We can't afford to turn a blind eye to myopia.

BACKGROUND: Myopia is becoming increasingly prevalent throughout the world. It is an overlooked but leading cause of blindness, particularly among the working aged population. Myopia is often considered benign because it is easily corrected with glasses, contact lenses or refractive surgery. Traditionally myopia has been classified into physiological and pathological subtypes based on the degree of myopia present. Higher levels of myopia are associated with increased risk of pathological complications but it is important to note that there is no safe level of myopia. Even low levels of myopia increase the risk of retinal detachment and other ocular comorbidities which will be discussed in detail later. The most serious complication, myopic maculopathy, is the only leading cause of blindness without an established treatment and therefore leads to inevitable loss of vision in some myopes, even at a young age. AIM: To highlight the current myopia epidemic and the sight threatening complications associated with it. DESIGN: This is a commissioned review article. Data were gathered by performing a literature review, searching the PubMed database for recent articles regarding myopia. CONCLUSIONS: Myopia is a potentially blinding disease. By identifying at risk individuals and intervening before they become myopic, eye care practitioners can prevent or delay spectacle use, reduce the risk of the myriad of myopic complications, thereby improve the patient's quality of life and positively impact its socio-economic effects.

The acceptability and visual impact of 0.01% atropine in a Caucasian population.

BACKGROUND: Myopia is a condition of enormous public health concern, affecting up to 2.5 billion people worldwide. The most effective treatment to prevent myopia progression is atropine but at the cost of accommodative paresis and mydriasis, necessitating the use of bifocal glasses. Low-dose atropine (0.01%) has been found to be almost as effective with significantly reduced side effects. Since there are well-recognised differences in the effect of atropine between heavily pigmented Asian eyes and Caucasian eyes, this study aimed to determine the acceptability and tolerability of 0.01% atropine (by measuring visual performance and quality of life) as a treatment for myopia control in a Caucasian population exhibiting light irides. METHODS: 14 university students aged 18-27 were recruited to the study. Participants received one drop of 0.01% atropine daily into each eye over 5 days. A range of physiological, functional and quality of life measures were assessed at baseline, day 3 and day 5. RESULTS: The effect of atropine was statistically significant for pupil size (p=0.04) and responsiveness (p<0.01). While amplitude of accommodation reduced, the change was not statistically significant. Visual acuity (distance and near) and reading speed were not adversely affected. While there was a slight increase in symptoms such as glare, overall there was no quality of life impact associated with the use of low-dose atropine. CONCLUSIONS: Overall, 0.01% of atropine was generally well tolerated bilaterally and no serious adverse effects were observed. Therefore this dose appears to provide a viable therapeutic option for myopia control among Caucasian eyes.

Emmetropisation and the aetiology of refractive errors.

The distribution of human refractive errors displays features that are not commonly seen in other biological variables. Compared with the more typical Gaussian distribution, adult refraction within a population typically has a negative skew and increased kurtosis (ie is leptokurtotic). This distribution arises from two apparently conflicting tendencies, first, the existence of a mechanism to control eye growth during infancy so as to bring refraction towards emmetropia/low hyperopia (ie emmetropisation) and second, the tendency of many human populations to develop myopia during later childhood and into adulthood. The distribution of refraction therefore changes significantly with age. Analysis of the processes involved in shaping refractive development allows for the creation of a life course model of refractive development. Monte Carlo simulations based on such a model can recreate the variation of refractive distributions seen from birth to adulthood and the impact of increasing myopia prevalence on refractive error distributions in Asia.

Is myopia a failure of homeostasis?

