Olga Prenat: What was the driving force behind developing the IMI white papers?

Serge Resnikoff: The initial driving force was the late Professor Brien Holden, who was a true visionary. He recognized that myopia was becoming a significant public health issue and was keen to bring different forces together to address this. It all started with a momentous World Health Organisation scientific meeting on myopia in 2015, from which there were two clear outcomes— first, that myopia research and treatment was a constantly evolving area, and second—that it was critical to make the latest research accessible for practitioners. This impetus was really necessary to get things moving for the International Myopia Institute. The momentum was then sustained by Brien Holden Vision Institute, and the driving force now is the group of stakeholders involved in myopia management, including the scientific community, the clinicians and the industry, who have a common vision and are pushing things forward.

It is really about the mission of improving people’s lives through better vision. We are bringing all the different stakeholders in the eye care industry together, and hopefully we can also reach those who can really impact change, including the wider audience of health workers, educators, government and peak health bodies.

Monica Jong: It is really about the mission of improving people’s lives through better vision. We are bringing all the different stakeholders in the eye care industry together, and hopefully we can also reach those who can really impact change, including the wider audience of health workers, educators, government and peak health bodies.

Olga Prenat: What influenced you to be involved in this landmark effort?

Earl Smith: I have always been interested in the role of vision and how it influences the emmetropization process. Almost every child is clinically emmetropic by the time they are 3-4 years of age, and for this to happen, there must be a precise match between the eye’s axial length and its optical length. A mismatch as small as the thickness of an eyelash is enough to reduce vision performance. The eye is able to achieve this precise match in a large proportion of children early in life, which is a magical feat that caught my interest a long time ago. The primary reason to study emmetropization is to understand why in some children the eye becomes myopic later in life, largely associated with the onset and intensity of education. From a scientific perspective, it is a very interesting problem that has important public health implications.  I became much more active outside the lab with initiatives such as IMI, primarily because of the influence of Professor Brien Holden and his global efforts to eliminate preventable vision disability.

Ian Flitcroft: I started off life as a vision scientist in the 1980’s and back then, my supervisor Stuart Judge’s close friend Josh Wallman converted me to the new scientific religion of emmetropization. As a clinical pediatric ophthalmologist later on I was interested in this topic, but I saw that it was not really being applied. Research shows that it takes around 17 years from the first evidence of efficacy of a clinical intervention to widespread adoption, so my mission for the past few years has been to help narrow this gap. I also met Professor Brien Holden in 2015 and he was pivotal in raising the profile of myopia as an international issue. Kovin Naidoo, former CEO of Brien Holden Vision Institute and now Senior Vice President Social Impact: Africa & Latam and Advocacy at Essilor International, also played an important role back then to keep the momentum going. One of my missions is to shorten this time period of 17 years, by having a foot in both basic and clinical research as well as being an advocate for myopia management. I see IMI as a mechanism for chipping off a few years from this process.

Monica Jong: I was first exposed to myopia research through Professor Neville McBrien’s lectures in school, and was really fascinated about myopia and being able to alter the axial length of the eye through lenses. I eventually met Professor Brien Holden after finishing my postdoctoral fellowship and like many of you, he set me on the path here. It is also a very personal mission for me and I want to really improve people’s lives through better vision. One of my eyes is highly myopic and I have many family members who have high myopia, as high as -9.00D and -18.D. Myopia definitely had an impact on my quality of life as a child growing up. If I had known that all this knowledge was available back then, I might have had a different final refractive error and reduced my risk of future ocular complications.

Serge Resnikoff: I also met Brien Holden while I was working at the World Health Organization. Prior to that, I had worked as an ophthalmologist in Africa for 16 years, performing cataract surgeries and trying to control trachoma and river blindness. What I realized back then was that it is possible to make very significant changes globally from a public health perspective, for example, eliminating trachoma as a public health problem. When we had our first discussions with Brien in 2000, it was about uncorrected refractive errors and much broader than myopia, but for me it was very clear that this was the next main battle for the eye care community on a global level. Being involved in this is very exciting and can really enable us to change the face of the world, but we need to work together and translate science. It’s not easy, but it can be done.

Olga Prenat: Were there any obstacles that you had to overcome and how has the journey been so far?

Monica Jong: In its infancy, many people took some time to want to participate in the white paper process. Looking back now, it was quite a natural process of working in a very transparent way and being focused on the mission to advance myopia research and education. It was also possible thanks to our initial trailblazers like Ian Flitcroft, Earl Smith and Christine Wildsoet, followed by James Wolffsohn, who also independently came up with a similar concept. All this helped to really cement IMI.

Earl Smith: I think an important step was the collaborative relationship that developed between IMI and the International Myopia Conference (IMC). Getting IMI and IMC together has helped a lot in identifying who might be interested in being involved in this effort. 

