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Myopia Q&A

What Are the Various Types of Myopia Control?

1. Types of Myopia Control

There are four widely accepted types of myopia control treatments: Orthokeratology (OrthoK aka CRT), Atropine eye drops, Distance-Center Multifocal Contact Lenses and in some cases Bifocal or Multifocal Eyeglasses. Optometrists throughout the country use methods based on patient age, prescription and need, sometimes combining methods for maximum impact. There is a lot of bad information out there, and recommendations are made for methods that actually may INCREASE myopia such as “undercorrection”, where the doctor provides a lower prescription than needed.

2. Spectacle Lenses: Bifocal and Multifocal Eyeglasses

In some children with certain eye-muscle positioning known as Esophoria, studies have shown that wearing a different prescription for distance and near is helpful. This is usually achieved in Bifocal or Multifocal eyeglass lenses. Bifocals have shown to be more effective in some studies and preference has been given for bifocals where the line is placed at the lower margin of the pupil of the eye. For those parents with children with the Esophoria who prefer not to have the children where contacts or use eyedrops or are too young this method has been shown to help in some studies.

3. SOFT CONTACT LENS For MYOPIA CONTROL

Distance Center Multifocal Soft Contact Lenses , annular or EDOF (extended depth of focus) are worn precisely the same as regular soft contact lenses. An optical “trick” in the center of the lens has been shown in several studies to slow down the progression of myopia more effectively than orthokeratology or atropine drops. This method is rapidly gaining in popularity. At this writing there are only two brands of these lenses. Your doctor can help determine which brand might be best for you.

Soft multifocal lenses offered as daily disposable are the easiest for a child to insert and remove, increased comfort of wear throughout the day, encourages proper hygiene and safety while affording the child optimized vision and myopia control.

Distance Center Multifocal Soft Contact Lenses

Distance Center Multifocal Soft Contact Lenses are worn precisely the same as regular soft contact lenses. An optical “trick” in the center of the lens has been shown in several studies to slow down the progression of myopia. This method is rapidly gaining in popularity. At this writing there are only two brands of these lenses. Your doctor can help determine which brand might be best for you.

A distance-center multifocal soft contact lens may be the best place to start because it can result in 50% reduction in the progression of myopia and a 29% re-duction in axial elongation, suggesting the potential for soft multifocal contact lens myopia control.

Two designs from CooperVision, the Proclear ®and Biofinity® Multifocal, allow for a distance zone of 75% of the child’s average pupil. The peripheral region of the lenses, which progress to intermediate and near plus power, refocus the image shell for the paravisual axis rays.

This allows for sustained myopic defocus (refocusing of the image shell) and can slow myopia progression without com-promising visual function—even when presented to the retina simultaneously with a clear image. When fitting this de-sign, I tend to use a multifocal add power of no less than +1.50D to +2.00D (“D” design), with the appropriate distance power centrally.

CooperVision also has entered the arena of myopic control with the MiSight® daily disposable myopia control contact lens, which has alternating visual correction and treatment zones.

Another new entry to the market is the NaturalVue Multifocal 1 Day Contact Lenses ® with Neurofocus Optics from Visioneering Technologies, Inc. The lens is designed to provide spectacle-level stereo acuity and vision at near, intermediate and at a distance. A study from University of Waterloo found the lens designs of –10.00D led to nearly complete inhibition of defocus-induced myopia in chickens compared to control lenses (also –10.00D).

4. Medication

Drops are administered at bedtime using Atropine (0.01% to 0.05%) compounded, available in eye drop or ointment form, administered at bedtime, has been found in several studies to reduce the progression of myopia. Applied once a day, atropine treatment is continued as long as myopia progression continues. It is not a cure, but it has shown to control myopia in many patients and in some cases may be used in conjunction with bifocal eyeglasses to enhance the myopia control effect.

5.ORTHO-K: Orthokeratology

Orthokeratology, also known as OrthoK or CRT (corneal re-shaping technology) is a method where rigid gas permeable lenses are applied to the eye while asleep. The gentle pressure exerted on the cornea, or surface of the eye overnight results in the temporary “molding” of the outer layers, providing “lens like” effects for the user. It could be compared to “orthodontia (braces) for the eyes”. The gentle molding of the surface of the cornea corrects the vision but also controls the myopia progression.

