Eye Health and Lockdown: Managing the Perfect Storm

Tom,* a 22-year orthokeratology (OK) patient, presented after recently relocating to Melbourne from New South Wales to study dentistry. Since moving, he had been experiencing difficulty with his OK treatment. Tom had been wearing OK contacts since age 14 for partial correction of his high myopia. He reported that recently, his vision had been variable and he had been experiencing trouble tolerating his lenses. As he had moved during the COVID-19 pandemic, much of his learning was done remotely online. He reported his prescription had been stable in recent years, but he has a very strong family history of myopia – most of his family are myopic, many of which are highly myopic. His mother is a -10D myope and his maternal aunt a -16D myope.

I would be interested to see if we would also ‘win’ the title for the driest and most myopic eyes in Australia

Subjective refraction gave R -6.25/- 1.50×160 (6/6=), L -6.00/-1.75×177 (6/6=). Examination revealed grade two superficial punctuate keratitis in both eyes (Figures 1 and 2), a reduced tear film and tear film break up time of less than two seconds in each eye. Meibography revealed significant shortening of the meibomian glands in both eyes L>R (Figures 3 to 6).

Axial length measures were R 27.44mm and L 27.19mm.

A lengthy discussion about Tom’s refractive options ensued. These included:

• Refit his orthokeratology lenses, as his lenses were now two years old,
• Switch to soft multifocal contact lenses,
• Switch to myopia control spectacles, or
• Switch to single vision spectacles, with and without low dose atropine.

The pros and cons of all these options were discussed at length. Tom was also instructed to perform hot compresses, use ocular lubrication, and do blink training.

make sure you maintain good visual hygiene which means regular rest breaks, good room lighting, longer working distances. Make sure you remember to blink…

DISCUSSION

Well here we are, in Melbourne, and as I write this, we are in the middle of lockdown 6.7 (or wherever we are at now). We are only able to perform urgent clinical care, and many patients have been presenting with the same complaints of tired, sore, irritated and/or blurry eyes.

Stay at home orders have been necessary to limit the spread of COVID-19; workplaces, schools, restaurants, and all venues are closed, streets empty, and we have been forced into solitude. The world has quickly pivoted to allow for remote work and learning, with technology being our saviour – enabling classes, meetings, and all communication to continue online. However, as a consequence, we’ve seen a massive increase in screen time and time spent indoors. Screen time has not been restricted solely to work and educational purposes – it has become our means of remaining socioemotionally connected with each other as well as providing entertainment, information and even a means for shopping. Worldwide, screen usage has increased to unprecedented levels. While workplaces are often set up ergonomically, home environments are not necessarily so, especially given that we didn’t envisage that the home would become the office or place of study.

THE GROWING PREVALENCE OF DRY EYE

I hear complaints about fatigued and dry eyes every day now, and I find myself defaulting into autopilot to recite the same messages – “make sure you maintain good visual hygiene which means regular rest breaks, good room lighting, longer working distances. Make sure you remember to blink…” Undoubtedly, many practitioners have been encountering similar patients with similar symptoms and offering similar advice. We are all aware of the impact of excessive visual display unit use, which can lead to ‘computer vision syndrome’, which encompasses a range of symptoms including eye strain, fatigue and dry eye disease. Tom’s situation is worrying as he is still young, yet already showing degradation of his meibomian glands.

…adult myopia is not clearly understood – most of the studies on myopia control have been conducted on children…

Already, many studies report significant increases in dry eye and eye strain due to COVID-19 lockdowns, which have in part contributed to mental health stress.^1-3 In our practice, dry eye appears to be occurring more frequently and at increasingly younger ages – probably as a result of environment and lifestyle, or perhaps because I am looking for it more? Having a meibographer is fantastic because showing, rather than telling, has a far greater effect on patient awareness – a picture truly tells a thousand words.

INCREASING MYOPIA PROGRESSION

It has also been well documented that limited time outdoors and increased near work can lead to myopia progression.⁴ Tom is a complex myopia case. He had previously accepted partial myopia correction with OK contact lenses and single vision distance spectacles of prescription -2.50DS in both eyes to correct the residual myopia. Although this was not ideal – when his treatment had been initiated, the priority had been myopia control given his high myopia and strong family history. It has been shown that partial correction of myopia in high myopes reduces the rate of myopic progression.⁵ Now that he is an adult, we hope he has stopped progressing, particularly as he has been stable for some time.

Adult myopia is not clearly understood; most of the studies on myopia control have been conducted in the paediatric and adolescent age group, and we have no clear science on adult myopia. With that said, environment surely would play a major role, so careful education about maintaining good visual hygiene is crucial, particularly in these ‘unprecedented times’ of extreme levels of screen usage. The COMET study found that with half of myopes stable at age 15, a quarter will continue to progress after 18 and 10% after age 21.⁶ Adults can continue to progress, albeit slower than children, with one third of 20–25 year old myopes progressing by 1D or more over five years.⁷

Of course these figures are from studies from pre-COVID-19 times, and the amount of screen usage has increased dramatically since then. Anecdotally, since COVID-19, I am finding myopia progression in many of my patients – not just my kids and teens, but also in many adults.

