Objective data to determine the risk factors of myopia

In practice, today, the behav-ioral risks are usually identified through questionnaires or in a face-to-face conversation. In many cases, however, parents and chil-dren are unable to provide ac-curate information about their personal behavioral risks, as these are not recorded consciously and therefore difficult to quantify. Therefore, it is difficult for the optometrist to give a clear and concise recommendation for be-havioral changes that parents and children could follow.

Moreover, in the course of myopia management, the optometrist has no objective control over whether there has been any change in the child’s behavior that could signifi-cantly influence the further devel-opment of the myopia.

Here, Vivior is able to offer added value for myopia management by recording of the objective visual behavior to determine myopia risk factors.

Myopia Management

In view of the sharp increase in myopia across the world and the associated increase in eye diseases involving severe myopia1, myopia management in children is becom-ing more and more important in optometry.

Usually, the first step in myopia management is the identification of the risk factors that enhance the development of severe myopia.

Apart from age, refraction/axial length, and genetic factors (myopia in the family, ethnic background), a child’s behavioral and environmen-tal risks should also be investigat-ed.2 At the same time, parents and children must be informed about the respective risks and about possible measures to reduce the avoidable risk.

The Vivior Concept

Vivior is a technology startup com-pany from Zürich, Switzerland, that aims to optimize vision perfor-mance based on innovative sen-sor technology in conjunction with cloud-based artificial intelligence. For the first time, specific visual be-havior data can be obtained over a period of several days, during which the Vivior Monitor is worn. On this basis, personalized solu-tions can be implemented to cor-rect the patient’s vision.

Today the Vivior Monitor is already used in ophthalmology for the se-lection of an intraocular lens (IOL), and in optometry for determining customer needs when selecting single-vision and progressive lens designs. The wide-ranging opto-metric applicability is a further ad-vantage of Vivior’s technology.

Written and illustrated by Andreas Kelch & Daniel Boss

Lifestyle activitiesData on distance, light, orientation, movement, activity, and context are obtained.

Cloud-based data processingThe data are collected and uploaded into a high-security cloud in Switzerland for processing and visualization.

Measurement resultsThe distribution of the viewing distance is represented graphi-cally.

The Vivior Monitor can be attached easily to any spectacle frames and, because it weighs only 14 grams, the customer is not inconvenienced by the Monitor when wearing the glasses. During the period that it is worn (at least 4 days), the Monitor measures the following data using various sensors:

• distances to objects in the visual field

• light conditions• head movement and

position

Once the wearing time is com-pleted, the Vivior data are stored anonymously in the cloud and are processed, using artificial intelli-gence in order to determine the type and duration of visual activ-ities (such as reading, work on the computer, time outdoors, etc.).

Using a Web application the op-tometrist can analyze the re-sults and discuss them with the customer. In addition, using the application, he can gen-erate various customer reports, which explain the results regard-ing the specific visual behavior

and the customized solutions in a customer-friendly way.

Apart from customer reports for the selection of single-vision and varifocal glasses, Vivior is now also offering a myopia report to clarify the objective behavioral risk fac-tors for children.

Vivior Myopia Report:Risk Factor Evaluation

The Vivior Myopia Report focus-es on behavioral risk factors that have been associated with a higher risk for myopia onset and progres-sion These risk factors are visual-ized in the report in a spider chart and evaluated using a 3-star scor-ing system. A risk factor scoring fewer stars and covering less area means that the visual behavior as-sociated with it bears a higher risk for the development and/or pro-gression of myopia. The risk factor charts are evaluated separately for weekdays and weekends, in order to highlight potential differences in behavior.

Vivior Myopia Report: Recommendations

On the basis of the objective eval-uation of the behavioral risks a personal and algorithm-based recommendation for the child’s behavior is given in the myopia re-port.

A recommendation to spend more time outdoors is given if the aver-age “time spent outdoors” per day (including weekdays and week-end), is less than 1 hour.

A recommendation to increase the reading distance is given if the measured “near-vision distance” is less than 30 cm.

The recommendation to take more breaks during near-vision activities is given if the measured “near-vi-sion episode duration” is more than 30 min.

Figure: Vivior process visualization

Figure: Myopia Risk Factors

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Extension of the Myopia Manage-ment Offer and Greater Customer Connectivity in Treatment

The Vivior Myopia Report is an ad-dition to the conventional treat-ments in myopia management and should not be regarded as a substi-tute for them.

The optometrist obtains a reliable determination of the behavioral risk factors from the objective data and can then, with the help of ar-tificial intelligence, give specific

recommendations regarding changes in behavior.

Furthermore, he can use the re-port in order to evaluate the be-havioral risks periodically as part of myopia management, and thereby map out the course of treatment.

The report helps parents and children in the assessment of per-sonal risk and should at the same time motivate them to implement the intended changes in behavior that have favorable effects on the further development of the myopia.

The objective measurement of vi-sual behavior with the Vivior Moni-tor involves the child more strongly into the myopia management.

The new way of representing the risk factors and the algo-rithm-based evaluation should likewise have a positive effect on compliance.

