Negative lens-induced myopia in infant monkeys: effects of high ambient lighting

IMI - Report on Experimental Models of Emmetropization and Myopia

The results of many studies in a variety of species have significantly advanced our understanding of the role of visual experience and the mechanisms of postnatal eye growth, and the development of myopia. This paper surveys and reviews the major contributions that experimental studies using animal models have made to our thinking about emmetropization and development of myopia. These studies established important concepts informing our knowledge of the visual regulation of eye growth and refractive development and have transformed treatment strategies for myopia. Several major findings have come from studies of experimental animal models. These include the eye's ability to detect the sign of retinal defocus and undergo compensatory growth, the local retinal control of eye growth, regulatory changes in choroidal thickness, and the identification of components in the biochemistry of eye growth leading to the characterization of signal cascades regulating eye growth and refractive state. Several of these findings provided the proofs of concepts that form the scientific basis of new and effective clinical treatments for controlling myopia progression in humans. Experimental animal models continue to provide new insights into the cellular and molecular mechanisms of eye growth control, including the identification of potential new targets for drug development and future treatments needed to stem the increasing prevalence of myopia and the vision-threatening conditions associated with this disease.

Oral crocetin administration suppressed refractive shift and axial elongation in a murine model of lens-induced myopia

Increased global incidence of myopia necessitates establishment of therapeutic approaches against its progression. To explore agents which may control myopia, we screened 207 types of natural compounds and chemical reagents based on an activity of a myopia suppressive factor, early growth response protein 1 (Egr-1) in vitro. Among the candidates, crocetin showed the highest and dose-dependent activation of Egr-1. For in vivo analysis, experimental myopia was induced in 3-week-old C57BL/6 J mice with −30 diopter (D) lenses for 3 weeks. Animals were fed with normal or mixed chow containing 0.003% (n = 19) and 0.03% (n = 7) of crocetin during myopia induction. Refraction and axial length were measured at 3-week-old and the 6-week-old with an infrared photorefractor and a SD-OCT system. Compared to controls (n = 14), crocetin administration showed a significant smaller change of refractive errors (−13.62 ± 8.14 vs +0.82 ± 5.81 D for 0.003%, p < 0.01, −2.00 ± 4.52 D for 0.03%, p < 0.01) and axial elongation (0.27 ± 0.03 vs 0.22 ± 0.04 mm for 0.003%, p < 0.01, 0.23 ± 0.05 mm for 0.03%, p < 0.05). These results suggest that a dietary factor crocetin may have a preventive effect against myopia progression.

The ipRGC-driven pupil response with light exposure and refractive error in children

PURPOSE

The intrinsically photosensitive retinal ganglion cells (ipRGCs) signal environmental light, control pupil size and entrain circadian rhythm. There is speculation that ipRGCs may be involved in the protective effects of light exposure in myopia. Here, the ipRGC-driven pupil response was evaluated in children and examined with light exposure and refractive error.

METHODS

Children ages 5-15 years participated. Subjects wore an actigraph device prior to the lab visit for objective measures of light exposure and sleep. For pupillometry, the left eye was dilated and presented with stimuli, and the consensual pupil response was measured in the right eye. Pupil measurements were preceded by 5 min dark adaptation. In Experiment 1 (n = 14), 1 s long wavelength light ('red,' 651 nm, 167 cd m^-2 ) and 10 increasing intensities of 1 s short wavelength light ('blue,' 456 nm, 0.167-167 cd m^-2 ) were presented with a 60 s interstimulus interval. A piecewise two-segment regression was fit to the stimulus response function to determine the functional melanopsin threshold. Pupil responses were analysed with light exposure over the previous 24 h. For Experiment 2 (n = 42), three 1 s red and three 1 s blue alternating stimuli were presented with a 60 s interstimulus interval. Following an additional 5-min dark adaption, the experiment was repeated. Pupil metrics included peak constriction, the 6 s and 30 s post-illumination response (PIPR), early and late area under the curve (AUC). Following pupil measurements, cycloplegic refractive error and axial length were measured.

RESULTS

For Experiment 1, PIPR metrics demonstrated a graded response to increasing intensity blue stimuli, with a mean functional melanopsin threshold of 6.2 ± 4.5 cd m^-2 (range: 0.84-16.7 cd m^-2 ). The 6 s PIPR and early AUC were associated with 24-h light exposure for high intensity stimuli (33.3 and 83.3 cd m^-2 , p < 0.005 for both). For Experiment 2, there were no associations between pupil metrics and refractive error. The 6 s PIPR and early AUC to blue stimuli were significantly increased for Trial 2 compared to Trial 1.

CONCLUSIONS

The ipRGC-driven pupil responses in children were robust and similar to responses previously measured in an adult population. The 6 s PIPR and early AUC to high intensity blue stimuli were associated with previous light exposure. There were no associations between the ipRGC-driven pupil response and refractive status in this cohort.

Effects of the Tyrosinase-Dependent Dopaminergic System on Refractive Error Development in Guinea Pigs

Purpose

To determine if myopia in albino guinea pigs is linked to altered ocular dopamine (DA) levels in both the retinal and uveal dopaminergic systems.

Methods

Retina and retinal pigment epithelium (RPE)/choroid were dissected from eyes of 2-week-old albino myopic (AM) and pigmented hyperopic (PH) guinea pigs. The levels of DA, dihydroxy-phenyl acetic acid (DOPAC), and homovanillic acid (HVA) were determined. Tyrosine hydroxylase (TH) and tyrosinase activities were also measured. PH animals received daily unilateral peribulbar injections of either kojic acid (tyrosinase inhibitor) or vehicle for 2 to 4 weeks. Refractive errors and ocular axial dimensions were measured by eccentric infrared photoretinoscopy and A-scan ultrasonography.

Results

Retinal DA levels were similar between the two strains, but AM eyes had higher levels of DOPAC. RPE/choroid DA and tyrosinase activity in AM eyes were lower than in PH eyes (P < 0.01); however, the DA turnover was higher (P < 0.05). After 2 weeks of kojic acid treatment, PH eyes developed significant myopia, accompanied by elongated vitreous chambers and axial lengths. Inhibition of tyrosinase activity was linearly correlated with a myopic refraction shift (R = 0.79, P < 0.01). PH animals that received 62.5 ng/mL kojic acid treatment daily for 2 weeks followed by 625 ng/mL for 2 more weeks became more myopic and had deeper anterior chambers compared to those that received the 62.5 ng/mL dose over this period (P = 0.04).

