Current Optical Interventions in Controlling Myopia Progression
By Loujain Alqahtani, Optometry doctor
and student of the Expert Certificate in Clinical Optometry
Myopia is an emerging pandemic with prevalence reaching an alarmingly high level globally. The accelerated evolution of lifestyles over recent decades with more time dedicated to near work, combined with a marked reduction of outdoor activities likely explains this epidemic (He et al., 2015; Ip et al., 2008; Nickels et al., 2019). Myopia has been predicted to affect nearly 50% of the world’s population by 2050 (Holden et al., 2016). Due to the significant economic health burden and serious sight-threatening complications associated with myopia such as myopic macular degeneration, retinal detachment, glaucoma, and cataract, controlling myopia progression is obligatory nowadays more than ever to increase the quality of life and ocular health and reduce the social impact and burden (Holden et al., 2013). However, this article will focus on optical intervention in controlling myopia progression.
Theories behind myopia progression
1. Failure of emmetropisation
During the normal process of emmetropisation, the eye expands in all directions and is associated with mechanical stretching and thinning of the crystalline lens, which reduces the lens power. A decoupling between this process of axial elongation and flattening of the corneal and lens curvature causes escalated axial growth and arrest of lens thinning by disruption of the equatorial expansion, leading to myopia (Mutti, 2010). The Collaborative Longitudinal Evaluation of Ethnicity and Refractive Error (CLEERE) Study, an observational study of ocular development and myopia onset, found that children who became myopic showed significantly more axial elongation that accelerated (up to 3 times faster) one year before the onset of myopia, making axial growth a major determinant of the refractive status of the eye (Mutti et al., 2007).
2. Peripheral retinal hyperopic defocus
Myopic eyes usually have greater accommodative lag during near viewing, producing more peripheral retinal hyperopic defocus (a blur caused by having the image focused behind the retina) than emmetropic eyes, which has been theorized to encourage more axial elongation (Seidemann et al., 2002). Peripheral hyperopic defocus was first indicated as a potential mechanism for myopia progression in the 1970s (Hoogerheide et al., 1971). Since that time, several animal and human clinical studies have strongly suggested that peripheral retinal defocus might mediate eye growth even under a clear foveal image (Smith et al., 2009). Based on these findings, the discovery of the retinal ability to detect the sign of defocus was key in developing optical interventions to control myopia progression. It is still unknown how the optical signals are activated or inhibited in the choroid, retina, and sclera, and how the signals control structural changes that cause increased axial length (AL).
Indications for intervention:
Progression of more than 0.5D over a year with adequate refractive correction.
- – High-risk factors:
- – Younger age at onset.
- – Family history or siblings with myopia.
- – Environmental risk factors such as reduced outdoor activity and excessive near work.
(Saxena et al., 2022)
Treatment modalities for myopia control
Figure 1. Summary of the treatment modalities for myopia control.(Saxena et al., 2022)
The concept of controlling myopia progression.
Myopia control should start as soon as possible. Experiments have demonstrated that reducing accommodation lag and/or central and peripheral hyperopic defocus can be used to alter eye growth in a highly regulated manner involving both direction and magnitude. (Figure2) Until recently, numerous hypotheses have been proposed to explain the myopia control effect of optical interventions, including:
– Reduction and correction of accommodative lag (Aller et al., 2016).
– Alteration of the peripheral retinal image to decrease hyperopic defocus (Sankaridurg et al., 2011).
– Obligation of extended myopic defocus in the retina (Lam et al., 2013).
– Optimization of the quality of retinal image for the points in front of the retina and degrading quality of retinal image for the points behind the retina (Cooper et al., 2018).
Optical interventions for myopia management
1. Spectacle
- Under‑corrected spectacles in myopia was a common approach earlier. Based on the basis that it reduces the accommodative demand at near and therefore the blur that drives the accommodative response, this practice lost popularity after studies showed that it can worsen myopia rather than inhibit its progression (Chung et al., 2002).
- Bifocal spectacles aimed to reduce the accommodative lag during prolonged near work have shown some benefits. A study was conducted on Chinese–Canadian myopic children, comparing the efficacy of single vision lenses (SVL), +1.50D bifocals, and + 1.50D bifocals with 3Δ base-in prism in the near segment during three years’ period. The study found that both bifocal groups had less axial elongation (0.25 mm and 0.28 mm, respectively) and conclude that bifocal spectacle can significantly lower myopia progression. They observed greater efficacy of prismatic bifocals in children with higher accommodation lag (Cheng et al., 2014).
- Progressive addition lenses (PALs) spectacles are designed to reduce both accommodation lag and peripheral hyperopic defocus. Several randomized clinical trials (RCT) conducted in different countries evaluating the efficacy of PALs in slowing myopia progression (using either +1.50 or +2.00 D add power compared with SV lenses, found that although PALs resulted in a statistically significant reduction of myopia progression, often the difference from progression with SV lenses was <0.25 and considered clinically insignificant (Hasebe et al., 2008; Gwiazda et al., 2003; Yang et al., 2009).
