MYOPIA

• Myopia , also called near- or shortsightedness, is a refractive defect of the eye in which collimated light produces image focus in front of the retina when accommodation is relaxed.

• Those with myopia see nearby objects clearly but distant objects appear blurred. With myopia, the eyeball is too long, or the cornea is too steep, so images are focused in the vitreous inside the eye rather than on the retina at the back of the eye.

Classification
• Axial myopia is attributed to an increase in the eye's axial length • Refractive myopia is attributed to the condition of the refractive elements of the eye

• Refractive myopia further sub classified : Curvature myopia is attributed to excessive, or increased, curvature of one or more of the refractive surfaces of the eye, especially the cornea Index myopia is attributed to variation in the index of refraction of one or more of the ocular media

Clinical entity
• Various forms of myopia have been described by their clinical appearance • Simple myopia is more common than other types of myopia and is characterized by an eye that is too long for its optical power (which is determined by the cornea and crystalline lens) or optically too powerful for its axial length. Both genetic and environmental factors, particularly significant amounts of near work, are thought to contribute to the development of simple myopia.

• Degenerative myopia, also known as malignant, pathological, or progressive myopia, is characterized by marked fundus changes, such as posterior staphyloma, and associated with a high refractive error and subnormal visual acuity after correction. This form of myopia gets progressively worse over time. Degenerative myopia has been reported as one of the main causes of visual impairment

• Nocturnal myopia, also known as night myopia or twilight myopia, is a condition in which the eye has a greater difficulty seeing in low illumination areas, even though its daytime vision is normal. Essentially, the eye's far point of an individual's focus varies with the level of light. Night myopia is believed to be caused by pupils dilating to let more light in, which adds aberrations resulting in becoming more nearsighted. A stronger prescription for myopic night drivers is often needed. Younger people are more likely to be affected by night myopia than the elderly.

• Pseudomyopia is the blurring of distance vision brought about by spasm of the ciliary muscle.

• Induced myopia, also known as acquired myopia, results from exposure to various pharmaceuticals, increases in glucose levels, nuclear sclerosis, or other anomalous conditions. The encircling bands used in the repair of retinal detachments may induce myopia by increasing the axial length of the eye.

• Index myopia is attributed to variation in the index of refraction of one or more of the ocular media. Cataracts may lead to index myopia.

• deprivation myopia is a type of myopia that occurs when the eyesight is deprived by limited illumination and vision range, or the eye is modified with artificial lenses or deprived of clear form vision. In lower vertebrates this kind of myopia seems to be reversible within short periods of time. Myopia is often induced this way in various animal models to study the pathogenesis and mechanism of myopia development.

• Nearwork Induced Transient Myopia (NITM), is defined as short-term myopic far point shift immediately following a sustained near visual task. Some authors argue for a link between NITM and the development of permanent myopia

Degree
• Myopia, which is measured in diopters by the strength or optical power of a corrective lens that focuses distant images on the retina, has also been classified by degree or severity

• Low myopia usually describes myopia of −3.00 diopters or less

• Medium myopia usually describes myopia between −3.00 and −6.00 diopters . Those with moderate amounts of myopia are more likely to have pigment dispersion syndrome or pigmentary glaucoma

• High myopia usually describes myopia of −6.00 or more. People with high myopia are more likely to have retinal detachments and primary open angle glaucoma. They are also more likely to experience floaters, shadow-like shapes which appear singly or in clusters in the field of vision. Roughly 30% of myopes have high myopia

Age of onset
• Congenital myopia, also known as infantile myopia, is present at birth and persists through infancy

• Youth onset myopia occurs prior to age 20.
appears during childhood, particularly the school-age years. This form of myopia is attributed to the use of the eyes for close work during the school years.

• Adult onset myopia
– Early adult onset myopia occurs between ages 20 and 40. – Late adult onset myopia occurs after age 40

Epidemiology
• The global prevalence of refractive errors has been estimated from 800 million to 2.3 billion. The incidence of myopia within sampled population often varies with age, country, sex, race, ethnicity, occupation, environment, and other factors. Variability in testing and data collection methods makes comparisons of prevalence and progression difficult.

