Spotlight on Myopia in Singapore

Singapore, a city state in Southeast Asia, has the second highest population density of the world and is a thriving city with magnificent economic development and growth of wealth over the past few decades. However, the urban lifestyle and closed living spaces due to the high population density has led to a high prevalence of myopia. Intriguingly, in Singapore, the prevalence of myopia is high even in ethnic groups that are not myopic in other regions or countries of the world. We invited Dr Li Lian Foo and Dr Leo Seo Wei, from Singapore who are at the forefront of managing the myopic epidemic for an interview about the situation on ground.

Leo Seo Wei: The prevalence of myopia in Singapore is among the highest in the world, with 65 percent of our children being myopic by Primary 6 (typically 12 years old), and 83 percent of young adults being myopic. By 2050, it is projected that 80 to 90 per cent of all Singaporean adults above 18 years will be myopic and 15 to 25 per cent of these individuals may have high myopia. The COVID pandemic had worsened the situation. Up to 20 per cent of children now have high myopia, compared to just around 10 per cent a decade ago. The average age of myopia has also decreased significantly, which equates to earlier onset and more years of progression and higher myopia eventually.

Li Lian Foo: In Singapore, awareness of myopia is generally quite high, given the prevalence of the condition and the focus on public health initiatives targeting childhood myopia. Many parents and carers are aware that myopia is common, especially in school-aged children. However, the depth of their understanding about its progression, potential long-term effects, and available control measures can vary.

In clinical practice, it’s often necessary to provide education about the importance of early intervention and the range of treatment options, such as atropine eye drops, orthokeratology, or specialized spectacle and contact lenses. Many parents may not fully grasp the significance of controlling myopia progression or the potential risks of high myopia, such as retinal detachment or glaucoma, later in life. Additionally, most parents have a basic understanding of myopia progression in terms of degree (dioptres), as this is commonly discussed in eye check-ups. However, many are unaware of the role axial length plays in the progression of myopia.

So, while there is a general awareness of myopia, targeted education about myopia management and long-term care remains a crucial aspect of patient consultations.
 

Leo Seo Wei: The Health Promotion Board (HPB) has put in place the National Myopia Prevention Programme (NMPP) since 2001, which includes vision screening in pre-schools, primary and secondary schools. Preschool students and Primary 1 (usually seven years old) students who were found to have defective vision in routine screening were referred to Refraction Clinics at the Student Health Centre, Health Promotion Board, for further assessment. Cycloplegic refraction was also made available for students who required it. Following assessments, children who required glasses were given a prescription to purchase spectacles at optical shops in the community. Children detected or suspected to have severe myopia, amblyopia or other eye conditions were referred to pediatric ophthalmologists at one of the public hospitals or to an ophthalmologist in private practice, as chosen by the parents. Students at higher educational levels were referred to optometrists in the community for further vision assessment and correction with spectacles. To ensure that students from poorer socioeconomic backgrounds were not deprived of necessary vision correction, through the NMPP, the Spectacles Voucher Fund was launched. These students would receive a 50 Dollar voucher for spectacle frames, and their spectacle lenses were provided free of charge by a sponsoring partner.

Vision screening was complemented by a public education to increase awareness and encourage outdoor activities. Public forums were also organised regularly to help parents and families understand myopia, including the risks of complications, and to provide tips on how to inculcate good eye care habits in their children. The message was widely promoted through the mass media, including television commercials, the radio and popular parents’ magazines. Information on childhood myopia was also readily available on the website of the Health Promotion Board, Singapore.

NurtureSG, an effort co-led by the Ministry of Health and the Ministry of Education, also recognised that parents play an important role in their child’s eye care. In July 2017, the taskforce published a mini-booklet, ‘5 Habit Hacks For A Healthier Child’, to educate parents on the importance of more time outdoors to prevent the early onset of myopia.

Leo Seo Wei: I have seen all sorts of myopia complications including glaucoma, cataracts, staphyloma, retinal detachment, myopic macular degeneration (lacquer cracks, Fuchs spots, choroidal neovascularization). There has been an increase through the years and the patients are getting younger too. My youngest case of pediatric retinal detachment in high myopia was a four-year-old child!

The ongoing Singapore Epidemiology of Eye Diseases (Seed) High Myopia study found the following: At least two out of three highly myopic adults will develop pathologic myopia by the age of 70. Almost all older adults with extreme myopia of worse than 12 D will develop pathologic myopia when they reach 80 or 90 years of age.

