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Myopia: incidence, pathogenesis,


management and new possibilities
of treatment
Damian Czepita
Department of Ophthalmology, Pomeranian Medical University, Szczecin, Poland

Recently, a substantial increase in the prevalence of myopia was observed. Particularly high levels of myopia were
found among children. Probably, it is caused by intensive near visual work such as: reading, writing, working on a computer.
In this paper the definition and classification of myopia were described. The incidence, pathogenesis, management and new
possibilities of treatment of this refractive error have been given. Special attention has been paid to the results of experimental
and clinical studies of drugs inhibiting the progress of myopia.
Key words: myopia, incidence, pathogenesis, management, treatment.
Russian Ophthalmological Journal 2014; 1:96–101

Despite myopia being a serious contemporary social based on the degree of the refractive error:
problem no effective treatment method for this refractive 1) low (<3 D)
error has been developed. Only a few methods of myopia 2) medium (3–6 D)
management have been developed so far. The lack of an 3) high (> 6 D)
effective method of myopia treatment is caused by the based on the age of onset:
incomplete understanding of the pathogenesis of this 1) congenital (present at birth and persisting
disease [1–9]. through infancy)
Therefore, the aim of this paper was to describe and 2) youth-onset (<20 years of age)
evaluate contemporary views on the incidence, patho- 3) early adult-onset (20–40 years of age)
genesis, management and new treatment possibilities 4) late adult-onset (>40 years of age)
of myopia. based on the clinical entity:
Description and classification of myopia. Myopia is a 1) simple (less than 6 D, without pathological
refractive error, in which parallel light rays, after refraction changes)
by the cornea, lens and other centers of the optical system 2) nocturnal (occurring only in dim illumination)
of the eye are focused in front of the retina. 3) pseudomyopia (is the result of an increase in
Myopia can be classified as axial and refractive. In ocular refractive power due to overstimulation of the eye’s
axial myopia the axial length is increased with the eye accommodative mechanism or ciliary spasm)
having normal refractive power. In refractive myopia 4) degenerative (a high degree of myopia associated
the axial length of the eye is normal, but the refractive with degenerative changes in the posterior segment of the
power is increased. The near point and far point come eye also known as pathological myopia)
closer. A decrease in the amplitude of accommodation, 5) induced (is the result of exposure to various
decrease of visual acuity, a loss of balance between ac- pharmaceutical agents, variation in blood sugar levels,
commodation and convergence, micropsia, deforma- nuclear sclerosis of the crystalline lens, or other anomalous
tion of the retinal image, night blindness, photopho- condition. This myopia is often temporary and reversible)
bia, dyschromatopsia and constriction or visual field [10–12].
defects occur. Incidence of myopia. Myopia is currently a serious
Currently the most accepted classification of myopia health issue, which unfortunately up until now has not
in the world is: been solved.

