Short-sightedness, and the risk of blindness, is becoming a worldwide problem and increasingly affecting very young children, writes Richard Godwin in The Telegraph – who is himself affected by myopia.
He writes:
Every morning I pull down my lower eyelids in turn and smush a contact lens on to each of my eyeballs. I’m pretty good at this and can do it without a mirror. After a heartbreaking diagnosis when I was 12, my vision declined throughout my teenage years, finally stabilising at -4.5 dioptres, which means objects come into focus at 22.22cm (i.e, one metre divided by 4.5) in front of my face.
My eyeballs are the wrong shape. They grew into eggs instead of perfect 24mm spheres. My increased axial length – the distance from my corneas in the front to my retinas at the back – means objects come into focus in the wrong place. Without contacts or glasses, everything is underwater.
Like most of my fellow myopes (people who are short-sighted), I view this as a mild hindrance but a manageable one.
It hadn’t occurred to me until I began speaking to the world’s leading myopia experts that I suffer from a disease. Least of all a preventable disease – one that if left to spread at its current rate will result in millions of people going blind.
It sounds alarmist and yet when you look at the numbers, alarm feels appropriate. Necessary, even.
The global myopia rate tripled between 1990 and 2023, found a recent study in the British Journal of Ophthalmology. The WHO predicts that by 2050, half of the world will need glasses and 10% will be high myopic (that’s a -6 dioptre prescription or higher), which carries severe risks of complications and even blindness.
“Myopia should be viewed less as an inconvenience and take its proper place as a disease,” said Dr Donald Mutti, professor in optometry at Ohio State University. “Not all myopic eyes have the pathologies that threaten vision. But myopia increases risk for ocular disease.”
Huge worry, expense
Ocular diseases include cataracts, glaucoma, and the two that cause the experts most concern. One is retinal detachment, when vitreous fluid – the jelly inside your eyeballs – begins to leak and pushes the retina away at the back, “like a bubble in wallpaper” as a leaflet from Moorfields Eye Hospital in London describes it.
Moorfields has been handing out many such leaflets recently. Amid a “substantial” increase in retinal detachment surgery, the hospital recently reported a jump in the proportion of myopes undergoing the treatment – from less than 10% in 2012 to more than 40% in 2023 – with the steepest rise among younger patients.
“If your retina detaches, you lose vision,” said Dr Annegret Dahlmann-Noor, the paediatric ophthalmologist who led the Moorfields study. “It starts in the periphery and moves towards the centre and if it gets to the point where it affects your central vision, recovery is usually not complete. We’ve seen some teenagers and people in their early 20s present with retinal detachments.”
The other condition that “really destroys” your vision is macular degeneration, now the leading cause of blindness in working age people in China, said Dr Jan Roelof Polling, who is part of the myopia working group at Erasmus University Medical Centre in Rotterdam.
“As your eyeballs grow longer, it puts the tissues under strain,” he said. “The stretching is OK when you’re young. But when you’re older you lose collagen – and there’s lots of collagen in the eye. So now the eye is stretched but it has holes in it.”
Younger and younger
Again, this is a condition that once mainly affected older people but is now hitting ever-younger patients. Unlike retinal detachment, there’s not much that can be done about it. “You can have injections into the eyeball to take the bleed away but that’s about it,” said Polling. “One-third of all high myopes develop myopic macular degeneration, which almost always results in visual impairment or blindness.”
If you scale that up, you begin to see the cause for alarm. The world population is expected to be 10bn by 2050. One 10th of that is 1bn. One third of that is 333m.
“That’s why we’re starting to worry now,” says Polling. “You only have to look at China, where 80%-90% of people have myopia and a significant proportion become blind or visually impaired within their working careers. It’s a huge worry and expense. This will become a much bigger problem.”
‘We don’t simply inherit genes from our parents – we inherit their lifestyles too’
Why has the world’s sight deteriorated so badly? The current estimate is that 15%-20% of British teenagers are myopic, but our data-gathering isn’t nearly as good as it is in East Asia and Singapore, where this is already recognised as a catastrophe. In Singapore, the “myopia capital of the world”, around 80% of adults are myopic. In Seoul, South Korea, it affects 96.5% of 19-year-old males.
This is where we are heading, said Dahlmann-Noor. “We analysed hundreds of data sets last year, using a rigid algorithm to find out what the underlying problem was when a five-year-old already had myopia. We would do our diagnostic tests and we would reliably be able to find something wrong, genetically, metabolically, whatever.
