Quantitative analysis of the effect of near lens addition on accommodation and myopigenesis

Purpose. To develop a quantitative, objective, and scientific basis for understanding the effects of applying near bifocal additions (ADDs) on oculomotor control and myopia development. This is important because myopia is a major public health problem that affects 25% of the U.S. population and 75% or more in Asian countries. It is also associated with an increased risk for vision-threatening conditions, such as retinal breaks and detachments, as well as glaucoma. Methods. A comprehensive model of refractive error development was constructed based on a dual-interactive feedback model of accommodation and vergence, which represented the short-term dynamics pathway, with the addition of both genetic and environmental (defocus-induced axial growth) components in a long-term pathway. An alternating near- and far-viewing paradigm was simulated, with varying amounts of ADDs, to obtain a parametric relationship between the root mean square of accommodative error (AE) and the induced refractive error (IRE). The parametric relationship provided the crucial linkage between the long-term growth pathway and the conventional short-term dynamics pathway. ADD is the simulated lens placed before the eyes only during near viewing, whereas IRE is the simulated lens fixed before the eyes that represents the optical effect of slowly progressive refractive development caused by near work. Results. A V-shaped functional relationship was found between AE and IRE. The left half of the curve is associated with hyperopic defocus and myopigenesis, whereas the right half is associated with myopic defocus and hyperogenesis. Introduction of an ADD shifts the V-shaped curve horizontally. Thus, an 'optimal' ADD can be used to shift the minimum of the accommodative error curve to the zero IRE point, and thereby reduce or eliminate retinal defocus and its potential towards myopigenesis. On the other hand, sensitivity analysis of model parameters shows that increasing the accommodative convergence crosslink gain (AC) shifts the curve to the right and results in a tendency towards myopigenesis, which is consistent with clinical findings in progressive myopia. Conclusions. The model can be used to specify the precise ADD needed for an individual to retard or eliminate retinal defocus-induced myopic progression. If future experiments show that using the 'optimal' ADD results in the greatest benefit (i.e., least myopia progression), there will be considerable worldwide public health benefit.