MYOPIA
(AXIAL Vs REFRACTIVE)
BY: RITUPARNA SAHOO, 2ND YEAR PG, OPHTHALMOLOGY, VIMSAR, BURLA
MYOPIA
Aka near/short-sightedness.
Refractive error where parallel rays of light
coming from infinity are focused Infront of
light sensitive retina, with accommodation at
rest.
CLASSIFICATION
ETIOLOGY BASED :
1. AXIAL MYOPIA: due to increase in antero-posterior length of eyeball.
2. CURVATURAL MYOPIA : due to increase in curvature of either cornea
(keratoconus/keratoglobus) or lens (anterior/posterior lenticonus, microspherophakia,
intumescent cataract, diabetic cataract etc) or both.
3. POSITIONAL MYOPIA : due to anterior placement of intraocular lens.
4. INDEX MYOPIA : due to increase in refractive index of any media like cornea, AH, lens
(nuclear sclerosis).
5. MYOPIA DUE TO EXCESS ACCOMMODATION : due to spasm of ciliary muscle.
CLINICAL TYPES
ACQUIRED MYOPIA
TYPES:
1.CONGENITAL/ 2.SIMPLE/
DEVELOPMENTAL/ • INDEX MYOPIA
INFANTILE MYOPIA • CURVATURAL MYOPIA
SCHOOL MYOPIA
• POSITIONAL MYOPIA
• CONSECUTIVE MYOPIA
• PSEUDOMYOPIA/
ACCOMMODATIVE
MYOPIA
3.PATHOLOGICAL/ • SPACE MYOPIA
DEGENERATIVE/ 4.SECONDARY/ • NOCTURNAL/
PROGRESSIVE ACQUIRED MYOPIA TWILIGHT MYOPIA
MYOPIA • INDUCED MYOPIA
• MYOPIA OF
PREMATURITY
• DRUG INDUCED
MYOPIA
AGE BASED CLASSIFICATION :
1. CONGENITAL-since birth
2. YOUTH ONSET- before 20 years of
age. E.g-Simple myopia
3. EARLY ADULT ONSET- between 20-40
years of age. E.g- early onset acquired
nuclear sclerosis
DEGREE OF MYOPIA:
4. LATE ADULT ONSET- beyond 40 years
of age. E.g- acquired age related LOW-BELOW 3D
nuclear sclerosis MODERATE- 3D TO 6D
HIGH-MORE THAN 6D
AXIAL MYOPIA
The total refractive power of eye remains
constant, but axial length(distance
between anterior corneal surface and
retina measured along visual axis) is
increased.
REFRACTIVE MYOPIA
The axial length remains constant, but
refractive power of one or more of its
optical elements increases.
REFRACTIVE MYOPIA
Borish further divided refractive myopia into :
Index myopia-anomalous RI of one or more of the
medias, thereby increasing the refractive power.
Curvature myopia-reduced radius of curvature
of one or more refractive surfaces produces
increased diopteric power.
Anterior chamber myopia-decrease in AC depth
increases the refractive power of the eye.
AXIAL MYOPIA
• Commonest cause of myopia.
• Normal axial length= 22-24mm
If it exceeds >/=26mm : HIGH MYOPIA
If it exceeds >/=32mm : PATHOLOGICAL MYOPIA
• Axial length may again be increased in following :
a) Pathological/ High myopia-high degree >6D & associated with
degenerative changes of eye.
b) Congenital myopia- e.g- Buphthalmos in congenital glaucoma, in
prematures, in birth defects like Marfan’s or Homocystinuria
c) Posterior staphyloma
ETIO-PATHOGENESIS IN PATHOLOGICAL MYOPIA
GENETIC FACTORS(MAJOR) GENERAL GROWTH PROCESS
DEFECTS(MINOR)
Rapid progressive growth outside normal biological variation
Retinal stretching
Sclera , being distensible, also stretches
Increased axial length
Choroidal degenerations
Retinal degenerations
Vitreous degenerations too
CLINICAL CLUES OF DIAGNOSIS
SYMPTOMS :
• Diminished distant vision.
• Half shutting of eyes in children to create a stenopoetic slit effect
• Asthenopia due to dissociation between accommodation & convergence
• Behavioral changes- being introvert, studious, loosing interest in outdoor activities.