Conclusions

The uveal tyrosinase-dependent dopaminergic system is involved in the development of guinea pig refraction. Enhancing uveal tyrosinase activity might slow down the development of myopia.

The Adenosine Receptor Antagonist, 7-Methylxanthine, Alters Emmetropizing Responses in Infant Macaques

Purpose

Previous studies suggest that the adenosine receptor antagonist, 7-methylxanthine (7-MX), retards myopia progression. Our aim was to determine whether 7-MX alters the compensating refractive changes produced by defocus in rhesus monkeys.

Methods

Starting at age 3 weeks, monkeys were reared with −3 diopter (D; n = 10; 7-MX −3D/pl) or +3D (n = 6; 7-MX +3D/pl) spectacles over their treated eyes and zero-powered lenses over their fellow eyes. In addition, they were given 100 mg/kg of 7-MX orally twice daily throughout the lens-rearing period (age 147 ± 4 days). Comparison data were obtained from lens-reared controls (−3D/pl, n = 17; +3D/pl, n = 9) and normal monkeys (n = 37) maintained on a standard diet. Refractive status, corneal power, and axial dimensions were assessed biweekly.

Results

The −3D/pl and +3D/pl lens-reared controls developed compensating myopic (−2.10 ± 1.07 D) and hyperopic anisometropias (+1.86 ± 0.54 D), respectively. While the 7-MX +3D/pl monkeys developed hyperopic anisometropias (+1.79 ± 1.11 D) that were similar to those observed in +3D/pl controls, the 7-MX −3D/pl animals did not consistently exhibit compensating myopia in their treated eyes and were on average isometropic (+0.35 ± 1.96 D). The median refractive errors for both eyes of the 7-MX −3D/pl (+5.47 D and +4.38 D) and 7-MX +3D/pl (+5.28 and +3.84 D) monkeys were significantly more hyperopic than that for normal monkeys (+2.47 D). These 7-MX–induced hyperopic ametropias were associated with shorter vitreous chambers and thicker choroids.

Conclusions

In primates, 7-MX reduced the axial myopia produced by hyperopic defocus, augmented hyperopic shifts in response to myopic defocus, and induced hyperopia in control eyes. The results suggest that 7-MX has therapeutic potential in efforts to slow myopia progression.

A Review of Current Concepts of the Etiology and Treatment of Myopia

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. Thus, understanding its etiology, epidemiology, and the results of various treatment regiments may modify current care and result in a reduction in morbidity from progressive myopia. This rapid increase cannot be explained by genetics alone. Current animal and human research demonstrates that myopia development is a result of the interplay between genetic and the environmental factors. 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. Recently, there has been an increase in efforts to slow the progression of myopia because of its relationship to the development of serious pathological conditions such as macular degeneration, retinal detachments, glaucoma, and cataracts. We reviewed meta-analysis and other of current treatments that include: atropine, progressive addition spectacle lenses, orthokeratology, and multifocal contact lenses.

Narrow-band, long-wavelength lighting promotes hyperopia and retards vision-induced myopia in infant rhesus monkeys

The purpose of this investigation was to determine the effects of narrow band, long-wavelength lighting on normal refractive development and the phenomena of lens compensation and form-deprivation myopia (FDM) in infant rhesus monkeys. Starting at 24 and continuing until 151 days of age, 27 infant rhesus monkeys were reared under long-wavelength LED lighting (630 nm; illuminance = 274 ± 64 lux) with unrestricted vision (Red Light (RL) controls, n = 7) or a +3 D (+3D-RL, n = 7), -3 D (-3D-RL, n = 6) or diffuser lens (From Deprivation (FD-RL), n = 7) in front of one eye and a plano lens in front of the fellow eye. Refractive development, corneal power, and vitreous chamber depth were measured by retinoscopy, keratometry, and ultrasonography, respectively. Comparison data were obtained from normal monkeys (Normal Light (NL) controls, n = 39) and lens- (+3D-NL, n = 9; -3D-NL, n = 18) and diffuser-reared controls (FD-NL, n = 16) housed under white fluorescent lighting. At the end of the treatment period, median refractive errors for both eyes of all RL groups were significantly more hyperopic than that for NL groups (P = 0.0001 to 0.016). In contrast to fluorescent lighting, red ambient lighting greatly reduced the likelihood that infant monkeys would develop either FDM or compensating myopia in response to imposed hyperopic defocus. However, as in the +3D-NL monkeys, the treated eyes of the +3D-RL monkeys exhibited relative hyperopic shifts resulting in significant anisometropias that compensated for the monocular lens-imposed defocus (P = 0.001). The red-light-induced alterations in refractive development were associated with reduced vitreous chamber elongation and increases in choroidal thickness. The results suggest that chromatic cues play a role in vision-dependent emmetropization in primates. Narrow-band, long-wavelength lighting prevents the axial elongation typically produced by either form deprivation or hyperopic defocus, possibly by creating direction signals normally associated with myopic defocus.

Proteomic analysis of chick retina during early recovery from lens‑induced myopia

Myopia development has been extensively studied from different perspectives. Myopia recovery is also considered important for understanding the development of myopia. However, despite several previous studies, retinal proteomics during recovery from myopia is still relatively unknown. Therefore, the aim of the present study was to investigate the changes in protein profiles of chicken retinas during early recovery from lens-induced myopia to evaluate the signals involved in the adjustment of this refractive disorder. Three-day old chickens wore glasses for 7 days (−10D lens over the right eye and a plano lens as control over the left eye), followed by 24 h without lenses. Protein expression in the retina was measured by two-dimensional fluorescence difference gel electrophoresis (2D-DIGE). Pro-Q Diamond phosphoprotein staining 2D gel electrophoresis was used to analyze phosphoprotein profiles. Protein spots with significant differences (P<0.05) were analyzed by mass spectrometry. The minus lens-treated eye became myopic, however following 24 h recovery, less myopia was observed. 2D-DIGE proteomic analysis demonstrated that three identified protein spots were upregulated at least 1.2-fold in myopic recovery retinas compared with those of the controls, Ras related protein Rab-11B, S-antigen retina and pineal gland and 26S proteasome non-ATPase regulatory subunit 14. Pro-Q Diamond images further revealed three protein spots with significant changes (at least 1.8-fold): β-tubulin was downregulated, while peroxiredoxin 4 and ubiquitin carboxyl-terminal hydrolase-L1 were upregulated in the recovery retinas compared with the control eye retinas. The present study detected previously unreported protein changes in recovering eyes, therefore revealing their potential involvement in retinal remodeling during eye ball reforge.

