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Theories Behind Myopia Progression

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Jacinto Santodomingo-Rubido
Jacinto Santodomingo-Rubido
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Abstract and Figures

The prevalence of myopia has been increasing substantially in recent decades and continues to be on the rise. In fact, it has been estimated that by 2050 around 50% of the world’s population (~ 2 billion people) would be myopic.1 The mechanisms involved in myopia onset and progression remain unclear. Several theories, including (1) lag of accommodation; (2) mechanical tension; and (3) peripheral refraction have been proposed to explain the aetiology behind myopia progression,2 with the latter theory being the most popular currently (Figure 1). This document aims at providing a brief summary of the different and most commonly accepted theories used to explain how myopia progresses.
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All content in this area was uploaded by Jacinto Santodomingo-Rubido on Jun 22, 2017
Content may be subject to copyright.
MYOPIA'PROGRESSION'THEORIES'
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INTRODUCTION'
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CLOSING'REMARKS'
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Efficacy Comparison of 16 Interventions for Myopia Control in Children
Article
Full-text available
  • Jan 2016
  • OPHTHALMOLOGY
Purpose: To determine the effectiveness of different interventions to slow down the progression of myopia in children. Methods: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov from inception to August 2014. We selected randomized controlled trials (RCTs) involving interventions for controlling the progression of myopia in children with a treatment duration of at least 1 year for analysis. Main outcome measures: The primary outcomes were mean annual change in refraction (diopters/year) and mean annual change in axial length (millimeters/year). Results: Thirty RCTs (involving 5422 eyes) were identified. Network meta-analysis showed that in comparison with placebo or single vision spectacle lenses, high-dose atropine (refraction change: 0.68 [0.52-0.84]; axial length change: -0.21 [-0.28 to -0.16]), moderate-dose atropine (refraction change: 0.53 [0.28-0.77]; axial length change: -0.21 [-0.32 to -0.12]), and low-dose atropine (refraction change: 0.53 [0.21-0.85]; axial length change: -0.15 [-0.25 to -0.05]) markedly slowed myopia progression. Pirenzepine (refraction change: 0.29 [0.05-0.52]; axial length change: -0.09 [-0.17 to -0.01]), orthokeratology (axial length change: -0.15 [-0.22 to -0.08]), and peripheral defocus modifying contact lenses (axial length change: -0.11 [-0.20 to -0.03]) showed moderate effects. Progressive addition spectacle lenses (refraction change: 0.14 [0.02-0.26]; axial length change: -0.04 [-0.09 to -0.01]) showed slight effects. Conclusions: This network analysis indicates that a range of interventions can significantly reduce myopia progression when compared with single vision spectacle lenses or placebo. In terms of refraction, atropine, pirenzepine, and progressive addition spectacle lenses were effective. In terms of axial length, atropine, orthokeratology, peripheral defocus modifying contact lenses, pirenzepine, and progressive addition spectacle lenses were effective. The most effective interventions were pharmacologic, that is, muscarinic antagonists such as atropine and pirenzepine. Certain specially designed contact lenses, including orthokeratology and peripheral defocus modifying contact lenses, had moderate effects, whereas specially designed spectacle lenses showed minimal effect.
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Relative Peripheral Hyperopia Does Not Predict Development and Progression of Myopia in Children
Article
Full-text available
  • Sep 2015
Purpose: To test the hypothesis that relative peripheral hyperopia predicts development and progression of myopia. Methods: Refraction along the horizontal visual field was measured under cycloplegia at visual field angles of 0°, ±15°, and ±30° at baseline, 1 and 2 years in over 1700 initially 7-year-old Chinese children, and at baseline and 1 year in over 1000 initially 14-year olds. One refraction classification for central refraction was "nonmyopia, myopia" (nM, M), consisting of nM greater than -0.50 diopters (D; spherical equivalent) and M less than or equal to -0.50 D. A second classification was "hyperopia, emmetropia, low myopia, and moderate/high myopia" (H, E, LM, MM) with H greater than or equal to +1.00 D, E, -0.49 to +0.99 D, LM, -2.99 to -0.50 D, and MM less than or equal to -3.00 D. Subclassifications were made on the basis of development and progression of myopia over the 2 years. Changes in central refraction over time were determined for different groups, and relative peripheral refraction over time was compared between different subgroups. Results: Simple linear regression of central refraction as a function of relative peripheral refraction did not predict myopia progression as relative peripheral refraction became more hyperopic: relative peripheral hyperopia and relative peripheral myopia predicted significant myopia progression for 0% and 35% of group/visual field angle combinations, respectively. Subgroups who developed myopia did not have more initial relative peripheral hyperopia than subgroups who did not develop myopia. Conclusions: Relative peripheral hyperopia does not predict development nor progression of myopia in children. This calls into question the efficacy of treatments that aim to slow progression of myopia in children by "treating" relative peripheral hyperopia.
