Visual Symptoms and Compliance with Spectacle Wear in Myopic

Children: Double-Masked Comparison between Progressive

Addition Lenses and Single Vision Lenses
|unho Sucmuru, Sutoshi Huschc

, und Hiroshi Ohtsuhi

Dejor|men|ofOjh|holmoloyy,OloyomoUniversi|yGroduo|eSchoolofMedicine,
Den|is|ryondPhormoceu|icolSciences,Oloyomo7008558,Jojon
vogvossivo addiiion lonsos (!ALs) ov biIocal
spociaclos avo usually pvoscvibod io conponsaio
Iov ago-volaiod doioviovaiion oI acconnodaiivo Iunc-
iion in pvosbyopic adulis, bui !ALs avo sonoiinos
also pvoscvibod io childvon undov diovoni civcun-
siancos. ov oxanplo, !ALs havo boon usod Iov
voIvaciivo covvociion in paiionis wiih acconnodaiivo
osoivopia showing a high acconnodaiivo convovgonco
io acconnodaiion (AC/A) vaiio [i, 2], psoudophaLic
oyos aIiov suvgovy Iov congoniial caiavaci [3], and
paihologic ov iaivogonic acconnodaiivo insu cioncy
[49]. !n addiiion, sovoval clinical ivials voconily
vopoviod ovidonco ihai !ALs slow nyopia pvogvossion
in childvon [iOi3].
On iho oihov hand, ihovo avo sovoval pvoblons wiih
iho uso oI !ALs. ivsi, in ovdov io obiain a cloav
inago, paiionis nood io uso iho appvopviaio pavi oI iho
lons doponding on iho disianco io iho visual objoci.
ov oxanplo, bluvvod vision in iho downwavd gazo duo
io iho noav addiiion nay poso a pvoblon in asconding
ov dosconding siaivs. Socond, pvisnaiic oocis oI iho
laioval sidos oI iho pvogvossivo covvidov nay induco
F
Jhc uim of this study is to c!urify visuu! symptoms und comp!iuncc vith spcctuc!c vcur in chi!drcn
using progrcssivc uddition !cnscs (FALs). Nincty-tvo chi!drcn, purticiputing in u rundomizcd, douh!c-
mushcd, crossovcr triu! to dctcrminc vhcthcr FALs rcducc myopiu progrcssion (mcunSD ugc. 11.0
1. ycurs; rcfructivc crrors. B.111.B1 D), vorc FALs (1.0 D ncur uddition) or sing!c vision
!cnscs (SVLs) for 18 months, u!tcrnutc!y. A qucstionnuirc survcy vus pcrformcd und 12 months
uftcr thc hcginning of thc usc of thc !cnscs (-month survcy), und thc rcsu!ts vcrc compurcd hctvccn
FAL- und SVL-vcuring pcriods. In thc FAL-vcuring pcriod, thc chi!drcn rcportcd di cu!ty in udupt-
ing to ncv!y providcd spcctuc!cs (B), disturhunccs in distuncc vision (22), vcrtigo in thc !utcru!
guzc (11), und di cu!ty in usccnding und dcsccnding stuirs (9). Hovcvcr, thc frcqucncy of thcsc
symptoms vus not signicunt!y dicrcnt from thut rcportcd in thc SVL-vcuring pcriod. Jhcrc vus no
dicrcncc in comp!iuncc vith spcctuc!c vcur hctvccn thc FAL- und SVL-vcuring pcriods, und 98 of
thc chi!drcn vcuring FALs rcportcd cxcc!!cnt comp!iuncc. Jhc rcsu!ts of this study indicutc thut,
compurcd vith SVLs, thc FALs providc u simi!ur !cvc! of comfort und comp!iuncc vith spcctuc!c vcur
for myopic chi!drcn.
Kcy vords. uosiionnaivo suvvoy, nyopic childvon, pvogvossivo addiiion lonsos, doublo-nasLod siudy
Acta Med. Okayama, 2008
Vol. 62, No. 2, pp. 109117
Copyvighi 2OO8 by OLayana Univovsiiy Modical School.
OriyinolAr|icle
hiip ://oscholavship.lib.oLayana-u.ac.jp/ano/
Rocoivod Augusi i4, 2OO7 ; accopiod Novonbov 3O, 2OO7.

