The International Myopia Institute (IMI) has released IMI2 – a second series of whitepapers that builds on the first, and aims to provide consensus on the key components of myopia management.
IMI2 recognises the importance of myopia as a public health issue and a global desire to address the challenge. The ground-breaking reports present the collective voices of over 100 global myopia experts following a rigorous process of debate, discussion and external peer review.
To gain an understanding of the reports, released in March 2021, mivision interviewed IMI’s Executive Director Monica Jong and BHVI’s and IMI Taskforce Chair Professor Padmaja Sankaridurg to find out more.
Following on from the energy that went into developing IMI1, how do you describe the process of developing IMI2?
Professor Padmaja Sankaridurg: IMI updates were presented at various meetings and conferences in 2019; there was significant interest and enthusiasm, and agreement on what was needed for the next key IMI papers. The first set of key papers focussed on science, interventions and management. There was a need for IMI2 to focus on the impact of myopia, complications associated with myopia, risk factors and practice patterns.
Dr Monica Jong: This time around there was even more enthusiasm and excitement surrounding the whole process. The first volume of white papers made such a huge impact at all levels – practitioners, peak health bodies and the eye care industry, and progressed the area in terms of bringing myopia management to places where it was unheard of or in its infancy, for example Siberia and Brazil.
The IMI 2019 white papers also helped change the way clinicians thought of myopia – an ocular condition as opposed to being a purely refractive issue. More than that, the white papers gave people an evidence-based starting point to work from, or to justify what they are doing in practice, and recommended definitions that promote better patient diagnosis and management.
… in the very near future we may have a role in treating pre-myopia
How many global experts were involved and from where?
Professor Sankaridurg and Dr Jong: Over 134 global experts representing every continent were involved, from China to France to Russia. We operate like the United Nations – no cultural barriers, just experts who want to contribute freely and openly. We have experts across public health, health economic modelling, ophthalmologists, researchers and practitioners leading the science and research on myopia contributing to IMI.
How did COVID-19 impact the committee’s ability to effectively collaborate and how did you overcome challenges associated with this?
Dr Monica Jong: COVID-19 was a challenge as many of our taskforce members had their clinical practice and teaching impacted. For some, COVID-19 had increased their workload already, but many see the importance of what the IMI is trying to achieve and made sure to dedicate some time to this initiative.
Professor Sankaridurg: The approach taken by the various task forces varied; in some groups each of the task members had their allocated piece whereas in some other groups, the chair led the way and sought input from the team as required. I led the Impact of Myopia taskforce, where each member had an assigned task and we communicated primarily via email, the missing piece was a face-toface meeting. When the drafts arrived, we had a core group that synthesised the document and sent it back to the team for review and edit. Other than some time delays with some deadlines, there weren’t any major issues – in spite of their busy schedules, everyone in the team was generous with their time and effort.
How have you measured the impact of IMI1 and what are those measurements telling us?
Dr Monica Jong: Citations in the peer review literature are an objective way to look at the impact of your work and are what government health bodies and other institutions would judge the quality and impact on. It’s been phenomenal that in two years of publication, the IMI interventions paper and IMI definitions paper have been cited up to 76 times already. It really shows the importance of what has been published. The Holden et al 2016 paper, estimating myopia prevalence in 2050, was another huge one with 763 citations in five years – while not an IMI paper, it shows the value of the contributions one can make to really advance the efforts in the area of myopia. The average citations of a paper across all subjects in general is below 10, so already with these citations of the IMI papers, we are in the top 2% of most cited work.
What do you believe to be the most ground-breaking aspects of IMI2?
Professor Sankaridurg: As with IMI, IMI2 is a collective effort involving all involved in myopia research; ophthalmologists, optometrists, biological scientists, and epidemiologists.
Dr Monica Jong: The most groundbreaking aspects of IMI are that we are one voice made of over one hundred experts, who are collaborating because we all know how important myopia is as a public health issue and we want to address the challenge. We have a transparent mission to advance myopia research and management to prevent future vision loss and blindness. It’s the first time a group like IMI has been established in myopia, and we have very simple aims with huge outcomes, which are to produce white papers that can be used for advocacy, education, research and clinical management. We have translated our clinical summaries into over 12 international languages, ensuring that even in places where no one can access scientific papers or where myopia management does not exist, people can learn about myopia management in their native language and know that they can treat myopia.
…with these citations of the IMI papers, we are in the top 2% of most cited work
Can you provide an overview of the updated burden of myopia?
