9
Implications for Stakeholders and an Agenda for Future Research

This report has summarized what is known about the current prevalence of myopia, how prevalence has changed in the past several decades, techniques for diagnosing and assessing myopia, factors that contribute to the onset and progression of myopia, the biological mechanisms involved in the development and progression of myopia, options for treating myopia, barriers to the diagnosis and treatment of myopia, and strategies to mitigate these barriers. Across all of these topics, the committee has identified knowledge gaps and made recommendations for future actions to further develop the knowledge base related to myopia and to reduce the incidence and negative consequences of the disease.

This chapter presents implications for stakeholders who would have critical roles in carrying out the recommendations, which are also presented at the end of each chapter where they are organized by topic. Here they are organized by stakeholder group, including eye care professionals; parents and caregivers; policy-making agencies and organizations at the local, state, federal, and global levels; payors; industry partners; and researchers and funding agencies. Some information may be repetitive; this is intentional and aims to facilitate stakeholders from each facet to read a limited number of sections if their preference is to remain focused on how they and their finite resources can affect change. The final section targeted toward researchers and funding agencies proposes an agenda for future research.

OPHTHALMOLOGISTS, OPTOMETRISTS, OTHER CLINICIANS, AND PROFESSIONAL SOCIETIES

While a variety of assessment and diagnostic technologies are clinically available to identify and characterize the myopic eye, there is no consensus on what the mandatory assessment and diagnostic components of a clinical examination of the myopic patient should be, aside from clinical standards for routine and comprehensive examinations in general. This lack of standardization creates variability in clinical care and affects the availability of data for downstream analyses, such as for population studies and artificial intelligence efforts. To address these issues, ophthalmologists, optometrists, and other professionals who conduct vision examinations or screenings, organizations representing them (such as the American Academy of Pediatrics, American Academy of Pediatric Ophthalmology and Strabismus, American Academy of Optometry, and American Academy of Ophthalmology), researchers, and other stakeholders in the field of myopia should discuss and develop consensus standards for the assessments and diagnostics that they deem most important for population-level studies.

Ophthalmologists and optometrists should utilize cycloplegia both for refraction and for visualizing the fundus exam in patients with myopia, particularly for younger patients who have

large accommodative and pupil constriction ability. Fundus imaging is valuable for assessing posterior eye pathologies associated with myopia, as it records color views of the retina. If possible and available, other objective structural measurements of the eye should be obtained, including measurements of axial length and the use of optical coherence tomography.

Vision screening is ineffective without receipt of follow-up eye care for children that need it. Therefore, it is critical that vision screening programs provide effective strategies to ensure that children identified with potential vision impairment receive a comprehensive eye exam by an eye care professional (skilled in providing vision care to children) to diagnose vision disorders and provide treatment. Comprehensive eye exams by eye care professionals, along with facilitators such as social workers or community health workers as patient navigators who assist caregivers with scheduling comprehensive eye exams and provide frequent reminders to attend appointments, have been shown to be effective in increasing follow-up compliance. However, myopia is a lifelong condition requiring follow-up eye examinations and, when needed, replacement of lost or broken glasses. The same barriers to the initial detection of children’s vision problems impact continuing care, underscoring a need for an eye care home.

Treatment options for myopia progression have increased in the last 20 years, with clinical trials showing that axial growth of the human eye can be slowed down with optical and pharmaceutical intervention. Current treatments for myopia progression include multifocal optical corrections (orthokeratology, soft multi- and dual-focal contact lenses, peripheral refractive error spectacles) and atropine eye drops. Atropine is the only pharmacological treatment for myopia progression widely available and used across the globe. Stronger concentrations of atropine produce better treatment effects but more side effects, including rebound effect. Atropine 0.01% is the mostly widely used, although its treatment effects appear limited. Overall, treatments for myopia progression have limited effects. The largest treatment effect of any published treatment option remains under 0.75 diopters (D) over 2 years, based on recent systematic reviews of myopia treatment options. Some treatment options are effective in the first year and less effective in subsequent years.

A majority of counties in the United States do not have a pediatric eye care specialist. The Association of Schools and Colleges of Optometry, the National Medical Association, and the American Medical Association should use innovative means to encourage optometric and medical graduates of all backgrounds to pursue residencies in pediatric optometry, and residents to pursue fellowships in pediatric ophthalmology. Additionally, eye doctors who have no formal training in pediatrics should be encouraged to pursue continuing education to enhance vision care of the child. Innovative strategies that create direct collaboration patterns and incentive programs to improve the vision care workforce, especially the workforce in medically underserved communities, are likely to foster increased access to care.