Covvosponding auihov. !hono : 8i862357297; ax : 8i862225O59

-nail : shasoboCnd.oLayana-u.ac.jp (S Hasobo)
ivansioni dviIi oI spaiial localizaiion. Consouonily,
sono paiionis conplain oI voviigo ov dizzinoss whon
changing ihoiv gazo hovizonially [i4]. Jhivd, lons
Ivanos avo liLoly io bo doIovnod and displacod in iho
downwavd divociion, ospocially in childvon [i5].
Misalignnoni oI iho lonsos would bo novo pvoblonaiic
wiih !ALs ihan wiih SVLs. !i is uncloav how chil-
dvon can copo wiih ihoso pvoblons associaiod wiih iho
uso oI !ALs in daily aciiviiios. Jhoso pvoblons nay
voduco conplianco wiih spociaclo woav.
Howovov, clinical siudios on how childvon doal wiih
ihoso pvoblons havo boon liniiod [i4, i6]. !n ihis
siudy, wo povIovnod uosiionnaivo suvvoys in childvon
paviicipaiing in a vandonizod, doublo-nasLod, cvoss-
ovov ivial io doiovnino whoihov !ALs slow nyopia
pvogvossion. Ly conpaving iho vosulis oI iho uos-
iionnaivos boiwoon !AL- and SVL-woaving poviods,
wo iviod io doiovnino whoihov childvon can uso !ALs
conIoviably and how iho diovonco in iho lons dosign
aocis conplianco wiih spociaclo woav.
Suhjccts und Mcthods
SuhJccIs. Ninoiy-iwo childvon (noanSD
ago: ii.Oi.6 yoavs; noan sphovical ouivaloni
voIvaciivo ovvovs: 3.iii.34 D, 43 givls) wovo
vocvuiiod Ivon paviicipanis in iho Myopia Conivol
Jvial wiih !ALs in Japanoso Childvon [i3]. Jhis
ivial was dosignod as a cvossovov ivial, whovoin iho
childvon wovo vandonly allocaiod io woaving !ALs
(n46) ov SVLs (n46) ai iho iniiial visii, and oach
child swiichod Ivon !ALs io SVLs ov vico vovsa in
iho niddlo oI iho ivial poviod oI 3 yoavs.
Jho inclusion cviiovia oI ihis ivial wovo: i) iho
sphovical ouivaloni voIvaciivo ovvov was Ivon
6.OO D io i.25 D in oiihov oyo; 2) asiignaiisn
was oual io ov loss ihan i.5O D in boih oyos; 3)
anisonoivopia was oual io ov loss ihan i.5O D; 4)
bosi-covvociod visual acuiiy was oual io ov boiiov
ihan i.O (covvosponds io 2O/2O); 5) no naniIosi siva-
bisnus; 6) ago was Ivon 6 io i2 yoavs; 7) bivih
woighi was oual io ov novo ihan i25O g; 8) no oyo
disoaso oxcopi Iov voIvaciivo ovvov; 9) no oxpovionco
oI woaving !ALs ov coniaci lonsos; and iO) woaving
SVLs boIovo onivy inio ihis ivial.
Jhis siudy and pvoiocols conIovnod io iho ionois
oI iho Doclavaiion oI HolsinLi. !nIovnod consoni (pav-
onis) and assoni (childvon) wovo obiainod aIiov vovbal
and wviiion oxplanaiions oI iho naiuvo and possiblo
consouoncos oI iho siudy. Jho paviicipanis also
agvood io uso iho siudy glassos pvovidod ai all iinos iI
possiblo.
SccIoclc rcscrihiug roIocol. MC lonsos
(Sola !niovnaiional, San Diogo, CA, USA), which
had a noav addiiion powov oI i.5O D wiih a pvo-
gvossivo covvidov oI iO nn, wovo pvovidod io iho
childvon. Jho noav addiiion powov oI i.5O D was
choson bocauso ii voducos acconnodaiivo donand in
daily aciiviiios io iho lovol oI ionic acconnodaiion
(appvoxinaioly i.5 D), whovo a lag oI acconnodaiion
doos noi occuv in ihoovy [i3]. Jho disiani pvoscvip-
iion (ov lons powov in iho Iav pavi oI !ALs) was sini-
lavly doiovninod ai iho nininun sphovical powov ihai
pvovidod a disiani visual acuiiy oI i.O (covvosponding
io 2O/2O) aIiov conploio covvociion oI asiignaiisn,
which was shown by non-cycloplogic auiovoIvaciion,
wiih a cylindvical lons. Ai iho Iollow-up visiis schod-
ulod ovovy 6 nonihs and non-schodulod visiis whon
childvon vopoviod pvoblons, disiani visual acuiiy
ihvough iho siudy glassos was noasuvod. Whon iho
visual acuiiy was loss ihan O.7 (appvoxinaioly covvo-
sponding io 2O/3O) in ai loasi i oyo, now lonsos wovo
pvoscvibod using iho sano pvocoduvo noniionod abovo.
All oI iho siudy glassos wovo pvovidod io iho childvon
Ivoo oI chavgo.
Jho spociaclo Ivanos wovo nado oI shapo-nonovy
alloys and cavoIully adjusiod so ihai iho iiing poini
oI iho lons was in alignnoni wiih iho coniov oI iho
onivanco pupil (iho bacL voviox disianco: i2 nn, pan-
ioscopic anglo: 6 dogvoos). Howovov, a considovablo
downwavd doviaiion oI iho lonsos was obsovvod ai iho
6-nonih visii [i5]. JhovoaIiov, wo usod a nodiod
iiing pvoiocol in which iho iiing poini was soi 3
4 nn abovo iho pupil coniov.
QucsIiouuoirc surccys. Quosiionnaivo suv-
voys wovo adninisiovod ai iho 6-, i2-, 24-, and
3O-nonih visiis. Jho uosiionnaivo was nado up oI
sinplo uosiions so ihai young childvon nighi bo ablo
io answov oasily. Jhoy consisiod oI 5 uosiions io bo
answovod by solociing i oI 2 possiblo answovs, and i
uosiion io bo answovod by solociing i oI 3 possiblo
answovs. Quosiion (Q) i ovaluaiod iho adapiabiliiy ai
iho boginning oI iho spociaclo uso, and Qs 2 and 3
ovaluaiod disiuvbancos in disianco vision and in noav
vision, vospociivoly. Qs 4 and 5 ovaluaiod pvoblons
oxpociod io occuv duo io iho opiical chavaciovisiics oI
110 Acta Med. OkayamaVol. 62, No. 2 Suemaru et al.
iho !ALs, i.e. di culiy in asconding ov dosconding
siaivs and dizzinoss ov voviigo in iho laioval vision,
vospociivoly. Q 6 ovaluaiod conplianco wiih spociaclo
woav (iino oI uso). Jho answovs wovo collociod by a
uosiionov, who ovally asLod uosiions whilo pvosoni-
ing a docunoni indicaiing iho uosiions and possiblo
answovs. Jho pavonis wovo noi pvosoni duving ihis
pvocoduvo.
Jho allocaiion oI iho spociaclo iypo (!ALs ov
SVLs) was cavoIully nasLod Ivon iho childvon, ihoiv
