Sight nearby is better than far

MYOPIA

WHAT IS MYOPIA
Myopic people see near objects clearly, but far away is everything blurred. Myopia later in life (after 40 years) is very useful because reading glasses isn't always required, it's even possible you don't need your glasses anymore (if the myopia is equal or less than -3. Myopia of more than -5 is not practical because the text has to close should be kept).

REASON
The eye is too long (-3 diopters indicates 1 mm too long) so that the light through the lens projected the images FOR the retina instead of on the retina. It is therefore a length deviation and not a disease!

SIGNS
Myopic patients squints easy their eyes to something in the distance and are all keen to see closer than normal viewing
(a book or TV).
 
TREATMENT
Exercises and vitamins do not help. A negative glass or contact lenses move the image back and so is the length of the eye deviation resolved. There should be set that myopic patients are ideal candidates for contact lenses. Contact lenses having a myopic focus and  is very thin, which is enduring for wearing contact lenses. Initially, the glasses only be worn for far vision (TV, table, car drive). If the strength is more than -2.5 dioptres is advisable to wear the glasses all the time, because in daily life the visual impairment is too much without correction. Not wearing the glasses can not damage vision. The reverse should also be made: wearing glasses won't  increase your myopia.

The moment you feel that your best by wearing glasses, there may be given thought of contact lenses. This from the age of 10 to 12 years. You should carefully cope with your contact lenses. If the myopia is stable at 20-25 years you can possibly think of definitive correction with laser or "scratches". The laser treatment has been much improved, so scratches are seldom performed.
Ask our specific information folder if you do are interested.

EVOLUTION
As the patient grows, the eyes usually also gets bigger and stronger glasses are required (a -0.5 -0.25 extra per year).
Annual monitoring is therefore appropriate, otherwise the school results suffer from the poorer visibility. Be expected that the evolution stops at growthstop (approximately 20 to 25 years), unless the patient reads a lot of close work (eg computer). Then the myopia evolve somewhat. In patients with very high myopia (more than -6 / this is exceptional!), The myopia even after 25 y evolve (or spontaneous by pregnancy). Sometimes, there occur weak spots in the retina due to too much stretching of the membrane in the eye. This may, although rare - lead to poor visibility and retinal tears. A retinal tear can eventually lead to retinal detachment (even rarer). The sight of flashing lights, black spots and distortion in this context are warning signs that you should spend time with an ophthalmologist. More than -8 was therefore more than once also, for safety reasons, rejected for military service.

  CAN YOU INHIBIT MYOPIA/ NEARSIGHTEDNESS IN CHILDREN ?  

  Myopia is progressively increasing especially in Asia. In Europe today, 33% are myopic (more than -0.75) . 3% have more than -6 .  There has been a marked increase since 2000. It is expected that by 2050 50% of the population will be nearsighted. So inhibiting myopia seems useful

  (a) Usually an eye normalises at 0: "emmetropisation"

It is known that every child is born with an eye that is too short (= farsighted) . By tightening the lens , the child can "adjust" that and glasses are not needed , unless the farsightedness is too pronounced (more than +2). Due to growth of the eye , the deficiency is going to grow out and your eye becomes +- 23 mm long at 18 years (= mature eye ) = 0 dioptres (= "emmetropia") .   0.1 mm too much or too little already immediately results in -0.25 or +0.25 +-. So: a small deviation already gives an immediate big effect.  1 mm deviation is already directly -3 (for too long) or +3 (for too short)

  (b) How can that normalisation process ("emmetropisation") be disrupted ?

• heredity : if the 2 parents are myopic, a child is 7 times more likely to be myopic
• Ethnicity : Asians seem to develop more myopia than whites ("caucasian race )
• close work (reading/ computer/ gaming/ smartphone) makes your eye more myopic. Proof: In the past, the eskimos (almost all hunters) had almost no nearsightedness. Now that the eskimos also start using computers and mobile phones, they become nearsighted.  Close work means you tighten the lens of your eye= accommodation.  So too much accommodation would trigger myopia. We don't yet know exactly how this works. Possibly accommodation provokes pressure increase and can induce length growth.  Another hypothesis: accommodation would pull on the choroid under the retina, leading to thinning. Thus, the retina would become deeper = increase in axial length

c) Why inhibit increase in myopia ?

