T H E M E

MYOPIA

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Points de Vue, the International Review of Ophthalmic Optics created
by Essilor in 1979, is committed to providing prescribers (all eye care
professional involved in prescription throughout the world) with
forward-looking and useful information for their practices and effective
patient care.

Points de Vue is an expert-to-expert publication, sharing the latest

knowledge on scientific evidence, clinical practice, market insights,
patient needs and innovative solutions.

CARRACEDO Gonzalo
CHRIEN Sebastian
FRANCHI Christian
LONGO Adèle
MASSE Alain
MESLIN Dominique
PAILLE Damien
CAVANAGH Maureen PEREIRA Léonel
HERZBERG Cary POUSSIN Stanislas
LEUNG Dennis REMIASOVA Monika
WILLIAMS J. Bruce MISKOVIC Jan

This 73rd issue welcomes

25 experts
sharing their perspectives on
“Myopia”. DROBE Bjöne
KOH Patricia
GARCIA Sergio LU Fan
PRADA Javier YEO Anna

JONG Monica
NAIDOO Kovin
READ A. Scott
SANKARIDURG Padmaja

F O R A N Y CO MMEN TS O R Q UESTI O N S,
C O N TA C T U S AT: P O IN TSD EVUE@ ESSILO R.CO M
We strive to answer within 24 hours. We are at GMT+01
 EDITO
Eva Lazuka-Nicoulaud
Director of the Publication

MYOPIA
TACKLING A PANDEMIC
Surprisingly enough for a non-infectious condition, myopia is reaching pandemic proportions
across the world.

Record-breaking figures. In the US and Europe, the prevalence of myopia has doubled over
the last century, reaching 40-50% of young people (aged < 35) today. East Asia has been hit
particularly badly. In countries such as Singapore, China and Korea, myopia affects around
80-90% of urban teenagers, compared to 10-20% sixty years ago. Recent work from the Brien
Holden Vision Institute (BHVI) estimates that by 2050, five billion people, or half the world’s
population, will be myopic and one billion, or 10%, highly myopic.1 A record-high myopia of
-108 diopters has recently been compensated in Slovakia, Europe, representing new
challenges for eye care practitioners and the ophthalmic industry.2 While the direct global
socio-economic impact of myopia has not yet been determined,
the economic burden of uncorrected refractive error (URE),
which is largely caused by myopia, is estimated to be more than “Sur p r is ing ly eno u g h f o r a
US$269 billion (per annum) – and this number is growing as the
no n- infectio us co n d i t i o n ,
pandemic spreads.3
my o p ia is r eaching p a n d e m i c
The good news. Over the past few months there has been a
p r o p o r tio ns acr o s s t h e w o r l d ”
notable increase in alarming publications in scientific journals
and the media on the myopia crisis. However, leading research
centers and medical universities have been vigorously focused for some time on furthering
understanding of the condition and developing new treatments for it.4 Etiology investigations
have uncovered that myopia onset and its progression in children are correlations of both
hereditary (nature) and environmental factors (nurture). The latter can be modified by
encouraging greater exposure to natural light through outdoor activities5 and adopting good
reading posture. We take the opportunity in this issue to share some perspectives from
25 experts – scientists and eye care practitioners – taking a look at their approach to
understanding, correcting6 and treating myopia, plus preventing its progression in children.7

Hope in sight. Biochemical research for the myopia pathogenic mechanism will continue to
be a hot topic. Luckily, the progress made over the past decade gives us reason for hope. At
present, the overwhelming majority of myopia cases can be corrected with regular prescription
eyeglasses, contact lenses or refractive surgery. There are also the solutions that correct and
control myopia progression in children. Specific multifocal contact lenses, Myopilux®
ophthalmic lenses8 and orthokeratology (Ortho-K) are all recognized as safe and effective
procedures in the long term.9 While pharmacological interventions such as atropine eye drops
at low concentration do not correct myopia, they effectively control its progression. There is
no doubt tailor-made solutions help patients live their life to the fullest. One need look no
further than Mr. Miskovic, the man with the world’s highest degree of myopia at -108D – as
a successful photographer, he is pursuing his dream !10

1. Jong M, Sankaridurg P, Naidoo K, Myopia: A public health crisis in waiting, 6. Franchi Ch, Longo A, Meslin D, High Myopia: The specificities of refraction
- Page 44 and optical equipment - Page 34
2. Chrien S, Masse A, Pereira L, Poussin S, Remiasova, Record-high myopia 7. Garcia S, Herzberg CM, Leung D, Prada J, Williams BT, Orthokeratology
solved by an alliance of experts: -108.00 D - Page 66 in clinical practice across the world - Page 28
3. Cavanagh M, Myopia rise and vision health issues left in its wake - Page 49 8. Yeo A, Koh P, Paille D, Drobe B, Myopia and Effective Management Solutions
4. Lu F, A look at myopia research in China - Page 12 - Page 56
5. Read AS, Light exposure and childhood myopia - Page 20 9. Herzberg CM, Carracedo G, A look at progress in orthokeratology - Page 06
10. Miskovic J, Practicing the art of photography with -108 D myopia - Page 72
VERBATIM
“1 I N 1 0 P E O P L E
WO R L D W I D E WI LL
BE A T RI SK F O R
P E RM AN E N T BL I N D N E S S
BY T H E YE A R 2 0 5 0 .”
PROF. KOVIN NAIDOO
quotation used in M. Cavanagh’s article page 49

“OUR MISSION IS IN PART TO HELP FIND

SOLUTIONS TO THE MYOPIA EPIDEMIC
WHICH THREATENS THE EYE HEALTH OF
PRESENT AND FUTURE GENERATIONS”
DR. CARY HERZBERG
article page 6

“MYOPIA USUALLY RESULTS

“LESS THAN 60 MINUTES OF BRIGHT FROM INHERITED GENES
OUTDOOR LIGHT EXPOSURE
INTERACTING WITH
APPEARS TO BE A RISK FACTOR
FOR FASTER EYE GROWTH AND ENVIRONMENTAL FACTORS.”
HENCE MYOPIA DEVELOPMENT AND PROF. FAN LU
PROGRESSION IN CHILDHOOD.” article page 12

PROF. SCOTT A. READ

article page 20

“THE MYOPIA EPIDEMIC CREATES A

SIGNIFICANT PUBLIC HEALTH PROBLEM
AROUND THE WORLD.”
MAUREEN CAVANAGH
article page 49

“PEOPLE WITH MYOPIA, ESPECIALLY HIGH MYOPIA,

ARE AT HIGHER RISK OF DEVELOPING OTHER VISION
DISORDERS THAT CAN LEAD TO BLINDNESS.”
PROF. KOVIN NAIDOO
quotation used in M. Cavanagh’s article page 49

Points de Vue - International Review of Ophthalmic Optics

4 Number 73 - Autumn 2016
 CONTENT
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03 EDITORIAL
06 EXPERTS’ VOICE 43 MARKET WATCH
44. MYOPIA: A PUBLIC HEALTH CRISIS IN WAITING
06. A LOOK AT PROGRESS IN
Dr. Monica Jong, Prof. Padmaja Sankaridurg,
ORTHOKERATOLOGY OVER THE LAST DECADE
Prof. Kovin Naidoo
Dr. Cary M Herzberg, Dr. Gonzalo Carracedo
49. MYOPIA RISE AND VISION HEALTH ISSUES LEFT
12. A LOOK AT MYOPIA RESEARCH IN CHINA
IN ITS WAKE
Prof. Fan Lu
Maureen Cavanagh

19 SCIENCE 55 PRODUCT
20. LIGHT EXPOSURE AND CHILDHOOD MYOPIA
56. MYOPIA AND EFFECTIVE MANAGEMENT
Prof. Scott Read
SOLUTIONS
Dr. Anna Yeo, Patricia Koh, Dr. Damien Paillé,
Dr. Björn Drobe
66. RECORD-HIGH MYOPIA SOLVED BY
AN ALLIANCE OF EXPERTS: -108.00 D
27 CLINIC Sebastian Chrien, Alain Massé, Léonel Pereira,
28. ORTHOKERATOLOGY IN CLINICAL PRACTICE Stanislas Poussin, Monika Remiašová
ACROSS THE WORLD
Bruce T. Williams, Sergio Garcia, Javier Prada,
Dennis Leung, Dr. Cary M Herzberg
34. HIGH MYOPIA: THE SPECIFICITIES
OF REFRACTION AND OPTICAL EQUIPMENT 71 ART AND VISION
Christian Franchi, Adèle Longo, Dominique Meslin
72. PRACTICING THE ART OF PHOTOGRAPHY
WITH -108 D MYOPIA
Jan Miskovic

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Points de Vue - International Review of Ophthalmic Optics

5 Number 73 - Autumn 2016
EXPERT’S VOICE
A LOOK AT PROGRESS
IN ORTHOKERATOLOGY

Corneal reshaping through orthokeratology as a means to control myopia progression

has made tremendous progress over the past decade. Below, Dr. Cary M Herzberg,
president of the International Academy of Orthokeratology and Myopia Control
(IAOMC), discusses the developments that have been made in the field and how
the IAOMC hopes to continue to push the scientific envelope in the years to come.
Dr. Gonzalo Carracedo of the University Complutense in Madrid
then details how orthokeratology has come to be recognized worldwide
as a safe and effective procedure in the long term.

Dr. Cary M Herzberg Dr. Gonzalo Carracedo

OD FIAO, president of the International OD, MsC, PhD, University Complutense
Academy of Orthokeratology and Myopia of Madrid, Spain.
Control (IAOMC), USA.

Dr. Herzberg has been practicing Orthokeratology and myopia Dr. Gonzalo Carracedo joined the University Complutense of
control for over thirty-five years. He has lectured extensively Madrid as an assistant professor of optometry and contact lenses
on the topic, written numerous articles and holds a patent in 2006. He is also currently a lecturer at the European University
on the first scleral Orthokeratology design. He is co-founder, of Madrid, where he teaches about specialty contact lenses.
President, board member and fellow of the International Academy He obtained his PhD (European mention) with a thesis entitled
of Orthokeratology & Myopia Control (IAOMC) and the founder, “Adenine dinucleotides as molecular biomarkers of dry eye”.
President and a board member American Academy of He belongs to the Ocupharm Diagnostics research group,
Orthokeratology and Myopia Control(AAOMC) formerly The which focuses on the ocular surface, contact lenses and dry
Orthokeratology Academy of America(OAA). He is an advisory eye research and development. He is also a member of the GICO
board member of the Gas Permeable Lens Institute (GPLI) and research group, which is specialized in myopia control, corneal
a former contact lens design consultant to C&H Contact Lens. aberrations and vision. His PhD thesis dealt with nucleotides as a
He has visiting Professor status at Tianjin Medical University, marker of dry eye in different conditions, including when wearing
Shandong Medical University and He Eye Hospital/University. contact lenses or in the context of refractive surgery and systemic
disease related to dry eye. He is the author of 38 papers (some
related to myopia control and orthokeratology) in peer-review
journals such as IOVS, Current Eye Research and Experimental
Eye Research. He has also been a reviewer for these journals,
plus the Journal of Optometry and the Journal of Ocular
Pharmacology and Therapeutics. He has been involved in 16
research projects (four as the main researcher) regarding the
ocular surface (i.e. keratoconus, dry eye myopia and contact
lenses) and glaucoma.

KEYWORDS
Orthokeratology, Ortho-K, myopia control, corneal reshaping,
peripheral defocus

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 EXPERTS’ VOICE
“OUR MISSION IS IN PART TO HELP FIND SOLUTIONS
TO THE MYOPIA EPIDEMIC WHICH THREATENS
THE EYE HEALTH OF PRESENT AND FUTURE GENERATIONS”
DR. CARY HERZBERG

T
he orthokeratology (Ortho-K) effect was first observed as a side Ten years of progress
effect of contact lenses made of Poly methyl methacrylate
(PMMA), which flattened in their radius of curvature over time. Three overriding themes stand out in the past
“What started as a method to reduce temporarily the refractive error decade of progress in orthokeratology. They are
of nearsighted individuals evolved, with the help of innovative design the technologies, safety/efficacy and myopia
choices, to advanced engineering of the corneal surface of the eye,” control. “The progress in these three areas has
explains Dr. Cary M. Herzberg, OD FIAO, president of the International been nothing short of astounding and has
Academy of Orthokeratology and Myopia Control (IAOMC). cleared the path forward to an exciting new era
for the non-surgical treatment of refractive states
With the optics and resulting aberrations of an oblate corneal surface of the human visual system,” says Dr. Herzberg.
including spherical aberration, advanced design choices could pro-
vide solutions for progressive myopia and presbyopia. Ortho-K also The last decade has seen phenomenal growth in
attracted maverick practitioners, who brought a spirit of imaginative the technologies that impact orthokeratology
innovation to the world. “It has been my honor to have led several design. It’s difficult to comprehend how much
of these organizations and to have helped found the international progress has been made in such a short period
academy, which now spans the globe,” continued Dr. Herzberg. of time. Little more than a decade ago the
“Our mission is in part to help find solutions to the myopia epidemic FDA approved Bausch&Lomb’s Vision Shaping
which threatens the eye health of present and future generations”. Treatment (VST) for applications of low to
moderate myopia and astigmatism. This came
just a couple of years on the heels of the

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EXPERTS’ VOICE

certification of Paragon Vision Sciences’ CRT® designs, which pointed to potential ways these new appli-
contact lenses. What would prove even more cations would be possible.
significant was the approval of topographical
mapping, combined with CAD/CAM (computer- Hard as it is to believe, less than a decade ago Ortho-K was
aided design and computer-aided manufacturing) illegal in China. This was because of a laissez-faire attitude
technology for state-of-the-art Ortho-K lens and risks present in the care of lenses that existed at the
designing. This meant the imagination became time. Dozens of cases of corneal scarring with sight loss led
the limit for exciting new breakthroughs in ortho- to the government ban as the new century dawned. “Today, a
keratology. much different picture exists due to the regulation of the
industry and the elimination of questionable and dangerous
Having FDA approval of corneal reshaping was a behavior in the care of Ortho-K lenses,” Dr. Herzberg explains.
major advance, but what took place after was “The numbers coming out of China speak for themselves –
inspired by an industry poised to develop the over 1.5 million lenses have been fit with zero incidences of
vast potential promise that had been lying sight-threatening outcomes.” The Ortho-K environment in
dormant for decades. Almost ten years prior to the US has always been focused on safety first, and the expe-
the FDA’s decision new lens fabrication techno- riences there with corneal molding reflect that. In addition,
logies experienced a new era of accuracy in numerous studies have shown that risks inherent in wearing
producing products that had better process tole- Ortho-K lenses only at night are no more significant than with
rance than the equipment utilized to measure any soft lens worn overnight.
the human visual system for them. Along with
this was the use of computer-assisted lathing Most practitioners who perform corneal reshaping do so for
systems to make a reality of even the most com- myopia control. Surprisingly, the first landmark study
plex designs, themselves the product of powerful demonstrating this procedure was the one on Longitudinal
new technologies. The FDA approval allowed Orthokeratology Research In Children (LORIC) by Pauline
research and development to focus on more Cho a little more than a decade ago. Since its publication
accurate and faster procedures for the Ortho-K many more have been done providing an unequivocal answer
effect. At the same time, research and develop- to the growing myopia epidemic that affects young people,
ment of non-FDA approved areas – specifically damaging their visual system as they age. Along with low
high myopia and astigmatism – brought new dose atropine, bifocal soft contacts and a change in life-
investment and products. Lastly, developments style, Ortho-K is set to play a huge role going forward in
in hyperopia and presbyopia seemed more likely slowing down myopic progression and its sight-threatening
in light of recent success in more conventional complications.

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8 Number 73 - Autumn 2016
 EXPERTS’ VOICE
The future of the International Academy of Orthokeratology
& Myopia Control

“The International Academy of Orthokeratology (IAO) was founded The academy will place more emphasis on
five years ago in Orlando, Florida, at the fifth annual meeting of the research in the field of myopia control and
Orthokeratology Academy of America(OAA), which has since become Ortho-K in the next decade. Indeed, the
the American Academy of Orthokeratology & Myopia Control change in our name was only one small part in
(AAOMC),” says Herzberg. This year at the annual meeting of the IAO this process, as structurally the organization
in Gold Coast, Australia, the name will officially be changed to changed as well, opening up vast new funding
include the words myopia control. The organization is open to all resources for further research. “The future looks
disciplines that promise answers to the growing myopia epidemic especially bright – we will continue in our world-
afflicting present and future generations. Including myopia control wide efforts to help contain the disease of
was brought about by an over ninety percent approval rating in each myopia, which threatens the health and well-
of our five sections: Europe (EurOK), Latin America (ALOCM), being of our chil-dren,” concludes Dr. Herzberg.
Oceania (OSO), Asia (IAOA) and North America (AAOMC). Emphasis
on myopia control as well as Ortho-K has been a reality in the IAO The evidence-based effectiveness and safety
for the last five years, making the name change a mere formality. of orthokeratology

The academy over the years has remained in relative terms a group The role of peripheral refraction in myopia pro-
that is small in numbers but very influential and effective in achie- gression control and how the peripheral defocus
ving results. As an example, the concept of an international body to image influences eye growth has been studied
set standards of practice and oversee development worldwide for for the past decade (Smith EL, 2013).1 “The
Ortho-K was first proposed in 2002 at the first Global Orthokeratology development of animal models of refractive
Symposium (GOS) in Toronto, Canada. Over the next almost ten years errors has made a huge contribution to our
there were many efforts to launch such a group which ended in fai- understanding of the regulation of eye growth,”
lure. The first substantial talks, which related to bringing a worldwide explains Gonzalo Carracedo, OD, MsC, PhD,
organization into existence within our academy, took place in 2009 University Complutense of Madrid, Spain.
at an education meeting in Phoenix, Arizona. Despite many chal-
lenges, which caused previous efforts to fail, the group was launched This field has also generated a huge body of lite-
two years later. We expect exponential growth in the future, but we rature linking retinal defocus and eye growth.
will strive to retain the feel of a small and flexible organization, which The first evidence that visual experience has an
has served us so well in the past. influence on eye growth was discovered by

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EXPERTS’ VOICE

“IN THE COMING YEARS, RESEARCH SHOULD BE FOCUSED

ON UNDERSTANDING THE WHOLE MECHANISM (PHYSICAL
OR OPTIC AND BIOCHEMICAL) TO DEVELOP BETTER,
MORE EFFICIENT SOLUTIONS, TO COMPLETELY HALT
THE PROGRESSION OF MYOPIA”
DR. GONZALO CARRACEDO

Wiesel and Raviola in 1977.2 They demonstrated (Smith EL, 2009).4 In humans, the role of the peripheral
that the sutured eyes of monkeys developed retina in relation to refractive error and eye growth has largely
myopia associated with expansion of the poste- been evaluated, with numerous studies examining the rela-
rior segment both equatorially and axially, tionship between foveal refraction and off-axis or peripheral
postulating that this was due to lack of a clear refraction (Flitcroft DI., 2012).5 Current research interest is
retinal image. The evidence that the peripheral centered heavily around the influence of peripheral refraction
retinal image can influence eye growth has on myopic progression. Based on this theory different optical
recently been provided by experiments in rhesus treatment strategies have been proposed and tested, and as
monkeys (Smith EL, 2005).3 These experiments with orthokeratology (Ortho-K), used to reshape the cornea of
demonstrated that deprivation of the peripheral a myopic eye.
retina can stimulate axial eye growth despite
normal central vision and indicates that There are several studies performed since 2004 linking ortho-
influences on the peripheral retina can outweigh keratology and myopia control. Walline et al. in the CRANYON
signals from the central retina. study found that children who wore orthokeratology for two
years showed less axial length growth and therefore less myo-
More recently lens-induced peripheral hyperopia pia progression (57%) than children who wore monofocal soft
has also been shown to produce central myopia contact lenses (Walline et al., 2009).6 However, the MICOS

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10 Number 73 - Autumn 2016
 EXPERTS’ VOICE
study only found a 32% reduction in myopia in the
ortho-K group compared to the eyeglasses group
(Santodoming et al., 2012).7
KEY TAKEAWAYS
Regarding orthokeratology safety, there have been a
total of 123 instances of microbial keratitis in ortho-
keratology patients reported between 1997 and 2007. • In the past decade orthokeratology has progressed
Most of the reported cases were found in East Asian in leaps and bounds to non-surgical advanced
children ranging in age from 9 to 15 years of age,
engineering of the corneal surface.
mainly due to inappropriate lens care, the patient not
following practitioner’s instructions and continuation of
lens wear despite discomfort. Common organisms found • The IAOMC is set to enjoy exponential growth,
were Pseudomonas aeruginosa and Acanthamoeba.
with a focus on orthokeratology and myopia control
Other studies have found an incidence of microbial
keratitis of 7.7 per 10,000 patients per year of wear, in the next decade.
making orthokeratology wearers only slightly more sus-
ceptible to infection than daily soft contact lens wearers
• Several studies over the past 12 years have linked
(4.1 per 10,000) and better than 30-day extended
wear silicone hydrogel lens wearers (14.4 per 10,000 orthokeratology to myopia control.
patients) wear. Also, the incidence for orthokeratology
is slightly less than with LASIK surgery, which has an
• Orthokeratology has been shown to be effective in
incidence of 9 per 10,000 patients per year (Solomon
et al., 2003).8 In conclusion, the long-term safety and reducing and controlling the progression of myopia.
efficacy of orthokeratology use has been demonstrated,
with few cases of severe adverse incidents reported
• The question today is not whether orthokeratology
and a high efficacy in reducing and controlling the
progression of myopia. halts myopia progression but rather when should it
be applied.
Remaining scientific and clinical challenges ahead

Although peripheral refraction is the most accepted

hypothesis, results from all studies show that other
mechanisms are involved in myopia control with ortho- REFERENCES
1. Smith E.L., Optical treatment strategies to slow myopia progression: effects of the visual extent of the optical
keratology. Accommodation, high-order aberration as treatment zone. Exp Eye Res, 2013;114:77-88.

well as light power could be participating in the com- 2. Wiesel T.N., Raviola E., Myopia and eye enlargement after neonatal lid fusion in monkeys, Nature 1977; 266,
66e68.
plex task to control eye growth. Moreover, these are just 3. Smith E.L., Kee C.S., Ramamirtham R., Qiao-Grider,Y., Hung L.F., Peripheral vision can influence eye growth
and refractive development in infant monkeys, Invest. Ophthalmol. Vis. Sci. 2005; 46, 3965e3972.
the physical mechanisms, which trigger a biochemistry 4. Smith E.L., Hung L.F., Huang J., Relative peripheral hyperopic defocus alters central refractive development
signal pathway (Young et al., 2009).9 “In the coming in infant monkeys, Vision Res. 2009; 49, 2386e2392.
5. Flitcroft DI. The complex interactions of retinal, optical and environmental factors in myopia aetiology.
years, research should be focused on understanding the Prog Retin Eye Res. 2012;31:622-60.

whole mechanism (physical or optic and biochemical) 6. Walline J.J., Jones L.A., Sinnott L.T., Corneal reshaping and myopia progression, Br. J. Ophthalmol, 2009; 93,
1181e1185.
to develop better, more efficient solutions, to comple- 7. Santodomingo-Rubido J, Villa-Collar C, Gilmartin B, Gutierrez-Ortega R., Myopia control with orthokeratology
contact lenses in Spain: refractive and biometric changes. Invest Ophthalmol Vis Sci. 2012;53:5060-5.
tely halt the progression of myopia,” suggests Dr. 8. Solomon R, Donnenfeld ED, Azar DT, et al. Infectious keratitis after laser in situ keratomileusis:
Carracedo. In terms of the clinical challenges, the results of an ASCRS survey. J Cataract Refract Surg. 2003; 29(10):2001-2006.
9. Young T.L. Molecular genetics of human myopia: an update. Optom Vis Sci. 2009; 86:E8-E22
current question to answer is not if orthokeratology
controls myopia progression but when this treatment
must be applied. How much growth of myopia every
year is necessary to make orthokeratology treatment
mandatory? In this matter, clinicians should develop an
international protocol suggesting the best way to use
myopia control devices such as Ortho-K. •

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EXPERTS’ VOICE

A LOOK AT MYOPIA
RESEARCH IN CHINA

Wenzhou Medical University (WMU) is one of the leading educational and research medical
universities in China. Beyond its academic excellence and high-end medical services,
WMU is a leader in advanced research in ophthalmology and optometry.
Against the backdrop of an unprecedented rise in myopia in East Asia,
several research programs at WMU have been vigorously dedicated to furthering
understanding of the condition and developing new treatments for it.
This interview with Professor Lu Fan, the president of Wenzhou Medical University,
explores in depth the scope of the latest scientific and clinical efforts to slow down
the myopia pandemic.

