EYEZONE: Brien Holden Vision Institute



By Stephen Davis MPH, Daveena Brain, Courtenay Holden MComm, Dr Padmaja Sankaridurg PhD Boptom, Kovin Naidoo PhD OD./strong>





The prevalence of myopia has been growing alarmingly throughout the world, especially in urban Asia, with current prevalence in children around school-leaving age being as high as 84% in Taiwan1, 78% for 15-year-olds in urban China2, while in South Korea 97% of male military conscripts aged 19 years were reported to be myopic.3

The situation in the Middle East (part of the ‘North Africa and Middle East’ region reported by Holden et al in 20164) is set to change dramatically in the coming decades, with the prevalence of myopia projected to increase from 14.6% to 52.2% by 2050 across the region. Consequently, the rate of high myopia (–5.00 D or less) will rise significantly, from 1% in 2000 to 5.5% in 2050.4

As myopia increases so does the risk of vision impairment caused by comorbidities such as myopic macular degeneration cataract, retinal detachment, and glaucoma.5 Holden et al projected that if current trends continue, there will be a 7-fold increase in the number of people with vision loss resulting from high myopia from 2000 to 2050, and myopia will become a leading cause of permanent blindness worldwide.4

Worryingly, myopic macular degeneration is a leading cause of blindness in some locations, e.g. Shanghai, China6 and Tajimi, Japan.7 The potential impact in terms of both human suffering and strain on health systems is enormous.

Slowing the progression of myopia, so that people do not become highly myopic, is achievable if they are targeted early with the correct treatment while the eye is still developing. For this reason, providing children with quality eye exams and the correct myopia management treatment (where needed) is critical if we are to stave off a potential public health crisis.

In this respect, while researchers continue to develop more efficacious methods of ‘controlling myopia’, a number of optical and pharmacological interventions are currently available to eye care practitioners. The effectiveness of many of these can be understood through an evidence-based myopia ‘calculator’ that was recently developed and deployed by Brien Holden Vision Institute.8

Additionally, lifestyle interventions may also delay the onset of myopia, in particular, increased time outdoors.9 In China the effectiveness of glass classrooms that provide children in school with access to increased natural light, along with enforced periods of outdoor play, are currently being evaluated.

But, overall, there is a deficit in research, awareness, policy and systems to appropriately deal with this crisis. Governments, health care providers and, critically, parents, are only beginning to understand the potential impact of myopia on the vision of individuals, and more broadly, on health care budgets and economic productivity. This is reflected even in high-income countries, where eye care is advanced (albeit unaffordable to some people), but where school eye health programs and vision assessments, are generally not in place to detect myopia early in a child’s development.

The situation is far worse in low-income countries, where around 90% of the world’s vison impaired people live, many of which lack sufficient numbers of trained personnel who can detect and manage myopia in children.10

Furthermore, it will take considerable time, effort and resources before interventions start to make an impact and even then, millions of children will still become myopic and be at risk of developing high myopia. The numbers of children that require, and will require spectacles, is dramatically increasing.

In this environment, business as usual will not meet the level of need required. Change will only happen with innovative, scalable action on a previously unprecedented scale.

How do we meet this challenge?

We need to advocate for, design and implement strong public health programs, with the involvement of a diverse group of stakeholders (parents, teachers, government, professional bodies and children). This necessitates raising awareness among government and health agencies, driving policy change, implementing appropriate health education initiatives, developing the necessary human resources to implement programs, along with ongoing evaluation of efforts.


Raising awareness amongst the eye care, health and education sectors, government health bodies and international health agencies, is the first step in getting the myopia ‘epidemic’ on to health care agendas. There has been some success, such as the World Health Organization global scientific meeting held on myopia in Sydney in February 2015, in conjunction with the Brien Holden Vision Institute that sets the guidelines for management and policy development to address the issue. Also, some governments, such as in China, are beginning to take notice and implement a series of programs to address this challenge.

These advocacy efforts require robust evidence; global, regional and local data (such as some of the references cited here) are also important in demonstrating the potential consequences of inaction.

We need to ensure that myopia is not only on the agenda of eye related organisations but also development organisations that seek to address education, poverty and the overall well-being of children in our world.

Policy change

A critical early step is to have child eye health recognised in national health care plans and for child eye health integrated into school health programs and funding appropriately prioritised to support the implementation of such programs.

Health Promotion and Education

Raising awareness amongst the general population and specifically parents, children and teachers, about the risk of myopia and the need to utilise eye health services, is critical to an effective response. Providing evidence-based and appropriate messages to these groups about the importance of eye checks at school-going age and adopting beneficial lifestyles, is also integral to preventing the onset or slowing the progression of myopia.

Workforce development

In many locations, several levels of human resources are needed to ensure children receive the treatment required to manage myopia. In some of these, school vision checks will be conducted by teachers or primary health care workers, who require appropriate training. At the next tier, a sufficient number of optometrists are required to meet the existing and future demand for specialist eye care. For this to become a reality the continued development and support of optometry schools is crucial as well as the upskilling of existing practitioners in countries where cycloplegic skills etc. are lacking.