pavonis, and iho uosiionovs ihvoughoui ihis siudy. Ai
iho nal (36-nonih) visii, an addiiional uosiionnaivo
(Q 7) was povIovnod io ovaluaio iho dogvoo oI iho
nasLing againsi spociaclo allocaiion. Hovo, iho chil-
dvon wovo vouosiod io soloci i oI 3 possiblo
answovs: i) Usod !ALs in iho vsi halI oI iho ivial,
2) Usod !ALs in iho socond halI oI iho ivial, and 3)
Uncloav.
AsscssmcuI o] cliuicol chorocIcrisIics.
Doiails oI iho noasuvononi oI voIvaciivo ovvovs, lag
oI acconnodaiion, and hoiovophovia havo boon
vopoviod [i3, i7] and avo bvioy sunnavizod hovoin.
RoIvaciivo ovvovs wovo noasuvod wiih cycloplogic
auiovoIvaciion (NidoL ARK2OOO, Canagovi, Japan).
Lags oI acconnodaiion wovo noasuvod wiih an opon-
viow auiovoIvaciov WV-5OO (Cvand SoiLo, uLuyana,
Japan) undov Iull voIvaciivo covvociion wiih spociaclo
lonsos whilo iho subjoci was binoculavly looLing ai a
high conivasi Maliaso cvoss locaiod i6.O, 2O.9, 32.5
and 5O.5 cn in Ivoni oI iho oyos (covvosponding io an
acconnodaiivo donand oI i.966.24 D). Jho noan oI
iho diovoncos boiwoon iho acconnodaiivo vosponso
and iho oociivo acconnodaiion donand was vogavdod
as a vopvosoniaiivo lag oI acconnodaiion.
Hoiovophovia ai noav (33 cn) and disianco (5 n) was
noasuvod undov iho voIvaciivo covvociion using iho
pvisn and aliovnaiing covov iosi.
SIoIisIicol ouolyscs. Jho lons powov and
dogvoo oI anisonoivopia oI iho spociaclos ai iho bogin-
ning oI ihoiv uso wovo conpavod boiwoon iho !AL- and
SVL-woaving poviods aIiov iho voIvaciivo valuos wovo
convoviod io M (sphovical ouivaloni), J
O
(diopivic
powov oI a JacLson cvoss cylindov ai axis O dogvoos),
and J
45
(diopivic powov oI a JacLson cvoss cylindov ai
axis 45 dogvoos) by diopivic powov naivix [i8].
Sinco iho lons iypo was swiichod ai iho niddlo oI iho
ivial (i.e., ai iho i8-nonih visii), iho uosiionnaivo
vosulis Ivon iho 6- and 24-nonih visiis wovo conbinod
Iov ovaluaiion 6 nonihs aIiov iho boginning oI iho
spociaclo uso (6-nonih suvvoy), and ihoso Ivon iho i2-
and 3O-nonih visiis wovo conbinod Iov ovaluaiion i2
nonihs aIiov iho boginning oI iho spociaclo uso
(i2-nonih suvvoy). Jho vosulis wovo ihon conpavod
boiwoon !AL- and SVL-woaving poviods ai iho
6-nonih suvvoy and boiwoon iho 6- and i2-nonih suv-
voys in iho !AL-woaving poviod by iho chi-suavo ov
ishovs oxaci pvobabiliiy iosi. Jho volaiionships
boiwoon iho uosiionnaivo vosulis and iho basolino
clinical chavaciovisiics wovo analyzod using a caiogov-
ical logisiic vogvossion nodol. Jho volaiionship
boiwoon conplianco wiih spociaclo woav and voIvaciivo
ovvovs was analyzod using a coniinuous logisiic
vogvossion nodol. Jho siaiisiics wovo calculaiod using
JM! vovsion 5.Oia (SAS !niovnaiional, Roading,
LovLshivo, UK).
Rcsu!ts
Conploio vosulis oI iho uosiionnaivos wovo
obiainod Ivon 89 childvon; 6 wovo losi io Iollow up.
Jho noan (SD) ago ai basolino was ii.Oi.6 yoavs
in iho !AL-siaviing childvon and ii.Oi.7 yoavs in
iho SVL-siaviing childvon, wiih no signicani diov-
onco boiwoon iho gvoups. Jhovo was no signicani
diovonco in iho lons powov and dogvoo oI anisonoivo-
pia oI iho siudy glassos boiwoon iho !AL- and SVL-
woaving poviods (Jablo i).
Jho childvon oasily answovod iho uosiionnaivos,
and iho uosiionnaivo pvocoduvo was usually conploiod
in 3 nin. Jablo 2 (loIi and coniov colunns) conpavos
iho vosulis oI iho uosiionnaivos boiwoon iho !AL-
and SVL-woaving poviods ai iho 6-nonih suvvoy. !n
iho !AL-woaving poviod, di culiy in adapiaiion io iho
now glassos (Qi) was iho nosi Ivouonily vopoviod
answov (36), Iollowod by disiuvbanco in disianco
vision (Q2) and dizzinoss ov voviigo in iho laioval
vision (Q5). Jho Ivouoncios oI disiuvbanco in noav
vision (Q3) and di culiy in asconding ov dosconding
siaivs (Q4) wovo boih loss ihan iO. No signicani
diovonco was Iound boiwoon in iho !AL- and SVL-
woaving poviods in any oI ihoso uosiions. Jablo 2
(vighi colunn) conpavos iho vosulis in iho !AL-
woaving poviod boiwoon iho 6- and i2-nonih suvvoys.
Jho di culiy in asconding ov dosconding siaivs (Q4)
docvoasod signicanily ai iho i2-nonih suvvoy.
Jho conplianco wiih iho spociaclo uso was noi sig-
111 Visual Symptoms and Compliance with PALs in Children April 2008
nicanily diovoni boiwoon !AL- and SVL-woaving
poviods. !n iho !AL-woaving poviod, 79 oI iho
childvon answovod ihai ihoy always usod iho glassos.
Whon conbinod wiih iho i9 who answovod ihai ihoy
usually usod ihon, 98 oI iho childvon wovo saiisIac-
iovily conpliani wiih iho !ALs (Jablo 2). Jho vola-
iionship boiwoon iho conplianco and voIvaciivo ovvovs
is shown in ig. i. !n boih ivoainoni poviods, iho
conplianco inpvovod wiih an incvoaso in iho dogvoo oI
nyopia. Appvoxinaioly i5 oI iho childvon wiih low
nyopia vopoviod poov conplianco (i.e., woaving ihon
only ai class) in iho SVL-woaving poviod
Jablo 3 shows iho volaiionship boiwoon iho uos-
iionnaivo vosulis obiainod ai iho 6-nonih suvvoy and
basolino clinical chavaciovisiics such as ago, voIvac-
iivo ovvov, noav hoiovophovia, and lag oI acconnoda-
iion. Jhovo was no signicani covvolaiion boiwoon any
oI ihoso conbinaiions in iho !AL-woaving poviod.
112 Acta Med. OkayamaVol. 62, No. 2 Suemaru et al.
Table 1 Comparison of lens power and degree of anisometropia
of the study glasses between PAL- and SVL-wearing periods at
baseline (mean SD)
PALs (n92) SVLs (n95) -value