Points de Vue: Professor Lu Fan, what are the key

challenges regarding myopia in China? What have been the
most significant achievements in scientific and clinical
Prof. Fan Lu practice over the past ten years?
MD, MS/OD, President of Wenzhou
Medical University, China Prof. Fan LU: Myopia control and management still face
Prof. Lu Fan graduated from WMU in 1986, majoring in general significant challenges. First, an increasing number of patients
medicine. Following graduation, she completed a residency in with progressing myopia tend to be younger than in the past.
ophthalmology at the affiliated hospital. In 1991, Prof. Lu Fan Second, the overuse of smartphones has dramatically changed
completed a master’s degree in Optics and Ophthalmology. people’s behavior. Children, for example, tend to spend a lot
She later attended the New England of College of Optometry of time reading at a very short distance. The prevalence of
(NECO), becoming the first graduate of the joint MS/OD program myopia among both urban and rural children has gone up as
offered by NECO and WMU. After her doctor of optometry (OD) a result. Third, the impact of high myopia on an individual’s
degree in 2002, Prof. Lu Fan returned to China to help pioneer
eyesight is unpredictable and uncontrollable.
the establishment of optometry as a medical discipline in the
country. She was the recipient of the 2002 China National Award
for Outstanding Women.
We have done a lot of scientific and clinical research work
Prof. Lu Fan has been involved extensively with the advancement focusing on myopia in the past decade. As to the basic
of eye care and optometric education in China, training leaders research, we have found that the level of dopamine (DA) and
in medical education and the health care system. In May 2010, its receptors affect the occurrence of myopia. Interventions
she was given an honorary doctor of science degree from the regarding myopia have made large steps forward. Many new
New England College of Optometry in recognition of her concepts and techniques appear to help control myopia, such
contribution and advancement of the profession of optometry in as the correction of peripheral refraction errors, the usage of
China. In October 2015, she was appointed president of WMU. orthokeratology and atropine eye drops. In addition, adequate
Her research focuses on vision functions, refractive surgery, outdoor activities are critical for myopia prevention.
contact lenses and refractive techniques in myopic children.
Prof. Lu Fan has authored several publications in relation
to these research fields.

KEYWORDS
Myopia, high myopia, myopia control, myopia management, dopamine
(DA), peripheral refraction errors, orthokeratology (Ortho-K), atropine,
outdoor activities, eyeglasses, contact lenses, myopia prevention, genetic
therapy, refractive surgery, keratoconus, posterior scleral reinforcement
(PSR), etiology, ocular bio-imaging.

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12 Number 73 - Autumn 2016
 EXPERTS' VOICE
“ MANY NEW CONCEPTS AND TECHNIQUES APPEAR
TO HELP CONTROL MYOPIA, SUCH AS THE CORRECTION
OF PERIPHERAL REFRACTION ERRORS, THE USAGE
OF ORTHOKERATOLOGY AND ATROPINE EYE DROPS.
IN ADDITION, ADEQUATE OUTDOOR ACTIVITIES
ARE CRITICAL FOR MYOPIA PREVENTION. ”

How would you define the current scope of myopia research

at Wenzhou Medical University (WMU)?
What are the top three research areas?

The entire project of myopia research at WMU combines resources Progress is made step by step in the field of
from the eye hospital with those of the school of optometry and biochemical mechanisms for human myopia.
ophthalmology. The research fields cover clinical practices, genetic However, there is much still to be done. For
studies, biology, innovation in medicine, ocular imaging developments, example, the results of the animal model need to
etc. The top three research areas are: 1) fundamental research, be studied further when applied to human
including establishing animal models, dopamine effects and genetic beings. Myopia is not the outcome of a single
therapy, which are supported by the National Basic Research Program gene and pathway, and the potential target of
of China (973 Program); 2) clinical studies on the correlation of child pharmacological approach may need more
behavior and myopia, epidemiological investigations, myopic function detection. Therefore, a lot of work still has to be
changes and visual acuity after refractive surgery; 3) optometric done to develop an effective treatment for
interventions, such as optical corrections, rigid gas permeable (RGP) myopia.
lenses and orthokeratology, which are always the areas most beneficial
to the public. What are WMU’s key areas of research on
refractive surgery in myopia treatment?
What can be learned from research on biochemical mechanisms How would you define the key clinical
regarding myopia onset and its progression? challenges and post-operative concerns in
What are the perspectives for eye care professionals for a patients, especially those with high myopia?
potential pharmacological approach in myopia treatment?
The refractive surgery center at WMU’s eye
Although myopia is the most common human eye disorder in the hospital is one of the biggest and most important
world, the exact cause is still unclear. Myopia usually results from refractive surgery affiliations in China today.
inherited genes interacting with environmental factors. Multiple About five thousand patients undergo refractive
genetic myopic loci and pathways have been identified. The onset of surgery annually in our center. A full 98% are
myopia and its progression interact as an entity and a complex myopia patients. Among the myopia patients,
disorder. 88% are aged 20 to 30.

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EXPERTS' VOICE

“ ACCORDING TO OUR STUDIES,

WEARING ORTHO-K LENSES OVER THE LONG TERM
CAN IMPROVE ACCOMMODATION AMPLITUDE,
CHANGE WAVEFRONT ABERRATION AND CORRECT
PERIPHERAL REFRACTIVE ERRORS. ALL FACTORS
COMBINED TOGETHER SLOW THE AXIAL LENGTH
ELONGATION, WHICH DELAYS MYOPIA PROGRESSION ”

As to the key clinical challenges and post- also try surgery of posterior scleral reinforcement (PSR) for
operative concerns when it comes to refractive very high myopia control. The PSR aims to reduce the posterior
surgery, safety is the most important and segment structure changes induced by high myopia. We do
persistent issue. Although the techniques and find the PSR is helpful for delaying axial length elongation
surgical skills at the facility are mature and and improving visual acuity after surgery. Above all, high
advanced, there is still a small group of patients myopia and its complications are more likely to cause
that suffer from severe complications. One of the blindness. More efforts are being made with respect to
worst complications is keratoconus. The most refractive surgery to ensure visual health.
possible reason is that these patients are not
suitable candidates and they might already have There are many optical methods to correct and control
sub-clinical keratoconus before the refractive myopia progression in clinical settings. What is the current
surgery. Therefore, strict candidate screening is research focus with regard to optical solutions at WMU?
critical. Given this, we did research focusing on How will the latest findings in this area influence future
sub-clinical keratoconus filtering. Using the clinical practice?
study results, we built the diagnostic indices for
sub-clinical keratoconus detection. In addition, At WMU’s eye hospital, eyeglasses, soft contact lenses,
longitudinal parts are still ongoing to prove our daytime RGP lenses and orthokeratology (Ortho-K) are all
custom-designed indices can discriminate used for the correction of myopia in patients. One of the
effectively. We do hope the results will be helpful influential research areas is orthokeratology. The mechanism
when selecting candidates and improving safety. of how orthokeratology slows myopia progression is a hot
topic. According to our studies, wearing Ortho-K lenses over
In terms of the patients with high myopia, the long term can improve accommodation amplitude, change
intraocular refractive surgery is preferable to wavefront aberration and correct peripheral refractive errors.
surgery on the cornea. The anterior/posterior All factors combined together slow the axial length elongation,
chamber implantation of intraocular lenses which delays myopia progression.
(IOLs) might cause severe endothelial cell loss.
As a consequence, cataract surgery is more
recommended for the older patients with high
myopia. Moreover, monitoring the fundus
changes is quite important as well. Currently, we

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 EXPERTS' VOICE
What can we learn from etiology findings?
What are the most myopigenic conditions for myopia onset
and its progression in children?
What factors can/can’t be modified?

In terms of the etiology, it is very complicated. Myopia is not only posture. Video games produce the shortest
caused by a hereditary factor, but it is also affected by environment working distance and the highest head tilt.
factors. A lot of different theories, such as genetic loci changes, RNA Illuminance and contrast significantly influence
alterations during the process of transcription and translation and near posture. The worst posture comes when
various pathways, have been constructed to interpret the occurrence there is low illumination and contrast. Thus,
of myopia. The most myopigenic condition is always the hereditary recommendations for parents should be: 1) work
one. A child with two myopic parents has a greater likelihood of being in a bright environment (≥ 300lux); 2) ensure a
myopic than a child with only one myopic parent. However, at present high contrast for the text when reading; 3) make
this cannot be controlled when the baby is born. Luckily, there are sure there is an adequate working distance,
some environmental factors that can be modified to postpone the especially for video games. In addition, the lens
onset of myopia and its progression, such as good reading habits, type, such as single vision lenses or progressive
enough outdoor activities and a healthy diet. addition lenses (PALs), and the near-phoria
status affected near vision posture. During
What are the key vision functions that have been studied in myopic reading, myopic esophoric children used a lower
children, and what specificities have already been uncovered portion of their PALs compared with exophoric
through WMU’s research? What do we know about the relationship children, resulting in greater addition power,
between visual and behavioral functions – such as posture – which might partially explain why myopic
in children with regard to myopia progression? children with near esophoria exhibited superior
treatment effects in myopia control clinical trials
The key vision function that we have studied is lag of accommodation. using PALs. Therefore, I think the near-work
Near vision posture is indirectly linked to myopia through lag of posture plays an important role in the
accommodation, peripheral defocus, light and contrast. Based on our development of myopia progression in children.
previous studies, tasks done at short distances significantly influence

“ THE KEY VISION FUNCTION THAT WE HAVE STUDIED

IS LAG OF ACCOMMODATION. NEAR VISION POSTURE
IS INDIRECTLY LINKED TO MYOPIA THROUGH LAG OF
ACCOMMODATION, PERIPHERAL DEFOCUS, LIGHT
AND CONTRAST. ”

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EXPERTS' VOICE

FIG.1 The ocular OCT images and accommodation response curve. A represents the OCT
image of the anterior segment and lens; B is the OCT image of the ciliary body; and C is the
accommodation stimulus response curve. AS: accommodation stimulus; Latency: the time
accommodation starts from the point ACC (accommodation) stimulus is given; Peak velocity:
the speed required to reach the peak; Amplitude: the maximum amount of accommodation;
Bars = 500μm.

How can the research in ocular bio-imaging What are the key collaborative projects and partnerships
help better understand accommodation that WMU has initiated to accelerate research on myopia?
mechanisms in myopia onset, its progression
and its control in human eyes? Myopia research is a big project, including the mechanism,
What are the latest findings in this area? image recording, visual functions and corrections. We
collaborate with Prof. Xiongli Yang from the Chinese Academy
Ocular bio-imaging is helpful evidence in of Sciences on the myopic mechanism and pathway study and
researching accommodation mechanisms for Zeng Changqin from the Chinese Science Academy for
myopia. Using the custom-built optical studying the genetics of high myopia. Also, we work together
coherence tomography (OCT) system, the lens, with ESSILOR to study the visual function in myopic students.
ciliary body and anterior segment can be imaged
(Fig. 1-A, B). Combined with the open-filed Beyond research, how would you define the key educational
autorefractor and wavefront aberration system, challenges in optometry and ophthalmology with regard to
the accommodation function parameters and all myopia? How can education be helpful in growing eye care
the ocular aberration variations can be captured services and preventing the pandemic of myopia?
simultaneously. With this system, we keep
records of the accommodation response curves The way optometry and ophthalmology for myopia correction
for Ortho-K lens wearers (Fig 1-C). As a result, and treatment are studied needs to be rethought. Talented
the accommodation response speed and individuals with a medical background are the optimal
amplitude improves after three and five months. backups for specialized training. Both the clinical skills and
The long-term effects need to be studied further. human concerns are required for professional proficiency.

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 EXPERTS' VOICE
“ A COMMITMENT TO PUBLIC HEALTH BY ALL OF SOCIETY
WILL POSITIVELY PROMOTE HIGH MYOPIA MANAGEMENT.
ENHANCING THE LEVEL OF PUBLIC EDUCATION IS AN
ESSENTIAL STEP, AND THE PARTICIPATION OF DIFFERENT
MEDIA SHOULD BE ENCOURAGED. ”

However, with the increasing demand of public eye care, system What, in your opinion, is the key role ophthalmic
training at present is still insufficient. Training for optometrists and clinicians (i.e. ophthalmologists, optometrists
ophthalmologists is desperately needed at different angles and levels. and optical dispensers) should be playing in
The standardized clinical flow, including the doctors, sales assistants, preventing the complications of high myopia?
dispensers and after-service staff, should be established as a team
work. A personalized and accurate prescription is the basic guarantee Ophthalmic clinicians working as a team is key to
of the entire process. Therefore, only when prevention, control and ensuring a high medical quality. Medical con-
treatment are based on high qualifications will myopia management sultation and specialized guidance at the hospital
reach a high standard. are the basis for managing high myopia. Patients
will then learn to step up their vigilance for the
What other initiatives do you believe are required to improve the complications of high myopia. It is a beneficial
level of public awareness and that of the public health services to way to guarantee timely awareness and treatment
reduce the rates of high myopia? for high myopia complications.

A commitment to public health by all of society will positively promote Where to next?
high myopia management. Enhancing the level of public education is What are the key areas in scientific research,
an essential step, and the participation of different media should be clinical practice and medical education with
encouraged. Combining the basic awareness of myopia with the regard to myopia in next decade?
elementary education of children is a critical step. Next, a basic
medical insurance system will bring the public a brand-new concept. We have already made big steps forward in myopic
The most significant way is to ensure primary eye care is covered by research and clinical work in the past decade. In
the basic medical insurance system. Once there is awareness of the coming future, medical education for
myopia, the appropriate medical advice and diagnosis can be ophthalmic clinicians must be a priority. China’s
provided. Lastly, establishing a triple-level patient transferring system rapid economic development means the need for
will support prompt treatment for high myopic patients when the primary eye care is growing fast. Strict and
complications and emergencies occur. standard training of myopia management is
critical. On the other hand, biochemical research
for the myopia pathogenic mechanism will
continue to be a hot topic. Transforming achie-
vements in the lab into clinical practice is the
ultimate goal of all researchers and physicians. •

Interview by Eva Lazuka-Nicoulaud

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EXPERTS' VOICE

“ WE HAVE ALREADY MADE BIG STEPS FORWARD IN

MYOPIC RESEARCH AND CLINICAL WORK IN THE PAST
DECADE. IN THE COMING FUTURE, MEDICAL EDUCATION
FOR OPHTHALMIC CLINICIANS MUST BE A PRIORITY. ”

Wenzhou Medical University is a well-known me-

dical science university under the joint governance
of the Zhejiang Provincial Government, the
National Health and Family Planning Commission
and the Chinese Ministry of Education. Its origins
extend back to the establishment of Zhejiang
Medical School in 1912. In 1958, part of this
school moved from Hangzhou to Wenzhou in
southeastern China, becoming Zhejiang Second
Medical College and later Wenzhou Medical
University. Covering 1.27 km², the four-campus
university is a key higher-education institution in
Zhejiang province.

WMU has medical doctoral degree programs in

ophthalmology and the visual sciences, surgery,
obstetrics & gynecology, laboratory medicine,
internal medicine, pediatrics, gerontology, neuro-
logy, psychiatry & mental health, dermato-
venerology, imaging & nuclear medicine, otorhino-
laryngology, oncology, rehabilitation medicine,
sports medicine, anaesthesiology, emergency
medicine, biological therapy & reproductive medi-
cine. WMU also has eight primary-discipline
master’s degree programs. Its five affiliated
hospitals offer high-quality medical service to
some 20 million people.

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 Several research programs
SCIENCE
have already made
significant progress
in understanding
and developing new
treatments for myopia in
the past decade. Recent
studies have evidenced
a clear link between
myopia progression and
environmental factors.
They suggest new
preventive measures
in childhood myopia.

P.20 What does research say about outdoor

light exposure and childhood myopia?

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SCIENCE
LIGHT EXPOSURE AND
CHILDHOOD MYOPIA

There is evidence in many countries globally that the prevalence of myopia is on the rise.
Advances in measurement technology now allow many environmental factors potentially
associated with the development and progression of myopia to be quantified reliably and
sampled densely. Our recent prospective longitudinal study of Australian schoolchildren,
utilising wearable sensor technology has provided the first direct evidence of a significant
relationship between personal ambient light exposure and eye growth in childhood;
demonstrating that greater daily light exposure is associated with slower eye growth.
These findings support the potential for interventions aimed at increasing daily outdoor
light exposure, to reduce the development and progression of myopia in childhood.

R
ecent decades have seen a rapid rise in the
prevalence of myopia in many developed nations
around the world, with myopia prevalence levels
greater than 90% reported in young populations in some
developed Asian cities.1 Using modelling based upon the
current trends in myopia development and progression, a
Associate Professor Scott A. Read recent study predicted that around half of the world’s
Director of Research, population will be myopic, and that approximately 1 billion
Contact Lens and Visual Optics Laboratory people worldwide will have high myopia (5.00 D or more)
Queensland University of Technology,
by the year 2050.2 The potential public health costs of
School of Optometry and Vision Science,
these rising levels of myopia (and associated increase in
Australia
high levels of myopia) are dramatic, given the known
Scott Read is an Associate Professor in the School association between myopia and many sight threatening
of Optometry and Vision Science at the Queensland eye diseases, such as retinal detachment, glaucoma and
University of Technology, Brisbane, Australia. retinal degenerations that have all been linked to myopia
Since receiving his PhD in 2006, Scott has held a severity.3
variety of research and academic positions and has
published over 60 peer-reviewed research papers, This “myopia boom”4 therefore provides a strong catalyst
with the majority of this work focusing upon human for the development of reliable methods to reduce both
myopia. He recently received the “Zeiss Young the development and progression of myopia in the
Investigator Award in Myopia Research” for his population in order to limit the detrimental visual and
distinguished contributions to the myopia research public health effects of increasing levels of myopia. The
field. He has also been an Associate Editor for rapid increase in myopia prevalence in recent decades
Clinical and Experimental Optometry and acts as a points firmly towards a role for environmental influences
Topical Associate Editor for Optometry and Vision upon the development of myopia.5 However, the exact
Science. environmental factors involved in the regulation of eye
growth and the development and progression of myopia
are still not fully understood. A more comprehensive
understanding of the various factors impacting upon the
KEYWORDS
Myopia, light exposure, eye growth, outdoor activity, refractive error.

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“ Our finding s s up p o r t the p o tential fo r
int ervent ions a imed at incr eas ing d aily o utd o o r
light exposur e to r ed uce the d evelo p ment
and progress io n o f my o p ia in child ho o d . ”

normal growth of the eye and hence the development and primates.10 In humans, evidence of a potential role of light
progression of myopia in childhood is likely to be critical exposure in myopia has arisen from a number of
for the development of effective myopia control epidemiological studies that have shown that children who
interventions. report spending greater time outdoors also exhibit a
significantly lower prevalence and incidence of myopia
A move to outdoors compared to children reporting less daily outdoor time
Over the years, a range of different environmental factors (see Sherwin et al11 for a review of recent studies examining
have been proposed as potentially playing a role in human the association between myopia and outdoor activities).
myopia development, with factors related to near-work, Childhood eye growth and myopia progression is also
education and academic achievement being a major focus known to vary according to the time of the year, with
of many studies.6 More recently, perhaps spurred on by the slower eye growth documented in summer months (where
sometimes equivocal findings of studies examining the more environmental light and thus opportunities to spend
association between myopia and near work, a shift in the time outdoors is available), and faster eye growth is
focus of refractive error research has occurred, with a documented in winter months (where less environmental
move away from traditional near work measures and a light is available).12
broader focus on additional potential environmental
factors (e.g. outdoor activities).7 Evidence has been Since spending time outdoors also typically involves
emerging from both human epidemiological studies, and exposure to high intensity outdoor light (often more than
research with animals, that ambient light exposure may be 100 times brighter than the typical indoor light levels), it
an important additional environmental factor that plays a has been hypothesised that the associations found
role in myopia. Animal studies demonstrate that normal between more outdoor activity and less myopia, support a
eye growth appears to be influenced by environmental potential role for light exposure in myopia development.13
light levels, since rearing young chickens in dim ambient However, it is important to note that the majority of the
light environments has been shown to result in more rapid previous studies examining outdoor activity and childhood
eye growth and the development of more myopic refractive myopia (and studies of seasonal variations in childhood
errors compared to rearing animals in bright ambient eye growth) have not objectively assessed the habitual
light conditions.8 Similarly, exposure to bright ambient ambient light levels experienced by the children in their
light conditions appears to block the development of studies. Instead, this previous work has relied upon
experimental (form deprivation) myopia in chickens9 and questionnaires to quantify children’s activities and make

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SCIENCE

FIG.1 Example of light exposure and physical activity recordings from a representative ROAM study participant over a single 24-hour
period (yellow line shows light exposure, black bars show physical activity and blue shading indicates sleep period overnight), derived from
the Actiwatch-2 devices worn on the non-dominant wrist and programmed to record data every 30 seconds. Each child in the study wore
the device continuously for two 14-day periods (separated by approximately 6 months) over the first 12 months of the ROAM study.

estimates of their daily outdoor time, which does not emmetropia (mean spherical equivalent refraction of
provide an objective assessment of light exposure. Based +0.35 ± 0.31 D). Each participant in the study had a
on this research it is difficult to know conclusively whether series of ocular measurements, including measures of
the mechanism underlying the protective effects of axial eye length collected every six months over the 18
outdoor activities is due to light exposure or another factor month study period. Additionally, objective measurements
related to being outdoors (e.g. more physical activity or of each child’s individual ambient light exposure and
less near focussing). physical activity were also collected twice in the first 12
months of the study (approximately six months apart).
Seeing the light These measures were collected using Actiwatch-2 devices
Our recent research, taking advantage of wearable light (Philips Respironics, USA), a wrist watch sized device that
sensor technology, has therefore aimed to improve our contains a light sensor and an accelerometer, programmed
understanding of the factors underlying eye growth and to collect simultaneous measures of ambient light
myopia in childhood by examining for the first time the exposure and physical activity every 30-seconds of the day
relationship between objectively measured ambient light over each of the two 14-day periods of sensor wear (Fig.
exposure and children’s eye growth. The Role of Outdoor 1). This represents over 80,000 individual measures of
Activity in Myopia study (ROAM study) was an 18-month light exposure and physical activity from each child over
prospective longitudinal study of eye growth in myopic and the course of the study. These measures allowed us to
non-myopic children. The experimental procedures and examine the potential association between longitudinal
outcomes from the ROAM study have been reported in changes in eye growth and children’s habitual ambient
detail in a number of recent publications.14-16 One hundred light exposure and physical activity.
and one children, aged between 10 and 15 years of age, Analysis of these densely sampled light exposure and
were enrolled in the study, including 41 myopic children physical activity data revealed differences in the typical
(mean spherical equivalent refraction -2.39 ± 1.51 D) and daily pattern of activities of the myopic and non-myopic
60 non-myopic children with refractive errors close to children in the study.14,15 Although the daily variations in

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FIG.2 Average daily light exposure (left) and physical activity (right), averaged across each 60 minutes of the day for the myopic (red line) and
non-myopic (blue line) children in the ROAM study. Error bars represent the standard error the mean. Vertical dashed lines indicate the mean
timing of the school breaks and grey shading indicates the standard deviation of the break times.16

environmental light exposure and physical activity were slightly faster eye growth than girls). Additionally, axial eye
observed to closely follow the pattern of children’s typical growth was also significantly associated with the children’s
school day (with peaks in activity and light exposure found average daily light exposure, with lower daily light exposure
before and after school and during lunch breaks in the being associated with faster axial eye growth. To examine
school day), myopic children were found to exhibit the relationship between light exposure and eye growth in
significantly lower average daily light exposure compared more detail, the children in the study were further
to the non-myopic children, with the largest differences categorised (based upon a tertile split of their individual
being found at times immediately before and after school average daily light exposure levels, regardless of their
and at lunchtime (Fig. 2). This is indicative of less outdoor refractive status) as being habitually exposed to low,
activities for the myopic children over these times. moderate or high daily ambient light levels (Fig. 4).
Although there were trends observed for the myopic Children habitually exposed to low daily ambient light
children to also have slightly lower daily physical activity levels (who on average were exposed to only 56 minutes of
levels, differences associated with physical activity were bright outdoor light per day) were found to exhibit
not statistically significant. significantly faster axial eye growth. These analyses
included adjustments for refractive status, which suggests
The average axial eye growth observed in the myopic and that these effects of light exposure on eye growth are
non-myopic children in the study is illustrated in Figure 3. occurring independent of refractive error. Over the 18
Analysis of these data revealed a number of statistically months of the study, children exposed to low daily
significant predictors of eye growth in this population of light levels, exhibited approximately 0.1 mm greater eye
children, including the presence of myopia (where, as growth than children habitually exposed to moderate and
expected myopic children showed faster eye growth, high ambient light levels, which equates to a clinically
indicative of myopia progression in this group), younger significant ~0.3 D more myopic progression in refraction.
age (where younger children showed more rapid eye growth
than older children) and gender (where boys showed

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SCIENCE

FIG.3 Average axial eye growth observed over the 18 month study in the myopic and non-myopic children. Error bars represent standard
error of the mean. Linear mixed models analyses revealed that the presence of myopia, younger age, male gender and lower daily light
exposure were all significantly associated with the rate of axial eye growth.15

FIG.4 Average axial eye growth over the 18 month study after categorising children based upon their average daily light exposure as
being habitually exposed to high, moderate or low ambient light levels (regardless of their refractive status). Children exposed to low
daily light levels exhibited significantly faster eye growth. Error bars represent standard error of the mean.15

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“ These res ults p r o vid e us with the fir s t
direct e vid ence o f a r elatio ns hip
bet ween am b ient lig ht ex p o s ur e and the
rat e of eye gro wth in child ho o d and s ug g es t
t hat low lig ht ex p o s ur e is a r is k facto r
for more rapid ey e g r o wth and hence my o p ia
develop ment and p r o g r es s io n. ”

The use of wearable sensor technology in this study Clinical recommendations

provides important new insights into the mechanisms While the ROAM study has provided new insights into the
underlying the previously documented relationship factors influencing eye growth in childhood, the study also
between more myopia and less outdoor activities. Our provides us with empirical evidence regarding light
findings support an important role for bright ambient light exposure and eye growth that can be used to guide clinical
exposure in the protective effects of outdoor activities and recommendations to children and their parents. The
suggest that increased physical activity outdoors is not a children in the study categorised as habitually experiencing
key factor involved. These results provide us with the first low daily light exposure, on average spent less than 60
direct evidence of a relationship between ambient light minutes per day in bright outdoor light levels and also
exposure and the rate of eye growth in childhood and exhibited significantly faster eye growth than the other
suggest that low light exposure is a risk factor for more children in the study. This suggests that less than an hour
rapid eye growth and hence myopia development and of bright outdoor light exposure per day appears to
progression. An important aspect of ambient light exposure predispose children to faster eye growth and hence risk for
as a risk factor for myopia is the fact that it is a modifiable myopia development and progression. Significantly slower
environmental factor. Children can modify their activities/ eye growth was seen in the children, who on average spent
behaviour in order to change their daily light exposure and ~120 minutes per day exposed to bright outdoor light
potentially have an impact upon their rate of eye growth levels, which suggests that increasing daily bright light
and hence risk for development and progression of myopia. exposure by an additional 60 minutes per day is likely to
These findings therefore support the potential for public have an impact upon slowing axial eye growth (and hence
health interventions aimed at increasing daily light reducing the risk of myopia development and progression).
exposure to reduce myopia development and progression This is supported by two recent studies17,18 where
in childhood. interventions to increase children’s outdoor time (by either
40 minutes or 80 minutes per day) were found to
significantly reduce the incidence of myopia in populations
of East Asian children.

