Lecture two

Myopia

Gizachew T.
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 Out line
• Definition of myopia
• Classification of myopia
• Risk factors of myopia
• Natural history of myopia
• Common signs, symptoms and complications of
myopia
• Diagnosis of myopia
• Management of myopia
• Prognosis of myopia
• summary
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 Myopia
• What is myopia?
• What are major types of myopia?
• What are the common signs and
symptoms of myopia?
• What are treatment options of myopia?

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 Definition
Myopia is the refractive anomaly of the eye in
which the conjugate focus of the retina is at some
finite point in front of the eye, when the eye is
not accommodating.
The refractive condition in which parallel light
rays from an object at optical infinity are focused
by the eye in front of the retina, with
accommodation relaxed.

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 Classification of myopia
Type of Classes of myopia
classification
Clinical entity • Simple myopia
• Nocturnal myopia
• Pseudomyopia
• Degenerative myopia
• Induced myopia
Degree • Low myopia (<3.00 D)
• Medium myopia (3.00 D-6.00 D)
• High myopia (>6.00 D)
Age of onset •Congenital myopia (present at birth and persisting
through infancy)
•Youth-onset myopia (<20 years of age)
•Early adult-onset myopia (20-40 years of age)
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•Late adult-onset myopia (>40 years of age)
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 1. Simple myopia
• The refractive status of the eye depend on the
optical power of the cornea, the crystalline lens
and the axial length.
• This is may either too long AL for its optical power
or, less commonly, too optically powerful for its
axial length.
• It is more common than the other types of myopia
• Usually <6.00D and found in combination with
astigmatism as well as in the form of anisometropia

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 2. Nocturnal myopia
Occurring only in dim illumination
Is primarily due to increased accommodative
response associated with low levels of light.
Because there is insufficient contrast for an
adequate accommodative stimulus, the eye
assumes the intermediate dark focus
accommodative position rather than focusing for
infinity.

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 3. Pseudomyopia

 Result of an increase in ocular refractive power due

to over stimulation of the eye's accommodative
mechanism or cilliary spasm.
 The patient only appears to have myopia due to an
inappropriate accommodative response.

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 4. Degenerative Myopia

 A high degree of myopia associated with

degenerative changes in the posterior segment of
the eye
 Result in abnormal visual function, such as a
decrease in best corrected visual acuity or changes
in visual fields.
 Retinal detachment and glaucoma are relatively
common.

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 5. Induced myopia
• Resulted due to exposure of various
pharmaceutical agents, variation in blood sugar
levels, nuclear sclerosis of the crystalline lens.
• Often temporary and reversible nature

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 Risk factors

Possible Risk Factors for Myopia Development

1. Family history of myopia more common for 2
parents(33-60% Vs 23-40%)
2. Presence of myopia on non cycloplegic retinoscopy in
infancy, decreasing to emmetropia before entry into
school.
3. Refractive error of emmetropia to 0.50 D of hyperopia
(in children and young adults)
4. Against-the-rule astigmatism

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 Cont.….

5. Decreased accommodative function or near point

esophoria
6.Substantial amount of near work on a regular
basis
7.Steep corneal curvature or high axial length to
corneal radius ratio
8. Conditions temporarily obscuring the retina from

clear image formation during infancy

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 Natural history
A. Simple myopia
 Although the precise etiology of simple myopia is
unknown, both inheritance and environmental factors
play significant roles.
 Progression of simple myopia can occur in adulthood.

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 B. Nocturnal Myopia
 Occurring under conditions of darkness or very
dim illumination,
 Largely/entirely due to an increase in
accommodation associated with the decreased
accommodative cues in darkness.
 The accommodative dark focus appears to be
relatively stable, at least over a period of days.

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 C. Pseudomyopia
 Encountered in younger patients performing excessive
close work.
 Sustained or excessive near demands result in
hypertonicity of the cilliary body.
 Emmetropic or slightly hyperopic patient clinically
appears to be myopic or a myopic patient appears to be
more so.
 Presumably, the condition is longstanding.