Means of the right and left lens power (distance prescription)

M 3.181.47D 3.011.18D 0.39
J0 0.130.31D 0.110.31D 0.86
J45 0.020.08D 0.020.08D 0.83
Dierence between the right and left lens power (anisometropia)
M 0.120.48D 0.100.49D 0.81
J0 0.030.18D 0.070.23D 0.16
J45 0.040.22D 0.040.22D 0.89
The spherical and cylindrical power of the spectacle lenses were
converted to M (spherical equivalent), J0 (dioptric power of a
Jackson cross cylinder at axis 0 degrees), and J45 (dioptric power of
a Jackson cross cylinder at axis 45 degrees) using a dioptric power
matrix [18]. PALs, progressive addition lenses; SVLs, single
vision lenses.

: unpaired -test.
Table 2 Comparisons of the questionnaire results between PAL- and SVL-wearing periods at the 6-month survey and between the 6-
and 12-month surveys in the PAL-wearing period
Type of spectacles
6-month survey
-value
12-month survey
PALs SVLs PALs
-value
(n87) (n91) (n89)
Q1: Was it di cult to adapt to the new spectacles?
Yes 31 (36%) 27 (31%) 0.45 N/A N/A
No 55 (64%) 61 (69%)
Q2: Is there any di culty when looking at the blackboard?
Yes 19 (22%) 14 (15%) 0.27 15 (17%) 0.40
No 68 (78%) 77 (85%) 74 (83%)
Q3: It there any di culty when reading or writing?
Yes 5 ( 6%) 6 ( 7%) 0.82 1 ( 1%) 0.12
No 82 (94%) 85 (93%) 88 (99%)
Q4: Is there any di culty when ascending or descending the stairs?
Yes 8 ( 9%) 4 ( 4%) 0.20 0 ( 0%) 0.00

No 79 (91%) 87 (96%) 89 (10%)

Q5: Do you feel vertigo or dizziness in lateral vision?
Yes 10 (11%) 6 ( 6%) 0.25 3 ( 3%) 0.05
No 77 (89%) 85 (93%) 86 (96%)
Q6: I use the spectacles:
1) at class only 2 ( 2%) 5 ( 5%) 0.50 3 ( 3%) 0.18
2) usually 16 (18%) 14 (15%) 8 ( 9%)
3) always 69 (79%) 72 (79%) 78 (88%)