At -3 you can still see quite far without correction.  At -6 it becomes more difficult. At -8, your vision is very poor without correction ! Moreover, the retina is stretched over the eye, which is too long, creating weak spots that can rupture or along which abnormal blood vessels can grow and bleed. This is why, at the time, you were rejected for army service if you had more than -8 . Certainly with age these phenomena can occur, and nowadays people get older and older!  It is therefore understandable that parents are worried about rapid myopia development in their child.  Laser treatment for myopia can solve the dioptre problem of your eye, but does nothing about the possible weakening due to length deviation. -8 usually corresponds to an axial length of 26 mm . However, sometimes you can already be at 26 mm with -6. Axial length is actually more important than dioptre to predict later patology.  The goal is to stay below an axial length of 26 mm. Women are best to stay below 25.5 mm 


     (d) How to inhibit myopia (= "myopia management" ) ?
You can't change anything about heredity and ethnicity.  However, you can try to make myopia progress at a slower rate. There are 3 starting points for this :  

• Children who are more up close evolve more towards myopia . Lifestyle advice can help.  Here we already give the following important rule 20-20-2: after 20 minutes of close-up work, interrupt for 20 seconds / about 2 hours of outdoor play per day, preferably during daylight. Not keeping your mobile phone too close can also help
• When you are working close , the eye lens has to focus for close-up, like a camera ("accommodating") . One tried to see if accommodation reduction with drops of atropine, could inhibit myopia and this has been conclusively proven in between. One was also able to find out the ideal amount of atropine per day in between. Initially, a concentration of 1% was used, which worked well but had many side effects: reading was no longer possible / pupil was too wide open, with light aversion.  A drop of 0.01% atropine in the evening in children with blue eye seems ideal for a good effect (+- 50% inhibition ) with little or no side effects.  In children with dark eyes, 0.05 % is more likely to be applied
• "Orthokeratology treatment (short : ortho-K) ": For over 30 years, attempts have been made to adjust the cornea by fitting special hard lenses, which flatten (not deform ! ) the cornea. This reduced the power of the corneal lens : myopia correction. It was thought that this would work like orthodontic braces and that the treatment could be stopped after 1 or 2 years.  However, it turned out that a permanent treatment was needed like the night brace in orthodontics. So the "night lens" was invented, e.g. Coopervision's Dreamlite. Critics felt that the zone of flattening (= the optical zone) was actually too small, especially at the higher dioptres: (for -3, 3 mm of flattening was achieved. Knowing that laser treatment offers an optical zone of 6 to 6.5 mm, that seems little .   For -5, the optical zone was even smaller : Therefore, treating more than -5 did not seem possible.   Strangely enough, the children had little trouble with this.  Moreover, after some time the children with ortho K treatment appeared to become myopic less quickly (+- 50 % inhibition ) . The working hypothesis is the following.  The small optic area centrally gives good vision / the side of the cornea remains myopic of more than 2 dioptres ("myope defocus" ) and this was found to give inhibition of myopia ( explanation in the next paragraph ) .  So you see that every disadvantage (= small optical area ) can also have an advantage (myopia inhibition ).  However, night lenses must be closely monitored (must not cause any deformation) and must be replaced annually because the oxygen permeable material deforms after some time and no longer gives the correct flattening.

  e) The working hypothesis of the Ortho k lens ("myope defocus")  originated in myopia-inhibiting glasses and contact lenses, which recently came on the market and also give an inhibition of +- 50% :


