used. Studies are required to determine
the optimal cycloplegic regimen for studying myopia progression in children and adults of
For more information,
different ethnic please contact:
backgrounds, including the cycloplegic agent, the concentration (number of
drops) and time before measurement.

18 The impact of myopia and high myopia

10. Conclusions
Documented increases in the prevalence of myopia and high myopia worldwide are a serious
public health concern. Data to inform research, clinical practice and public health policy must
be produced urgently. The participants in this joint consultation agreed on recommendations
for consistent use of international terminology for obtaining internationally comparable, accurate
data on the prevalence of myopia and high myopia. They agreed on definitions of myopia and
high myopia and a description of the pathologic consequences of myopia. They further agreed
that myopia and high myopia should be included as attributable causes of vision impairment in
epidemiological surveys, and that the term “myopic macular degeneration” should be used to
categorize the blinding retinal diseases associated with high myopia, in preference to the many
other terms in current use. The consultation provided an opportunity to categorize myopic
defects, evaluate the evidence on myopia control strategies and identify gaps in knowledge
that must be filled urgently as a basis for evidence-based strategies to reduce the prevalence
of high myopia and associated vision impairment.

IMPACT OF INCREASING
PREVALENCEOF MYOPIA
AND HIGH MYOPIA
Report of the Joint World Health Organization–Brien Holden
Vision Institute Global Scientific Meeting on Myopia

The impact of myopia and high myopia 19

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24 The impact of myopia and high myopia

Annex 1. Participants
Professor Mingguang He, Centre for Eye Dr Solange R. Salomão, Federal University of São
Research Australia Melbourne, Australia, and Paulo, São Paulo, Brazil [email protected]
Zhongshan Ophthalmic Centre, Guangzhou, China
[email protected]
Professor Brien Holden, Brien Holden Vision Professor Padmaja Sankaridurg, Brien Holden
Institute, Sydney, Australia Vision Institute, Sydney, Australia
[email protected] [email protected]
Professor Jost B. Jonas, Ruprecht Karl University of Professor Seang Mei Saw, National University of
Heidelberg, Heidelberg, Germany Singapore, Singapore
[email protected] [email protected]
Dr Monica Jong, Scientific Secretary, Brien Holden Professor Earl L Smith III, University of Houston,
Vision Institute, Sydney, Australia Houston, Texas, USA
[email protected] [email protected]
Professor Jafer Kedir, Jimma University, Jimma, Dr Klaus Trier, clinical practice, Hellerup, Denmark
Ethiopia [email protected] [email protected]
Dr Ivo Kocur, World Health Organization, Geneva, Dr Susan Vitale, National Institutes of Health,

IMPACT OF INCREASING
Switzerland [email protected] Washington DC, USA [email protected]
Dr Silvio Paolo Mariotti, World Health Organization, Professor Tien Y. Wong, National University of
Geneva, Switzerland [email protected] Singapore, Singapore [email protected]

PREVALENCEOF MYOPIA
Dr Hasan Minto, Brien Holden Vision Institute,
Islamabad, Pakistan
[email protected]
Professor Abbas Ali Yekta, Mashhad University of
Medical Sciences, Mashhad, Islamic Republic of
Iran [email protected]

AND HIGH MYOPIA

Professor Ian Morgan, Australian National University
Canberra, Australia
[email protected]
Professor Kovin Naidoo, Brien Holden Vision
Institute, Durban, South Africa
[email protected]
Professor Kyoko Ohno-Matsui, Tokyo Medical and Professor Olavi Pärssinen, University of Jyvaskyla,
Report of theTokyo,
Dental University, Joint World
Japan Health Organization–Brien
[email protected] Holden
Jyvaskyla, Finland [email protected]
Vision Institute
Dr Gullapalli Global
(Nag) Rao, Scientific
L V Prasad Eye InstituteMeeting on Myopia
Professor Serge Resnikoff, Consultant, Geneva,
(LVPEI), Hyderabad, India [email protected] Switzerland [email protected]
Professor Jialiang Zhao, Peking Union
Medical College Hospital, Beijing, China
[email protected]

