about myopia management a new approach

1. MYOPIA
CONTROL
STRATEGIES
Sarbind Kumar Yadav
Senior optometrist
kumarsarbind@gmail.com

2. Introduction
■ The term myopia is first
described by Galen (131-
201 AD) and derived it from
a Greek word “Myein” (to
close) and “Ops” (eye).
■ Myopia results from
mismatch between axial
length of eye and it’s
refractive elements leading
images to form in front of
retina causing blurred
vision for distance.

3. Global prevalence of myopia
■ The global prevalence of myopia is increasing singnificantly.
■ A study by Holden et.al in 2016, reported that
- in 2010, myopia affected 1.9 billion people worldwide or 28% of global
population
- By 2050, myopia is projected to almost about affect 5 billion people or 50% of
the
global population.
■ Prevalence is more in urban than rural area.

4. Prevalence cont….
22.9
28.3
33.9
39.9
45.2
49.8
1.4 2 2.6 3.4 4.1 4.8
0
10
20
30
40
50
60
2000 2010 2020 2030 2040 2050
Prevalence in %
Affected population in
billions

5. Prevalence in Nepal
■ Many population based studies on children showed that prevalence of myopia is
more in urbanized west Asian countries with prevalence of 16.5% in Nepal
(2008).
■ In 2482 Nepalese secondary school children aged 10-15 years, myopia
prevalence is reported from 10% in 10 years old to 27.3% in 15 years old.

6. Increased Prevalence after COVID 19
Pandemic.
•Less time outdoor.
•More near work and digital screen time.
•Continuous near work
Increased
Progression

7. Risk factor for Myopia
Development/Progression
MORE NEAR WORK
2+ hours per day spent on
near work (not including
school work) can increase
the risk of myopia.
MYOPIC PARENT(S)
There is a 25% chance a child
will develop myopia if one
parent is myopic and 50% if
both are myopic.
LESS NATURAL LIGHT
Less than 60-90 minutes per day
spent outdoors in natural sun
light contribute to myopia.
Specific binocular vision and focusing disorders
increase the risk of myopia.
VISION DISORDERS <9 YEARS ONSET
Myopia progresses faster at an early age.
Especially if child is less than 9 years old.

8. 1.0 Standard procedures for
examination
Following steps summarizes the standard procedures for myopia examination.
1.1 History taking
1.2 Refraction
1.3 Binocular vision and accommodation tests
1.4 Slit lamp examination
1.41 Anterior segment
1.42 Posterior segment
1.5 Corneal Topography
1.6 Axial length measurement

9. 1.1 History taking
■ Age, sex, history of ocular and general health, ocular surgeries.
■ Parental history of myopia.
■ Age of myopia onset.
■ History of myopia progression, if available.
■ Previous myopia control treatment, if any.

10. 1.2 Refraction
■ Aim: Best corrected visual acuity.
■ Goal: Ocular accommodation should be relaxed.
■ Procedure:
- Cycloplegic (1% tropicamide/cyclopentolate/atropine).
- non-cycloplegic (standard clinical subjective refraction technique).

11. 1.3 Binocular vision and
accommodation tests
■ Studies suggest that myopia control strategies affect pediatric accommodation
and binocular vision.
■ Involves evaluation of
- Accommodative accuracy
- Accommodative Amplitude
- Accommodative facility
- Vergence ( hetrophorias both for distance and near, near fixation disparity,
AC/A ratio.

12. 1.4 Slit lamp examination
■ Anterior segment evaluation: Dry eye evaluation.
■ Posterior segment evaluation: Dilated fundus examination, OCT, fundus photo
in case of findins.
■ IOP
■ Myopia control treatments can induce dry eye related disorders.

13. 1.5 Corneal Topography
■ May be indicated for contact lens fitting.

14. 1.6 Axial length measurement
■ Routinely employed in myopia control studies to determine the outcome of
reduced axial elongation.
■ Increases in 0.1mm/year associated with normal eye growth.
■ Increase of 0.2 – 0.3 mm/year is associated with increasing myopia.
■ But myopia progression can occur with smaller AL changes in an individual.
■ Currently an uncertain diagnostic factor in clinical myopia management.
■ Useful factor in risk of myopia pathology.

15. 2.0 Visual Habits and Environmental
Evaluation
■ Association between near work and outdoor time to myopia.
■ It is preferred to obtain and record the visual habits of the individual I.e. The
daily average hours of time spent on near work and time spent outdoor.