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Conclusions
The work summarised in this article helps to improve our
understanding of the role of light exposure in the regulation
of human eye growth and refractive error development and
progression and supports the potential for future myopia KEY TAKEAWAYS
control interventions aiming to increase daily bright light
exposure. However, more research is still needed to further
• There is evidence of a rapid increase in myopia
our understanding of a range of aspects regarding light
exposure and myopia. These factors include the relative prevalence in recent decades in many developed
importance of the spectral composition of light, the countries.
optimum timing of light exposure and the specific intensity
of light that is most important in the regulation of human • An improved understanding of the environmental
eye growth. Additional knowledge from further research in factors underlying eye growth and myopia in
this field may allow more targeted myopia control
childhood is crucial for developing effective myopia
interventions to be developed in the future, which from the
perspective of myopia control, looks to be bright. • control interventions.

Acknowledgements: This work was supported by an • Recent work utilising wearable sensors
Australian Research Council Discovery Early Career demonstrates the first direct evidence of a
Research Award (DE120101434). I gratefully acknowledge relationship between lower daily light exposure
my co-investigators Michael Collins and Stephen Vincent
and faster axial eye growth.
for their contributions to the work presented in this paper.

• Less than 60 minutes of bright outdoor light

exposure appears to be a risk factor for faster eye
growth and hence myopia development and
progression in childhood.

• These results support the potential for myopia

control through increased daily light exposure
(e.g. interventions to increase daily time outdoors).

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spent outdoors and myopia in children and adolescents: a systematic review and meta-analysis. Ophthalmology.
1. Jung S-K, Lee JH, Kakizaki H, Jee D. Prevalence of myopia and its association with body stature and 2012;119:2141-2151.
educational level in 19-year-old male conscripts in Seoul, South Korea. Invest Ophthalmol Vis Sci.
2012;53:5579-5583. 12. Donovan L, Sankaridurg P, Ho A, Chen X, Lin Z, Thomas V, Smith EL, Ge J, Holden B. Myopia progression
in Chinese children is slower in summer than in winter. Optom Vis Sci. 2012;89:1196–1202.
2. Holden BA, Fricke TR, Wilson DA, Jong M, Naidoo KS, Sankaridurg P, Wong TY, Naduvilath TJ, Resnikoff S.
Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmology. 13. Rose KA, Morgan IG, Ip J, Kifley A, Huynh S, Smith W, Mitchell P. Outdoor activity reduces the prevalence
2016;123:1036-1042. of myopia in children. Ophthalmology. 2008;115: 1279–1285.

3. Flitcroft DI. The complex interactions of retinal, optical and environmental factors in myopia aetiology. 14. Read SA, Collins MJ, Vincent SJ. Light exposure and physical activity in myopic and emmetropic children.
Prog Retin Eye Res. 2012;31:622-660. Optom Vis Sci. 2014;91:330-341.

4. Dolgin E. The myopia boom. Nature. 2015;519: 276–278. 15. Read SA, Collins MJ, Vincent SJ. Light exposure and eye growth in childhood. Invest Ophthalmol Vis Sci.
2015;56:3103-3112.
5. Morgan IG, Rose K. How genetic is school myopia? Prog Retin Eye Res. 2005; 24:1-38.
16. Read SA. Ocular and environmental factors associated with eye growth in childhood. Optom Vis Sci. 2016;
6. Morgan IG, Ohno-Matsui K, Saw S-M. Myopia. The Lancet. 2012;379:1739-1748. 93: 1031–1041.
7. Mutti DO, Zadnik K. Has near work’s star fallen? Optom Vis Sci. 2009; 86:76-78. 17. Wu P-C, Tsai C-L, Wu H-L, Yang Y-H, Kuo H-K. Outdoor activity during class recess reduces myopia onset
8. Cohen Y, Belkin M, Yehezkel O, Solomon AS, Polat U. Dependency between light intensity and refractive and progression in schoolchildren. Ophthalmology. 2013;120:1080-1085.
development under light-dark cycles. Exp Eye Res. 2011;92:40–46. 18. He M, Xiang F, Zeng Y, Mai J, Chen Q, Zhang J, Smith W, Rose K, Morgan IG. Effect of time spent outdoors
9. Ashby R, Ohlendorf A, Schaeffel F. The effect of ambient illuminance on the development of deprivation at school on the development of myopia among children in China: A randomized clinical trial. JAMA.
myopia in chicks. Invest Ophthalmol Vis Sci. 2009;50:5348–5354. 2015;15:1142-1148.
10. Smith EL, Hung L-F, Huang J. Protective effects of high ambient lighting on the development of form
deprivation myopia in rhesus monkeys. Invest Ophthalmol Vis Sci. 2012;53:421–428.

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26 Number 73 - Autumn 2016
 The Increasing prevalence
CLINIC
of myopia may significantly
influence clinical practice
in the future. Vision care
professionals are looking
for the latest technologies
in screening, correcting
and treating the condition.
They also have to adapt
protocols and pay special
attention to patients with
high myopia.

P.28How does Orthokeratology (Ortho-K)

practice develop across the world?
P.34What are the specificities of refraction
and optical equipment in patients with
high myopia?

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27 Number 73 - Autumn 2016
CLINIC
ORTHOKERATOLOGY
IN CLINICAL PRACTICE
ACROSS THE WORLD

Many factors must be taken into account when controlling myopia progression.
There is no doubt genetics plays a role in the development of myopia in children.
But lifestyle is also an important factor to consider. In terms of safe and effective treatment,
orthokeratology is now known to be successful in controlling myopia and has even been
shown to slow down progression in individuals with high myopia. While it has developed
substantially in Latin America, it is effectively mainstream in the US and a common
treatment in China, where there are numerous orthokeratology clinics in city hospitals.
Currently, orthokeratology is also on the rise in Europe.

T
here has been a tremendous increase over the past
few decades in the prevalence of myopia worldwide.
Dr. Bruce T. Williams,
Practitioners are more and more concerned with
OD, FIAO, Seattle, USA
regard to the increased incidence of patients moving
into the category of high myopia. The ocular health
consequences of sequelae related to high myopia can be
Dr. Sergio Garcia, devastating in later life. Many clinicians are implementing
O.D., optometrist Mscv and a systematic approach to establish a control protocol for
Faculty, Universidad de La Salle their patients with rapidly progressing myopia.
Bogotá, Colombia
A comparative survey of methods for controlling
Dr. Javier Prada, progressive myopia
O.D., optometrist director of the “Looking at ways to manage progressive myopia first
ophthalmology program at the requires identifying those who are at highest risk,” explains
University of Costa Rica and vice- Dr. Bruce T. Williams, OD, FIAO. Some of the risk factors
president of ALOCM, Costa-Rica include whether or not one or both parents are myopic,
especially if one or both are highly myopic. Other factors
to consider are myopic siblings or a family history of ocular
Dr. Dennis Leung, disease associated with myopia. Ethnicity is important, as
O.D., FIAO, California, USA the literature shows us that Asians are at a much higher
risk.

It is becoming increasingly apparent that lifestyle plays a

Dr. Cary M Herzberg
OD FIAO, President of the
significant role in how myopia develops in young
International Academy of individuals. Several studies have shown that time spent
Orthokeratology and Myopia outdoors has a protective effect.1,2,3,4,5,6,7,8 Whether it is
Control (IAOMC), USA higher levels of illumination, less near-distance tasks or
increased levels of vitamin D, the effect has been clearly
demonstrated. Limiting the amount of near work like
reading and the use of electronic devices, could be
beneficial, especially for kids that have higher associated
KEYWORDS
Myopia, high myopia, Orthokeratology, Ortho-K, myopia control,
risk factors.
dopamine, atropine, pirenzapine, multifocal contact lenses, executive
bifocals, progressive spectacle lenses, prismatic multifocal spectacle
lenses, vision therapy

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28 Number 73 - Autumn 2016
 CLINIC
“ Looking at way s to manag e p r o g r es s ive
myopia firs t r eq uir es id entify ing tho s e
who a r e at the hig hes t r is k”

Most children should reach emmetropia by the age of Soft multifocal lenses have recently shown promise but
eight-years-old. A six-to-eight-year-old child at approxi- have some disadvantages, such as blurred distance vision
mately -1.00 diopter will typically add a half diopter per and dryness, not to mention they limit some of the
year and end up at -5.00 to -6.00 by the mid-teens. It is activities in which children can participate.
important to initiate a protocol to limit the progression of
myopia. By reducing the rate of progression by 1/3, you Orthokeratology has consistently been shown to reduce the
reduce the likelihood of the individual developing high progression by approximately 45%.12 Orthokeratology has
myopia by 70%. If you can reduce the rate by 50%, the the advantage of only being worn overnight while sleeping.
likelihood is reduced by 90%. Parents are usually there to supervise insertion and
removal, and the child wears no lenses while at school
When designing a strategy to develop a protocol for myopia during the day. Orthokeratology sets up a unique
prevention, encouraging the patient and parents to topographical shape on the anterior cornea. The central
incorporate beneficial lifestyle changes should be the first cornea is flattened to focus on the fovea, and the mid-
priority. The practitioner can then look at the available peripheral cornea is steepened to create a myopic defocus
options for implementing a plan for the individual. We on the peripheral retina, reducing the stimulus of the
know that correcting the refractive error with traditional normal hyperopic defocus for axial elongation and
single vision spectacle lenses or regular soft/rigid contact subsequent increases in myopia (Fig. 1 and Fig. 2).
lenses will inherently cause more peripheral hyperopic
defocus, encouraging axial elongation and an increase in By designing lenses with specific optic zone diameters,
myopia. radii and reverse curve radii and widths, effective treatment
can be accomplished for most minus refractive errors and
Progressive addition lenses have been shown to reduce astigmatic components. Fortunately, the positive effect of
progression by 14% (and up to 37.2% in esophoric myopia control is even greater for patients that have
children, with high lags of accommodation when compared already progressed to higher states of myopia. This
to the regular single vision lens group).9 This is certainly procedure can literally stop further progression of those
an alternative, but it is not as effective as we would like. already in the category of high myopia.
The industry is working on developing executive-style
bifocals that contain a prismatic component, which makes The following pictures show the axial (Fig. 3) and
them a more effective spectacle lens alternative (they tangential (Fig. 4) topographical plots of a high myope.
show three-year results of myopia progression reduction of Note the area under the reverse curve is much steeper and
51% when compared to regular single visions lenses).10 rises above the original reference sphere, producing a
peripheral add power of well over the recommended
Pharmacological intervention has had a profound effect. It minimum of +4.00 diopters. This produces a substantial
is as much as 90% effective in reduction rates.11 There myopic peripheral defocus to eliminate the stimulus for
are certainly concerns, especially in children, when axial elongation and progressive myopia.
starting with pharmaceutical agents. A six-year-old child
on anti-muscarinic drug therapy for the next 12 years The advantages of orthokeratology over other forms of
could face serious unknown consequences. Proper dosage myopia prevention are clear and numerous. It has proven
for safe and effective treatment has not been firmly to be safe and effective when compared to all forms of
established, and there are reports of a significant rebound contact lens wear. Even in cases where full myopic
effect after discontinuation. correction could not be achieved, the rate of progression

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Number 73 - Autumn 2016 29
CLINIC
“ When desig ning a s tr ateg y to d evelo p
a prot ocol for my o p ia p r eventio n, enco ur ag ing
t he pat ient and p ar ents to inco r p o r ate b eneficial
lifest yle chang es s ho uld b e the fir s t p r io r ity . ”

has been slowed by greater than 50%, as in a study vision impairment worldwide.14 He also noted that it was
published by Pauline Cho at Hong Kong Polytechnic the second most common cause of blindness. This is
University.13 The child has parental supervision; the lenses estimated to cost US$202 billion per annum. That said,
are only worn in a closed eye environment, reducing the what are rank-and-file eye care professionals doing to
chance for loss or foreign body involvement. The child is address the problem? “If any one of us had a patient
free to participate in swimming and all kinds of activities sitting in the chair with a known sight-threatening
that might be limited by the use of other solutions. condition, which was in anyway treatable, would we tell
them that we were going to cover the symptoms and just
Orthokeratology should be presented to all young patients watch the condition progress until it reached the end
with progressive myopia as the safest and most effective point? Of course not. Yet this is what many of us are doing
strategy to reduce the progression of myopia to proven today,” explains Dr. Williams.
“safe” levels. If that turns out not to be accepted, then
other forms should be presented as well. Some form of The worldwide epidemic of progressive myopia is gaining
progressive myopia reduction should become the standard strength every day. In the article “Global Prevalence of
of care for these patients to reduce the possibility of Myopia and High Myopia and Temporal Trends from 2000
eventual sight-threatening complications. through 2050,”15 authors stated: “Myopia and high
myopia estimates from 2000 to 2050 suggest significant
Latest achievements in orthokeratology increases in prevalence globally, with implications for
In 2010, Bourne et.al estimated that 108 million people planning services, including managing and preventing
were affected by myopia, making it the leading cause of myopia-related ocular complications and vision loss among

FIG. 1 OCT view of Reverse Geometry Orthokeratology lens on the Cornea

FIG. 2 Topographical perspective view of post Ortho-K cornea.

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30 Number 73 - Autumn 2016
 CLINIC
almost 1 billion people with high myopia.”A study These increases are not going unnoticed by industry. Many
conducted in Shanghai, China, of more than 5000 companies are hurriedly trying to develop specialty lenses
subjects published in November 2012 found that 95.5% for both contacts and spectacles to in some way slow or
of university students were myopic.16 Of them, 19.5% stop the progression of myopia in those patients that are
were highly myopic, greater than -6.00 diopters. Myopic at high risk of reaching severe myopia.
prevalence in the United States rose from 25% in the
early 1970s to 41.6% in the early 2000s. Study after Today, there are several ways to halt the formerly inevitable
study in virtually every sector of the planet has shown an process that leads to severe myopic degenerative disease.
alarming increase in the number of people with myopia. There are many controlled studies that prove effective
measures can be taken to slow the steady rate of increasing
For years clinicians and scientist have debated whether axial elongation and the devastating consequences
myopia is a result of genetics (nature) or environmentally thereof. These include pharmaceutical agents such
induced (nurture). Studies have shown that having one or Atropine and Pirenzapine, multifocal contact lenses,
two myopic parents significantly increases a child’s executive bifocals, progressive spectacle lenses, prismatic
chance of becoming myopic. Children today have multifocal spectacle lenses and vision therapy.
significantly increased near demand and tend to spend One method that has been shown to be particularly
less time outdoors in natural light. It has been shown that effective in reducing the myopia progression rate by 50%
spending more time outdoors results in less myopia. This is orthokeratology.18 This is the programmed use of
is possibly due to less near demand, pupil constriction or specially designed contact lenses to flatten the central
the release of retinal transmitters such as dopamine and cornea while steepening the mid-peripheral cornea to
vitamin D that may inhibit eye growth. It stands to reason temporarily reduce myopia. This procedure has the
that if we subscribe to the theory of emmetropization beneficial side effect of altering the peripheral retinal
being regulated by visual feedback, the majority of the defocus from a hyperopic posture to a myopic posture.
feedback should come from some distance substantially That, in effect, removes the stimulus for axial elongation.
greater than 20cm. Hence, the progression of myopia is significantly reduced
and sometimes stopped altogether.
Walline (2012) suggests that a 50% reduction in the rate
of myopia progression of -0.75D/yr. would keep a seven- Orthokeratology has evolved significantly over the last 50+
year-old -1.00 diopter child at -3.62D instead of -7.00D years since George Jessen first suggested it. It started as
in the span of just eight years.17 This would significantly a programmed sequential fitting of flatter and flatter
reduce the possibilities of developing severe ocular contact lenses to alter the anterior corneal curvature to
manifestations of myopia-related intraocular disease. temporarily correct myopia. We now have designs that can

FIG. 3 Axial difference topography map of post Ortho-K cornea showing -7.25D refractive FIG. 4 Tangential difference topography map of post Ortho-K cornea showing -7.25D
change. refractive change.

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Number 73 - Autumn 2016 31
CLINIC

address nearly every scenario that is presented. Designs Medellin in 2015) reported on 50 patients, with an
that correct low myopia and high myopia, astigmatism and average of 20/20 for both eye and without infections.
mixed astigmatism, hyperopia and ectasia. We can
produce lenses that have toric base curves, toric alignment The academy is working on statistics and screening in the
curves, oval treatment zones and varied return zone different countries to develop a Latin American sample
depths. The reverse geometry lenses have moved from the census of the percentage of the prevalence of myopia.
original 3 curve designs to 4, 5 and 6 curves. There are This will help prevention and treatment with different
computer-assisted programs that import topographies and methods to avoid a rise in high myopia in the future.
design lenses to align up to 8 semi-meridians of the
cornea to optimize the fluid forces behind the lens for Ortho-K in the US & China
maximum treatment. There is work going on to decenter In the United States, the FDA approved nightwear Ortho-K
the treatment zone to align better with the line of sight by Paragon CRT in June 2002. Since then, Ortho-K has
instead of the geometric center of the cornea so as to become a mainstream practice in optometry. Today, there
reduce induced astigmatism and higher order aberrations. are thousands of Ortho-K fitters that use CRT lenses and
also other innovative Ortho-K designs such as GOV, Ortho-
As the technology advances so will our ability to design tools and Wave, to name a few. Many experienced Ortho-K
lenses that do the best job possible to retard the specialists find that by the off-label use of these other
progression of myopia, increasing the odds of sparing the designs, they can correct the degree of myopia at a much
vision of so many. higher range than that approved for CRT lenses. It is not
unusual for a patient with myopia of 8 diopters or even
Ortho-K in Latin America higher to see 20/20 after just one week of treatment
In Latin America, orthokeratology (Ortho K) formally began using these custom designed lenses.
to be practiced after the first global Ortho-K meeting held
in Toronto, Canada in 2002. A small group of innovators The American Academy of Ortho-K and Myopia Control
from different countries, including Mexico, Guatemala, also fuels the enthusiasm for use of Ortho-K in the US,
Costa Rica, Colombia, Venezuela, Uruguay, Chile and and there are more than 500 members. Each year, the
Brazil, went and participated in the first meetings, academy hosts the Vision By Design (VBD) conference in
although only few of them decided in the coming years to different locations around the country. The next VBD will
offer the treatment to patients. This was mostly due to the be held in April 2017 in Dallas, Texas; the event is
lack of digital or CNC (Computer Numerical Control) lathes expected to attract hundreds of old and new Ortho-K
in Latin America needed to produce the lenses, which fitters. They will learn and share knowledge about fitting
have a reversed curve (they cannot be manufactured with techniques and concepts regarding myopia control and
common lathes). prevention. Custom soft lenses and diluted Atropine
treatment have been introduced in recent years at VBD,
Today, there are have fitters in Mexico, Guatemala, Costa which adds more tools to address the growing trends in
Rica, Colombia, Peru, Brazil, Argentina, Uruguay and myopia.
Chile, although recent studies from the one-year-old
Academia Latino Americana de Ortho K y Control de On the opposite side of the globe in Asia and the Pacific
Miopia (ALOCM), showed that the most cases fitted and Rim, due to the large percentage and high degree of
currently in use are in Costa Rica and Colombia, with myopia among Asians, Ortho-K is most often promoted as
around one thousand patients using the treatment with a means of myopia control. In China, a large number of
success. hospitals in all of the major cities have specialized
Ortho-K clinics. The number of patients successfully
Evidence has been provided for both countries that the treated by Ortho-K is greater than that in the rest of the
orthokeratology is a safe treatment, with an about 55% world. However, due to government restrictions, many
rate of myopia progression control (three- year study by new design innovations available in US are not available
Javier Prada et al. in Costa Rica, presented at WCO in in China. Other countries in the Pacific Rim where

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32 Number 73 - Autumn 2016
 CLINIC
Ortho-K are very popular include Taiwan, Singapore, Hong
Kong and Australia, where the Orthokeratology Society of
Oceania will host its annual congress in September 2016.
While the number of eye care providers in Asia and the KEY TAKEAWAYS
Pacific Rim practicing Ortho-K is likely to outnumber the
US it is certain the number of patients that need treatment
for myopia may be many times higher. • Lifestyle changes should be the number one priority
Ortho-K in Europe for patients when developing a strategy to prevent
Unlike in the US or China, it is much easier in Europe to myopia.
bring a new product to market, especially one that is
innovative and groundbreaking. The CE certification
required to sell a product in the European market has • According to a study by Pauline Cho of Hong Kong
been in place since 1985. It guarantees the manufacture’s Polytecnic University, orthokeratology slows the rate
product meets the requirements of the applicable of progression of myopia more than 50%.
European community directives. This environment brings
the ultimate in innovative new products to Europe’s doors
much more quickly in certain cases, especially those that • Children today spend less time outdoors, which has
fall in between the “cracks”. A classic example is the new been shown to foster myopia progression.
versions of lens design software, which can be accessed
for yearly fees and provide state-of-the-art lens designing
possibilities. This would be illegal in China if the product • Orthokeratology prescriptions for myopia control
hadn’t first been approved by the CFDA, a process that is are on the rise in Europe, but they are still behind those
expansive and time consuming. Ortho-K prescriptions for
myopia control have been on the rise these last few years, in the US, where the lenses have become mainstream,
but they still trail behind China and the US. This can be and China, where many hospitals in cities have
attributed in part to the lower incidence of myopia in specialized orthokeratology clinics.
Europe, especially when compared with China. •

REFERENCES 10. Cheng D, Woo GC, Drobe B, Schmid KL. Effect of bifocal and prismatic bifocal spectacles on myopia
progression in children: three-year results of a randomized clinical trial. JAMA Ophthalmol. 2014
1. Sherwin JC, Reacher MH, Keogh RH, Khawaja AP, Mackey DA, Foster PJ. The association between time Mar;132(3):258-64.
spent outdoors and myopia in children and adolescents: a systematic review and meta-analysis. Ophthalmology.
2012;119:2141-2151. 11. W. Chua; V. Balakrishnan; D. Tan; Y. Chan; ATOM Study Group, Efficacy Results from the Atropine in the
Treatment of Myopia (ATOM) Study, nvest Ophthalmol Vis Sci. 2003, Vol.44, 3119.
2. Rose KA, Morgan IG, Ip J, Kifley A, Huynh S, Smith W, Mitchell P. Outdoor activity reduces the prevalence
of myopia in children. Ophthalmology. 2008;115: 1279–1285. 12. Sun Y, Xu F, Zhang T, Liu M, Wang D, Chen Y, Liu Q. Correction: Orthokeratology to Control Myopia
Progression: A Meta-Analysis. PLoS One. 2015 Jun 11;10(6):e0130646.
3. Read SA, Collins MJ, Vincent SJ. Light exposure and physical activity in myopic and emmetropic children.
Optom Vis Sci. 2014;91:330-341. 13. Cho P, Cheung SW. Retardation of myopia in Orthokeratology (ROMIO) study: a 2-year randomized clinical
trial. Invest Ophthalmol Vis Sci 2012;53: 7077-85
4. Read SA, Collins MJ, Vincent SJ. Light exposure and eye growth in childhood. Invest Ophthalmol Vis Sci.
2015;56:3103-3112. 14. Bourne RR, Stevens GA, White RA, et al., Causes of vision loss worldwide, 1990-2010: a systematic analysis.
The Lancet Global Health 2013; 1(6):e339–49..
5. Read SA. Ocular and environmental factors associated with eye growth in childhood. Optom Vis Sci.
2016; 93: 1031–1041. 15. Holden BA, Fricke TR, Wilson DA, et al. Global Prevalence of Myopia and High Myopia and Temporal Trends
from 2000 through 2050. Ophthalmology 2016.
6. Wu P-C, Tsai C-L, Wu H-L, Yang Y-H, Kuo H-K. Outdoor activity during class recess reduces myopia onset
and progression in schoolchildren. Ophthalmology. 2013;120:1080-1085. 16. Sun J, Zhou J, Zhao P, Lian J, et al., High Prevalence of Myopia and High Myopia in 5060 Chinese University
Students in Shanghai, Invest Ophthalmol Vis Sci. 2012; 53(12):7504-9.
7. He M, Xiang F, Zeng Y, Mai J, Chen Q, Zhang J, Smith W, Rose K, Morgan IG. Effect of time spent outdoors
at school on the development of myopia among children in China: A randomized clinical trial. JAMA. 17. Jeffrey J. Walline, Myopia Control with Corneal Reshaping Contact Lenses, Invest Ophthalmol Vis Sci. 2012,
2015;15:1142-1148. Vol.53, 7086.