Scleral ultrastructure and biomechanical changes in rabbits after negative lens application

AIM

To address the microstructure and biomechanical changes of the sclera of rabbits after negative lens application by spectacle frame apparatus.

METHODS

Five New Zealand rabbits of seven weeks post-natal were treated with -8 D lens monocularly over the course of two weeks. Refractive errors and axial length (AXL) were measured at the 1^st, 7^th and 14^th days of the induction period. Ultrastructure of sclera was determined with electron microscopy. Biomechanical properties were tested by an Instron 5565 universal testing machine.

RESULTS

Lens-induced (LI) eyes elongated more rapidly compared with fellow eyes with AXL values of 15.56±0.14 and 15.21±0.14 mm (P<0.01). Fibril diameter was significantly smaller in the LI eyes compared with control ones in the inner, middle, and outer layers (inner layer, 63.533 vs 76.467 nm; middle layer, 92.647 vs 123.984 nm; outer layer, 86.999 vs 134.257 nm, P<0.01, respectively). In comparison with control eyes, macrophage-like cells that engulfed fibroblasts, dilated endoplasmic reticulum, and vacuoles in fibroblasts were observed in the inner and middle stroma in the LI eyes. Ultimate stress and Young's modulus were lower in the LI eyes compared with those in the control eyes.

CONCLUSION

Negative lens application alters eye growth, and results in axial elongation with changes in scleral ultrastructural and mechanical properties.

Long-wavelength (red) light produces hyperopia in juvenile and adolescent tree shrews

In infant tree shrews, exposure to narrow-band long-wavelength (red) light, that stimulates long-wavelength sensitive cones almost exclusively, slows axial elongation and produces hyperopia. We asked if red light produces hyperopia in juvenile and adolescent animals, ages when plus lenses are ineffective. Animals were raised in fluorescent colony lighting (100-300 lux) until they began 13days of red-light treatment at 11 (n=5, "infant"), 35 (n=5, "juvenile") or 95 (n=5, "adolescent") days of visual experience (DVE). LEDs provided 527-749 lux on the cage floor. To control for the higher red illuminance, a fluorescent control group (n=5) of juvenile (35 DVE) animals was exposed to ∼975 lux. Refractions were measured daily; ocular component dimensions at the start and end of treatment and end of recovery in colony lighting. These groups were compared with normals (n=7). In red light, the refractive state of both juvenile and adolescent animals became significantly (P<0.05) hyperopic: juvenile 3.9±1.0 diopters (D, mean±SEM) vs. normal 0.8±0.1D; adolescent 1.6±0.2D vs. normal 0.4±0.1D. The fluorescent control group refractions (0.6±0.3D) were normal. In red-treated juveniles the vitreous chamber was significantly smaller than normal (P<0.05): juvenile 2.67±0.03mmvs. normal 2.75±0.02mm. The choroid was also significantly thicker: juvenile 77±4μmvs. normal 57±3μm (P<0.05). Although plus lenses do not restrain eye growth in juvenile tree shrews, the red light-induced slowed growth and hyperopia in juvenile and adolescent tree shrews demonstrates that the emmetropization mechanism is still capable of restraining eye growth at these ages.

EPIDEMIC OF PATHOLOGIC MYOPIA: What Can Laboratory Studies and Epidemiology Tell Us?

PURPOSE

To systematically review epidemiologic and laboratory studies on the etiology of high myopia and its links to pathologic myopia.

METHODS

Regular Medline searches have been performed for the past 20 years, using "myopia" as the basic search term. The abstracts of all articles have been scrutinized for relevance, and where necessary, translations of articles in languages other than English were obtained.

RESULTS

Systematic review shows that there is an epidemic of myopia and high myopia in young adults in East and Southeast Asia, with similar but smaller trends in other parts of the world. This suggests an impending epidemic of pathologic myopia. High myopia in young adults in East and Southeast Asia is now predominantly associated with environmental factors, rather than genetic background. Recent clinical trials show that the onset of myopia can be reduced by increasing the time children spend outdoors, and methods to slow the progression of myopia are now available.

CONCLUSION

High myopia is now largely associated with environmental factors that have caused the epidemic of myopia in East and Southeast Asia. An important clinical question is whether the pathologic consequences of acquired high myopia are similar to those associated with classic genetic high myopia. Increased time outdoors can be used to slow the onset of myopia, whereas methods for slowing progression are now available clinically. These approaches should enable the current epidemics of myopia and high myopia to be turned around, preventing an explosion of pathologic myopia.

The epidemics of myopia: Aetiology and prevention

There is an epidemic of myopia in East and Southeast Asia, with the prevalence of myopia in young adults around 80-90%, and an accompanying high prevalence of high myopia in young adults (10-20%). This may foreshadow an increase in low vision and blindness due to pathological myopia. These two epidemics are linked, since the increasingly early onset of myopia, combined with high progression rates, naturally generates an epidemic of high myopia, with high prevalences of "acquired" high myopia appearing around the age of 11-13. The major risk factors identified are intensive education, and limited time outdoors. The localization of the epidemic appears to be due to the high educational pressures and limited time outdoors in the region, rather than to genetically elevated sensitivity to these factors. Causality has been demonstrated in the case of time outdoors through randomized clinical trials in which increased time outdoors in schools has prevented the onset of myopia. In the case of educational pressures, evidence of causality comes from the high prevalence of myopia and high myopia in Jewish boys attending Orthodox schools in Israel compared to their sisters attending religious schools, and boys and girls attending secular schools. Combining increased time outdoors in schools, to slow the onset of myopia, with clinical methods for slowing myopic progression, should lead to the control of this epidemic, which would otherwise pose a major health challenge. Reforms to the organization of school systems to reduce intense early competition for accelerated learning pathways may also be important.