16. 3.0 Exploratory Tests
3.1 Relative peripheral refraction (uncorrected eye).
3.2 Higher order aberration.
3.3 Pupil size.
3.4 Sub-foveal choroidal thickness.
3.5 Wearable devices to track visual habits and environment.

17. 3.1 Relative peripheral refraction
(uncorrected eye)
■ Several cross sectional studies illustrate an association between relative
peripheral hyperopia and central refraction.
- greater relative peripheral hyperopia found in myopia, with relative peripheral
myopia found in hyperopia and emmetropia.
■ Hoogerheide evaluated 375 pilots and suggested that relative peripheral
hyperopia in the horizontal meridian could be a risk factor for myopia
development.

18. 3.2 Higher-Order Aberrations
■ Though not fully understood, there is some association between higher-order
aberrations and myopia control.
■ OK lenses induce higher corneal levels of total corneal higher order aberrations,
appears to be associated with slower progression of myopia and smaller axial
elongation.

19. 3.3 Pupil size
■ It is difficult to ascertain the contribution of pupil size on myopia control (limited
data).
■ There is a single study that shows that children with an “above average”
scotopic pupil diameter (greater than 6.5 mm) exhibited a greater myopia control
than children with a “below average” scotopic pupil diameter with OK treatment.

20. 3.4 Sub-foveal Choroidal thickness
■ Studies have reported an
association between choroidal
thickness changes and myopia
progression, induced myopic
and hyperopic defocus and
myopia control interventions.
■ On going research aims on
relationship between myopia
onset and progression with
sub-foveal choroidal thickness
( SFCT) at macular region and
other areas of the retina.

21. 3.5 Wearable devices to track visual
habits and environment
■ Time spent on near work/outdoors, has been largely determined by
questionnaire.
■ Light data loggers (LDLs) have been used to make objective measurement of
ambient light levels.
■ Objective measurement of light intensity continue to show an association
between time spent outdoors and myopia protection.

22. 4.0 Selecting a Treatment Strategy
4.1 Predicting Progression rate
4.2 Selecting a treatment
4.21 Baseline Refractive Error
4.22 Binocular Vision status
4.23 Ethnicity
4.3 Safety, Compliance and cost consideration

23. 4.1 Predicting Progression Rate
■ Myopia may progress at a faster rate in those:
- that are of younger age
- have higher baseline myopia
- have experienced past myopia progression of more than 0.50D/year.
- can also progress more in winter than summer.

24. 4.2 Selecting a Treatment
4.21 Baseline Refractive Error
■ Longer duration of myopia progression results in greater magnitude of myopia.
■ Child’s age and baseline refractive error must be considered together in the selection of
treatment.
■ Baseline refractive error will determine the availability of treatment i.e.
- Children with small astigmatic error 0.50D – spherical multifocal soft cantact lenses.
- astigmatism of 0.75D spectacles with spherical MFSCLs.
- astigmatism<1.50D – Spherical OK lenses.
- higher astigmatism – toric periphery or other design.
Individuals of younger age and higher degree of baseline refractive error may benefit most from
OK lenses.

25. 4.22 Binocular Vision Status
■ Children with higher lags of accommodation and near esophoria – have greater
myopia control effects with progressive addition lenses (PAL).
■ Children with lower lags of accommodation (<1.25D) – have greater myopia
control with prismatic bifocals (+1.50D add and 3 prism diopters base in in the
near segment of each lens).
■ Children with lower baseline accommodative amplitude – have greater control
response to OK lenses.

26. 4.23 Ethnicity
■ Limited studies investigating the role of ethnicity on myopia treatment.
■ Recent meta analysis suggested- greater myopia control with atropine treatment
in children of Asian compared with European ethnicity.

27. 4.3 Safety, Compliance and Cost
Consideration
■ Clinicians must determine whether children can safely self administer and
comply with the treatment.
■ Children (and/or parent/ guardians) must demonstrate appropriate contact lens
handling skills for safe and successful lens wear and maintenance.
■ Clinicians must be aware of contraindications to atropine eye drop use so that it
can be administered.
■ The annual cost of professional management and lens materials or drug costs
should be discussed with parents prior to initiating treatmant.