In addition, high myopia can be associated with clinical features that resemble glaucomatous damage, which make an accurate glaucoma diagnosis challenging. Careful longitudinal follow-up is required.

Li Lian Foo: In my practice, I also frequently encounter myopia-related complications, particularly in patients with high myopia. As said, some of the most common complications include myopic macular degeneration, retinal detachment, glaucoma, and early-onset cataracts.

Over recent years, a concerning trend is the increasing number of younger patients developing high myopia, putting them at higher risk of these complications earlier in life. This trend appears to correlate with the rising rates and earlier onset of myopia in children, likely driven by lifestyle factors. As a result, we're seeing a shift towards premature development of myopia-related complications, leading to more frequent cases of vision-threatening issues like myopic maculopathy and retinal issues at younger ages.
 

Li Lian Foo: In my experience, one of the key challenges in pediatric myopia management in Singapore is the intense academic pressure faced by children from a young age. This pressure leads to long hours of near work, such as reading, studying, and using digital devices, which are significant contributors to the early onset and progression of myopia. Reducing near-work activities is a difficult task for many families, as education is highly prioritized in Singaporean culture.

Another challenge is the lack of outdoor time. While there is increasing awareness about the protective effects of outdoor activity in slowing myopia progression, many children still spend limited time outside due to academic demands and the urban lifestyle, where outdoor spaces may be less accessible. Additionally, many parents in Singapore are working full-time and may not have the time to take their children outdoors regularly. This, combined with the hot and humid weather conditions, makes it even more challenging to ensure children get adequate exposure to natural light, which is crucial for myopia prevention.
Furthermore, while Singapore's healthcare system is well-developed, the cost of myopia control treatments, such as Ortho-K lenses or specialized myopia control spectacle lenses or contact lenses, may be prohibitive for some families, limiting their accessibility to more advanced treatment options.

Leo Seo Wei: I would like to add, that sometimes too many options will overwhelm the parents and patient. This results in them switching myopia control options too quickly. Cultural factors such as our heavy emphasis on academic success and the schools’ increasing use of personal learning device (PLD) inevitably result in more near work activity. Environmental factors, such as urban living with limited outdoor space often exacerbate the challenges in myopia control.

Leo Sei Wei: We often need to correct misconceptions. Many parents mistakenly think that their myopic child can simply undergo LASIK (laser vision correction) in the future and that will solve their problems. What they don’t realise is that refractive surgery only gets rid of the need to wear glasses but it does not change the potentially blinding complications of myopia such as retinal detachment and myopia macular degeneration. It is vital to communicate the long-term risks of myopia progression and the importance of early intervention.

Li Lian Foo: In myopia management, I see that actively listening to parents' concerns and preferences is the most crucial aspect of communication, as it enables a personalized approach that aligns treatment plans with their expectations and lifestyle. For optimal outcomes, this must be complemented by providing clear, simple explanations free of medical jargon, showing empathy in addressing their concerns, and maintaining transparency about the potential benefits and limitations of different myopia control strategies. These elements together foster a collaborative and effective partnership with parents.
 

Leo Seo Wei: I have just presented at the ESCRS meeting a network meta-analysis of combination therapy for myopia control. Generally, the combination treatments are seen to work better than monotherapy.

Li Lian Foo: Recently, I’ve been focusing on research that uses AI and fundus imaging to predict high myopia in children. By applying deep learning algorithms to analyze retinal images, we're identifying subtle patterns, particularly in the regions of the optic disc and macula, which may signal a higher risk for progressive myopia. These regions are critical in detecting early changes that traditional methods might miss. The goal is to enhance early detection and provide more accurate risk assessments, enabling timely interventions before myopia progresses to more severe stages. Preliminary findings have shown promising accuracy, potentially transforming pediatric myopia management.
 

Leo Seo Wei: In my opinion, more innovations in optical methods and more clarity on appropriate atropine dose, frequency and tapering regime would be beneficial. I also think, that more data on repeated Low Level Red Light Therapy (which has not been HSA approved in Singapore) will help in future myopia management.

Li Lian Foo: I think that one key innovation that would be most beneficial would be the use of genetic profiling and AI-driven risk prediction models, which has the potential to identify children at higher risk of developing high myopia at an early age. By analyzing genetic predispositions and using AI to predict myopia progression, these tools enable targeted early interventions for those most vulnerable to rapid myopia advancement. This allows for a more proactive and precision approach, where innovative myopia control tools, such as customized optical solutions, atropine eye drops, and emerging therapies like red-light therapy, can be deployed more effectively.