The International Myopia Institute (IMI) represents the consensus body of global myopia experts working towards the ultimate goal of advancing myopia research and education, to prevent blindness in the future. The landmark IMI white paper reports were published in 2019 and are making significant headway in the recognition of myopia as a public health concern, and in advancing research and clinical practice. A result of the first truly collaborative global effort, they provide a well-defined, evidence-based picture to help eye care practitioners to uptake myopia management.
Olga Prenat, Global Director of Education and Professional Relations at Essilor International and Chief Editor of Points de Vue, recently invited myopia experts, IMI chair Prof Serge Resnikoff, and committee members Prof Ian Flitcroft, Prof Earl Smith and Dr Monica Jong to share their inspiring journey with the initiative and discuss how the white papers are critical to improving clinical myopia management.
What was the driving force behind developing the IMI white papers?
Prof Resnikoff: The initial driving force was the late Professor Brien Holden, who was a true visionary. He recognised that myopia was becoming a significant public health issue and was keen to bring different forces together to address this. It all started with a momentous World Health Organisation scientific meeting on myopia in 2015, from which there were two clear outcomes – first, that myopia research and treatment was a constantly evolving area, and second – that it was critical to make the latest research accessible for practitioners. This impetus was really necessary to get things moving for the International Myopia Institute. The momentum was then sustained by the Brien Holden Vision Institute, and the driving force now is the group of stakeholders involved in myopia management, including the scientific community, the clinicians and the industry, who have a common vision and are pushing things forward.
Dr Jong: It is really about the mission of improving people’s lives through better vision. We are bringing all the different stakeholders in the eye care industry together, and hopefully we can also reach those who can really impact change, including the wider audience of health workers, educators, government and peak health bodies.
Research shows that it takes around 17 years from the first evidence of efficacy of a clinical intervention to widespread adoption
What influenced you to be involved in this landmark effort?
Prof Smith: I have always been interested in the role of vision and how it influences the emmetropisation process. Almost every child is clinically emmetropic by the time they are three to four years of age, and for this to happen, there must be a precise match between the eye’s axial length and its optical length. A mismatch as small as the thickness of an eyelash is enough to reduce vision performance. The eye is able to achieve this precise match in a large proportion of children early in life, which is a magical feat that caught my interest a long time ago. The primary reason to study emmetropisation is to understand why in some children the eye becomes myopic later in life, largely associated with the onset and intensity of education. From a scientific perspective, it is a very interesting problem that has important public health implications. I became much more active outside the lab with initiatives such as IMI, primarily because of the influence of Professor Brien Holden and his global efforts to eliminate preventable vision disability.
Prof Flitcroft: I started off life as a vision scientist in the 1980s and back then, my supervisor, Stuart Judge’s close friend Josh Wallman, converted me to the new scientific religion of emmetropisation. As a clinical paediatric ophthalmologist later on, I was interested in this topic, but I saw that it was not really being applied. Research shows that it takes around 17 years from the first evidence of efficacy of a clinical intervention to widespread adoption, so my mission for the past few years has been to help narrow this gap.
I also met Professor Brien Holden in 2015 and he was pivotal in raising the profile of myopia as an international issue. Kovin Naidoo, former CEO of Brien Holden Vision Institute and now Senior Vice President Social Impact: Africa & Latam and Advocacy at Essilor International, also played an important role back then to keep the momentum going. One of my missions is to shorten this time period of 17 years, by having a foot in both basic and clinical research, as well as being an advocate for myopia management. I see IMI as a mechanism for chipping off a few years from this process.
Dr Jong: I was first exposed to myopia research through Professor Neville McBrien’s lectures in school, and was really fascinated about myopia and being able to alter the axial length of the eye through lenses. I eventually met Professor Brien Holden after finishing my postdoctoral fellowship and like many of you, he set me on the path here. It is also a very personal mission for me and I want to really improve people’s lives through better vision. One of my eyes is highly myopic and I have many family members who have high myopia, as high as -9.00D and -18.D. Myopia definitely had an impact on my quality of life as a child growing up. If I had known that all this knowledge was available back then, I might have had a different final refractive error and reduced my risk of future ocular complications.
Prof Resnikoff: I also met Brien Holden while I was working at the World Health Organisation. Prior to that, I had worked as an ophthalmologist in Africa for 16 years, performing cataract surgeries and trying to control trachoma and river blindness. What I realised back then, was that it is possible to make very significant changes globally from a public health perspective, for example, eliminating trachoma as a public health problem. When we had our first discussions with Brien in 2000, it was about uncorrected refractive errors and much broader than myopia, but for me it was very clear that this was the next main battle for the eye care community on a global level. Being involved in this is very exciting and can really enable us to change the face of the world, but we need to work together and translate science. It’s not easy, but it can be done.