28. 5.0 Myopia Controlling Treatment Options
5.10 Optical
5.11 Spectacles
5.12 Contact Lenses
5.20 Pharmacological
5.30 Environmental Modifications

29. 5.10 Optical
5.11 Spectacles
 Under correction with spectacles.
 Single vision peripheral defocus correcting lenses
 Bifocal spectacles
 Invisible bifocal or no-line bifocal
 Progressive addition lenses (PALs)
 The utility of using spectacles lenses for slowing myopia progression has many advantages
over other forms of myopia management:
- easy to fit
- are mostly well accepted and well tolerated
- are affordable by most
- are minimally invasive

30. 5.11 Spectacles
■ Under correction with spectacles – considered to slow myopia progression by
reducing the accommodative demand during near work.
■ A recent study comparing myopia progression in uncorrected and fully corrected
12 years old children; this study shows slower progression in uncorrected group.
■ However, another study showed that myopia progression significantly decreased
with increasing under correction.

31. 5.11 Spectacles
■ Single vision peripheral defocus
correcting lenses – studies have
reported relative peripheral hyperopia
in myopic eye when fully corrected
with SV.
■ Ensure that the image onto the
retina centrally (for optimal vision) but
induces myopic defocus in the
periphery (myopia control).
■ The correction of the natural
peripheral hyperopic defocus
affecting corrected myopic eyes send
signal to the eye to reduce continued
elongation that may result in reduction
of myopia progression.
■ Unique spectacles lens that manages
peripheral defocus and thus reducing
myopia progression in children’s eyes.
■ Contains more than 400 focal points. Normal lens Defocus lens

32. 5.11 Spectacles
■ Bifocals Spectacles
 Reducing or eliminating lag of accommodation during extended near work.
 Reducing accommodative demand – cause reduction in ciliary muscle tension
potentially reducing stress on the overlying sclera.
 Induce myopic shift in peripheral refractive errors, at least in superior retinal field.
 Invisible and no-line bifocals work same as bifocal the only difference is there is no line
in glass.
Add +1.50D alone or +1.50D with 3D base in prism
A study shows that bifocal glass is more better than SV lenses in controlling myopia in children older than 3 years.

33. 5.11 Spectacles
■ Progressive addition lenses
(PALs) :
 reduce accommodative lag during
near work
 Reduce accommodative demand
 Children with larger accommodative
lag and near esophoria have greater
myopia control with PALs

34. 5.11 Spectacles
■ Evidence on the efficacy of spectacle lenses with various optical designs for myopia control are not
homogeneous as that observed with contact lens option.
■ Myopia control with spectacles in human has weaker effect than animals which may due to:
 non – compliance
 Limited amount of defocus (plus defocus)
 Reduced wearing time due to visual distortion and restricted peripheral vision.
■ As result, myopia control spectacles are generally reversed as a second line treatment for those
who are:
 Either not suitable for myopia control contact lenses
 Not ready for myopia control contact lenses.
 Are lacking of motivation for myopia control contact lenses.

35. 5.12 Contact Lenses
■ SV soft contact lenses
■ Gas-permeable contact lenses
■ Soft multifocal (MF) contact lenses
■ Orthokeratology

36. 5.12 Contact Lenses
■ SV soft contact lenses
 There is no substantial evidence in the literature that conventional soft cotact
lens wear leads to either slower or faster myopia progression than spectacle.

37. 5.12 Contact Lenses
■ Gas –permeable contact lenses
 Alignment fit GPs (not OK design)
 Recent well conducted studies showed that use of these lenses did not impact
axial elongation.
 Apparent control of myopia was likely due to corneal flattening.

38. 5.12 Contact Lenses
■ Soft multifocal (MF) contact lenses
 Main categories of MFSCL designs:
 Concentric ring or bifocal design
 Progressive power of peripheral add lens
design.
■ Majority of investigated MFSCLs for myopia
control incorporate a relative +2.00D
treatment correction creating simultaneous
images on the retina.
■ Some commercially available MFSCLs that
were originally designed for presbyopia
correction have been used for myopia control
treatment.