Observers
Dr Adriana Berezovsky, Federal University of São Paulo, São Paulo, Brazil [email protected]
Mr Tim Fricke, Brien Holden Vision Institute, Sydney, Australia [email protected]
Dr David Wilson, Brien Holden Vision Institute, Sydney, Australia [email protected]

The impact of myopia and high myopia 25

Annex 2. Programme
Day 1. Monday 16 March 2015 – Chairs: Professor Serge Resnikoff and Dr Ivo Kocur
09:00 Welcome Professor Brien A.
Holden
09:20 Welcome – The scope and purpose of the meeting Dr Ivo Kocur and
Dr Silvio Mariotti
09:45 The magnitude of myopia Professor Brien A.
The prevalence of myopia and higher levels of myopia at global and Holden
regional levels and projected increase to 2050
10:15 Vision impairment and blindness in myopia Professor Tien Y.
Wong
Vision impairment in myopia and comorbid conditions
Permanent vision impairment caused by myopia
Prevalence of vision impairment and blindness associated with myopia
Prevalence and risks for comorbidity with myopia
11:00 Morning tea
11:30 Terminology and classification of high myopia and pathological myopia Professor Kyoko
Ohno-Matsui
Definition, classification and terminology of myopia and higher myopia,
including the vision impairment
12:00 Myopic macular degeneration Professor Jost B.
Jonas
Definition, description, characteristics and effects
12:30 Impact of myopia on society Professor Seang Mei
Saw
Myopia and complications of myopia and social and economic impacts
13:00 Lunch
14:00 Breakout sessions – Definitions
Group 1. Definitions and methods for prevalence studies of myopia and high myopia and data
(to include refractive error and vision impairment due to higher levels of myopia) – current state of
surveys of WHO and rapid assessment of avoidable blindness
Group 2. Definition of myopic macular degeneration (MMD) for surveys and future publications,
protocol for measuring the prevalence of MMD in epidemiological surveys and future publications,
including a grading scale and quantification of MMD. Terminology, classification, survey methods
and protocols
15:30 Afternoon tea
16:00 Plenary session: Definitions, review of outcomes
17:30 Close Day 1

Group 1 Group 2
Facilitator: Professor Kovin Naidoo Facilitator: Professor Serge Resnikoff
Reporter: Mr Tim Fricke (observer) Reporter: Dr Monica Jong
Participants: Professor Jafer Kedir, Dr Ivo Kocur, Participants: Dr Adriana Berezovsky (observer),
Dr Hasan Minto, Professor Ian Morgan, Professor Professor Mingguang He, Professor Brien Holden,
Olavi Pärssinen, Dr Solange R. Salomão, Professor Professor Jost B. Jonas, Dr Silvio Mariotti
Padmaja Sankaridurg
Professor Kyoko Ohno-Matsui, Professor Gullipalli
Professor
For Seang Mei
more information, Saw,
please Professor Earl L. Smith III,
contact: (Nag) Rao, Dr Klaus Trier, Professor Tien Y. Wong,
Dr Susan Vitale, Dr David Wilson (observer), Professor Professor Jialiang Zhao
Abbas Ali Yekta

26 The impact of myopia and high myopia

Day 2. Tuesday 17 March 2015 – Chairs: Professor Mingguang He and Dr Silvio Mariotti
09:00 The day’s activities Chair
09:10 Evidence related to the causes of myopia: optical and environmental Professor Earl L.
Smith III
Evidence on the causes of myopia progression, e.g. retinal image profile,
and the role of the macula and the periphery in the induction of myopia,
environment (light), myopia induction models
09:25 Evidence related to the causes of myopia: genetics, parental history, other Professor Seang Mei
Saw
Relation of genetics and parental myopia with myopia, Singapore study
and CREAM consortium
09:40 Evidence related to the causes of myopia: genetics and environmental risk Professor Mingguang
factors for onset and progression of myopia He
Nine years of follow-up data from the Guangzhou Twin Cohort Study
09:55 Discussion
10:10 Evidence for myopia control: optical Professor Padmaja
Sankaridurg
Review of the evidence on the effects of optical intervention: peripheral
plus, extended depth of focus, orthokeratology, bifocal spectacles
10:35 Evidence for myopia control: outdoors, behavioural Professor Ian Morgan
Review of the evidence on the effects of environmental and behavioural