This review examines the hypothesis that human myopia is primarily a failure of homeostasis (i.e. regulated growth) and also considers the implications this has for research into refractive errors. There is ample evidence for homeostatic mechanisms in early life. During the first few years of life the eye grows toward emmetropia, a process called emmetropization. The key statistical features of this process are a shift of the mean population refraction toward emmetropia and a reduction in variability. Refractive errors result when either this process fails (primary homeostatic failure) or when an eye that becomes emmetropic fails to remain so during subsequent years (secondary homeostatic failure). A failure of homeostasis should increase variability as well as causing a possible shift in mean refraction. Increased variability is indeed seen in both animal models of myopia such as form deprivation and in human populations from the age of 5 or 6 onwards. Considering ametropia as a homeostatic failure also fits with the growing body of evidence that a wide range of factors and events can influence eye growth and refraction from gestation, through infancy, childhood and into adulthood. It is very important to recognize that the refraction of an eye is not a simple trait like eye colour but the consequence of the complex process of eye growth throughout life. To understand how an eye ends up with a specific refraction it is essential to understand all the factors that may promote the attainment and maintenance of emmetropia. Equally important are the factors that may either disrupt early emmetropization or lead to a loss of emmetropia during later development. Therefore, perhaps the most important single implication of a homeostatic view of myopia is that this condition is likely to have a very wide range of causes. This may allow us to identify subgroups of myopia for which specific environmental influences, genes or treatments can be found, effects that might be lost if all myopes are considered to be equivalent.

The complex interactions of retinal, optical and environmental factors in myopia aetiology.

Myopia is the commonest ocular abnormality but as a research topic remains at the margins of mainstream ophthalmology. The concept that most myopes fall into the category of 'physiological myopia' undoubtedly contributes to this position. Yet detailed analysis of epidemiological data linking myopia with a range of ocular pathologies from glaucoma to retinal detachment demonstrates statistically significant disease association in the 0 to -6 D range of 'physiological myopia'. The calculated risks from myopia are comparable to those between hypertension, smoking and cardiovascular disease. In the case of myopic maculopathy and retinal detachment the risks are an order of magnitude greater. This finding highlights the potential benefits of interventions that can limit or prevent myopia progression. Our understanding of the regulatory processes that guide an eye to emmetropia and, conversely how the failure of such mechanisms can lead to refractive errors, is certainly incomplete but has grown enormously in the last few decades. Animal studies, observational clinical studies and more recently randomized clinical trials have demonstrated that the retinal image can influence the eye's growth. To date human intervention trials in myopia progression using optical means have had limited success but have been designed on the basis of simple hypotheses regarding the amount of defocus at the fovea. Recent animal studies, backed by observational clinical studies, have revealed that the mechanisms of optically guided eye growth are influenced by the retinal image across a wide area of the retina and not solely the fovea. Such results necessitate a fundamental shift in how refractive errors are defined. In the context of understanding eye growth a single sphero-cylindrical definition of foveal refraction is insufficient. Instead refractive error must be considered across the curved surface of the retina. This carries the consequence that local retinal image defocus can only be determined once the 3D structure of the viewed scene, off axis performance of the eye and eye shape has been accurately defined. This, in turn, introduces an under-appreciated level of complexity and interaction between the environment, ocular optics and eye shape that needs to be considered when planning and interpreting the results of clinical trials on myopia prevention.

Targeted mydriasis strategies for diabetic retinopathy screening clinics.

PURPOSE: To examine factors necessitating pupil dilation to achieve gradable diabetic screening photographs using a digital non-mydriatic camera and to establish techniques to predict the need for dilation and to validate them. METHODS: Prospective clinic-based cross-sectional study with follow-up validation study. The participants' involved consecutive patients attending the diabetic retinopathy screening clinic at a University Hospital. Best corrected visual acuity, age, sex, pupil size, mean spherical equivalent, cataract grade and the requirement for dilation to achieve gradable photographs in 90 patients were recorded. Data analysis using principal component analysis and multivariate analysis of variance derived a set of equations to predict the requirement for dilation. The predictive powers of these equations were validated in an independent group of 51 patients. RESULTS: Smaller pupil size, denser nuclear colour, older age, poorer best-corrected visual acuity, cortical lens opacity and posterior subcapsular lens opacity were associated with the need for dilation (P<0.001 in all). Single variables used in isolation had a poorer predictive value than combining variables. Dilating patients with either a pupil size>3.75 mm or age>59 years correctly allocates 83 and 78% of patients, respectively to dilation or not. Combining pupil size with age produces a decision table that improves the predictive value to 84%. In the validation study this table had a predictive value of 80%. CONCLUSION: We have produced and validated criteria based on a range of clinical variables for application in a clinical setting that allows for the development of targeted mydriasis.