- Defocus incorporated multiple segments (DIMS) is a novel spectacle lens that was associated with significant retardation of myopia progression and axial elongation in myopic children. The DIMS lens is a plastic spectacle lens with a central optical zone of 9 mm for correcting distance viewing and circular multiple rounds defocus segments with add power of +3.50 D (Figure 3). This design simultaneously introduces constant myopic defocus and provides clear vision at all viewing distances. Over two years, children wearing DIMS spectacle lenses had a significant reduction in myopia progression by 52% and axial elongation by 62% compared with those wearing SVL. The greatest effect on slowing myopia progression was observed during the first six months of lens wear (Lam et al., 2019).
Figure 2. The design of the Defocus Incorporated Multiple Segments (DIMS) spectacle lens. (Lam et al., 2019).
2. Contact Lenses
- Soft multifocal contact lenses are increasingly used for controlling myopia progression in children, although some designs were originally intended for use by presbyopes and are used off-label. Center‑distance multifocal contact lenses are intended to provide clear distance vision while imposing myopic defocus by increasing plus power in the lens periphery via using aspheric optics or concentric rings of additional plus that can negate the hyperopic defocus as a putative stimulus to slow eye growth (Wildsoet et al., 2019).
Soft multifocal contact lenses have been explored in several RCTs so far, which demonstrated a reduction in myopia progression of on average 36.4% and a decrease in axial elongation by 37.9% (Cheng et al., 2016; Sankaridurg et al., 2019; Walline et al., 2013)
- Defocus-incorporated soft contact lens (DISC) is a bifocal soft CL with a concentric ring design, comprised of a correction zone in the center and alternating treatment and correction zones extending towards the periphery. A 2-year RCT conducted on Chinese schoolchildren in Hong Kong, showed that daily wearing of DISC lens led to 25% less myopia progression and 31% less axial elongation than SVL. The children were recommended to wear lenses for 5–10 h/day and Requested to wear full spectacles prescription after contact lens wear. It has been observed that slowing myopia progression and AL elongation reached approximately 50% for those maintaining wearing time over 5 h/day and increased with daily wearing hours. (Lam et al., 2019).
MiSight® 1 day (CooperVision) is a daily disposable soft CL that has been recently approved by the US Food and Drug Administration (FDA) to control the progression of myopia in children. The lens has a large central correction zone of 3.36 mm surrounded by concentric zones of alternating distance and near powers which together produce two focal planes. The correction zone corrects the refractive error, while the treatment zones produce 2.00D of simultaneous myopic defocus during both distance and near viewing. A 3-year multicentric RCT reported a 59% reduction in mean cycloplegic SE and a 52% reduction in AL elongation with the MiSight lens compared with soft SVL. These lenses are currently indicated in myopes aged 8–12 years with −0.75D to − 4D of myopia (Chamberlain et al., 2019).
- Orthokeratology: also known as ortho-k (OK), is rigid gas-permeable (RGP) lenses that tend to be worn overnight to temporarily and reversibly correct myopia. Although the initial goal of OK was to eliminate the need for daytime optical corrections, OK has proven to be effective in slowing myopia progression (VanderVeen et al., 2019). OK uses the reverse geometry technique to reshape the cornea by flattening the central cornea and steepening the corneal mid-periphery. This effect seems to occur by redistributing the epithelial cells to the mid-periphery while flattening the central cornea via a thinning of the epithelial layer (Kim et, 2018). This remodeling of the cornea was found to be effective in slowing myopia progression by eliminating peripheral hyperopic defocus. Recently, OK has been considered to be one of the most effective optical treatments for myopia control. Two published RTC in 2- year period, the Retardation of Myopia in Orthokeratology (ROMIO) study (Cho & Cheung, 2012)and the High Myopia–Partial Reduction Orthokeratology (HM-PRO) study (Charm & Cho, 2013)revealed that the axial elongation was reduced by 43% to 63% respectively. The reduction was more pronounced in younger, more rapidly progressing myopic children (age 7–8 years: 20% vs. 65% progression [control]) than in older children (age 9–10 years: 9% vs. 13% progression [control]). In addition, the efficacy and acceptable safety have been confirmed even in several long-term studies up to 10 years (Hiraoka et al., 2018).
This article covers a variety of interventions aimed at slowing myopia progression. No one strategy appears to reliably achieve this outcome in all individuals, and their role in high myopia is still unclear. The possibility of a rebound phenomenon after discontinuation of such a myopia treatment remains unknown. Ongoing research may lead to a better understanding of the persistence of treatment effects over time, as well as the exploration of more novel approaches to myopia control.
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