References:

1. Holden, B. A. et al. Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050. Ophthamology 123, 1036–1042 (2016).

2. Gifford, K. L. et al. IMI – Clinical Management Guidelines Report. Investig.Opthalmology Vis. Sci. 60, M184 (2019).

3. Xiong, S. et al. Time spent in outdoor activities in relation to myopia prevention and control: a meta-analysis and systematic review. Acta Ophthalmol. 95, 551–566 (2017).

4. Ho, C. L., Wu, W. F. & Liou, Y. M. Dose-response relationship of outdoor exposure and myopia indicators: A systematic review and meta-analysis of various research methods. Int. J. Environ. Res. Public Health 16, (2019).

5. Lanca, C. & Saw, S. The association between digital screen time and myopia: A systematic review. Ophthalmic Physiol. Opt. 40, 216–229 (2020).

6. Mutti, D. O., Mitchell, G. L., Moeschberger, M. L., Jones, L. A. & Zadnik, K. Children’s Refractive Error. Investig. Opthalmology Vis. Sci. 43, 3633–3640 (2002).

7. Ip, J. M. et al. Role of Near Work in Myopia: Findings in a Sample of Australian School Children. Investig. Opthalmology Vis. Sci. 49, 2903 (2008).

8. Huang, H., Chang, D. S. & Wu, P. The Association between Near Work Activities and Myopia in Children—A Systematic Review and Meta-Analysis. PLoS One 10, e0140419 (2015).

9. Kee, C. S. et al. Temporal constraints on experimental emmetropization in infant monkeys. Investig. Ophthalmol. Vis. Sci. 48, 957–962 (2007).

10. Benavente-Perez, A., Nour, A. & Troilo, D. Short Interruptions of Imposed Hyperopic Defocus Earlier in Treatment are More Effective at Preventing Myopia Development. Sci. Rep. 9, 25–29 (2019).

11. Read, S. A. et al. Patterns of daily outdoor light exposure in Australian and Singaporean children. Transl. Vis. Sci. Technol. 7, (2018).

12. Read, S. A., Collins, M. J. & Vincent, S. J. Light Exposure and Eye Growth in Childhood. Investig. Opthalmology Vis. Sci. 56, 6779 (2015).

13. Wu, P.-C. et al. Myopia Prevention and Outdoor Light Intensity in a School-Based Cluster Randomized Trial. Ophthalmology 125, 1239–1250 (2018).

A recommendation to spend more time outdoors is given if the measured “time spent out-doors,” averaged over all measur-ing days (including weekdays and weekend), is less than 1 hour per day. In this case the correspond-ing control box is marked.

A recommendation to increase the reading distance is given if the measured “near-vision dis-tance” is less than 30 cm.

The recommendation to take more breaks during near-vision activities is given if the measured “near-vision episode duration” is more than 30 min.

Explanations regarding the optimization of visual behavior

The “Time spent Outdoors” is calculated as the average time spent outdoors per day (in hours per day). For a better comparison between multiple customer visits the calculated time is standardized at a Monitor wear-ing time of 10 hours. Beneficial effects of increased time spent outdoors on the myopia indicators have been shown in numerous studies3,4. Star scoring: :< 1 hour per day, :> 3 hours per day, Recommended time: 2-3 hours per day

The “Near Distance” is calculated as mean distance of all close-up activities (in centimeters), i.e. it is a mea-sure of the visual distance during activities such as reading, smartphone use, and other close-up work. A short “near-vision distance” is associated with a higher risk of myopia in various studies 5–8.Star scoring: :< 25 cm, :> 35 cm, Recommended distance: > 30 cm

The “Near Activity Duration” is calculated as the average duration of uninterrupted close-up activity with-out any breaks of more than 15 minutes. Studies indicate that long, uninterrupted near-vision episodes (e.g. uninterrupted reading without breaks) are associated with a higher risk of myopia 7,8. Animal tests on monkeys indicate that breaks of 15 minutes or more have a protective effect9,10 . Star scoring: : > 37.5 min :< 22.5 min, Recommended “Near Activity Duration”: < 30 min

The “Total Near-Vision Time” is the average total time per day (in hours per day) of all close-up activities (such as reading, use of smartphones, etc.). Various studies indicate an increased risk of myopia due to a longer time spent on close-up activities5–8 . As not all studies support these findings, no recommendation on behavior in respect of “total near-vision time” is being given at present. Star scoring: : > 5.5 hours per day, :< 2.5 hours per day

The “Average Illumination” is the mean ambient illuminance (in lux) during the wearing time. This risk fac-tor is based on studies 11–13 in which a faster progression of myopia was demonstrated in children exposed to a smaller dose of light. Star scoring: : < 400 lux, :> 1000 lux

The “Monitor Wearing Time” is the average time per day [in hours per day] during which data were collect-ed with the Vivior Monitor. It is not a risk factor associated with myopia and serves as a control measure-ment, to show whether enough data were collected for a reliable risk factor assessment.Star scoring: : < 4 hours per day, :> 10 hours per day, no recommendation

Explanations regarding the myopia risk factors