Professional associations such as the American Academy of Optometry, American Optometric Association, and American Academy of Ophthalmology should create a national database of eye care providers that provide care to children, especially children under the age of 6 years, and the types of health insurance they accept. This database should be in a format that is easily accessible by caregivers and the general public.

INDIVIDUALS WITH MYOPIA AND PARENTS/CAREGIVERS OF CHILDREN WITH OR AT RISK OF DEVELOPING MYOPIA

Time outdoors is consistently reported to protect against myopia, especially in the younger years. Exact recommendations for exposure time and time of day are yet to be developed, but existing evidence shows that time outdoors for children during daylight can delay (or may even prevent) the onset of myopia. This is a significant finding, as children whose onset of myopia occurs at a young age are more likely to develop a higher amount of eventual myopia than children with onset at older ages. It is also important to ensure that outdoor time is safe for the skin by using sunscreen, and hats or sunglasses should be worn to protect the eyes against short-wavelength exposure.

As discussed in Chapter 8, children ages 12 months to 3 years should receive instrument-based screening to detect disorders of the eye that may lead to vision impairment from amblyopia, and children should receive visual acuity screening at ages 3, 4, 5, 6, 8, 10, 12, and 15 years. Instrument-based screening is recommended as an alternative to visual acuity assessments for children ages 3 to 5 years who are unable or unwilling to complete visual acuity screening or who have developmental delays or neurodevelopmental disorders such as attention deficit hyperactivity disorder (ADHD) or autism spectrum disorder (ASD). If any component of the vision screening is abnormal, the parent or caregiver should receive a referral to take the child to an eye care provider for a comprehensive eye examination. As myopia is a lifelong condition that worsens throughout childhood, it is important to establish an eye care home and adhere to treatment long-term, including replacement of corrective glasses if broken or lost.

POLICY-MAKING AGENCIES AND ORGANIZATIONS AT THE STATE AND LOCAL, FEDERAL, AND GLOBAL LEVELS

Local and State Departments of Health and Departments of Education

Vision screening is important in identifying children with vision impairment and facilitating access to treatment, but many children are not receiving vision screening and, when they do, they often do not make it to the eye doctor or get the needed glasses. One model that has been used successfully is to provide vision screening to all children in congregate locations (schools, fairs, etc.). An alternative that has been successful when resources are scarce is to offer vision screening to targeted groups at increased risk of vision problems or of not receiving treatment. For underserviced populations, vision screenings held at community health centers and federally qualified health centers are an excellent way to provide access to vision care. To expand universal screening programs, school boards can also take advantage of Medicaid dollars provided through the Healthy Schools Campaign.

Vision screening is ineffective without receipt of follow-up eye care for the children who need it. Therefore, it is critical that vision screening programs provide effective strategies to ensure that children identified with potential vision impairment receive a comprehensive eye exam by an eye care professional (skilled in providing vision care to children) to diagnose vision disorders and provide treatment. These strategies should involve deliberate and collaborative efforts between eye care providers, public health units, health insurance plans (Medicaid and the Children’s Health Insurance Program), early-intervention and school-based services, and other stakeholder institutions and agencies.

Onsite comprehensive eye exams by eye care professionals, in conjunction with facilitators such as social workers or community health workers who assist caregivers with scheduling comprehensive eye exams and provide frequent reminders to attend appointments, have been shown to be effective. Strategies to ensure compliance with treatment and receipt of follow-up eye care should extend beyond the initial comprehensive eye exam to support the replacement of broken or lost glasses and ongoing comprehensive eye care and the establishment of an eye care home. Future coordinated care should follow “Best Practices and Policy: 12 Components of a Strong Visual Health System of Care” provided by the National Center for Children’s Vision and Health, especially as myopia is a lifelong condition requiring regular intervention.

Federal Agencies

Myopia is a disease with increasing worldwide prevalence and severity, and the impact of its downstream complications needs to be taken seriously. Federal agencies have an important role to play in promoting behaviors that may be protective against myopia, as well as promoting the screening, diagnosis, and treatment of myopia. An important first step is for the Centers for Medicare & Medicaid Services to classify myopia as a disease and therefore a medical diagnosis. This reclassification is needed to ensure that efforts not only to treat blurry vision resulting from uncorrected or undercorrected refractive error, but also to prevent and manage the progression of myopia. This may help get the warranted attention from stakeholders such as federal and state agencies, professional associations, patients, and caregivers, thus increasing feasibility of care for the public beyond a simple pair of glasses.