0.01 -value for a comparison between PAL- and SVL-wearing periods : -value for a comparison between the 6- and
12-month surveys in the PAL-wearing period N/A: not available The total sample number for each question diered due to unavailable
data
Howovov, in iho SVL-woaving poviod, signicani cov-
volaiions wovo Iound boiwoon disiuvbanco in noav
vision (Q3) and ago and boiwoon conplianco wiih spoc-
iaclo woav (Q6) and voIvaciivo ovvovs.
!n iho uosiionnaivo vogavding iho spociaclo alloca-
iion (Q7), iho answovs wovo covvoci in 35 (54),
incovvoci in i6 (24), and uncloav in i2 (22) (daia
wovo noi availablo Iov 25 childvon). Signicanily novo
childvon answovod covvocily ihan incovvocily (!oavson
iosi, jO.Oi9).
Discussion
!n ihis uosiionnaivo suvvoy, iho nyopic childvon
woaving !ALs Ivouonily vopoviod visual synpions
such as disiuvbanco in disianco vision, disiuvbanco in
noav vision, di culiy in asconding ov dosconding
siaivs, and voviigo ov dizzinoss in laioval vision.
Howovov, iho Ivouoncy oI ihoso synpions was noi
signicanily diovoni Ivon ihai vopoviod by iho chil-
dvon woaving SVLs. Mosi (98) oI iho childvon wovo
conpliani wiih iho uso oI !ALs, and ihovo was no
nood io disconiinuo iho uso oI !ALs ov io chango io
SVLs in any oI iho childvon duving iho i8-nonih
ivoainoni poviod. Jhoso vosulis indicaio ihai childvon
can uso !ALs wiihoui signicani visual pvoblons in
ihoiv daily aciiviiios.
JisuolsymIomsossocioIcduiIhIhcusco]
IAIs. Jho Ivouoncy oI di culiios adapiing io iho
nowly pvoscvibod spociaclos did noi diov signicanily
boiwoon iho !AL- and SVL-woaving poviods. !n iho
Covvociion oI Myopia valuaiion Jvial (COMJ)
[i4], iho pvoblon was obsovvod novo Ivouonily in
!AL-woaving childvon ihan in SVL-woaving childvon
i wooL aIiov iho boginning oI iho uso oI iho spociaclos,
bui iho diovoncos sponianoously disappoavod i nonih
laiov. !n iho Iaco oI an opiical disiuvbanco such as
nowly pvoscvibod glassos, diovoni oculonoiov and
sonsovy sysions show adapiivo vosponsos io nainiain
visual povIovnanco. Ropoviodly, an adapiivo vosponso
in ionic vovgonco [i9], AC/A vaiio [2O], and a son-
sovy nochanisn ihai osiablishos spaiial localizaiion
[2i, 22] iaLos sovoval houvs io wooLs io conploio.
Jhoso oxpovinonial ndings woll oxplain iho vosulis
obiainod in COMJ childvon. Howovov, bocauso ouv
uosiionnaivo was povIovnod 6 nonihs aIiov iho chil-
dvon siaviod io uso !ALs, ihoiv nonovy concovning
ihis synpion in ihis oavly adapiaiion poviod nay havo
boon uncloav.
Jho disiuvbanco in disianco vision (Q2) is nainly
oxplainod by iho individual pvogvossion oI nyopia duv-
ing iho 6-nonih iniovval boiwoon iho suvvoys. !n ihis
113 Visual Symptoms and Compliance with PALs in Children April 2008
6 5 4 3 2
at class
0.25
0.50
0.75
always
usually
always
usually
R
e
s
p
o
n
s
e

p
r
o
b
a
b
i
l
i
t
y
at class
1.00
0.00
0.25
0.50
0.75
1.00
0.00
7
1
6 5 4 3 2 7 1
PAL-wearing period SVL-wearing period
Spherical equivalent refractive error (D)
Fig. 1 Cumulative probability plot of compliance with spectacle wearing as a function of refractive errors determined at the 6-month
survey.
Using a logistic regression model, the graph is divided into 3 response categories: at class only, usually, and always. The vertical distance
between the curves represents the probability for each category. The correlation was signicant in SVL-wearing children (P0.01, R
2

0.06).
114 Acta Med. OkayamaVol. 62, No. 2 Suemaru et al.
Table 3 Results obtained at the 6-month survey and the clinical characteristics at baseline
clinical
characteristics
levels
PAL-wearing period SVL-wearing period
n odds ratio -value n odds ratio -value
Q1: Was it di cult to adapt to the new spectacles? - Yes
age 10 yrs 27 1.00 0.25 23 1.00 0.06
10, 12 yrs 41 1.37 41 2.23
12 yrs 24 0.38 26 0.31
refractive error 3 D 50 1.00 0.28 47 1.00 0.23
3 D 37 0.60 42 0.89
near heterophoria 2 PD 31 1.00 0.46 35 1.00 0.03
2 PD 50 1.43 50 1.20
lag of 1.75 D 28 1.00 0.93 28 1.00 0.63
accommodation 1.75 D 28 1.05 27 0.91
Q2: Is there any di culty when looking at the blackboard? - Yes
age 10 yrs 27 1.00 0.08 23 1.00 0.46
10, 12 yrs 41 3.53 41 0.44
12 yrs 24 0.33 26 1.07
refractive error 3 D 50 1.00 0.02 47 1.00 0.41
3 D 37 0.38 42 1.41
near heterophoria 2 PD 31 1.00 0.17 35 1.00 0.02
2 PD 78 2.15 50 4.23
lag of 1.75 D 28 1.00 0.27 28 1.00 0.28
accommodation 1.75 D 28 0.49 27 0.63
Q3: Is there any di culty when reading or writing? - Yes
age 10 yrs 27 1.00 0.22 23 1.00 0.01

