2024 UK and Ireland modified Delphi consensus on myopia management in children and young people.

INTRODUCTION: This work aimed to establish the largest UK and Ireland consensus on myopia management in children and young people (CYP). METHODS: A modified Delphi consensus was conducted with a panel of 34 optometrists and ophthalmologists with expertise in myopia management. RESULTS: Two rounds of voting took place and 131 statements were agreed, including that interventions should be discussed with parents/carers of all CYP who develop myopia before the age of 13 years, a recommendation for interventions to be publicly funded for those at risk of fast progression and high myopia, that intervention selection should take into account the CYP's hobbies and lifestyle and that additional training for eye care professionals should be available from non-commercial sources. Topics for which published evidence is limited or lacking were areas of weaker or no consensus. Modern myopia management contact and spectacles are suitable first-line treatments. The role and provision of low-concentration atropine needs to be reviewed once marketing authorisations and funding decisions are in place. There is some evidence that a combination of low-concentration atropine with an optical intervention can have an additive effect; further research is needed. Once an intervention is started, best practice is to monitor non-cycloplegic axial length 6 monthly. CONCLUSION: Research is needed to identify those at risk of progression, the long-term effectiveness of individual and combined interventions, and when to discontinue treatment when myopia has stabilised. As further evidence continues to emerge, this consensus work will be repeated to ensure it remains relevant.

Conformation of the anterior segment in human myopia.

PURPOSE: Topography of the in vivo anterior segment is of relevance in understanding its role in myopia and in the development of ocular surgical procedures. Using 3D magnetic resonance (MR) images of the human eye, regional variations in surface area (SA) and bulbosity of four anterior segment regions were investigated in association with refractive status (Rx), axial length (AL) and total ocular volume (OV). METHODS: T2-weighted ocular MR images from 43 adults aged 18-40 years (mean ± SD; 28.65 ± 6.20) comprising 20 non-myopes (≥-0.50) 0.57 ± 1.38 and 23 myopes (<-0.50) -6.37 ± 4.23 MSE (D) were collected. 2D representations of each quadrant (superior-temporal [ST], superior-nasal [SN], inferior-temporal [IT] and inferior-nasal [IN]) of the anterior section (3.5-9 mm) were fitted with second-order polynomials. Polynomials were integrated and rotated about the x-axis to generate SA; dividing the SA by 4 provided relative quadrantial SA. The x2 coefficient provides indices of bulbosity. OV was derived from the 3D MRI scans. Rx and AL were measured using cycloplegic autorefraction and the Zeiss IOLMaster, respectively. One- and two-way repeated-measures ANCOVAs tested differences in SA and bulbosity for Rx, gender, ethnicity and age. Pearson's correlation coefficient tested the relationship between MRI-derived metrics and biometry. RESULTS: Significant differences in SA were observed between quadrants (p < 0.001) with differences between ST versus IN, IN versus IT and SN versus IT. An interaction effect (p = 0.01) for Rx suggested smaller temporal (ST and IT) and larger nasal (SN and IN) SA in myopes. AL and myopic Rx were negative correlated (p < 0.05) with SA at IN, SN and IT. OV was significantly associated with SA at ST. Bulbosity showed no regional differences nor an effect of AL or Rx. CONCLUSION: Significant regional variation in SA exists across the anterior segment that is modulated by Rx and AL. It is unclear whether these structural characteristics are a precursor or consequence of myopia and may warrant investigation when developing biomechanical interventions.

Optimising curve fitting techniques to look for standardisation of the analysis of defocus curves derived from multifocal intraocular lenses.

INTRODUCTION: To establish the most appropriate curve fitting method to allow accurate comparison of defocus curves derived from intraocular lenses (IOLs). METHODS: Defocus curves were plotted in five IOL groups (monofocal, extended depth of focus, refractive bifocal, diffractive bifocal and trifocal). Polynomial curves from 2nd to 11th order and cubic splines were fitted. Goodness of fit (GOF) was assessed using five methods: least squares, coefficient of determination (R2adj ), Akaike information criteria (AIC), visual inspection and Snedecor and Cochran. Additional defocus steps at -2.25 D and -2.75 D were measured and compared to the calculated visual acuity (VA) values. Area under the defocus curve and range of focus were also compared. RESULTS: Goodness of fit demonstrated variable results, with more lenient methods such as R2adj leading to overfitting and conservative methods such as AIC resulting in underfitting. Furthermore, conservative methods diminished the inflection points resulting in an underestimation of VA. Polynomial of at least 8th order was required for comparison of area methods, but overfitted the EDoF and monofocal groups; the spline curve was consistent for all IOLs and methods. CONCLUSIONS: This study demonstrates the inherent difficulty of selecting a single polynomial function. The R2 method can be used cautiously along with visual inspection to guard against overfitting. Spline curves are suitable for all IOLs, guarding against the issues of overfitting. Therefore, for analysis of the defocus profile of IOLs, the fitting of a spline curves is advocated and should be used wherever possible.