Retinal dysfunction and refractive errors: an electrophysiological study of children.

AIMS: To evaluate the relation between refractive error and electrophysiological retinal abnormalities in children referred for investigation of reduced vision. METHODS: The study group comprised 123 consecutive patients referred over a 14 month period from the paediatric service of Moorfields Eye Hospital for electrophysiological investigation of reduced vision. Subjects were divided into five refractive categories according to their spectacle correction: high myopia (< or = -6D), low myopia (>-6D and < or = -0.75D), emmetropia (>-0.75 and <1.5D), low hyperopia (> or = 1.5 and <6D), and high hyperopia (> or = 6D). Patients with a specific diagnosis at the time of electrophysiological testing were excluded. Only the first member of any one family was included if more than one sibling had been tested. All tests were performed to incorporate ISCEV standards, using gold foil corneal electrodes where possible. In younger patients skin electrodes and an abbreviated protocol were employed. RESULTS: The mean age of patients was 7.1 years with an overall incidence of abnormal electrophysiological findings of 29.3%. The incidence of abnormality was higher in high ametropes (13/25, 52%) compared to the other groups (23/98, 23.5%). This difference was statistically significant (chi2 test, p = 0.005). There was also a significant association between high astigmatism (>1.5D) and ERG abnormalities (18/35 with high astigmatism v 20/88 without, chi2 test, p = 0.002). There was no significant variation in frequency of abnormalities between low myopes, emmetropes, and low hyperopes. The rate of abnormalities was very similar in both high myopes (8/15) and high hyperopes (5/10). CONCLUSIONS: High ametropia and astigmatism in children being investigated for poor vision are associated with a higher rate of retinal electrophysiological abnormalities. An increased rate of refractive errors in the presence of retinal pathology is consistent with the hypothesis that the retina is involved in the process of emmetropisation. Electrophysiological testing should be considered in cases of high ametropia in childhood to rule out associated retinal pathology.

Ocular shape and myopia.

INTRODUCTION: To learn if eye shape might be a useful parameter in refractive research. MATERIALS AND METHODS: Laboratory research on eye growth mechanisms is summarised. The available clinical literature relating refraction to eye shape and peripheral refraction is critically assessed in the context of the laboratory research on refractive development. RESULTS: Almost all refraction research assesses optical and length parameters exclusively along the visual axis. Contemporary laboratory research demonstrates a remarkable phylogenic conservation of the neural mechanisms regulating refractive development. On-axis image quality regulates central refractive development in animals and probably, to some extent, in humans. Off-axis image quality at the retina depends on anterior segment geometry and optics, and on the 3-dimensional conformation of the retina. In chicks, eye shape is a predictable parameter linked to the underlying neural mechanisms modulating eye development. Based on the sparse clinical literature in human adults and children, the eye shapes induced in chicks are also seen in human subjects in patterns suggesting that eye shape may be a useful parameter in clinical studies. CONCLUSION: The diverse findings suggest that incorporating the 3-dimensional conformation of the eye into future clinical studies may help resolve many of the ambiguities in contemporary refractive research.

Intraocular lenses in children: changes in axial length, corneal curvature, and refraction.