MANAGING TOM’S CASE

While preventing myopic progression is important, Tom is struggling to see as his vision is variable and this is impacting his learning.

Soft multifocal contact lenses were offered as an option. Novel myopia control contact lenses are available, including the CooperVision MiSight lens, however Tom’s prescription was outside the available range with this particular lens There has been some evidence that centre distance multifocal contact lenses and extended depth of focus soft contact lenses can slow myopic progression, however given his dry eye, Tom would probably struggle to tolerate soft contact lenses on a full-time daily wear basis. His ocular surface makes any form of contact lenses, be it orthokeratology or soft contact lenses, a challenge.

Recently a novel spectacle lens – the DIMs spectacle lens – has been made available in Australia as the Hoya MiyoSmart spectacle lens. This has been shown to reduce the rate of progression of myopia in children. It was offered to Tom as an option, but unfortunately it is only available in one lens material – polycarbonate, which is 1.59. At Tom’s prescription, this would result in a thicker than desirable edge thickness.

Low dose atropine was also discussed, however the level of atropine to use is unclear, with higher concentrations being more effective but also eliciting the most side effects.

This patient is a conundrum, with COVID-19 compounding his complications. He needs to be able to see to learn, but partaking in myopia management techniques may hinder this ability. His long axial length poses a great concern, as longer axial lengths are highly correlated with sight loss. Axial lengths of greater than 26mm are at risk of myopic maculopathy with the risk of myopic maculopathy increasing exponentially with increasing axial length.8 The environment he is subject to demands that he stay indoors and use screens for long periods, which is the perfect storm for dry eye and myopia development. It’s a tricky balance between allowing him the best environment to learn and reduce his risk of progression. There is no ‘right’ answer for a patient like this, except to educate him on the importance of environment and make sure he maintains the best possible visual hygiene.

WHO WINS?

In 2016, Brien Holden et al predicted that at the rate of increasing prevalence of myopia at that time, 50% of the world would be myopic and 10% would suffer from high myopia by 2050.⁹ However, the modelling used had not anticipated a pandemic that encouraged environmental factors for myopia development and progression, such as increased time indoors and time spent on screens. Some studies have already reported a significant increase in the prevalence of myopia in children, with a Hong Kong study finding an increase in prevalence of myopia in children aged six to eight-years-of-age from 11.6% in pre-COVID-19 to almost 30%!¹⁰ This represents a 2.5-fold increase in the age group that should be hyperopic or emmetropic, which is alarming as we know the younger the age of onset, the greater the resultant myopia. They also found an almost doubling in the rate of progression of myopia and axial elongation in this same subset.

Those of you who know me, know that I love winning. I’ve been pretty smug about living in a city that has formerly won most liveable city in the world multiple times. Unfortunately, by the time this is published, Melbourne will probably have the record for the most locked down days in the world. I would be interested to see if we would also ‘win’ the title for the driest and most myopic eyes in Australia.

*Patient name changed for anonymity. 

Jessica Chi is the director of Eyetech Optometrists, an independent speciality contact lens practice in Melbourne. She is the current Victorian, and a past national president of the Cornea and Contact Lens Society, and an invited speaker at meetings throughout Australia and beyond. She is a clinical supervisor at the University of Melbourne, a member of Optometry Victoria Optometric Sector Advisory Group and a Fellow of the Australian College of Optometry and the British Contact Lens Association. 

References 

1. Barbarino S. A narrative review of current understanding and classification of dry eye disease with new insights on the impact of dry eye during the Covid-19 pandemic. OphthalmolTher (2021) 10:495-507. 
2. Napoli PE et al. The ‘quarantine dry eye’: The lockdown for Coronavirus disease 2019 and its implications on ocular surface health. Risk Management and Healthcare Policy 2021:14 1629-1636 
3. Saldanha IJ et al. Impact of the Covid-19 pendemic on eye strain and dry eye symptoms. 
4. Xiong, Shuyu et al. “Time spent in outdoor activities in relation to myopia prevention and control: a metaanalysis and systematic review.” Actaophthalmologica vol. 95,6 (2017): 551-566. doi:10.1111/aos.13403 
5. Charm J, Cho P. High myopia-partial reduction ortho-k: a 2-year randomized study. Optom Vis Sci. 2013 Jun;90(6):530-9. 
6. Myopia stabilization and associated factors among participants in the Correction of Myopia Evaluation Trial (COMET). Investigative ophthalmology & visual science 54, 7871-7884, doi:10.1167/iovs.13-12403 (2013). 7. Gifford P. Myopia progression in adults: What we do and don’t know. mivision 2020. 8. Tideman JW, Snabel MC, Tedja MS, van Rijn GA, Wong KT, Kuijpers RW, et al. Association of Axial Length With Risk of Uncorrectable Visual Impairment for Europeans With Myopia. JAMA Ophthalmol. 2016;134(12):1355-63. 
7. Holden BA, Fricke TR et al. Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmology. 2016; 123: 1036-1042 
8. Zhang X, Cheung SSL, Chan HN, et al. Myopia incidence and lifestyle changes among school children during the COVID-19 pandemic: a population-based prospective study [published online ahead of print, 2021 Aug 2]. Br J Ophthalmol. 2021;bjophthalmol-2021-319307