• In some areas, such as China, India and Malaysia, up to 41% of the adult population is myopic to -1dpt • A recent study involving first-year undergraduate students in the United Kingdom found that 50% of British whites and 53.4% of British Asians were myopic

• In Greece, the prevalence of myopia among 15 to 18 year old students was found to be 36.8%. • In the United States, the prevalence of myopia has been estimated at 20%. Nearly 1 in 10 (9.2%) American children between the ages of 5 and 17 have myopia. Approximately 25% of Americans between the ages of 12 and 54 have the condition

Ethnicity and race
• The prevalence of myopia has been reported as high as 70-90% in some Asian countries, 30-40% in Europe and the United States, and 10-20% in Africa

Education, intelligence, and IQ
• A number of studies have shown that the prevalence of myopia increases with level of education and many studies have shown a relationship between myopia and IQ. • According to Arthur Jensen, myopes average 7-8 IQ points higher than nonmyopes

• The relationship also holds within families, and siblings with a higher degree of refraction error average higher IQs than siblings with less refraction error. Jensen believes that this indicates myopia and IQ are pleiotropically related as they are caused or influenced by the same genes.

• No specific mechanism that could cause a relationship between myopia and IQ has yet been identified. Another possible explanation is that high levels of reading is a common cause for both intelligence and myopia, as it supposed that large amounts of close work is a causal factor of myopia

Etiology and pathogenesis
• Because in the most common, "simple" myopia, the eye length is too long, any etiologic explanation must account for such axial elongation. To date, no single theory has been able to satisfactorily explain this elongation

• Among mainstream researchers and eye care professionals, myopia is now thought to be a combination of genetic and environmental factors

• There are currently two basic mechanisms believed to cause myopia: also known as pattern deprivation and optical defocus.

• Form deprivation occurs when the image quality on the retina is reduced; optical defocus occurs when light focuses in front of or behind the retina. Numerous experiments with animals have shown that myopia can be artificially generated by inducing either of these conditions. In animal models wearing negative spectacle lenses, axial myopia has been shown to occur as the eye elongates to compensate for optical defocus.

Theories
• Combination of genetic and environmental factors: In China,
myopia is more common in those with higher education background and some studies suggest that near work may exacerbate a genetic predisposition to develop myopia

• myopia— determined by heritage — some people are at a higher risk to develop myopia when exposed to modern environmental conditions with a lot of extensive near work like reading. In other words, it is often not the myopia itself which is inherited, but the reaction to specific environmental conditions — and this reaction can be the onset and the progression of myopia.

• Genetic factors — The wide variability of the prevalence of myopia in different ethnic groups has been reported as additional evidence supporting the role of genetics in the development of myopia

• Genetic factors include an inherited, increased susceptibility for environmental influences like excessive near work, and the fact that some people do not develop myopia in spite of very adverse conditions is a clear indication that heredity is involved somehow in any case

• Environmental factors — It has been suggested that a genetic susceptibility to myopia does not exist. A high heritability of myopia (as for any other condition) does not mean that environmental factors and lifestyle have no effect on the development of the condition

• Other theories suggest that the eyes become strained by the constant extra work involved in "nearwork" and get stuck in the near position, and eye exercises can help loosen the muscles up thereby freeing it for far vision.

• These primarily mechanical models appear to be in contrast to research results, which show that the myopic elongation of the eye can be caused by the image quality, with biochemical processes as the actuator

• Common to both views is, however, that extensive near work and corresponding accommodation can be essential for the onset and the progression of myopia

• Near work • Diet and nutrition - One 2002 article suggested that myopia may be caused by over-consumption of bread in childhood, or in general by diets too rich in carbohydrates, which can lead to chronic hyperinsulinemia. • Stress has been postulated as a factor in the development of myopia

Diagnosis
• A diagnosis of myopia is typically confirmed during an eye examination by an ophthalmologist or an optometrist. Frequently an autorefractor or retinoscope is used to give an initial objective assessment of the refractive status of each eye, then a phoropter is used to subjectively refine the patient's eyeglass prescription.