96 © Damian Czepita
Department of Ophthalmology, Pomeranian Medical University, Szczecin, Poland
Over the past 50 years the incidence of myopia has tions temporarily obscuring the retina from clear imagery
significantly risen. Currently an estimated 1.6 billion during infancy.
people worldwide suffer from myopia. Based on global It is currently believed that the risk factors for myopia
estimates, it is believed that by the year 2020 around are: sleeping in illuminated rooms until the age of 2 years,
2.5 billion people, being 1/3 of the world population will high level of education, having a high IQ, infrequent
have developed myopia. In the U.S.A. and in Western outdoor activity, passive exposure to cigarette smoke
Europe an estimated 1/4 of the population aged over [4, 8, 11, 15–23].
40 years old will have myopia. Role of accommodation. However, it is without
In East and Southwestern Asian countries such as doubt that the most important environmental factor for
Singapore, China, Taiwan, Hong Kong, Japan and South myopia is intensive near work such as reading, writing or
Korea a major rise in the incidence of myopia has been working on a computer. Numerous publications confirm
observed. It was determined that 80–90% of children this finding, shown in Table 2.
graduating from high school have myopia. In this group, It is widely believed that the more frequent incidence
between 10–20% of children suffer from high myopia. of myopia in people subjected to intensive near work is
The prevalence of myopia among schoolchildren caused by accommodative spasm. During intensive near
living in different countries and environments is pre- work the image viewed is focused slightly posterior to the
sented in Table 1. The prevalence among schoolchildren retina, which may induce accommodative spasm, defor-
aged 5–18 years varies from 1.2–35.1% depending on mation of the image on the retina and an increase of axial
the country and environment. This refractive error has a length of the eyeball.
high prevalence rate in China, but occurs rarely in Nepal It has been observed that watching television is
and South Africa. It has been also established that myopia tiring for the eyesight but does not lead to a more frequent
occurs more frequently in children from urban rather than incidence of myopia. This is most probably due to the fact
rural areas [1–5, 8, 11, 13]. that most people watch television from a distance of a few
Myopia prevalence among Polish students ranging meters with little risk of developing accommodative spasm
from 6 to 18 years is presented in Figure 1 [3, 4]. [4, 5, 11, 17, 23–27].
Pathogenesis of myopia. The incidence of myopia Role of peripheral retina. Based on the latest clini-
depends on genetic and environmental factors. Myopia cal and experimental studies it has been proven that the
is inherited in a mono- or polygenic fashion. Mono- peripheral retina plays a role in the development of the
genic inheritance occurs rarely as autosomal dominant, eye. It has been shown that in the myopic eye, there is a
autosomal recessive and X-linked transmitted. Polygenic
inheritance occurs much more frequently.
Current studies have identified genes responsible
for myopia higher than 6 D on chromosomes 1–5, 7, 8,
10–12, 14, 17–22. Genes responsible for myopia lower
than 6 D have been found on chromosome 7.
Myopia is present in many syndromes such as: Cohen,
Cornelia de Lange, Down, Ehlers-Danlos, Kniest, Kno-
bloch, Marfan, McCune-Albright, Noonan, Prader-Willi,
Rubinstein-Taybi, Stickler, Weill-Marchesani, fetal alco-
hol and also in homocystinuria, congenital night blindness,
deficiency of ornithine aminotransferase and prolidase, Figure. Myopia incidence among Polish students ranging from 6 to
lack of a sufficient amount of calcium, fluoride and sele- 18 years. Vertical axis: prevalence in %. Horizontal axis: age in years.
nium in food and in premature infants
[2, 8, 9, 11, 14]. Table 1. Prevalence of myopia among schoolchildren
In 1997 Goss et al. [10] des- Author, Year Country Environment Age (years) Myopia (%)
cribed the following risk factors for of publication
the development of myopia: positive Maul, 2000 Chile Urban 5–15 6.8
family history of myopia; presence of Pokharel, 2000 Nepal Rural 5–15 1.2
myopia on noncycloplegic retinoscopy Zhao, 2000 China Rural 5–15 16.2
in infancy, decreasing to emmetropia
Dandona, 2002 India Rural 7–15 4.1
before entry into school; refractive
Murthy, 2002 India Urban 5–15 7.4
error of emmetropia to 0.5 D of hy-
peropia; against-the-rule astigmatism; Naidoo, 2003 South Africa Semirural/Urban 5–15 2.9
decreased accommodative function He, 2004 China Urban 5–15 35.1
or near point esophoria; substantial Goh, 2005 Malaysia Urban 7–15 19.3
amount of near work on a regular basis; Czepita, 2008 Poland Urban 6–18 13.9
steep corneal curvature or high axial
Czepita, 2008 Poland Rural 6–18 7.5
length to corneal radius ratio; condi-

Russian Ophthalmological Journal 2014; 1:96–101 Myopia: incidence, pathogenesis, management 97