10, 12 yrs 41 0.93 41 0.00

12 yrs 24 0.00 26 N/A
refractive error 3 D 50 1.00 0.87 47 1.00 0.09
3 D 37 0.86 42 0.28
near heterophoria 2 PD 31 1.00 0.63 35 1.00 0.08
2 PD 50 1.66 50 3.88
lag of 1.75 D 28 1.00 0.51 28 1.00 0.28
accommodation 1.75 D 28 0.44 27 1.70
Q4: Is there any di culty when ascending or descending the stairs? - Yes
age 10 yrs 27 1.00 0.55 23 1.00 0.05
10, 12 yrs 41 1.64 41 0.29
12 yrs 24 0.33 26 0.00
refractive error 3 D 50 1.00 0.26 47 1.00 0.05
3 D 37 0.40 42 0.62
near heterophoria 2 PD 31 1.00 0.96 35 1.00 0.06
2 PD 50 0.96 50 0.58
lag of 1.75 D 28 1.00 0.12 28 1.00 0.23
accommodation 1.75 D 28 0.20 27 1.08
siudy, iho nodiod iiing pvoiocol was usod in iho
!AL-woaving poviod as doscvibod abovo. Jho upwavd
ivansposiiion oI !ALs Ivon iho lovol oI iho onivanco
pupil would voduco ihoiv nogaiivo diopivic ooci and
also induco bluvvod inagos ai disianco. Howovov, iho
Ivouoncy oI ihis synpion was noi signicanily diov-
oni boiwoon iho !AL- and SVL-woaving poviods,
indicaiing ihai iho iiing pvoiocol was noi pvoblonaiic
in disianco vision.
Disiuvbanco in noav vision (Q3) was nuch loss Ivo-
uoni ( 7). Wvighi e|ol. [23] vopoviod ihai ovon
childvon wiih no objociivo abnovnaliiy oIion con-
plainod oI pvoblons wiih noav vision whon ihoy wovo
vouosiod io answov uosiionnaivos. !n ouv siudy, iho
odds vaiios Iov ihis synpion docvoasod wiih ago
(Jablo 3). JhovoIovo, ihis synpion nay bo aiivibuiod
io such a psychological iondoncy associaiod wiih young
childvon.
Jho Ivouoncy oI iho di culiy in asconding ov
dosconding siaivs (Q4) in iho !AL-woaving poviod was
2 iinos highov ihan ihai in iho SVL-woaving poviod ai
iho 6-nonih suvvoy (alihough iho diovonco was noi
siaiisiically signicani). Howovov, ihis synpion con-
ploioly disappoavod ai iho i2-nonih suvvoy. Whon iho
childvon looL ihvough iho noav addiiion pavi oI !ALs,
iho disiani linii oI cloav vision boconos closov by iho
anouni oI iho noav addiiion. JhovoIovo, bluvvod
inagos in iho down gazo nay pvoduco a visL oI acci-
donial Ialls whon asconding ov dosconding siaivs. As
noniionod abovo, wo doiovninod iho disiani pvoscvip-
iion wiih a slighi undovcovvociion: O.74 D on avovago
[i3]. JaLing iho dopih oI Iocus oI iho oyo (usually,
O.5 D [24]) inio accouni, iho disiani linii oI cloav
vision ihvough iho noav addiiion pavi was
57 cn: iOO cn/(i.5OO.74O.5 D). Jhis calculaiion
woll oxplains why sono childvon woaving !ALs
vopoviod ihis pvoblon. !n iho COMJ childvon, iho
Ivouoncy oI ihis synpion in !AL-woaving childvon
was signicanily highov ihan ihai in SVL-woaving
childvon i wooL aIiov iho spociaclo woaving bogan,
bui ihis diovonco disappoavod aIiov i nonih [i4].
Jho diovoni vosulis boiwoon ihoiv siudy and ouvs avo
pavily oxplainod by iho diovonco in lons dosign.
Howovov, iho longov-iovn (i2-nonih) inpvovononi oI
ihis synpion ihai wo Iound in ihis siudy suggosis ihai
iho childvon vouivod a longov poviod io loavn opiinal
oyo-hoad coovdinaiion in asconding ov dosconding
siaivs in addiiion io iho abovo-noniionod oculonoiov
and sonsovy adapiaiions.
Sniih e|ol. pvoscvibod !ALs wiih a gvoaiov noav
115 Visual Symptoms and Compliance with PALs in Children April 2008
Table 3
Q5: Have you ever felt vertigo or dizziness in lateral vision? - Yes
age 10 yrs 27 1.00 0.41 23 1.00 0.03
10, 12 yrs 41 1.29 41 1.83
12 yrs 24 0.27 26 11.3
refractive error 3 D 50 1.00 0.35 47 1.00 0.19
3 D 37 0.52 42 0.78
near heterophoria 2 PD 31 1.00 0.56 35 1.00 0.08
2 PD 50 0.66 50 3.89
lag of 1.75 D 28 1.00 0.26 28 1.00 0.99
accommodation 1.75 D 28 2.61 27 1.04
Q6: I use the spectacles: - at class only or usually
age 10 yrs 27 1.00 0.34 23 1.00 0.39
10, 12 yrs 41 1.99 41 0.57
12 yrs 24 0.42 26 1.15
refractive error 3 D 50 1.00 0.12 47 1.00 0.01