39. 5.12 Contact lenses
Soft multifocal (MF) contact lenses
■ In clinical practice, MFSCLs incorporating patient’s full distance refractive error and relative
+2.00 to 2.50D treatment correction be initially selected.
■ MFSCLs that manipulate optical defocus across larger areas of the visual fields have been
suggested to result in greater myopia control.
■ To date, there has been no systematic investigation comparing the efficacy of myopia control
associated with different add powers.
■ As currently available MFSCLs, particularly lenses with higher add powers, can significantly
reduce quality of vision. It is essential that visual acuity and quality of vision are monitored.
■ If patient experiences significant reduction in VA and/or subjective quality of vision with
selected MFSCLs, can be solved by
 An over refraction and incorporated into lens power.
 Reduce the add power until acceptable vision is achieved
 Try a different lens deisgn

40. 5.12 Contact Lenses
■ Orthokeratology (corneal reshaping therapy)
 Reshaping of the cornea to be achieved with overnight wear.
 Initial goal – to eliminate the need of daytime optical correction.
 OK has proven to be effective in slowing myopia progression by
- inducing relative myopic shift in peripheral refractive errors in all meriadians.
- altering higher order aberrations.

41. 5.20 Pharmacological Treatment
■ Topical Atropine (nonselective irreversible anti-muscarinic antagonist)
■ Pirenzepine (an M1 Muscarinic receptor antagonist)
■ Oral 7-methylxanthine (adenosine antagonist)
■ Topical Timolol (nonselective beta-adrenergic antagonist)

42. 5.20 Pharmacological Treatment
Topical Atropine
■ Concentration – 1%, 0.5%, 0.25%, 0.1%, 0.01%.
■ Bedrossian (1971) – 150 children aged 7to 13 years reported no myopia
progression in 75% of eyes treated daily with 1% atropine over a period of 1
year..
■ Other studies show 60% and 76% reduction in myopia progression.
■ Shih and colleagues (1999) 200 children aged 6 to 13 years treated with 0.5%,
0.25% or 0.1% atropine over a period of 2 years, reduction in myopia
progression were 61%, 49% and 42% respectively.
■ Studies have reported that mean progression rates of myopia -0.2, -0.3, -0.4 and
0.5D for the four atropine groups (1%, 0.5%, 0.1% and 0.01%).

43. 5.20 Pharmacological Treatment
Topical atropine
■ Side effect of topical atropine
 Mydriasis
 Reduced accommodation
 Symptoms of glare and photophobia
 Blur at near
 Allergic reaction
 Systemic toxicity
Can be minimized by :
Photochromatic glasses
Progressive glasses

44. 5.20 Pharmacological
■ Pirenzepine
 A double masked, palcebo controlled, randomized study in an Asian population
used 2% pirenzipine gel administered twice daily and found myopic progression
was reduced by 44% and axial length elongation by 39% compared with control
group over 12 months.
 A US based, two year multisite clinical trail yielded a similar reduction in myopia
progression with 2% pirenzapine compared with the placebo treatment, at 41%.
 Pirenzipine is currently not available as a treatment option and appears not to
be targeted by industry for development.

45. 5.20 Pharmacological
7-Methylxanthine
■ In human subjects only limited to Denmark.

46. 5.20 Pharmacological
Timolol
■ The driving principle for this approach is biomechanical (i.e., to lower IOP as a
method of slowing ocular elongation).
■ A study by Jensen, 0.2% timolol twice daily but the results were disappointing.
■ Timolol lowered IOP significanntly.

47. 5.3 Environmental Modification
■ Prevalence is more in
urban than rural, which is
highly suggestive of an
important role of
environmental factors in
myopia genesis.

48. Myopia and Visual Environment
■ The major environmental factors considered to play a role in eye growth regulation,
development and progression of childhood myopia can be summarized under three
headings.
A. Myopia, near work and education.
B. Myopia and outdoor activities.
C. Myopia and the urban environment.

49. Myopia, Near work and Education
How does near work contribute to myopia?
■ The evidence is inconsistent, but spending more time on near work such as reading, writing, or screen
are considered as risk factor for development/progression of myopia.
■ Accommodation – although earlier studies reported that myopic children and adults have higher
accommodative lag
No association between myopia progression & accommodative lag.
Accommodative lag associated with myopia may be a consequence rather than causative factor.
■ European study showed that the odds of myopia increased by 2% for each additional “diopter hour”.
■ Another study showed that a close working distance (20-25 cm), a head tilt when reading, continuous
reading for more than 45 minutes increases the risk of myopia.

