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Every second person in the world will be short-sighted. It will definitely happen before 2050. Surgical correction of refractive errors deprives us of glasses, but only for a while, because it does not inhibit the progress of the disease. We talk to Prof. Andrzej Grzybowski, ophthalmologist, head of the Department of Ophthalmology UWM in Olsztyn and president of the Ophthalmology Foundation 21.
Zuzanna Opolska, Medonet: Professor, are we in danger of the plague of myopia?
Prof. Andrzej Grzybowski, ophthalmologist: In the case of Southeast Asia, we can speak of an epidemic. In countries such as Singapore, South Korea, China and Japan, almost 90 percent of people struggle with myopia. young adults. This is an unprecedented scale! The latest epidemiological studies in Europe show that nearsightedness in the 20-30 age group is around 50%. And if we compare today’s statistics with those from a decade ago, we will notice a constant upward trend. Of course, the dynamics of changes in Europe and Asia are different, but the direction in which we are going unfortunately the same … Until recently, high myopia was believed to be mainly genetically determined. We know that myopic parents are more likely to have nearsighted children, but the mechanism of inheritance itself is not fully understood. Today, we know more and more that the cause of the increase in the occurrence of myopia are environmental factors related to the development of civilization, such as early school education, working closely or the use of electronic devices. We will not run away from laptops, tablets and smartphones, but perhaps we should give up pressure and excessive expectations towards young children. In Europe, as in Asia, we have moved the limit of school initiation to the age of 6. This shows that we should not go any further. Every day I meet parents who observe the progression of myopia in their child and ask me what can be done?
In that case, Professor, what can be done?
It is worth betting on prevention. We cannot prohibit children from using equipment, but we can limit the amount of time they spend in front of the screen. Good use of new technologies means active, age-appropriate and developing child’s thinking. And if you want to eliminate a laptop or tablet from his life, it is worth offering him something in return. Ideally, this “something” will be time spent outdoors. Recent studies from Asia have shown that two-hour daylight exposure not only prevents myopia but also inhibits it. So, in a way, it can balance screen time as well as genetic strain. Even artificial light of appropriate intensity and duration of exposure inhibits the development of myopia. In China, special glass schools are being designed, where greater access to sunlight will be possible. We come to two truths that were obvious to our grandparents and grandmothers. First, you should read in good lighting, and secondly, it’s good to spend your time outdoors. Only this time we find scientific confirmation of this.
What other factors may influence the development of myopia?
Mother’s age, smoking during pregnancy, and even gender. Young women are twice as likely to be nearsighted than their male peers, but the question “why” is still unanswered. Another factor has to do with what I said before, which is more time outdoors. It turns out that the risk of developing myopia in children from urban environments is 2,6 times higher than in children living in the countryside.
What are the risks of myopia?
The danger is not just wearing glasses. Of course, with high myopia above -8D, thick lenses affect the comfort of vision. But that’s not the biggest problem yet – in most cases, we can have refractive surgery and eliminate the need for glasses. Unfortunately, the methods of surgical correction of refractive errors do not solve the most important problem of myopia, which is excessive axial length of the eyeball. Figuratively speaking, during the development of axial myopia – the eye grows and the retina on the growing eye is stretched, i.e. it becomes thinner. It’s like blowing a balloon that can burst at some point. In this way, holes are formed in the retina or its detachment. Epidemiological studies show that high myopia increases the risk of many serious ophthalmic diseases such as glaucoma, cataracts or retinal detachment. For example, in people with high myopia, i.e. above -6D, the risk of developing glaucoma increases more than 14 times, cataracts 3,3 times above -6D, while with myopia above -8D, the risk of developing a retinal detachment increases even 7,8 times.
Do we have a reason to worry if we have low myopia?