3 D 37 0.42 42 0.16
near heterophoria 2 PD 31 1.00 0.39 35 1.00 0.67
2 PD 50 0.40 50 1.25
lag of 1.75 D 28 1.00 0.41 28 1.00 0.56
accommodation 1.75 D 28 0.56 27 0.58

0.01 minus sign indicates exo-deviation. The total sample numbers for each question diered due to missing data.
addiiion ( 3.OO ov 3.5O D) io a snall nunbov oI
hypovopic childvon, and ihoy vopoviod no pvoblon
dovivod Ivon ihoiv uso [2]. A noav addiiion in !ALs
has boih diopivic and pvisnaiic oocis oI diovoni
dogvoos doponding on iho anouni oI iho addiiion, bui
childvons sonsovy and noiov adapiaiion abiliiios soon
io bo powovIul onough io conponsaio Iov ihoso disiuv-
bancos. Whon wo nowly pvoscvibo !ALs io childvon
in clinics, howovov, iho childvon should bo wavnod oI
iho visL oI accidonial Iall whon asconding ov doscond-
ing siaivs, as whon pvosbyopic adulis avo pvoscvibod
ihon.
ComliouccuiIhsccIoclcucor. Jho con-
plianco wiih spociaclo woav in iho !AL-woaving
poviod was as high as in iho SVL-woaving poviod.
Jhis vosuli voocis iho nding ihai !ALs did noi
causo a signicani pvoblon in daily aciiviiios as shown
by iho vosulis oI Qs i5. !n addiiion, ii is plausiblo
ihai iho absonco oI a diovonco in appoavanco boiwoon
!ALs and SVLs conivibuiod io iho high conplianco.
!voscvipiion oI oxocuiivo-iypo biIocal spociaclos was
voconnondod Iov childvon [i, 25] bocauso iho hovi-
zonial lino sopavaiing iho noav and Iav vision pavis oI
iho lonsos holps childvon idoniiIy iho pvopov pavi oI
iho lonsos and holps clinicians nd nisalignnoni oI iho
lonsos. Howovov, school childvon usually do noi liLo
io woav biIocal spociaclos sinply bocauso iho appoav-
anco is cloavly diovoni Ivon ihai oI SVLs.
!niovosiingly, in childvon wiih low-gvado nyopia,
iho conplianco wiih spociaclo woav was boiiov in iho
!AL-woaving poviod ihan iho SVL-woaving poviod
(Jablo 3 and ig. i). SVLs (nogaiivo sphovical
lonsos) incvoaso iho acconnodaiivo donand Iov a
visual objoci locaiod ai a noav disianco, whovoas ihis
ooci is voducod wiih !ALs. !i nay Iollow ihai SVL-
woaving childvon iondod io iaLo o ihoiv glassos whon
looLing ai closo objocis. Jhis considovaiion was pavily
suppoviod by iho vosuli Ivon Q3 (Jablo 3): iho odds
vaiio Iov di culiy in voading ov wviiing in SVL-
woaving childvon wiih low nyopia ( 3 D) was
3-iinos highov ihan in ihoso wiih nodovaio io high
nyopia ( 3 D), alihough iho diovonco was noi
siaiisiically signicani.
EcoluoIiouo]moskiug. !ALs nado a cloav
conivibuiion io iho nainionanco oI iho nasLing whon
conpavod wiih biIocal spociaclos [26], bui ouv vosulis
indicaiod ihai iho nasLing Iov iho spociaclo allocaiion
was noi always nainiainod. !i is pvobablo ihai aliov-
naiions in povcopiual inagos ihvough iho spociaclos
ihai wovo povcoivod whon iho childvon swiichod lons
iypo Ivon !ALs io SVLs ov vico vovsa ai iho cvoss-
ovov poini havo sovvod as cluos io iho spociaclo allo-
caiion. Howovov, iho vosuli oI Q6 indicaios ihai ihis
oxioni oI unnasLing did noi inuonco iho conplianco
wiih spociaclo woav as a wholo.
!n conclusion, iho vosulis oI ihis uosiionnaivo
suvvoy povIovnod as pavi oI a doublo-nasLod clinical
ivial dononsivaiod ihai ihovo was no signicani diov-
onco in visual synpions ov in conplianco wiih spoc-
iaclo woav boiwoon iho !AL- and SVL-woaving povi-
ods. Childvon can oasily adapi io and uso !ALs (ai
loasi ihoso wiih a i.5O D noav addiiion) wiihoui
signicani visual pvoblons duving daily aciiviiios.
AcLnowlognonis.Jhis vosoavch was suppoviod by iho Japanoso
Minisivy oI ducaiion, Culiuvo, Spovis, Scionco and Jochnology,
Cvani-in-Aid Iov Scioniic Rosoavch (C) No. i539O532. Jho auihovs
ihanL Mogano JanaLa Chain Lid (Hivoshina, Japan) Iov holp in iho
pvopavaiion and adninisivaiion oI iho siudy glassos and Dv. Shovin
lsayod Iov holp in pvopaving iho nanuscvipi.
Rcfcrcnccs
1. Jacob JL, Beaulieu Y and Brunet E: Progressive addition lenses
in the management of esotropia with a high accommodation/con-
vergence ratio. Can J Ophthalmol (1980) 15: 166169.
2. Smith JB: Progressive-addition lenses in the treatment of accom-
modative esotropia. Am J Ophthalmol (1985) 99: 5662.
3. Choy CK, Siu AW, Lam FY, Tse JT and Lau SY: Addition lens
alleviates reading-induced ocular stress. Clin Exp Optom (2000)