Professor Sankaridurg: If we wind back the conversation to prevalence of myopia, the current figures for myopia prevalence support the trajectory estimated in the Holden 2016 paper. For example, in Japan, myopia in adults increased from 37.7% in 2005 to 45.8% in 2017. In urban China, it rose from 22.9% to 31.5% from 2001 to 2015.
The burden of myopia is manyfold and includes impact on education, impact of uncorrected vision, direct costs of myopia to individuals, quality of life issues with and without correction, the risk of complications, and thereafter, there is the collective impact on society with respect to economic burden (both direct costs as well as costs due to lost productivity).
There is lot of work to be done in fully understanding the aforementioned but as an example, with respect to direct costs, studies out of Singapore estimate the costs at SG$959 annually per person aged over 40 years. Potential lost productivity due to vision impairment from myopia was estimated at US$244 billion and another $6 billion from MMD for 2015 alone.
One way to better understand the impact, is to place these figures in context of other health conditions. In Singapore, for 2011, the direct costs associated with myopia were US$755 million and said to be much higher than, for example, Parkinson’s or pulmonary disease.
What priorities for myopia management have been defined in IMI2 and how do these differ from the first?
Professor Sankaridurg and Dr Jong: The priorities remain the same, with more emphasis on premyopes and managing high myopia. There are also updates on new interventions and combination therapy which are important to myopia management. We also talk about areas that have had a lot of practitioner interest, such as accommodation and binocular vision in myopia development and progression.
What new interventions have been included in IMI2?
Professor Sankaridurg: What we now have is more evidence on certain strategies. For example, three year data with contact lenses, such as that from MiSight, is exciting and provides the practitioner with much confidence in prescribing such products. Additionally, there is data on newer types of myopia control strategies, for example multi-segment spectacles which offer further insight. There is also a focus on trying to understand if we can provide improved efficacy with combination treatments.
Dr Monica Jong: This area is changing at a fast pace and so it is both exciting and challenging for practitioners to keep up. For example, in 2020 alone there were over one thousand peer review articles published on myopia, and then a lot of articles in the professional trade press, and commentary in the social media space. As the IMI white papers are authored by a large group of experts reviewing the evidence, the IMI serves to be a reliable source that associations, policy-makers and practitioners can refer to when developing guidelines and recommendations specific to their region.
What is now the agreed role of accommodative lags on myopia development and myopia control and with this in mind, how should practitioners, parents and patients be advised?
Professor Sankaridurg: The area of accommodation and binocular vision and how they respond to blur, working distance and type of target is quite a complex area and studies so far have not been able to provide any conclusive evidence. The key is to evaluate the patient’s binocular vision status and accommodation before correction or myopia control procedures and observe any changes in the context of their baseline status.
What new findings have been agreed regarding the role of near-work, screens and myopia?
Professor Sankaridurg: The risk factor report identifies that education and time outdoors are key factors associated with onset and progression. However, although there is association, the mechanisms underpinning or causing onset and progression remain uncertain. The IMI paper delves into the proposed mechanisms and brings us up-to-date on where we are and the gaps. For example, consider education and myopia; is it near work, accommodative lag, or peripheral hyperopic defocus or signalling of ON OFF pathways or limited time outdoors?
With respect to screen time and myopia, the evidence for an association is not entirely clear. As has been said in the IMI risk factor report, myopia was observed at high prevalence even prior to the digital revolution. Although screen time per se may not be the causative factor, it may be a surrogate for time spent on near activities or lack of time on distance based activities. We need to examine this area closely. For example, how do we place this in the context of a recent study from China, which showed that in 123,000 children, there was an increased prevalence during the lockdown period in the younger children six to eight years, compared to previous years.
What is now the agreed definition for pre-myopia and how will this impact the approach taken by eye care professionals?
Dr Monica Jong: The recommended definition proposed by the IMI for pre-myopia is a refractive state of an eye from <=0.75D to < 0.50D in children where a combination of baseline refraction, age, and other quantifiable risk factors provide a sufficient likelihood of the future development of myopia to merit preventative interventions.
Eye care professionals now have a basis to identify those at risk, monitor them regularly, and advise patients on lifestyle risk factors. Today, there are studies being conducted on children with pre-myopia, so in the very near future we may have a role in treating pre-myopia.
What are the key recommendations for preferred practice patterns as identified by Prof Jost Jonas, and how achievable will these be within an Australian context?