Treatment, management, and prevention
• Eyeglasses, contact lenses, and refractive surgery are the primary options to treat the visual symptoms of those with myopia. Orthokeratology is the practice of using special rigid contact lenses to flatten the cornea to reduce myopia

Eye-exercises and biofeedback
• Practitioners and advocates of alternative therapies often recommend eye exercises and relaxation techniques. However, the efficacy of these practices is disputed by scientists and eye care practitioners. A 2005 review of scientific papers on the subject concluded that there was "no clear scientific evidence" that eye exercises were effective in treating myopia.

Prevention
• There is no universally accepted method of preventing myopia. Commonly attempted preventative methods include wearing reading glasses, eye drops and participating in more outdoor activities

• Some clinicians and researchers recommend plus power (convex) lenses in the form of reading glasses when engaged in close work or reading instead of using single focal concave lens glasses commonly prescribed

• Pirenzepine eyedrops had a limited effect on retarding myopic progression in a recent, placebo-control, double-blinded prospective controlled study

• Daylight may prevent myopia. Australian researchers had concluded that exposure to daylight appeared to play a critical role in restricting the growth of the eyeball, which is responsible for myopia or short-sightedness. They compared children from other developed countries such as Singapore and Australian children spent about 2-3 hours a day outdoors which could increased dopamine in the eyes that restrict distorted shaping of the eye

Myopia control
• Various methods have been employed in an attempt to decrease the progression of myopia. The use of reading glasses when doing close work may provide success by reducing or eliminating the need to accommodate. Altering the use of eyeglasses between full-time, parttime, and not at all does not appear to alter myopia progression. Bifocal and progressive lenses have not shown significant differences in altering the progression of myopia.

Hyperopia

• Hyperopia, also known as far-sightedness, long-sightedness or hypermetropia, is a defect of vision caused by an imperfection in the eye (often when the eyeball is too short or when the lens cannot become round enough), causing inability to focus on near objects, and in extreme cases causing a sufferer to be unable to focus on objects at any distance. As an object moves toward the eye, the eye must increase its power to keep the image in focus on the retina. If the power of the cornea and lens is insufficient, as in hyperopia, the image will appear blurred.

Clinical entity
• People with hyperopia can experience blurred vision, asthenopia, accommodative dysfunction, binocular dysfunction, amblyopia, and strabismus.

• Hyperopia is often confused with presbyopia, another condition that frequently causes blurry near vision. Presbyopes who report good far vision typically experience blurry near vision because of a reduced accommodative amplitude brought about by natural aging changes with the crystalline lens.

Diagnosis
• Visual acuity is affected according to the amount of hyperopia, as well as the patient's age, visual demands, and accommodative ability

Treatment
• Various eye care professionals, including ophthalmologists, optometrists, orthoptists, and opticians, are involved in the treatment and management of hyperopia. At the conclusion of an eye examination, an eye doctor may provide the patient with an eyeglass prescription for corrective lenses

• Minor amounts of hyperopia are sometimes left uncorrected, however, larger amounts may be corrected with convex lenses in eyeglasses or contact lenses. Convex lenses have a positive dioptric value, which causes the light to focus closer than its normal range. • Hyperopia is sometimes correctable with various refractive surgery procedures (LASIK). It can also be corrected with special concave lenses.

Astigmatism

• Astigmatism is an optical defect in which vision is blurred due to the inability of the optics of the eye to focus a point object into a sharp focused image on the retina. This may be due to an irregular or toric curvature of the cornea or lens

• An optical system with astigmatism is one where rays that propagate in two perpendicular planes have different foci. If an optical system with astigmatism is used to form an image of a cross, the vertical and horizontal lines will be in sharp focus at two different distances

Types
• Based on focus of the principal meridians
• Simple astigmatism • Simple hyperopic astigmatism – first focal line coincides with the retina while the second is located behind the retina • Simple myopic astigmatism – first focal line is located in front of the retina while the second focal line is located on the retina

• Compound astigmatism
• Compound hyperopic astigmatism – both focal lines are located behind the retina • Compound myopic astigmatism – both focal lines are located in front of the retina