• Uncorrectable LOV in progressive cases
• Muscae volitans- due to degenerated liquified vitreous
• Night blindness- due to chorio-retinal degenerations
SIGNS :
1.SLIT LAMP for anterior segment examination
• Prominent elongated eyeball & large cornea in case of axial myopia
• Deep AC in both types
• Sclera may appear bluish if pathological myopia
• Slightly large & sluggishly reacting pupils
• Any abnormal conditions like keratoconus, lenticonus etc can be easily picked up
Enlarged eyeballs with bluish sclera. Keratoconus Lenticonus
2.FUNDUSCOPY for posterior segment examination
• Refractive myopia is not associated with much fundus changes. In few cases myopic
temporal crescent can be seen
• But rapid increase in axial length seen in pathological myopia is always associated with
following degenerative changes:
a) Vitreous liquefaction/ opacities / posterior vitreous degenerations seen as Weiss Reflex
b) Optic disc appears large and pale
c) Temporal myopic crescent
d) Peripapillary & supertraction crescent
e) Tassellated fundus initially
f) Tigroid fundus g) Diffuse chorio-retinal atrophic
patches
h)Lacquer cracks i) Lattice degenerations/Snail track
lesions
j) Forster fuchs spots k) Retinal tears/holes
l) Posterior staphyloma
INVESTIGATIONS TO RULE OUT AXIAL OR REFRACTIVE MYOPIA:
1. COMPLETE CYCLOPLEGIC REFRACTION- determines true RE, avoids over-correction
due to accommodation, differentiates axial & refractive myopia
2. AXIAL LENGTH MEASUREMENT- A scan or OCB(optical coherence biometry) to
identify axial myopia
3. CORNEAL KERATOMETRY or COMPUTERISED KERATOGRAPHY- to measure corneal
curvature & other topographic details
4. PACHYMETRY- to assess corneal thickness to decide the type of surgery
5. VISUAL FIELD ASSESSMENT-shows contraction & sometimes ring scotomas seen
in pathological myopia
6. ELECTRORETINOGRAPHY- subnormal due to chorio-retinal atrophy
7. UBM
8. BSCAN
9. OCT
TREATMENT OF MYOPIA
OPTICAL MANAGEMENT
• Appropriate Concave/Minus lenses are prescribed
• For low degrees of myopia upto -6D, following guidelines are present:
a) In children upto 3years-Preferred practice pattern: Paediatric eye evaluation 2012
follows
b) In those above 3 years- Myopia is fully corrected & regular followups needed.
Those below 30years usually accept full myopic corrections, but those above 30
years are under corrected for comfortable near vision.
• For high myopia(>-10D), irrespective of age of patients, under correction is
needed for comfortable binocular vision and to avoid minification of images &
problems of near vision.
*** Minimum minus power providing maximum
vision is prescribed in myopia.
*** Never overcorrect myopia.
LOW VISION AIDS: For patients with progressive myopia with advanced degenerative
changes, where vision cant be obtained with spectacles or contact lens
SURGICAL MANAGEMENT
KERATOREFRACTIVE PROCEDURES
1.Incisional-Radial keratotomy(RK)
2.Lamellar- •
Freeze keratomileusis of Barraquer
• Non freeze keratomileusis
LENS BASED
• Keratomileusis in situ(BKS procedure)
• Anterior lamellar keratoplasty PROCEDURES
• Refractive lenticule extraction (ReLeX)
• Phakic refractive lens(PRL)
3.Laser ablation- Surface ablation Intrastromal ablation • Refractive lens
• PRK exchange(RLE)
• Advanced PRK • LASIK
• LASEK • C-LASIK
• Epi-LASIK • I-LASIK COMBINED LENS AND
• Transepithelial PRK CORNEA BASED
PROCEDURES-
4.Orthokeratology
5.Intracorneal implants- Intracorneal contact lens, • Bioptics
Intrastromal corneal ring segments(Intacs) • Trioptics
Gel injectable adjusted keratoplasty
Photoablative Inlays(PAI-LASIK)
SUMMARY OF CHOICE OF PROCEDURES
LOW – MODERATE MYOPIA -1D TO -8D PREVENTIVE MEASURES
• LASIK= for -1 to -8D THERAPEUTIC MANAGEMENT- Using
• Epi-LASIK=for thin corneas(1-6D) &
0.01% atropine e/d or 2% pirenzepine
normal cornea(-1 to -10D) e/g
• INTACS= for -1 to -3 D GENERAL MEASURES- Balanced diet,
• ORTHOKERATOLOGY= for below
early management of associated
18years of age with myopia -1 to -3D diseases
GENETIC COUNSELLING- Advising
HIGH MYOPIA >-8D against marriage between 2 people
with progressive myopia
• PRL= preferred below 40years age VISUAL HYGIENE- Proper posture &
• RLE= preferred above 40years age adequate illumination while near
work
