In this episode of CLS Live!, which originally aired in February 2022, Jason Jedlicka, OD, clinical professor at Indiana University School of Optometry and chief of the school’s Cornea and Contact Lens Service, interviewed Kate Gifford, PhD, BAppSc(Optom)Hons, an internationally renowned clinician, scientist, optometrist, and peer educator. In addition to being a visiting research fellow at Queensland University of Technology Australia, she and her husband—optometrist Dr. Paul Gifford—cofounded Myopia Profile, an educational platform on childhood myopia management, which she now does full time. Dr. Gifford is also a member of the Global Myopia Symposium (GMS) Program Committee.

Q. Jason Jedlicka, OD: Go back 20 years ago on your concept of why people got myopia. Do you have a different perspective on the environmental versus the inherited aspects of it?

A: Kate Gifford, PhD, BAppSc(Optom)Hons: We weren’t taught anything about myopia control at university because it wasn’t really a thing. There were a couple of studies published on bifocal or progressive lenses and nothing really measuring axial length. So, the evolution of contact lenses has been an important part of where myopia control and management really started. But 20 years ago, we really thought that myopia was genetic.

Now we understand that it is more environmental and that the growth of myopia is moving too quickly to just be genetic. The likely driving factors in terms of environment can be put simply as not enough green time and too much screen time. Although, the interesting thing about genetics and environment is that they do interplay.

The biggest risk of you becoming myopic is not being as hyperopic as you should be at a young age. And the biggest risk of you becoming a high myope or having faster progression is younger age. And that’s independent now of genetics and ethnicity. Genetics might play a role in development of those individual factors, but those appear to be the biggest driver now of myopia development and progression.

Dr. Jedlicka: If you go back many years ago, the genetic component might have been the major aspect of it and then we changed our behavior, so the behavior part has become a bigger part of it.

Dr. Gifford: And it might be hard to define an inflection point. People might think [it happened] when we got iPhones, but…[they weren’t] ubiquitous. There are other elements like educational pressures, particularly in Asian countries, that are correlated with increasing rates of myopia. It’s been an evolution toward bigger eyeballs, which is not a good thing.

Q: Dr. Jedlicka: I want to get to this international perspective on myopia and the Global Myopia Symposium (GMS). This meeting is truly international, because most of the thinking and research into myopia and most of myopia management has been done outside of the U.S. for the bulk of the time. Talk about the meeting for someone who hasn’t been to one before.

A: Dr. Gifford: GMS was held virtually in 2020 and again in 2021. And this year it’s virtual again, Sept. 8-10. Right from the outset, I was very keen—as was the entire planning committee—to really put the global into GMS. Last year, we had a half-day session that ran concurrently with the Asia Optometric Congress—and that was actually the most heavily attended session. The largest [concentration of myopes by population] is not in the U.S., it’s in Asia. So, we really need to get this message out to make the biggest difference in every country but [to] also make sure that we really are getting this information to where we have the greatest concentration of myopes.

We have speakers [and attendees] from all over the world. We didn’t want to spend a lot of time talking about the global growth of myopia, risk factors, etc. We could have a bit of that foundational information at the start, and then the whole rest of the conference needed to be focused on practical aspects. Whether that be understanding treatments, processes, or the business side of putting myopia management into practice. It’s really designed to be evidence-based but intensely practical. Case studies, treatments, all this sort of stuff, so our colleagues can really work out what they’re going to do next to improve their myopia management in practice.

Q. Dr. Jedlicka: I wanted to talk about this idea of managing myopia because, a lot of times, we get so into our little sphere—or a region, or country—and how we do things. Can you talk about how myopia is managed in North America versus Asia versus Australia, etc.

A: Dr. Gifford: You’re going to find innovators and the early adopters in certain countries who are right up there, probably independent of their country of practice. The thing that is fascinating is that the scope of practice is very different across the world. So, in the U.S., Australia, and New Zealand, most or all practitioners can prescribe atropine. That’s not the case in pretty much everywhere else in the world. But we all prescribe glasses, we can all prescribe contact lenses, and we can all try to do something other than just prescribing single-vision corrections to manage myopia.

Australia has quite a bit of myopia in its urban areas because it has a very high population of Asian ethnicity who are of greater risk of developing myopia. We have a lot of access to products, we have a high scope of practice, and we don’t have regulatory barriers to new products as much as the U.S. does.

In the U.S., in Asia, and in the U.K., there are a lot of parallels of where practitioners are really starting to understand now that myopia isn’t just a pair of glasses, that it does need to be managed, and the access to products—especially in the last year or two—is really growing.

Q. Dr. Jedlicka: Think about where we are now with management—orthokeratology; some soft multifocal lenses; in some parts of the world, we have spectacle lenses that have peripheral blur (not here in the U.S. yet); atropine and the pharmacological interventions. Is there something else that’s going to come along in the next five, 10, 15 years that you can see that’s going to be added to that? Or is something going to take over as the lead approach?

A: Dr. Gifford: We have so many amazing products that have been researched or released in a small number of countries, so increasing access to products is going to be a big thing that’s going to happen over the next couple years. In terms of brand-new approaches to treatment, perhaps we’ll have light-emitting glasses for people for whom outdoor time isn’t as feasible. We definitely have some new research on formulations of atropine…we need to understand about compounding versus commercial preparations and how that could potentially influence efficacy with atropine.

But I think what’s really going to happen over the next couple of years is understanding more about these treatments and how similar they might all be in terms of efficacy. That doesn’t mean every patient needs to wear contact lenses or every patient needs to have atropine. That means we can tailor the treatment to the patient rather than trying to shove everyone into one box. I think we’re going to understand more about combination treatments—combining atropine with optical treatments, when we should stop, and how well do treatments work successively.

Q. Dr. Jedlicka: Can we somehow migrate away from thinking about myopia progression as a refractive condition and more as an ocular disease?

A: Dr. Gifford: The short answer is “Yes, we have to.” There is more than enough evidence now to indicate that myopia is a disease of the eye. An analogy that we have used is likening myopic diopters or millimeters of axial length to intraocular pressure (IOP). IOP of 26 mmHg might not cause damage to the patient, but it is likely to greatly increase the risk of damage to the optic nerve. It’s not something that a patient feels or necessarily sees until it’s really late, in terms of glaucoma symptoms.

Research has shown that someone whose eye length is > 26mm has at least a one-quarter risk of suffering vision impairment in their lifetime. And if the eyeball stretches to > 30mm, that’s 90% who will suffer vision impairment in their lifetime. So, if we can have that preventative eye health approach to glaucoma, we need to translate that to myopic diopters, and even more so, millimeters of axial length. CLS

CATCH CLS LIVE! Watch this livestream’s full interview—and catch past and future episodes in the series via the online version of Contact Lens Spectrum at clspectrum.com or our Facebook or LinkedIn pages. Additionally, you can subscribe to Contact Lens Spectrum’s YouTube channel (bit.ly/clsyoutube22 ) to view this and other past interviews and to receive notifications for upcoming ones.