IMPACT OF INCREASING
interventions
Examples of health policy and possible myopia control activities and
interventions implemented – e.g. Chinese Taipei considering laws to monitor

PREVALENCEOF MYOPIA
the time spent on near devices, and “and or the time” in Wuhan, China
11:00 Morning tea
11:30 Evidence for myopia control: lessons for atropine Professor Tien Y.

AND HIGH MYOPIA

Wong
Review of the evidence on the effects and use of atropine
12:00 Evidence for myopia control: therapeutic 7-methylxanthine Dr Klaus Trier
Review of the evidence on the effects and use of 7-methylxanthine
Report
12:30 of the
Lunch Joint World Health Organization–Brien Holden
13:30
Vision Breakout session:
Institute Global Future research needed
Scientific Meeting
on Myopia
Group 1. Epidemiological research on the prevalence of myopia, high myopia, blindness and vision
impairment due to myopia (cataracts, glaucoma, MMD)
Group 2. Definition of MMD for surveys and future publications, protocol for measuring the
prevalence of MMD in epidemiological surveys and future publications, including a grading scale
and quantification of MMD. Terminology, classification, survey methods and protocols
Group 3. Vision impairment and blindness due to myopia
Group 4. Draft recommendations on the public health implications of interventions
15:30 Afternoon tea
16:00 Plenary session: Future research review and outcomes Group reporters

Moderator: Dr Silvio
Mariotti
17:30 Close of day 2

The impact of myopia and high myopia 27

Breakout groups Group 3
Group 1 Facilitator: Professor Nag Rao
Facilitator: Dr Susan Vitale Reporter: Dr Monica Jong
Reporter: Dr Hasan Minto Participants: Professor Jost B. Jonas, Professor
Kyoko Ohno-Matsui, Dr Solange R. Salomão,
Participants: Mr Tim Fricke (observer), Professor
Professor Abbas Ali Yekta, Dr Adriana Berezovsky
Jafer Kedir, Dr Ivo Kocur, Dr David Wilson (observer),
(observer)
Professor Olavi Pärssinen
Group 4
Group 2
Facilitator: Professor Tien Wong
Facilitator: Professor Earl Smith III
Reporter: Professor Kovin Naidoo
Reporter: Professor Padmaja Sankaridurg
Participants: Professor Brien Holden, Dr Silvio Mariotti,
Participants: Dr Silvio Mariotti, Professor Seang Mei
Professor Serge Resnikoff, Professor Mingguang He
Saw, Dr Klaus Trier, Professor Jialiang Zhao

Day 3. Wednesday 18 March 2015 – Chair: Professor Brien A. Holden

09:00 Brief outline of the morning Chair
Housekeeping: transfers to the airport, lunch, luggage storage
09:10 Plenary session: conclusions and recommendations Presenter: Dr Ivo
Kocur
• Action plan/roadmap for establishing definitions of myopia, high myopia
and MMD, further research needed Moderator: Dr Silvio
Mariotti
• Conclusions and recommendations and next steps, i.e. creating a
category for MMD in blindness surveys, dealing with myopia progression
at clinical level
Follow-up meeting and agreed timelines
12:00 Close
12:10 Lunch

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28 The impact of myopia and high myopia