Validation of Macular Choroidal Thickness Measurements from Automated SD-OCT Image Segmentation

PURPOSE

Spectral domain optical coherence tomography (SD-OCT) imaging permits in vivo visualization of the choroid with micron-level resolution over wide areas and is of interest for studies of ocular growth and myopia control. We evaluated the speed, repeatability, and accuracy of a new image segmentation method to quantify choroid thickness compared to manual segmentation.

METHODS

Two macular volumetric scans (25 × 30°) were taken from 30 eyes of 30 young adult subjects in two sessions, 1 hour apart. A single rater manually delineated choroid thickness as the distance between Bruch's membrane and sclera across three B-scans (foveal, inferior, and superior-most scan locations). Manual segmentation was compared to an automated method based on graph theory, dynamic programming, and wavelet-based texture analysis. Segmentation performance comparisons included processing speed, choroid thickness measurements across the foveal horizontal midline, and measurement repeatability (95% limits of agreement (LoA)).

RESULTS

Subjects were healthy young adults (n = 30; 24 ± 2 years; mean ± SD; 63% female) with spherical equivalent refractive error of -3.46 ± 2.69D (range: +2.62 to -8.50D). Manual segmentation took 200 times longer than automated segmentation (780 vs. 4 seconds). Mean choroid thickness at the foveal center was 263 ± 24 μm (manual) and 259 ± 23 μm (automated), and this difference was not significant (p = 0.10). Regional segmentation errors across the foveal horizontal midline (±15°) were ≤9 μm (median) except for nasal-most regions closest to the nasal peripapillary margin-15 degrees (19 μm) and 12 degrees (16 μm) from the foveal center. Repeatability of choroidal thickness measurements had similar repeatability between segmentation methods (manual LoA: ±15 μm; automated LoA: ±14 μm).

CONCLUSIONS

Automated segmentation of SD-OCT data by graph theory and dynamic programming is a fast, accurate, and reliable method to delineate the choroid. This approach will facilitate longitudinal studies evaluating changes in choroid thickness in response to novel optical corrections and in ocular disease.

Animal Studies and the Mechanism of Myopia-Protection by Light?

Epidemiological studies have demonstrated that spending time outdoors during your childhood is protective against the development of myopia. It has been hypothesized that this protective effect is associated with light-induced increases in retinal dopamine levels, a critical neuromodulator that has long been postulated to be involved in the regulation of ocular growth. This paper, along with the paper entitled "What do animal studies tell us about the mechanism of myopia-protection by light?" discusses the evidence provided by animal models for this hypothesis.

Development of Experimental Myopia in Chicks in a Natural Environment

Purpose

The hypothesis that outdoor exposure might protect against myopia has generated much interest, although available data find only modest clinical efficacy. We tested the effect of outdoor rearing on form-deprivation myopia in chicks, a myopia model markedly inhibited by high-intensity indoor laboratory lighting.

Methods

Unilaterally goggled cohorts of White Leghorn chicks were maintained in a species-appropriate, outdoor rural setting during daylight hours to the extent permitted by weather. Control chicks were reared indoors with incandescent lighting. Besides ocular refraction and ultrasound, we determined dopamine and 3,4-dihydroxyphenylacetic acid (DOPAC) content in retina and vitreous and measured mRNA expression levels of selected clock and circadian rhythm-related genes in the retina/RPE.

Results

Myopia developed in the goggled eyes of all cohorts. Whereas outdoor rearing lessened myopia by 44% at 4 days, a protective effect was no longer evident at 11 days. Outdoor rearing had no consistent effect on retinal or vitreous content of dopamine or DOPAC. Conforming to prior data on form-deprivation myopia, retina and vitreous levels of DOPAC were reduced in goggled eyes. Compared with contralateral eyes, the retinal expression of clock and circadian rhythm-related genes was modestly altered in myopic eyes of chicks reared indoors or outdoors.

Conclusions

Outdoor rearing of chicks induces only a partial decrease of goggle-induced myopia that is not maintained, without evidence that retinal dopamine metabolism accounts for the partial myopia inhibition under these outdoor conditions. Although modest, alterations in retinal gene expression suggest that studying circadian signals might be informative for understanding refractive mechanisms.

The Effects of the Relative Strength of Simultaneous Competing Defocus Signals on Emmetropization in Infant Rhesus Monkeys

Purpose

We investigated how the relative surface area devoted to the more positive-powered component in dual-focus lenses influences emmetropization in rhesus monkeys.

Methods

From 3 to 21 weeks of age, macaques were reared with binocular dual-focus spectacles. The treatment lenses had central 2-mm zones of zero-power and concentric annular zones that had alternating powers of either +3.0 diopters (D) and 0 D (+3 D/pL) or −3.0 D and 0 D (−3 D/pL). The relative widths of the powered and plano zones varied from 50:50 to 18:82 between treatment groups. Refractive status, corneal curvature, and axial dimensions were assessed biweekly throughout the lens-rearing period. Comparison data were obtained from monkeys reared with binocular full-field single-vision lenses (FF+3D, n = 6; FF−3D, n = 10) and from 35 normal controls.

Results

The median refractive errors for all of the +3 D/pL lens groups were similar to that for the FF+3D group (+4.63 D versus +4.31 D to +5.25 D; P = 0.18–0.96), but significantly more hyperopic than that for controls (+2.44 D; P = 0.0002–0.003). In the −3 D/pL monkeys, refractive development was dominated by the zero-powered portions of the treatment lenses; the −3 D/pL animals (+2.94 D to +3.13 D) were more hyperopic than the FF−3D monkeys (−0.78 D; P = 0.004–0.006), but similar to controls (+2.44 D; P = 0.14–0.22).

Conclusions

The results demonstrate that even when the more positive-powered zones make up only one-fifth of a dual-focus lens' surface area, refractive development is still dominated by relative myopic defocus. Overall, the results emphasize that myopic defocus distributed across the visual field evokes strong signals to slow eye growth in primates.

