Highlights from the 2019 International Myopia Summit on 'controversies in myopia'.

Myopia is an emerging public health issue with potentially significant economic and social impact, especially in East Asia. However, many uncertainties about myopia and its clinical management remain. The International Myopia Summit workgroup was convened by the Singapore Eye Research Institute, the WHO Regional Office for the Western Pacific and the International Agency for the Prevention of Blindness in 2019. The aim of this workgroup was to summarise available evidence, identify gaps or unmet needs and provide consensus on future directions for clinical research in myopia. In this review, among the many 'controversies in myopia' discussed, we highlight three main areas of consensus. First, development of interventions for the prevention of axial elongation and pathologic myopia is needed, which may require a multifaceted approach targeting the Bruch's membrane, choroid and/or sclera. Second, clinical myopia management requires co-operation between optometrists and ophthalmologists to provide patients with holistic care and a tailored approach that balances risks and benefits of treatment by using optical and pharmacological interventions. Third, current diagnostic technologies to detect myopic complications may be improved through collaboration between clinicians, researchers and industry. There is an unmet need to develop new imaging modalities for both structural and functional analyses and to establish normative databases for myopic eyes. In conclusion, the workgroup's call to action advocated for a paradigm shift towards a collaborative approach in the holistic clinical management of myopia

Spatial perception and progressive addition lenses

Progressive addition lenses (PALs) are an increasingly preferred mode for the correction of presbyopia, gaining an increased share of the prescription lens market. Sales volumes are likely to increase over the next few years, given the increasing cohort of presbyopic patients in the population. This research investigated adaptation to PAL wear, investigating head movement parameters with and without progressive lenses in everyday visual tasks, and examined symptoms of spatial distortions and illusory movement in a crossover wearing trial of three PAL designs. Minimum displacement thresholds in the presence and absence of head movement were also investigated across the lens designs. Experiment 1 investigated head movements in two common visual tasks, a wordprocessing copy task, and a visual search task designed to replicate a natural environment task such as looking for products on supermarket shelving. Head movement parameters derived from this experiment were used to set head movement amplitude and velocity in the third experiment investigating minimum displacement thresholds across three PAL designs. Head movements were recorded with a Polhemus Inside Track head movement monitoring system which allows real time six degrees of freedom measurement of head position. Head position in azimuth, elevation and roll was extracted from the head movement recorder output, and data for head movement angular extent, average velocity (amplitude/duration) and peak velocity were calculated for horizontal head movements Results of the first experiment indicate a task dependent effect on head movement peak and average velocity, with both median head movement average and peak velocity being faster in the copy task. Visual task and visual processing demands were also shown to affect the slope of the main sequence of head movement velocity on head movement amplitude, with steeper slope in the copy task. A steeper slope, indicating a faster head movement velocity for a given head movement amplitude, was found for head movements during the copy task than in the search task. Processing demands within the copy task were also shown to affect the main sequence slopes of velocity on amplitude, with flatter slopes associated with the need for head movement to bring gaze to a specific point. These findings indicate selective control over head movement velocity in response to differing visual processing demands. In Experiment 2, parameters of head movement amplitude and velocity were assessed in a group of first time PAL wearers. Head movement amplitude, average and peak velocity were calculated from head movement recordings using the search task, as in Experiment 1. Head movements were recorded without PALs, on first wearing a PAL, and after one month of PAL wear to assess adaptation effects. In contrast to existing literature, PAL wear did not alter parameters of head movement amplitude and velocity in a group of first time wearers either on first wearing the lenses or after one month of wear: this is due to task related effects in this experiment compared to previous work. Task demand in this experiment may not have required wearers to use the progressive power corridor to accomplish identification of visual search targets, in contrast to previous studies where experimental conditions were designed to force subjects to use the progressive corridor. In Experiment 3, minimum displacement thresholds for random dot stimuli were measured in a repeated measures experimental design for a single vision lens as control, and three PAL designs. Thresholds were measured in central vision, and for two locations in the temporal peripheral field, 30° temporal fixation and 10° above and below the horizontal midline. Thresholds were determined with and without the subjects' head moving horizontally in an approximate sinusoidal movement at a frequency of about 0.7 Hz. Minimum displacement thresholds were not significantly affected by PAL design, although thresholds with PALs were higher than with a single vision lens control. Head movement significantly increased minimum displacement threshold across lens designs, by a factor of approximately 1.5 times. Results indicate that the local measures of minimum displacement threshold determined in this experiment are not sensitive to lens design differences. Sensitivity to motion with PAL lenses may be more a global than a localized response. For Experiment 4, symptoms of spatial distortion and illusory movement were investigated in a crossover wearing trial of three PAL designs, and related to optical characteristics of the lenses. Peripheral back vertex powers of the PALs were measured at two locations in the right temporal zone of the lenses, 15.6 mm temporal to the fitting cross, and 2.7 m above and below the horizontal to the fitting cross. These locations corresponded to the zones of the lenses through which minimum displacement thresholds were measured in the previous experiment. The effect of subjects' self movement on symptoms is able to discriminate between PAL designs, although subjective symptoms alone were not related to the lens design parameters studied. Subjects' preference for one PAL design over the other designs studied in this experiment is inversely related to the effect on subject movement on their symptoms of distortion. An optical parameter, blur strength, derived from the power vector components of the peripheral powers, may indicate preference for particular PAL designs, as higher blur strength values are associated with lower lens preference scores. Head movement amplitude and velocity are task specific, and are also influenced by visual processing demands within tasks. PALs do not affect head movement amplitude and velocity unless tasks are made demanding or performed in less natural situations designed to influence head movement behaviour. Both head movement and PALs have large effects on minimum displacement thresholds; these effects may be due in part to complexity of the subjects' task within the experiment. Minimum displacement thresholds however were not influenced by PAL design. The most sensitive indicator for subject's preference of PALs was the effect of subjects' self movement on their perception of symptoms, rather than the presence of actual symptoms. Blur strength should be further investigated for its role in PAL acceptance