8. Jin JX, Hua WJ, et al., Effect of outdoor activity on myopia onset and progression in school-aged children 16. Sun J, Zhou J, Zhao P, Lian J, et al., High Prevalence of Myopia and High Myopia in 5060 Chinese University
in northeast china: the sujiatun eye care study, BMC Ophthalmology. 2015 Students in Shanghai, Invest Ophthalmol Vis Sci. 2012; 53(12):7504-9.

9. Gwiazda JE, Hyman L, Norton TT, et al.; COMET Group. Accommodation and related risk factors associated 17. Jeffrey J. Walline, Myopia Control with Corneal Reshaping Contact Lenses, Invest Ophthalmol Vis Sci. 2012,
with myopia progression and their interaction with treatment in COMET children. Invest Ophthalmol Vis Sci. 2004 Vol.53, 7086.
Jul;45(7):2143-51.

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Number 73 - Autumn 2016 33
CLINIC
H I G H M Y O P I A:
THE SPECIFICITIES
OF REFRACTION AND
OPTICAL EQUIPMENT

The specific needs of highly myopic patients require special attention

from eye care professionals. This article describes both the visual discomfort and main
visual disorders associated with high myopia and explains the risks of visual impairment.
It also discusses the specificities of refraction and the choice of optical equipment.
In addition, it makes recommendations on frame selection and advise
on the optimal selection of ophthalmic lenses.

Christian Franchi Adèle Longo Dominique Meslin

Optician, Optique Vaneau, Research Manager, Director of Technical and
Paris, France. Essilor Instruments, Professional Relations
Paris, France. Europe, Essilor International,
Paris, France.
Christian Franchi graduated from the EOL An optician and optometrist, Adèle Longo Educated in France as an optician (Optical
(Ecole d’Optique et Lunetterie - School of worked in an optical store while pursuing her School of Morez) and optometrist (University
Optics) in Lille, France, and trained at the ICO studies at the Institut des Sciences de la of Paris Sud), Dominique has spent most of
(Institut et Centre d’Optométrie – International Vision (Institute of Vision Sciences) in St his professional career at Essilor. He began
College of Optometry) in Bures sur Yvette, Étienne, France, where she obtained her in Research and Development working on
France. He has practiced in Paris as an optometrist certification. In 2011, she joined physiological optics and then held various
optician since 1979. Throughout his the Research and Development department positions in technical marketing and
professional experience in tending to his at Essilor International in the Low Vision communication for Essilor International in
wearers’ visual health, Christian has Research Center within the Paris Vision France and also in the USA. He was the
continued to deepen his technical expertise. Institute. In this context, she has worked to Director of Varilux University (now Essilor
He was particularly interested in ophthalmic improve the functional assessment of Academy Europe) for more than 10 years,
optical surfaces, their designing and patients with low vision. Currently with and is now the Director of Professional
implementation in optical equipment. With Essilor Instruments, Adèle is working on Relations and Technical Affairs for Essilor
the advent of digital surfacing technologies in upstream studies and works as a low vision Europe. Throughout his career, Dominique
2006, Christian has worked on methods of consultant at the same time in order to teach has facilitated numerous training seminars
detecting a wearer’s actual visual axes and on at the university and in centers for visually for eye care professionals worldwide. He is
tracking the eye’s center of rotation behind a impaired patients. the author of several scientific articles and
corrective lens. He patented the OPHTAGYRE various technical publications for Essilor,
process in 2008. Christian Franchi is also a including the “Ophthalmic Optics Files”
lecturer at several training seminars. series.

KEYWORDS
High myopia, pathological myopia, retinopathy, maculopathy, vision loss, visual
acuity, contrast sensitivity, night vision, glare, recovery time from glare, quality
of life, refraction, special lenses, lenticular lens, myopic rings, accommodation,
minification effect.

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34 Number 73 - Autumn 2016
 CLINIC
“T he s p ecific need s
of highly my o p ic p eo p le r eq uir e
sp ecial attentio n fr o m
eye car e p r o fes s io nals . ”

I
n recent years, the prevalence of myopia has been 1 Visual concerns of high myopia
increasing in all regions of the world. As reported in
many studies, myopia’s pandemic trends are putting 1.1. Reduced visual acuity
researchers, clinicians and the industry of ophthalmic One of the difficulties frequently encountered by highly
optics on the alert. Two aspects are emphasized in the myopic people is the difficulty to read small print, despite
mid-term projections: the number of people affected by wearing optimal correction. Karen Rose2 measured the
myopia worldwide will increase steadily and, among them, maximum acuity attained by 120 subjects with various
the proportion of cases with high myopia is also going to degrees of myopia, which was offset by their usual
increase. Thus, the prevalence of myopia (individuals with correction (contact lenses, eyeglasses, etc.). The results
mild to high myopia) in the world’s population could reach showed an average loss of two acuity lines on a logarithmic
25% by 2020 and nearly 50% by 2050, and the average scale (0.2 on the Minimum Angle of Resolution [MAR]
prevalence of high myopia (over -5.00 D) would increase log) between medium myopia (-1.50 to -3.75) and high
from 2.7% to almost 10% by 2050.1 In other words, myopia (beyond -10.00 D​​), objectifying the subjects’
myopic individuals would account for five billion people in problems.
2050 and highly myopic individuals would account for
one billion people (Fig. 1). These figures show the 1.2. Reduced contrast sensitivity
significance of the phenomenon that is now considered a The Melbourne Department of Optometry and Vision
major public health problem, and compel us to better Sciences3 has measured the contrast sensitivity of various
understand the day-to-day discomfort felt by slightly and myopic subjects. Even after adjusting for the lenses’
highly myopic people so as to improve their eye care minification effect, the contrast sensitivity determined for
management. the 10 most myopic subjects (greater than -4.00 D)
appears worse than for the others (Fig. 2). This explains
the difficulty of deciphering low contrast characters, which
is necessary in everyday life – when reading certain forms
or newspapers, for example. This shows us the importance
of measuring contrast sensitivity during a patient’s visual
management in order to offer the proper solutions:
for  example, adding additional lighting can be useful,
since it allows for an increase in the apparent contrast of
objects viewed.

1.3. Deteriorated vision thresholds under low

and bright lights
The study by Mashige4 on 100 subjects tells us about the
need to suggest lighting that is neither too weak nor too
FIG. 1 N
 umber of individuals with myopia and high myopia, estimated strong for these myopic individuals. To that effect, he
by decade between 2000 and 2050. Adapted from Holden et al.1 measured night vision thresholds and vision thresholds
under glare. For measuring night vision thresholds (light

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CLINIC
Contrast sensitivity (%)

1.4. Increased recovery time after glare

In addition, the recovery time after glare, defined as the
time required to regain the initial performance after being
exposed to glare, is longer for myopic than for hyperopic
subjects (Fig. 4), especially in subjects with a high degree
of myopia. This shows, for example, the difficulties
experienced by these highly myopic at the exit of a tunnel.

Mean glare recovery times (secs.)

Spatial frequency (c/deg)
FIG. 2 T
 he contrast sensitivity loss in high myopia occurred at high (but not
low) spatial frequencies. The filled dots and empty dots, with black lines:
these correspond respectively to the initial findings of highly myopic
patients and control subjects. The gray shaded area: lower confidence
limit at 95% of the contrast sensitivity function, modeled for control
subjects. The black dotted curve: represents the position of the model for Myopic Hyperopic
highly myopic patients corrected for the difference in image magnification
FIG. 4 Average recovery time after glare on myopic and hyperopic eyes.4
compared with the control subjects.3

threshold level authorizing vision), he decreased ambient 1.5. Decline in the quality of life and social impact
lighting until the subjects indicated that they could The VF-14 (result between 0-100) and the VQOL (0-5) are
no  longer see the target. The procedure to measure two questionnaires on quality of life that have been
the  thresholds of vision under glare was identical by completed by subjects with different degrees of myopia.2
simply  adding a glare source. Results showed The results showed that the highest myopia levels are
more  significant vision thresholds for myopic than for directly associated with lower general satisfaction in the
hyperopic subjects (Fig. 3), which shows a relative achievement of all day-to-day living activities due to visual
weakness in the adaptability of myopic subjects at difficulties, particularly when driving. The study of these
different light levels. questionnaires reveals that the difficulties are not only
visual, but also concern aesthetics, practical and financial
Mean Night Vision and Glare Vision thresholds (cd/m )

aspects. This  decline in quality of life is essentially

2

measured in subjects affected with high myopia (<-10.00

D). Accordingly, the social and psychological impact,
resulting from their anguish of losing sight, is very
significant.

2. Risks of visual impairment in high myopia

2.1. Pathologic myopia (retinopathy and maculopathy)

A person with high myopia presents a very significant risk
of developing eye diseases, which can sometimes cause
serious retinal damage 5 leading to various eye
complications and subsequent deficiencies in the visual
Myopic Hyperopic Myopic Hyperopic
field. Indeed, the excessive axial elongation of the highly
Refractive status
myopic eye may cause the mechanical stretching of the
FIG. 3 M
 ean night vision (gray bars) and glared vision (clear bars) thresholds
of myopic and hyperopic eyes.4 outer layers of the eyeball, resulting in such various

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36 Number 73 - Autumn 2016
 CLINIC
much more significant. Very often, highly myopic people
remove their glasses for near vision. This allows them to
avoid viewing too small objects (reduced in size by their
lenses), as well as bringing documents too close to their
eyes to magnify them.

When the need for magnification is more significant due

A B to visual impairment, it is interesting to suggest a bright
field magnifier, an optical system that is placed directly
on a document, thus allowing for magnification of the text
and offering a high apparent contrast via concentration of
light. Note that it is imperative to adapt the magnifier in
relation to the focus distance of the myopic readers when
they take off their glasses.
C D
Electronic systems can, in the same way, meet even
FIG. 5 P
 hotographs showing pathological changes on the fundus of four highly
myopic eyes - (a) Myopic Choroidal Neovascularization; (b) Myopic
greater magnification requirements and are the only ones
Macular Degeneration; (c) Myopic Macular Degeneration with Staphyloma; able to offer colorful image processing or reversed
(d) Geographic Atrophy Myopic Degeneration with Posterior Staphyloma. contrasts to optimize the vision of those with high myopia.

Significant light sensitivity as reported in high myopia and

pathological changes as staphylomas, atrophic lesions or visual impairment involves testing color filters that can
chorioretinal cracks, choroidal neovascularization, and optimize vision while reducing the risk of glare. The
more (Fig. 5).6 The choroidal peripapillary and sub-foveal analysis of lighting environments at work and at home, the
thinning, scleral thinning, and irregular deformations of elimination of sources of glare, and the addition of
the eyeball have been associated with various lesions in spotlights can help highly myopic people in achieving their
the case of high myopia. Given the increasing prevalence daily tasks.
of high myopia, pathologic myopia (retinopathy and
different categories of maculopathy7) is likely to increase 3. Specificities of refraction in high myopia
dramatically in the coming decades. Therefore, the
detection of pathological changes should be evaluated In the case of high myopia, it is important to practice
early. Using advanced imaging technology could help comprehensive measurements of visual functions and to
identify people at risk and help in the management and prioritize those functions that are the most impacted (e.g.,
monitoring of high myopia. visual acuity, contrast sensitivity, glare, etc.). Attention
should be paid to day-to-day situations in which patients
Beyond choroidal neovascularization and macular experience discomfort (low and bright lights, night vision,
degeneration, high myopia has also been associated with etc.). The refraction of high myopia requires special
the risk of other eye diseases, including glaucoma.8 precautions12, especially complete control of the distance
Regarding cataracts and the potential association between the glass and the eye (Fig. 6). It is therefore
with high myopia, the results diverge depending on the preferable for the prescription to be filled, or at least
study.9 Overall, high myopia is a major cause of visual finalized, with trial frames. The lenses should be placed
impairment worldwide.10, 11 near the eye and, if possible, to the rear of the trial frame to
ensure the closest simulation of the conditions in which the
2.2. Management of visual impairment final frames will be worn. If the prescription is of a very high
Pathological or not, high myopia often leads to significant power and is beyond the capabilities of the refractor or
visual impairment. Magnification needs thus become the trial lenses, the refraction will be carried out over the

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CLINIC

Defocalization

FIG. 6 V
 ariation in the correction of myopia with the vertex distance (d). The lens movement from L0 to L1 causes defocusing. The focal length of the corrective
lens becomes ƒ´L1 > ƒ´L0. To compensate myopia, the power should be decreased if the lens is closer to the eye.

patient’s current glasses (over-refraction technique) with an To remember:

additional lens support placed on the patient’s frames.
A person with high myopia often suffers from relatively low A variation of 4 mm of the vertex distance requires an
visual acuity and is therefore not very sensitive to small adjustment of the prescription according to the values ​​
variations of sphere and a cylinder of 0.25 D; 0.50 D shown in the table below. It is therefore imperative to
variations will thus be preferred during examination. As with take into account small changes in vertex distance
any conventional refraction13, it can be started with starting at 10.00 D. In the absence of such precision,
measurements from the autorefractometer’s refraction or the correction is assumed to be determined for an
the prescription previously worn by the patient. To determine eyeglass positioned 12 mm away from the eye. Ideally,
the sphere the fogging method can be used, with a high fog the prescriber will indicate the distance at which the
(+2.50 D) and larger increments of 0.50 D. To confirm the refraction was established on the prescription.
axis and the power of the astigmatism, a ± 0.50 D cross
cylinder will be more efficient than a ±  0.25  D cross
cylinder. Corrective Vertex variation Effect
power Power variation
A very important aspect of the refraction of high refractive
errors is the inclusion of the vertex distance: it  can 10.00 D 4 mm 0.50 D
significantly alter the value of the prescription. The closest
the lens is to the myopic eye, the lesser its power needs to 15.00 D 4 mm 1.00 D
be concave; the principle is to always match the lens’
image focal point with the far point of the eye (Fig. 6). A 20.00 D 4 mm 1.50 D
person with -20.00 D myopia with a prescription based on
a 12 mm vertex distance will thus need a prescription of
-19.25 D if the lens is placed at 10 mm and of -20.75 D close to the patient’s eyes and, if possible, with offset
if it is placed at 14 mm. joints that reduce the size of the lenses and ensure proper
distribution of the lenses around the eyes. The optician
Conversely, presbyopic people with high myopia can help will adjust it to ensure that the lens is perpendicular to the
their near vision by creating an additive effect by simply direction of the gaze when the eye is in its primary position.
pushing their glasses farther away: for example, a person The choice of the frame will also take into account the
with -20.00 D myopia who pushes his or her glasses away insertion height of the temples in the frame front according
by 4 mm thus creates an addition of about 1.50 D. to the frame position on the nose and the ears; the temples
will be adapted accordingly. Before measuring the right
4. The importance of frame choice and left pupillary distances and heights, the final frame
is to be perfectly adjusted to the patient’s face. Finally,
The choice of frames is especially important with high the vertex distance will be systematically measured or
myopia. The frame should be small to allow its positioning otherwise evaluated in order to confirm the refraction.

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38 Number 73 - Autumn 2016
es branches sur la face prenant Notons aussi que les faces avant de ces verres étant
le sommet du sillon auriculaire très plates, les reflets générés sont grands et très visi-
et le profil des branches sera bles et il s’avère indispensable, dans la mesure où cela
vant toute mesure de centrage est techniquement réalisable, que leurs surfaces soient
laires –, elle sera parfaitement traitées antireflet.

CLINIC
atient. Enfin, pour confirmer la
re-œil sera systématiquement
uée.

iaux » pour

oins des forts myopes, les fabri-

es qui leurs sont spécialement
diés pour réduire l’épaisseur au
ment une gamme de puissance
unifocaux et -25,00 D en verres
chniques sont successivement
es pour réduire l’épaisseur au FIG. 7 Special lenses for high myopia.

ce de réfraction entraîne l’apla-

5. Special
res, ce qui permet lenses for
d’amincir lehigh myopia
mple, de réaliser avec un maté- Figure 2. Verres « spéciaux » pour forts myopes.
To meet the needs of high myopia, manufacturers offer that is often far enough to the side so as to avoid hindering
special lenses designed to reduce the edge’s thickness, the wearer whose lenses are placed close to the eye.
commonly covering a power range of up to -40.00 D in The higher the power of the prescription, the more the
single vision and -25.00 D for progressive lenses. Different central optical zone
n° 199 •isAvril
reduced
2016 (30, 25 and 20 mm) in
techniques are used, sequentially or simultaneously, to order to achieve prescriptions of up to -40.00 D (Fig. 7f).
reduce the thickness at the edge of the lens (Fig. 7):  an For such a power, one can opt for bi-concave lenses whose
increase of the refractive index causes the flattening of the power is negative on both sides and can achieve extreme
two surfaces, thereby thinning the lens’ edge; for example, power that can even exceed -100 D with a bi-concave and
with an n = 1.67 index material, a -15.00 D lens can have bilenticular lens!14
a thickness that is close to that of a -10.00 D lens made​​ The front faces of these lenses are very flat, generating
of a classic material with an n = 1.50 index (Fig. 7a and lots of reflections that are very visible; it is therefore
b); the reduction of the optical aperture or a “lenticular” indispensable for their surfaces to be treated with antiglare
lens will allow the thickness to be reduced even more (anti-reflective) coating as long as it is technically feasible.
significantly. It involves the creation of a facet at the rear
edge of the lens, which divides the lens into two parts – a 5.1. Concave lenticular lenses
central, “optical” zone and a peripheral “facet” – and In order to achieve a high power lens with great aesthetics,
considerably improves aesthetics (Fig. 7c to e). This facet manufacturers are producing so called “lenticular” lenses.
can be optically concave (negative power), plano (no They are composed of a central optical zone and a non-
power) or convex (positive power), according to the desired corrective annular zone on the periphery, called the facet.
thickness reduction (Fig. 7c, d, e). Moreover, the These two zones can be either separate, with a  visible
smoothing of the edge (Fig. 8) improves aesthetics and edge separation, or continuously connected via the
minimizes the image’s doubling effect at the limit of the smoothing of this edge (Fig. 8).
optical zone. It nevertheless creates a blurred vision zone

Facet

Edge

Optical zone
Concave
Concaveglass lenswith
glass lens with
concave edge facet and
Concave glass lens with convex Sharp edge Smoothed edge
concave edge facet and
smoothed edge
edge facet smoothed edge
FIG. 8 Concave lenticular lens

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Lenticular lenses: optimum diameter of the optical zone

The goal of using lenticular lenses is to reduce the thickness of the lenses without limiting the visual comfort of the
wearer. Indeed, optical apertures that are too small hinder visual comfort. Conversely, optical apertures that are too
big unnecessarily increase thickness. To manage this compromise, it is useful to determine the optimum diameter for
the optical zone.
The visual comfort is linked to the angular object field available behind the lens, which typically needs to be +- 30°
for the central optical field. Depending on the wearer’s individual habits, it is necessary to consider a certain margin
when defining this central optical field.
Once determined, the target object half-field, the diameter of the useful optical zone, can be calculated. It is
a function of the distance of the lens to the eye’s center of rotation to the lens (LQ’) and the power of the lens P.
The results are summarized in Table I.
The temporal field is the most compelling: in case of astigmatism, the P power to be used for the calculation is the
power of the 0°-180° meridian.

Space perceived by the eye through a concave lens:

increased ½ apparent field ω
Diameter of the optical area

C.Franchi nov.2015

Lens Power (P) -10.00 -15.00 -20.00 -25.00 -30.00 -40.0

Ø ZO with ω = 30° 23 21 19 18 16.5 14.5

Ø ZO with ω = 40° 33.5 30.5 28 26 24 21

Ø ZO with ω = 45° 40 36 36 31 28.5 25

Ø ZO with ω = 50° 48 43 40 36.5 34 30

Table I. Diameter that has to be given to the optical zone (ZO) depending on the lens power (P) to get an object
half-field of ω.