Bio-environmental factors associated with myopia: An updated review

Experimental studies in animals, as well as observational and intervention studies in humans, seem to support the premise that the development of juvenile myopia is promoted by a combination of the effect of genetic and environmental factors, with a complex interaction between them. The very rapid increase in myopia rates in some parts of the world, such as Southeast Asia, supports a significant environmental effect. Several lines of evidence suggest that humans might respond to various external factors, such as increased activity in near vision, increased educational pressure, decreased exposure to sunlight outdoors, dietary changes (including increased intake of carbohydrates), as well as low light levels indoors. All these factors could be associated with a higher prevalence of myopia.

Environmental Factors and Myopia: Paradoxes and Prospects for Prevention

The prevalence of myopia in developed countries in East and Southeast Asia has increased to more than 80% in children completing schooling, whereas that of high myopia has increased to 10%-20%. This poses significant challenges for correction of refractive errors and the management of pathological high myopia. Prevention is therefore an important priority. Myopia is etiologically heterogeneous, with a low level of myopia of clearly genetic origins that appears without exposure to risk factors. The big increases have occurred in school myopia, driven by increasing educational pressures in combination with limited amounts of time spent outdoors. The rise in prevalence of high myopia has an unusual pattern of development, with increases in prevalence first appearing at approximately age 11. This pattern suggests that the increasing prevalence of high myopia is because of progression of myopia in children who became myopic at approximately age 6 or 7 because age-specific progression rates typical of East Asia will take these children to the threshold for high myopia in 5 to 6 years. This high myopia seems to be acquired, having an association with educational parameters, whereas high myopia in previous generations tended to be genetic in origin. Increased time outdoors can counter the effects of increased nearwork and reduce the impact of parental myopia, reducing the onset of myopia, and this approach has been validated in 3 randomized controlled trials. Other proposed risk factors need further work to demonstrate that they are independent and can be modified to reduce the onset of myopia.

Time outdoors, blood vitamin D status and myopia: a review

Myopia is a major public health concern throughout the world but whether vitamin D played a role in myopia development remains unknown.

Intravitreally-administered dopamine D2-like (and D4), but not D1-like, receptor agonists reduce form-deprivation myopia in tree shrews

We examined the effect of intravitreal injections of D1-like and D2-like dopamine receptor agonists and antagonists and D4 receptor drugs on form-deprivation myopia (FDM) in tree shrews, mammals closely related to primates. In eleven groups (n = 7 per group), we measured the amount of FDM produced by monocular form deprivation (FD) over an 11-day treatment period. The untreated fellow eye served as a control. Animals also received daily 5 µL intravitreal injections in the FD eye. The reference group received 0.85% NaCl vehicle. Four groups received a higher, or lower, dose of a D1-like receptor agonist (SKF38393) or antagonist (SCH23390). Four groups received a higher, or lower, dose of a D2-like receptor agonist (quinpirole) or antagonist (spiperone). Two groups received the D4 receptor agonist (PD168077) or antagonist (PD168568). Refractions were measured daily; axial component dimensions were measured on day 1 (before treatment) and day 12. We found that in groups receiving the D1-like receptor agonist or antagonist, the development of FDM and altered ocular component dimensions did not differ from the NaCl group. Groups receiving the D2-like receptor agonist or antagonist at the higher dose developed significantly less FDM and had shorter vitreous chambers than the NaCl group. The D4 receptor agonist, but not the antagonist, was nearly as effective as the D2-like agonist in reducing FDM. Thus, using intravitreally-administered agents, we did not find evidence supporting a role for the D1-like receptor pathway in reducing FDM in tree shrews. The reduction of FDM by the dopamine D2-like agonist supported a role for the D2-like receptor pathway in the control of FDM. The reduction of FDM by the D4 receptor agonist, but not the D4 antagonist, suggests an important role for activation of the dopamine D4 receptor in the control of axial elongation and refractive development.

Animal models in myopia research

Our current understanding of the development of refractive errors, in particular myopia, would be substantially limited had Wiesel and Raviola not discovered by accident that monkeys develop axial myopia as a result of deprivation of form vision. Similarly, if Josh Wallman and colleagues had not found that simple plastic goggles attached to the chicken eye generate large amounts of myopia, the chicken model would perhaps not have become such an important animal model. Contrary to previous assumptions about the mechanisms of myopia, these animal models suggested that eye growth is visually controlled locally by the retina, that an afferent connection to the brain is not essential and that emmetropisation uses more sophisticated cues than just the magnitude of retinal blur. While animal models have shown that the retina can determine the sign of defocus, the underlying mechanism is still not entirely clear. Animal models have also provided knowledge about the biochemical nature of the signal cascade converting the output of retinal image processing to changes in choroidal thickness and scleral growth; however, a critical question was, and still is, can the results from animal models be applied to myopia in children? While the basic findings from chickens appear applicable to monkeys, some fundamental questions remain. If eye growth is guided by visual feedback, why is myopic development not self-limiting? Why does undercorrection not arrest myopic progression even though positive lenses induce myopic defocus, which leads to the development of hyperopia in emmetropic animals? Why do some spectacle or contact lens designs reduce myopic progression and others not? It appears that some major differences exist between animals reared with imposed defocus and children treated with various optical corrections, although without the basic knowledge obtained from animal models, we would be lost in an abundance of untestable hypotheses concerning human myopia.

What Do Animal Studies Tell Us about the Mechanism of Myopia-Protection by Light?

: Human studies have provided strong evidence that exposure to time outdoors is protective against the onset of myopia. A causal factor may be that the light levels outdoors (30,000-130,000 lux) are much higher than light levels indoors (typically less than 500 lux). Studies using animal models have found that normal animals exposed to low illuminance levels (50 lux) can develop myopia. The myopia and axial elongation, produced in animals by monocular form deprivation, is reduced by light levels in the 15,000 to 25,000 range. Myopia induced with a negative-power lens seems less affected, perhaps because the lens provides a powerful target for the emmetropization mechanism. Animal studies suggest that raising the light levels may have their effect by increasing retinal dopamine activity, probably via the D2 receptor pathway, altering gene expression in the retina and reducing the signals that produce axial elongation.