1) Myopia inhibiting glasses  since 2020 : 
  Ortho K taught : Myopia is not just a too-long eye.  Better is : A myopic eye is too long centrally (= myopia ) but shorter laterally (= more normal ) . If you correct myopia with a normal eyeglass or contact lens , the image does arrive centrally on the retina but the image on the side of the retina falls behind the eye . So "farsightedness" on the side . Apparently the eye does not like that and the accommodation is tightened to make the side normal again so that the centre becomes nearsighted again .   This creates a vicious circle that leads to progressive myopia .  So to make a myopia inhibiting glass or lens, you have to manage to keep some myopia left ("a myope defocus") on the side of the retina  The first available myopia-inhibiting lens on this principle was "Miyosmart" from Hoya.     Very soon after came "Stellest" from Essilor .   By 2023, other brands were added in Europe, from which the same myopia inhibition (50%) can probably be expected. 

  Each type of myopia inhibiting glass has its own way of giving a myope defocus on the side :

• Miyosmart - Hoya : +- 450 microlenses - Dims technology= defocus incorporated multiple segments
• Stellest - Essilor : +-1021 microlenses - Halt technology = highly aspherical lenslet target
• Myocare - Zeiss : - CARE technology = cylindrical annular refractive elements = alternative zones of defocus and correction zones
• Mycon (stands for MY opie CON trol ) - Rodenstock - horizontal progression control: myope defocus of +2 nasal (= nasal side) and +2.5 temporal, based on the established anatomical asymmetry in the eye 
• Sight glass vision by Nikon/Coopervision: diffusion optics technology = thousands of micro dots, which gently scatter the light to reduce side contrast on the retina - not yet available in Belgium (but in the Netherlands and Israel)

The different lenses each have a different way of achieving myope defocus. The future will tell whether they are all equally efficient= +- 50% inhibition. 

These lenses do cost +- twice as much as standard lenses : +- 390 € for a pair.  Most glasses do give the guarantee that if the myopia evolves 0.5 dioptres within the year, new glasses will be given for free

  NOTE: what about photochromatic lenses

Several myopia inhibiting lenses exist in photochromatic version = discolouring with light.  This is useful when relatively high-dose atropine drops ( more than 0.05%) are also used.  Those children usually have light shyness because the pupil is also dilated by atropine, as a side effect.


  NOTE: What about blue filters on glasses ?

Computer screens emit a lot of blue light.   This blue light is in the colour spectrum dcht to UV light and gives a bit more trouble ("blue hazard") . Blue light is also deflected more by the lens of the eye so that it is focused on the retina ("blue haze") .   Blue light filtering therefore gives more comfort for computer work but has no effect on myopia inhibition .  Blue light would be necessary for a good day and night rhythm ("the biological clock - controlled by melatonin) .  However, enough blue light still enters the eye not to disturb the biological clock. 


What to think : The optometrists strongly believe in blue filters.  The eye doctor world is scientifically unconvinced of the importance.  However, blue filters are cool because they give a slight blue shine to the lenses . Otherwise, the lenses have a yellow-green shine, which is called "gold anti-reflection" .  This is perceived as less aesthetic.

  2) Contact lenses :
The technique of hypermetropic correction on the side , has long existed in contact lenses (unlike glasses) .  Namely: double vision contact lenses (centre far / side +2 reading aid ) , which are normally applied for reading problems at age (from 45 years ) meet this requirement .  They could therefore , immediately be applied to children and indeed gave myopia inhibition for +- 50 % . On this principle, a day lens was also developed ("misight lens" ) , which works with a double reading ring of +2 (= treatment zone - shown as dark zone on the drawing) and a double optical zone: "activ control technology". This should be better than the standard double-vision lens - centre far .  There is now already experience with this day lens since 2016 .  Day lenses are also better for children: no maintenance required .   Price : 600 € - exist up to -10 - no cylinder

REMARK1: Myopia inhibiting lenses and contact lenses are only available from opticians, who completed the myopia management training !  Ask whether your optician is experienced in myopia management

 REMARK2: With undercorrection of myopia, which used to be widely used as myopia inhibition, you also have to accommodate less.  This could be protective.   However, studies show that slight undercorrection does not seem to work well. You would probably have to undercorrect +2 to get effect, which is not practical .  Moreover, distance vision is not optimal with undercorrection . Reading, studying and gaming without myope glasses (can be done perfectly down to -3 ) might give protection though

  3) In the future maybe other possibilities : E r being tested with the Iveena eye drop available to cross-link the sclera, making it stronger and less stretching

  e) How to tackle myopia inhibition  in practice ?