The Centers for Disease Control should produce guidelines, supported by departments of education and healthcare providers, promoting more time outdoors for children. Consideration should be given to ensure that outdoor time is safe for the skin and eye by using sunscreen and other protection against short-wavelength exposure. These guidelines should include children across the age range of 3 to at least 16 years.

The U.S. Department of Health and Human Services, in collaboration with departments of education at the state level, should take measures to ensure that children receive a vision screening before first grade and a comprehensive eye exam when needed. To facilitate this:

• Federal agencies, such as the Centers for Disease Control and Prevention, and other agencies that support public health programming should encourage the implementation of effective vision care programs for children by providing funding or other incentives for vision health care systems that follow the 12 Components of a Strong Vision Health System of Care provided by the National Center for Children’s Vision and Eye Health.
• The Department of Health and Human Services (DHHS) should oversee the provision of cost-effective, standardized, evidence-based national vision screening guidelines to detect refractive errors, amblyopia, and other vision conditions. These guidelines should include a consensus on the ideal target age for screening, screening frequency, types of screening tests, tools, and referral criteria.
• For children under age 7, the referral criteria for instrument-based screening should include any amount of myopia or a family history of myopia based on the evidence that these predict likely progression to significant myopia.

• The Centers for Medicare & Medicaid Services should require reimbursement for vision screening to not be bundled into the global code of well-child visits.

An integrated, national data surveillance system for collecting data on vision screening, referrals to eye care providers, and outcomes of referrals at the state level is also needed. This data system would not only enhance care integration and communication, but also enable monitoring to ensure that follow-up care is received. A surveillance system would also support the DHHS Office of Disease Prevention and Health Promotion’s (OASH) Healthy People 2030 goal of increasing the proportion of children who get vision screening. To facilitate the creation of this system:

• The Centers for Medicare & Medicaid Services should include vision screening in the Core Set of Children’s Health Care Quality Measures that are reported annually by all states.
• The National Institutes of Health’s All of US Research Program and Healthy Brain and Child Development Study should include additional measures of adult and child vision disorders.

Global Organizations

Global organizations such as the World Health Organization and the International Myopia Institute should collect best practices for improving access to vision care for medically underserved populations.

The Centers for Disease Control and Prevention should coordinate with the World Health Organization so that both organizations are using consistent, harmonized definitions and monitoring methods. Data subsequently collected should then consistently follow these methods so that future worldwide comparisons can be used to identify the influence of economic development, lifestyle, and ethnicity on the prevalence of refractive error.

International and national entities (e.g., International Myopia Institute, National Eye Institute, and similar) should collaborate to further efforts to develop a consortium/network repository for myopia-related clinical data. This would be beneficial for standardization not only for clinical care but also for research, particularly with artificial intelligence efforts.

PAYORS

As mentioned above, for patients with myopia, particularly for younger patients who have accommodative ability, clinicians should utilize cycloplegia both for refraction and for visualizing the fundus. Clinicians should also obtain other objective assessments of the eye, including more robust structural measurements such as axial length and optical coherence tomography. Health and vision insurance providers and other payors should reimburse for evaluation of these tests that may help identify disease elements of myopia, in addition to the determination of refractive error. Such examinations and tests should be covered at least annually to allow for longitudinal, cohesive care.

INDUSTRY PARTNERS

Children are most at risk for progression of myopia, and designing assessment and diagnostic technologies tailored to children enhances the description of their myopic eyes. This may allow for more precise treatment for this critical population. Developers of assessment and diagnostic technologies should consider the ability to use the technology in multiple age groups and settings as a major design criterion. This includes making the technology time-efficient to perform and “child-friendly.” Technologies that are portable and cost-effective for the end user are also more likely to increase accessibility and have broader adoption.

Researchers and developers of assessment and diagnostic technologies should design assessments and tests to better understand the myopic eye, its development, and its environment (the visual diet). In addition to identifying eyes that are already myopic, there is a need to also identify eyes at risk of myopia (i.e., pre-myopic state in childhood) or other key events (e.g., pre-pathologic myopia state in adulthood). Other diagnostic technologies to support these goals include, for example, biometric and functional measurements to develop individualized eye modeling, improved choroidal imaging, and imaging technologies to measure 3D eye shape and assess the refractive state across the entire retina.