Ian Flitcroft: On the journey so far, my verdict is that the train has just left the station. Getting the train out of the station was not a trivial undertaking as it involved building a station, building a train and getting people on the train. We are now slowly building the tracks in front of us. The section of the tracks that we still need to build includes educating everyone coming out of top-tier optometry schools in a different mode of thinking and also reeducating current practitioners in active management. Another section of the tracks that we need to build is a viable business model, without which it is difficult to reach the mass market. Until we can get enough of the population managed, we are not going to shift the dial.

Serge Resnikoff: Bringing people from very different places on the planet to work together on a voluntary basis and in a transparent manner was challenging to some extent. It also took some time for people to trust that IMI was not driven by the agenda of a single organization, and was a truly collective effort. It is also important to keep in mind that there is no ‘one size fits all approach’ when it comes to myopia management across different regions. IMI has managed to deal with this so far, and this is an ongoing challenge for us.

Olga Prenat: Could you share some key milestones and successes of this historic effort?

Serge Resnikoff: Key milestones include the establishment of IMI in 2015, the publication of the white papers in February 2019, the dissemination and presentation of the papers in conferences including Association for Research in Vision and Ophthalmology (ARVO), American Academy of Optometry, International Myopia Conference, and World Ophthalmology Congress. Other important milestones have been holding our advisory board meetings. Since we are functioning as a virtual network, meeting physically for these advisory board meetings has been important, because this is where we can really assess and discuss the way forward. The next important milestone will be the new series of the white papers which will be published in 2021. 

The next important milestone will be the new series of the white papers which will be published in 2021.

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Olga Prenat: How important is it to build a strong foundation on myopia management for practitioners and how will standardization help in research and patient management in the future?

Ian Flitcroft: Since myopia management is a new therapeutic area, there is a unique chance to standardize right from the start. There are some shining examples where standardization helps to both coalesce research and allow research to be compared and implemented, such as in diabetic retinopathy and retinopathy of prematurity. I don’t think we have convinced everybody with the white paper on definitions and classifications of myopia, but we have set some standards. The bedrock of evidence-based medicine has to be a cohesive set of standards and reporting standards, which are both equally important.

Monica Jong: The classification of myopia is really critical. The definitions paper at least sets a standard so that clinicians talking about patients know that they are talking about the same thing. Pre-myopia is an entirely new definition that was put forward in the white paper, which is particularly helpful for clinicians. If they can see signs of pre-myopia based on the age and level of hyperopia, they can provide lifestyle counseling advice. Having such definitions could help standardize clinical trials or advance research studies and also allows for easier comparison among studies.

Olga Prenat: What do you think is critical to see a paradigm shift in the way clinicians practice myopia management, and how long will it take?

Ian Flitcroft: I’m hoping it will take less than 17 years! I think a paradigm shift is going to take one of two things—clear guidance on the minimum standard of care from professional organizations and associations. Professional organizations can take a better lead, but it is also equally important for people involved in research to give them information that allows them to make that leap of faith. The second aspect which people don’t want to talk about is financial incentivization, which changes behavior faster than almost anything else. We’re also missing a simple, safe, easy and effective treatment at the moment, which needs to be easy for eye care practitioners, parents and easy for the children too. That’s a good goal to aim for.

Earl Smith: I agree that educating eye care practitioners is important, but it also needs to go beyond that to educate the broader medical community on the public health impact of myopia. Pediatricians and school nurses are often the first to measure visual acuity in children, but unfortunately many still don’t think myopia is a treatable condition. Moreover, a lot of eye care practitioners are not comfortable prescribing contact lenses or atropine to young patients, so if we could develop spectacle lens designs that are as effective or more effective, it will go a long way in moving the needle. In essence, we need a safe and effective treatment, which is suitable for a large proportion of the population.

Olga Prenat: What’s next—in 2020, 2021 and beyond— do you foresee any challenges?

Serge Resnikoff: Other than the white papers, we have decided to produce yearly digests so that people are better informed about significant new findings presented globally. If we want to have a global impact, it is critical that we have better communication with different countries, so we are also setting up a network of ambassadors to translate science for eye care practitioners in that specific country. We are also looking at ways of better involving general practitioners and pediatricians. Finally, it is important to get the parents involved in understanding what myopia is, what opportunities exist and why these opportunities are so important to take advantage of.

Olga Prenat: What else needs to be done to advance clinical myopia management globally?

Ian Flitcroft: Going back to Earl’s religious conversion theme, the people who are the biggest enthusiasts of religion are the most recent converts, and the most recent converts are practitioners who have either incorporated myopia management in their practice or reimagined their entire practice around it. They are going to be some of the most influential people in getting everyday practitioners to adopt myopia management.

Earl Smith: First—education is going to be critical to broadening the reach of this technology. Second—getting a simple, safe and effective treatment option that can be used with almost any person, is absolutely key.

Monica Jong:  Accessibility of myopia management solutions is important. A simple solution with no side effects suitable to manage myopia in most children would be the ideal solution. At the same time, advocacy at the peak health body level and producing evidence for policy makers about the burden of myopia is essential. Once you have policy in place, then associations will adopt these new standards of care.