One-year post-operative comparison of visual function and patient satisfaction with trifocal and extended depth of focus intraocular lenses.

PURPOSE: To evaluate visual performance with trifocal and extended depth of focus IOL at 1 year post-operatively. SETTING: BMI Southend Hospital. DESIGN: Cohort study. METHODS: An age-matched cohort of forty subjects bilaterally implanted with the AT LISA 839MP trifocal IOL (20 patients, 40 eyes) and the Tecnis Symfony extended depth of focus IOL (20 patients, 40 eyes) were assessed at 3-6 months and 12-18 months post-operatively. Primary outcome measures were distance (6 m), intermediate (70 cm), near visual acuity (40 cm), and analysis of defocus profiles. Secondary outcomes included contrast sensitivity, Radner reading performance, quality of vision and assessment of halos. RESULTS: Distance visual acuity (VA) and defocus areas were similar (p = 0.07). No significant difference in intermediate VA was noted but the intermediate area of focus was greater in the EDoF (0.31 ± 0.12 LogMAR*m-1) compared to the trifocal (0.22 ± 0.08LogMAR*m-1) (p = 0.02). However, all near metrics were significantly better in the trifocal group. 80% of trifocal subjects were spectacle independent compared to 50% EDoF subjects. Quality of vision questionnaire found no significant differences between groups, however halo scores were greater at 3-6 months in the trifocal group (p < 0.01) but no differences were noted at 12-18 months. CONCLUSIONS: Near vision is significantly better for the trifocal, thus greater levels of spectacle independence. The range of intermediate vision was greater for the EDoF but no difference in intermediate VA. In the early period, differences in contrast sensitivity and halo size/intensity were noted, however, by one-year these measures were not significantly different.

Predicting the Postoperative Addition Power of a Multifocal Intraocular Lens at the Spectacle Plane.

PURPOSE: To establish a simple clinical method of predicting addition power achieved with a multifocal intraocular lens (IOL). METHODS: In this prospective cohort study, 41 patients were bilaterally implanted with the Bi-Flex MY multifocal IOL (Medicontur) with +3.50 diopters (D) near addition power. Monocular defocus curves were plotted for each patient and effective addition power was calculated as the dioptric difference between the distance and near inflection points of the defocus curve. Six biometry formulas (Haigis, Holladay, SRK/T, Hill RBF, Barrett Universal II, and Holladay 2) were used to predict the addition power at the spectacle plane. RESULTS: Mean effective addition power was 2.60 ± 0.29 D, with significant (P < .01) differences between the prediction methods. Significant differences were found between predicted and effective addition when the Holladay, SRK/T, Hill RBF, and Holladay 2 formulas were used. A moderate but significant correlation (r = 0.342, P = .033) was found with the Barrett formula, and this was also the method to show the least proportional bias with Bland-Altman analysis. CONCLUSIONS: The study demonstrates that the effective addition power can be predicted using the proposed simple clinical method derived using the Barrett Universal II formula. The proposed technique may have significant clinical value in screening for patients where ocular biometry may lead to aberrant addition power. [J Refract Surg. 2021;37(5):318-323.].

In vivo measures of anterior scleral resistance in humans with rebound tonometry.

PURPOSE: To measure regional variations in anterior scleral resistance (ASR) using a ballistic rebound tonometer (RBT) and examine whether the variations are significantly affected by ethnicity and refractive error (RE). METHODS: ASR was measured using a RBT (iCare TA01) following calibration against the biomechanical properties of agarose biogels. Eight scleral regions (nasal, temporal, superior, inferior, inferior-nasal, inferior-temporal, superior-nasal and superior-temporal) were measured at locations 4mm from the limbus. Subjects were 130 young adults comprising three ethnic groups whose RE distributions [MSE (D) ± S.D.] incorporated individuals categorised as without-myopia (NM; MSE ≥ -0.50) and with-myopia (WM; MSE < -0.50); British-White (BW): 26 NM + 0.52 ± 1.15D; 22 WM -3.83 ± 2.89D]; British-South-Asian (BSA): [9 NM + 0.49 ± 1.06D; 11 WM -5.07 ± 3.76D; Hong-Kong-Chinese (HKC): [11 NM + 0.39 ± 0.66D; 49 WM -4.46 ± 2.70D]. Biometric data were compiled using cycloplegic open-field autorefraction and the Zeiss IOLMaster. Two- and three-way repeated measures analysis of variances (anovas) tested regional differences for RBT values across both refractive status and ethnicity whilst stepwise forward multiple linear regression was used as an exploratory test. RESULTS: Significant regional variations in ASR were identified for the BW, BSA and HKC (p < 0.001) individuals; superior-temporal region showed the lowest levels of resistance whilst the inferior-nasal region the highest. Compared to the BW and BSA groups, the HKC subjects displayed a significant increase in mean resistance for each respective region (p < 0.001). With the exception of the inferior region, ethnicity was found to be the chief predictor for variation in the scleral RBT values for all other regions. Mean RE group differences were insignificant. CONCLUSIONS: The novel application of RBT to the anterior sclera confirm regional variation in ASR. Greater ASR amongst the HKC group than the BW and BSA individuals suggests that ethnic differences in anterior scleral biomechanics may exist.