  BE CONVINCED

Myopia can be inhibited and it is also necessary , because otherwise a child will become too myopic, leading to poorer vision without glasses but also to major eye diseases later in life.  Prevention, as always , is better than cure

  WHEN TO START

- First, you need to be sure it is real myopia. Children cannot always choose glasses properly. This is why we rely on objective measurements with the autorefractor.  Especially young children can tighten their own lens when measuring ("accommodating" ) and that gives a false image of myopia : "pseudo myopia" . This can be ruled out by measurements after application of eye drops , which temporarily prevent lens accommodation : "cycloplegic refraction" .  This is especially necessary if a myope correction is prescribed for the first time 

  -Watch out for "patological myopia" : You have to think about it when myopia arises in children under 5 years of age that evolves rapidly.    Causes are then structural abnormalities in the eye thv cornea (dystrophy) / anterior chamber angle (congenital glaucoma ) / lens (congenital cataract ) / vitreous (Stickler syndrome ) / retina (premature retinopathy / hereditary dystrophy ) and sclera (Marfan syndrome / pseudoxanthoma elasticum )

General genetic disorders (such as Down and mental retardation ) can also accompany mypie.  Also certain blood abnormalities such as homocystinuria.    The latter is best ruled out with a finger prick if a child has more than -2 at 5 years of age

Patological myopia is another type of myopia, those that do not respond or respond less well to myopia management

  GENERAL RULES AT THE START :


·       It is best to start myopia prevention if it appears that a child of myopic parents is already myopic at an early age (6 to 8 years). If a child is nearsighted from -1 at the age of 7, you can predict that it will be -6 at the age of 16. If the myopia doesn't start until 11 years old, you end up with -3 at 16, which is less serious.  ·       You should certainly do it if there seems to be rapid evolution: more than 1 diopter per year = more than 0.5 diopter every 6 months.  

You should also do it faster if the child already has a relatively long eye : more than 23 mm at 6a 7 years e.g.  Tideman growth curves can estimate the risk.  Determining an axial length at the beginning of treatment therefore seems useful

 
WHICH TREATMENT TO CHOOSE ?
a) First and foremost, the treatment must be "evidence-based" (= scientifically proven ) . This is actually already true for all possible treatments nowadays : atropine eye drops and the myopia inhibiting glasses and contact lenses.    Indeed, many studies have already been done.  The most well-known studies are those by the Erasmus hospital in Rotterdam ( group of Dr Klaver - even got a study grant in 2021 to further refine myopia management on behalf of the European community ) and by the Brien Holden vision clinic in Australia.    The latter body developed a free tool ("the myopia calculator "), which you can easily find on the internet .  That "calculator" predicts, on a scientific basis, the evolution of myopia if you apply or not a certain treatment (e.g. multisegment lenses ) to an Asian child of 8 years with -1.5 :  normally the child would end at -7  at the age of  18. With management it arrives at -3.25= 57% inhibition

    Because this is a relatively new science (since 1970 ) , some things are still uncertain (e.g.: what is the effect of combining atropine with myopia-inhibiting glasses or lenses / what is the exact mechanism of action of atropine and myopia-inhibiting glasses and lenses ) .  The guidelines may still change slightly next year .  However, it is already clear that myopia inhibition is possible (for 50 % - not 100 % !   I.e. 0.25 dioptre evolution per year instead of 0.5 dioptre ) and also necessary to keep myopia below -6 (= axial length 26 ) to avoid myopic problems such as retinal detachment and myopic macular degeneration later in life.

  b) In addition, the clinical experience of the myopia expert is important .  This is why one expert sometimes suggests a different treatment from another:  Ophthalmologists more easily choose the medical treatment with drops of Atropine, which they know better than myopia-inhibiting glasses and lenses. However, when using atropine, there is always still a need for glasses and/or lenses to correct myopia.   In this, the optician usually makes the choice.   The first infomation available shows that myopia-inhibiting lenses still work slightly additionally with the low dose of atropine, which is almost always prescribed nowadays. 