6. Vision of a person with high myopia that has been -20.00 D myopia, who would apparently accommodate to
corrected with ophthalmic lenses 5.00 D to focus at an object 20 cm from his or her glasses,
actually accommodates to approximately 3.10 D if the
During the optical correction of high myopia, several lens is placed at 12 mm from the eye. Similarly, although
specific optical phenomena occur.15, 16 They can be it seems as though such patients converge substantially to
summarized as follows: look 20 cm away, their convergence effort is actually
much less due to the basic internal prismatic effects
6.1. Lesser accommodation and lesser convergence provided by their lenses at near vision.
Through his or her ophthalmic lenses, a highly myopic
person will accommodate and converge less than would an 6.2. Reduced visual acuity
emmetropic or hyperopic person and less than if fitted With high myopia, the vertex distance causes a minification
with contact lenses. Indeed, the vertex distance plays effect (reduction in size) in both the images seen by
a significant role, and its effects are all the more significant wearers through their lenses and the wearer’s eyes as seen
when the power is strong. For example, a person with by other people. Due to this reduction in size, wearers with

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40 Number 73 - Autumn 2016
 CLINIC
1
M=
1-dxP

FIG. 9 Calculation of the lens’ minification effect (left) and perceived reduction of eyes’ size in highly myopic wearers (right).

high myopia usually have significantly lower visual acuity 6.3. Peripheral image duplication
with ophthalmic lenses than with contact lenses. The Image duplication occurs at the edge of lenses with strong
minification effect, mainly caused by the vertex distance, negative power. Indeed, the last beam of light passing
is given by the following formula: through the lens is refracted towards the outside and the
first external beam of light on the outside of the lens is not
M = 1 / (1 – d x P) refracted. The same object is thus seen twice, once sharply
within the lens and once blurred on the outside of the
where d = vertex distance and P = power of the lens (Fig. lens. For the wearer, this means that the peripheral image,
9). or its perception, is doubled at the edge of the lens (or the
edge of the central optical zone), especially if the edge of
For example, for a -20.00 D lens placed at 12 mm, the the frame is thin or missing (rimless frames or those with
minification effect is about 20%. Accordingly, if a a nylon thread).
patient’s maximum acuity was 20/20 with contact lenses,
it may only be 20/25 with eyeglasses simply due to this 6.4. Phenomenon of the myopic rings
optical effect. That is one reason why opticians should One of the particularities of the correction of high myopia
always seek a frame that is positioned closer to the with ophthalmic lenses is the emergence of unsightly
patient’s eyes to minimize this effect as much as possible. rings on the periphery of the lens, which are more visible
As it has already been reminded, it is imperative to validate when looking at the wearer sideways. These rings are
refraction specifically for that particular vertex distance. the images at the edge of the lens reflected multiple times
on the  front and back of the lens. Polishing the lens
edge  and/or reducing the optical aperture considerably
To remember: decreases them.

• The magnification/minification effect changes with 7. The convenience of special lenses for high myopia
the vertex distance.
• The closer the lens is to the eye, the weaker the Surgical treatment or contact lenses cannot be used for all
effect is. highly myopic patients, and ophthalmic lenses are still
• Effect on visual acuity: VA is lower with eyeglasses relevant for high myopia. A wide range of lenses with
than with contact lenses for someone with high powers commonly reaching -40.00 D in single vision
myopia. lenses and -25.00 D in progressive lenses are available,
and the technical know-how of the lens manufacturer
can go even further. Recently, a record -108.00 D myopia
Minification Vertex distance Minification was corrected with ophthalmic lenses by an alliance of
effect for a lens (mm) effect for a lens French-Slovak experts.17 With careful, precise imple-
power -10.00 D power -20.00 D mentation by the optician, the wearer benefits from a
comfortable visual experience. These special lenses,
0.909/-9.3% 10 mm 0.833/-16.7% meant for extreme prescriptions, remain insufficiently
known of and used by eye care professionals, and would
0.893/-10.7% 12 mm 0.806/-19.4% be of great service to the highly myopic population, which
continues to grow in numbers.
0.877/-12.3% 14 mm 0.781/-21.9%

0.762/-13.8% 16 mm 0.757/-24.3%

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Number 73 - Autumn 2016 41
CLINIC

8. Conclusion

The number of young and old people with high myopia will
increase in the future. Their care requires precise
measurement of several visual functions and under various KEY TAKEAWAYS
conditions in order to understand the origin of their
discomfort. It is also necessary to carefully study all the
parameters affecting the final refraction, from the visual • The specific needs of highly myopic people require
exam to the adaptation of the optical equipment. Moreover, special attention from visual health specialists.
it seems imperative to study the difficulties patients
encounter in their entirety in order to offer comprehensive, • The main discomforts of those with high
multidisciplinary care. • myopia include:
- Reduced visual acuity
- Reduced sensitivity to contrast
- Deteriorated vision thresholds under low
REFERENCES
1. Holden B, Fricke T, Wilson D, et al. Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000
and bright lights
through 2050; Ophthalmology, 2016. - Elongation of recovery time after glare
2. Rose K, Harper R, Tromans C. Quality of life in myopia, Br. J. Ophthalmol, 2000.
3. Jaworski A, Gentle A, Zele AJ, Vingrys AJ, McBrien NA, Altered Visual Sensitivity in Axial High Myopia: A Local
- Decline in quality of life and social impact.
Postreceptoral Phenomenon?, Investigative Ophthalmology & Visual Science, 2006.
4. Mashige K, Night vision and glare vision thresholds and recovery time in myopic and hyperopic eyes; African Vision
and Eye Health 2010, S Afr Optom. • High myopia is often associated with risks
5. Verkicharla PL, Ohno-Matsui K, Saw SM. Current and predicted demographics of high myopia and an update of its
associated pathological changes, Ophtalmologic & physiological optics. 2015
of high visual impairment and eye diseases such
6. Wong TY et al. Epidemiology and disease burden of pathologic myopia and myopic choroidal neovascularization: as retinopathy and maculopathy (staphylomas,
an evidence-based systematic review. Am J Ophthalmol, 2014.
7. Ohno-Matsui K, Kawasaki R, Jonas JB et al. International photographic classification and grading system for myopic
atrophic lesions, chorioretinal cracks, choroidal
maculopathy. Am J Ophthalmol, 2015.
neovascularization, macular degeneration,
8. Morgan IG1, Ohno-Matsui K, Saw SM. Myopia. Lancet. 2012 May 5; 379 (9827): 1739-48.
9. Pan CW, Cheng CY, Saw SM, Wang JJ, Wong TY. Myopia and age-related cataracts: a systematic review and meta-
glaucoma, etc.).
analysis. Am J Ophthalmol. 2013 Nov; 156(5): 1021-1033.

• The refraction of high myopia requires special

10. Iwase A, Araie M, Tomidokoro A, Yamamoto T, Shimizu H, Kitazawa Y; Tajimi Study Group. Prevalence and causes of
low vision & blindness in a Japanese adult population: the Tajimi Study. Ophthalmology. 2006 Aug; 113(8): 1354-62.
11. Wu L, Sun X, Zhou X, Weng C. Causes and three-year incidence of blindness in Jing-An District, Shanghai, China
2001-2009. BMC Ophthalmol. 2011 May 5; 11:10.
precautions, comprehensive measures of visual
12. Franchi C, Meslin D. L’équipement optique du fort myope en verres ophtalmiques, Les Cahier d’Ophtalmologie,
no. 199, April 2016.
functions and the inclusion of the vertex distance.
13. Réfraction pratique, Cahiers d’optique oculaire, Essilor Academy, 2008.
14. Un record pour Essilor: une prescription de -104 dioptres. Les Cahiers d’Ophtalmologie, no. 188, 2015. • The optical equipment of those with high myopia
15. Corbé JP, Menu G, Chaine, Traité d’optique physiologique et clinique. Chapter 8.2. Vision de l’amétrope corrigé par
verres de lunettes, Paris, Doin, 1993. should be tailored to their needs. The practitioner
16. Roth A, Gomez A, Péchereau A, La réfraction de l’œil: du diagnostic à l’équipement optique, Paris, Elsevier-Masson,
2007.
will choose an appropriate frame and opt for
17. Chrien S et al., Record-high myopia solved by an alliance of experts: -108.00 D, Points de Vue, International Review special lenses in a range dedicated to high myopia.
of Ophthalmic Optics, www.pointsdevue.com, 2016.

Points de Vue - International Review of Ophthalmic Optics

42 Number 73 - Autumn 2016
 A large body of market
MARKET
WATCH
research shows alarming
data on myopia
development around the
world. These trends raise
important questions on the
implications for planning
comprehensive eye care
services, improving
practitioner and patient
education and anticipating
a reduction of the myopia
burden.

P.44What do the myopia trends

predict for the future?
P.49Is myopia a growing health
issue? Why is it so?

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43 Number 73 - Autumn 2016
MARKET WATCH
M Y O P I A:
A P U B L I C H E A LT H C R I S I S
IN WAITING
The prevalence of myopia and high myopia is on the rise across the world.
Recent work from the Brien Holden Vision Institute esti­mates that by 2050, five billion
(50%) people will be myopic, one billion (10%) highly myopic. This may have important
implications for planning comprehensive eye care services, including refractive ser­vices
such as spectacles and contact lenses for correcting and slowing myopia progression.
Optical and environmental interventions can help in preventing and managing high
myopia related ocular complications and reduce the burden of myopia.

Dr. Monica Jong Prof. Padmaja Sankaridurg Prof. Kovin Naidoo

B. Optom, PhD Program Leader, Myopia CEO, Brien Holden Vision
Senior research fellow, Brien Program at the Brien Holden Institute, Australia. OD, MPH,
Holden Vision Institute, Australia. Vision Institute, Australia. PhD, FAAO, FCOptom(Hon)

Doctor Monica Jong is a senior research Prof. Padmaja Sankaridurg is Program An academic, researcher, educator and
fellow at the Brien Holden Vision Institute Leader, Myopia Program at the Brien internationally celebrated public health
and her clinical research is focussed on Holden Vision Institute. She was awarded leader, Prof. Kovin Naidoo has been
myopia control and high myopia. her B.Opt degree from the Elite School of revolutionising access and delivery to eye
She received her optometry degree and Optometry, Chennai, India in 1989, Ph.D care for the disadvantaged throughout the
PhD from the University of Melbourne, in 1999 from the University of New South world. A powerful public health advocate,
and her thesis examined the relationship Wales, Australia and MIP in 2012 from he has devoted his working life to reducing
between retinal structure and retinal University of Technology, Australia. After avoidable blindness and vision impairment,
function in retinitis pigmentosa using OCT. working for a number of years at the L.V. with specific emphasis on refractive error.
She was also the recipient of the David and Prasad Eye Institute, India as the Chief
Sandra Smith Fellowship which allowed her of Contact Lens Services, she took up a Professor Naidoo is the CEO of the Brien
to pursue her postdoctoral studies in ocular position at the Brien Holden Vision Institute Holden Vision Institute and Chairperson of
blood flow imaging in Type 2 diabetes (formerly the Institute for Eye Research) the International Agency for the Prevention
at the Department of Ophthalmology, and the Vision Cooperative Research of Blindness (Africa), Associate Professor
University Health Network, University of Centre. of Optometry at the University of KwaZulu-
Toronto. Some of Monica’s activities at the She is also a Conjoint Professor at the Natal (UKZN), and Adjunct Faculty at Salus
Brien Holden Vision Institute include School of Optometry and Vision Science, University in Philadelphia. He is also a
managing the analysis of the Zhongshan University of New South Wales, Australia. Vision Impact Institute advisory board
Opthalmic Center (ZOC) and BHVI high She has been actively researching myopia member.
myopia database in China, advocating for for approximately 12 years. In addition, she He has published extensively in
the recognition of high myopia as a cause is also involved in post graduate supervision epidemiology and public health.
of blindness through her role in the and manages the Intellectual Property
International Agency for the Prevention of portfolio of the Institute. She has over
Blindness (IAPB). 50 articles in peer reviewed journals.

KEYWORDS
myopia, high myopia, vision impairment, myopic macular degeneration,
myopia control, myopia management, public health issue

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44 Number 73 - Autumn 2016
 MARKET WATCH
“ The econo mic b ur d en o f unco r r ected
dist ance refr active er r o r was es timated
t o be U S$ 2 0 2 b illio n p er annum,
of which my o p ia is the main caus e. ”

I
n recent times, the issue of myopia has featured heavily High myopia (≤ - 7.90 D) in the USA has already increased
in mainstream media with headlines such as “the 8-fold over 30 years from 0.2% to 1.6%.4 In 18-year-old
myopia boom”1 and “night time contact lenses stop Taiwanese students, 21.0% had high myopia (≤ -6.00 D)
children becoming short-sighted”.2 The growing concern in 2000 compared with 10.9% in 1983.6 Globally in
surrounding myopia has already led to governments in 2000, most people with myopia were below age 40, and
some parts of the world taking measures to ameliorate this little myopia was seen in those over 40. By 2030, the
problem. In Taiwan, a law was passed “banning too much prevalence of myopia is projected to be approximately
screen time,” and public health campaigns in Singapore 50% for all age groups above 20 years, and by 2050 to
encouraged children to spend more time outdoors. Given 68%7 (Fig. 2). Regions with traditionally little myopia,
these messages, we may be left wondering about the size such as Eastern Europe and Southern Africa will also see
of the burden of myopia, and the strategies and/or a large shift towards myopia in the near future, approaching
solutions required to reduce it. prevalences of 50% and 30% by 2050. This is likely due
to lifestyle changes as a result of urbanisation and
development (Fig. 3).3
The size of the problem
Recent work from the Brien Holden Vision Institute What are the consequences?
estimates that the prevalence of myopia (≤ -0.50 D) will Uncorrected refractive error is the leading cause of
increase worldwide, from 28% (2 billion) of the global distance vision impairment globally, affecting 108 million
population in 2010, to nearly 50% (5 billion) of the world people, and is the second most common cause of global
population by 2050. As a consequence, the prevalence of blindness.8 The economic burden of uncorrected distance
high myopia (≤ -5.00D) is also likely to increase from 4% refractive error was estimated to be US$202 billion per
(277 million) in 2010, to nearly 10% (1 billion) by the annum, of which myopia is the main cause.9 With the
year 2050.3 Figure 1 illustrates the prevalence of myopia rising prevalence of myopia, the economic burden of
and high myopia from 2000 through to 2050. uncorrected refractive error associated with myopia will
rise. In addition, myopia is associated with ocular
The shift towards myopia complications such as myopic macular degeneration,
The shift towards myopia has been rapid in some parts of retinal detachment, cataract and glaucoma, which impose
the world, such as the USA, where the prevalence of a significant health and economic burden. Myopic macular
myopia increased from 26% to 42% from 1972 to 2004.4 degeneration is already a frequent cause of vision
In Singapore, the prevalence of myopia was 47% in adults impairment in Japan,10 China,11 Netherlands12 and
in their 20s, and 26% in adults in their 50s.5 Denmark13. It is important to note that any level of myopia

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5 000 49.8%
Myopia
4 500
High Myopia 45.2%

Number of people (in millions)

4 000
3 500 39.9%

3 000
34.0%
2 500
28.3%
2 000
22.9%
1 500
9.8%
1 000 7.7%
6.1%
5.2%
500 4.0%
2.7%
0
2000 2010 2020 2030 2040 2050
Year

FIG. 1 T
 he estimated global prevalence of myopia and high myopia per decade from 2000 to 2050 based on
current trends. The number of people in millions is listed on the y-axes. Adapted from Holden et al.3

2000 2010 2020 2030 2040 2050

70,0
65,5 65,7 65,3
63,6
62,2
60,7 59,8 59,8
60,0

50,0

40,0
Prevalence (%)

30,8
30,0

20,0

10,0

0,0
10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80 to 89 90+

Age groups

FIG. 2 T
 he global generational shift in myopia indicates that in the earlier decades of 2000 up to 2030, the majority of myopia is occurring in
those under forty years with little myopia seen in those over forty. After 2030, the prevalence of myopia will be affecting all age groups.
Adapted from Holden et al.3

70
66,4
65,3 2000 2030 2050
62

60 58,4
56,2
55,1
54,1 53,4
52,2 53
51,7
50,7 50,4 50,7
50 47,4

40
Prevalence %

30,2
30 27,9
26,8
23,8
22,7

20

10

FIG. 3 The increasing prevalence of myopia estimated across the world from the year 2000 to 2050. Modified from Holden et al. 2016.3

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46 Number 73 - Autumn 2016
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“ The fut ure es timates o f my o p ia, s ug g es t
t hat at leas t o ne b illio n p eo p le ar e
pot ent ially at r is k o f d evelo p ing p er manent
vision impairment and b lind nes s as s o ciated
with hig h my o p ia”

increases the risks of the above mentioned problems Future needs

compared to emmetropes, but the risk increases An effective myopia management strategy that combines
exponentially once you reach high myopia.14 For myopia of the individual’s needs, based on their risk profile (for
-5.00 D to -7.00 D, the risk of glaucoma is 3.3 times example, age, lifestyle, familial history), and matched to
higher, the risk of cataract is 5.5 times higher, the risk of the appropriate intervention strategy is required to reduce
retinal detachment is 21.5 times higher, and the risk of the burden of myopia, both at the individual and the
myopic macular degeneration is 40.6 times higher.14 The community level. Recognising the need, the World Health
future estimates of myopia suggest that at least one billion Organisation (WHO) convened a Global Scientific Meeting
people are potentially at risk of developing permanent on Myopia in collaboration with the Brien Holden Vision
vision impairment and blindness associated with high Institute in Sydney, Australia in 2015. At this forum,
myopia.15 leading experts in myopia met to examine the latest
evidence, identify gaps in knowledge, and define policies
Strategies to manage the burden for the management of myopia. It is expected that this
Both environmental and genetic factors are thought to report will be published soon and will provide myopia
contribute to the onset and progression of myopia, but it management guidelines for governments, industry, health
has been suggested that environmental factors have a care workers, and practitioners.
larger role to play in the rapid increase in the prevalence
of myopia. A heavily indoor and near-activity based Conclusion
lifestyle16,17, with less time outdoors18, combined with Close to five billion and one billion people will be affected
the intense education commencing at very young ages, by myopia and high myopia respectively by 2050. This will
as is occurring in many East Asian countries, are major have important implications for planning comprehensive
contributing factors.16 eye care services, including refractive services such as
spectacles and contact lenses for correcting and slowing
Evidence is now growing to support the use of interventions myopia progression, as well as preventing and managing
in slowing myopia progression. Optical interventions that high myopia related ocular complications. The optical
modulate the visual feedback and environmental industry also has a key role to play in education,
interventions promoting increased outdoor time can developing, and supporting appropriate myopia
successfully delay and slow the progress of myopia in an management strategies to help reduce the burden of
individual. Optical strategies shown to slow the progress myopia. •
of myopia include ortho-K (30% to 57%)19,20, multifocal-
type soft contact lenses (25% to 72%)20, and executive More information
bifocals (39% to 51%).21 Progressive addition spectacles For further details, “Global Prevalence of Myopia and High
are limited to 15% to 20.21 Time outdoors has successfully Myopia and Temporal Trends from 2000 through 2050”
reduced the number of new cases of myopia by up to is available via open access at http://www.sciencedirect.
50%, and can effectively delay the onset of myopia, com/science/article/pii/S0161642016000257.
but its ability to slow the rate of progression of myopia
is not clinically significant.22,23 In addition, certain
pharmaceutical approaches have also shown promise, with
low dose atropine (0.01%) slowing the progress of myopia
by almost 59%.24 The long term effects of atropine use are
not yet clear.

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Number 73 - Autumn 2016 47
MARKET WATCH

REFERENCES
1. Dolgin E. The myopia boom. Nature 2015;519:276-8.
2. Knapton S. Night time contact lenses stop children becoming short-sighted. In: Telegraph T, ed.2015.
3. Holden BA, Fricke TR, Wilson DA, et al. Global Prevalence of Myopia and High Myopia and Temporal Trends
from 2000 through 2050. Ophthalmology 2016.
4. Vitale S, Sperduto RD, Ferris FL, 3rd. Increased prevalence of myopia in the United States between 1971-
1972 and 1999-2004. Archives of ophthalmology 2009;127:1632-9.
KEY TAKEAWAYS
5. Pan CW, Dirani M, Cheng CY, Wong TY, Saw SM. The age-specific prevalence of myopia in Asia: a meta-
analysis. Optometry and vision science : official publication of the American Academy of Optometry
2015;92:258-66.
6. Lin LL, Shih YF, Hsiao CK, Chen CJ. Prevalence of myopia in Taiwanese schoolchildren: 1983 to 2000.
Annals of the Academy of Medicine, Singapore 2004;33:27-33. • The prevalence of myopia and high myopia is on the
7. Wilson DA, Jong M, Sankaridurg P, Fricke TR, Resnikoff S, Naidoo K. A global generational shift in myopia.
Association for Research in Vision and Ophthalmology. Seattle, USA2016. rise across the world.
8. Bourne RR, Stevens GA, White RA, et al. Causes of vision loss worldwide, 1990-2010: a systematic analysis.
The Lancet Global health 2013;1:e339-49.
9. Fricke TR, Holden BA, Wilson DA, et al. Global cost of correcting vision impairment from uncorrected refractive
error. Bulletin of the World Health Organization 2012;90:728-38. • Estimates suggest that by 2050, five billion (50%)
10. Iwase A, Araie M, Tomidokoro A, et al. Prevalence and causes of low vision and blindness in a Japanese
adult population: the Tajimi Study. Ophthalmology 2006;113:1354-62.
11. Wu L, Sun X, Zhou X, Weng C. Causes and 3-year-incidence of blindness in Jing-An District, Shanghai,
people will be myopic, one billion (10%) highly myopic.
China 2001-2009. BMC ophthalmology 2011;11:10.
12. Verhoeven VJ, Wong KT, Buitendijk GH, Hofman A, Vingerling JR, Klaver CC. Visual consequences of
refractive errors in the general population. Ophthalmology 2015;122:101-9.
13. Buch H, Vinding T, La Cour M, Appleyard M, Jensen GB, Nielsen NV. Prevalence and causes of visual
• Increasing myopia is associated with increased risk
of sight threatening complications such as myopic
impairment and blindness among 9980 Scandinavian adults: the Copenhagen City Eye Study. Ophthalmology
2004;111:53-61.
14. Flitcroft DI. The complex interactions of retinal, optical and environmental factors in myopia aetiology.
Progress in retinal and eye research 2012;31:622-60. macular degeneration, glaucoma and cataracts.
15. Holden BA, Jong M, Davis S, Wilson D, Fricke T, Resnikoff S. Nearly 1 billion myopes at risk of myopia-
related sight-threatening conditions by 2050 - time to act now. Clinical & experimental optometry :
journal of the Australian Optometrical Association 2015;98:491-3.
16. Morgan IG, Ohno-Matsui K, Saw SM. Myopia. Lancet 2012;379:1739-48.
17. Lim LT, Gong Y, Ah-Kee EY, Xiao G, Zhang X, Yu S. Impact of parental history of myopia on the development
• There is evidence that optical and environmental
of myopia in mainland china school-aged children. Ophthalmology and eye diseases 2014;6:31-5.
18. Jones LA, Sinnott LT, Mutti DO, Mitchell GL, Moeschberger ML, Zadnik K. Parental history of myopia, sports
interventions can slow the progress of myopia and
reduce the burden of myopia.
and outdoor activities, and future myopia. Investigative ophthalmology & visual science 2007;48:3524-32.
19. Si JK, Tang K, Bi HS, Guo DD, Guo JG, Wang XR. Orthokeratology for Myopia Control: A Meta-analysis.
Optometry and vision science : official publication of the American Academy of Optometry 2015;92:252-7.
20. Huang J, Wen D, Wang Q, et al. Efficacy Comparison of 16 Interventions for Myopia Control in Children:
A Network Meta-analysis. Ophthalmology 2016;123:697-708.
21. Cheng D, Woo GC, Drobe B, Schmid KL. Effect of bifocal and prismatic bifocal spectacles on myopia
progression in children: three-year results of a randomized clinical trial. JAMA ophthalmology 2014;132:258-64.
22. Wu PC, Tsai CL, Wu HL, Yang YH, Kuo HK. Outdoor activity during class recess reduces myopia onset and
progression in school children. Ophthalmology 2013;120:1080-5.
23. He M, Xiang F, Zeng Y, et al. Effect of Time Spent Outdoors at School on the Development of Myopia Among
Children in China: A Randomized Clinical Trial. JAMA : the journal of the American Medical Association
2015;314:1142-8.
24. Chia A, Lu QS, Tan D. Five-Year Clinical Trial on Atropine for the Treatment of Myopia 2: Myopia Control
with Atropine 0.01% Eyedrops. Ophthalmology 2015.

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48 Number 73 - Autumn 2016
 MARKET WATCH
MYOPIA RISE AND VISION
H E A LT H I S S U E S L E F T I N
ITS WAKE

Myopia continues to be a growing problem around the world.

A recent study1 predicts that by 2050 about half of the world’s population will be myopic.
While genetics plays a role, researchers point to the increasingly digital lifestyles
of young people as one culprit of the epidemic.
The sheer volume of this vision impairment will have consequences not only for those
with it, but also for the communities and nations where they live, work or go to school.

A
s our world grows and develops, our vision is getting
worse. That’s the takeaway from an important body
of research data about the world’s vision, with a
laser focus on myopia and its impact.