Repeatability and Validity of Lens Densitometry Measured With Scheimpflug Imaging

Purpose To assess the repeatability and validity of lens densitometry derived from the Pentacam Scheimpflug imaging system. Setting Eye Clinic, Queensland University of Technology, Brisbane, Australia. Methods This prospective cross-sectional study evaluated 1 eye of subjects with or without cataract. Scheimpflug measurements and slitlamp and retroillumination photographs were taken through a dilated pupil. Lenses were graded with the Lens Opacities Classification System III. Intraobserver and interobserver reliability of 3 observers performing 3 repeated Scheimpflug lens densitometry measurements each was assessed. Three lens densitometry metrics were evaluated: linear, for which a line was drawn through the visual axis and a mean lens densitometry value given; peak, which is the point at which lens densitometry is greatest on the densitogram; 3-dimensional (3D), in which a fixed, circular 3.0 mm area of the lens is selected and a mean lens densitometry value given. Bland and Altman analysis of repeatability for multiple measures was applied; results were reported as the repeatability coefficient and relative repeatability (RR). Results Twenty eyes were evaluated. Repeatability was high. Overall, interobserver repeatability was marginally lower than intraobserver repeatability. The peak was the least reliable metric (RR 37.31%) and 3D, the most reliable (RR 5.88%). Intraobserver and interobserver lens densitometry values in the cataract group were slightly less repeatable than in the noncataract group. Conclusion The intraobserver and interobserver repeatability of Scheimpflug lens densitometry was high in eyes with cataract and eyes without cataract, which supports the use of automated lens density scoring using the Scheimpflug system evaluated in the stud

A visual profile of Queensland Indigenous children

Purpose Little is known about the prevalence of refractive error, binocular vision, and other visual conditions in Australian Indigenous children. This is important given the association of these visual conditions with reduced reading performance in the wider population, which may also contribute to the suboptimal reading performance reported in this population. The aim of this study was to develop a visual profile of Queensland Indigenous children. Methods Vision testing was performed on 595 primary schoolchildren in Queensland, Australia. Vision parameters measured included visual acuity, refractive error, color vision, nearpoint of convergence, horizontal heterophoria, fusional vergence range, accommodative facility, AC/A ratio, visual motor integration, and rapid automatized naming. Near heterophoria, nearpoint of convergence, and near fusional vergence range were used to classify convergence insufficiency (CI). Results Although refractive error (Indigenous, 10%; non-Indigenous, 16%; p = 0.04) and strabismus (Indigenous, 0%; non-Indigenous, 3%; p = 0.03) were significantly less common in Indigenous children, CI was twice as prevalent (Indigenous, 10%; non-Indigenous, 5%; p = 0.04). Reduced visual information processing skills were more common in Indigenous children (reduced visual motor integration [Indigenous, 28%; non-Indigenous, 16%; p < 0.01] and slower rapid automatized naming [Indigenous, 67%; non-Indigenous, 59%; p = 0.04]). The prevalence of visual impairment (reduced visual acuity) and color vision deficiency was similar between groups. Conclusions Indigenous children have less refractive error and strabismus than their non-Indigenous peers. However, CI and reduced visual information processing skills were more common in this group. Given that vision screenings primarily target visual acuity assessment and strabismus detection, this is an important finding as many Indigenous children with CI and reduced visual information processing may be missed. Emphasis should be placed on identifying children with CI and reduced visual information processing given the potential effect of these conditions on school performanc