Were there any obstacles that you had to overcome and how has the journey been so far?
Dr Jong: In its infancy, many people took some time to want to participate in the white paper process. Looking back now, it was quite a natural process of working in a very transparent way and being focused on the mission to advance myopia research and education. It was also possible thanks to our initial trailblazers like Ian Flitcroft, Earl Smith and Christine Wildsoet, followed by James Wolffsohn, who also independently came up with a similar concept. All this helped to really cement IMI.
Prof Smith: I think an important step was the collaborative relationship that developed between IMI and the International Myopia Conference (IMC). Getting IMI and IMC together has helped a lot in identifying who might be interested in being involved in this effort.
Prof Flitcroft: On the journey so far, my verdict is that the train has just left the station. Getting the train out of the station was not a trivial undertaking as it involved building a station, building a train and getting people on the train. We are now slowly building the tracks in front of us. The section of the tracks that we still need to build includes educating everyone coming out of top-tier optometry schools in a different mode of thinking and also re-educating current practitioners in active management. Another section of the tracks that we need to build is a viable business model, without which it is difficult to reach the mass market. Until we can get enough of the population managed, we are not going to shift the dial.
Prof Resnikoff: Bringing people from very different places on the planet to work together on a voluntary basis, and in a transparent manner, was challenging to some extent. It also took some time for people to trust that IMI was not driven by the agenda of a single organisation, and was a truly collective effort. It is also important to keep in mind that there is no ‘one size fits all approach’ when it comes to myopia management across different regions. IMI has managed to deal with this so far, and this is an ongoing challenge for us.
Could you share some key milestones and successes of this historic effort?
Prof Resnikoff: Key milestones include the establishment of IMI in 2015, the publication of the white papers in February 2019, the dissemination and presentation of the papers in conferences including Association for Research in Vision and Ophthalmology (ARVO), American Academy of Optometry, International Myopia Conference, and World Ophthalmology Congress. Other important milestones have been holding our advisory board meetings. Since we are functioning as a virtual network, meeting physically for these advisory board meetings has been important, because this is where we can really assess and discuss the way forward. The next important milestone will be the new series of the white papers which will be published in 2021.
How important is it to build a strong foundation on myopia management for practitioners, and how will standardisation help in research and patient management in the future?
Prof Flitcroft: Since myopia management is a new therapeutic area, there is a unique chance to standardise right from the start. There are some shining examples where standardisation helps to both coalesce research and allow research to be compared and implemented, such as in diabetic retinopathy and retinopathy of prematurity. I don’t think we have convinced everybody with the white paper on definitions and classifications of myopia, but we have set some standards. The bedrock of evidence based medicine has to be a cohesive set of standards and reporting standards, which are both equally important.
Dr Jong: The classification of myopia is really critical. The definitions paper at least sets a standard so that clinicians talking about patients know that they are talking about the same thing. Pre-myopia is an entirely new definition that was put forward in the white paper, which is particularly helpful for clinicians. If they can see signs of pre-myopia based on the age and level of hyperopia, they can provide lifestyle counselling advice. Having such definitions could help standardise clinical trials or advance research studies, and also allows for easier comparison among studies.
What do you think is critical to see a paradigm shift in the way clinicians practice myopia management, and how long will it take?
Prof Flitcroft: I’m hoping it will take less than 17 years! I think a paradigm shift is going to take one of two things – clear guidance on the minimum standard of care from professional organisations and associations. Professional organisations can take a better lead, but it is also equally important for people involved in research to give them information that allows them to make that leap of faith. The second aspect, which people don’t want to talk about, is financial incentivisation, which changes behaviour faster than almost anything else. We’re also missing a simple, safe, easy and effective treatment at the moment, which needs to be easy for eye care practitioners, parents and easy for the children too. That’s a good goal to aim for.
Prof Smith: I agree that educating eye care practitioners is important, but it also needs to go beyond that to educate the broader medical community on the public health impact of myopia. Paediatricians and school nurses are often the first to measure visual acuity in children, but unfortunately many still don’t think myopia is a treatable condition. Moreover, a lot of eye care practitioners are not comfortable prescribing contact lenses or atropine to young patients, so if we could develop spectacle lens designs that are as effective or more effective, it will go a long way in moving the needle. In essence, we need a safe and effective treatment, which is suitable for a large proportion of the population.
Accessibility of myopia management solutions is important. A simple solution with no side effects suitable to manage myopia in most children would be the ideal solution
What’s next – in 2020, 2021 and beyond – do you foresee any challenges?
Prof Resnikoff: Other than the white papers, we have decided to produce yearly digests so that people are better informed about significant new findings presented globally. If we want to have a global impact, it is critical that we have better communication with different countries, so we are also setting up a network of ambassadors to translate science for eye care practitioners in that specific country. We are also looking at ways of better involving general practitioners and paediatricians. Finally, it is important to get the parents involved in understanding what myopia is, what opportunities exist and why these opportunities are so important to take advantage of.