The effects last all day, providing vision for users without wearing glasses or contact lenses during their waking hours. The effects are dramatic and free people from issues with glasses or regular contact lenses for sports, swimming and performing the activities they love to perform. Orthokeratology has many peer-reviewed, randomized and some longitudinal studies that show it is an effective method to reduce the progression of myopia and, in many cases, halt it altogether.

Standard gas permeable designs do not provide significant control of axial length and myopic progression. Myopia control with orthokeratology, however, is highly achievable.

See additional information at these link:

/eye-care-services/frequently-asked-eye-health-questions/faq-corneal-refractive-therapy-orthokeratology/

/wp-content/uploads/sites/1270/2016/05/CRT_-_Orthokeratology_Informed_Consent_01-04-2016.pdf

FYI: History of Orthokeratology

Orthokeratology dates back more than 70 years. Eyecare practitioners used a progression of polymethyl methacrylate (PMMA) lenses in a sequentially flatter base curve to compress the central cornea.

As we approached the mid-1990s, manufacturers began using more advanced lathe and computer designs, which enabled them to take the original reverse peripheral curve lenses developed in the 1980s and advanced the study of orthokeratology. This led us to the “modern-day” reverse geometry accelerated corneal reshaping with overnight ortho-k lenses.

There are a variety of orthokeratology lenses for controlling myopia. Each has a unique design but follows similar concepts of method. Ortho-k can reduce the amount of myopic refractive error and affect the progression of myopia as a child ages.

6.Vision Therapy

As the doctor will determine in their exam, the question is what other visual function factors can play a role in myopia progression. If the child is close to no power or emmetropic prior to starting school – and if the parents are nearsighted or myopic – there is a very high chance the child will progress into myopia.

Often the use of basic vision therapy exercise may be beneficial and fun for the child. It is often recommend to:

  1. Reduce reading time into increments or sets of time
  2. Reduce digital time to 20 minutes with 20 second break and look 20 feet away
  3. Close your eyes for a few moments prior to resuming nearpoint work
  4. Consider ergonomic stretching – get up out of the chair.
  5. Line markers for reading: each line of the paragraph with a index card and read line by line. At the end of the paragraph – stop – close your eyes – think and recite or write about what was just read.
  6. Tracking games: Pacman, Tetris, Space Invaders, Othello, Match targets, Simon are examples of videos games that are terrific for eye tracking – but remember for short sets of time.
  7. Base Out Prismatic glasses for individuals with myopia with an esophoria (inward eye posture)
  8. Anti-fatique (low plus add) progressive lenses to assist in near point work ocular stress
  9. UVA or Transitions protecting spectacle lenses
  10. Push – Ups and Jumps with various targets

a. BASIC PENCIL PUSHUP

    1. Hold a pencil out at arm’s length in front of you. Slowly bring it toward your nose. When you see 2 pencils, push the pencil out slightly until you see 1 again. Focus on the pencil tip for 10 seconds, and then push it back out to arm’s length. Repeat.
    2. Hold a pencil out at arm’s length in front of you. Bring it toward you. When you can no longer focus on the pencil, push it out slightly until you can focus on it. Hold it there. Alternately, focus on pencil tip, then object in the distance, then back to pencil.

    b. Jumps: NEAR & FAR: Brock String or Ruler Jumps

    1. The concept is to teach the eyes to refocus with more flexibility at distance then intermediate (18-24”) and then nearpoint (14-16”) dependent upon the child’s or adults working distances.
    2. Brock string is a common vision therapy tool. It consists of a white flexible cord or string, approximately 10 – 15 feet in length, with colored wooden beads that can be moved to various positions along the length of the string.
    3. The Brock offers instant feedback to the participant if their eyes are working together to focus on an object at various distances. The Brock string is often used invision therapy for patients with vergence disorders such asConvergence Insufficiency, patients withAmblyopia (also calledLazy Eye), and for patients withStrabismus.
    4. https://www.good-lite.com/cw3/Assets/documents/911115_BrockStringInstructions.pdfq13 image 01
    5. USING RULERS: This can also be done with rulers which afford an accommodative target at distance intermediate and near.
    1. Stretch your arms to full length – hold one ruler in your hand
    2. With the other hand – place a second ruler at your mid-arm
    3. Then simply look at a distance target such as clock on the distant wall – read the numbers –stop
    4. Look the furtherest ruler and start to read the numbers 1-2-3-4-5 stop
    5. Go the ruler in the other hand closer to you and continue to read 6-7-8-9-10 stop
    6. Go back to the first ruler : 11-12-13-14 stop
    7. Go back to the closer ruler: 1-2-3-4-5 stop
    8. Back to the first ruler: 6-7-8-9-10 stop and repat multiple times.