AIM: To assess changes in axial length, corneal curvature, and refraction in paediatric pseudophakia. METHODS: 35 eyes of 24 patients with congenital or developmental lens opacities underwent extracapsular cataract extraction and posterior chamber intraocular lens implantation. Serial measurements were made of axial length, corneal curvature, objective refraction, and visual acuity. RESULTS: For patients with congenital cataracts (onset < 1 year age) the mean age at surgery was 24 weeks. Over the mean follow up period of 2.7 years, the mean increase in axial length of 3.41 mm was not significantly different from the value of an expected mean growth of 3.44 mm (paired t test, p = 0.97) after correction for gestational age. In the developmental cataract group (onset > 1 year of age) the mean age at surgery was 6.4 years with a mean follow up of 2.86 years. This group showed a mean growth in axial length of 0.36 mm that was not significantly different from an expected value of 0.47 mm (paired t test, p = 0.63). The mean preoperative keratometry was 47.78 D in the congenital group and 44.35 D in the developmental group. At final follow up the mean keratometry in the congenital group was 46.15 D and in the developmental group it was 43.63 D. In eyes followed for at least 2 years, there was an observed myopic shift by 24 months postoperatively of 3.26 D in the congenital cases (n = 10) and 0.96 D in the developmental cases (n = 18). CONCLUSION: The pattern of axial elongation and corneal flattening was similar in the congenital and developmental groups to that observed in normal eyes. No significant retardation or acceleration of axial growth was found in the eyes implanted with IOLs compared with normal eyes. A myopic shift was seen particularly in eyes operated on at 4-8 weeks of age and it is recommended that these eyes are made 6 D hypermetropic initially with the residual refractive error being corrected with spectacles.

The lens paradigm in experimental myopia: oculomotor, optical and neurophysiological considerations.

The lens-rearing paradigm has developed great importance in the field of experimental myopia. Although an apparently simple paradigm, the results of any experiment can be influenced by a variety of factors including habitual viewing distance, ocular refraction, oculomotor performance and the spatial sensitivity of the retinal elements involved in retinal image assessment. Computer modelling has been used to evaluate the expected impact when lenses are placed in front of a primate eye as a function of the above parameters. Spatial band-pass responses of the mechanisms responsible for emmetropization are predicted to lead to a limited range of retinal defocus over which compensation to lenses could occur. Even assuming an equal ability to detect hyperopic and myopic defocus, it is predicted that primate eyes should be able to compensate for a much larger range of minus lenses than plus lenses. This derives from the ability of the accommodation system to keep retinal defocus within this operating range over a wider range of minus lenses than plus lenses. The range over which compensation can occur will depend on the spatial tuning of the elements responsible for detecting retinal defocus and capabilities of the accommodation system. The observed asymmetry in responses of the primate eye to rearing with plus and minus lenses and observed differences between primates and chickens in lens rearing studies may therefore be partly attributable to optical and neurophysiological considerations.

A model of the contribution of oculomotor and optical factors to emmetropization and myopia.

The purpose of this work was to investigate quantitatively the interactions between accommodation, vergence and a mechanism of emmetropization driven by optical blur within the retinal image with a view to developing a model that provides an explanation of both normal emmetropization and near-work associated myopia. The simulations of the change in the refractive state of the eye over time that derive from this model indicate that optical regulation of eye growth can result in emmetropization, i.e. a progressive reduction in refractive errors over time leading towards emmetropia. This occurs when viewing conditions involve a preponderance of distance work. With increasing near work, the model predicts that the refraction of the eyes will converge towards myopia. In keeping with the previously reported associations of myopia with esophoria, poor accommodation function and high AC/A ratios, these conditions increase the amount of myopia produced under intensive near viewing conditions but do not lead to myopia during mainly distance viewing. This model provides quantitative validation of the hypothesis that the epidemiological association between myopia and increased nearwork may be caused by a disturbance of normal emmetropization by steady state errors of accommodation. The same model can explain normal emmetropization, increasing myopia with increasing nearwork demands and the currently recognised oculomotor associations that have been reported to precede the development of myopia.

Accommodation in binocular contour rivalry.

Although contour rivalry is known to suppress the contribution of the non-dominant eye to some visuomotor mechanisms such as the pupillary light reflex, there have been no reports of the impact of rivalry on accommodation control. In the situation where the accommodation demands in the two eyes are in dynamic conflict, it has been reported that the accommodation response can be modelled in terms of a vector average of the appropriate response in the two eyes. This study compared the binocular interactions in the accommodation system with rivalrous and non-rivalrous stimuli. Accommodation was continuously monitored with an infrared optometer, while the accommodation demand in the two eyes was dynamically modulated independently in the two eyes. When the visual target was perceptually rivalrous the previously described binocular interactions were abolished and the accommodation response closely followed the accommodation demand presented to the dominant eye.

Who should see eye casualties?: a comparison of eye care in an accident and emergency department with a dedicated eye casualty.