Visual function and subjective perception of vision after bilateral implantation of monofocal and multifocal IOLs: a randomized controlled trial.

PURPOSE: To examine monocular and binocular visual function and patient-reported outcomes after implantation of multifocal IOLs (mIOLs) or monofocal IOLs, using a rigorous series of clinical assessments. SETTING: BMI Southend Hospital, United Kingdom. DESIGN: Prospective, randomized, double-masked clinical trial. METHODS: One hundred patients were randomized for bilateral implantation of either a Bi-Flex 677MY mIOL or a Bi-Flex 677AB IOL and were assessed at 3 to 6 months (V1) and 12 to 18 months (V2). Primary outcomes included distance, intermediate, and near logarithm of the minimum angle of resolution (logMAR) visual acuities (VAs) and defocus curve profile assessment. Secondary outcomes included reading speed, contrast sensitivity (CS), and the subjective perception of quality of vision. RESULTS: Forty-seven subjects with monofocal IOL and 43 mIOL subjects completed the study. Uncorrected (mIOL: 0.10 ± 0.09 logMAR; IOL: 0.09 ± 0.11 logMAR) and corrected (mIOL: 0.04 ± 0.06 logMAR; IOL: 0.01 ± 0.07 logMAR) distance VAs were comparable (P > .05). Uncorrected near VA (mIOL: 0.23 ± 0.13 logMAR; IOL: 0.55 ± 0.20 logMAR, P < .001) and distance-corrected near VA (mIOL: 0.24 ± 0.13 logMAR; IOL: 0.54 ± 0.17 logMAR, P < .001) were significantly improved with mIOLs. There was no significant difference in distance-corrected intermediate VA (mIOL: 0.38 ± 0.13 logMAR; IOL: 0.39 ± 0.13 logMAR, P = .431). Defocus curves demonstrated an increased range-of-focus among mIOLs (mIOL: 4.14 ± 1.10 diopter [D]; IOL: 2.57 ± 0.77 D). Pelli-Robson CS was different at V1 (P < .001) but similar by V2 (P = .059). Overall satisfaction was high (>90%) in both groups for distance tasks whereas significantly different for near tasks (mIOL, 18.45 ± 16.53 logUnits; IOL, 55.59 ± 22.52 logUnits). CONCLUSIONS: Uncorrected near visual acuity was demonstrably better with mIOLs and there was greater subjective satisfaction with quality of near vision. Halos reported by the mIOL group were significant compared with the IOL group but did not show an adverse effect on overall satisfaction.

IMI - Clinical Myopia Control Trials and Instrumentation Report.

The evidence-basis based on existing myopia control trials along with the supporting academic literature were reviewed; this informed recommendations on the outcomes suggested from clinical trials aimed at slowing myopia progression to show the effectiveness of treatments and the impact on patients. These outcomes were classified as primary (refractive error and/or axial length), secondary (patient reported outcomes and treatment compliance), and exploratory (peripheral refraction, accommodative changes, ocular alignment, pupil size, outdoor activity/lighting levels, anterior and posterior segment imaging, and tissue biomechanics). The currently available instrumentation, which the literature has shown to best achieve the primary and secondary outcomes, was reviewed and critiqued. Issues relating to study design and patient selection were also identified. These findings and consensus from the International Myopia Institute members led to final recommendations to inform future instrumentation development and to guide clinical trial protocols.

Validation of Novel Metrics from the Accommodative Dynamic Profile.

