Perspective

Five steps may help fight progressive myopia

A five-step strategy, based on functional aspects and pathogenetic considerations, could help prevent the onset and reduce the progression of myopia in children and adults.

“Myopia is growing to epidemic proportions. It affects 85% to 90% of adults in Asian cities and as much as 33% in the United States. Developing effective prevention and treatment strategies is crucial and urgent,” OSN Optics Section Editor Jack T. Holladay, MD, MSEE, FACS, said in an interview with Ocular Surgery News.

The pharmacological relaxation of sustained accommodation in childhood has shown mild success, whereas optical strategies such as bifocals, progressive addition lenses, contact lenses, orthokeratology and undercorrection have been less successful. The primary side effect of atropine is mydriasis causing photophobia and the need for photochromic lenses to protect from harmful UV light. In addition, there appears to be an initial increased rate of myopia progression after the cessation of atropine treatment (“rebound”), presumably due to the strong cycloplegic effect of the atropine. Also, the psychological effects on children need to be taken into consideration, Holladay said.

Jack T. Holladay
Jack T. Holladay

According to Holladay, two factors have been overlooked in the pathogenesis of myopia, and these factors provide the rationale for a new myopia treatment strategy.

The first overlooked factor is sustained accommodative convergence. The convergence is mediated by the medial rectus muscles, which contract simultaneously. The origin of the medial rectus is from both the upper and the lower parts of the common ring tendon (annulus of Zinn) and from the sheath of the optic nerve. The insertion of the medial rectus is about 5.5 mm from the medial limbus.

“The contractile force of the medial rectus is transferred from its insertion as a tensile force to the medial perilimbal sclera, then to the cornea, the temporal perilimbal sclera, the temporal sclera, posterior pole and finally anchored to the lamina cribrosa and sheath of the optic nerve. The stretching or tensile force is equal (in equilibrium) in all these components, like a chain of five rubber bands of unequal elasticity linked end to end. The tensile strength of the cornea is several times that of the perilimbal sclera, which in turn is more than the temporal sclera and posterior pole. The latter two are the weakest links in the chain, and the stretching results in elongation of the axial length with a commensurate increase in myopia,” Holladay said.

As one approaches the posterior pole, the curvature of the globe increases so that the path of the outer scleral collagen fibers is longer than the inner fibers, creating more stretch on the outer fibers in this area. As the outer scleral fibers of the posterior pole fatigue, the tensile force is transferred to the inner sclera and then through the choroid, which provides no support because it is like a sponge. The next structure moving inward is Bruch’s membrane, which is inelastic and more like glass or plastic. As it fatigues from the tensile force, lacquer cracks form and then the pigment epithelium is disrupted, forming Fuchs spots. Finally, there is damage to the photoreceptors and inner retina with loss of central vision, Holladay said.

The second overlooked factor that determines a person’s response to the tensile or stretching force in the temporal sclera and posterior pole is the individual’s elastic properties of the sclera. Instruments such as the Corvis (Oculus) and Ocular Response Analyzer (ORA, Reichert) are available to evaluate the elasticity of collagen in the eye. Just as with keratoconus and open-angle glaucoma, increased elasticity of the collagen makes a person more susceptible to stretching of the sclera and progressive myopia. These elasticity measurements can be taken in young children to identify those at highest risk for myopic progression.

“My goal is to change the way people think about progressive myopia and show a new way of dealing with it by using a five-step approach,” Holladay said.

The first step is to identify children with a family history of myopia.

“Studies on the genetics of myopia are well established. In 10 or 15 years, we may be able to locate the genetic marker and not only change the progressive myopia gene but also the collagen gene. Meanwhile, we can identify children who are at risk by looking at their family history and measuring refraction and scleral elasticity early in their life,” Holladay said.

The second step is to increase the number of hours of outdoor activity. Studies have shown that increasing the hours of outdoor play has a more significant effect on the progression of myopia than any other intervention to date.

“By regularly interrupting near activities, such as playing outside, the sustained stretch of looking at near is reduced to a momentary stretch of maybe 30 to 40 minutes, with pauses in between, in which the medial rectus muscles relax as well as the sustained stretch on the sclera,” Holladay said.

The third step is a new paradigm, measuring collagen elasticity as a risk factor with the Corvis and ORA.

After this, as a fourth step, collagen cross-linking in the temporal sclera and posterior pole will be performed in children and young adults with unusually elastic sclera, like the treatment of keratoconus.