Child eye health programs

Child eye health programs, integrated into school health initiatives are the logical way in most settings to reach a majority of children with the services and education needed to detect myopia and promote preventative behaviours. Fortunately, resources and evidence-based knowledge are available to health agencies, education departments and NGOs, to implement these programs and support the development of eye care systems. For example, the Standard Guidelines for Comprehensive School Eye Health Programs,11 developed through the Our Children’s Vision campaign, provides guidance and direction to those planning and implementing eye health initiatives in schools.

Support is also growing among global eye care bodies, such as the International Agency for the Prevention of Blindness (IAPB), which has now formally acknowledged the need to advocate for, support and help coordinate efforts in this area through its newly formed School Eye Health Working Group.


Much research is needed to complete an accurate epidemiological picture of child eye health across the world. More specifically, there is an urgent need to better understand the mechanisms of myopia progression and the effectiveness of optical, pharmacological and lifestyle interventions currently available and those under development. Also, research that addresses the key drivers of behaviour change as well as evaluation of programs is crucial to understanding their effectiveness, and improving outcomes.

China beginning to take action

Some initiatives in China, where myopia is predicted to affect 65% of the population by 2050,4 demonstrate how governments have begun to respond to this pending crisis. In particular, the Shanghai Government are funding some major initiatives, including a survey of vision and refractive error screening in the megacity, which began in 2014 and captured nearly one million children aged 4-14 years.

Through the Shanghai Eye Disease Prevention and Treatment Centre they are now conducting a study with 6,000 children wearing light measuring devices to investigate the impact of increased time outdoors on myopia development.

In concert with these research studies have been some novel health education initiatives to promote the value of increased outdoor activities in slowing myopia progression. For example, a community fun run that was combined with vision assessments, or a drawing competition for children with the theme connecting outdoor activity and healthy eyes.

Our Children’s Vision – a global campaign bringing these elements together

Our Children’s Vision global campaign, initiated in 2015, is upscaling, accelerating and expanding access to eye health services to more children in more locations. The campaign is a global coalition of collaborative, inter-sectoral relationships between international development partners, public and private sector and individual practitioners to drive service provision, health promotion, education and awareness, and policy change. Our Children’s Vision is a catalyst to build a critical mass of new networks, creating the momentum needed to achieve long-term global commitment to providing child eye health services. The campaign is aiming to reach 50 million children by the year 2020 thus focussing the spotlight on an important public health issue, the vision of our children.

How can eye care practitioners and industry get involved?

While sophisticated eye care systems may exist in our own communities, it is incumbent on the eye care sector as a whole to support efforts to ensure children within our regions and globally have healthy vision and the best start possible in life. Professional bodies are another avenue that can effectively contribute to Our Children’s Vision. The World Council of Optometry and IAPB are Global Supporters of the campaign and the Eastern Mediterranean Council of Optometry is an Implementing Partner.

Our Children’s Vision, in partnership with the World Council of Optometry, is reaching out to optometrists to get involved, either directly through providing services in their local communities, or via financial support to the campaign via the new ‘Adopt a School’ initiative.

1. Lin ll, Shis YF, Hsiao CK, Chen CJ. Prevalence of myopia in Taiwanese schoolchildren: 1983 to 2000. Annals of Academy of Medicine, Singapore. 2004; 33:27-33.
2. He, M., Huan, W., Zheng, Y., Huang, L. & Ellwein, L. B. 2004. Refractive error and visual impairment in urban children in southern China. Investigative Ophthalmology and Vision Science, 45, 793-799.
3. Jung, S.-K., Lee, J. H., Kakizaki, H. & Jee, D. 2012. Prevalence of Myopia and its Association with Body Stature and Educational Level in 19-Year-Old Male Conscripts in Seoul, South Korea. Investigative Ophthalmology & Visual Science, 53, 5579-5583.
4. Holden BA, Fricke TR, Wilson DA, Jong M, Naidoo KS, Sankaridurg P, Wong TY, Naduvilath TJ, Resnikoff S, Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050, Ophthalmology, May 2016 Volume 123, Issue 5, Pages 1036–1042.
5. R.F. Spaide, K. Ohno-Matsui, L.A. Yannuzzi. Pathologic Myopia, Springer, New York (2014), cited in Holden et al.
6. Wu, L., Sun, X., Zhou, X. & Weng, C. 2011. Causes and 3-year-incidence of blindness in Jing-An District, Shanghai, China 2001-2009. BMC Ophthalmol, 11, 10.
7. Iwase, A., Araie, M., Tomidokoro, A., Yamamoto, T., Shimizu, H., Kitazawa, Y. & Tajimi Study, G. 2006. Prevalence and causes of low vision and blindness in a Japanese adult population: the Tajimi Study. Ophthalmology, 113, 1354-62.
8. Brien Holden Vision Institute, Myopia Calculator, Available at: https://brienholdenvision.org/translational-research/myopia/myopia-calculator.html
9. Read SA, Collins MJ, Vincent SJ. Light Exposure and Eye Growth in Childhood. Invest Ophthalmol Vis Sci. 2015 Oct;56(11):6779-87. doi: 10.1167/iovs.14-15978.
10. World Health Organization, 2014, Visual impairment and blindness, Key facts. Available at: http://www.who.int/mediacentre/factsheets/ fs282/en/
11. Standard Guidelines for Comprehensive School Eye Health Programs, 2016. Available at: https://academy.brienholdenvision.org/courses/school-eye-health





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