Effects of Long-Wavelength Lighting on Refractive Development in Infant Rhesus Monkeys

PURPOSE

Differences in the spectral composition of lighting between indoor and outdoor scenes may contribute to the higher prevalence of myopia in children who spend low amounts of time outdoors. Our goal was to determine whether environments dominated by long-wavelength light promote the development of myopia.

METHODS

Beginning at 25 ± 2 days of age, infant monkeys were reared with long-wavelength-pass (red) filters in front of one (MRL, n = 6) or both eyes (BRL, n = 7). The filters were worn continuously until 146 ± 7 days of age. Refractive development, corneal power, and vitreous chamber depth were assessed by retinoscopy, keratometry, and ultrasonography, respectively. Control data were obtained from 6 monkeys reared with binocular neutral density (ND) filters and 33 normal monkeys reared with unrestricted vision under typical indoor lighting.

RESULTS

At the end of the filter-rearing period, the median refractive error for the BRL monkeys (+4.25 diopters [D]) was significantly more hyperopic than that for the ND (+2.22 D; P = 0.003) and normal monkeys (+2.38 D; P = 0.0001). Similarly, the MRL monkeys exhibited hyperopic anisometropias that were larger than those in normal monkeys (+1.70 ± 1.55 vs. -0.013 ± 0.33 D, P < 0.0001). The relative hyperopia in the treated eyes was associated with shorter vitreous chambers. Following filter removal, the filter-reared monkeys recovered from the induced hyperopic errors.

CONCLUSIONS

The observed hyperopic shifts indicate that emmetropization does not necessarily target the focal plane that maximizes luminance contrast and that reducing potential chromatic cues can interfere with emmetropization. There was no evidence that environments dominated by long wavelengths necessarily promote myopia development.

Responses of the Ocular Anterior Segment and Refraction to 0.5% Tropicamide in Chinese School-Aged Children of Myopia, Emmetropia, and Hyperopia

Purpose. To investigate the changes of anterior segment after cycloplegia and estimate the association of such changes with the changes of refraction in Chinese school-aged children of myopia, emmetropia, and hyperopia. Methods. 309 children were recruited and eligible subjects were assigned to three groups: hyperopia, emmetropia, or myopia. Cycloplegia was achieved with five cycles of 0.5% tropicamide. The Pentacam system was used to measure the parameters of interest before and after cycloplegia. Results. In the myopic group, the lenses were thinner and the lens position was significantly more posterior than that of the emmetropic and hyperopic groups in the cycloplegic status. The correlations between refraction and lens thickness (age adjusted; r = 0.26, P < 0.01), and lens position (age adjusted; r = −0.31, P < 0.01) were found. After cycloplegia, ACD and ACV significantly increased, while ACA significantly decreased. Changes in refraction, ACD, ACV, and ACA were significantly different among the three groups (P < 0.05, all). Changes of refraction were correlated with changes of ACD (r = 0.41, P < 0.01). Conclusions. Myopia presented thinner lenses and smaller changes of anterior segment and refraction after cycloplegia when compared to emmetropia and hyperopia. Changes of anterior chamber depth were correlated with refraction changes. This may contribute to a better understanding of the relationship between anterior segment and myopia.

Exposure to sunlight reduces the risk of myopia in rhesus monkeys

Exposure to sunlight has recently been postulated as responsible for the effect that more time spent outdoors protects children from myopia, while early life exposure to natural light was reported to be possibly related to onset of myopia during childhood. In this study, we had two aims: to determine whether increasing natural light exposure has a protective effect on hyperopic defocus-induced myopia, and to observe whether early postnatal exposure to natural light causes increased risk of refractive error in adolescence. Eight rhesus monkeys (aged 20-30 days) were treated monocularly with hyperopic-defocus (-3.0D lens) and divided randomly into two groups: AL group (n=4), reared under Artificial (indoor) Lighting (08:00-20:00); and NL group (n=4), exposed to Natural (outdoor) Light for 3 hours per day (11:00-14:00), and to indoor lighting for the rest of the light phase. After being reared with lenses for ca. 190 days, all monkeys were returned to unrestricted vision until the age of 3 years. Another eight age-matched monkeys, reared with unrestricted vision under artificial lighting since birth, were employed as controls. The ocular refraction, corneal curvature and axial dimensions were measured before lens-wearing (at 23±3 days of age), monthly during the light phase, and at the age of puberty (at 1185+3 days of age). During the lens-wearing treatment, infant monkeys in the NL group were more hyperopic than those in the AL group (F=5.726, P=0.032). Furthermore, the two eyes of most NL monkeys remained isometropic, whereas 3 of 4 AL monkeys developed myopic anisometropia more than -2.0D. At adolescence, eyes of AL monkeys showed significant myopic anisometropia compared with eyes of NL monkeys (AL vs NL: -1.66±0.87D vs -0.22±0.44D; P=0.002) and controls (AL vs Control: -1.66±0.87D vs -0.05±0.85D; P<0.0001). All differences in refraction were associated with parallel changes in axial dimensions. Our results suggest that exposure to natural outdoor light might have an effect to reduced hyperopic defocus-induced myopia. Also, the data imply that early life exposure to sunlight may help to maintain normal development of emmetropization later in life, and thus lower the risk of myopic anisometropia in adolescent monkey.

Intermittent episodes of bright light suppress myopia in the chicken more than continuous bright light

PURPOSE

Bright light has been shown a powerful inhibitor of myopia development in animal models. We studied which temporal patterns of bright light are the most potent in suppressing deprivation myopia in chickens.

METHODS

Eight-day-old chickens wore diffusers over one eye to induce deprivation myopia. A reference group (n = 8) was kept under office-like illuminance (500 lux) at a 10:14 light:dark cycle. Episodes of bright light (15 000 lux) were super-imposed on this background as follows. Paradigm I: exposure to constant bright light for either 1 hour (n = 5), 2 hours (n = 5), 5 hours (n = 4) or 10 hours (n = 4). Paradigm II: exposure to repeated cycles of bright light with 50% duty cycle and either 60 minutes (n = 7), 30 minutes (n = 8), 15 minutes (n = 6), 7 minutes (n = 7) or 1 minute (n = 7) periods, provided for 10 hours. Refraction and axial length were measured prior to and immediately after the 5-day experiment. Relative changes were analyzed by paired t-tests, and differences among groups were tested by one-way ANOVA.

