UnitedStates.78Thesubjectsreceivedpirenzipine0.5%forthefirstweek,1.

0%forthesecondweek,
and2.0%foranadditional2weeks.Anotherstudyof49adultmalevolunteersfoundthatpirenzepine
ophthalmicgelat0.5%,1.0%,and2.0%waswelltolerated,producedminimalmydriasis,andtheonly
adverseeventnotedwasatransientunilaterallossofvisualacuityinonepatientwhichrecoveredby
thenextvisit.79Althoughrandomisedclinicaltrialsarecurrentlyinprogress,efficacydataarenotyet
available.

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TROPICAMIDE EYE DROPS

Tropicamideisashortactingcycloplegicagentthatrelaxesciliarymuscletoneandblocks
accommodation.Inastudyof61childrenaged616yearsgiven0.4%tropicamideeyedrops,the
averagedegreeofmyopiawasreducedfrom0.85Dto0.62D.80Therewas,however,nocontrol
group.Amatchedpairdesignof

dosesofatropine(1%atropine)may,however,beassociatedwithanincreasedincidenceandseverity
oflocaleffects(examplesincludemydriasis,photophobia,blurredvision,allergicdermatitis)and
systemiceffects34,68,69;lowerdosesofatropine(0.5%,0.25%,0.1%)werebettertolerated.68Thelong
termsideeffectsofatropineeyedropsinchildrenarerelativelyunknownandtheremaybeariskof
longtermultravioletlightrelatedretinaldamageandcataractformationasaresultofchronicpupillary
dilatation.64
PirenzipineisarelativelyselectiveM1subtypemuscarinicreceptorantagonistandM1receptorsare
foundintheciliaryprocesses.7074Inbothavianandmammalianmodels,pirenzipinehasbeenshownto
blockformdeprivationmyopiaandaxialelongation.7577Thetolerabilityofpirenzipinegelformulation
wastestedinadoublemaskedplacebocontrolledrandomisedclinicaltrialofchildrenaged912years
inthe

Atropinesuppressesgrowthhormonesecretionfromthepituitaryglandwhichcoulddisturbnormal
eyegrowth.57,58
ThefirstreportsofatropinetreatmentformyopiawerebyWellsinthe19thcentury.3In1979,
Bedrossianevaluatedtheeffectof1%atropineointmentinstilledonceatnightinoneeyefor1year
withthefelloweyeasthecontrolinanonrandomisedtrial.After1year,treatmentwasswitchedtothe
felloweye,andthecontroleyesshowedsignificantincreasesintherateofmyopia. 59However,the
felloweyemaynotbesuitableasacontrolastheremaybesystemicresidualeffectsofatropineonthe
felloweye.Severalotherstudieshaveevaluatedtopicalatropinetherapybutunfortunatelyhad
sufficientmethodologicalflawstoprecludeanyreliableconclusions.15,16,6067Arangeofconcentrations
(0.1%to1%)ofatropineeyedropsweretestedinthreerandomisedclinicaltrialsofschoolchildrenin
Taiwanandtherateofprogressionofmyopiaintheatropinegroupwassignificantlylowercompared
withthecontrolgroup.34,68,69Higher

tropineisanalkaloidfromthedeadlynightshadeAtropabelladonnaandhasseveralproposed
mechanismsofaction.Firstly,atropinemayblockaccommodationandreducetheputativeeffectsof
excessiveaccommodationontheprogressionofmyopia.11Secondly,atropineisanonselective
muscarinicantagonistandithasbeenobservedthatinanimalstreatedwithatropine,formdeprivation
myopiamaybesuppressedwithretardationofaxiallengthelongation.5355Atropinealsoaffects
dopamineneurotransmitterreleasefromcellularstoresandthusmayinfluenceretinalsignalsthat
controlthegrowthoftheeye.56Thirdly,atropinemayreachsufficientlevelsinthebloodstreamtohave
systemiceffects.