Objective and subjective methods of assessing time taken for accommodative change (ToAC) include accommodative dynamics (AD) and accommodative facility (AF). This study investigates the validity of novel metrics derived from the AD-profile and explores their relationship with AF. AD were assessed using a modified open-field autorefractor in 43 healthy adults. Non-linear regression curves were fitted to the data to derive: latency-of-accommodation (nLoA) and -disaccomodation (nLoD), Time-for-accommodation (ToA) and -disaccommodation (ToD), and objective-ToAC (oToAC). Latencies were also calculated through visual inspection of the AD data as in previous studies (pLoA and pLoD). AF was used to assess subjective-ToAC. Statistical analysis explored the relationships between the AD-metrics and AF. Subjects were assessed on three visits to examine intra- and inter-observer repeatability. nLoA and nLoD were greater than pLoA (p = 0.001) and pLoD (p = 0.004) respectively. nLoA and nLoD also demonstrated greater intra- and inter-observer repeatability than pLoA and pLoD. AF demonstrated a moderate, inverse correlation with ToA (p = 0.02), ToD (p = 0.007), and oToAC (p = 0.007). ToD was the single best accommodative predictor of AF (p = 0.011). The novel method for deriving latency was more repeatable, but not interchangeable with the techniques used in previous studies. ToD was the most repeatable metric with the greatest association with AF.

Comparison of reliability and repeatability of corneal curvature assessment with six keratometers.

BACKGROUND: Keratometric methodology varies between instruments and the differences may have a clinical impact. We investigated the agreement and reproducibility of six keratometers. METHODS: Keratometry was performed on 100 subjects at two separate sessions with IOLMaster 500, Pentacam, OPD scanner, Medmont E300, Javal-Schiøtz and TMS-5. A second observer assessed 30 subjects to determine inter-observer variability. A single individual was assessed on 10 separate sessions to determine intra-observer variability. Data were analysed using coefficient of variation (CV) and intra-class correlation coefficient (ICCC) for intra-observer variation. Inter-observer concordance was evaluated by the ICCC. Bland-Altman plots, Pearson's correlation coefficient and repeated measures analysis of variance were used to assess agreement of data produced by the instruments. RESULTS: OPD scanner and Javal-Schiøtz mean spherical equivalent (MSE) results were systematically different (p < 0.001) from other instruments (flatter and steeper, respectively). J0 /J45 were similar for all instruments (p < 0.05). Bland-Altman comparison plots indicated that Pentacam and IOLMaster demonstrated greatest level of agreement (ICC results MSE = 0.992, J0 = 0.934 and J45 = 0.890). Agreement (ICC) between observers for MSE ranged from 0.955 to 0.995 for all instruments; lower levels of agreement were found for J0 /J45 (0.289 to 0.901). IOLMaster showed greatest correlation and Medmont the lowest. All instruments showed high intra-observer repeatability of MSE (CV 0.1 to 0.3 per cent). The J0 /J45 readings showed greater variability (CV range 8.8 to 57.6 per cent). CONCLUSION: When considering MSE alone IOLMaster, Pentacam, OPD scan and Medmont may be considered interchangeable; however, assessment of astigmatism shows greater variability between instruments, sessions and observers.

Tablet App halometer for the assessment of dysphotopsia.

PURPOSE: To assess the validity and repeatability of the Aston Halometer. SETTING: University clinic, United Kingdom. DESIGN: Prospective, repeated-measures experimental study. METHODS: The halometer comprises a bright light-emitting-diode (LED) glare source in the center of an iPad4. Letters subtending 0.21° (~0.3 logMAR) were moved centrifugally from the LED in 0.05 degree steps in 8 orientations separated by 45 degrees for each of 4 contrast levels (1000, 500, 100, and 25 Weber contrast units [Cw]) in random order. Bangerter occlusion foils were inserted in front of the right eye to simulate monocular glare conditions in 20 subjects (mean age 27.7 ± 3.1 years). Subjects were positioned 2 meters from the screen in a dark room with the iPad controlled from an iPhone via Bluetooth operated by the researcher. The C-Quant straylight meter was also used with each of the foils to measure the level of straylight over the retina. Halometry and straylight repeatability was assessed at a second visit. RESULTS: Halo size increased with the different occlusion foils and target contrasts (F = 29.564, P < .001) as expected and in a pattern similar to straylight measures (F = 80.655, P < 0.001). Lower contrast letters showed better sensitivity but larger glare-obscured areas, resulting in ceiling effects caused by the screen's field-of-view, with 500 Cw being the best compromise. Intraobserver and interobserver repeatability of the Aston Halometer was good (500Cw: 0.84 to 0.93 and 0.53 to 0.73) and similar to the straylight meter. CONCLUSION: The halometer provides a sensitive, repeatable way of quantifying a patient-recognized form of disability glare in multiple orientations to add objectivity to subjectively reported discomfort glare.