RESULTS

Compared with the reference group, exposure to continuous bright light for 1 or 2 hours every day had no significant protective effect against deprivation myopia. Inhibition of myopia became significant after 5 hours of bright light exposure but extending the duration to 10 hours did not offer an additional benefit. In comparison, repeated cycles of 1:1 or 7:7 minutes of bright light enhanced the protective effect against myopia and could fully suppress its development.

CONCLUSIONS

The protective effect of bright light depends on the exposure duration and, to the intermittent form, the frequency cycle. Compared to the saturation effect of continuous bright light, low frequency cycles of bright light (1:1 min) provided the strongest inhibition effect. However, our quantitative results probably might not be directly translated into humans, but rather need further amendments in clinical studies.

The effects of simultaneous dual focus lenses on refractive development in infant monkeys

PURPOSE

We investigated the effects of two simultaneously imposed, competing focal planes on refractive development in monkeys.

METHODS

Starting at 3 weeks of age and continuing until 150 ± 4 days of age, rhesus monkeys were reared with binocular dual-focus spectacle lenses. The treatment lenses had central 2-mm zones of zero power and concentric annular zones with alternating powers of +3.0 diopter [D] and plano (pL or 0 D) (n = 7; +3D/pL) or -3.0 D and plano (n = 7; -3D/pL). Retinoscopy, keratometry, and A-scan ultrasonography were performed every 2 weeks throughout the treatment period. For comparison purposes data were obtained from monkeys reared with full field (FF) +3.0 (n = 4) or -3.0 D (n = 5) lenses over both eyes and 33 control animals reared with unrestricted vision.

RESULTS

The +3 D/pL lenses slowed eye growth resulting in hyperopic refractive errors that were similar to those produced by FF+3 D lenses (+3 D/pL = +5.25 D, FF +3 D = +4.63 D; P = 0.32), but significantly more hyperopic than those observed in control monkeys (+2.50 D, P = 0.0001). One -3 D/pL monkey developed compensating axial myopia; however, in the other -3 D/pL monkeys refractive development was dominated by the zero-powered portions of the treatment lenses. The refractive errors for the -3 D/pL monkeys were more hyperopic than those in the FF -3 D monkeys (-3 D/pL = +3.13 D, FF -3D = -1.69 D; P = 0.01), but similar to those in control animals (P = 0.15).

CONCLUSIONS

In the monkeys treated with dual-focus lenses, refractive development was dominated by the more anterior (i.e., relatively myopic) image plane. The results indicate that imposing relative myopic defocus over a large proportion of the retina is an effective means for slowing ocular growth.

Bright light induces choroidal thickening in chickens

PURPOSE

Bright light is a potent inhibitor of myopia development in animal models. Because development of refractive errors has been linked to changes in choroidal thickness, we have studied in chickens whether bright light may exert its effects on myopia also through changes in choroidal thickness.

METHODS

Three-day-old chickens were exposed to "bright light" (15,000 lux; n = 14) from 10 AM to 4 PM but kept under "normal light" (500 lux) during the remaining time of the light phase for 5 days (total duration of light phase 8 AM to 6 PM). A control group (n = 14) was kept under normal light during the entire light phase. Choroidal thickness was measured in alert, hand-held animals with optical coherence tomography at 10 AM, 4 PM, and 8 PM every day.

RESULTS

Complete data sets were available for 12 chicks in bright light group and nine in normal light group. The striking inter-individual variability in choroidal thickness (coefficient of variance: 23%) made it necessary to normalize changes to the individual baseline thickness of the choroid. During the 6 hours of exposure to bright light, choroidal thickness decreased by -5.2 ± 4.0% (mean ± SEM). By contrast, in the group kept under normal light, choroidal thickness increased by +15.4 ± 4.7% (difference between both groups p = 0.003). After an additional 4 hours, choroidal thickness increased also in the "bright light group" by +17.8 ± 3.5%, while there was little further change (+0.6 ± 4.0%) in the "normal light group" (difference p = 0.004). Finally, the choroid was thicker in the "bright light group" (+7.6 ± 26.0%) than in the "normal light group" (day 5: -18.6 ± 26.9%; difference p = 0.036).

CONCLUSIONS

Bright light stimulates choroidal thickening in chickens, although the response is smaller than with experimentally imposed myopic defocus, and it occurs with some time delay. It nevertheless suggests that choroidal thickening is also involved in myopia inhibition by bright light.

Seasonal variations in the progression of myopia in children enrolled in the correction of myopia evaluation trial

PURPOSE

To investigate monthly and seasonal variations in the progression of myopia in children enrolled in the Correction of Myopia Evaluation Trial (COMET).

METHODS

An ethnically diverse cohort of 469 myopic 6- to <12 year-old children was randomized to single vision or progressive addition lenses and followed for 3 years with 98.5% retention. Progression of myopia was measured semiannually by noncycloplegic autorefraction (Nidek ARK 700A) and annually by cycloplegic autorefraction, with the former measurements used in these analyses. The semiannual progression rate was calculated as (change in spherical equivalent refraction between two consecutive semiannual visits/number of days between the two visits) times 182.5. Months were categorized as the midpoint between two visit dates. Seasons were classified as winter (October through March) or summer (April through September). The seasonal difference was tested using a linear mixed model adjusting for demographic variables (age, sex, ethnicity), baseline refraction, and treatment group.

RESULTS

Data from 358 children (mean [± SD] age = 9.84 ± 1.27 years; mean myopia = -2.54 ± 0.84 diopters [D]) met the criteria for these analyses. Myopia progression varied systematically by month; it was slower in April through September than in the other months. Mean progression in winter was -0.35 ± 0.34 D and in summer was -0.14 ± 0.32 D, a statistically significant difference (0.21 D, P < 0.0001). The same seasonal pattern was found by age, sex, ethnicity (except in the small sample of Asians), lens type, and clinical center.

