“This was a phenomenon that I had anticipated to see later”

In the past, when children younger than five came through her clinic with myopia, further tests often revealed an underlying condition.

Now, Dahlmann-Noor recounts how those tests often come back negative.

“Those young children have simple myopia,” she shared.

“That concerns me because with earlier onset and more years for progression, the lifetime risk of complications is much higher,” Dahlmann-Noor emphasised.

Alongside her Moorfields colleagues, Dahlmann-Noor has investigated the question of whether myopia is responsible for a reported increase in retinal detachment repair surgeries in both England and Scotland.

The study, which was published in Eye, found a substantial increase in the proportion of Moorfields Eye Hospital patients undergoing retinal detachment surgery who have myopia – from less than 10% in 2012 to more than 40% in 2023.

Dahlmann-Noor told OT that while she anticipated rising myopia levels would have an effect on the pathology seen in secondary care, she was surprised that – when it comes to retinal detachment surgeries, as least – this uplift is already happening.

“This was a phenomenon that I had anticipated to see later,” she said.

“The increase was even more pronounced in the younger age group,” Dahlmann-Noor added.

Among those younger than 60 undergoing retinal detachment repair, more than half of patients had myopia.

Over the 11-year period that the researchers examined, beginning in 2012, the most common age group for someone to have a retinal detachment repair shifted from between 60 and 64, to between the ages of 55 and 59.

Prevalence

Dahlmann-Noor shared that the public health effects of increasing myopia levels can already be seen in some east Asian countries, where more than eight in ten young adults have myopia.

“The number of people who are losing vision because of complications related to myopia is much, much higher than here,” she said.

Dahlmann-Noor shared that the evidence suggests between 25% and 30% of young adults in Europe have myopia – although there is a lack of up-to-date epidemiological studies for the UK population specifically.

She would like to see funding invested in research addressing a number of key questions around myopia.

“We need to get accurate figures for the UK on how many children and young people have myopia and how severe it is,” she said.

“Then we need to find out how many adults suffer sight threatening complications because of their myopia,” Dahlmann-Noor shared.

Turning to current methods for managing myopia progression – such as specialised soft contact lenses and spectacle lenses – Dahlmann-Noor shared that there is a growing evidence base supporting the efficacy of these interventions.

“The evidence is coming through from studies in the UK and Europe, as well as studies in East Asia, that they are very effective and can reduce progression,” she said.

Dahlmann-Noor highlighted that longer-term data shows a drop in final myopia levels by more than one dioptre over five years.

“Mathematical models predict that a one dioptre reduction may reduce the rate of complications, particularly myopic maculopathy, by 40% – so that is a very significant number,” she emphasised.

The influence of outdoor time and near work

Turning to the factors that are driving increasing myopia levels, Dahlmann-Noor shared that the evidence suggests changing lifestyles are the main influence.

“There is also a genetic component, but you not only share your genes with your parents – you also share your parents’ lifestyle,” she said.

A reduction in exposure to bright sunlight through less outdoor time and more time spent on near work activities are two key aspects of this lifestyle shift.

Dahlmann-Noor shared that the amount of time children spend on screens is a concern – although she does not think that there is something intrinsic to digital devices that is exacerbating progression.

“We have to bear in mind that this trend started way before the smartphone was invented,” she said.

For me, this is one of the Holy Grails in ophthalmology – to be able to influence the growth of the eye. That is just monumental

She highlighted that the sheer amount of time spent on screens, and the fact that some of these screens are smaller and require a high near focus drive, could be driving myopia progression.

Dahlmann-Noor shared that parents will come into her clinic with a pram that has a smartphone holder so their children can watch cartoons while being pushed through a park.

“I would much prefer that they had an outward facing pushchair and were looking at the ducks in the park than Peppa Pig on a smartphone,” she said.

Funding

As myopia management interventions are only available privately in the UK, Dahlmann-Noor believes that there is currently an issue of equity in access.

“Myopia tends to run in families, both because of genetics and because of lifestyle, so families who have several children with myopia may be priced out of the options that are available,” she said.

In order for myopia management to be funded on the NHS, Dahlmann-Noor explained that a case would need to be made to the National Institute for Health and Care Excellence establishing effectiveness and cost savings.

Dahlmann-Noor highlighted that reducing myopia levels would help to ease the social care burden and loss of economic productivity associated with sight loss in later life – but these costs come decades after the onset of myopia.

“The problem with preparing a case for public funding is that there is this lag of more than 30 years between myopia developing in childhood and the sight threatening complications,” she said.

Researchers are now turning their attention to developing models based in health economics that establish the anticipated savings of myopia management.

A professional passion

Dahlmann-Noor shared with OT that myopia is essentially eye growth that has not stopped when it is supposed to, leading to increased axial length in the eye.

“What we are seeing now in myopia is that there is accelerated growth and then it doesn't stop at the right time,” she said.

As a myope herself, Dahlmann-Noor empathises with young patients who come through her clinic worried because the number of activities they can do without their glasses or contact lenses is dwindling by increments.

“They ask me, ‘What am I doing wrong? And when will this stop?’,” she said.

Although she recognises the same feelings of uncertainty that she experienced in her patients, Dahlmann-Noor highlighted that there are interventions available today that were not an option when she was a teenager.

“For me, this is one of the Holy Grails in ophthalmology – to be able to influence the growth of the eye. That is just monumental,” Dahlmann-Noor said.