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Efficacy, Safety and Acceptability of Orthokeratology on Slowing Axial Elongation in Myopic Children by Meta-Analysis
Article
Full-text available
  • Aug 2015
  • CURR EYE RES
To compare the efficacy, safety and acceptability of a treatment group (Orthokeratology) to a control group (single vision Spectacles) on slowing axial elongation in children. We searched studies in MEDLINE, EMBASE and the Cochrane Library up to January 2015 for randomized controlled trials (RCTs) and observational studies. We pooled the mean differences between the Orthokeratology and Control groups for axial elongation and the OR for rates of adverse events and dropout. Three RCTs and six cohort studies with 667 children aged 6-16 years old were included. Two years' mean differences in axial elongation were -0.27 mm (95% confidence intervals [CI], -0.32 to -0.23) in all studies, -0.28 mm (95% CI, -0.35 to -0.20) in RCTs and -0.27 mm (95% CI, -0.32 to -0.22) in cohort studies (p < 0.01). At 6 months, 1 year, 1.5 years and 2 years, mean differences in axial elongation were -0.13 mm, -0.19 mm, -0.23 mm, and -0.27 mm (p < 0.01), respectively. The effect was greater in Asian children than Caucasian (-0.28 mm versus -0.22 mm) and in children with moderate to high myopia when compared to children with low myopia (-0.35 mm versus -0.25 mm). Orthokeratology had more non-significant adverse events (odd ratio [OR], 8.87; 95% CI, 3.79-20.74; p < 0.01) but comparable dropout rates (OR = 0.84, 95% CI, 0.40-1.74, p = 0.64) than control. Orthokeratology has significantly greater efficacy in controlling axial elongation in children compared to Spectacle correction. The safety and acceptability results are good, and there appears to be a greater myopia control effect in Chinese children compared to Caucasians, and in those with higher initial myopia.
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Relative Peripheral Refractive Error and the Risk of Onset and Progression of Myopia in Children
Article
Full-text available
  • Jan 2011
To investigate whether relative peripheral hyperopia is a risk factor for either the onset of myopia in children or the rate of myopic progression. The risk of myopia onset was assessed in 2043 nonmyopic third-grade children (mean age ± SD = 8.8 ± 0.52 years) participating in the Collaborative Longitudinal Evaluation of Ethnicity and Refractive Error (CLEERE) Study between 1995 and 2007, 324 of whom became myopic by the eighth grade. Progression analyses used data from 774 myopic children in grades 1 to 8. Foveal and relative peripheral refractive error 30° in the nasal visual field was measured annually by using cycloplegic autorefraction. Axial length was measured by A-scan ultrasonography. The association between more hyperopic relative peripheral refractive error in the third grade and the risk of the onset of myopia by the eighth grade varied by ethnic group (Asian children odds ratio [OR] = 1.56, 95% confidence interval [CI] = 1.06-2.30; African-American children OR = 0.75, 95% CI = 0.58-0.96; Hispanics, Native Americans, and whites showed no significant association). Myopia progression was greater per diopter of more hyperopic relative peripheral refractive error, but only by a small amount (-0.024 D per year; P = 0.02). Axial elongation was unrelated to the average relative peripheral refractive error (P = 0.77), regardless of ethnicity. Relative peripheral hyperopia appears to exert little consistent influence on the risk of the onset of myopic refractive error, on the rate of myopia progression, or on axial elongation.