Vision problems and reduced reading outcomes in Queensland schoolchildren

Purpose - This study assessed the relationship between vision and reading outcomes in Indigenous and non- Indigenous schoolchildren to determine whether vision problems are associated with lower reading outcomes in these populations. Methods - Vision testing and reading assessments were performed on 508 Indigenous and non-Indigenous schoolchildren in Queensland, Australia divided into two age groups: Grades 1- 2 (6-7 years of age) and Grades 6-7 (12-13 years of age). Vision parameters measured included cycloplegic refraction, near point of convergence, heterophoria, fusional vergence range, rapid automatized naming and visual motor integration. The following vision conditions were then classified based on the vision findings: uncorrected hyperopia, convergence insufficiency, reduced rapid automatized naming and delayed visual motor integration. Reading accuracy and reading comprehension were measured with the Neale reading test. The effect of uncorrected hyperopia, convergence insufficiency, reduced rapid automatized naming and delayed visual motor integration on reading accuracy and reading comprehension were investigated with ANCOVAs. Results - The ANCOVAs explained a significant proportion of variance in both reading accuracy and reading comprehension scores in both age groups, with 40% of the variation in reading accuracy and 33% of the variation in reading comprehension explained in the younger age group, and 27% and 10% of the variation in reading accuracy and reading comprehension, respectively, in the older age group. The vision parameters of visual motor integration and rapid automatized naming were significant predictors in all ANCOVAs (pConclusions - Both reduced rapid automatized naming and visual motor integration were associated with poorer reading outcomes in Indigenous and non-Indigenous children. This is an important finding given the recent emphasis placed on Indigenous children’s reading skills and the fact that reduced rapid automatized naming and visual motor integration skills are more common in this group

Near binocular visual function in young adult orthokeratology versus soft contact lens wearers

Purpose: To compare near point binocular vision function of young adult myopes wearing orthokeratology (OK) lenses to matched single vision soft disposable contact lens (SCL) wearers. Methods: A retrospective clinical record analysis of all OK wearers (18–30 years) presenting over an 18 month period was undertaken. Data was extracted for 17 OK wearers, with 17 SCL wearers matched for age, refractive error and duration of contact lens wear. Binocular vision data included horizontal phoria (phoria), horizontal base-in (BIFR) and base-out fusional reserves (BOFR) and accommodation accuracy (AA). Results: The OK group was 25.8 ± 3.2 years, with a duration of wear of 45.7 ± 25 months and refractive error of R −2.09 ± 1.23D, L −2.00 ± 1.35D. Compared to matched SCL wearers the OK group were significantly more exophoric (OK −2.05 ± 2.38Δ; SCL 0.00 ± 1.46Δ, p = 0.005) and had better accommodation accuracy (OK 0.97 ± 0.33D; SCL 1.28 ± 0.32D, p = 0.009). BIFR and BOFR were not different in the two groups. Frequency histograms showed that more SCL wearers had high lags of accommodation (AA ≥ 1.50D: 8 SCL,2 OK) and esophoria (≥1Δ: 5 SCL,1 OK) than OK wearers. A positive correlation was found between refraction and phoria in the SCL group (r = 0.521, p = 0.032). Conclusion: Young adult myopes wearing OK lenses display more exophoria and lower accommodative lags at near compared to matched single vision SCL wearers. Young adult myopes with specific binocular vision disorders may benefit from OK wear in comparison to single vision SCL wear. This has relevance to both the visual acceptance of OK lenses and in managing risk factors for myopia progression

