Editor’s Perspective

Myopia Management Begins with Lifestyle and Visual Hygiene Guidance

January 3, 2022

By Dwight Akerman, OD, MBA, FAAO, FBCLA, FIACLE

When should myopia management be implemented, and on which children? Progression is highly likely once a child is identified as pre-myopic or myopic. The goal of myopia management is to limit axial length and refraction as much as possible but certainly to keep the axial length below 26 mm and Rx less than -6.00D. According to the International Myopia Institute Prevention of Myopia and Its Progression report, at a minimum, lifestyle advice and visual hygiene guidance should be provided to all pre-myopic and myopic children. This advice encompasses outdoor exposure, close work time, and working distance. 

Outdoor exposure during childhood is the most critical lifestyle risk factor known thus far. Outdoor exposure prevents or delays the onset of myopia and potentially slows progression. The protective effect of being outside is currently explained by a high light intensity leading to a higher retinal dopamine secretion, although other mechanisms may also play a role.

A practical piece of advice that combines several recommendations is the 20-20-2 rule: after 20 minutes of close work, children should gaze in the distance for at least 20 seconds, and play outside for at least 2 hours a day. In addition, close work should be performed at a distance of at least 12 inches (30 cm.)

In summary, eye care professionals should advise children and parents to:

  • Apply the WHO guidelines for children under 5 years of age.
  • Ensure that children over the age of 5 spend more time outdoors and less time on digital devices. Recommend outdoor sport and play of at least 2 hours per day in total, spread between outdoor school activity and after school.
  • Take breaks every 20 minutes by looking across the room for 20 seconds when using a digital device or reading and spend a minimum of 2 hours per day outdoors (20-20-2 rule).
  • Children should not spend more than three hours a day – in addition to school time – on close work such as reading, homework, or screen-time.
  • Reading and digital device usage should be performed at a distance of at least 12 inches (30 cm.)

For further information on this critical topic, please read the excellent article written by Dr. Divya Jagadeesh, Which Environmental Factors Potentially Reduce the Progression of Childhood Myopia? 

Best professional regards,

Dwight H. Akerman, OD, MBA, FAAO, FBCLA, FIACLE
Chief Medical Editor

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