The statistics are alarming – myopia is projected to affect

almost half of the world’s population by 2050.1 The
consequences are just as unsettling, as myopia, when
Maureen Cavanagh left uncorrected, can lead to severe vision impairment and
President of the Vision Impact Institute, even blindness. By mid-century, nearly five billion will
USA have the vision impairment with about one billion suffering
from high myopia. In the United States and Canada, the
Maureen Cavanagh is the president of the Vision Impact number of myopic is estimated to climb to 260 million, or
Institute. She joined Essilor in 2005 and has held various close to half of the population, up from 89 million in
executive leadership positions within the company. 2000; and high myopia cases jump an astounding five
Cavanagh has extensive experience in vision healthcare,
times to 66 million by that year.1
having worked for Johnson & Johnson’s Vistakon and
Spectacle Lens divisions before joining Essilor. Cavanagh
earned her bachelor’s degree from Bridgewater State
These are part of the findings of a meta-analysis by the
University. She has received numerous industry awards, Brien Holden Vision Institute of 145 studies covering 2.1
including the Optical Women’s Association (OWA) million people.1 Also known as nearsightedness, myopia is
Pleiades Award in 2015 and Jobson’s Most Influential a refractive error that causes items close by to be seen
Women in Optical 2012. Cavanagh was appointed distinctly while distance vision is blurry. High myopia is a
President of the OWA in July 2016. severe form in which the eyeball becomes too long and
can lead to retinopathies or even retinal detachment.

Young people are becoming myopic at an alarming rate in

many countries – insuring that they will have a lifetime of
www. visionimpactinstitute.org
blurry vision unless they get the aid of optical prescription
(eyeglasses, contact lenses, ortho-k) or have refractive
surgery. This will have long-term consequences for public
health around the globe, especially in less-developed
regions where healthcare delivery is more challenged.

KEYWORDS
Myopia, myopic, blindness, vision impairment, eye disease,
digital eye strain, digital screen(s), public health, Asia

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Myopia epidemic in parts of Asia

2000 2050 Research indicates there are regional variations in the

prevalence of myopia. Asia – the world’s largest and most
1.4 billion 4.8 billion populous continent – is perhaps where its impact is more
widespread. And East Asia – comprised of China, Japan,
Myopia Hong Kong, Mongolia, North Korea, South Korea and
22.9 percent of 49.8 percent of
world population world population Taiwan – is experiencing an epidemic with reports as high
as 40 percent in Japan and 50 percent in Taiwan.2 The
prevalence of myopia is more than two times higher among
163 million 938 million East Asians than white people of the same age.2
High Myopia
2.7 percent of 9.8 percent of China is especially hard hit. As it is the most populous
world population world population country on Earth, it also has the largest population with
vision defects. The results of the recent domestic white
TAB Myopia estimates1
paper on China’s National Vision Health, (conducted by
Prof. Li Ling, Head of the China Center for Health
“Two things are extremely worrying about these Development) are alarming. In 2012, close to 500 million
projections,” said Professor Kovin Naidoo, CEO of the people over the age of five had an uncorrected visual
Brien Holden Institute and Vision Impact Institute advisory defect in China, among which 450 million had myopia. By
board member. “First, the accelerated growth of cases of 2020, nearly 700 million people are expected to have
myopia is incredible, which speaks to how our contemporary myopia in China – twice the population of the United
lifestyles are affecting our behavior. And second is that States. Undeniably, there is a huge increase from 60 years
people with myopia, especially high myopia, are at higher ago when the country was still isolated from the global
risk to develop other vision disorders that can lead to economy and only 10-20 percent of its population had
blindness.” myopia.2

He said that 1 in 10 people worldwide will be at risk for A comparative study of six- and seven-year-old students of
permanent blindness by the year 2050, as high myopia Chinese ethnicity in Singapore and Sydney had interesting
especially increases the risk of cataracts, glaucoma, results when it explored the prevalence of myopia among
retinal detachment and myopic macular degeneration – all the focus population and possible risk factor.4 The major
of which can cause irreversible vision loss. finding was that myopia was more prevalent in Singapore

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(29.1 percent) and significantly lower in Sydney (3.3 showed that African-Americans were significantly less
percent). Hereditary influences were about the same in likely to have myopia than whites.5
both locations: one or more parents reported having
myopia for 68 percent of the students in Sydney and 71 Lifestyle factors into the spread of myopia
percent in Singapore parents. The primary lifestyle
difference between the two student groups was that the Once thought to be only a matter of genetics, several of
children in Sydney spent more time outdoors each week the studies point to lifestyle and environmental con-
(average of 13.75 hours) than those in Singapore (3.05 siderations as contributing to the increasing occurrence of
hours on average). The researchers also hypothesized that myopia.
academic pressure in Singapore schools played a role in
the difference. According to the Brien Holden Institute meta-analysis of
myopia research data1, “The projected increases are
However, myopia is not limited to Asian nations. A widely considered to be driven by environmental factors
retrospective examination of 13 repeated prevalence (nurture), principally lifestyle changes resulting from a
studies analyzed data about the changing prevalence combination of decreased time outdoors and increased
of myopia over 13 years with Israelis from 16 to 22 near-work activities, among other factors.”
years old.5 The overall occurrence of myopia increased
significantly to 28.3 percent in 2002 from 20.3 percent Many researchers are pointing to the advent of digital
in 1990. The causes of this increase were not certain; devices in the past 30 years as contributing to the
however, evidence pointed to genetic as well as prevalence of myopia (due to short working distance).
environmental components, such as higher amounts of There are now more mobile devices in use around the
near work and more years of education. globe than there are people on the planet.7

Research shows similar results in the United States. One The Holden study points to the under-40 age group,
study compared myopia rates from 1971-72 to the period especially in Asia, as being extremely susceptible to
of 1999-2004, with the later period showing substantially myopia because of reliance on smartphones, personal
higher myopia rates than 30 years earlier.6 computers and related technology for communications,
entertainment, news and education.1
Some regions and ethnicities report very low rates of
myopia, such as among Australian Aborigines and Solomon The competitive education systems in Singapore, Korea,
Islanders, where occurrence was in the 2-5 percent range. Taiwan and China are another factor, according to the
And a comparative study of urbanites in the United States study, causing students to spend more time studying at

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“ Myopia will have lo ng - ter m co ns eq uences

for publi c health ar o und the g lo b e,
especially in les s - d evelo p ed r eg io ns wher e
healt hcare d eliver y is mo r e challeng ed . ”

computers. The comparative study of young students in impairment in 2007 at an estimated cost of more than
Sydney and Singapore also referred to this, noting the $269 billion per year.8
competitive academic environment of the island city-
state.4 Research from 2006 showed that more than 3.6 million
Americans suffered from visual impairment, blindness or
Socio-economic impact of myopia other eye diseases in 2004 – creating a financial burden
totaling $35.4 billion. And $8 billion of that total was loss
While the direct socio-economic impact of myopia has not of productivity. The annual impact to the U.S. government
been determined yet, the effect of poor vision on the budget was $13.7 billion.9
global economy is well documented. This myopia epidemic
creates a significant public health problem around the The National Medical Research Council of Singapore
world. The economic burden of uncorrected refractive commissioned a study of the economic cost of myopia. In
error (URE), largely caused by myopia, is estimated to be 2009, the mean annual direct cost of myopia for school-
more than $269 billion per year8, and that number will aged children in Singapore was $148 (U.S. dollars)
grow as the epidemic spreads. It is affecting developing annually, with the median cost at $125 (U.S. dollars) per
nations as well as the developed world. Actually, the Brien student.10
Holden study mentions that developed nations are seeing
a faster rise in myopia because of increased urbanization Public health consequences
and development, which usually means more digital
device use and higher education levels. This spreading myopia scourge will have a long-term
impact on public health and productivity around the world
The World Health Organization (WHO) reports that URE in the decades ahead. While the number of myopia cases
for distance is the main cause of low vision and the second may be rising faster in developed nations, the impact
leading cause of blindness after cataracts. WHO estimates could be greater in less-developed countries, where
point to URE as a bigger cause of productivity loss globally corrected vision could be the key to getting an education
than any other preventable vision disorders, with 0.8-4.0 for a child or an escape from poverty for an adult.
percent of the world’s population affected by visual

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 MARKET WATCH
More research is required to determine the exact causes Admittedly, people around the globe are not going to give
and consequences of myopia. The projections of the up their digital devices. We are hooked. However, certain
spread of myopia are cause for concern for public health precautions can help avoid digital eye strain, according to
officials worldwide. As the young people with myopia grow the Vision Council. For students and desk-bound workers,
into middle age, they will be more susceptible to the the optimal optical arrangement is to have the computer
pathological effects of the condition, especially those with screen at an arm’s length (20-24 inches) distance from
high myopia, which will have an impact on public health the eyes. Computer eyewear can filter out the potentially
services. Officials should start planning and budgeting harmful blue light that digital screens emit, as well as
now for the coming need. eliminate glare and alleviate eyestrain.13

The antidotes Finally, we need to remember that the most important

action in the fight against myopia and its related damage
The growing body of research about the spread of myopia is to visit a trained eyecare professional for an annual
is giving us reason for hope. The overwhelming majority of comprehensive eye examination. This is especially
myopia cases can be corrected with prescription important for children as their eyes are still developing
eyeglasses, contact lenses or refractive surgery. and early intervention is key. •

Beyond optical solutions that correct myopia, research

points to increased time outside in sunlight as the antidote
to the condition. In one study, a randomized clinical trial
in Guangzhou, China, researchers followed 952 children
in the intervention group and 951 in the control group
with a mean age of 6.6 years. The cumulative rate of
myopia was 30.4 percent in the intervention group and
39.5 percent in the control group. The important finding
was that 40 minutes of additional activity outside in
natural light resulted in a reduced incidence of myopia
during the next three years.11

More time spent outside playing also means less time

inside in front of a computer or smartphone screen.
Modern lifestyles spent in front of digital screens do have
an impact on vision. The Vision Council reports that 75
percent of Americans who use two or more devices
simultaneously report digital eye strain symptoms, such as
blurry vision and eye fatigue.12

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MARKET WATCH

“ The most imp o r tant actio n in the fig ht

against myo p ia and its r elated d amag e is
t o visit a t rained ey ecar e p r o fes s io nal fo r an
annual com p r ehens ive ey e ex aminatio n. ”

REFERENCES
1. Holden B, Fricke T, Wilson D, et al. Global Prevalence of Myopia and High Myopia and Temporal Trends from
2000 through 2050; Ophthalmology, 2016.
2. Pan CW, Dirani M, Cheng CY, Wong TY, Saw SM. The age-specific prevalence of myopia in Asia: a meta-
analysis. Optometry and Vision Science: official publication of the American Academy of Optometry 2015;
92:258-66.
3. Dolgin E. The myopia boom. Nature March 2015;519:276-8. KEY TAKEAWAYS
4. Rose K, Morgan I, Smith W, Burlutsky G, Mitchell P, Saw SM, Myopia, Lifestyle and Schooling in Students of
Chinese Ethnicity in Singapore and Sydney. JAMA Ophthalmology, April 1, 2008.
5. Dayan YB, Levin A, Morad Y, Grotto I, Ben-David R, Goldberg A, Onn E, Avin I, Levi Y, Benyamini O, The
Changing Prevalence of Myopia in Young Adults: A 13-Year Series of Population-Based Prevalence Surveys.
IOVS (Investigative Ophthalmology and Visual Science), August 2005. • Myopia is projected to affect half of the world’s
6. Vitale S, Sperduto RD, Ferris III FL, Increased Prevalence of Myopia in the United States Between 1971-1972
and 1999-2004. JAMA Ophthalmology, Dec. 14, 2009. population by 2050.
7. Boren ZD, There Are Officially More Mobile Devices than People in the World. The Independent, Oct. 7, 2014.
8. Smith TST, Fricke KD, Holden BA, Fricke TD, Naidoo KS, Potential Lost Productivity Resulting from the Global
Burden of URE. Bulletin World Health Organization, 2009.
9. Rein DB, Zhang P, Wirth K, Lee PP, Hoerger TJ, McCall N, Klein R, Tielsch JM, Vijan S, Saaddine J, The
Economic Burden of Major Adult Visual Disorders in the United States. JAMA Ophthalmology, Dec. 1, 2006.
• Young people in Asia are especially susceptible
10. Lim MCC, Gazzard G, Sim EL, Tong L, Saw SM, Direct Costs of Myopia in Singapore. National Medical
Research Council, 2009.
to myopia.
11. He M, Xiang F, Zeng Y, Mei J, Chen Q, Zheng J, Smith W, Rose K, Morgan IG, Effect of Time Spent Outdoors
at School on the Development of Myopia in Children in China: A Randomized Clinical Trial. Journal of the
American Medical Association, Sept. 15, 2015.
12. Eyes Overexposed: The Digital Device Dilemma, 2016 Digital Eye Strain Report. The Vision Council. • There are links between myopia and the increasing
use of digital devices, such as smartphones and
13. De Larrard B, The new range of Eyezen™ lenses: what are the benefits perceived by wearers during screen
use? Points de Vue, International Review of Ophthalmic Optics, N72, Autumn 2015.

personal computers.

• Research shows that increased time spent outside

can reduce the onset of myopia in young people.

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54 Number 73 - Autumn 2016
 There are several options
PRODUCT
to manage myopia. The
solutions can be classified
depending on their ability
to correct and/or control
myopia progression in
childhood. In the case of
extremely high myopia,
optical interventions
require new creative
methods in prescribing
and manufacturing.

P.56What are the solutions and their

efficacy in myopia management?
P.66How did optical experts solve the
record-high myopia of -108.00 D?

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55 Number 73 - Autumn 2016
PRODUCT
MYOPIA AND EFFECTIVE
MANAGEMENT SOLUTIONS

Myopia is becoming a real public health concern across the world.

The number of myopic people is increasing rapidly. The prevalence of high myopia is also
expected to rise. Understanding myopia development and methods to slow its progression is
currently one of the biggest stakes for researchers and clinicians from around the world. In
this paper, a few Vision Scientists at Essilor have put together a general overview of myopia
condition. In this article they review the definition of myopia, its evolution and causes. They
describe available solutions for myopia management and discuss the relative efficacy for
each solution. Finally, they focus on Myopilux®, the specific range of ophthalmic lenses
which have been proven to effectively correct and control myopia progression in children.

Dr. Anna Yeo

B Optom (Hons); M App Sc; Dr. Damien Paillé
PhD, Senior Vision Scientist, B Sc Optom; M Sc; PhD, Senior
Essilor Center of Innovation Vision Scientist, Essilor Center of
& Technology Asia Innovation & Technology Europe

Dr. Anna Yeo Chwee Hong joined Essilor R&D Asia in May 2013
Dr. Damien Paillé is a member of Essilor International’s optical
as a Senior Vision Scientist after teaching optometry for 23 years
at the Singapore Polytechnic. Her current research interest is adult research and development team, based in Paris, France. Damien
myopia, on which she has conducted research internally at CI&T holds a degree in optometry and practiced as an optician before
Asia and in collaboration with other teaching institutions such as completing and defending a doctoral thesis in 2005 in cognitive
Zhongshan University and Singapore and Ngee Ann Polytechnics. sciences at the University of Paris VIII in collaboration with the College
She is also a member of the Scientific Committee in Wenzhou-Essilor de France and the Renault company. He then pursued post-doctoral
International Research Centre (WEIRC) for which she helps to review studies at the Laboratory for Perception and Motion Control in Virtual
research protocols and scientific publication. Dr. Anna Yeo has been Environments (a joint Renault-CNRS laboratory), before joining Essilor
a member of the Optometry and Opticianry Board (OOB) in Singapore International’s research and development team in 2007. He currently
and the Chairperson for the Credentials Committee, OOB since 2008.
works in the Vision Sciences department.

Dr. Björn Drobe

Patricia Koh
B Sc Optom; M Sc; PhD, Associate
Optom; B BioMed; MPH,
Director, Wenzhou Medical
Technical Manager, Essilor
University - Essilor International
Mission Division
Research Center (WEIRC)

Born and raised in Singapore, Patricia is an Optometrist with a Dr. Björn Drobe obtained a B.Sc. in Optometry, a M.Sc. in Cognitive
background in Biomedical Science and a Master’s in Public Health. Sciences and a Ph.D. in Vision Sciences in Paris, France. He joined
She joined Essilor R&D Singapore in 2005, focusing on progressive the French Essilor Int. research team in 1998, working mainly on the
myopia in children and ethnic differences such as postural behavior. interaction between ophthalmic lenses and the human visual system,
In 2014, Patricia moved to Essilor Mission Division as Technical as well as on progressive myopia in children. From 2007 to 2013,
Manager to support the group’s social initiatives on training and Dr. Drobe relocated to Essilor R&D Singapore for a higher involvement
exploring base of the pyramid innovation. in myopia research. Since June 2013, he is the associate director of
WEIRC (Wenzhou Medical University – Essilor International Research
Center), managing an international research team on myopia in
children.
KEYWORDS
Myopia, myopia control, myopia correction, high myopia risks, hyperopic
defocus, accommodative lag, heredity, lifestyle, blue light, dopamine, atropine,
Ortho-K, orthokeratology, prismatic bifocal lenses, multifocal contact lenses,
progressive addition lenses, refractive surgery, outdoor light exposure, Myopilux

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56 Number 73 - Autumn 2016
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A
lthough high rates of myopia have been reported in On the other hand, the rate is as low as 5.0% among
some Asian cities for years, recent publications have schoolchildren in rural China (5-18 y.o.)4 and 10.8%
highlighted the importance of and increases in this among the 15-year-olds in New Delhi.5
condition throughout Asia, as well as in the US and in In the US, the literature highlights an increase in myopia,
Europe. As a result, the number of myopic people is with its prevalence among 12- to 54-year-olds increasing
expected to exceed a third of the world’s population by from 25.0% between 1971-1972 to 41.6% between
2020, or 2.5 billion people out of a total population of 7.6 1999- 2004; the highest rate is reported to be 44.0%
billion. The loss of quality in vision, not only affecting among 25- to 34-year-olds between 1999-2004.6
daily life, has also raised the biggest concern due to an More recently, in Europe, the prevalence of myopia has
expected increase in eye pathologies and blindness been estimated to be 30.6% among 25- to 90-year-olds,
associated with the severity of myopia. Therefore, it is of with the highest prevalence of 47.2% observed in the
great importance to understand myopia development and 25- to 29- year-old age group.7
methods to slow its progression. In this paper we focus on:
1/ Myopia definition, evolution and causes, 2/ Available 1.2. What is myopia?
solutions for myopia management, 3/ Myopilux® new range In most cases, myopia occurs because the eyeball is too
of ophthalmic lenses for myopic children. long relative to the focusing power of the cornea and lens
of the eye. This is called axial myopia.
1. Myopia Figure 1 shows an emmetropic eye and a myopic eye. In
1.1. A worldwide phenomenon an emmetropic eye, light rays from far objects are focused
A recent Asian meta-analysis of 50 studies covering on the retina resulting in a clear image. In a myopic eye,
countries from Iran to Japan has reported an average light rays from far objects are focused in front of the
myopia rate of ~28%1, with strong disparities based on retina resulting in a blurred image.
age and geographical region. The highest prevalence is
reported among urban young people in Korea, where the In practice, without any correction, a myope experiences
rate reaches 96.5% among 19-year-old adults2, whereas blurry vision when looking at far-away objects. The higher
in Beijing, the prevalence of myopia is 74% among 17- to the level of myopia, the shorter the distance of clear
18-year-olds.3 vision from the eye. Typically, a -2.00 D myope will see
clearly at approximately 50 cm, whereas a -5.00 D myope
Cornea Iris Lens Retina will see clearly only at approximately 20 cm.

1.3. From myopia to high myopia and longer term risks

Myopia is a progressive phenomenon in which onset and
strongest progression are mainly reported during
childhood.8 On average, myopia progression rates are-
0.55 D per year among Caucasian children, and at a
higher rate of -0.82 D per year among Asian children.9
With such a rapid progression during childhood, the risk
to become highly myopic in adulthood is high (currently,
high myopia is defined as below -6.00 D). In Taiwan, the
prevalence of high myopia has increased from 10.9% in
Figure 1a: Emmetropic eye 1983 to 21.0% in 2000 among 18-yea-rold students.10
In Singapore, the prevalence of high myopia increased
from 13.1% between 1996-1997 to 14.7% between
2009-2010 among 17-29-year-old men.11 In Europe, a
5.9% prevalence of high myopia prevalence is reported
among 15- to 19-year-olds olds, according to data
FIG. 1 Emmetropic (top) and myopic (bottom) eyes collected in 2013.7

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Although myopia may not have any eye health impact, Regarding lifestyle, near-vision-demanding tasks and
being highly myopic may have a great impact on ocular limited time spent outdoors are known to influence
health. It has been shown that a -8.00 D myope has 10 myopia development.
times more risk for the development of retinal pathologies
than a -4.00 D myope (Fig. 2).12,13 High myopia Intense near vision activities performed by children
has also been reported to be a risk factor for other have been associated with myopia development in
ocular pathologies, including glaucoma, choroidal neo- many studies.20-24 When looking at a near object, the
vascularization, and myopic macular degeneration.14 accommodative response of a myopic child is lower
Regarding cataract, there are divergent studies on its link than the proximity of the object, resulting in a slightly
with high myopia.15 Overall, high myopia is a leading defocused image (Fig. 3); light rays from near objects are
cause of visual impairment worldwide.16,17 focused behind the retina. This phenomenon is called the
accommodative lag. It has been found to be higher in
Therefore, it is of great importance to understand myopia myopes than in emmetropes.25-27
development and to find ways to slow the progression of
myopia during childhood. The accommodative lag increases with proximity (Fig. 4)
and creates a stimulus for the eye to elongate, leading to
1.4. Myopia, a multi-factorial refractive error myopia progression.26,28 The risk of developing myopia
Myopia development during childhood (onset and increases as the working distance is shorter and the
progression) is due to multiple factors, which are amount of near work is greater.
commonly split into two groups: heredity and lifestyle,
often referred to as nature and nurture. A large amount of near work combined with a lack of
outdoor activities are also highly associated with higher
Regarding heredity, it has been shown that children with myopia prevalence in children.29-31 It is still unclear how
two myopic parents are on average two to three times more outdoor activities impact myopia, and several hypotheses
likely to be myopic than children with non-myopic have been raised. Recent studies have suggested the
parents.18 More specifically, genetic studies have identified existence of interactions between light conditions and
numerous candidate genes and loci that may contribute to myopia development. As light intensities are much higher
myopia development.19 outdoors than indoors32, pupils are more constricted
outdoors. This would result in a greater depth of field and
less image blur, resulting in less myopia progression.31
80
Ref. 13

60
Accommodative
lag
Ref. 12
40

20 E
0
-10.00 -6.00 -2.00 0.00
-8.00 -4.00

FIG. 2 Risks of developing retinopathy as a function of myopia degree FIG. 3 The accommodative lag in near vision tasks
Figure 2: Risks

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58 Number 73 - Autumn 2016
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favors myopia development. In particular, higher
educational levels and hand-held digital device use tend
to favor indoor work while exerting a higher demand on
our eyes. For instance, research has shown that when
using handheld video games, children adopt closer
working distances, which in turn may favor myopia onset
and progression.34

2. Solutions for myopia management

There are currently several options available to manage
myopia. They can be classified according to their ability
to correct and slow myopia progression during childhood
as shown in Figure 5.

2.1. Solutions that correct myopia but do not control

its progression
Single vision lenses are the most common non-invasive
solutions for myopia correction. Contrary to common
FIG. 4 Influence of proximity on accommodative response belief, under-correction of myopia does not prevent it
from progressing. One study showed that undercorrection
Another hypothesis is the release of dopamine from the of 0.75 D led to a 30% more myopic prescription after 2
retina, which would act as an inhibitor for eye growth, years, which was statistically significant.35 Another study
and which is known to be stimulated by blue light in the showed that undercorrection of 0.50 D led to a 21% more
range of 460-500 nm. With higher amounts of light myopic prescription after 1.5 years.36 Other studies also
outdoors, dopamine secretion would prevent the eye from showed that over-correction is not recommended for
elongating.33 myopia control either.37,38 As a consequence, to correct
myopia and to avoid the risk of more rapid myopia
In practice, modern lifestyle in cities, associated with progression, full correction should always be chosen
limited outdoor activities and intense near vision tasks, based on regular eye examinations.

Myopia control
efficacy

Prismatic bifocal lenses(3)

Most Atropine(1) Ortho-K(2)

efficient Progressive addition lenses(3)
Multifocal contact lenses(4)

Time spent
outdoors Peripheral addition lenses(4)

Not Refractive surgery (5)

efficient
Single vision lenses &
Standard contact lenses
No Yes Myopia
(1) 2-year clinical trial, 1 year after cessation, (2) Correction up to -6.00D only,
correction
(3) 3-year clinical trials, (4) 1-year clinical trials, (5) Under certain medical condition only.