and new possibilities of treatment
tendency for peripheral refraction to be shifted towards half of the cycle and excessive rise in the second half of
hyperopia. This process is associated with axial elongation the menstrual cycle. Furthermore, the rise of activity of
in which the eyeball is ellipsoid in shape. It is believed that alkaline phosphatase in the blood; the rise of the secretion
the peripheral retina sends stimulation signals inducing of inorganic phosphatase in urine; the fall of magnesium,
the growth of the eyeball. calcium and phosphorus compounds levels in the blood;
The results of these observations have already been the increase of calcium concentration and the fall of chro-
put to clinical use. There is currently ongoing research mium concentration in hair and other trace elements in
into producing bent lenses in spectacles as well as contact tear fluid; the fall of copper concentration in the sclera;
lenses in which the peripheral part has positive sphere value. the increase of free radicals in the vitreous have been
Preliminary results seem to be favorable [5, 26, 28, 29]. observed. High levels of: aspartate, threonine, serine,
Role of corneal shape. Lately, it has been shown that glutamate, -aminoadipate, glycine, alanine, citruline,
the eyelid pressure on the cornea during reading or visual -aminobutyrate, valine, cysteine, methylhistidine,
work on a computer may lead to the development of 3-methylhistidine have been found in the blood serum of
corneal aberrations. These changes occur more often in patients with high myopia [33, 35–41].
myopic eyes than in emmetropic eyes. It has been observed Myopia management. There are a lot of non-surgical
that reading or working on a computer leads to different methods of management in low and high myopia [42–44].
topographical locations of these corneal aberrations. Some of them are presented in Table 3. The large amount
Reading compared to visual work on a computer tends of presented methods portrays their low effectiveness.
to induce more corneal aberrations. It is believed that Myopia can be corrected with spectacles, contact
corneal aberrations which develop as a result of reading lenses or by refractive surgery. Spectacles have the ad-
or visual work on a computer may play an important role vantages of:
in the development of myopia [30, 31]. 1) being more economical in most cases;
Anatomical changes. In the course of myopia, the 2) providing a level of safety against injury to the
axial length, the anterior chamber depth and the vitreous better seeing eye;
chamber depth increases. The thickness of the retina, cho- 3) serving as a modality for other optical modifica-
roidea, and sclera is reduced. Degenerative changes take tions (bifocal or prism) in the management of residual
place in the retina, choroidea, optic nerve and the vitreous binocular anomalies [45].
body. Dispersion of the photoreceptors, narrowing of the A clear method of spectacle correction has not been
vessels of the retina, choroidea, ciliary body, mechanical established (full correction or undercorrection). In world
stretching and rupture of the Bruch’s membrane-pigment literature only 4 papers have been written on the subject.
epithelium-choriocapillaris complex,the increase of In two of the publications myopia has been described to
disfigures of the lamina cribrosa, the lengthening, the progress more slowly when using full correction [46, 47].
narrowing, the disfiguring of the weak connection of col- In the other two articles the opposite finding was disco-
lagenous fibers of the sclera occurs [2, 11, 32–34]. vered [48, 49].Therefore, this problem requires further
Biochemical changes. Despite intensive and long clinical studies. The majority of doctors, however, prefer
term studies carried out on the
Table 2. Dependency between reading, writing, working on a computer, watching television
pathogenesis of myopia, we still
and myopia
know very little about the biochemi-
Author, Country Dependency Dependency between Dependency between
cal reactions occurring in the course Year of between reading, working on watching television
of myopia. It has been determined publication writing and myopia a computer and myopia and myopia
that during the course of myopia: Nyman, Sweden –
the activity of hyaluronidase in 1988
the blood increases, the amount Wong, 1993 Hong +
of excreted acid mucopolysaccha- Kong
rides in urine increases, the level of Toppel, Germany –
1994
somatotrophic hormone in blood
Rechichi, Italy –
increases, the level of cortisol in 1996
blood increases, there is a decrease Cole, 1996 Australia +
of excreted 17-hydroxycorticoster- Mutti, 1996 U.S.A. –
oids along with 17-ketosteroids in Kinge, 2000 Norway +
urine, the level of testosterone in Saw, 2001 Singapore +
blood of men decreases. In women, Mutti, 2002 U.S.A. +
excessive increase of 17 -estradiol Loman, U.S.A. –
secretion in the first half of the cycle 2002
and excessive decrease in the second Saw, 2006 Singapore –
half of the menstrual cycle take Jones, 2007 U.S.A. – –
place along with excessive decrease Czepita, Poland + + –
of secreted progesterone in the first 2010

98 Myopia: incidence, pathogenesis, management Russian Ophthalmological Journal 2014; 1:96–101


and new possibilities of treatment
Table 3. Non-surgical methods of management in low and high myopia
Management in low myopia Management in high myopia
temporary usage of spectacles permanent usage of spectacles
keeping hygiene of visual work: correct illumination, reading keeping hygiene of visual work: correct illumination, reading from a distance
from a distance of 30 cm, doing breaks during visual work of 30 cm, doing breaks during visual work
topical administration of: pilocarpine, cyclopentolate, topical administration of: ethylmorphine, timolol, tolasoline
tropicamide, homatropine, atropine, epinephrine,
phenylephrine, timolol, labetalol
bifocal spectacles application of drugs sealing the vessels and improving circulation: calcium,
bilberry extract, rutoside, xanthinol nicotinate, penthoxiphylline
progressive spectacles application of biostimulating drugs: tree aloe extract, mud distillate, total
extract of the eye bulb, placenta extract, peat extract, liquid polymeric
composition
exercises in plus glasses application of vitamins: A, B1, B2, B6, B12, C, D, E, F, PP
reading in prisms application of: cocarboxylase, iron, phosphorus, heparin, thyroid and
parathyroid extract, ozone, blood transfusion
orthokeratology lenses diet with plenty of fresh fruits and vegetables
contact lenses contact lenses