usuallywornovernight,withthepotentialcomplicationsofinfectivekeratitisrelatingtoclosedeye
contactlenswear.However,cornealflatteningdoesnottreattheintrinsiccauseofmyopiaandmaybe
aremedyratherthanacure.IntheBerkeleyOrthokeratologyStudy,80subjectswererandomisedto
orthokeratologyoracontrolgroupwearingcontactlensesfittedinthestandardclinicalmanner.There
wasasignificantlylargerreductioninmyopiaforthepatientsrandomisedtoorthokeratology,butthe
reductiondidnotpersistafterorthokeratology.52Thus,orthokeratologyhaslittleclinicalvalueforthe
retardationofmyopiaprogression.

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ATROPINE AND PIRENZIPINE EYE DROPS

spectaclewearerswas2.3Dincontrastwith1.3Dforcontactlenswearers(p<0.05).51Nomajor
adverseeventswerenoted.However,inamorerecentandlargerrandomisedclinicaltrialofrigid
contactlenseswith383Singaporechildrenaged612yearsover2years,therewasnosignificant
differencesintherateofprogressionofmyopiaoraxiallengthinthetwogroups(KatzJetal,
submittedforpublication)

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ORTHOKERATOLOGY
Thetechniqueknownasorthokeratologyhasbeenpractisedfordecades:thecorneaisflattenedby
fittingprogressivelyflatterrigidcontactlensesuntilthecornealshapeissufficientlyalteredtoachieve
myopiareduction.52Thetemporaryalterationofcornealshapeandhencecorrectionofmyopiaallows
forperiodsofclearunaidedvisionduringthedaywithouttheuseoflenses,butrequiresconstantuseof
retainerlens,

Inthe3yearHoustonstudyofrigidgaspermeablecontactlenses,100myopicchildrenaged813
yearswerefittedwithParapermoxygenpluscontactlensesandwerecomparedwith20spectacle
wearers.Theaverageprogressionofmyopiawassignificantlydifferent:0.48Dperyearforrigid
contactlenswearerscomparedwith1.53Dperyearforspectaclewearers.50However,theallocation
oftreatmentwasnotrandomised.Itwasalsoobservedthatapproximatelyhalfoftheeffectofrigidgas
permeablecontactlenseswasduetotransientcornealflattening.Inanonrandomisedstudyof45rigid
contactlenswearersand45spectaclewearersinSingapore10yearoldchildren,themeanincreasein
myopiaovera3yearperiodof
polymethylmethacrylate(PMMA)hardcontactlenses,thusalteringtheshapeofthecornea. 49
However,therewerehypoxiarelatedcornealchanges.Newrigidgaspermeablelenseswithhigh
oxygenpermeabilityareasuitableandsaferalternative.45Thepotentialmechanismsofactionofrigid
contactlensesincludetransientflatteningofthecornea,andimprovedqualityoftheretinalimagewith
reducedperipheralimageblur.Perhapsrigidcontactlensesmayevenretardaxialelongation.
However,thepermanenceofthesemechanismsofactionisstillunknown.
Ininfantprimateswearingminuscontactlenses,compensatoryoculargrowthmayleadtofunctional
myopia.38,39Alargenumberofreportsontheefficacyofvarioustypesofcontactlenses(silicone
acrylatecontactlenses,hydrophiliccontactlenses,hydrogellenses)werenotrandomised,hadsmall
samplesizes,andhighdropoutrates.4047Inarandomisedclinicaltrialoftheefficacyofsoftcontact
lensesin175childrenbyHornerandassociatesintheUnitedStates,therewasnosignificantdifference
intherateofprogressionofmyopiabetweenthecontactlens(0.36Dperyear)andcontrolgroup
(0.30Dperyear).48
Morrisonin1956fitted1021myopicchildren(79years)flatterthantheflattestcurvaturewith

reductionoftheprogressionofmyopia(meanmyopiaprogression1.19Dperyearinmultifocalgroup
versus1.40Dperyearinsinglevisiongroup)in227myopicchildrenaged612yearsafter1
years.34TheCorrectionofMyopiaEvaluationTrial(COMET)isalargeongoing3yearmulticentre
randomised,doublemaskedtrialevaluatingtheeffectofprogressiveadditionlensesversussingle
visionlensesin469myopicchildren(sphericalequivalentbetween1.25and4.50D)aged611
yearsintheUnitedStates.35,36Theresultsfromthistrialmayprovidenewevidencefortheefficacyof
multifocallenses.