Annex 3. Regions defined in the WHO
Global Burden of Disease programme
Subregion Countries
High-income region
Asia-Pacific, high income Brunei Darussalam, Japan, Republic of Korea, Singapore
Australasia Australia, New Zealand
North America, high income Canada, United States of America
Western Europe Andorra, Austria, Belgium, Cyprus, Denmark, Finland, France, Germany,
Greece, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, Netherlands, Norway,
Portugal, Spain, Sweden, Switzerland, United Kingdom of Great Britain and
Northern Ireland
South Asia region
South Asia Afghanistan, Bangladesh, Bhutan, India, Nepal, Pakistan
Sub-Saharan Africa region
Central Africa Angola, Central African Republic, Congo, Democratic Republic of the Congo,
Equatorial Guinea, Gabon

IMPACT OF INCREASING
East Africa Burundi, Comoros, Djibouti, Eritrea, Ethiopia, Kenya, Madagascar, Malawi,
Mauritius, Mozambique, Rwanda, Seychelles, Somalia, Sudan, Uganda, United
Republic of Tanzania, Zambia

PREVALENCEOF MYOPIA
Southern Africa
West Africa
Botswana, Lesotho, Namibia, South Africa, Swaziland, Zimbabwe
Benin, Burkina Faso, Cameroon, Cape Verde, Chad, Côte d’Ivoire, Gambia,
Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Nigeria,

AND HIGH MYOPIA

Senegal, Sierra Leone, São Tomé and Príncipe, Togo
Other regions
Central Asia Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Mongolia, Tajikistan,
Turkmenistan, Uzbekistan
Report
East Asia of the Joint World
China, Health
Hong KongOrganization–Brien Holden
SAR (China), Macau SAR (China), Democratic People’s
Vision Institute GlobalRepublic
Scientific Meeting
of Korea, on Myopia
Taiwan (China)
South-east Asia Cambodia, Indonesia, Lao People’s Democratic Republic, Malaysia, Maldives,
Myanmar, Philippines, Sri Lanka, Thailand, Timor-Leste, Viet Nam
Oceania Fiji, Kiribati, Marshall Islands, Micronesia (Federated States of), Papua New
Guinea, Samoa, Solomon Islands, Tonga, Vanuatu
Central Europe Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Hungary,
Montenegro, Poland, Romania, Serbia, Slovakia, Slovenia, the former Yugoslav
Republic of Macedonia
Eastern Europe Belarus, Estonia, Latvia, Lithuania, Republic of Moldova, Russian Federation,
Ukraine
Andean Latin America Bolivia (Plurinational State of), Ecuador, Peru
Central Latin America Colombia, Costa Rica, El Salvador, Guatemala, Honduras, Mexico, Nicaragua,
Panama, Venezuela (Bolivarian Republic of)
Southern Latin America Argentina, Chile, Uruguay
Tropical Latin America Brazil, Paraguay
Caribbean Antigua and Barbuda, Bahamas, Barbados, Belize, Cuba, Dominica,
Dominican Republic, Grenada, Guyana, Haiti, Jamaica, Saint Lucia, Saint
Vincent and the Grenadines, Suriname, Trinidad and Tobago
North Africa and Middle East Algeria, Bahrain, Egypt, Iran (Islamic Republic of), Iraq, Jordan, Kuwait,
Lebanon, Libya, Morocco, Occupied Palestinian Territory, Oman, Qatar, Saudi
Arabia, Syrian Arab Republic, Tunisia, Turkey, United Arab Emirates, Yemen

The impact of myopia and high myopia 29

For more information, please contact:

30 The impact of myopia and high myopia

IMPACT OF INCREASING
PREVALENCEOF MYOPIA
AND HIGH MYOPIA
Report of the Joint World Health Organization–Brien Holden
Vision Institute Global Scientific Meeting on Myopia

The impact of myopia and high myopia 31

For more information, please contact:

Department for Management of NCDs, Disability,

Violence and Injury Prevention (NVI)
ISBN 978 92 4 151119 3
World Health Organization
20, avenue Appia
CH-1211 Geneva 27
For more information, please contact:
Switzerland
Tel: +41 22 791 2111
Fax: +41 22 791 3111
www.who.int/blindness

32 The impact of myopia and high myopia