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 D. Degenerative Myopia
Enlargement of the eye may affect the appearance of the
optic nerve.
The retina is temporarily stretched away from the optic
nerve (myopic conus).
The peripheral retina is also affected, producing
characteristic changes of degenerative myopia
Severe congenital myopia during infancy typically
becomes degenerative myopia.

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 E. Induced Myopia
The natural history depends upon the initiating
condition or agent.
A refractive shift toward myopia after about age
60 is usually associated with the development of
nuclear sclerosis of the crystalline lens.
Generally the etiology of myopia is revised in
the next table

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Type of Myopia Etiologies
Simple Myopia • Inheritance
• Significant amounts of near work
• Unknown
Nocturnal Myopia • Significant levels of dark focus of accommodation
Pseudomyopia • Accommodative disorder
• High exophoria
• Cholinergic agonist agents/ miotic agents
Degenerative • Inheritance
Myopia • Retinopathy of Prematurity
• Interruption of light passing through ocular media
• Unknown
Induced Myopia • Age-related nuclear cataracts
• Exposure to sulfonamides and other pharmaceutical
agents
• Significant variability in blood sugar level
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 Common Signs, Symptoms,
and Complications
The most common symptom is blurred distance vision.
In simple myopia and degenerative myopia, blur is
constant.
In nocturnal myopia, blurred only in dim illumination
In pseudomyopia, the blurred may be constant or
intermittent with greater distance blur occurring after
near work.
In induced myopia blur can vary from transient to
constant, depending upon the particular agent or
condition causing it.
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 With the exception of pseudomyopia and some forms
of induced myopia, asthenopic symptoms are not
characteristic of myopia.
If asthenopia is present in a patient with myopia, it is
usually due to some other cause, such as astigmatism,
anisometropia, an accommodative dysfunction, or to a
vergence disorder.
Patients who have nocturnal myopia often complain
of difficulty driving at night and/or blurred distance
vision at night.

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 Patients with pseudomyopia frequently have
fluctuations in distance visual acuity that correspond
to fluctuations in accommodation.
The definitive sign of pseudomyopia is significantly
more minus power on the manifest refraction than on
the cycloplegic refraction.
Degenerative or pathological myopia is generally
high myopia that is congenital or of early onset.
Patients with myopia are more likely to have a
retinal detachment than patients with hyperopia, and
the risk for retinal detachment increases as the degree
myopia increases.
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Early detection and prevention of myopia

Reduced unaided distance visual acuity is a possible

indication of myopia, particularly when unaided near
visual acuity is normal or better than unaided distance
acuity.
Myopia can be detected by visual acuity testing,
retinoscopy, autorefraction, or photorefraction.
Objective refraction only doesn’t detect myopia.

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 Diagnosis of Myopia
1. Patient history
A. Simple Myopia
– The only symptom typical of simple myopia is blurred
distance vision and the blur is constant.
B. Nocturnal Myopia
– primary symptom of nocturnal myopia is blurred
distance vision in dim illumination.
– Difficulty seeing road signs when driving at night
C. Pseudomyopia
– A distance blur that is transient, especially when it is
greater after near task.

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D. Degenerative Myopia
– Constant distance blur
– Degree of myopia
– Close working distance due to the magnitude of the
uncorrected myopia.
– The patient may notice flashes of light or floaters
associated with vitreoretinal changes.
E. Induced Myopia
– The time course of the distance blur depends upon the
agent or the condition that has induced the myopia

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2. Ocular examination
a. Visual Acuity
– Both unaided distance and near visual acuities should
be measured.
b. Refraction
– Retinoscopy
– Autorefractor
– subjective refraction
– Cycloplegic refraction

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c. Ocular Motility, Binocular Vision, and
Accommodation
– Because convergence excess, accommodative
insufficiency, and accommodative infacility are
frequently observed in patients with myopia.
d. Ocular Health Assessment and Systemic Health
Screening
– direct or indirect ophthalmoscopy or fundus
biomicroscopy and measurement of intraocular
pressure.