• Mixed astigmatism – focal lines are on both sides of the retina (straddling the retina)

Prevalence
• According to an American study published in Archives of Ophthalmology, nearly 3 in 10 children between the ages of 5 and 17 have astigmatism • A recent Brazilian study found that 34% of the students in one city were astigmatic. Regarding the prevalence in adults, a recent study in Bangladesh found that nearly 1 in 3 (32.4%) of those over the age of 30 had astigmatism

• A number of studies have found that the prevalence of astigmatism increases with age

Diagnosis
• 1. Symptoms
• Although mild astigmatism may be asymptomatic, higher amounts of astigmatism may cause symptoms such as blurry vision, squinting, asthenopia, fatigue, or headaches

• 2.Signs and tests
• A keratometer may be used to measure the curvature of the steepest and flattest meridians in the cornea's front surface. A may also be used to obtain a more accurate representation of the cornea's shape.

Treatment
• Astigmatism may be corrected with eyeglasses, contact lenses, or refractive surgery. Various considerations involving ocular health, refractive status, and lifestyle frequently determine whether one option may be better than another

• In those with keratoconus, rigid gas permeable contact lenses often enable patients to achieve better visual acuities than eyeglasses. If the astigmatism is caused by a problem such as deformation of the eyeball due to a chalazion, treating the underlying cause will resolve the astigmatism. Should the person suffer from severe astigmatism, they will be advised to wear hard rigid gas permeable lenses rather than the more comfortable soft lenses

Presbyopia
• Presbyopia is a vision condition in which the crystalline lens of your eye loses its flexibility, which makes it difficult for you to focus on close objects

• Presbyopia may seem to occur suddenly, but the actual loss of flexibility takes place over a number of years. Presbyopia usually becomes noticeable in the early to mid-40s. Presbyopia is a natural part of the aging process of the eye. It is not a disease, and it cannot be prevented.

• Similar to grey hair and wrinkles, presbyopia is a symptom caused by the natural course of aging

• The ability to focus on near objects declines throughout life, from an accommodation of about 20 dioptres (ability to focus at 50 mm away) in a child to 10 dioptres at 25 (100 mm) and leveling off at 0.5 to 1 dioptre at age 60 (ability to focus down to 1-2 meters only).

Symptoms
• The first symptoms most people notice are difficulty reading fine print, particularly in low light conditions, eyestrain when reading for long periods, blur at near or momentarily blurred vision when transitioning between viewing distances. Many advanced presbyopes complain that their arms have become "too short" to hold reading material at a comfortable distance

• A delayed onset of seeking correction for presbyopia has been found among those with certain professions and those with miotic pupils.In particular, farmers and homemakers seek correction later, whereas service workers and construction workers seek eyesight correction earlier.

• In optics, the closest point at which an object can be brought into focus by the eye is called the eye's near point. A standard near point distance of 25 cm is typically assumed in the design of optical instruments, and in characterizing optical devices such as magnifying glasses.

• In the classic book, 'Eye and Brain' by Gregory, for example, the lens is said to be suspended by a membrane, the 'zonula', which holds it under tension. The tension is released, by contraction of the ciliary muscle, to allow the lens to fatten, for close vision. This would seem to imply that the ciliary muscle, which is outside the zonula must be circumferential, contracting like a sphincter, to slacken the tension of the zonula pulling outwards on the lens

Treatment
• Presbyopia is not routinely curable - the loss of focusing ability can be compensated for by corrective lenses including eyeglasses or contact lenses. In subjects with other refractory problems, convex lenses are used. In some cases, the addition of bifocals to an existing lens prescription is sufficient. As the ability to change focus worsens, the prescription needs to be changed accordingly.

• In order to reduce the need for bifocals or reading glasses, some people choose contact lenses to correct one eye for near and one eye for far with a method called "monovision

• Surgery • New surgical procedures may also provide solutions for those who do not want to wear glasses or contacts, including the implantation of accommodative intraocular lenses (IOLs). , which increase the space between the ciliary body and lens, have not been found to provide predictable or consistent results in the treatment of presbyopia