Technologies to better capture and quantify the visual experience of children and animals included in studies of myopia are also needed. Industry partners have an important role in providing:

• Comprehensive quantification of the features of the visual diet of preschool and school-age children; and
• Sensors that can be used by researchers to accurately monitor the visual diet of children including time outdoors, working distance, and screen time.

Developers of electronic devices should collaborate with academic scientists to conduct research on the visual consequences of the use of electronic devices, especially in children at risk of developing myopia.

RESEARCHERS AND FUNDING AGENCIES

The committee identified many gaps in the knowledge base related to myopia. This section presents an agenda for data collection and research organized by topic area, including prevalence, factors that contribute to the onset and progression of myopia, mechanisms involved in myopia pathogenesis, treatment strategies and barriers to detection and treatment of myopia.

Myopia Prevalence

While there is evidence that myopia is increasing worldwide, there are scant data for the current prevalence in the United States, and existing data are not sufficient to precisely quantify the increase in prevalence (see Chapter 3). One major limitation of the research on prevalence is inconsistency in what is used as the threshold for determining myopia; in reviewing the literature, the committee encountered studies that used a range of cut points (0.25, 0.50, 0.75, and 1.00 D); measurement techniques and the age of assessment also vary across studies. The manner in which myopia is determined is also heterogenic including automated measures, lensometry,

self-report, and others. Large-scale surveillance studies with representative populations have not been funded in more than 20 years. To improve data on prevalence in the United States:

• The Centers for Disease Control and Prevention and state health departments should collect consistent data on the prevalence of myopia in the United States, prioritizing surveillance on myopia prevalence in children and using standardized procedures. A central repository should be created so that consistent data can be uploaded into a central data base.
  • For such population statistics, the data should comprise objective measures at various ages, collected longitudinally from an early age, and repeated cross-sectional measurements using consistent methodology.
  • The data should include the entire distribution of refractive errors, not just the mean and the age of onset. Otherwise, a shift in part of the distribution (e.g., high myopia) or age of onset (e.g., starting before age six) that would suggest the need for different policy/practice responses could be obscured.
• Researchers investigating myopia prevalence should use standardized procedures and upload data into a central database. The data should comprise objective measures at various ages, collected longitudinally from an early age or by repeated cross-sectional measurements using constant methodology. The data should include the entire distribution of refractive errors, not just the mean and the age of onset. New data-gathering efforts should place U.S. data in the context of worldwide trends to allow for comparisons to formulate novel hypotheses about etiology and treatment development especially related to national education policies and practices, urban development, and outdoor lifestyle tendencies.
• The National Institutes of Health’s All of US Research Program and its Healthy Brain and Child Development Study should include additional measures of adult and child vision disorders that would generate valuable data across the country that will inform research questions and eye care policies.

Factors that Contribute to the Onset and Progression of Myopia

The environmental variable with the highest level of evidence contributing to myopia is the protective effect of time outdoors (see Chapter 5). The implication is that the prevalence of myopia is increasing, at least in part, because of inadequate time spent outdoors by recent generations of children. Of the features of the outdoor environment that may be beneficial in delaying the onset of myopia, the strongest evidence is for increased luminance (i.e., brightness), which likely works, at least in part, through dopaminergic signaling. However, studies addressing other salient differences between the indoor and outdoor environments, such as the spectral composition of light (i.e., light at different wavelengths), have yet to be tested widely in humans. Furthermore, the data supporting the roles of near work and electronic devices in myopia is limited or inconclusive, even though these factors are often stated as the cause for myopia. (See Chapter 5 for discussion of the research on near work and electronic devices.)

