Research Library

High myopia (≥ −6.00 D) triples open-angle glaucoma risk — and with 940 million high myopes projected globally by 2050, East Asia faces a compounding glaucoma epidemic within a single generation.

• Global myopia projected at 49.8% (4.76 billion people) by 2050; high myopia at 9.8% (938 million)
• East Asia accounts for ~65% of global high myopia burden; Singapore adult myopia prevalence is 82% (SiMES cohort)
• High myopia (≥ −6.00 D) carries OR 3.3 for primary open-angle glaucoma across a 12-study meta-analysis
• High myopes show ~0.8 dB/year faster visual field progression compared with emmetropic glaucoma patients

Singapore's national School Myopia Programme has reduced Primary 1 myopia prevalence from ~34% in 2000 to ~26% by 2023 — proof that structured outdoor time and early atropine use work at a population level.

• P1 myopia rate: ~34% (2000) → ~26% (2023), a 23% relative reduction in under 25 years
• ATOM-2 trial: atropine 0.01% achieved 52% reduction in myopia progression vs placebo over 2 years
• National SMP recommendation: ≥ 2 hours outdoor time daily, in place since 2016
• SCORM study: each additional hour outdoors per day correlated with −0.17 D/year less myopia progression

The 2026 Singapore optometry consensus aligns with IMI: HAL spectacles and 0.05% atropine now rank as the highest-efficacy single interventions, with combination optical-plus-pharmacological therapy offering up to 75–80% axial length reduction.

• HAL lenses (Stellest, Essilor): ~67% reduction in axial elongation vs monofocal at 2 years; 3-year follow-up data confirmed 2024
• DIMS lenses (MiYOSMART, Hoya): ~52% axial length reduction vs monofocal at 2 years; 3-year data confirms maintained efficacy
• Ortho-K: 32–55% AL reduction across published RCTs vs spectacle control
• LAMP-2 trial: atropine 0.05% achieved 57% slower progression vs 24% for 0.01% — now preferred first-line pharmacological dose in Singapore for fast progressors

TFOS DEWS III (2025) redefines dry eye disease around three driver subtypes — Evaporative, Aqueous-Deficient, and Pain-Dominant — and recommends a maximum of two diagnostic tests for standard optometry settings.

• Three primary driver subtypes: Evaporative (MGD-dominant), Aqueous-Deficient (lacrimal gland dysfunction), Pain-Dominant (central sensitisation)
• Two-test diagnostic pathway endorsed: OSDI ≥ 13 + NIBUT < 10 s or FTBUT < 10 s is sufficient for primary care diagnosis
• 30–40% of DED patients carry a mixed subtype; treatment-refractory cases must be screened for pain-dominant subtype
• Meibography now formally endorsed as standard-of-care for MGD grading in clinical optometry settings

TFOS DEWS III replaces the single treatment step-ladder with three parallel, driver-targeted algorithms — one for each DED subtype — because a single escalation sequence fails mixed-subtype and pain-dominant patients.

• Algorithm 1 (Evaporative/MGD): warm compress + lid hygiene → IPL or LLT → topical cyclosporine → omega-3 in this subtype only
• Algorithm 2 (Aqueous-Deficient): preservative-free artificial tears → punctal plugs → topical cyclosporine 0.1% or lifitegrast → autologous serum
• Algorithm 3 (Pain-Dominant): identify central sensitisation; co-manage with specialist; pharmacological options outside optometry scope
• Omega-3 removed from universal first-line; retained only in Algorithm 1 (Evaporative) — not for aqueous-deficient or pain-dominant subtypes

SNEC data shows a threefold rise in trabeculectomy rates among Singapore adults aged 40–50 over the past decade, with high myopia identified as the primary independent risk factor for early surgical intervention.

• Trabeculectomy in 40–50 age group at SNEC: 3× increase from 2012 to 2022
• High myopia (AL > 26 mm) independently associated with ~0.8 dB/year faster VF progression vs emmetropic glaucoma patients
• 40% of new glaucoma diagnoses in Singapore's 40–50 age group had pre-existing high myopia
• IOP response to prostaglandin analogues ~23% lower in high myopes — proposed mechanism: thinner, more compliant sclera

The 2023–2025 IMI update confirms HAL spectacles and 0.05% atropine as the highest-efficacy single interventions, with combination optical-plus-pharmacological therapy achieving up to 80% axial length reduction — the strongest evidence yet for combination myopia control.

• HAL (Stellest): 67% reduction in axial elongation vs monofocal SV; 3-year sustained efficacy confirmed 2024
• DIMS (MiYOSMART): 52% AL reduction vs monofocal at 2 years; 3-year data maintains effect without rebound
• 0.05% atropine (LAMP-2): 57% slower progression vs 24% for 0.01% — superior evidence for fast progressors
• Repeated low-level red light (RLRL): 75–80% slower AL elongation in RCTs — highest single-modality efficacy; not yet registered in Singapore as of 2026

TFOS DEWS III does not replace DEWS II — it refines it: the 2017 vicious cycle model is retained but extended with neuropathic pain as a distinct disease driver and the ocular surface microbiome as a new homeostasis modulator.

• DEWS III retains: hyperosmolarity + inflammation + neurosensory abnormality as the core triad; OSDI as primary symptom measure
• DEWS III adds: ocular surface microbiome as a homeostasis modulator; Pain-Dominant subtype formally classified
• DEWS III removes: omega-3 from universal first-line; mandatory 6-test diagnostic battery replaced by 2-test pathway
• Key shift: max 2 diagnostic tests for primary care optometry (OSDI + objective measure) vs DEWS II's 6-test full sequence

The LiGHT trial showed 74.2% of newly diagnosed OAG and OHT patients treated first with SLT remained medication-free at 3 years, with superior disease control vs prostaglandin drops — making SLT the evidence-based first-line option that Singapore optometrists should co-manage around.

• LiGHT trial: 74.2% of SLT-first patients remained medication-free at 36 months; SLT group had less VF progression than drops group at 3 years
• SLT-first group had lower total healthcare cost over 3 years vs drops-first — a cost-dominant outcome
• SLT effect duration: 60–70% maintain efficacy at 5 years; retreatment is safe and effective if needed
• UKGTS: latanoprost reduced mean VF deterioration by 0.48 dB/year vs placebo — confirms prostaglandins remain pharmacological gold standard when SLT is not chosen

An axial length increase of ≥ 0.10 mm/year in children, or a refractive shift of ≥ 0.50 D/year, signals active myopia progression requiring treatment review — and axial length is a more reliable progression metric than refraction alone.

• IMI threshold: AL growth > 0.10 mm/year = clinically significant; consider treatment intensification immediately
• Tideman nomogram: AL > 26 mm corresponds to lifetime relative risk of myopic maculopathy of 7–41× (sex- and age-dependent)
• Cycloplegic refraction preferred for monitoring — manifest refraction underestimates progression by ~0.25 D in children
• 6-monthly AL monitoring for all children on myopia control therapy; 12-monthly for stable adolescents aged ≥ 16 years