Measurement of Scleral Thickness in Humans Using Anterior Segment Optical Coherent Tomography.

Anterior segment optical coherent tomography (AS-OCT, Visante; Zeiss) is used to examine meridional variation in anterior scleral thickness (AST) and its association with refractive error, ethnicity and gender. Scleral cross-sections of 74 individuals (28 males; 46 females; aged between 18-40 years (27.7±5.3)) were sampled twice in random order in 8 meridians: [superior (S), inferior (I), nasal (N), temporal (T), superior-temporal (ST), superior-nasal (SN), inferior-temporal (IT) and inferior-nasal (IN)]. AST was measured in 1mm anterior-to-posterior increments (designated the A-P distance) from the scleral spur (SS) over a 6mm distance. Axial length and refractive error were measured with a Zeiss IOLMaster biometer and an open-view binocular Shin-Nippon autorefractor. Intra- and inter-observer variability of AST was assessed for each of the 8 meridians. Mixed repeated measures ANOVAs tested meridional and A-P distance differences in AST with refractive error, gender and ethnicity. Only right eye data were analysed. AST (mean±SD) across all meridians and A-P distances was 725±46 µm. Meridian SN was the thinnest (662±57 µm) and I the thickest (806±60 µm). Significant differences were found between all meridians (p<0.001), except S:ST, IT:IN, IT:N and IN:N. Significant differences between A-P distances were found except between SS and 6 mm and between 2 and 4 mm. AST measurements at 1mm (682±48 µm) were the thinnest and at 6mm (818±49 µm) the thickest (p<0.001); a significant interaction occurred between meridians and A-P distances (p<0.001). AST was significantly greater (p<0.001) in male subjects but no significant differences were found between refractive error or ethnicity. Significant variations in AST occur with regard to meridian and distance from the SS and may have utility in selecting optimum sites for pharmaceutical or surgical intervention.

Ocular biometric correlates of ciliary muscle thickness in human myopia.

PURPOSE: Anterior segment optical coherent tomography (AS-OCT) is used to further examine previous reports that ciliary muscle thickness (CMT) is increased in myopic eyes. With reference to temporal and nasal CMT, interrelationships between biometric and morphological characteristics of anterior and posterior segments are analysed for British-White and British-South-Asian adults with and without myopia. METHODS: Data are presented for the right eyes of 62 subjects (British-White n = 39, British-South-Asian n = 23, aged 18-40 years) with a range of refractive error (mean spherical error (MSE (D)) -1.74 ± 3.26; range -10.06 to +4.38) and separated into myopes (MSE (D) <-0.50, range -10.06 to -0.56; n = 30) and non-myopes (MSE (D) ≥-0.50, -0.50 to +4.38; n = 32). Temporal and nasal ciliary muscle cross-sections were imaged using a Visante AS-OCT. Using Visante software, manual measures of nasal and temporal CMT (NCMT and TCMT respectively) were taken in successive posterior 1 mm steps from the scleral spur over a 3 mm distance (designated NCMT1, TCMT1 et seq). Measures of axial length and anterior chamber depth were taken with an IOLMaster biometer. MSE and corneal curvature (CC) measurements were taken with a Shin-Nippon auto-refractor. Magnetic resonance imaging was used to determine total ocular volume (OV) for 31 of the original subject group. Statistical comparisons and analyses were made using mixed repeated measures anovas, Pearson's correlation coefficient and stepwise forward multiple linear regression. RESULTS: MSE was significantly associated with CMT, with thicker CMT2 and CMT3 being found in the myopic eyes (p = 0.002). In non-myopic eyes TCMT1, TCMT2, NCMT1 and NCMT2 correlated significantly with MSE, AL and OV (p < 0.05). In contrast, myopic eyes failed generally to exhibit a significant correlation between CMT, MSE and axial length but notably retained a significant correlation between OV, TCMT2, TCMT3, NCMT2 and NCMT3 (p < 0.05). OV was found to be a significantly better predictor of TCMT2 and TCMT3 than AL by approximately a factor of two (p < 0.001). Anterior chamber depth was significantly associated with both temporal and nasal CMT2 and CMT3; TCMT1 correlated positively with CC. Ethnicity had no significant effect on differences in CMT. CONCLUSIONS: Increased CMT is associated with myopia. We speculate that the lack of correlation in myopic subjects between CMT and axial length, but not between CMT and OV, is evidence that disrupted feedback between the fovea and ciliary apparatus occurs in myopia development.