Generally, ophthalmologists are more concerned when ortho K treatment is applied by the optician (= adjusting the cornea with an oxygen permeable hard lens, worn at night (the "night lens" ) ) .  The reasons are : relatively small optical area and risk of distortion and infection (admittedly rather rare with proper follow-up by an optometrist experienced with ortho K lenses .   It is certainly justifiable to propose such treatment. provided there is stricter follow-up than with spectacle lenses or soft lenses . It is clear that ophthalmologist and optometrist should work well together ("co-management" ) to achieve the best possible myopia inhibition.  Here, trust and belief in each other's ability is important. Good to know : Some opticians specialise in myopia management . You can sometimes tell by the logos at the entrance to the shop: MYOPIA MANAGEMENT EXPERT


        (c) There is also the personal preference of parents and child :

- With parents, the price tag regularly plays a role.  Fortunately, atropine eye drops have become cheaper in recent years.  Night lenses are usually the most expensive treatment because of replacement and frequent follow-up. If parents wear lenses themselves, they are usually more likely to opt for contact lenses.


  - With children, fright plays a major role .   Sometimes children can react almost hysterically to the application of eye drops and certainly when using contact lenses.  The best effect is achieved with a combination of atropine drops and myopia-inhibiting lenses. The age of the child also determines the treatment options:

• Under the age of 5, treatment with atropine is not recommended.
• Under 8 years, contact lenses are not yet possible: you can only work with atropine eye drops and special glassesSpecial glasses and lenses only work well if the child wears the correction constantly. This is necessary from -2 a -2.5 . Below the prescription of -2, atropine is  preferred unless the child wears glasses full time , even when it's less than -2
• Above 8 years, contact lenses can be tried if your child is motivated.  Lenses give your child more normal vision (= lenses reduce the image) and more freedom, especially for contact sports. Usually, multifocal monthly lenses are started , because they are slightly easier to manipulate and cheaper : 150 € for 6 months. Afterwards, you can switch to special daily lenses, which inhibit myopia : this is more expensive though( +- 600 € per year ) .  For children, daily lenses are easier because they require no maintenance

 HOW TO FOLLOW   THE TREATMENT ? -Eventual check after 1 month:  to see whether the therapy is well tolerated. 

-Subsequent checks every 6 months with determination of dioptre.  Axial length measurement is also useful.  This measurement is more objective and shows how the myopia risk evolves.  A favourable evolution is a motivation for the child and parents to continue treatment.

   WHEN TO STOP : Based on age and changes in axial length 

a) Age is important : It is important to maintain myopia prevention for several years during the teenage years !   Between 5 and 10 years, most myopia evolution happens. Between 10 and 15 years, myopia evolution flattens out.  Usually myopia evolution stops at 18 YEARS , but studying can still give a slight evolution .   If your eye is nearsighted of more than -6, myopia evolution can continue even after studies !  Certainly pregnancies can play a role . Whether treatment is still useful after the age of 18 is not yet clear. 

  b) Axial length is important: If the axial length seems to stabilise after 15 years more than 1 year, treatment with atropine can be reduced slowly : 1 day per week less every 6 months. 

  HOW TO STOP  THE TREATMENT : 

-Atropine 0.01% must be tapered slowly to avoid a rebound effect, i.e. a rebound of myopia after discontinuation.  The following approach is common: reduce atropine by 1 drop per week every month: 7 days per week becomes 6 days per week and after 1 month 5 days per week and so on.

    MYOPIA INHIBITION - PERSEVERANCE IS THE MESSAGE