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Studies using concentric ring bifocal and peripheral add multifocal contact lenses to slow myopia progression in school-aged children: a meta-analysis
Article
  • Nov 2016
  • OPHTHAL PHYSL OPT
Purpose: To evaluate the effect of soft contact lens with concentric ring bifocal and peripheral add multifocal designs on controlling myopia progression in school-aged children. Methods: We systematically searched MEDLINE, EMBASE, Cochrane Library and reference lists of included trials. Methodological quality of included trials was assessed using Jadad Scale and Newcastle-Ottawa Quality Assessment Scale items. Results: We identified five randomised controlled trials (RCTs) and three cohort studies with a total of 587 myopic children. Compared with the control group, concentric ring bifocal soft contact lenses showed less myopia progression with a weighted mean difference (WMD) of 0.31 D (95% CI, 0.05~0.57 D, p = 0.02) and less axial elongation with a WMD of -0.12 mm (95% CI, approximately -0.18 to -0.07 mm, p < 0.0001) at 12 months. Relative to the control group, peripheral add multifocal soft contact lenses showed less myopia progression with a WMD of 0.22 D (95% CI 0.14~0.31 D, p < 0.0001) and less axial elongation of -0.10 mm (95% CI -0.13~0.07 mm, p < 0.0001) at 12 months, respectively. The soft contact lenses with concentric ring bifocal and peripheral add multifocal designs produced additional myopia control rates of 30~38% for slowing myopia progression and 31~51% for lessening axial elongation within 24 months. Conclusions: Both concentric ring bifocal and peripheral add multifocal soft contact lenses are clinically effective for controlling myopia in school-aged children, with an overall myopia control rates of 30~50% over 2 years. Concentric ring bifocal soft contact lenses seem to have greater effect than peripheral add multifocal soft contact lenses.
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Regional Changes in Choroidal Thickness Associated With Accommodation
Article
  • Oct 2015
  • INVEST OPHTH VIS SCI
Purpose: To characterize the changes occurring in choroidal thickness (ChT) across the posterior pole during accommodation using enhanced-depth imaging optical coherence tomography (OCT). Methods: Forty participants (mean age 21 ± 2 years) had measures of ChT and ocular biometry taken during accommodation to 0, 3, and 6 diopter (D) stimuli, with the Spectralis OCT and Lenstar biometer. A Badal optometer and cold mirror system was mounted on both instruments, allowing measurement collection while subjects viewed an external fixation target at varying accommodative demands. Results: The choroid exhibited significant thinning during accommodation to the 6 D stimulus in both subfoveal (mean change, -5 ± 7 μm) and parafoveal regions (P < 0.001). The magnitude of these changes varied by parafoveal meridian, with the largest changes seen in the temporal (-9 ± 12 μm) and inferotemporal (-8 ± 8 μm) meridians (P < 0.001). Axial length increased with accommodation (mean change, +5 ± 11 μm at 3 D, +14 ± 13 μm at 6 D), and these changes were weakly negatively associated with the choroidal changes (r2 = 0.114, P < 0.05). Conclusions: A small, but significant thinning of the choroid was observed at the 6 D accommodation demand, which was greatest in the temporal and inferotemporal parafoveal choroid, and increased with increasing eccentricity from the fovea. The regional variation in the parafoveal thinning corresponds to the distribution of the nonvascular smooth muscle within the uvea, which may implicate these cells as the potential mechanism by which the choroid thins during accommodation.
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Axial Elongation Associated with Biomechanical Factors During Near Work
Article
  • Jan 2014
  • OPTOMETRY VISION SCI
To investigate the changes occurring in the axial length, choroidal thickness, and anterior biometrics of the eye during a 10-minute near task performed in downward gaze. Twenty young adult subjects (10 emmetropes and 10 myopes) participated in this study. To measure ocular biometrics in downward gaze, an optical biometer was inclined on a custom-built height- and tilt-adjustable table. Baseline measures were collected after each subject performed a distance primary gaze control task for 10 minutes to provide washout period for previous visual tasks before each of three different accommodation/gaze conditions. These other three conditions included a near task (2.5 diopters [D]) in primary gaze and a near (2.5 D) and a far (0 D) accommodative task in downward gaze (25 degrees), all for 10 minutes' duration. Immediately after and then 5 and 10 minutes from the commencement of each trial, measurements of ocular biometrics (e.g., anterior biometrics, axial length, choroidal thickness, and retinal thickness) were obtained. Axial length increased with accommodation and was significantly greater for downward gaze with accommodation (mean ± SD change, 23 ± 13 μm at 10 minutes) compared with primary gaze with accommodation (8 ± 15 μm at 10 minutes) (p < 0.05). A small amount of choroidal thinning was also found during accommodation that was statistically significant in downward gaze (13 ± 14 μm at 10 minutes; p < 0.05). Accommodation in downward gaze also caused greater changes in anterior chamber depth and lens thickness compared with accommodation in primary gaze. Axial length, choroidal thickness, and anterior eye biometrics change significantly during accommodation in downward gaze as a function of time. These changes seem to be caused by the combined influence of biomechanical factors (i.e., extraocular muscle forces, ciliary muscle contraction) associated with near tasks in downward gaze.