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3. Supplementary tests
• Fundus photography
• A- and B-scan ultrasonography
• Visual fields
• Tests such as fasting blood sugar

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 Management of myopia
Goals : to give clear, comfortable, efficient binocular
vision and maintaining good ocular health.
Available Treatment Options
a. Optical Correction( spectacle Vs contact lens)
b. Medical (Pharmaceutical) avoid induced
myopia & reduce rate of progression(atropine)
c. Vision Therapy
d. Orthokeratology
e. Refractive Surgery

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 Management strategies
a. Simple myopia
Pediatric Cases
It is generally not necessary to correct myopia of less
than about 3 D in infants and toddlers.
Myopia of more than 1.00-2.00 D in preschool
children can be corrected with minus lenses.
Adolescent and Adult Cases
Any degree of myopia should be corrected give clear
distance vision.

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b. Nocturnal Myopia
prescribe minus lenses for use only at night or in dark
conditions.
For patients who require spectacle correction of myopia under
normal illumination may need pairs of spectacles, the second
Rx should incorporate the additional minus power for night
time.
c. Pseudomyopia
goal of treatment for pseudomyopia is to relax the
patient's accommodation.
The full minus lens power from the manifest
refraction should not be prescribed for long-term use.

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 Pseudomyopia….
Treating the accommodative dysfunction which may include:
– Vision therapy
– Instillation of a cycloplegic agent to eliminate
accommodative spasm
– Near point plus lens addition
– Instruction in visual hygiene
Pseudomyopia occasionally occurs secondary to
high exophoria as a means of maintaining fusion
through accommodative convergence.
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 d. Degenerative Myopia
Contact lenses offer expanded visual field and improved
cosmesis in the correction of high myopia.
A disadvantage of contact lenses is that greater
accommodation is required, resulting nearpoint blur and
eyestrain.
When spectacles are prescribed, minimize weight and
optimize the appearance of the spectacles by using small
eye sizes, round lens shapes, high-index lenses, thick eye
wire frames, dark frames, and antireflection coatings.
Vertex distance - determined and incorporated in lens
prescriptions>-5.00D.
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e. Induced Myopia
• Treatment depends upon the causative agent.
• This treatment may involve preventing future
exposure to the agent.
• Referral to an appropriate practitioner

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Visual hygiene recommendations include
the following:
• When reading or doing intensive near work, take a
break about every 20-30 minutes.
• When reading, maintain proper distance from the book.
• Be sure illumination is sufficient for reading.
• Avoid glare on the page by using a diffuse light
• Do the visual task using a relaxed upright posture.
• Place a limit on the time spent watching television and
watching video games.

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 Patient Education
• Instructions concerning frequency of wearing
spectacles or contact lenses.
• Off the spectacle to read at near if the degree low
• Try to relax accommodation
• Advise on the recall or follow up
• Avoid the causes of blunt trauma and to wear eye
protection(polycarbonate lenses)

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Prognosis and Follow-up
– The prognosis for correction of simple myopia is very
good.
– Patients can achieve better distance vision with
correction.
– Depending upon the degree of myopia, astigmatism,
anisometropia, and the patient's accommodation and
Vergence functions, the patient may or may not see
better at near with correction.
– Follow-up at 6-month intervals may be appropriate
for children who have unusually high myopia
progression rates.
– Adults with simple myopia should be examined at
least every 2 years.

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 – Contact lens wearers generally require more frequent
follow up.
– The patient with nocturnal myopia should be
evaluated 3-4 weeks after receiving the correction for
nighttime seeing, to determine whether the
correction has eliminated the symptoms or not.
– prognosis for correction of nocturnal myopia is
good.
– Treatments for pseudomyopia are usually successful,
but the course of treatment may be slow and it may
require several weeks.
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 – The prognosis for patients with degenerative myopia
varies with the retinal and ocular changes that occur.
– Examinations should be conducted on an annual or
more frequent basis, depending upon the nature and
severity of retinal and ocular changes
– Regular retinal examination, visual fields testing,
and measurement of intraocular pressure are
important aspects of follow-up care.
– In cases of induced myopia, both prognosis and
recommended frequency of follow-up examination
depend upon the inducing agent or condition.

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 THANK YOU!!!

ANY QUESTION?

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