    COMPLEX DECISION

    Myopia control is a complex management decision based on many factors. The primary factors are the awareness and concern of the parents, while other concerns are the capabilities and understanding of the child. Each approach must be planned from a long term perspective using a building block approach.

    We hope that this detailed FAQ summary is helpful for parents and patients in their understanding of Myopia and Myopia Control and the life long implications.

    Please feel free to communicate with our offices to discuss.

    www.seelife.net

    hopewelleye@kennethdaniels.net

    Kenneth Daniels, OD, FAAO, is an adjunct assistant clinical professor and National Eye Institute clinical investigator attending preceptor in Cornea and Specialty Contact Services at the Pennsylvania College of Optometry, and he is in private practice in Hopewell and Lambertville, NJ.

     

     

     

    What are the Optometric / Ophthalmic Treatments for Myopia?

    q12 image 01 Clinical Options

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    Case example: A 6-year-old Asian female who presented for an exam already had –1.00D of myopia, and both her parents were significantly myopic. As studies have shown, early manifestations of myopic refractive error and the number of myopic parents are significant predictors of the child’s risk of myopia progression. Her young age and the onset of myopic shift related to refractive error and axial length before the onset of juvenile myopia.

    We could obviously prescribe glasses to correct the presenting ametropia (refractive error) and re-evaluate in six months, or flat-top bi-focals or progressive addition lenses could be used to relax accommodative stress. However, these options will not have a lasting effect on myopic progression, delaying it by only 0.25D to 0.50D.

    We could also consider using atropine in conjunction with corrective spectacle lenses. Studies suggest that might be appropriate, particularly if the child is not ready to be fit with contact lenses.

    There are also behavioral modifications, such as an extra 40 minutes of time outdoors, which research shows can re-duce the progression of myopia, and following the 20-20-20 rule (a 20-second break to view something 20 feet away every 20 minutes) to reduce eyestrain from increased use of digital devices. The other option: using contact lenses to halt the progression of myopia.

    The goal of a proper contact lens design is to control the stress of accommodation in which the eye tries to refocus the image shell. The result of this stress is increased axial length of the eye, which causes myopia to progress.

    Standard gas permeable contact lenses cannot control this stress successfully, because the basic lens design only provides refractive correction. To control accommodative stress, a gas permeable design requires central corneal epithelial compression, with the spread of the tissue to the periphery. This allows the paracentral region to refocus the image shell onto the peripheral parafoveal.

    As such, in this case we would highly suggest Extended Depth of Focus soft multifocal daily disposable contact lenses (NaturalVue® or the MiSight®) which have been shown to be as effective as orthokeratology and atropine. More importantly, the child can be easily taught in the insertion and removal of soft lenses with higher and safer compliance with their use.

     

    What options do we have for slowing this patient’s myopic progression?

    1.Behavior modification is the first step in myopia control.

    • Reduced Technology Time
    • Reduced Near Point Ocular Stress
    • Time Outdoors.

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      Behavioral modifications, such as an extra 40 minutes of time outdoors, which research shows can reduce the progression of myopia, and following the 20-20-20 rule (a 20-second break to view something 20 feet away every 20 minutes) to reduce eyestrain from increased use of digital devices. The other option: using contact lenses to halt the progression of myopia.

      A 2017 report by the Common Sense Media, a nonprofit organization, suggests that 98% of households with kids under eight have a mobile device. It is also reported that 42% of children of age eight and younger now have their own mobile devices, with the average usage being two hours and 19 minutes. As well, a majority of teenagers spend more than four hours per day with screen media.4 Therefore, children and teenagers are exposed to these short viewing distances and electronic displays for a significant amount of time.