83: 1215.
4. Russell GE and Wick B: A prospective study of treatment of
accommodative insu ciency. Optom Vis Sci (1993) 70: 131135.
5. Rosenfeld M and Meredith FC: Eect of near vision addition
lenses on the accuracy of the accommodative response.
Optometry (2001) 72: 1924.
6. Yen MY, Liu JH, Kao SC and Shiao CH: Comparison of the
eect of atropine and cyclopentlate on myopia. Ann Ophthalmol
(1989) 21: 180187.
7. Shih YF, Chen CH, Chou AC, Ho TC, Lin LL and Hung PT:
Eects of dierent concentrations of atropine on controlling myopia
in myopic children. J Ocul Pharmacol Ther (1999) 15: 8590.
8. Lee JJ, Fang PC, Yang IH, Chen CH, Lin PW, Lin SA, Kuo HK
and Wu PC: Prevention of myopia progression with 0.05 atro-
pine solution. J Ocul Pharmacol Ther (2006) 22: 4146.
9. Stewart RE, Margaret Woodhouse J and Trojanowska LD: The
use of bifocal spectacles with children with Downs syndrome.
Ophthalmic Physiol Opt (2005) 25: 514522.
10. Leung J TM and Brown B: Progression of myopia in Hong Kong
Chinese schoolchildren is slowed by progressive lenses. Optom
Vis Sci (1999) 76: 346354.
11. Edwards MH, Li RW, Lam, CS, Lew JK and Yu BS: The Hong
Kong progressive lens myopia control study. Study design and
main outcome. Invest Ophthalmol Vis Sci (2002) 43: 28522858.
116 Acta Med. OkayamaVol. 62, No. 2 Suemaru et al.
12. Gwiazda J, Hyman L, Hussein M, Everett D, Norton TT, Kurtz D,
Leske MC, Manny R, Marsh-Tootle W and Scheiman M: A ran-
domized clinical trial of progressive addition lenses versus single
vision lenses on the progression of myopia in children. Invest
Ophthalmol Vis Sci (2003) 44: 14921500.
13. Hasebe S, Nonaka T, Nakatsuka C and Ohtsuki H: Myopia con-
trol trial with progressive addition lenses in Japanese schoolchil-
dren: Baseline measures of refraction, accommodation and het-
erophoria. Jpn J Ophthalmol (2005) 49: 2330.
14. Kowalski PM, Wang Y, Owens RE, Bolden J, Smith JB and
Hyman L: Adaptability of myopic children to progressive addition
lenses with a modied tting protocol in the correction of myopia
evaluation trial (COMET). Optom Vis Sci (2005) 82: 328237.
15. Hasebe S, Nakatsuka C, Hamasaki I and Ohtsuki H: Downward
deviation of progressive addition lenses in a myopia control trial.
Ophthalmic Physiol Opt (2005) 25: 310314.
16. Dias L, Hyman L, Manny E, Fern K and the COMET group:
Evaluation the self-esteem of myopic children over a 3-year period:
The COMET experience. Optom Vis Sci (2005) 82: 338347.
17. Nakatsuka C, Hasebe S, Nonaka F and Ohtsuki H:
Accommodative lag under habitual seeing conditions: Comparison
between adult myopes and emmetropes myopic and emmetropes.
Jpn J Ophthalmol (2003) 47: 291298.
18. Thibos LN, Wheeler W and Horner D: Power vectors: an applica-
tion of Fourier analysis to the description and statistical analysis of
refractive error. Optom Vis Sci (1997) 74: 367375.
19. Oohira A, Zee DS and Guyton DL: Disconjugate adaptation to
long-standing, large amplitude, spectacle-corrected anisometropia.
Invest Ophthalmol Vis Sci (1991) 32: 16931703.
20. Miles FA and Judge SJ: Optically-induced changes in the neural
coupling between vergence eye movement and accommodation in
human subjects, in Functional Basis of Ocular Motility Disorders,
Lennerstrand G, Zee DS and Keller EL eds, Pergamon, New York
(1982) pp 9396.
21. Adams WJ, Banks MS and van Ee R: Adaptation to three-dimen-
sional distortions in human vision. Nat Neurosci (2001) 4: 1063
1064.
22. Guyton DL: Prescribing cylinders. The Problem of Distortion. Surv
Ophthalmol (1977) 22: 177188.
23. Wright JD and Boger WP 3rd: Visual complaints from healthy chil-
dren. Surv Ophthalmol (1999) 44: 113121.
24. Green DG, Powers MK and Banks MS: Depth of focus, eye size
and visual acuity. Vision Res (1980) 20: 827835.
25. von Noorden GK: Binocular Vision and Ocular Motility. Theory
and Management of Strabismus, 4th ED, The CV Mosby, St
Louis (1990) pp 458460.
26. Dong LM, Hyman L, Manny RE, Thomas J, Dias L, McLeod J
and Gwiazda J: Evaluating masking in a randomized, double-
masked clinical trial in children with myopia. Optom Vis Sci (2006)
83: 4652.
117 Visual Symptoms and Compliance with PALs in Children April 2008