Child myopia: The GP’s role

James Best

6/01/2021 1:40:14 PM

Paediatric GP Dr James Best shares his insights on a ‘major public health concern’ that is often considered a benign disorder.

Child's eye
The majority of children’s myopia progression typically occurs between the ages of 6–17.

A recent roundtable meeting hosted by the Australia and New Zealand Child Myopia Working Group provided some excellent insights into myopia.
Chaired by Dr Loren Rose, a Sydney-based paediatric ophthalmologist, the group is a collaboration of leading optometrists and ophthalmologists whose aim is to set a recommended standard of care for child myopia management in order to slow its progression.
Why talk about myopia?
Myopia, or short-sightedness, is often regarded as a benign disorder. After all, vision can be corrected with glasses, contact lenses, and refractive surgery in adulthood.
However, it is a major public health concern.
Myopia’s prevalence has been rising around the globe and it is estimated that half of the world’s population will be myopic by 2050. The forecasts are slightly higher for Australia and New Zealand at 55%, and we already have an estimated 36% of the population affected. In addition, the World Health Organization (WHO) recognises that myopia, if not fully corrected, is a major cause of visual impairment as increasing myopia can lead to serious eye health problems in the future.
At the roundtable meeting, we discussed our profession’s level of understanding of myopia and the impact it can have on patients.
I would expect most GPs would know what myopia is; however, their level of understanding about what is significant myopia, and when you screen for it, would be variable.
Training has changed enormously over the past few decades, and I think the role of ophthalmology and optometry in particular has also changed considerably. The back of the eye has largely disappeared from general practice in a generation or so as distinct from other areas such as skin checks, which have increased.
I think myopia and screening is probably underdone in general practice. Emerging evidence means there is probably a case to bring sight back into general patients’ consultations, especially for young families.
We certainly understand that children may not be able to see the board in a school environment and this would affect learning and likely range of other activities, but I think GPs’ understanding of comorbidities may vary.
I was surprised to learn during the roundtable that myopia is so strongly associated with lifelong increased risks of eye diseases such as retinal detachment, glaucoma, cataracts and a form of macular degeneration.
Myopia can be managed
It is important to manage myopia because all myopic eyes are at greater risk of experiencing potentially blinding comorbidities, and the risks increase with the condition’s severity.
Given the risk of comorbidities, I believe there is an opportunity to raise awareness of potential for myopia presenting in secondary schools. I do not believe the fact myopia becomes more common in the secondary years is well known and it would be beneficial for GPs to be aware of this situation.
Many children may have had a vision screening at pre-school, but a key insight for me was that the majority of myopia progression typically occurs between the ages of 6–17. This means many children may continue to experience undetected and unnecessary vision problems and often assume their vision is normal.

Modern lifestyle factors such as prolonged near tasks like reading and looking at screens may influence the development of myopia.

Where is the myopia knowledge gap?
The knowledge gap is not really the problem; the ‘doing gap’ is the problem – doing visual acuity.
Prior to attending the roundtable, re-examining a child’s eyesight would not have occurred to me. The challenge remains how to get GPs doing visual acuity at a population level.
This is where the referral pathway becomes critical.
Engaging GPs about myopia as a public health issue
As we all know, GPs get the whole gamut of health messages. Checking vision is just one of the hundreds of things of which we need to be aware.
The roundtable raised some valuable insights about the importance of educating teachers and parents directly with a simple message. Essentially, look out for the early warning signs of myopia and remember the ‘three S’s’:

  • Sitting closer to the front of class/TV at home
  • Squinting to see further away
  • Schoolwork performance is declining or there unexplained changes in behaviour at school
What was of greatest interest to you (and potentially your colleagues) from the roundtable?
The answer may be the influence of variable age groups, genetics and ethnicity on a child developing myopia.
If both parents are short-sighted, the risk of the child being myopic is six times greater than the general population. The risk is around three times greater if one parent is short-sighted.
Modern lifestyles may also influence the development of myopia, including low levels of outdoor activity, low levels of light exposure, and prolonged near tasks such as reading and looking at screens. Of course, there are other benefits to reading books, and other negative impacts of looking at screens.
Recent epidemiological surveys have shown that increased amounts of time outdoors protect against the development of myopia, minimising the risk of myopia associated with near work or with having myopic parents. The protective effect seems to be associated with total time outdoors, rather than with specific engagement in sport.
However, I learnt that more research is needed to determine if it is to do with the intensity or brightness of the light or the distances on which children focus, but what is proven is that there is a link between outdoor time and its benefit to delaying a child’s myopia development.
Given that outdoor play is free, ‘more green time, less screen time’ is a timely reminder for moderation in an increasingly digital world – and a simple message for patients.
The opportunity
Future consideration of what that referral pathway looks like for all is important. A starting point would be an appointment with an optometrist, accessible to all, to have a conversation about how to best manage eye health for every child.
GPs may find Child Myopia a useful resource to provide patients with relevant facts and information.
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Dr Lisa Simpson   7/01/2021 8:25:13 AM

I was s a myopic diagnosed at 8 years of age with school screening. I think screening at school captures more children. After reading article, it really only promoted screening and I learned nothing about how to prevent comorbidities. None of the risk factors were applicable for me- parents normal vision, played outside like every other kid in 80s. Strabismus is really imrtent for us to find in first 4 years when they are having scheduled health checks. Perhaps blue book can include a 6 or 8 year old check that would universally be attended?