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Axial length and choroidal thickness changes accompanying prolonged accommodation in myopes and emmetropes
Article
  • Sep 2012
The time course of elongation and recovery of axial length associated with a 30min accommodative task was studied using optical low coherence reflectometry in a population of young adult myopic (n=37) and emmetropic (n=22) subjects. Ten of the 59 subjects were excluded from analysis either due to inconsistent accommodative response, or incomplete anterior biometry data. Those subjects with valid data (n=49) were found to exhibit a significant axial elongation immediately following the commencement of a 30min, 4 D accommodation task, which was sustained for the duration of the task, and was evident to a lesser extent immediately following task cessation. During the accommodation task, on average, the myopic subjects exhibited 22±34μm, and the emmetropic subjects 6±22μm of axial elongation, however the differences in axial elongation between the myopic and emmetropic subjects were not statistically significant (p=0.136). Immediately following the completion of the task, the myopic subjects still exhibited an axial elongation (mean magnitude 12±28μm), that was significantly greater (p<0.05) than the changes in axial length observed in the emmetropic subjects (mean change -3±16μm). Axial length had returned to baseline levels 10min after completion of the accommodation task. The time for recovery from accommodation-induced axial elongation was greater in myopes, which may reflect differences in the biomechanical properties of the globe associated with refractive error. Changes in subfoveal choroidal thickness were able to be measured in 37 of the 59 subjects, and a small amount of choroidal thinning was observed during the accommodation task that was statistically significant in the myopic subjects (p<0.05). These subfoveal choroidal changes could account for some but not all of the increased axial length during accommodation.
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Accommodation, refractive error and eye growth in chickens
Article
  • Feb 1988
  • VISION RES
We raised chickens with defocusing lenses of differing powers in front of their eyes. For this purpose, small hoods made from soft, thin leather were carefully fitted to their heads. Lenses were attached to the hoods by velcro fasteners and could be easily removed for cleaning. The powers of the lenses were such that their optical effects could be compensated for by accommodation. It was verified by infrared (IR) photoretinoscopy that the chickens could keep their retinal images in focus. Wearing a lens resulted in a consistent shift of the non cycloplegic refractive state (measured without the lens) which was in the direction to compensate for the lens. We used a sensitive technique (precision= ± 50 μm as estimated from the variability of repeated measurements) to measure the posterior nodal distance (PND) in excised eyes of birds grown with lenses. The PND, in turn, was used to compare eyes treated with different lenses. It was found that the PND was increased in eyes which were treated with negative lenses compared to those treated with positive lenses. This effect occurs independently in both eyes and it is not due to changes in corneal curvature. We discuss our result in terms of a closed-loop feedback system for the regulation of eye growth.
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Spectacle lenses aller eye growth and refractive status of young monkeys
Article
  • Sep 1995
The influence of visual experience on ocular development in higher primates is not well understood. To investigate the possible role of defocus in regulating ocular growth, spectacle lenses were used to optically simulate refractive anomalies in young monkeys (for example, myopia or nearsightedness). Both positive and negative lenses produced compensating ocular growth that reduced the lens-induced refractive errors and, at least for low lens powers, minimized any refractive-error differences between the two eyes. These results indicate that the developing primate visual system can detect the presence of refractive anomalies and alter each eye's growth to eliminate these refractive errors. Moreover, these results support the hypothesis that spectacle lenses can alter eye development in young children.
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