The main risks are associated with high myopia. It is assumed on average that it constitutes about 10 percent. low myopia. Even 20 years ago it was believed that the so-called School myopia develops and stabilizes during education, but never becomes high. Today we know that myopia develops linearly, and that in children of myopic parents, progression is much faster. However, no one can guarantee a child with -1D that he will not have a much higher defect in the future. If today in China 80 percent. of the population is short-sighted, of which 10 percent. has high myopia, knowing the risk of complications, we can try to estimate the problems the Chinese will struggle with in the coming years. Countries much richer per capita, such as Japan, South Korea and Singapore, will handle the consequences better. This is why the Chinese understood the seriousness of the situation so quickly and introduced glass schools as part of the public health program, and treatment with atropine became the standard.
Is the use of atropine drops popular in Europe?
This is happening more and more. The first reports of treatment with atropine come from the late nineteenth century, later in the 80s and 90s many studies on this subject were carried out, but the purely scientific evidence was provided by the ATOM 1 and ATOM 2 studies conducted in Singapore in 2004-2010. If a child has a visual impairment progressing by -1D per year, parents are offered atropine treatment as a non-standard therapy. There is no preparation with a concentration of 0,01% on the market, so it is made in a pharmacy on a prescription. We apply the drops once a day in the evening.
It is an “off label” therapy – that means that the characteristics of the drug product atropine do not contain information about its use in the treatment of myopia. The use of “off label”, ie off-label, is a common medical practice, giving a chance to patients for whom the options of formally authorized therapies have been exhausted or do not exist. Remember that the procedure for obtaining drug registration for a new indication is complex, time-consuming and costly. Additionally, administrative procedures tend to lag behind clinical practice. Another reason pharmaceutical companies are not interested in atropine may be its low price.
Can there be side effects with atropine treatment?
The first two-year ATOM 1 study with atropine at a concentration of 1%. proved the effectiveness of the treatment, but at the same time there were side effects in the form of pupil dilation, photophobia, accommodation disorders and allergic symptoms. In another ATOM 2 study, various concentrations of atropine were used: 1 percent, 0,5 percent, 0,01 percent. It turned out that low concentrations are still effective and have no side effects. I can confirm this on the basis of my own observations. At the moment, I am looking after about 20 children who are receiving atropine at a concentration of 0,01 percent. and tolerate the treatment very well. The effectiveness of the therapy is about 50%. At the moment it is the pharmacological treatment that gives the best results, of course we do not know how myopia will behave after 10 or 15 years. The research conducted so far has a limited time perspective – the longest one lasted five years.
Which of the other treatments for myopia are effective?
When it comes to pharmacological treatment, pirenzepine, which is currently unavailable, has similar effects to atropine. Research on its operation in 2004 was conducted by Professor R. Michael Siatkowski, who comes from a Polish family, in the USA. Effective non-pharmacological methods include orthokeratology and contact lenses modifying peripheral vision.
Orthokeratology is the use of a gas-permeable hard contact lens at night to shape the cornea. About 50 percent qualify for this method. short-sighted children, however, it requires good cooperation with the child and good hygiene. Peripheral vision modifying contact lenses are not yet commercially available, but tested in clinical trials mainly in Asia. In December, together with a PhD student optometrist, we submitted a project to the National Center for Research and Development on the assessment of the effectiveness of contact lenses modifying peripheral vision.
Let’s move on to methods that are popular, but do not help …
I suspect that their use results from the discomforting helplessness for both sides. My parents refuse to accept that there’s nothing that can be done and the doctor doesn’t want to be the one who says I’m sorry but I can’t help you. A good example is undercorrecting the refractive error. For many years it was believed that a smaller correction would make the eye work and the progression of myopia would stop. Today we know that this is not reflected in reality. Another thing are supplements, about which most doctors are very critical. Advertising slogans such as “strong eyes” or “your child’s eyesight does not know the price” mislead consumers. There is not a single supplement on the market whose use would be scientifically justified in the prevention or treatment of myopia. These products not only do not heal, but also strain our wallets. However, this is a topic for another conversation.
More information on atropine treatment can be found on the website of the “Ophthalmology 21” Foundation for Supporting the Development of Ophthalmology in Poznań – http://okulistyka21.pl/