      The electronic displays are a contributing factor in myopia development, it is likely that they do so by increasing the amount of time children are exposed to hyperopic defocus and not the magnitude of the hyperopic defocus. In an effort to control myopia progression spending time outdoors might be a preventive factor for myopia. Also, the reduction of time spent on electronic devices. Electronic devices could indirectly be contributing to myopia development by influencing children to spend more time inside and less outside.

      The simple reduction and moderation of time spent at nearpoint task and digital technology have been shown to reduce myopic progression. The easiest method is to set time limits for reading and use of digital technology. Monitor reading techniques and encourage short breaks to enhance understanding and allow for ocular stress reduction.

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      2.Diet Control for Good Eye Health

      First of all the eye is a highly metabolized organ requiring good nutrition to maintain proper vascular blood flow and reduction of oxidative stress. As such – everyone should be seeking proper nutrition, which is not only good for the eyes, but good for the general health of the body.

      The healthier the body – the healthier your eyes. We will recommend the Mediterranean type diet full of colorful vegetables – lean proteins – high in quality Omega (EFA) and low on poorly processed sugars. This is also sometimes referred to as the DASH diet.

      Children who developed myopia had a generally lower intake of many of the food components than children who did not become myopic. The differences were statistically significant for energy intake, protein, fat, vitamins B1, B2 and C, phosphorus, iron, and cholesterol. (https://www.myopiainstitute.com/types-of-myopia-control/nutrition-and-its-role-myopia-progression/)

      The Mediterranean-DASH Intervention for Neurodegenerative Delay diet, or more commonly, the MIND diet, combines the portions of the DASH diet and the Mediterranean diet. Both the DASH diet and the Mediterranean diet have been shown to improve cognition; however, neither were developed to slow neurodegeneration.

      10 foods to eat on the MIND diet:

      • Green leafy vegetables (like spinach and salad greens): At least six servings a week
      • All other vegetables: At least one a day and choose non-starchy veggies for their low-cal/high nutrient ratio
      • Nuts (a variety of kinds): Five servings a week
      • Berries (like blueberries or raspberries): Two or more servings a week
      • Beans (all beans, lentils and soybeans): At least three servings a week
      • Whole grains (like oatmeal or quinoa): Three or more servings a day
      • Fish (like salmon or trout): Once a week
      • Poultry (like chicken or turkey): Two times a week
      • Olive oil: Use it as your main cooking oil
      • Dark Berry juices with high anti-oxidant concentrations.

      5 foods to limit or avoid on the MIND diet:

      • Red meat: Less than four servings a week
      • Butter and margarine: Less than a tablespoon daily
      • Cheese: Less than one serving a week
      • Pastries and sweets: Less than five servings a week
      • Fried or fast food: Less than one serving a week

      The following items have been linked to good eye health:

      ANTIOXIDANTS

      • Vitamin C is found in papaya, bell peppers, strawberries, broccoli, oranges, kiwi, and pineapple.
      • Vitamin E is found in sunflower seeds, peanut butter, almonds, spinach, tomatoes, and swiss chard.
      • Beta-carotene is found in carrot juice, pumpkins, spinach, carrots, and sweet potatoes.
      • Zinc is found in seafood such as cooked oysters, beef and lamb, wheat germ, and spinach.

      LUTEIN & ZEAXANTHIN

      • These act as antioxidants in the eye and are found in leafy green vegetables such as spinach and kale. The greener the bitter the better.

      ESSENTIAL FATTY ACIDS

      • These EFAs are Omega-3 and Omega-6 fatty acids. They are found in fish, fish oil, sunflower seeds and leafy vegetables.

      q11 image 04

      3.Time Outdoors

      A protective effect of improved outdoor time for onset but not progression of myopia. Outdoor time is considered to reduce the risk of developing myopia.

      The protective effects of bright light against the development of myopia have shown that the effect is, at least in part, mediated by dopamine within the retina.

      Dopamine (DA) is one of the retinal neurotransmitters involved in the signaling cascade that controls eye growth by vision. Dopamine is a major neurotransmitter in the retina involved in signal transmission in the visual system. Studies in animal eyes suggest that dopamine participates in visually guided eye growth regulation.

      The Avon Longitudinal Study of Parents and Children (ALSPAC), also known as the Children of the 90s study, followed nearly 7000 children in Great Britain and found that those who spent little time outdoors daily at 8-9 years of age were 40% more likley to develop myopia by age 15 than those who spent 3 hours a day or more outdoors in the summer and more than 1 hour daily in the winter.