CONCLUSIONS

The slower progression of myopia found in summer is likely related to children's spending more time outdoors and fewer hours in school. The data have clinical implications regarding the time of year and the frequency with which myopic children have eye examinations and the need for precise timing of visits in clinical trials testing new myopia treatments. (ClinicalTrials.gov number, NCT00000113.).

Visual regulation of refractive development: insights from animal studies

Investigations employing animal models have demonstrated that ocular growth and refractive development are regulated by visual feedback. In particular, lens compensation experiments in which treatment lenses are used to manipulate the eye's effective refractive state have shown that emmetropization is actively regulated by signals produced by optical defocus. These observations in animals are significant because they indicate that it should be possible to use optical treatment strategies to influence refractive development in children, specifically to slow the rate of myopia progression. This review highlights some of the optical performance properties of the vision-dependent mechanisms that regulate refractive error development, especially those that are likely to influence the efficacy of optical treatment strategies for myopia. In this respect, the results from animal studies have been very consistent across species; however, to facilitate extrapolation to clinical settings, results are presented primarily for nonhuman primates. In agreement with preliminary clinical trials, the experimental data show that imposed myopic defocus can slow ocular growth and that treatment strategies that influence visual signals over a large area of the retina are likely to be most effective.

Quantifying light exposure patterns in young adult students

Exposure to bright light appears to be protective against myopia in both animals (chicks, monkeys) and children, but quantitative data on human light exposure are limited. In this study, we report on a technique for quantifying light exposure using wearable sensors. Twenty-seven young adult subjects wore a light sensor continuously for two weeks during one of three seasons, and also completed questionnaires about their visual activities. Light data were analyzed with respect to refractive error and season, and the objective sensor data were compared with subjects' estimates of time spent indoors and outdoors. Subjects' estimates of time spent indoors and outdoors were in poor agreement with durations reported by the sensor data. The results of questionnaire-based studies of light exposure should thus be interpreted with caution. The role of light in refractive error development should be investigated using multiple methods such as sensors to complement questionnaires.

Myopic shift and outdoor activity among primary school children: one-year follow-up study in Beijing

Purpose

To assess whether a change in myopia related oculometric parameters of primary school children in Beijing was associated with indoors and outdoors activity.

Methods

The longitudinal school-based study included school children who were examined in 2011 and who were re-examined in 2012. The children underwent a comprehensive eye examination including ocular biometry by optical low-coherence reflectometry and non-cycloplegic refractometry. Parents and children had a detailed interview including questions on time spent indoors and outdoors.

Results

Out of 681 students examined at baseline, 643 (94.4%) returned for follow-up examination. Within the one-year period, mean time spent daily outdoors increased by 0.4±0.9 hours, mean axial length by 0.26±0.49 mm, the ratio of axial length divided by anterior corneal curvature (AL/CC) by 0.03±0.06, and myopic refractive error by −0.06±0.89 diopters. In multivariate analysis, elongation of axial length was significantly associated with less total time spent outdoors (P = 0.02; standardized coefficient beta −0.12) and more time spent indoors with studying (P = 0.007; beta: 0.14) after adjustment for maternal myopia (P = 0.02; beta: 0.12). An increase in AL/CC was significantly associated with less time spent outdoors (P = 0.01; beta:−0.12) after adjustment for paternal myopia (P = 0.003; beta: 0.15) and if region of habitation was excludedors for leisure (P = 0.006; beta:−0.13), with less total time spent outdoors (P = 0.04; beta:−0.10), or with more time spent i. An increase in myopic refractive error, after adjustment for age, was significantly associated with less time spent outdo ndoors with studying (P = 0.005; beta: 0.13).

Conclusions

A change in oculometric parameters indicating an increase in myopia was significantly associated with less time spent outdoors and more time spent indoors in school children in Greater Beijing within a study period of one year. Our study provides additional information on the potentially helpful role of outdoors activity in the prevention of myopia. Public health care measures such as school agendas may potentially take it into account.

Light levels, refractive development, and myopia--a speculative review

Recent epidemiological evidence in children indicates that time spent outdoors is protective against myopia. Studies in animal models (chick, macaque, tree shrew) have found that light levels (similar to being in the shade outdoors) that are mildly elevated compared to indoor levels, slow form-deprivation myopia and (in chick and tree shrew) lens-induced myopia. Normal chicks raised in low light levels (50 lux) with a circadian light on/off cycle often develop spontaneous myopia. We propose a model in which the ambient illuminance levels produce a continuum of effects on normal refractive development and the response to myopiagenic stimuli such that low light levels favor myopia development and elevated levels are protective. Among possible mechanisms, elevation of retinal dopamine activity seems the most likely. Inputs from intrinsically-photosensitive retinal ganglion cells (ipRGCs) at elevated light levels may be involved, providing additional activation of retinal dopaminergic pathways.

Time outdoors and the prevention of myopia

Recent epidemiological evidence suggests that children who spend more time outdoors are less likely to be, or to become myopic, irrespective of how much near work they do, or whether their parents are myopic. It is currently uncertain if time outdoors also blocks progression of myopia. It has been suggested that the mechanism of the protective effect of time outdoors involves light-stimulated release of dopamine from the retina, since increased dopamine release appears to inhibit increased axial elongation, which is the structural basis of myopia. This hypothesis has been supported by animal experiments which have replicated the protective effects of bright light against the development of myopia under laboratory conditions, and have shown that the effect is, at least in part, mediated by dopamine, since the D2-dopamine antagonist spiperone reduces the protective effect. There are some inconsistencies in the evidence, most notably the limited inhibition by bright light under laboratory conditions of lens-induced myopia in monkeys, but other proposed mechanisms possibly associated with time outdoors such as relaxed accommodation, more uniform dioptric space, increased pupil constriction, exposure to UV light, changes in the spectral composition of visible light, or increased physical activity have little epidemiological or experimental support. Irrespective of the mechanisms involved, clinical trials are now underway to reduce the development of myopia in children by increasing the amount of time they spend outdoors. These trials would benefit from more precise definition of thresholds for protection in terms of intensity and duration of light exposures. These can be investigated in animal experiments in appropriate models, and can also be determined in epidemiological studies, although more precise measurement of exposures than those currently provided by questionnaires is desirable.