Attendees had the pleasure of listening to two very good lecturers at a recent New Jersey Society of Optometric Physicians’ seminar on the topic of Myopia Control. The second presenter was Nick Despotidis, O.D., who has built a niche specialization in the subject matter popularized through his TEDx talk, and two books (My Children Are Nearsighted Too and A Parent’s Guide For Raising Children With Healthy Vision).
The first presenter was Alan Glazier, O.D., influential through the popular social media vehicle he spearheads, ODs on Facebook.
While Dr. Glazier’s presentation was informative, it perpetuated what seems to have become a meme of sorts in the Myopia Control Industry. That is, that the role of accommodation in myopia is irrelevant. This is based on the premise that “there is no evidence binocular and accommodative status influences progression”.
I’d like to differentiate two issues here that tend to be conflated. One is large population studies of how prescribing for patients with early progressive myopia tends to influence the rate of progression; the other is how to satisfactorily prescribe for individual patients. Dr. Glazier is of the camp that the key influence on myopia is whatever physiological factors result in a direct increase in axial length. Interestingly, on several occasions, he issued “apologies to COVD docs” who might feel that accommodation has any bearing on this and therefore that under-prescribing minus or anything related to vision therapy might have any clinically significant impact on myopia progression. The issue revolves principally around the nature of peripheral retinal defocus and how that triggers an increase in axial length thereby increasing myopia.
In a textbook on Clinical Pearls in Refractive Care, I provided examples that run counter to Dr. Glazier’s blanket assertion. How does one explain the patient who shows a manifest auto-refractor and subjective finding of -1.50 OU to 20/20, but a cycloplegic auto-refractor finding and subjective of -0.50 OU? One cannot explain it on the basis of axial length increase, or on properties of the peripheral retina that change due to dilation. This type of myopic decrease on refraction does not occur when the cycloplegic effect has worn off but the patient is still dilated. The only logical explanation is that a component of myopia in this case is accommodative in nature. It is the most direct, objective evidence for a particular patient of what some refer to as a pseudo-myopic shift.
Dr. Glazier did mention that when the patient presents with esophoria, a multifocal Rx providing plus for near can exert a modest influence on the progression of myopia. To that I would add that when multifocals are prescribed, either a flat-top or round segment should be utilized. This avoids undesirable defocus in the retinal periphery that is neither hyperopic nor myopic in nature, but simply distorted.
Rather than myopia industry memes that discount any influence of nearpoint stress factors for select patients, I prefer the more nuanced approach espoused by myopia researchers Morgan and Rose that myopia is heterogenous in nature. There are individual patients for whom alleviating nearpoint stress is relevant. Writing in the journal Clinical and Experimental Optometry they state:
“While none of the evidence used to support a strongly genetic origin for myopia has proven to be strong, there are several lines of evidence that support a role for defined environmental factors. The two strongest environmental factors that have emerged are education (possibly mediated by nearwork) and time outdoors … A different way of looking at this issue is suggested here, based on recognition of the fact that myopia is a heterogeneous condition aetiologically, with numerous rare syndromic and non‐syndromic forms based on genetic variation that together account for myopia in only a low percentage of the population. There is also a major form of myopia, school myopia, that is strongly influenced by environmental factors such as exposure to schooling and the amount of time spent outdoors.”