What else needs to be done to advance clinical myopia management globally?
Prof Flitcroft: Going back to Earl’s religious conversion theme, the people who are the biggest enthusiasts of religion are the most recent converts, and the most recent converts are practitioners who have either incorporated myopia management in their practice or reimagined their entire practice around it. They are going to be some of the most influential people in getting everyday practitioners to adopt myopia management.
Prof Smith: First – education is going to be critical to broadening the reach of this technology. Second – getting a simple, safe and effective treatment option that can be used with almost any person, is absolutely key.
Dr Jong: Accessibility of myopia management solutions is important. A simple solution with no side effects suitable to manage myopia in most children would be the ideal solution. At the same time, advocacy at the peak health body level, and producing evidence for policy makers about the burden of myopia is essential. Once you have policy in place, then associations will adopt these new standards of care.
Prof Serge Resnikoff MD PhD is an international expert in global ophthalmology and public health. He currently serves as Chair for the International Myopia Institute (IMI). He has published more than 230 scientific articles in peer-reviewed journals, authored and co-authored several chapters in medical textbooks and presented more than 250 invited lectures. His professional experience also includes senior positions at the World Health Organisation (WHO) and the industry. He has received numerous awards for his contributions to research and education.
Dr Monica Jong is the Executive Director of the IMI, BHVI, Sydney, a lecturer in the Discipline of Optometry and Vision Science, University of Canberra, Canberra, and a visiting fellow of the School of Optometry and Vision Science, UNSW, Sydney, secretary of the Refractive Error Working Group, IAPB. Her research interests include refractive error, understanding myopia risk factors, myopia control, and the public health impacts. Dr Jong has co-supervised graduate students, authored peer reviewed articles, and the WHO report on “The Impact of myopia and high myopia.” She also co-created the Brien Holden Vision Institute global online myopia management education program and speaks regularly at key international meetings.
Ian Flitcroft is a consultant paediatric ophthalmologist at the Children’s University Hospital, Dublin. He is also Associate Clinical Professor of Ophthalmology in UCD and Adjunct Professor of Vision Science at the Technological University Dublin. He has been involved in the field of experimental myopia for 25 years. As well as his research on the mechanisms guiding eye growth, he has been a long term advocate for the public health implications of myopia and for the need for biological treatments of myopia. He is a lead investigator on several myopia treatment trials.
Professor Earl Smith currently holds the Greeman- Petty Professorship in Vision Development. His research interests are focused on the optics of the eye; Professor Smith received the Glenn Fry Award and the Prentice Medal from the American Academy of Optometry for his research on the role of vision in regulating refractive development and eye growth. He is a Fellow of the American Academy of Optometry, an ARVO Fellow (inaugural class), a member of the National Optometry Hall of Fame, a past Member and Chair of NIH NEI’s Central Visual Processing Study Section and a past member of NIH’s National Advisory Eye Council.
The IMI White papers are available at www. myopiainstitute.org/imi-white-papers.html. The new series of the IMI white papers will be published in 2021.
This interview is from a virtual roundtable held with myopia experts from the International Myopia Institute and was first published in Points de Vue – International Review of Ophthalmic Optics, by Essilor International. To read the original article visit www.pointsdevue.com/article/global-evidencebased- effort-makes-inroads-improving-clinicalmyopia- management.
Education of eye care practitioners in active myopia management is critical, and it also then needs to go beyond them to educate healthcare providers, teachers, parents and policy makers.
A simple, safe, easy and effective spectacle lens solution, which is suitable to manage myopia in almost any child, is critical to shift the dial on myopia management.
Advocacy at the peak health body level, and producing evidence for policy makers about the burden of myopia, is essential to move the needle on widespread adoption of myopia management.
IMI White Papers: Series Two Coming Your Way
Dr Monica Jong
Myopia management is one of the hottest areas of research and practice in the eye care profession, making its way onto the agenda of all global eye care meetings in recent years. This exciting, evidence-based area is continually advancing in research and technologies with new information published daily online, in social media and reported at scientific meetings.
The International Myopia Institute provides one credible, comprehensive and regularly updated source of information in the form of white papers.
IOVS has reported record downloads of the IMI white papers first series, making it one of the most downloaded and highly cited papers in its first year of publication
With so much information on myopia available, it’s understandable that practitioners at the front line of delivering vital patient care can find it challenging to know where to turn for evidence-based information.
With this in mind, the International Myopia Institute (IMI) was formed in 2015, bringing together experts to make all the evidence available in one place, in the form of white papers.
Over 80 experts came together in the IMI to review, debate, discuss and develop the first IMI white papers which comprised: Definitions and Classifications; Experimental Models; Interventions; Clinical Management Guidelines; Clinical Trial Guidelines; Genetics; and Industry and Ethical Guidelines.