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      What are the Options to Control Myopia?

      There are excellent alternatives:

      1. Behavioral Modifications
      2. Vision therapy for accommodative related dysfunction; and simple behavioral changes to enhance flexibility of focusing.
      3. Relaxation (20-20-20 rule) of the visual system
      4. Multifocal soft contact lenses
      5. Orthokeratology, or CRT (Corneal refractive technologies)
      6. Low dose atropine (0.01% to 0.05%) dosed at bedtime
      7. Progressive Anti-fatigue spectacle lenses
      8. Customized (DIMS) Defocus Incorporated Multiple Segments spectacle lenses (not yet available in the US)
      9. Acupuncture (rarely performed in the US)

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      What are the Goals of Myopia Control?

      It should be understood: Myopia is a refractive error and cannot be “cured”. Our goal is to slow the progression and avoid visual difficulties and associated complications.

      The goal of myopia control is to reduce the progression to less than 0.3 diopters per year from an average of 0.75 diopters or more with standard refractive care. As well, a major reason to prevent progression is to reduce the risk of long term associated pathologies:

      Rate of progression:

      • Specs: 0.30 to 0.39 mm per year (-0.75 D to -1.00 D)
      • Goal of Myopia Control: < 0.20 mm (<-0.50 D)
      • Preferred goal is < 0.1 mm (or <-0.25 D)

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      What is Myopic Progression?

      Myopic Progression is based on the retinal “IMAGE SHELL”

      Myopic Progression is multifactorial. It is related to poor optical imaging by refractive eyewear and contact lenses, genetics, time spent outdoors, time spent on intensive near point work, time spent on digital technology and other factors.

      The eye is ever-growing based on environmental signals and stress placed on the eyes.

      The simple essence of myopia control is to focus all incoming images into the fovea centralis and bring parafoveal defocused images (the image shell) into focus to prevent accommodative stress.

      The image shell is where light is properly focused onto the center of the retina (fovea) but the light from the lenses through the pupil are defocus in the peripheral or para foveal area forcing the eye to work harder to try to focus this “out of focus” light.

      Image shells on the retina. Once the eye elongates in myopia, optical images from spherical lenses no longer fall on the retinal plane. The peripheral images are out of focus falling on a plane behind the retina. It is thought that the relative hyperopic error created is the stimulus for axial elongation. Current optical treatments move the peripheral focus in front of the retina.

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      Normal eyeglasses and contact lenses will not correctly focus light onto the peri-foveal are and as such, normal glasses or contacts may exacerbate myopia progression.

      But there are excellent alternatives: Orthokeratology, multifocal soft contact lenses, low dose atropine, customized (DIMS) Defocus Incorporated Multiple Segments spectacle lenses (not yet available in the US), vision therapy for accommodative related dysfunction; and simple behavioral changes to enhance flexibility of focusing.

      Long-term Risks of Children with High Myopia?

      • 5x the risk of early cataracts
      • 14x the risk of glaucoma
      • 22x the risk of retinal detachments (peripheral retina)
      • 41x the risk of maculopathy (disease of central retina)

      The effects of near-sightedness, or myopia, are not simply alleviated through glasses or contact lenses. With or without glasses or contact lenses, myopia typically progresses throughout the growth of the child and usually stabilizes after teenage years.

      q7 image01

      If myopia is not controlled the risk of advancement significant leading to not only to pathology but to functional lifestyle issues and safety.

      Eye doctors often refer to nearsightedness less than -5 or -6 diopters as “common myopia.” Nearsightedness of -6 diopters or more is commonly called “high myopia.”

      This distinction is important because high myopia increases a person’s risk of developing other eye problems that can lead to permanent vision loss or blindness. These problems include tearing and detachment of the retina, clouding of the lens (cataract), and an eye disease called glaucoma that is usually related to increased pressure within the eye. The risk of these other eye problems increases with the severity of the nearsightedness. The term “pathological myopia” is used to describe cases in which high myopia leads to tissue damage within the eye.

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      What Might Cause Myopia?

      The causes of myopia are multifactorial. Some of the causes are considered to be:

      1. Genetics (family trends of myopia)
      2. Environmental (the lack of time spent outdoors)
      3. Improper focusing through corrective eyewear and contacts (peripheral defocus)
      4. Excessive Nearpoint work
      5. Excessive time on digital technology

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      What is the prevalence and basic relationships of myopia progression?