FIG. 5 Solutions for myopia management, classified according to their ability to correct myopia progression

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Contact lenses have long been used to correct myopia. The lowest dosage (0.01%) showed a moderate myopia
However, the clinical efficacy of wearing standard soft slowing effect that was more sustained after cessation of
contact lenses in myopia control has not been the treatment. Unfortunately, this study did not include a
demonstrated.39 control group to be able to quantify the effects. Moreover,
in addition to its short-term side effects (photophobia due
As an alternative, refractive surgery, such as LASIK, offers to pupil dilatation, and reduced accommodation power),
a proven solution for correcting myopia in adulthood. atropine’s long-term side effects have not been
However, the method is invasive and does not control documented in children to date.
myopia or limit the risks of developing ocular pathologies
linked to high myopia. Indeed, refractive surgery modifies 2.3. Solutions that correct myopia and control myopia
the shape of the cornea at the front part of the eye, but it progression
does not change the axial length of the eyeball. Ophthalmic lenses with near vision addition have been
shown to be efficient in both correcting and slowing
2.2. Solutions that control myopia progression myopia progression and will be detailed in part 3. These
but do not correct it lenses have dedicated additional optical power in the
The least invasive method for myopia control is near vision zone that compensates for accommodative lag
undoubtedly to increase the time spent outdoors. A meta- in the myopic eye while the upper part of the lens allows
analysis performed on the association between time spent full myopia correction for far vision (Fig. 6). These lenses
outdoors and the risk of developing myopia in children has can either be prismatic bifocal lenses or progressive
indicated that spending one hour outdoors per week during addition lenses with an addition value and a design
childhood reduces the risk of developing myopia by 2%: adapted to children’s physiology. As of today, an addition
in other words, a child spending 10 hours more per week value of 2.00 D has been shown to be the most efficient
outdoors than another child has 20% less chance to compared to lower addition values for myopia control,43
become a myope later on.40 with up to 62% reduction in myopia evolution for
prismatic bifocal lenses.44
Atropine eye drops are also used in some countries in
clinical practice to slow down myopia progression. Initially Other ophthalmic lens designs, such as peripheral
it had been suggested that paralyzing accommodation addition lenses, have also been studied. The elongated
would result in less myopization, but later studies showed shape of myopic eyes results in a defocused image in the
alternative mechanisms and sites of action for atropine at periphery even with a perfect central focus (Fig. 7).45
either the retina or the sclera.41 Atropine has thus been It has been shown that this can cause elongation of the
studied in several clinical trials. One of them compared eyeball.46 Peripheral addition lenses are thus intended to
several dosages of atropine.42 The high dosages (above compensate for the peripheral hyperopic defocus and
0.1%) were efficient during treatment but were associated include two visual zones: the central zone of the lens
with a myopic rebound after the cessation of treatment. allows full myopia correction and the peripheral zone of

Peripheral hyperopic defocus

E
Near vision addition

FIG. 6 Near vision addition lenses FIG. 7 Peripheral hyperopic defocus

Figure 7: Peripheral hyperopic defocus

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60 Number 73 - Autumn 2016
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the lens presents a power addition for correcting the the cornea temporarily to push the focal point back to the
hyperopic defocus. In the main study conducted on this retina (Fig. 8). With a proper fitting protocol, Ortho-K can
concept, no statistically significant differences were correct myopia up to -6.00 D during daytime. Several
observed with the new designs compared to single vision recent meta-analyses also showed that Ortho-K slows
lenses. However, for the subgroup of younger children with down myopia progression by approximately 40% with
at least one myopic parent, myopia progression was careful education and regular monitoring to ensure
reduced by ~30.47 Nonetheless, it was only a one-year safety.51-53 Nonetheless, the long-term efficacy (including
study. Moreover, a two-year clinical trial showed that a possible rebound effect) as well as the long-term side
peripheral addition lenses do not enhance the therapeutic effects have not been assessed yet and should be evaluated
efficacy in slowing myopia progression versus near vision through further large-scale studies.
addition lenses only.48
3. Focus on Myopilux® lenses
As an alternative, in recent years, various multifocal Myopilux® is an all-in-one non-invasive range of near vision
contact lenses have been designed to retard the progression addition ophthalmic lenses for both myopia correction and
of myopia. Two one-year studies have shown a reduction myopia control throughout childhood.
of ~35% in myopia progression with multifocal soft
contact lenses.49,50 Although these studies showed 3.1. More than 10 years of research
promising results, there are no available results beyond Resulting from more than 10 years of exploratory research
the first year, thus no evaluation of rebound risks upon the by Essilor International myopia experts, Myopilux® lenses
cessation of wearing multifocal soft contact lenses. Several are based on a deep understanding of myopic children’s
new clinical trials are currently in progress. natural posture and physiology to ensure good ergonomics
and comfortable vision and provide a non-invasive solution
Another option is Orthokeratology (Ortho-K), also known as for myopia control.
corneal reshaping. The patient wears rigid contact lenses
overnight, with a specific reversed geometry; this flattens Regarding children’s posture, two studies were conducted
in China and Singapore. Children were asked to perform
their usual reading and writing tasks while their posture
was recorded in real time.54,55 The results highlighted
that when performing near vision activities, children
adopt a closer working distance than adults, leading to
Overnight wear higher convergence between far and near vision tasks, and
that children also prefer to use head over eye declination.
These findings were taken into consideration when
designing the lateral and vertical positioning of the visual
zones in Myopilux® lenses.

Regarding children’s physiology, the Myopilux® range has

been defined by taking into account children’s near phoria:
esophoria (tendency to “over convergence”), and exophoria
(tendency to “under convergence”) (Fig. 9).56

When wearing near vision addition lenses, as accom-

modation drives convergence, the reduction in accom-
FIG. 8 Orthokeratology
modation will result in less convergence in the eyes,
meaning an exophoric shift.57

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For esophoric profiles, near vision addition lenses will be The lens is adapted to children’s posture; its inset is
comfortable because the exophoric shift induced by the higher and its progression length is shorter than those
addition will partially compensate for their natural for adults. This is to fit to children’s closer working
esophoria. distance and preferred usage of head over eye declination
(Fig. 11).
However, for exophoric profiles, near vision addition lenses
lead to discomfort as they add exophoric shift and require Myopilux® Plus:
a higher fusional vergence demand. Nonetheless, it has Myopilux® Plus lenses should be chosen by parents
been shown that near base-in prisms can reduce the looking for an advanced solution for their esophoric
exophoria induced by near vision addition lenses. More children with progressive myopia. In addition to Myopilux®
precisely, a 3D base-in prism combined with a +2.00 D Lite lenses, it is tailored to each child’s specific visual
near addition on each lens brings visual comfort to the ergonomics and benefits from Wave Technology point-
child, with a phoria at its initial state.58 It results in an by-point calculation. It ensures tailored lateral positioning
efficient usage of these near vision addition eyeglasses. of the whole visual zones for enhanced visual comfort
and it provides the child with better visual resolution (Fig.
3.2. An innovative range of ophthalmic lenses 10).
Based on the above long-term exploration, as well as on
sophisticated lens surface calculation methods, high Myopilux® Max:
performance production means and efficient methods for Myopilux® Max lenses are highly recommended for
controlling lens manufacturing processes, the Myopilux® children whose myopia progression is more than -1.00 D
range of lenses is protected by six Essilor patents and is per year. Its design includes a prismatic bifocal made of
available in three product versions: Myopilux® Lite, two wide and aberration-free optical zones separated by a
Myopilux® Plus, and Myopilux® Max. segment line (Fig. 10):
- The upper part of the lens offers the visual correction
Myopilux® Lite: adapted to the prescription.
Myopilux® Lite lenses are recommended for esophoric - The lower part is dedicated to near vision with an
children with progressive myopia. Its design includes addition of +2.00 D and 3D base-in prism.
a progressive optical design, with a recommended - The wide visual zones as well as the short segment
addition of +2.00 D for better efficacy in myopia control height have been designed specifically for children.
(Fig. 10).

Myopilux® Myopilux® Myopilux®

Lite Plus Max
Esophore Exophore

Near vision addition

FIG. 10 N
 ear vision zone for Myopilux® Lite (left), Myopilux® Plus (center) and
FIG. 9 Near phoria. Myopilux® Max (right)
Figure 10: Myopilux Lite, Plus & Max

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62 Number 73 - Autumn 2016
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3.3. Validation through clinical trials on 600 children The concept of the Myopilux® Max lens was tested in a
Myopilux® lenses’ concept has been validated through two 3-year clinical trial. The objective of this study was to
major clinical trials with approximately 600 children, with determine whether bifocal and prismatic bifocal spectacles
third party ethics committees approval. control myopia progression in children with high rates of
myopia progression compared to SVLs. A total of 135
The concept at the heart of Myopilux® Lite and Myopilux® children aged seven to 13 years old were recruited and
Plus lenses was tested in the Correction of Myopia randomly assigned to wear SVLs, bifocal and prismatic
Evaluation Trial (COMET) study. The purpose was to bifocal lenses. The children were monitored for three years
evaluate the effect of progressive addition lenses (PALs) with visits every six months. The primary outcome was
compared with single vision lenses (SVLs) on the cycloplegic auto-refraction and the secondary outcome
progression of juvenile-onset myopia.59 A total of 469 was axial length growth.
children were recruited in this study. The children were The two-year and three-year results were published in the
randomly assigned to either wearing single vision lenses or Archives of Ophthalmology in 2010 and in the Journal of
PALs with +2.00 D addition. The children were monitored the American Medical Association Ophthalmology in
for three years with six monthly follow-up visits. The 2014.
primary outcome measure was progression of myopia, At year two, the progression of myopia in children wearing
which was determined by auto-refraction after cycloplegia. prismatic bifocal lenses was reduced by 55% compared to
The retention rate was extremely high with only 1% children wearing SVLs.44 This difference was highly
dropout rate. At the end of three years, the overall PALs significant. The best results were seen in the exophoric
group had a statistically significant reduction of 14% in group of children; those in the prismatic bifocal group had
myopia progression compared with single vision lenses a reduction of 62% in myopia progression compared with
(SVLs) that served as a control. However, a better effect of those wearing SVLs.
the PALs was observed in esophoric children with high At year three, children in the prismatic bifocal group had
lags of accommodation, whereas there was a statistically their myopia progression reduced by 51% (Fig. 12).61
significant reduction of 37.2% in myopia progression Moreover, contrary to other myopia control spectacle
compared to the SVLs group.60 lenses, prismatic bifocals were efficient in slowing myopia
progression for all children in different age groups, near
phoria types, lag of accommodation or number of myopic
parents.

Myopia Progression (D)

-2.50

Adult Shorter
-2.00 Standard Single Vision
working
distance
Child Higher head vs. eye
declination -1.50

Higher inset
-1.00
Shorter
progression
length -0.50
Prismatic Bifocal

0.00
Baseline 6 12 18 24 30 36
FIG. 11 Child posture Duration (months)

FIG. 12 M
 yopia progression of children wearing bifocal prismatic addition lenses
vs. single vision lenses over three years.

Figure 12: Myopia progression of children wearing bifocal prismatic

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Number 73 - Autumn 2016 63
Figure 11: Children posture
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Conclusion
Based on the current scientific state of the art and the
scope of clinician’s practice, a number of options for
myopia correction and myopia control are worthy of
KEY TAKEAWAYS
consideration. As far as non-invasive solutions are
concerned, ophthalmic lenses such as Myopilux®* can be • Myopia is a progressive phenomenon in which onset
prescribed for effective myopia correction and control.
In terms of protocol, the ideal recommendation would be: and strongest progression are mainly reported during
1/ Practice eye examinations at least annually childhood.
2/ Update child corrections when needed • Myopia development during childhood (onset and
3/ In case of ophthalmic lens prescription, choose near
vision addition lenses with a design adapted to children progression) is due to multiple factors, which are
needs (see chapter 3.2 for Myopilux® designs) commonly split into two groups: heredity and lifestyle,
4/ Encourage outdoor activities. • often referred to as nature and nurture.
• Regarding heredity, it has been shown that children
with two myopic parents are on average two to three
*Myopilux®: a non-invasive range of near vision addition times more likely to be myopic than children with non-
ophthalmic lenses designed by Essilor for both myopia
correction and myopia control. The availability of Myopilux myopic parents.
lenses can vary depending on country and should be • Regarding lifestyle, near-vision-demanding tasks
checked locally by contacting an Essilor representative. and limited time spent outdoors are known to influence
myo-pia development.
• There are currently several options available to
manage myopia and they can be classified according
to their ability to correct and slow myopia progression
during childhood:
- Solutions that correct myopia but do not control
its progression are: single vision ophthalmic lenses,
regular contact lenses, refractive surgery
- Solutions that control myopia progression but
do not correct it are: time spent outdoors, atropine
eye drops
- Solutions that correct myopia and control myopia
progression are: ophthalmic lenses with near vision
addition (such as Myopilux® offer), various
multifocal contact lenses and Orthokeratology
(Ortho-K).
• Myopilux® is an all-in-one non-invasive range of
near vision addition ophthalmic lenses (prismatic
bifocal and progressive designs) for both myopia
correction and myopia control throughout childhood,
• Resulting from more than 10 years of exploratory
research by Essilor International myopia experts,
Myopilux® lenses are based on a deep understanding
of myopic children’s natural posture and physiology
to ensure good ergonomics and comfortable vision.

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64 Number 73 - Autumn 2016
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7 Williams KM, Bertelsen G, Cumberland P, et al.; European Eye Epidemiology (E3) Consortium. Increasing 41 McBrien NA, Moghaddam HO, Reeder AP. Atropine reduces experimental myopia and eye enlargement
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8 Goss DA, Rainey BB. Relation of childhood myopia progression rates to time of year. J Am Optom Assoc. 42 Chia A, Chua WH, Wen L, Fong A, Goon YY, Tan D. Atropine for the treatment of childhood myopia:
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9 Donovan L, Sankaridurg P, Ho A, Naduvilath T, Smith EL 3rd, Holden BA. Myopia progression rates in urban 43 Leung JT, Brown B. Progression of myopia in Hong Kong Chinese schoolchildren is slowed by wearing
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Ann Acad Med Singapore. 2004 Jan;33(1):27-33. spectacles on myopic progression: two-year results. Arch Ophthalmol. 2010 Jan;128(1):12-9.

11 Koh V, Yang A, Saw SM, Chan YH, Lin ST, Tan MM, Tey F, Nah G, Ikram MK. Differences in prevalence of 45 Mutti DO, Sholtz RI, Friedman NE, Zadnik K. Peripheral refraction and ocular shape in children.
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2014 Aug;21(4):247-55. 46 Smith EL 3rd, Hung LF, Huang J. Relative peripheral hyperopic defocus alters central refractive development
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13 Liu HH, Xu L, Wang YX, Wang S, You QS, Jonas JB. Prevalence and progression of myopic retinopathy Holden B. Spectacle lenses designed to reduce progression of myopia: 12-month results.Optom Vis Sci. 2010
in Chinese adults: the Beijing Eye Study. Ophthalmology. 2010 Sep;117(9):1763-8. Sep;87(9):631-41.

14 Morgan IG1, Ohno-Matsui K, Saw SM. Myopia. Lancet. 2012 May 5;379(9827):1739-48. 48 Hasebe S, Jun J, Varnas SR. Myopia control with positively aspherized progressive addition lenses: a 2-year,
multicenter, randomized, controlled trial. Invest Ophthalmol Vis Sci. 2014 Sep 30;55(11):7177-88.
15 Pan CW1, Cheng CY, Saw SM, Wang JJ, Wong TY. Myopia and age-related cataract: a systematic review
and meta-analysis. Am J Ophthalmol. 2013 Nov;156(5):1021-1033. 49 Sankaridurg P, Holden B, Smith E 3rd, Naduvilath T, Chen X, de la Jara PL, Martinez A, Kwan J, Ho A,
Frick K, Ge J. Decrease in rate of myopia progression with a contact lens designed to reduce relative peripheral
16 Iwase A, Araie M, Tomidokoro A, Yamamoto T, Shimizu H, Kitazawa Y; Tajimi Study Group. Prevalence hyperopia: one-year results. Invest Ophthalmol Vis Sci. 2011 Dec 9;52(13):9362-7.
and causes of low vision & blindness in a Japanese adult population: the Tajimi Study. Ophthalmology.
2006 Aug;113(8):1354-62. 50 Anstice NS, Phillips JR. Effect of dual-focus soft contact lens wear on axial myopia progression in children.
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17 Wu L, Sun X, Zhou X, Weng C. Causes and 3-year-incidence of blindness in Jing-An District, Shanghai,
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18 Zhang X, Qu X, Zhou X. Association between parental myopia and the risk of myopia in a child.
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evidence for replication of 11 loci. PLoS One. 2014 Sep 18;9(9):e107110. 53 Wen D, Huang J, Chen H, Bao F, Savini G, Calossi A, Chen H, Li X, Wang Q. Efficacy and Acceptability of
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54 Drobe B, Seow EJ, Bao J, Wang Y, Lu F, Near vision posture in myopic Chinese children. ARVO Poster, 2011.
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23 Yi JH, Li RR. Influence of near-work and outdoor activities on myopia progression in school children. 57 Jiang BC, Tea YC, O’Donnell D. Changes in accommodative and vergence responses when viewing through
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24 Saw SM, Chua WH, Hong CY, Wu HM, Chan WY, Chia KS, Stone RA, Tan D. Nearwork in early-onset myopia. 58 Cheng D, Schmid KL, Woo GC. The effect of positive-lens addition and base-in prism on accommodation
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Scheiman M. A randomized clinical trial of progressive addition lenses versus single vision lenses on the
26 Gwiazda JE, Thorn F, Bauer J, Held R. Myopic children show insufficient accommodative response to blur. progression of myopia in children. Invest Ophthalmol Vis Sci. 2003 Apr;44(4):1492-500.
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60 Gwiazda JE, Hyman L, Norton TT, et al.; COMET Group. Accommodation and related risk factors associated
27 Yeo AC, Kang KK, Tang W. Accommodative stimulus response curve of emmetropes and myopes. with myopia progression and their interaction with treatment in COMET children. Invest Ophthalmol Vis Sci.
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28 Harb E, Thorn F, Troilo D. Characteristics of accommodative behavior during sustained reading 61 Cheng D, Woo GC, Drobe B, Schmid KL. Effect of bifocal and prismatic bifocal spectacles on myopia
in emmetropes and myopes. Vision Res. 2006 Aug;46(16):2581-92. progression in children: three-year results of a randomized clinical trial. JAMA Ophthalmol. 2014
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Xichang Pediatric Refractive Error Study report no. 2. Arch Ophthalmol. 2009 Jun;127(6):769-75.
30 Hepsen IF, Evereklioglu C, Bayramlar H. The effect of reading and near-work on the development of myopia in
emmetropic boys: a prospective, controlled, three-year follow-up study. Vision Res. 2001 Sep;41(19):2511-20.
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PRODUCT

RECORD-HIGH MYOPIA
S O LV E D B Y A N A L L I A N C E
OF EXPERTS: -108.00 D

Record-breaking! With lenses of -108.00 D sphere and 6.00 D cylinder, an alliance of

experts in Slovakia and France has made significant advances in the correction of severe
myopia. An expertise that will benefit many who have out-of-the-ordinary visual needs.
We revisit an exceptional human and technological adventure, as we dive into the story of
Jan Miskovic, a Slovak photographer, and his search for a 100+ diopter myopia correction.

A
n exceptional prescription for out-of-the-ordinary
Sebastian Chrien needs: RE: -106.00 (+6.00) 0°; LE: -108.00
Optometrist, Banská Bystrica, (+6.00) 25°. Collaboration between Franco-Slovak
Slovakia experts enabled the need evaluation, design, manufacture
and fitting of -108 diopter lenses to correct what is
probably the world’s highest degree of myopia. This
record, set in February 2016, topped the previous
achievement of -104 diopters set by the same team in
Alain Massée
January 2015. The story goes back nearly two years ago,
Head of Special lens surfacing
when a veritable chain of vision expertise was set up
projects, Essilor SL Lab (Special
between professionals in Slovakia and France with the
Lenses Laboratory), France
aim of pooling skills to push back the boundaries of what
is possible in optometry and optics. The team has already
proved their skill twice, and their work is intimately linked
Léonel Pereira to the unique case of Jan Miskovic, a 59-year-old Slovak
Workshop Manager, Surfacing who has suffered since childhood with severe myopia,
and Special Lenses, Essilor amblyopia in two eyes, astigmatism, strabismus and
SL Lab (Special Lenses keratoconus. This combination of conditions made
Laboratory), France treatment highly complex, particularly since his myopia is
still progressing, with an average loss in recent years of 4
to 5 diopters per year.

Stanislas Poussin Optometric skills at challenge of technical limits

Special Lenses Business Unit Via a chance meeting 30 years ago, Jan Miskovic
Manager, Essilor SL Lab (Special
consulted the ophthalmologist who was destined to
Lenses Laboratory), France
support him professionally throughout his life. In fact,
over the years that his ophthalmic disorders have been
progressing, Miskovic has never given up hope and has
regularly tested different treatments and optical solutions
Monika Remiašová and consulted numerous experts, even abroad. But he
Marketing Specialist, Essilor remains loyal to his ophthalmologist and optometrists in
Slovakia Slovakia, who provide the only solution that is effectively
working for him: the prescription of ophthalmic lenses as
close as possible to his correction requirements.

KEYWORDS
High myopia, keratoconus, amblyopia, astigmatism, strabismus, Essilor Mr
Blue edger, special lenses, biconcave double facet lens, World Sight Day,
Special lenses Laboratory (SL Lab), Essilor.

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66 Number 73 - Autumn 2016
 PRODUCT
“ W e are b ey o nd s tand ar d s in o p tics
and opt ometr y ; ther efo r e we inevitab ly
choose no n- s tand ar d means . . . ”

However, these requirements are not easy to evaluate. His contact with Essilor’s SL Lab (Special Lenses Laboratory)
correction went from -45 diopters in 2001 to -53 diopters in France, which draws on Essilor’s latest technological
in 2008 and -80 diopters in 2012, which at the time advances to provide solutions for patients suffering from
required the bonding of two lenses together, one on top of severe ametropia (refractive error),” explains Monika
the other, via polymerization. At the time, the limits of Remiasova, marketing specialist of the Group’s Slovak
technology seemed to have been reached, but the patient’s subsidiary. Remiasova contacted Benoit Herpeux, her
vision nevertheless continued to deteriorate creating new dedicated customer service representative at SL Lab, who
challenges for the eye care professionals. “We are beyond in turn forwarded the request to Alain Massée, head of
standards in optics and optometry; therefore we inevitably special lens projects at SL Lab. This new demand
choose non-standard means of measurement,” explains represented no small challenge for this first collaboration:
Sebastian Chrien, optometrist in Banská Bystrica in -104 D sphere, 6.00 D cylinder (and -103 D for the right
Slovakia, who is currently taking care of Jan Miskovic. eye)! Even so, the response was not long coming back. “I
“There are no instruments capable of measuring his sent an e-mail on 9 October in the morning and received
myopia level, so we place trial lenses in front of his glasses an enthusiastic “yes” the same day. In the meantime, the
and ask for his subjective reaction to estimate the required SL team had to adapt its calculation software to three-
correction as closely as possible. Nevertheless, we are digit figure correction (it only went up to -99 diopters),
guided by a single golden rule; the subjective improvement check that it had the right glass raw materials and begin
of any aspect of his sight,” pursues Mr Chrien. They met to think about the design of new surfacing tools,” explains
each other thanks to photography five years ago. Mr Chrien Remiasova.
is convinced that photography and optometry combined
together, can help in greater understanding of visual needs
and explain the ability of functional seeing despite such a
considerable visual impairment: “As a professional
photographer, Jan Miskovic is perfectly able to perceive
little nuances and changes. This definitively helps in The SL Lab, an expert in exceptional requirements
subjective optometric evaluation. He is knowledgeable In fact, the Slovak request fostered a spirit of competition
about image and its different forms. He understands the in the workshop of Essilor’s French laboratory at Les
mechanism of optical aperture, which may help him in Battants, in Ligny-en-Barrois, which made it possible to
enhancing depth of field. When he works, he can find a set a first record (of -104 diopters) in 2015. The new
compromise between visual aspects such as sharpness, target in 2016 was clear: meet the various technical and
contrast, luminosity, and movement. His photographic industrial challenges to reach -108 diopters with 6.00
perception of the world enables him to analyse elements diopters cylinder to prove that the Group can provide
such as perspective, while differentiating subjects with customized solutions for all eyeglass wearers, with no
unequal size and clarity and thus estimating distances. exceptions. “The lens design stage was the most
Usually, we do not perceive all of that; we unconsciously complex,” reveals Léonel Pereira, Workshop Manager,
take all elements for granted, so we do not even notice Surfacing and Special Lenses, SL LAB. “A lens of this
them. Jan’s vision is different. It is as if he was trained to power has to be biconcave. The main constraint concerns
watch with his mind,” Mr Chrien concludes. the rear surface and its short radius, which supports most
of the power in its spherical curve. A toric surface was
The Essilor network in action created on the front side, with a substantial but less
In 2014, Jan Miskovic participated in an event organized pronounced curve.” These specifics spurred the team to
by Essilor Slovakia for World Sight Day and the new optical opt for a high-index (1.807) mineral material, a biconcave
solution presented itself almost by chance. He questioned Superdiafal (=antireflective coating) with an asymmetrical
Essilor’s team there about the possibility of making special facet, which provides optimal optical performance for
lenses for high prescriptions, and his outlook immediately this correction level. The design calculations were made
brightened. “Of course, we had never before received a possible using the Special Lens Calculator (SLC),
request like this. But at the time we were starting to specifically developed to meet the requirements of special
develop our special lenses offer so we made preliminary lenses.