Table 4. Selected complications after LASIK procedure increased axial length and the associated complications.
Complications Frequency (%) After surgical procedures, degenerative changes of the
Dry eyes 20–40 retina do not regress, the risk of retinal detachment is not
Diffuse lamellar keratitis 2–4 reduced and myopia may still progress. Surgical methods
Epithelial ingrowth 1–3 only permit the individual freedom from wearing specta-
Flap wrinkles 0.2–4 cles or contact lenses. However, they do not inhibit the
Free cap 0.1–1 progress of the disease.
Infection (bacterial, fungal) 0.1 Therefore, people with refractive errors should
Over- and under-correction, poor centration, consider which method of correction they would like to
irregular astigmatism, contamination use. Is it better to wear spectacles and do not have any
Total 23.4–52.1 complications but have worse vision or wear contact lenses
and be forced to change them daily or once every month?
to prescribe undercorrection in patients up to the age of Finally, is it better to undergo surgical or laser refractive
18 years and after reaching 18 years of age give the full surgery and have to deal with the possibility of potentially
correction. irreversible complications?
Contact lenses appear to have certain advantages, New possibilities of myopia treatment. In 1975 David
including: H. Hubel and Torsten N. Wiesel, both laureates of the
1) reduction of aniseikonia in cases of refractive and Nobel Prize in Physiology or Medicine initiated studies
axial anisometropia; on drugs inhibiting the progress of myopia [52]. Currently,
2) improved cosmetics, which encourages better it has been observed that the following pharmacological
compliance with wearing the optical correction; agents: atropine, oxyphenonium, pirenzepine, chlorpy-
3) elimination or reduction of prismatic imbalance, rifos, 7-methylxanthine, apomorphine, reserpine, 6-hy-
weight problems, tilt, peripherical distortions, and visual field droxy dopamine, dextromethorphan, MK-801, APV,
restrictions experienced by users of spectacle lenses [45]. bicuculline, SR95531, CACA, TPMPA, dextrorphanol,
There are the following refractive surgeries: incision- levorphanol, D- and L-naloxane, L-NAME, formogua-
al corneal surgery (RK), ablative corneal surgery (PRK, namine, -xyloside, central and peripheral antagonist of
LASIK, LASEK, Intra-LASIK), keratoplasty (FTK, VIP, basic fibroblast growth factor and scleral crosslinking
LTK, CK), other corneal surgeries and devices, crystal- agent sinhibit the progress of myopia [2, 21, 53, 54].
line lens modifications. Each method has its advantages Hence, the pathogenesis of experimental myopia is
and disadvantages [50]. similar to the pathomechanism of progressive myopia. The
J. Messmer [51] has lately demonstrated the compli- above mentioned substances can be treated as potential
cations after correction of refractive errors with LASIK. drugs inhibiting the development of myopia among hu-
Many serious and less threatening complications were mans. Special interest of researchers is currently focused
observed. These complications have been compiled in on atropine, pirenzepine and 7-methylxanthine.
Table 4. According to Messmer as a result of postoperative R. Siatkowski et al. [55] from University of Okla-
progression of myopia, many patients need to undergo a homa have examined 277 children in the U.S.A. aged 8
second LASIK procedure. to 12 years with a spherical equivalent of –0.75 to –4D.
Surgical methods of refractive error correction do The examined children each received 2% pirenzepine
not solve the fundamental problem of myopia, which are topical eye ointment 2 times daily. After a year of use the

Russian Ophthalmological Journal 2014; 1:96–101 Myopia: incidence, pathogenesis, management 99


and new possibilities of treatment
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Ìèîïèÿ: çàáîëåâàåìîñòü, ïàòîãåíåç, òàêòèêà âåäåíèÿ ïàöèåíòîâ,


ñîâðåìåííûå âîçìîæíîñòè ëå÷åíèÿ

Äàìèàí ×åïèòà
Медицинский университет Померании, Щецин, Польша
profesor@czepita.pl
В последние годы наблюдается значительный рост распространенности миопии. Чаще всего возникновение
и прогрессирование близорукости происходит в детском возрасте. По-видимому, предрасполагающим фактором
является интенсивная зрительная работа на близком расстоянии: чтение, письмо, работа за компьютером.
В данной статье представлены современное определение миопии и ее классификация. Рассматриваются основные
аспекты заболеваемости, патогенеза, тактики ведения пациентов, современных методов лечения этого
вида аметропии. Особое внимание уделяется результатам экспериментальных и клинических исследований
лекарственных препаратов, направленных на профилактику прогрессирования миопии.
Ключевые слова: миопия, заболеваемость, патогенез, тактика ведения пациентов, лечение.
Ðîññèéñêèé îôòàëüìîëîãè÷åñêèé æóðíàë, 2014; 1:96–101

Russian Ophthalmological Journal 2014; 1:96–101 For correspondence: profesor@czepita.pl 101