Emergency care for eye complaints is provided both by accident and emergency (A&E) departments as well as by dedicated eye casualty departments. This study examines the role of each type of department and the quality of eye care provided. Significant differences were found between the accident and emergency department and the eye casualty department in the history, examination and management of eye patients. Most notably, there were significant differences in the quality of the assessment in the two institutions. Overall 19% (19/100) of A&E records had an inadequate history, compared with 2% (1/50) for eye casualty records. Fifty-nine per cent (59/100) of A&E records contained a significant examination omission, compared with only 8% (4/50) of eye casualty records. Most of the omissions related to a failure to perform an adequate, yet simple, ocular examination including failure to record visual acuity. In 44% (44-100) of A&E cases visual acuity was not recorded or recorded incorrectly. In comparison acuity omissions in eye casualty were present in only 4% (2/50) of cases.

Binocular interactions in accommodation control: effects of anisometropic stimuli.

In binocular viewing of real targets, the accommodative demand in the two eyes is not in general identical, yet the accommodation response in the two eyes is equal. In order to investigate how the accommodative signals from the two eyes are combined, this study has examined the effects of several forms of dynamic anisometropic stimulation on the accommodation response in both man and the rhesus monkey (Macaca mulatta). All experiments were performed in a computer-controlled haploscopic apparatus to allow independent control of the accommodative stimuli to the two eyes and of the vergence stimulus. The vergence stimulus was held constant while the accommodation demand was modulated independently in each eye. Accommodation was monitored continuously with a dynamic infrared optometer. Four anisometropic conditions were used. In two of these conditions, accommodation demand was varied sinusoidally with time in both eyes, but with phases differing by 90 degrees or 180 degrees between the two eyes. In the two remaining conditions, accommodation demand in one eye varied sinusoidally, while the accommodation demand was constant in the other. In all cases, the form of the target pattern was identified in the two eyes. The accommodation responses observed with these stimulus conditions were similar in both man and the monkey. When presented with conflicting stimuli in the two eyes, the accommodation response appeared to be best described as a compromise between the inputs to the two eyes; there were no indications of a purely random alternation of eye dominance of the form seen in binocular contour rivalry. When the accommodation demand was modulated in only one eye, there was a modulated accommodation response of similar phase to the control condition (i.e., both eyes modulated in phase) but with a much smaller gain (mean, 39% of control gain). When the accommodation demand was modulated in both eyes with a phase difference of 180 degrees, no significant modulation was observed in the accommodation response at the stimulation frequency. When the interocular phase difference was 90 degrees, a modulated response was observed that showed a mean phase lag 41 degrees more than that observed in the control condition (both eyes modulated in phase) and an appreciably smaller gain (mean, 55% of control gain). The extent to which the results can be described by a linear vector average of the uniocular inputs is considered.

Accommodation and flicker: evidence of a role for temporal cues in accommodation control?

Static accommodation responses to sinusoidal grating stimuli that displayed temporal modulations in luminance contrast (i.e. contrast flicker) were measured with a laser speckle optometer. The effects of a variety of temporal waveforms were investigated including square-wave modulations, sinusoidal modulations, and band-pass filtered noise. The effects of altering both the amplitude and the temporal frequency (0.4-30 Hz) of the contrast flicker and the spatial frequency of the stimulus (0.77-9.2 c/deg) were also examined. All the flicker waveforms investigated (square wave, sinusoidal and band-pass noise) reduced accommodative accuracy, the effect being most apparent at lower spatial frequencies (0.77-1.15 c/deg). With band-pass filtered noise the effects of flicker were most apparent with frequencies in the range 1-4 Hz, at both lower (0.4 Hz) and higher flicker frequencies (8-32 Hz) accommodations was less affected. It was found that flicker impaired accommodation under conditions where the contrast was at all times suprathreshold. This is incompatible with the proposal that flicker reduces accommodation responses because for part of each flicker cycle the stimulus was below threshold. However, these results are compatible with the alternative hypothesis that flicker impairs the ability of the accommodation system to utilize temporal cues such as those derived from the higher frequency component (1-2 Hz) of accommodative oscillations.