50. Digital Devices and Myopia
■ Recent studies have found that there is significant association between myopia
development/progression and digital screen time.
■ digital screen time constitute a significant form of near work which is a risk factor for
myopia development/progression.
■ The “American Optometric Association ” promotes the WHO recommendation that the
screen time be limited to one hour per day for children under five and no time at all for
children less than one year of age.

51. Reccommendations
•After 20 minutes of computer/near work take a 20 second break and look at 20 feet away.
•Reset your focus to a distance object to ease strain on vision.
•Place the computer screen 24 inches from eye and a position at a 15 degree below eye.
•Foot should firmly on the floor or foot rest.
•Rest back against a comfortable chair for shoulder and book support.
•Use special tinted and coated glass blocking blue rays which improves sleeping and thus
prevent myopia development.
•Limit excessive screen time.

52. Myopia and Outdoor Activities
■ High illumination – spending more time outdoor during day allows bright light to reach
the retina.
trigger photosensitive retinal ganglion cells & activate retinal
dopaminergic pathway
release dopamine
reduce axial length elongation
■ Pupillary miosis & increased depth of focus – distance viewing is result in less image
blur and decreased peripheral defocus delaying myopia onset.

53. Recommendations
■ A meta analysis of 17 studies, including samples with ethnicities summarized that
spending less than 13 hours a week outdoors is a risk factor of myopia.
■ Increasing time outdoors at least 1 hour per day may reduce the risk of developing
myopia by 45%.
■ A randomized clinical trial in china showed that increasing time outdoors by at least 40
minutes per day decreased onset of myopia in school children by 9% in three years.
■ Another study from Taiwan concluded that spending 80 minutes per day outdoors
reduced the onset of myopia by 9% in 1 year.
■ The current recommendations are for a minimum of 2 hours per day with adequate sun
protection e.g. wearing hats, sunglasses while engaging in outdoor activities.

54. Indoor Lighting
■ Several studies found that time spent under lighting levels greater than 3000 lux is a
protective factor for myopia.
■ A study in china from 2015 showed that even a modest increase in light levels in class
room from 100 to 500 lux provide a significant reduction in myopia and axial length
elongation.
■ A study conducted in china found that students who use LED lamps had larger myopic
refractive errors and longer axial length compared to students who use incandescent or
fluorescent lamps.

55. Myopia and Urban Environment
■ A consistent findings in studies of childhood myopia has been that myopia prevalence is
greater in urban areas, compared to children living in rural areas.
■ A population based study of teenage school children from china showed that prevalence of
myopia is 50% for children in urban regions compared to only 33% in rural areas.
■ Differences in the pattern of myopia prevalence and progression between urban and rural
regions could be driven by differences in near work and/or outdoor activities between these
two regions.
■ A number of recent studies indicate that a higher population density is significantly associated
with increased prevalence of myopia in children, independent of near work and outdoor
activities.
■ Studies shows that children living in smaller homes to have significantly higher prevalence; it
has been hypothesized that a constricted living space may result in an increased exposure to
hyperopic blur which promote myopia.

56. Sleep Habit and Myopia
■ Noting the seasonal variations and diurnal patterns of axial length and refractive error,
some others have raised the possibility of circadian rhythms playing a role in myopia
onset and progression.
■ Some studies showed that poor sleep may result in onset/progression of myopia.
■ Recommend to sleep adequately.

57. Nutrition and Myopia
■ A study from 2010 found that saturated fat and cholesterol intake is associated with
longer axial length.
■ Another study found that increased insulin level is associated with greater odds of
myopia.
■ Diet rich in highly refined carbohydrates can lead to worsening glycemic control which
may result in myopia progression /development.
■ Recommend to avoid food rich in refined sugars and carbohydrates.

58. Take Home Message
Maximize Outdoor Time
 Aim for two hour per day
Optimizing Indoor Lighting
 Maximize brightness for all indoor activities.
 Avoid LED lighting and replace with incandescent light.
Near Work
 Appropriate reading distance > 25cm.
 Regular break at every 45 minutes.
 Avoid head tilting.
 Regular near to distance fixation change.
Digital Devices
 Apply same as near work.
 Encourage desktop use over hand held devives.
 Where possible, set daily time limits.
Sleep Habits and Nutrition
Encourage healthy, regular sleep
patterns.
Avoid foods high in refined sugars
and fat.
Remember that these factors may
increase the risk of myopia, so pick
your battles.

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60. Thank You