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CONTACT LENSES
ContactlenseshavealonghistoryofuseasopticalcorrectionsincetheirintroductionbyEugenFickin
1888.37Contactlensesmayincreaseperipheralvision,providecosmeticbenefits,andpromotemore
outdooractivity.However,potentialcomplicationsofcontactlensuseincludeallergicconjunctivitis,
cornealinfiltrates,andinfectivekeratitis,andcontactlenshygienecompliancemaybeaproblemin
lessresponsiblechildren.

theprogressiveadditionlensmustbefittedveryhightofacilitatetheuseofthesegmentforreading.In
aclinicaltrialconductedbyLeungandBrowninHongKong,22childrenwereassignedtowear
progressivelenseswith+1.50Daddition,14tolenseswith+2.00Daddition,and32tosinglevision
lenses.Themeanprogressionrateofmyopiawas3.73Dforthechildrenassignedto+1.50D
additions,3.67Dforchildrenwearing+2.00Dadditions,and3.67Dforchildrenwearingsingle
visionlenses(p<0.001).However,theassignmentwasnotrandom:subjectswithevencaserecord
numberswereplacedintheprogressivelensesgroup,whilesubjectswithoddcaserecordnumbers
wereplacedinthesinglevisionlensesgroup.19ATaiwaneserandomisedclinicaltrialbyShihand
colleaguesshowedanonsignificantreductionoftheprogressionofmyopia(meanmyopiaprogression
1.19Dperyearinmultifocalgroup
Whenmyopiaisnotcorrected,lackofaclearvisualimagemayleadtoformdeprivationmyopia.11
Conversely,correctingachildsmyopiawithnegativelensesmayresultincompensatoryaberranteye
growthandthedevelopmentofmyopia.10Animalexperimentshaveshownthatcompensatorychanges
intheaxiallengthofaneyemayoccurinresponsetoerrorsignalsfromlensinduceddefocus.10,12Ina
nonrandomisedclinicaltrialevaluatingparttimedistancespectaclewearintheUnitedStates,43
myopeswerecategorisedintofourtreatmentgroups:(a)fulltimespectaclewear,(b)wearfordistance
viewingandthenaswitchtofulltimewear,(c)wearfordistanceviewingonly,and(d)nonwear.Over
aperiodof3years,therewerenosignificantdifferencesinrefractiveshiftsasmeasuredbynon
cycloplegicdistance
Whenmyopiaisnotcorrected,lackofaclearvisualimagemayleadtoformdeprivationmyopia.11
Conversely,correctingachildsmyopiawithnegativelensesmayresultincompensatoryaberranteye
growthandthedevelopmentofmyopia.10Animalexperimentshaveshownthatcompensatorychanges
intheaxiallengthofaneyemayoccurinresponsetoerrorsignalsfromlensinduceddefocus.10,12Ina
nonrandomisedclinicaltrialevaluatingparttimedistancespectaclewearintheUnitedStates,43
myopeswerecategorisedintofourtreatmentgroups:(a)fulltimespectaclewear,(b)wearfordistance
viewingandthenaswitchtofulltimewear,(c)wearfordistanceviewingonly,and(d)nonwear.Over
aperiodof3years,therewerenosignificantdifferencesinrefractiveshiftsasmeasuredbynon
cycloplegicdistance
Myopiaisclassifiedinasimplemanneras
i)simple

