What You Need to Know About the International Myopia Institute White Papers: Part 1

With the explosion of interest and subsequent research in the field of myopia growing over the last 10 to 15 years, the need for organizing the information we have about myopia has become obvious. Following a World Health Organization (WHO) meeting on myopia at the Brien Holden Vision Institute in Sydney Australia in 2015, leaders and researchers in the myopia management community set out to establish a comprehensive report on all aspects of myopia and its management.

Four years later, the International Myopia Institute (IMI) white papers have been published. The IMI white papers are to myopia management as the Dry Eye Workshop II reports (DEWS II) from the Tear Film and Ocular Surface Society (TFOS) are to dry eye and ocular surface disease. Seven subcommittees were formed within the IMI to address the following pieces of the myopia puzzle:

Each subcommittee published its own comprehensive report outlining everything we know on the subjects. Our multi-part series is intended to break down each report into the “need to know” pieces of information so that you can implement the information into everyday practice.

This, the first part in our series, serves as a primer for the following, more detailed reviews of each individual report.

Background to the need for myopia control

While not an official report in and of itself, this topic is covered extensively in the overview and introduction portion of the report. And rightfully so. Unless a need for myopia control exists, the details of how to implement it are useless. Refractive error development, age of onset, rate of progression, and differences in progression among ethnicities are briefly reviewed. The biggest take away from this section involves the increase in myopia prevalence.

Higher and higher percentages of the population are becoming myopic and developing higher degrees of myopia. This increase both in prevalence and severity of myopia increases the economic burden on governments and eye health providers to correct refractive error and treat the associated conditions (ex. myopic maculopathy) that result from myopia. The section also includes a brief review of our current understanding of both environmental and genetic factors of myopia development.

The first official sub-report does what we have struggled to do as myopia control community up to this point in time. It lays out a clear definition of what myopia is and classifies it based on specific criteria. Axial myopia is differentiated from refractive myopia, and degrees of myopia (pre, low, and high) are defined. This report lays the groundwork and provides the nomenclature that is used in the later reports.

Animal models are the star of the show in this report. Over 800 studies on a dozen model organisms have been performed to gain a better understanding of how manipulations of the environment can influence eye growth and refractive error development. The report reviews the systems of refractive error development that are conserved across species and highlights work on retinal defocus and its influence on eye growth, circadian rhythm contribution, and critical periods for development of refractive error. Environmental factors such as light intensity and spectral composition as well as neurotransmission cascades are also reviewed.

The genetics of myopia may be one of the most hotly contested areas of myopia control research. At one point in time, genetics looked to be the holy grail of understanding the condition. Since that time we have learned that the system is incredibly complex. Over 200 gene loci have been associated with myopia development. The genetics report summarizes phenotypical risks of becoming myopic as well as how gene expression in certain tissues can help us understand the mechanisms of myopia development.

Optical, pharmacological, and behavioral interventions to prevent and/or slow the progression of myopia are summarized in this report. The effects of a lack of treatment in various single vision correction modalities (specs, contacts, etc.) are covered in detail. Optical interventions such as multifocal glasses, multifocal contact lenses, and orthokeratology have been shown to slow progression to varying degrees. Pharmacological treatments besides atropine-only are summarized along with behavioral interventions such as time spent outside.

In this section, the subcommittee reviews previous studies and develops guidelines for future clinical trials. A treatment period of at least 3 years with a washout period of at least 1 year is recommended to ensure an accurate measurement of the myopia-controlling effects of a certain modality. Cycloplegic refraction with autorefraction and non-contact axial length measurements are recommended as the primary objective outcome measures. Secondary and exploratory measures are also reviewed.

The cost and benefit of myopia control is the main topic of this report. While much is still unknown about the risks of myopia, the practitioners’ responsibility to present all treatment options is highlighted. Additionally, sponsorship bias is discussed as more and more industry partnership begins in the myopia control community. Finally, disclosure of off-label status of most myopia control treatments to patients and parents is emphasized in this report.

The final report is all about how to implement myopia control in a clinical setting. Starting with identifying candidates and calculating myopia risk scores and ending with implementing control strategies; the committee details each step. Behavioral modifications such as time outdoors and limitation of near work is also discussed.

The International Myopia Institute white papers are the product of the first truly collaborative global effort to summarize what we know about myopia control. The goal of standardization of nomenclature and protocol will help to serve researchers, practitioners, and, ultimately, patients as our understanding continues to increase. Stay tuned for the remaining parts of this series where each report is reviewed in detail to help you make sense of the who, how, why, what, and when of myopia control.