“Finally, it is still beneficial to use bifocals when children are working at near, with a slight undercorrection for distance and including a base-in prism in the add to eliminate convergence at near. Convergence is a major cause of progressive myopia, perhaps even more than accommodation,” Holladay said.

Traditional bifocals that include a base-in prism in the lower segment are already made for low-vision patients. However, the near add is usually +6 D and would have to be reduced to +3 D, with a prism of 10 base-in in each lens. Progressive bifocals will require a progressive base-in prism. In addition, the child should be taught to hold objects no closer than 33 cm and preferably even farther.

“It is a simple five-step strategy and should have a great impact on reducing the myopic epidemic. Expanding cross-linking technology to the sclera will occur in the near future, and the other four steps can be implemented immediately,” Holladay said. – by Michela Cimberle

Disclosure: Holladay reports he is a consultant for Oculus.

A five-step strategy, based on functional aspects and pathogenetic considerations, could help prevent the onset and reduce the progression of myopia in children and adults.

“Myopia is growing to epidemic proportions. It affects 85% to 90% of adults in Asian cities and as much as 33% in the United States. Developing effective prevention and treatment strategies is crucial and urgent,” OSN Optics Section Editor Jack T. Holladay, MD, MSEE, FACS, said in an interview with Ocular Surgery News.

The pharmacological relaxation of sustained accommodation in childhood has shown mild success, whereas optical strategies such as bifocals, progressive addition lenses, contact lenses, orthokeratology and undercorrection have been less successful. The primary side effect of atropine is mydriasis causing photophobia and the need for photochromic lenses to protect from harmful UV light. In addition, there appears to be an initial increased rate of myopia progression after the cessation of atropine treatment (“rebound”), presumably due to the strong cycloplegic effect of the atropine. Also, the psychological effects on children need to be taken into consideration, Holladay said.

Jack T. Holladay
Jack T. Holladay

According to Holladay, two factors have been overlooked in the pathogenesis of myopia, and these factors provide the rationale for a new myopia treatment strategy.

The first overlooked factor is sustained accommodative convergence. The convergence is mediated by the medial rectus muscles, which contract simultaneously. The origin of the medial rectus is from both the upper and the lower parts of the common ring tendon (annulus of Zinn) and from the sheath of the optic nerve. The insertion of the medial rectus is about 5.5 mm from the medial limbus.

“The contractile force of the medial rectus is transferred from its insertion as a tensile force to the medial perilimbal sclera, then to the cornea, the temporal perilimbal sclera, the temporal sclera, posterior pole and finally anchored to the lamina cribrosa and sheath of the optic nerve. The stretching or tensile force is equal (in equilibrium) in all these components, like a chain of five rubber bands of unequal elasticity linked end to end. The tensile strength of the cornea is several times that of the perilimbal sclera, which in turn is more than the temporal sclera and posterior pole. The latter two are the weakest links in the chain, and the stretching results in elongation of the axial length with a commensurate increase in myopia,” Holladay said.

As one approaches the posterior pole, the curvature of the globe increases so that the path of the outer scleral collagen fibers is longer than the inner fibers, creating more stretch on the outer fibers in this area. As the outer scleral fibers of the posterior pole fatigue, the tensile force is transferred to the inner sclera and then through the choroid, which provides no support because it is like a sponge. The next structure moving inward is Bruch’s membrane, which is inelastic and more like glass or plastic. As it fatigues from the tensile force, lacquer cracks form and then the pigment epithelium is disrupted, forming Fuchs spots. Finally, there is damage to the photoreceptors and inner retina with loss of central vision, Holladay said.

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The second overlooked factor that determines a person’s response to the tensile or stretching force in the temporal sclera and posterior pole is the individual’s elastic properties of the sclera. Instruments such as the Corvis (Oculus) and Ocular Response Analyzer (ORA, Reichert) are available to evaluate the elasticity of collagen in the eye. Just as with keratoconus and open-angle glaucoma, increased elasticity of the collagen makes a person more susceptible to stretching of the sclera and progressive myopia. These elasticity measurements can be taken in young children to identify those at highest risk for myopic progression.

“My goal is to change the way people think about progressive myopia and show a new way of dealing with it by using a five-step approach,” Holladay said.

The first step is to identify children with a family history of myopia.

“Studies on the genetics of myopia are well established. In 10 or 15 years, we may be able to locate the genetic marker and not only change the progressive myopia gene but also the collagen gene. Meanwhile, we can identify children who are at risk by looking at their family history and measuring refraction and scleral elasticity early in their life,” Holladay said.

