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Adult-onset myopia: measurement and management

 Posted on November 30th 2021 by Connie Gan

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In this article:

Myopia which onsets in childhood usually stabilizes in the early twenties. How should we manage adult-onset myopia and progression?

Myopia onset typically occurs in childhood, but adult-onset myopia also occurs in clinical practice. While increased near tasks and reduced outdoor time can be risk factors for myopia onset in children, there is a stronger link between near work and myopia onset in adults. In this case, DS is interested in some advice from the Myopia Profile Facebook community on the options for myopia control in adult-onset myopia.

DS Hi guys, I know theres not a huge amount of research on myopia control in adults but just after some views from people that have done, or do, it. I have a 28 year old, first became myopic at the age of 21, progressed to -1.25 in a couple of years and has been that since. In the last 18 months she's progressed by -0.50 in one eye and -0.75 in the other. Works in retail, not studying, no other ocular problems. She's not too keen on using eyedrops so I was thinking of fitting her in MF CL's as I'm not aware of any downside to doing this (so long as VA is acceptable). Any thoughts from others with more experience in adults?DS - 1.75D and - 2.00D now

Adult-onset myopia

A person whose myopia manifests during adulthood (18 years old or older) is referred to as adult onset myope. Onal et al showed that 14.7% of myopic cases amongst Turkish medical student were adult-onset1, whilst Iribarren et al showed almost half of myopic office workers had shown onset after age of 21.2

Adult-onset myopes usually have low to moderate myopia.3 In a group of young adult clinical microscopists, 40% showed a myopic shift over two years, attributed to an increase in vitreous chamber depth with no change in corneal curvature, anterior chamber depth or lens thickness.4 One study also found that there could be a genetic contribution in adult-onset myopia.5

The risk factors for adult myopia onset and progression appear to be prolonged near work with short working distances, high AC/A ratio and high accommodative lag.7,8 Jiang et al found that there a link between high AC/A ratio with adult onset myopia.9 There have been no studies on this in adults, but in children an increased accommodative lag is hypothesized to generate hyperopic defocus and hence influence axial elongation.10 

Measuring axial length is important to understand ocular disease risk. Whilst there may or may not be changes in axial length in adult myopia, understanding the individual patient's axial length measurement helps to guide their ocular health management. Axial lengths over 26mm indicate high myopia and increased lifelong risk of pathology and vision impairment,11 requiring annual retinal health review.12

Measuring the corneal curvature is important to rule out any refractive changes owing to steepening corneal changes. Read more about this in Are you measuring the cornea in myopia management? The commenters mentioned their observations of axial length and adult myopia progression rates. The data cited by commenter MB is from the following research abstract.

PC I routinely measure AXL on young adult myopes and I have not seen axial elongation in adults. So myopia progression in this age group is probably due to corneal changes, lenticular changes, or accommodation. Most likely accommodation is my guess…MB Adult progression happens. Here are data on 268 university employees with five years of follow-up visit (68%) 17 (6.4%) progressed by at least –0.75 D mean progression = –1.17 ± 0.47 D mean increase in axial length = 0.36 ± 0.22 mm 43 (16.1%) progressed by at least –0.50 D

Myopia control options

Studies on myopia control efficacy in adult-onset progressive myopia - or myopia progression in adulthood - are limited when compared to studies done in children. Contact lens myopia control options were highly recommended by the commenters. There are two small studies indicating orthokeratology's ability to slow progression in adult myopes but neither had control groups.13,14

PC …Giving them some plus, especially the esophores, may help. OrthoK seems to help some mildly progressive adult myopes (who got fitted with OK for lifestyle reasons, with any slowing of progression a bonus), probably due to improvements in binocular vision. Multifocal CL might do the same. I wouldn’t use atropine - no evidence for its use on adults.PC I'll just add my observation that young, non-presbyopic adults don't seem to tolerate the optics of multifocal CLs as well as children... Ortho K appears to give a better visual experience for adults compared to multifocal CL.BR I don’t see any harm if she is wearing CLs - wearing multifocal contact lenses carries no more risk than a single vision CL. As long as acuity & comfort remain good & all options/risks/costs of cl wear are explained to the patient.LM Mutifocal CLs... but some older patients can have difficulty with perception of haloes.

Based on PC's personal observation, young adults tended to struggle adapting to multifocal soft contact lenses due to optical disturbances (e.g. halos and glare) more so than children. Kang et al showed low and high add multifocal contact lenses affected low contrast visual acuity in young adults.15 While a direct comparison between multifocal contact lens acuity and that achieved with orthokeratology (OK) has not been undertaken, one study has shown no impact of OK on visual acuity or visual performance in young adults.16

There is no longitudinal research on the role of low-concentration atropine for myopia control in adult populations. Kaymak et al studied the short-term effects of low-concentration atropine in young adults.17 After 0.01% atropine instillation the prior night, pupil dilation of around 1.5mm and reduced near point of accommodation by at least 1D was noted in both morning and afternoon. Therefore, it is possible that low-concentration atropine may be less tolerated by adults compared to children.

What about the visual environment?

The case mentions that the patient does not have an intensive screen-based job and is not studying. Since adult-onset myopia is linked to both binocular vision disorders and close viewing distances, measurement of the former and providing advice on the latter are also important for this patient. Perhaps her retail work time doesn't involve much screen work but her leisure time does - according to a 2021 survey, over half of US-based adults report spending at least 5 hours per day on their smartphones, not including any work-related smartphone use. Taking regular breaks and maintaining a reasonable viewing distance with smartphone use is important advice for all young adult myopes.

Take home messages

  1. Adult-onset myopia is typically associated with intense near work at short viewing distances, high AC/A ratio and high accommodation lag. Visual environment advice is important for all adult myopes.
  2. Research on adult myopia control options is limited. This is an important point to communicate to patients when considering options to correct myopia and potentially slow progression as well.
  3. Measurement of the corneal curvature to rule out pathology, and measurement of axial length to understand ocular disease risk, facilitate best-practice management of the adult-onset myope.


Further reading on adult myopia

Meet the Authors:

About Connie Gan

Connie is a clinical optometrist from Kedah, Malaysia, who provides comprehensive vision care for children and runs the myopia management service in her clinical practice.

Read Connie's work in many of the case studies published on MyopiaProfile.com. Connie also manages our Myopia Profile and My Kids Vision Instagram and My Kids Vision Facebook platforms.

About Kimberley Ngu

Kimberley is a clinical optometrist from Perth, Australia, with experience in patient education programs, having practiced in both Australia and Singapore.

Read Kimberley's work in many of the case studies published on MyopiaProfile.com. Kimberley also manages our Myopia Profile and My Kids Vision Instagram and My Kids Vision Facebook platforms.

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