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PRODUCT

The inner surface (eye side) of the lens was designed with
a power of -77 diopters and an optical aperture 18 mm in
diameter, combined with a base curve of +2.50 diopters,
unpolished to absorb unwanted reflection. The remainder
of the correction was produced on the external surface by
a -31 diopter curve (to obtain the total power of -108 D)
with a cylinder correction of 6.00 diopters, associated
again here with a base curve of +6.00 diopters and an
inverted torus to create a perfectly round optical aperture
of 24 mm diameter. “This optical aperture gives the
wearer a field of view of about +/- 30°, which is satisfactory
given the power of the lens. The curvature of the front
facet was selected to make a thinner lens possible, but
also to facilitate the mounting of the lens at an ideal eye-
lens distance,” Pereira concludes.
FIG. 1 L
 ens -108.00 (+6.00) 25 produced in Essilor SL Lab (Special Lens
Laboratory), France Creative know-how in lens manufacturing
and quality assurance
The manufacturing expertise called upon to produce
Miskovic’s lenses can be seen primarily in the creation of
the inner surface. A manual ramp-up process was used
with a tool specially designed by the SL Lab team to
rough out, smooth and polish a radius of about 10 mm,
using very precise manual technical moves. This initial
optical surface was then measured by reflection with a
radiuscope to one-hundredth of a millimeter, and this
radius measure was used to calculate the base curve of
the outer surface. “This stage is highly sensitive, since
achieving a toric surface over a very short distance
requires a high level of expertise and perfect technical
mastery. The process is adapted for pressure, cycle speed,
tooling. Each curve achieved is measured with the
radiuscope, which is how we obtain such a high degree of
FIG. 2 L
 ens ready for optical quality control with a radiuscope in Essilor SL Lab
precision,” comments Pereira.
(Special Lens Laboratory), France
Once the lenses were finalized, they then had to go
through quality assurance to verify that power deviation
from precision is less than 2%. Since no frontofocometer
is capable of measuring such a high level of optical power,
a radiuscope was once again used to validate the radii of
the base curves of the inner and outer surfaces to enable
calculation of the total refractive power of the lens (taking
into account the material index) with less than 0.2%
margin of error. Verdict: the challenge was successfully
met! Moreover, the Slovak subsidiary was able to follow
each step in real time and in pictures. “We communicated
throughout the process, sending photos to enable our
Slovak colleagues to better understand the development
of these lenses. It was also a good way to forge closer ties
between the teams, which will have more and more
FIG. 3 Lens reception in Slovakia
opportunities to work together,” Massée concludes.

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68 Number 73 - Autumn 2016
 PRODUCT
Optician and optometrists at work to deliver unique
lenses
It only took two weeks to manufacture the lenses and
send them to Essilor Slovakia, which entrusted the edging
FIG. 4 Lens marking before edging
and mounting to its partner, an independent optical store
run by two brothers. The store also provides edging and
mounting services for the Slovak subsidiary. “Every
precaution was taken during the shipping, handling,
marking, blocking, edging and mounting of these unique
lenses. The last step in particular proceeded without a
hitch on Essilor’s Mr Blue digital edger, which proved
perfect for this unusual task,” explains Monika Remiasova.
The selection of the frame required a great deal of
consideration since it had to be able to accommodate
these unique lenses with proper centering and an
optimum vertex distance.

Living generous and passionate life, while lenses meet

satisfaction
The precision work was masterfully accomplished by the
FIG. 5 Frame scanning with Essilor Mr Blue
optometrists and Essilor Slovakia’s team, according to Mr
Miskovic, who was delighted to recover visual acuity of
1/10 in each eye, which for him was highly satisfactory
compared to his initial condition (1/20). Despite his
residual visual impairment, he keeps on living with
outstanding energy and incredible generosity towards
others. “His vivacity and his focus on helping others are
exceptional. He is looking for children and adults with
considerable visual impairments to support them and find
a way to help them see better. His diverse activities and
social commitments seem prevent him from resigning to
his condition. By doing sports, he discovered that the
possibilities are endless and only depend on our will and
perseverance,” comments his optometrist, Mr Chrien. He
also keeps on living his passions. “It is quite amazing to
FIG. 6 Lens edging
hear Mr Miskovic talk about the improvement in his day-
to-day vision. With these new lenses, which he uses
primarily for distance vision during outdoor activities, he
can continue to work as a photographer and move about
freely for his reporting work (he even climbed Mount
Chopok, to an altitude of over 2,000 m!). What better way
to illustrate our mission,” enthuses Stanislas Poussin,
manager of the Essilor Group’s special lenses business
unit.

FIG. 7 Lens mounting

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PRODUCT
“ Rat her t han r eco r d - b r eaking achievements ,
t he int ern atio nal team effo r t ar o und
J an Misko vic is all ab o ut human
and t echno lo g ical ad vances … ”

An achievement that offers new hope

Naturally, the story of how a network of experts mobilized
to help Jan Miskovic and his severe myopia does not end
here. The progression of his disorder has prompted the
various professionals contributing to his care to develop
their expertise further and work ever more closely together
to meet his needs. After initial feedback from Mr Miskovic
in 2015, the SL Lab quickly proposed an improvement to
his lenses by reducing unwanted reflections (via the
expertise of Essilor’s Irish subsidiary, which specializes in
anti-reflective coatings for mineral lenses) and by moving
the lenses closer to his eyes.

In fact, the SL Lab has committed to always finding a

FIG. 8 Eyeglasses after mounting solution and developing all the instruments needed to
meet Miskovic’s visual needs and those of others who
suffer from severe ametropia. Rather than record-breaking
achievements, the international team effort around Jan
Miskovic is all about human and technological advances
that will benefit all those individuals with out-of-the
ordinary visual needs. •

KEY TAKEAWAYS

• An international collaborative effort was initiated

between Slovak ophthalmologist and optometrists, the
FIG. 9 Jan Miskovic and optometrist Sebastian Chrien
Essilor Slovakia subsidiary, Essilor’s SL Lab in France,
and the edging service of Essilor in Slovakia to meet the
needs of an eyeglass wearer suffering from progressive
high myopia.
• The Essilor teams responded in 2015 to a first record-
setting request to manufacture lenses with -104 D
sphere and 6.00 D cylinder. This extraordinary feat was
surpassed in 2016 with the production of -108.00
(+6.00) lens.
• To respond to this particular request, Essilor’s SL Lab
developed special techniques and innovative tools.
• The progression of Miskovic’s myopia is spurring
FIG. 10 Jan Miskovic delighted with his new eyeglasses
vision-care professionals and Essilor teams to push
back the technical limits of their offer and develop new
solutions for severe ametropia.

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70 Number 73 - Autumn 2016
 Creative work and
ART AND
VISION
especially the art of
photography require an
optimal quality of vision.
How to get to that level
in case of record-high
myopia? When a tailor-
made optical solution
provides a photographer
with compensation for his
vision disability, his talent
and intuition can do the
rest.

P.72The Incredible story of Mr. Miscovic:

how does he practice the art of
photography with -108 D myopia?

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71 Number 73 - Autumn 2016
ART AND VISION

PRACTICING THE ART

OF PHOTOGRAPHY
WITH -108 D MYOPIA

Jan Miskovic’s name is well-known in model-making, hydro-racing,

professional photography and the ophthalmic optics market!
In fact, this energetic Slovak has a record-high degree of myopia:
measured at -108 diopters. Despite his visual disability, however,
he is a true phenomenon who lives life to the fullest and has even made
his disability a motivating factor for his artistic creativity.

A
t first contact, this jovial Slovak almost comes
across as a cartoon character or some kind of
prankster, with good reason: Jan Miskovic’s
impressive -108 diopter facet lenses transform his eyes
into intriguing black dots. After exchanging a few words
and anecdotes, though, it only takes a few minutes to
realize that appearances can be deceiving, and that, in
reality, his gaze is extremely sensitive and sharp. And
that’s exactly what you would expect from a passionate
professional photographer, who proves by example that the
practice of his art and impaired vision are perfectly
compatible thanks to modern technology.

Living in harmony with his passions

“As a child, I developed a number of vision problems,

including amblyopia, astigmatism, strabismus,
keratoconus and, primarily, progressive myopia. These
problems became more severe and advanced more rapidly
following a racing accident in a hydroplane (a cross
between a motorcycle and a powerboat designed for
offshore racing), which caused severe injuries to both
eyes, not to mention the side effects of the antibiotics I
Jan Miskovic was forced to take, which also contributed to my declining
Photographer vision,” Jan explains. As a result, his myopia, measured at
-45 diopters in 2001, with a loss of 4-5 diopters per year,
has now (as he is about to turn 60) reached a record-
KEYWORDS setting degree of severity: -108 diopters. And even though
art, photography, visual disability, high myopia, Essilor special lenses,
Special Lenses Laboratory, SL Lab, astigmatism, Lions Club, low vision,
digital technology.

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72 Number 73 - Autumn 2016
 ART AND VISION
“ To t ake goo d p ho to s o f athletes , y o u need
t o underst a nd the mechanis ms o f their
discipline an d b as ic mo vements in o r d er to
capt ure t he ver y es s ence o f their s p o r t. ”

Sensations, both strong and gentle

“After earning an engineering degree and a doing a stint

in a state agency dedicated to coaching competitive
athletes, I started a company specializing in scale model-
making and moulding. This early professional ‘artistic’
endeavour gave me a chance to indulge my passion for
building miniature remote-controlled racing boats and
testing them in competition. I was a member of the
national team for a long time before becoming a coach,
first for Czechoslovakia, and then for Slovakia after the
dissolution.” At the same time, Jan’s attraction to nautical
activities led him to develop a passion for another, more
physical type of racing: hydroplane racing, which he
practiced from the mid-1990s up until his accident in
2001. Forced to adapt once again following this accident,
Jan was more determined than ever and decided to
become a coach – and a winning one at that, since his
protégé was none other than Marian Jung, a tenfold
European hydroplane-racing champion and a six-time
world champion. It’s obvious the man is addicted to speed
and thrills, but his favourite hobby demanded another,
gentler kind of feeling: photography has fascinated him
ever since he was a child, when he spent many Saturdays
with his father developing photos in the transformed
family bathroom. He practiced photography for a long time
as a hobby before taking the plunge and applying for his
licence as a professional sports photographer in the early
2000s, motivated by the rapid development of digital
Jan Miskovic in action technologies, which offered him a way to overcome his
visual limitations – and even turn them into a plus! This
proved to be a winning transition, as evidenced by the
advances in ophthalmic optics along with an international many awards he has won throughout the world, in such
Franco-Slovak collaboration between Essilor’s teams have diverse places as China, Qatar, Austria, Monte Carlo and
made it possible to design and manufacture corrective the United States.
lenses to meet his visual requirements (see article p. 66),
his continued ability to express his artistic talent primarily An instinctive photographer
depends on proper management of his disability and his
unshakeable optimism. Indeed, Jan is not the type of The first question that comes to mind in view of the
person to let life’s vagaries slow him down. He seizes every severity of his myopia is, “Does he really see what he is
opportunity to express himself, enrich his creativity, and photographing?” He answers frankly: “No! I can’t see the
broaden his experience. subject through the viewfinder, but I don’t need to see it;

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ART AND VISION

“ Y ou also nee d to lo o k fo r an o r ig inal ang le,

a unique point o f view, as clo s e as p o s s ib le
t o t he act io n, b ut witho ut d is r up ting it. ”

it is enough to know what I want to photograph. I know

where to position myself and when to press the shutter
button. It’s all about experience and feeling. My perception
of the environment is different, but I try to free myself
from the limitations people with good vision impose on
themselves, such as their focus on subject, framing,
lighting and so on.”

“Digital technology lets me shoot in burst mode – in

general six to seven perfectly clear shots – and select the
most expressive photos on my computer. For near vision,
I wear a pair of telescopic magnifying glasses designed for
computer work.” This connoisseur of strong emotions and
distinctive representations feels that nothing is more
important than the expressiveness of the subjects and
scenes he immortalizes. Jan regrets the current trend in
photographic circles that applauds clarity and technical
perfection over the raw emotion that he feels should
emanate from a photo.

Capturing unique moments

Jan claims that he doesn’t have any failed or insipid

photos to toss out. This is all the more surprising given
that his chosen field is sports photography. Here again,
it’s all about experience, knowledge of the subject, creative
spirit and a proper command of the equipment. “I’ve
always liked sports. I’ve practiced or coached a good Jan’s favourite photo is one of Pope John Paul II, taken
number of them and I’m in contact with several federations. during his visit to Banska Bystrica in 2003. “The area
To take good photos of athletes, you need to understand reserved for photographers was jam-packed, my view
the mechanisms of their discipline and basic movements was obstructed by the Swiss Guards, and the Pope’s
in order to capture the very essence of their sport. You also face was hidden in his hands during prayers – but all
need to look for an original angle, a unique point of view, of a sudden, he lowered his hands slightly and I shot
as close as possible to the action without disrupting it. the photo in a fraction of a second! This photo was
Many sports photographers are content to stick to one seen around the world, and I even enlarged and framed
position. I don’t hesitate to move around, to diversify my it and sent it to the Vatican.”
compositions. I also like to gradually zoom in on a scene,
to get closer to the main subject and the energy he or she
gives off.” He particularly likes to express this sensitivity
in water sports as well as in mountain sports, including
dogsled races, track athletics – and rodeos.

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74 Number 73 - Autumn 2016
 ART AND VISION

Jan likes to immortalize memorable moments, so it’s not surprising that a large share of his collection
of portraits is devoted to music, singers and instruments. “I like to calmly listen to jazz, in good com-
pany, but I can’t resist picking up my camera from time to time.”

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ART AND VISION

“ I don’t need to s ee it; it is eno ug h

t o know what I want to p ho to g r ap h…
It ’s all abo ut ex p er ience and feeling . ”

Of course, Jan has other strings to his photographic bow, participate in the Cesta světla (Way of Light), an annual
some of which are more intimate. Attracted to “faces with charitable event organized by the Slovak Union for the
character,” he admits to a special fondness for portraits Blind, which is set to celebrate its 13th event. “Both the
and boasts a fine collection of photographs of Slovak and sighted and visually impaired can participate in this big
international celebrities, nearly 900 of which are annual photo competition, which generates some
autographed. absolutely superb, highly original photos,” Jan explains,
pointing out that the event is followed by a travelling
Focusing on the future exhibition that he hopes, one day, will travel beyond
Slovakia’s borders.
He has collaborated with numerous national magazines
and has had exhibitions throughout the world, including in These are just a few examples, among many, of the
Lake Alfred (Florida), Monte Carlo, Budapest and philanthropic endeavours of a man in a day-to-day struggle
Bratislava. Recognition and a promising future in to improve his own condition via the practice of visual
photography are likely in the cards for this artist who, in yoga. “I spent six months mastering the technique, and I
any case, does not like to look back. “I have some have now been practicing these exercises for over three
wonderful memories, but I am not a fan of nostalgia. years to train my eyes and prevent excessive fatigue.
Living in the past and regretting ‘the golden age of The results are palpable, and I feel like my vision is
analogue photography,’ for instance, is counter-productive, deteriorating less rapidly than before. I would advise all
especially for someone like me who owes so much to visually impaired people to try these exercises.”
modern technology. And I’m not the only one who feels
this way! The new cameras and the array of possibilities With his big heart, enormous energy and overflowing
opened up by digital technology have made a huge enthusiasm, Jan Miskovic is a real phenomenon, which in
contribution to the development of sports photography,” his eyes is perfectly normal. He likes to recharge his
insists this inveterate Nikon fan, who works extensively batteries near the water, listen to jazz, and spend quality
with the D4S, an SLR perfect for motion photos, and who time with friends and family. He’s a man like any other,
has been greedily eyeing the brand-new D5. but also a consummate artist whose record of achievements
includes a singular summit: undoubtedly the world’s
Visions of hope highest degree of myopia! •

As energetic as he is, Jan is convinced that work – even

pleasant, artistic work – is not all there is to life. He
therefore engages in a wide range of activities, including
travel, exploration, and charitable commitments,
particularly in support of the blind and visually impaired.
For example, he is a member of the Lions Club in his
hometown of Banska Bystrica, where he works to raise
awareness and funds for children suffering from severe
disabilities (including visual and mental disabilities) and
for everyone suffering from severe refractive errors (i.e.
ametropia). His activism also led him to support and

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76 Number 73 - Autumn 2016
 ART AND VISION

Always looking for the best possible angle of view, Jan took advantage of the abundant snow to dig a hole and
position himself at ground level. “It was only when I saw the photo on my computer that I realized the dogs were
literally flying above the snow!”

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ART AND VISION

Hydroplane races are the only passion that Jan no longer indulges in since his accident.
“I miss the adrenaline, but I content myself with taking photos. I am especially attracted
to water and try to get as close to it as possible whenever I can.”

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78 Number 73 - Autumn 2016
 ART AND VISION

From a painful attack in Muay-Taï combat to a high jumper’s flop technique and the disturbing choreography of a rodeo,
Jan strives to capture movement, the essence of sports. “You need to look for an original angle, a unique point of view,
as close as possible to the action, but without disrupting it.”

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Number 73 - Autumn 2016 79
 PA S T A R T I C L E S I N R E L AT I O N T O T H E T H E M E « M YOPIA»
Y O U M AY F I N D I N T E R E S T I N G :

Myopia in the year 2000 and beyond A perspective on the evolution and management
Dr Franck J. Weinstock of myopia
[Points de Vue 30 - spring 1994] Kovin S. Naidoo, Diane B. Wallace
[Points de Vue 63 - Autumn 2010]
Ethnic variations in myopia
Noel A. Brennan Lenses to slow the progression of myopia
[Points de Vue 30 - spring 1994] Elodie Camaret, Björn Drobe
[Points de Vue 63 - Autumn 2010]
The correction of myopia in sportsmen
and women using contact lenses Experience with correcting myopia with different types
Philippe David of contact lenses
[Points de Vue 30 - spring 1994] Edward S. Bennett
[Points de Vue 63 - Autumn 2010]
Famous myopes
Pierre Amalric Sclera reinforcement treatment and prevention
[Points de Vue 30 - spring 1994] of complications of progressive myopia in children
Elena P. Tarutta, Elena N. Iomdina, Elena V. Viadro
The advantages of high-index lenses [Points de Vue 63 - Autumn 2010]
in the correction of myopia
Roger Coulibaly Myopia surgery
[Points de Vue 30 - spring 1994] Jean-Jacques Saragoussi
[Points de Vue 63 - Autumn 2010]
Myopia in Asia : a growing problem
Carly Sy Lam, Maurice Yap The latest advances in controlling myopia :
[Points de Vue 50 - Spring 2004] a clinical perspective
Amanda Alvarez, Christine Wildsoet
Drug treatments for Control of myopia Progression [Points de Vue 64 - Spring 2011]
Options for Now and the Future
Christine Wildsoet Accommodation stability and the progression
[Points de Vue 51 - Autumn 2004] of myopia in children
Trine Langaas, Norway, Patricia Riddell, United Kingdom
Children’ s Myopia in China [Points de Vue 66 - Spring 2012]
Lu Fan, Bao Jinhua, Qu Jia
[Points de Vue 55 - Autumn 2006] Myopia in young adulthood
Katrina Schmid, Australia
Myopia: what makes the eye grow longer? [Points de Vue 66 - Spring 2012]
Frank Schaeffel
[Points de Vue 63 - Autumn 2010] Prevalence and risk factors of myopia among schoolchildren
in Chimi, Taiwan
Pathological and risk factors of myopia Pei-Chang Wu, Taïwan
in Chinese Population [Points de Vue 66 - Spring 2012]
Zhao Kanxing, Zhang Lin, Wang Yan
[Points de Vue 63 - Autumn 2010]

The growth rate of myopic children’s eyes

and methods for slowing eye
Jane Gwiazda
[Points de Vue 63 - Autumn 2010]

Do you need more information on these articles?

Contact us: [email protected]

Points de Vue - International Review of Ophthalmic Optics

80 Number 73 - Autumn 2016
 EDITORIAL BOARD
The Editorial Board’s role is to define relevant themes and approve content proposals for each new issue of the magazine.
Its members represent 12 nationalities and speak 15 languages. They also ensure global and local relationships with authors,
eye care professionals and KOLs (Key Opinion Leaders).

Dr. John Ang Maralen Busche Laura De Yñigo William Harris Andy Hepworth Pedro Janowitzer
President, The International Vision Head of Product Marketing, Varilux Institute Director, Project Manager, Global Key BSc (hons), FBDO, Head of Marketing Vice President,
Academy, Vice-President, Essilor Germany Essilor Spain Opinion Leaders and Professional Relations, Essilor Latin America
Education & Professional Services, Professional Relations, Essilor UK
ESSILOR AMERA Essilor International

Eva Lazuka-Nicoulaud Dominique Meslin Charles-Éric Poussin Dr. Howard B. Purcell Alain Riveline Annie Rodriguez
Head of Publication Points de Director of Professional Consumer Innovation Manager OD, FAAO, Senior Corporate Senior Vice Director of Vision Health
Vue, Global Key Opinion Relations and Technical Next Generation Consumers, Vice President, Customer President, Global Marketing, Essilor France
Leaders and Professional Affairs, Essilor Europe Essilor International Development Group, Essilor International
Relations, Essilor International Essilor of America

Dr. Rod Tahran Louise Tanguay Tim Thurn Roberto Tripodi Lily Peng Zhang
OD, FAAO, Vice President, Special Projects, Optical Director of Professional Professional Relations and Technical Standard Manager,
Professional Relations, Schools and Events Services, Essilor Australia Professional Affairs, Shanghai Essilor Optical Co.,
Essilor of America Professional Relations, and New Zealand Essilor Italy LTD
Essilor Canada

SCIENTIFIC BOARD
The Scientific Board is represented by international peer-recognized experts. The members of Scientific Board are not funded
by Essilor for their work or for any contribution they may make to Points de Vue. The Scientific Board’s role is to ensure both
the integrity and credibility of the magazine. In fulfilling this role, the Scientific Board is able to amend and reject articles.

Prof. Clifford Brooks, Prof. Julián García Sánchez, Dr. Daniel Malacara,
Indiana University School of Optometry, United States Medical Faculty UCM, Spain M.Sc, PhD Optical engineering, Optic Research Centre,
Mexico
Prof. Christian Corbé, Prof. Mo Jalie,
Invalides Institute, France Founder President of the University of Ulster, UK Prof. Yves Pouliquen,
Representative Association for low vision Initiatives Member of the Académie de Médecine
(ARIBa), FranceCourt Expert Farhad Hafezi, and of the Académie Française, France
Professor and Chief Medical Officer, Ophthalmology
Dr. Colin Fowler, Clinic, Department of Clinical Neurosciences, Geneva Dr. Marcus Safady,
Director of Undergraduate Clinical, Studies Optometry University Hospitals, Switzerland Ophthalmologist, chairman of the Sociedade Brasileira
& Vision Sciences, Aston University, UK de Oftalmologia (S.B.O.), Rio de Janeiro, Brazil
Bernard Maitenaz,
Inventor of Varilux, Essilor France

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