ii)pathological
SimpleMyopiaisnotprogresivebeyondtheamountincludedwithinnormaldevelopment;isassociated
withgoodvisionandrequiresnotreatmentexceptopticalcorrection.
PathologicalMyopiaontheotherhandisadegenerativemyopiaaccompaniedbychangesinthe
posteriorsegmentoftheeyeballwithlengtheningofAPaxisoftheglobe.Besides,theaxial
pathologicalmyopia,thereareothertypesofmyopiaduetodefectsinthecurvatureofcorneaandlens
andduetodrauma.Today,IwillconfinemyremarksonlytopathologicalaxialMyopia.
Thepathologicalmyopiashowsdegenerativechangesintheposteriorpole.Thusitcanbenamedas
degenerativemyopia(DukeElder).Itmayoccurasanindependentdevelopmental(congenital)
conditionorinassociationwithotherocculardiseasesorgeneraldisease.
VonJeagerfirstdescribedcongenitalmyopiain1855.Sincethenanumberofcaseshavebeen
reported.Majorityofcongenitalmyuopiasremainstationary.Someprogressfurtherleadingto
detachmentoftheretina.Visionisgoodinsomecases,whileinothersitissubnormal.
beinducedareformdeprivationandopticaldefocus.Formdeprivationmyopiacanbeinducedbythe
applicationoftranslucentoccludersovertheanimalseyes.Localretinaleffectsmayoccurandthe
resultantscleralgrowthmodulatedbychemicalssuchasdopamine,growthfactors,andmuscarinic
antagonists.79Negativespectaclelensesinchicksinducecompensatoryaxialelongationandmyopia.10
Suitabletherapeuticmodalitiessuchaspharmacologicalinterventionsandopticalcorrectivedevices
thatmayretardtheprogressionofmyopiainmyopicindividualshavebeenreported.The
overwhelmingmajorityofthesereportshavebeencitedinoptometryandnotophthalmologyjournals.
Theopticalcorrectionofmyopiaandoptimalstrategiestopreventtheprogressionofmyopiahavebeen
developedandprescribedlargelybyoptometrists.Ontheotherhand,issuesregardingthecausesand
preventionofmyopiahaveonlygainedinterestamongophthalmologistsintherecentdecade.The
objectiveofthis

Myopiahasbeenknownformorethan2000yearsandwasfirstdescribedbytheancientGreeks.1,2
However,despitetherecordeduseofconvexlensesforpresbyopiainthelate13thcenturyinFlorence,
Italy,thecorrectionofmyopicrefractiveerrorhadtoawaitthedevelopmentofconcavelensesinthe
mid16thcentury.
Myopiamaybeclassifiedasschoolmyopiaoradultonsetmyopia.3Schoolmyopiadevelops
duringtheschoolageandstabilisesaround1517yearsofage,whileadultonsetmyopiadevelopsin
youngadults.Theaetiology,pathogenesis,andtreatmentofmyopiahavebeenhotlydebatedinthe
ophthalmiccommunityfordecades.4Thereareseveraltheoriesonthemechanismofdevelopmentof
myopiaarisingfromdisruptionoftheemmetropisationprocess.Emmetropisationisachievedwhenthe
opticalpoweroftheeyematchestheaxiallength,resultinginafocusedimageofadistantobjectonthe
retinawithoutaccommodativeeffort.5Ithasbeenproposedthatoveractingintraocularmusclesmay
resultinexcessiveaccommodationandinfluenceemmetropisation.6Thetwobasicmechanismsby
whichanimalmyopiamay

Previous studies have evaluated the efficacy of several interventions

to decrease the progression of myopia. These include devices that
alter the perception of the visual environment and pharmacological
treatments. There is no conclusive evidence thus far that alteration
of the pattern of spectacle wear, bifocals, ocular hypotensives, or

contact lenses retards the progression of myopia. Several

randomised clinical trials have demonstrated that the rate of
progression of myopia is lower in children given atropine eye drops
than those given placebo.