      Myopia, or nearsightedness, is becoming a worldwide public health crisis. In the United States, about one-third of the population has myopia and the prevalence is increasing.

      “Knowing your children’s potential risk of myopia and taking action before it’s too late can benefit their academic and athletic performance, personal growth and overall health.”

      Parents tend to wait until their child shows signs of visual difficulty. These can include not being able to see the whiteboard in school (66%), squinting more than normal (62%) and holding materials far away (52%).

      Global Myopia Awareness Coalition (GMAC) states that screening by the pediatrician is insufficient and that all children should be have a comprehensive exam by an eye care specialists to avoid the risk of vision problems later in life.

      Myopia occurs in more than 50% of the population in many industrialized countries and is expected to increase; complications associated with axial elongation from myopia are the sixth leading cause of blindness.

      The prevalence of myopia is higher in individuals whose both parents are myopic, suggesting that genetic factors are clearly involved in myopia development. At the same time, population studies suggest that development of myopia is associated with education and the amount time spent doing near work; hence, activities increase the exposure to optical blur as well as an interplay between genetic and the environmental factors.

      Myopia prevalence varies greatly in different ethnic and geographical populations [1]. Recent studies of American preschool children (aged 6–72 months) revealed a prevalence of:

      • 1.2% in non-Hispanic whites
      • 3.7% in Hispanics
      • 3.98% in Asians
      • 6.6% in African Americans

      Among older children, the difference between Asian and Caucasian populations is obvious; a study of Australian adolescents reported prevalence of 42.7% in 12 yr old and 59.1% in 17 yr old children of East Asian ethnicity, compared to 8.3% in 12 yr old and 17.7% in 17 yr old children of European Caucasian descent.

      If both parents of a child are myopic, their child will have about a 50 percent or greater chance of becoming myopic too. A non-myopic child with two myopic parents spends two or more hours per day outside, the child will decrease his chances of having myopia to that of having no myopic parents. However, once a child develops myopia, being outdoors will not slow the progression of the condition.

      Factors for myopia in schoolchildren included low outdoor time and near work, dim light exposure, the use of LED lamps for homework, low sleeping hours, reading distance less than 25 cm and living in an urban environment. Spending more time outdoors may also help improve mood. However, we should make sure that children are taking proper sun precautions like using sunscreen and wearing sun glasses.

      The eye will continue to grow disproportionately longer, which can cause complications, including retinal detachments, later in life. Therefore, we should make an effort to have young children spend some time outdoors every day.

      Children with early onset are at particular risk of complications associated with myopia, as progression over time might result in high myopia and myopic macular degeneration. Both genetic and environmental factors play a role in the increasing prevalence of myopia.

      [1]. Andrzej Grzybowski, et al A review on the epidemiology of myopia in school children worldwide Ophthalmology volume 20, Article number: 27 (2020) https://bmcophthalmol.biomedcentral.com/articles/10.1186/s12886-019-1220-0

      What is Myopia Control?

      Myopia Control is the term describing the treatment methods used to slow down or stop the progressive loss of far vision in children by preventing the eyeball from growing too long.

      As myopia among children is being described as ‘epidemic,’ a variety of techniques for treating them are coming to the forefront.

      Most forms of myopia can be managed with corrective lenses. Surgery is available to permanently correct some forms of myopia, although long-term effectiveness and safety has not been fully determined.

      Myopia occurs when the eyeball is too long, relative to the focusing power of the cornea and lens of the eye. This causes light rays to focus at a point in front of the retina, rather than directly on its surface.

      Nearsightedness can also be caused by the cornea and/or lens being too curved for the length of the eyeball. In some cases, myopia occurs due to a combination of these factors.

      Myopia typically begins in childhood, and you may have a higher risk if your parents are nearsighted. In most cases, nearsightedness stabilizes in early adulthood but sometimes it continues to progress with age.

      Myopia, also known as nearsightedness, is a refractive error that commonly develops during childhood. It causes blurry vision when looking at distant figures while nearby objects appear sharp. This problem may prevent your kids from seeing playmates from afar or notes written on their classroom boards, compromising their education and social skills.

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