This first landmark series of seven white papers was published in the Investigative Ophthalmology and Visual Sciences (IOVS) 2019 special issue and has become one of the most downloaded and highly cited papers in its first year of publication.
Indeed, peak health bodies, such as the World Health Organisation have reviewed the papers for definitions of myopia, high myopia and pathologic myopia. Undoubtedly, it will be the basis for future updates in eye health care. Since 2019, the IMI and its taskforces have been hard at work developing the second series of white papers, which will be published in early 2021. This new series of white papers aims to provide further consensus on the key components of myopia management.
DEFINITIONS AND CLASSIFICATIONS
Some highlights from the first series of white papers were the recommendations to unify the definitions of myopia and high myopia, and to agree on a separate definition for pathologic myopia. The basis for this is that recognising an ocular condition, and being able to manage it, requires a clinically relevant definition.
For the first time, pre-myopia has been proposed as an entirely new IMI definition. This will allow clinicians and researchers to better identify those at risk of myopia and high myopia.
The definition of pre-myopia is proposed to be, “A refractive state of an eye close to emmetropia in children where a combination of baseline refraction, age, and other quantifiable risk factors provide a sufficient likelihood of the future development of myopia to merit preventative interventions”.1
Another highlight of the series was the IMI Interventions white paper, which outlined the evidence for each of the interventions that can be implemented in an effort to slow myopia progression in an individual. As this area is advancing rapidly, with new interventions being trialled, the second series of white papers will include an Interventions Yearly Digest – a brief update on what is new in this exciting area.
The second series of the IMI white paper will also identify areas of priority and set up teams of experts tasked with examining all the evidence in the following areas:
- The burden of myopia, chaired by Professor Padmaja Sankaridurg, Brien Holden Vision Institute Sydney, will examine the cost of myopia, its associated ocular complications, social impact and myopia management;
- Paediatric high myopia, chaired by Professor Ian Flitcroft, Dublin Institute of Technology, will focus on children that are already highly myopic at very young ages and their management;
- Pathologic myopia and their associated complications, chaired by Professor Kyoko Ohno-Matsui, Tokyo Medical and Dental University, will examine the evidence for treatments;
- Preferred practice patterns, chaired by Professor Jost Jonas, Heidelberg University, will update the recommendations in clinical myopia management;
- Environmental risk factors and myopia, chaired by Professor Ian Morgan, Australian National University, will examine the role of all aspects of the environment in myopia development and progression, and their role in clinically addressing myopia;
- Accommodation and binocular vision in myopia, chaired by Dr Nicola Logan, Aston University, will examine the role of this in myopia and the application clinically; and
- The yearly digest, chaired by Professor Earl Smith, University of Houston and Dr Monica Jong, University of Canberra, will be an update on the latest in myopia research for each IMI section.
These white papers are underway and will be available in early 2021 following a rigorous process of debate, discussion and external peer review to ensure the highest level of evidence is available to guide practitioners, researchers and policy makers. It will be exciting to clarify the state of the evidence on the role of accommodative lags and myopia development and myopia control, which have been a source of confusion in clinical management lately. Additionally, the role of near-work, screens and myopia will be shared.
Until the release of the 2021 white papers, it is hoped that eye care practitioners globally will be able to use the IMI white papers (series one) and the clinical summaries of the white papers that have been translated into 12 international languages including Spanish, French, Japanese, German and Nepalese.
The IMI white papers are available at iovs.arvojournals.org/issues.aspx?issue id=937872#issueid=937872 and www.myopiainstitute.org/ imi-white-papers.html.
The IMI white paper clinical summaries are available at www.myopiainstitute.org/imi-whitepapers/ imi-clinical-summaries.html.
The efforts of the IMI are due to the global collaboration of experts who donate their time in this endeavour. The IMI will continue to create more freely available evidence-based resources with a mission to raise awareness, educate, and advance the area of myopia research and patient management, to prevent future vision impairment and blindness associated with increasing levels of myopia.
IMI is non-profit and founded by Brien Holden Vision Institute Sydney. All IMI members donate their time and expertise. IMI resources are made freely available thanks to Essilor, Coopervision, Zeiss, Alcon and the Vision Impact Institute.
- Flitcroft DI, He M, Jonas JB, Jong M, Naidoo K, Ohno- Matsui K, Rahi J, Resnikoff S, Vitale S, Yannuzzi L. IMI – Defining and Classifying Myopia: A Proposed Set of Standards for Clinical and Epidemiologic Studies. Invest Ophthalmol Vis Sci. 2019 Feb 28;60(3):M20-M30. doi: 10.1167/iovs.18- 25957. PMID: 30817826; PMCID: PMC6735818.