“Now? If we do the same tests, we find children with myopia who don’t have a thing wrong with them. They only have myopia. So there is a trend for the onset to be earlier.”
There is a strong genetic component to myopia. If both of your parents need glasses, you probably will too; myopia rates are also higher in certain Asian and Afro-Caribbean populations than in white people. Still, this doesn’t explain the rapid recent increase. It isn’t the gene pool that’s changed, said Dahlmann-Noor: “But what has changed dramatically are our lifestyles. We don’t simply inherit our genes from our parents – we inherit their lifestyles too.”
Two factors are particularly concerning. One is that children are not spending nearly as much time in daylight as they should. Daylight is thought to stimulate the release of dopamine in the retina, which inhibits eyeball growth.
Given that we evolved as an outdoor species but now spend around 90% of our lives indoors, the idea that our eyes struggle to cope with our low-light interiors isn’t so surprising. The other factor is that children spend far too long engaged in “near-work”, i.e, concentrating on things too close to their face, thus squeezing their eyeballs into the wrong shape from an early age.
Since myopia develops while the eyeball is still growing, the crucial window is in childhood. Hence the standard advice for children is known as the 20/20/2 rule: for every 20 minutes of near-work, spend 20 seconds focusing on something in the distance; most importantly, spend two hours outside daily. Also, go and get your eyes tested.
So, environment plays a crucial role. Much of the blame for the shockingly high rates of myopia in East Asia (notably in urban areas) seems to come down to the highly competitive education system.
East Asian children start school earlier, work longer days, receive far more homework, and spend very little time outdoors. Similarly, Singaporean children spend as little as half an hour a day outside.
More time outdoors
One of the few East Asian countries to have seen a decline in myopia rates is Taiwan, which in 2010 introduced a policy known as Tian-Tian 120, encouraging schools to incorporate 120 minutes of time outdoors into their daily schedules.
But it’s not solely schoolwork that’s to blame – children’s leisure time has shifted too. China also tops the global chart of hours spent playing video games each week (12.4 hours compared with the UK’s 7.2).
And one of the things Polling has noticed from studying Dutch teenagers is that it’s no longer principally the academic children who need glasses – it’s everyone. “There has long been an association with education and myopia,” he said. “It used to be that the kids with glasses went on to study at university, and the kids who played soccer stayed without glasses. That’s changed with people born after 2000. Everyone is on their phone.”
Dahlmann-Noor is reluctant to draw conclusions before the link between early eyeball development and devices has been more rigorously researched. However, she stressed that if children only had access to phones when they were 16 or 17, the effects on their eyesight wouldn’t be as bad.
“That’s when the eyeball has reached its final state. But I have families coming in who clip a smartphone to their child’s pushchair and have Peppa Pig running. Why does a one-year-old need to have Peppa Pig on a smartphone? These things have invaded everyone’s private space and we don’t even notice them anymore.”
We are fairly used to the idea that phones have made a generation of teenagers anxious, depressed, sleep-deprived, narcissistic, susceptible to terrible influencers – and the rest.
The wide adoption of the smartphone in 2010 plus a gradual erosion of unstructured outdoor play has prompted a teenage mental health catastrophe, resulting in higher rates of suicide and self-harm, particularly among teenage girls.
Nonetheless, the idea that these same forces might literally be destroying our children’s ability to see things clearly – might even eventually blind them – is not one I’ve seen discussed, even in the most tech-phobic parental forums. And yet: one Danish study found double the risk of myopia in 16 to 17-year-olds who used electronic devices over six hours a day. Chinese studies have correlated axial length with time spent on both computers and phones and confirmed a link.
It should be stressed, however, that experts are cautious about pushing the thesis too hard.
Jury out on blaming smartphones
Dahlmann-Noor said the myopia trend long predates smartphones. Concentrating on anything close to your face can be bad for your eyesight.
Moreover, it’s generally agreed that near-work is secondary to time outdoors as a determining factor. “If you’re looking at school children from six or seven or so, we have not found that near-work has the influence that people often think it does,” says Mutti. “It just doesn’t show up as that significant a factor in cohort or longitudinal studies.”