Professor Sankaridurg: The preferred practice patterns appropriately identifies that pre-myopes, or those with low myopia, is a category that needs to be observed and monitored closely and, if required, treated to prevent further risk. With respect to management approaches, in addition to the already defined categories of spectacles and contact lenses, there is an increased focus on combination and sequential treatments. In the Australian context, many of these treatments are available to the clinician.
Dr Monica Jong: In Australia, we are one of the most fortunate regions for accessing the whole range of available myopia management options. We have executive bifocals, defocus incorporated multiple segments (DIMS), the US Food and Drug Administration (FDA) has approved MiSight and off label contact lens treatments in enhanced depth of focus (EDOF) design and distance centred concentric designs. We also have therapeutic options, such as various concentrations of low-dose atropine, available via compounding pharmacies. Recently, new instruments to measure axial length, designed specifically for myopia management, have come on the market.
Even though myopia is going to be a huge public health challenge in the near future, myopia management is not yet part of standard practice in Australia or many other parts of the world. The professional associations, the eye care industry and our educational institutions need to continue supporting this area in terms of education, awareness and implementation in practice.
What’s next for the IMI?
Professor Sankaridurg: The IMI’s role is to advance research, patient management and education in myopia – therefore one of the key priorities is to ensure that any new information is translated appropriately back to the eye care community. As such, IMI will continually canvass the community and check for updates.
Dr Monica Jong: It’s a massive undertaking and a long journey to achieve this. Our short-term plans are to continue sharing the white papers and making it accessible to all, wherever practitioners are located in the world. We want to ensure our work is taken up by peak health bodies and policy-makers in due course – already it’s being referenced in the WHO World Report on Vision and the Lancet Global Health Commission. It is truly a collective effort – without the collective support of our taskforce members and the support of the eye care industry, our reach would be limited.
We have a lot of exciting plans going forward and while we cannot share some of them just yet, we will in time. The best way for people to find out the latest updates from IMI is to become a general member for free – then you will receive periodic email updates. We are also on Facebook and Twitter.
Dr Monica Jong B.Optom, PhD is an Assistant Professor, Discipline of Optometry, at the University of Canberra, Australia and IMI Executive Director at BHVI Sydney. She is also a Visiting Fellow, School of Optometry and Vision Science, University of New South Wales, Sydney and the Secretary of the Refractive Error Working Group, International Agency for the Prevention of Blindness.
Dr Jong is the Executive Director of the International Myopia Institute (IMI), a working group established after the first WHO-BHVI Meeting on Myopia in 2015. The IMI’s mission is to advance myopia research, education and patient management to prevent future vision impairment and blindness from high myopia related complications. Dr Jong has authored numerous peer reviewed publications in the area of myopia and high myopia risk factors, pathology and epidemiology. She co-authored the WHO report on the Impact of Myopia and High Myopia, and was the co-creator of the first global online myopia management education program, and speaks regularly at key international meetings. She also enjoys lecturing and mentoring students.
Prof Padmaja Sankaridurg is Head, Myopia Program and Head, Intellectual Property at the Brien Holden Vision Institute and Conjoint Professor at the School of Optometry and Vision Science, Sydney, Australia. She was awarded her B.Opt degree from Elite School of Optometry, India in 1989, Ph.D in 1999 from the University of New South Wales, and a Masters in Intellectual Property in 2012 from University of Technology. Prof Sankaridurg has been researching myopia for over 15 years. She participated as an expert at the WHO-BHVI global meeting of myopia, 2015, and is an Advisory board member, Chair of Taskforce on Impact of Myopia and a member of the Interventions and Harmonisation Committee, International Myopia Institute. She is also an Advisory board member for Review of Myopia Management, an online digital publication entirely devoted to myopia. Vision Monday named her as one of the ‘Women of Influence in Optical Industry Innovator section’ for 2018 and she is the recipient of the ‘International Optometrist of the year 2020’ awarded by the College Òptics-Optomeristes Catalunya (COOOC) and Associació Catalana de Teràpia Visual (ACOTV), Spain for her work in the area of myopia.
Prof Sankaridurg has over 100 articles in peer reviewed journals, is a co-inventor on many patents/applications, has authored several book chapters, supervised MSc and PhD students to completion, serves on the editorial board for many journals and has delivered many invited talks and podium presentations at national and international meetings. Prof Sankaridurg is actively involved in myopia education and has been instrumental in the development of many practice aids and guidelines including the BHVI Myopia Calculator, the BHVI Myopia Management guidelines and the ocular growth nomograms for Oculus.