How should we manage a presbyopic progressing myope?

Myopia generally stabilizes in early adulthood. However, some patients still continue to progress past this point. Here is a case of a 50-year-old woman who is still suffering myopia progression, along with difficulty adapting to her correction due to her myopia history in her teens and early adulthood. How can we best manage our presbyopic myopes? Her record is below (note that the name and date of birth have been changed and are illustrative only).

1. Lack of initial spectacle correction and under correction
   Lily suffered uncorrected myopia from age 9 to 15 and then undercorrected myopia from age 15 to 22. Throughout this time, she performed near tasks unaided. As she habitually lived with a reduced accommodative demand throughout childhood and early adulthood, her reduced accommodative function now is unsurprising.
2. Poor near vision with contact lenses
   This also highlights Lily's reduced ability to converge and accommodate. The accommodative demand increases for the myopic contact lens wearer compared to glasses.¹ Rueff et al showed that amongst a group of myopic contact lens wears reporting dry eye symptoms, 48.3% had a binocular vision disorder, with accommodative insufficiency and pseudo-convergence insufficiency being most common.² Lily's symptoms were invariably caused by the inability to meet the increased accommodative demand associated with contact lenses.
3. High near add for her age
   With reduced accommodative function with her distance prescription, Lily has required a near add to support her accommodation for near tasks, with a near boost lens at age 35 and her first pair of progressive addition lenses at age 40. At age 50, now she has a +1.75 Add.

The approach for managing adult progressing myopes is quite different to children. In Lily's case, her refraction was relatively stable from age 22 to age 40, with progression occurring in her 40s. This may be related to the intense screen time that came with recent work-from-home confinement due to the pandemic. Unlike childhood myopia where myopia control is the aim, the goal in managing adult myopia is to determine the best correction to provide comfortable distance and near vision, and to appropriately manage eye health.

As Lily's myopia has increased -0.75 D and -0.50D on the right and left eyes respectively she now suffers blurry distance vision. Therefore, a full distance correction should be able to resolve her distance vision problem.

As she has poor accommodation function, Lily requires a higher add, but this may not help the poor convergence. Since binocular vision issues at near can give symptoms similar to dry eye.² It is important to consider both accommodation and convergence to ensure Lily has comfortable vision overall. Even though Lily spent much time uncorrected or undercorrected at near earlier in her life, her moderate myopia makes this less functional now - she may be able to read her phone or a book unaided but not to the working distance of a laptop or computer screen.

It is also important to provide Lily advice to support comfortable near vision, such as taking regular breaks from close work and ensuring an appropriate reading distance. Advice on correct set up of computer screens to suit vision correction is also important. Finally, it should not be assumed that myopes can simply read comfortably at near without their glasses – recent research has shown that 42% of low myopes and 88% of high myopes with presbyopia find it difficult to read without glasses. Both low and high myopes have demonstrated improved quality of life when wearing progressive addition lenses compared to single vision corrections.³

Lily’s history reports near vision issues with contact lenses, which is presumed to have been before she was presbyopic. It is not known if she has tried multifocal contact lenses, which would improve near vision in presbyopia. Acuity outcomes, adaptation and stereoacuity have been shown superior in multifocal compared to monovision contact lens correction in presbyopes.⁴

It is important to monitor adult myopes for ocular disease, especially considering the increased risk of cataract, retinal detachment and myopic maculopathy which increases with higher refractive error, longer axial length and increasing age.⁵ Lily does not quite reach the criteria of high myopia, but she is close and her axial length could potentially be longer than 26mm which increases eye disease risk.⁶ In Lily's case, axial length has never been measured. Arranging to have this measurement taken at least once would provide better understanding of Lily's myopia pathology risk.

The  International Myopia Institute Clinical Management Guidelines recommends retinal health examination in all myopes, and annually in high myopes through dilated pupils as indicated. Additional imaging with fundus photos and/or OCT is recommended if retinal findings are noted, or to objectively document retinal features. Since early early detection generally allows for better prognosis, it is important to educate adult myopes of their increased risk of eye disease and hence the requirement for regular eye health examinations.

Lily’s myopic progression is presumably due to changes to her visual environment and lifestyle as her myopia had been relatively stable for many years prior. The risk factors associated with adult myopia progression are as follows.⁷

• Performing near work for a large proportion of the day
• Close near task distance
• High AC/A ratio
• High accommodative lag

Encouraging good visual hygiene will help manage the risk factors in order to avoid further myopia progression. This includes emphasizing the importance of regular breaks and the need for appropriate working distance for near tasks. The proper prescription of optical correction to support vision and visual function can manage these binocular vision conditions to improve visual comfort and reduce the likelihood of further progression.

1. In cases of adult myopia, the primary focus of our management is on providing comfortable distance and near vision for the patient, and monitoring for ocular health issues. Myopia progression can be observed in presbyopes, but there is little known about how frequently this occurs. Annual eye exams are recommended for high myopes, to provide full retinal assessment and evaluation for risk factors of other eye diseases associated with myopia.
2. The most immediate impact we can have for our presbyopic myopes is to ensure they have the best possible vision correction, with progressive addition lenses providing better quality of life outcomes than single vision spectacles, and multifocal contact lenses also providing an option.

• Managing Myopia In Presbyopic Adults

• Adult Myopia Progression and How to Treat It