The National Institutes of Health and other funders, including private foundations, should solicit and fund research to investigate novel questions about the genetic and environmental mechanisms contributing to myopia, with special emphasis on the following topics:

• Identification of specific features of the indoor and outdoor visual diet that cause or inhibit myopia development, including luminance levels and spectral characteristics of different light sources.
• The “ON/OFF imbalance hypothesis” which potentially links many salient visual differences between the outdoor and indoor environments with retinal pathways that have been implicated in myopigenesis, including dopaminergic amacrine cells and intrinsically photosensitive retinal ganglion cells (ipRGCs).
• The role of near work in causing myopia, versus other factors in the environment while engaging in near work which emphasize:
  • Preschool children as well as school-aged children, with special attention to the ages at which children are first exposed to these visual stimuli
  • Children at risk for the development of myopia
• Longitudinal studies of environmental risk factors for myopia that incorporate technologies for data capture of working distance, temporal properties of near activities, and the spectral characteristics of indoor and outdoor activities.
• Studies to further develop and validate promising diagnostic biomarkers (e.g., axial elongation and choroidal thickness changes, ocular shape, optical aberrations) and technologies that may be useful for myopia diagnostics, management, and understanding of the disease.
• Studies to assess both genetic factors—including polygenic scores—and environmental factors to account for confounding and interactive effects.
• Studies in animal models to better understand the mechanisms through which genetic and environmental influences lead to myopia.

Mechanisms Involved in Myopia Pathogenesis

While retinal signaling has been shown to be fundamental to emmetropization and myopia development, as opposed to higher order brain processing, the precise causal mechanisms that underlie this process have remained elusive (see Chapter 6). Importantly, the entire retina, not only the fovea, plays a critical role in regulating eye growth. Two potential mechanisms include, the ‘luminance network” and a closed feedback loop for homeostasis of eye growth.

The ‘luminance network’ of the retina has been proposed as a mechanistic link between the reduced time today’s child spends outdoors and the increased incidence of myopia. This network encodes light intensity and includes dopaminergic amacrine cells and melanopsin-expressing intrinsically photosensitive retinal ganglion cells, and is uniquely dependent on some subset of channels within the retinal ON pathways. However, a gap in knowledge exists as to how this system controls refractive eye growth. Closed-loop feedback is hypothesized to be essential for achieving precise homeostasis of eye growth. However, the exact roles of candidate retinal image properties—such as defocus, blur, contrast (spatial, spectral and temporal) and chromaticity—responsible for fine-tuning this process are currently unknown, and so are the specific mechanisms through which these features are encoded by the retinoscleral signaling cascade. More research is needed to determine how the retina encodes these image features and links them to refractive growth signals.

Funding agencies, including the National Institutes of Health, the National Science Foundation, the Department of Defense, and private foundations, as well as industry, should seek

to fund proposals across disciplines for both human and animal studies to investigate the biological and optical mechanisms of emmetropization and myopia. These studies should include:

• determining the visual environments stimulating ON pathways,
• molecular contributions to refractive eye growth,
• modeling studies to determine the interaction of contributing ocular and environmental elements,
• identification of candidates for retinoscleral signaling and retinal neurons that detect the sign of defocus,
• elucidating the role of the choroid in regulating eye growth,
• the changes in the sclera that lead to axial elongation,
• the influence of gene–environment interactions of myopia susceptibility,
• and the development of in-vitro experimental models to probe causal mechanisms on a cellular and subcellular level.

To accomplish this, funding agencies should target audacious proposals to foster the innovative, multi-disciplinary research that is needed to fully harmonize our understanding of visual information processing by the retina that leads to changes in scleral remodeling. Particular gaps in knowledge include the roles of the visual environment, ocular optics, retinal circuits, and signaling proteins involved in retinoscleral signaling, particularly the luminance pathway.

Experimental evidence from animal models indicates that the fovea is not necessary for emmetropization and myopia development. Thus, the field of myopia research should adopt a retinocentric—in contrast to a foveocentric—approach. Specifically:

• basic researchers should develop eye models that can be readily tailored to individual variation (“personalized models”) to link the visual diet to image formation across the entire retina.
• clinical researchers should propose optical treatments with a full understanding of the consequences for the peripheral retinal image.

Screening, Diagnosis, and Treatment

While treatment options for myopia progression have increased in the last 20 years, current optical treatments and the use of the only pharmacological treatment widely available, have limited effects (see Chapter 7). Time outdoors, an emerging treatment strategy is consistently reported to have protective effects. The current state of knowledge on treatment options reflects our limited understanding of the fundamental mechanisms of eye length regulations.

Current literature suggests that combination therapy shows minimal to no additive impact. However, studies have only used the minimally effective 0.01% concentration of atropine in combination with other treatments. Combination therapy should be studied using higher concentrations.

Clinical trials for myopia treatments have provided important insights into the progression of myopia. Predictors of myopia progression include a child’s existing refractive error, age, sex, and ethnic identity. Past myopia progression does not predict future progression.