Mutti has been collecting data on behavioural patterns and myopia since 1989 and is convinced time outdoors is the significant factor. “It’s clear kids are spending less time outdoors than they used to,” he said. “When I was a kid, my mom would encourage us to get out of the house, but indoors is just a lot more entertaining than it used to be. Parents have more concerns about unsupervised kids running wild on the streets.”
Many of these are perfectly rational. There are very few activities for even older children to safely do outdoors that don’t require parental supervision and/or cash.
Even as a “near-work sceptic”, Mutti is extremely concerned about the effect of screens on the very young. “To me, the preponderance of evidence is not in favour of near-work being so important in school-age kids,” he said. “But could near-work influence a young child’s eyes? A pre-schooler’s eyes? In my research on refractive development, there are strong effects of near-focusing on the development of infants’ eyes – maybe into the toddler years.”
He demonstrates this with balloons. “The focusing muscles act as a mechanical, tensing force at the front of the eye. If you put a squeeze around the balloon in the front, it elongates at the back. So it’s not hard to see how near-focusing could change the shape of an infant’s eye. That makes me very concerned about how toddlers are spending their time.”
And here is an “absolute difference” brought on by technology. “You no longer have to be able to read to be an intense near-worker as a toddler,” he said. “Small children love their iPads. They’re adept at swiping and scrolling and finding their next video, even at age two. I’m concerned about that…their intense use of electronic devices.”
Polling adds that just because it’s harder to find a direct link between myopia and screens doesn’t mean it doesn’t exist. “It’s relatively straightforward to measure light exposure or even simply how much time a child is outside. It’s much harder to measure focal distance.”
But either way, it hardly seems surprising that myopia rates rapidly accelerated during the Covid-19 pandemic, when children were both locked up indoors and forced to look at screens.
Pandemic
Indeed, the pandemic period of 2020 to 2023 saw a “notable” increase in myopia rates. One Scottish study found a 42% rise myopia incidence. And another in Hong Kong found myopia rates in six to eight-year-olds had doubled during the pandemic: 25% of six-year-olds and 46% of eight-year-olds were myopic.
It’s worth stressing again that the earlier myopia presents itself, the worse it will be. “It’s difficult because you don’t see immediate effects,” said Polling. “You need a lot of exposure from a very young age and then, at eight, you finally become myopic.”
Some parents with mild myopia aren’t too concerned if their child is diagnosed with a similar prescription, he said. But if you’re -3D at eight you are basically certain to be -6D or above at 18. And the macular degeneration might arrive in your 40s or 50s.
“These windows are precious and fleeting,” said Polling. “If we can delay the onset of myopia until 12 instead of 10, that’s a huge difference.”
What’s interesting is that when you raise this sort of thing with parents, they will often treat screens as a symptom of myopia as opposed to a cause.
The difficulty for ophthalmologists comes with framing a condition that will be perfectly manageable for most people and may not present any complications as a matter of urgency until decades down the line.
The thing about eyes, you take them for granted until you don’t. “I speak to people who have macular degeneration in their 40s and 50s,” said Dahlmann-Noor. “They are incredibly bitter. They say: ‘I wish someone had warned me that this was on the cards.’
Still, Dahlmann-Noor expresses some optimism. “For all my life, there was nothing you could do about the growth of the eyeball. You’d go and have your eyes measured, you’d get your new glasses, and that was it. But myopia has become such a problem that there has been a lot of research and there are finally treatments.”
It is not possible to stop or reverse the onset of myopia. But it is possible to slow it down. Corrective glasses and contact lenses work by creating a second image shell in front of the retina, which pulls the image forward and counteracts the elongation of the eyeball. These have been shown to slow the progression of myopia by 40%-50%.
Then there are atropine eye drops – widely prescribed in Asia (sometimes to pre-myopic infants).
There are factors beyond the control of medics. “These Big Tech companies need to start taking care of kids’ health,” said Polling. “They need to make their apps less addictive. And to warn parents not to give children phones before the age of six and keep them to a minimum after that.”
Given the extreme indifference tech companies have so far displayed towards the welfare of children, you’d have to say they are extremely unlikely to do that without being legally obliged to do so.
But there is something children can do, regardless Polling adds. “Just play outdoors.”
See more from MedicalBrief archives:
Daily eye drops slow children’s myopia, prevent future damage – Ohio study
The cost of lockdown on children’s eyesight – Chinese study
Many ophthalmologists are missing AMD indicators
Peek app uses teachers as opticians in Kenya