Neither she nor her husband needed glasses until middle age. Cassia van der Hoof Holstein was therefore a little surprised to learn that her 8-year-old daughter Viva had difficulty seeing the blackboard in class.
When Van der Hoof Holstein began reading about myopia in children, that surprise turned to worry. Understanding of pediatric myopia had advanced considerably since his own school days, when the need for glasses seemed little more than an inconvenience.
Today, modern life pushes the limits of human vision, at an ever younger age. More hours spent with screens close to our faces and fewer hours in natural light change the shape of our eyeballs, elongating the spheres from front to back.
Over the years, the stretched eyeball weakens and wobbles: retinal tears, macular degeneration, cataracts and glaucoma. The earlier this process starts in a child’s growing eye, the faster it progresses. Myopic children like Viva are at much higher risk of serious eye problems and potential blindness.
“Sight is so precious, and it’s scary to think that it could be affected,” Van der Hoof Holstein said recently from his home in San Francisco.
Viva selects new eyeglass frames at the UCSF vision clinic while her mother, Cassia van der Hoof Holstein, accompanies her.
(Paul Kuroda/For Time)
Viva is hardly alone. Over the past several decades, the percentage of children with myopia has steadily increased, while the age at diagnosis appears to be decreasing.
“The average age of onset of myopia is certainly getting younger and younger,” said Dr. Maria Liu, professor of clinical optometry and vision sciences at UC Berkeley and founder of the university’s Myopia Control Clinic. When the clinic started in 2013, diagnosis at age 6 or 7 was considered early-onset myopia. Today, she said, the clinic frequently sees myopic patients as young as 3 or 4 years old.
This is a global problem, not just an American one. In 1990, 24.3% of children and adolescents worldwide were myopic, study finds goodbye hundreds of scientific articles in 50 countries. This rate was 35.8% in 2023 and is expected to reach 39.8% by 2050.
Myopia in childhood can lead to headaches, learning difficulties, and the cost and inconvenience of glasses or contact lenses. The greatest concern looms in the coming decades, when today’s children will be older adults at higher risk of blindness or serious eye diseases.
Viva wears a device that tracks the distance of objects she looks at to help researchers track the progression of childhood myopia.
(Paul Kuroda/For Time)
A growing diagnosis rate and an aging population mean that half of the world’s population could become myopic by 2050with almost 10% – or just under a billion people – experiencing serious eye disease and vision loss.
In some regions of Europe, rate of vision loss linked to myopia we are already approaching those linked to complications of diabetes.
“There’s this tidal wave of visual complications related to myopia, but it’s hard to see when it’s such a slow, insidious process,” said Dr. Sarah Singh, assistant professor of clinical optometry and vision science at UC Berkeley.
Even if myopia has a strong genetic component, its increase is too rapid and too sudden to be explained by genetics alone, ophthalmologists emphasize. Doctors attribute today’s skyrocketing rates of myopia to two behavioral changes that occurred in childhood: more time spent looking closely and less time spent outdoors.
“Close to work,” as ophthalmologists call it, is a known contributing factor to myopia. Observers have noticed a link between myopia and voracious reading for as long as humans have been writing things down; Aristotle would have noted around 350 BC, squinting seems to help.
The advent of laptops, tablets and smartphones has dramatically accelerated the time children spend on surfaces within reach.
For six weeks, Viva wore glasses equipped with sensors that recorded light levels and the proximity of objects in her field of vision, removing them only for sleeping and horseback riding and diligently charging them each night.
(Paul Kuroda/For Time)
“The more time you spend on close-up activities, it increases your risk of myopia progression,” said Dr. Sudha Nallasamy, associate professor of clinical ophthalmology at the Keck School of Medicine of USC. “I tell parents to limit screen time for this reason.”
But screens aren’t the only ones to blame, Nallasamy and other ophthalmologists pointed out. Decreased time spent outdoors also appears to be a factor in the increase in cases of myopia. American children spend time outdoors fell precipitously over the decades, and many children now spend less than an hour per day in unstructured outdoor play.
“It’s an oversimplification to say that screens are the enemy,” said Dr. Annie Nguyen, assistant professor of clinical ophthalmology at Keck. “We still need to spend time outdoors…I can’t stress that enough.”
There is a clear relationship between myopia and the physical adjustment made by the eye during near work. The link between myopia and natural light, however, is not as well understood. One theory is that sunlight releases dopamine, which inhibits eye expansion.
The International Myopia Institute recommends that school-age children spend at least 80 to 120 minutes outside every day as a preventative measure. But the distribution of those minutes probably matters too, Liu said.
In animals, the protective “shut down” signal that natural light sends to the eye is most effective immediately after a period of elongation, suggesting that time spent outdoors immediately after screen time offers the greatest protection.
Signal effectiveness also fades over time, meaning that a single long outing to the zoo or park may be less beneficial than several outdoor escapades of at least 30 minutes each.
THE American Optometric Association. recommends adults follow the “20-20-20” rule during prolonged screen work to avoid eye strain: take a 20-second break every 20 minutes focused on an object 20 feet away. For children, this may not be enough.
“Based on what we know about the anatomical changes that occur in growing eyes, a 20-second break just to look at something else might not be enough to reset the system,” Singh said. To give the flexible tissues in the back of the eye enough time to return to their baseline state, the UC Berkeley clinic recommends that children’s screen breaks last at least five minutes each.
Myopia is not reversible, but emerging treatments could slow its progression.
Important research showed that low dose eye drops of the liquid medication atropine appears to significantly slow the progression of myopia in children, and it is commonly prescribed to children who are diagnosed with myopia or at higher risk of developing it.
Last year, the U.S. Food and Drug Administration allowed European eyewear company EssilorLuxottica will begin marketing its Stellest glasses, whose lenses correct vision and prevent the progression of myopia in children.
New research tools are also helping science better understand how children’s behavior influences the development of myopia. Dr. Elise Harb, a pediatric optometrist and clinical professor at UC Berkeley and UC San Francisco, uses child-friendly wearable technologies that collect a more detailed picture of a child’s visual environment and daily activities than traditional research questionnaires can provide.
She is preparing to launch a large, collaborative, international three-year study funded by the American Academy of Optometry Foundation that will follow children in the United States, Norway, Singapore and Australia to see what factors contribute to the development and progression of myopia.
UCSF Vision Clinic ophthalmologist Dr. Elise Harb in one of the exam rooms in San Francisco.
(Paul Kuroda/For Time)
“The myopia epidemic really began before electronic device use was ubiquitous in the home,” Harb said. “The general feeling is that (screen time) is probably not the only thing to blame, and this myopia is surely multifactorial.”
For Viva, who recently turned 13, contact lenses and glasses don’t interfere with her busy schedule of sports, theater and horse riding. She volunteered to participate in a study underway in Harb’s lab. For six weeks, she wore glasses equipped with sensors that recorded light levels and the proximity of objects in her field of vision, removing them only for sleeping and horseback riding and diligently charging them each night.
“We have a lot of conversations at home about the scientific method and how research advances … and she was eager to be able to contribute,” Van der Hoof Holstein said. “She thought it was pretty cool that her data could be useful to other kids.”
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