Long-range view of vision correction brightens the world for myopic children

SINGAPORE - With four in five young adults in Singapore living with myopia – a condition of the eye that makes faraway objects appear blurred – it was little wonder researchers at the Singapore Eye Research Institute (Seri) made myopia its key study focus.

“It was chosen because it was such a big problem as we now know,” said Professor Donald Tan, a former director of Seri.

In 1997, the newly set up institute carried out the first clinical trials on national servicemen when they came in for enlistment.

“We found that three-quarters of them were myopic. That means three-quarters of our young population were short-sighted,” said Prof Tan, who is now in private practice and a clinical professor at the Ophthalmology and Visual Sciences Academic Clinical Programme at Duke-NUS Medical School.

Seri is the research institute of the Singapore National Eye Centre (SNEC) and is directly affiliated to the NUS Yong Loo Lin School of Medicine and Duke-NUS Medical School

Myopia is caused by an elongation of the eyeball and is usually treated with corrective lenses. Studies estimate that on average, 30 per cent of the world is myopic and, by 2050, almost half will be. The hot spots for myopia are East and South-east Asia, where places such as South Korea, Taiwan, Singapore, China and Japan have a prevalence of between 80 and 90 per cent. 

Seri professor of ophthalmology research Saw Seang-Mei said: “Because we have had high rates of myopia for such a long time, we have a lot more experience than many other Asian countries in deciding the causes, the conditions.”

“I think myopia is firstly an Asian disease. It is also a very common disease, with 83 per cent of the young adult population in Singapore being myopic,” said Prof Saw, an epidemiologist who specialises in eye diseases. “As I see advances and breakthroughs in the field, I feel that we are helping to solve this epidemic of myopia in Asia.”

Prof Saw started researching a cohort of 9,979 children, from whom she identified some childhood predictive markers to narrow down myopic children who were at risk of developing high myopia and eyesight-threatening complications later in life.

“It’s been about 25 years since. From this cohort, we have defined the onset progression of myopia in children, the complications in the eye that occur early, the protective effect outdoors, the genes that may contribute to myopia as well as the effect of screen time and reading and writing,” she said.

Prof Saw’s work and that of other epidemiologists led to the recognition that myopia can cause many problems as people get older, such as retinal detachment, cataract and glaucoma, said Prof Tan.

“So it is a serious, potentially sight-threatening condition, and because it is so common in our Singapore population, we had to address it and we did.”

A major breakthrough was in the use of atropine eye drops in children who had myopia.

A drug derived from the Atropa belladonna plant, atropine was used as early as in the 1920s – and first used in Singapore in 1960 – to slow myopia progression.

However, atropine eye drops can cause side effects in children, such as increased sensitivity to glare from the sun and blurred close-up vision.

Researchers led by Prof Saw, who also heads the myopia unit at Seri, conducted a trial in the early 2000s, which showed that a lower dose of atropine at 0.01 per cent, instead of 1 per cent, concentration in the eye drops could also work.

The team, including Prof Tan, Associate Professor Audrey Chia, a paediatric ophthalmologist, and the late Professor Roger Beuerman, was the first to identify low-dose atropine eye drops as a viable treatment option that is both safe and effective for long-term use in children.

They found that it slowed down myopia by 50 to 60 per cent in two years in children aged six to 12, compared with the rate of 80 per cent in the same period using a higher dosage. The lower dosage of atropine also had fewer side effects.

Their work, funded by the Government, was the first to demonstrate that low-dose atropine could be used safely and effectively to slow down myopia in children.

For this, they were presented the President’s Science Award in 2019.

They also initiated public health messages that encouraged more outdoor activity, which relieves strain on the eyes, and better eye habits among children.

“We have come a long way after we carried out clinical trials in the early 1990s on myopia. We coined the term ‘atropine eye drops’ and we were the first, really, to launch the trials worldwide and make our mark,” said Prof Tan.

He added that today, low-dose Myopine eye drops developed by the SNEC are available in many countries and are undergoing final registration in countries like China.

“Everybody is following suit, so the great thing is that now different concentrations of atropine are being trialled globally,” Prof Tan said. 

“We found that we can stop the eyeballs from growing. In other words, we can stop children ending up (with myopia of) 1,000 degrees.

“We can reduce myopia by 60, 70 per cent and it has made a big clinical impact,” he said. “Today, it’s routine for eye doctors and GPs to say we can treat myopia with eye drops. That’s where we are today.”

Prof Saw also developed a fitness tracker that tracks outdoor activity in children and that enables a child to look at how much time he spends outdoors each day.

Prof Chia said: “From a time that we knew so little – 20 or 25 years back – to what it is today, so much has changed in the understanding and new stuff is coming on.

“It’s very exciting for a clinician because we can apply all this stuff directly to our patients and see what the response is.”

Prof Saw said the next step is to look at precision medicine, especially for children who are at high risk of fast progression of myopia much earlier.

Seri now has grants to develop artificial intelligence in treating eye diseases, including myopia.

Researchers at Seri developed an AI tool that can help evaluate children at risk of developing high myopia, and can assist doctors in early myopia management and control, such as whether a child should have eye drops or contact lenses.

Prof Tan said: “I think we have changed the world in terms of its view of myopia and that’s going to be a better thing, obviously.”