The second step is to increase the number of hours of outdoor activity. Studies have shown that increasing the hours of outdoor play has a more significant effect on the progression of myopia than any other intervention to date.

“By regularly interrupting near activities, such as playing outside, the sustained stretch of looking at near is reduced to a momentary stretch of maybe 30 to 40 minutes, with pauses in between, in which the medial rectus muscles relax as well as the sustained stretch on the sclera,” Holladay said.

The third step is a new paradigm, measuring collagen elasticity as a risk factor with the Corvis and ORA.

After this, as a fourth step, collagen cross-linking in the temporal sclera and posterior pole will be performed in children and young adults with unusually elastic sclera, like the treatment of keratoconus.

“Finally, it is still beneficial to use bifocals when children are working at near, with a slight undercorrection for distance and including a base-in prism in the add to eliminate convergence at near. Convergence is a major cause of progressive myopia, perhaps even more than accommodation,” Holladay said.

Traditional bifocals that include a base-in prism in the lower segment are already made for low-vision patients. However, the near add is usually +6 D and would have to be reduced to +3 D, with a prism of 10 base-in in each lens. Progressive bifocals will require a progressive base-in prism. In addition, the child should be taught to hold objects no closer than 33 cm and preferably even farther.

“It is a simple five-step strategy and should have a great impact on reducing the myopic epidemic. Expanding cross-linking technology to the sclera will occur in the near future, and the other four steps can be implemented immediately,” Holladay said. – by Michela Cimberle

Disclosure: Holladay reports he is a consultant for Oculus.

    Perspective

    There are potentially ways to lower the rate of progressive myopia. But this requires clinicians to become more active in the management of myopia and childrens parents to change lifestyle and habits of their children. Neither are easy tasks, but they are worthy tasks.

    Clinicians also need to interact with families, and be proactive and willing to engage in a conversation with patients and parents.

    The literature supports these efforts but is not definitive, so further data is needed before policy changes can be recommended and implemented nationwide.

    • Maria A. Woodward, MD, MSc
    • Service chief of cornea, external disease and refractive surgery; Assistant professor of ophthalmology and visual sciences; University of Michigan

    Disclosures: Woodward reports no relevant financial disclosures.

    Perspective
    Richard L. Lindstrom

    Richard L. Lindstrom

    We need to diagnose myopia early and treat it if progressive. Today, we do neither. So, we need to get these patients into an MDs or ODs office who is willing to treat them. Family history today and genetic screening eventually might help. If older siblings have progressive myopia and the parents are high myopes, the patient deserves to be followed closely and offered treatment.

    Outdoor activity helps, at least 1 hour a day. One of the benefits, according to Tsubota, may be exposure to UV light, so it has to be outside and in the daytime. Rest and look at something in the distance 10 minutes of every hour, or maybe 5 minutes every 30 minutes is better when on a digital device. Also, blink frequently while resting.

    Dr. Holladays points on convergence demand and insufficiency are good. NeuroLens from EyeBrain with a progressive prism stronger at near is an interesting option with an appropriate add. NeuroLens can use a progressive bifocal add, which is cosmetically nicer for children. It works for digital eye strain and might help for progressive myopia. We also have the new contact lens from Cooper. I struggle recommending orthokeratology, but there are some pretty supportive references. Low-dose atropine from a compounding pharmacy is available. Seems like 0.025% once a day is the best recommendation based on current studies. In regard to cross-linking, the challenge is how do we do it. Copper sulfate drops, as being developed by iVeena, might help if we can get them to the target sclera.

    Of course, today most of us are doing nothing, but there are primarily OD clinics specializing in progressive myopia popping up in most communities. If the ophthalmologist does not want to treat, refer. For a young child in the pre-contact lens age, I like outdoor activity, distance viewing every 30 minutes when on a digital device, a progressive bifocal with NeuroLens or a bifocal with base-in prism. Usually for NeuroLens, we have to refer to an OD with the equipment. For a patient old enough to wear a contact lens, we have the FDA-approved Cooper contact lens. If still progressing, I would offer dilute atropine.

    Again, we have 30 ophthalmologists and 20 ODs in our Unifeye Vision Partners clinics in Minnesota, and as of yet, we have no one focused on progressive myopia. We do not sell glasses, so that is a barrier. We have two OD practices in our city of about 4 million who are interested and have NeuroLens.

    • Richard L. Lindstrom, MD
    • OSN Chief Medical Editor

    Disclosures: Lindstrom reports he has equity in EyeBrain and iVeena and is a member of the medical advisory board of iVeena.