Myopia tends to progress faster when onset is at younger ages, which may suggest early treatment of myopia in the preschool years. It is unclear whether treatments known to be effective for low to moderate myopia in school-aged children are effective in preschool-aged children, and also unclear whether treatments for low to moderate myopia in school-aged children are effective in children with high myopia or myopia associated with genetic and systemic disorders.

Funding agencies and other funders, including the National Institutes of Health, Research to Prevent Blindness, and others, need to support research to develop new treatment strategies for myopia, and to determine mechanisms for current treatments. Progress in this area needs intentionally integrated, multidisciplinary basic and clinical vision science research. Areas of urgent focus are listed here.

• Develop fundamental studies—potentially including animal models—of the mechanisms by which existing and new therapies affect eye growth.
• Perform research on the mechanisms of atropine to determine the causes of treatment effects and side effects, thereby providing opportunities to optimize the treatment efficacy in children or to develop novel pharmaceuticals with fewer side effects.
• Design studies to identify the ideal dosing characteristics, including concentration and cadence, for more specific pharmaceuticals to slow eye growth.
• Develop new pharmaceutical options to provide structural scleral reinforcement, without creating dose-dependent side effects. Further research is needed to identify and develop pharmacological agents that are more effective and have fewer adverse effects than current options.
• Determine optimal parameters for time outdoors, including duration per day, chromatic elements, time of day, and needed safety measures, in order to prevent or delay myopia onset. Such studies may create the opportunity to develop treatments for myopia that can be used indoors, independently of time outdoors.
• Develop rigorous investigations of combination therapies.
• Conduct longer-term studies or assessments in adulthood to weigh the costs of myopia treatment against it benefits in terms of the ultimate amount of myopia and effects on ocular health.
• Combine bench and eye model studies of visual optics including the spectral composition of light, peripheral refractive characterization, and contrast to develop optical corrections for best visual performance and optical quality.
• Identify biomarkers of the pre-myopic, myopic, and treated eye to reveal novel pathways that can delay or prevent onset of myopia, to identify when to start treatments, and to monitor the effects of imposed treatments. A short-term biomarker that could reliably predict longer-term treatment outcomes is required.

It seems likely that myopia control treatments are to be used throughout childhood and perhaps through young adulthood, so the safety of any treatment is paramount. Scientists should focus on developing strategies to minimize short-term and long-term side effects.

Funding for multi-center randomized clinical trials should be directed toward longer-term human studies starting at earlier ages, on treatment and off treatment, to determine the long-term benefit with respect to ultimate refractive error and ocular health.

Barriers to Detection and Treatment of Myopia

While myopia can be identified through vision screening and comprehensive eye exams, multiple barriers exist to identifying and treatment myopia (see Chapter 8). Myopia starts at an early age when children are not able to communicate, or even realize, that they have blurry distance vision. Further, it is necessary that vision screening is followed by comprehensive eye exams and treatment. There are significant barriers to conducting research on these factors, including poor data collection for surveillance, limited funding to conduct research, ethical concerns about randomized trials, and poor representation of minoritized populations in research. The following recommendations focus on research areas that could facilitate removal of these barriers.

The National Institutes of Health, Agency for Healthcare Research and Quality, and other organizations that support research, such as Research to Prevent Blindness, should seek and encourage opportunities to fund work that will support continued efforts to determine:

• The effectiveness, cost-effectiveness, and implementation of novel interventions to improve access to vision screening and completed referrals to eye care providers compared to standard of care, especially for underserved populations that typically experience inequities in accessing care;
• The prevalence of myopia, referrals to eye care providers, completion of comprehensive eye exams, and treatment in children;
• Differences in reimbursement processes (e.g., bundled vs. unbundled with global code for well-child visits), reimbursement rates for various vision care services, and coverage for prescription glasses across the states; and
• Strategies for promoting completed referrals, follow-up care, compliance with wearing prescribed glasses, and improved public awareness on vision and eye health in children.

SUMMARY

Despite decades of research in myopia, there is much to be learned. The preponderance of evidence suggests that myopia should be treated beyond simply correcting blurry vision. It is a disease that can affect long-term visual health. Effectively treating myopia will require audacious research that translates vision and animal science to clinical practice patterns. Care of the myopic child who becomes the myopic adult will require intentional integration and coordinated strategic policies as the local, state, national, and global levels. Myopia is no longer just for eye doctors.