Review of guidelines for children\u27s vision screenings

The aim of children\u27s vision screenings is to detect visual problems that are common in this age category through valid and reliable tests. Nevertheless, the cost effectiveness of paediatric vision screenings, the nature of the tests included in the screening batteries and the ideal screening age has been the cause of much debate in Australia and worldwide. Therefore, the purpose of this review is to report on the current practice of children\u27s vision screenings in Australia and other countries, as well as to evaluate the evidence for and against the provision of such screenings. This was undertaken through a detailed investigation of peer-reviewed publications on this topic. The current review demonstrates that there is no agreed vision screening protocol for children in Australia. This appears to be a result of the lack of strong evidence supporting the benefit of such screenings. While amblyopia, strabismus and, to a lesser extent refractive error, are targeted by many screening programs during pre-school and at school entry, there is less agreement regarding the value of screening for other visual conditions, such as binocular vision disorders, ocular health problems and refractive errors that are less likely to reduce distance visual acuity. In addition, in Australia, little agreement exists in the frequency and coverage of screening programs between states and territories and the screening programs that are offered are ad hoc and poorly documented. Australian children stand to benefit from improved cohesion and communication between jurisdictions and health professionals to enable an equitable provision of validated vision screening services that have the best chance of early detection and intervention for a range of paediatric visual problems

Stability of peripheral refraction changes in orthokeratology for myopia

Purpose: Orthokeratology (OK) is known to alter relative peripheral refraction (RPR) with this presumed to be its key myopia control mechanism. A prospective, longitudinal study was performed to examine stability of OK-induced RPR changes in myopic children and young adults. Methods: RPR of twelve children (C)(8–16 years) and eight adults (A)(18–29 years) with spherical equivalent refraction of -0.75 to -5.00D were measured unaided and while wearing single vision soft contact lenses (SCL). Measurements were repeated after 1, 6 and 12 months of OK wear. RPR was measured using an open-field Shin Nippon SRW-5000 autorefractor at 10, 20 and 30 degrees nasally (N) and temporally (T), converted into power vectors M, J0 and J45. On-axis refractions and axial lengths (IOL Master) were also measured. Results: Compared to the unaided state, 1-month of OK wear shifted the RPR in the myopic direction at 30 T (C: p = 0.023; A:, p = 0.002) and 30 N (C&amp;A, p = 0.003) and was stable thereafter, with similar changes compared to SCL wear. J0 showed a myopic shift in comparison to both unaided and SCL correction in children but not adults, and J45 did not change in either group. The on-axis OK correction was predictive of the RPR shift in both children and adults at 30 T (C: r=−0.58, p = 0.029; A: r=−0.92, p Conclusion: Relative to both unaided and single vision SCL correction, OK shifted the RPR in the myopic direction; the RPR was stable from 1 to 12 months. The RPR shift in OK wear varied with the degree of myopia but was not correlated with myopia progression.</p

Zone of clear single binocular vision in myopic orthokeratology

Purpose: To examine the zone of clear single binocular vision (ZCSBV) in myopic children and young adults after 12 months of orthokeratology (OK) wear, in comparison with single-vision soft contact lens (SCL) wear. Methods: Twelve children (8-16 years) and 8 adults (18-29 years) were assessed with a series of near-point binocular vision tests when myopia was corrected using single-vision SCLs and again after 1 and 12 months of OK wear, and axial length was measured. The ZCSBV was constructed for baseline SCL wear and after 12 months of OK wear. Results: After 1 month of OK wear, increased accommodative responses were noted in children (C) and adults (A) as increased binocular amplitude (C:P 0.03, A:P 0.04) and reduced accommodative lag (C:P 0.01, A:P 0.01). Divergence reserves improved after 1 month in both groups (P,0.04), and a near exophoric shift was evident at 12 months (C:P 0.01, A:P 0.04). All changes at 1 month maintained stability at 12 months. An increase in accommodation and vergence responses without reduction in range resulted in an expansion of the ZCSBV in both age groups. Axial length did not significantly change in either children (P 0.25) or adults (P 0.72). Conclusion: In both pediatric and young adult myopes, the ZCSBV expands toward a more divergent, increased accommodation response in OK compared with SCL wear. This occurs without a corresponding loss of convergence or accommodation deactivation, indicating improved depth of focus. These findings are relevant to visual acceptance and possible mechanisms of OK's efficacy for myopia control. </p