Four reasons why binocular vision matters in myopia management

First published: June 29, 2018
Updated: August 16, 2021 and July 10, 2023

Binocular vision is a much neglected (and even maligned?) domain of eye care - even though I've had numerous colleagues say their professional excitement and learning opportunities have been reinvigorated through seeing the clinical imperative and application in practice. Not only does binocular vision assessment add so much more to your clinical picture, and make optometric life more interesting, it could be the secret sauce that helps us bridge the gap towards higher myopia control efficacy, or at the very least answer questions in cases where we get lower efficacy than expected.

Pre-myopes show a higher accommodative lag than their peers who do not become myopic, with the correlation becoming stronger after onset of myopia, indicating that this may be a feature and a cause of myopia.³ Children with higher response AC/A ratios have an increased risk of myopia development within one year of over 20 times.⁴

If we see esophoria and accommodative lag in combination with a lower than age-normal level of hyperopia (+0.75 or less at age 6-7 is the strongest risk factor for future myopia),¹ then controlling binocular vision is our main management tool for these children, along with recommending more time spent outdoors.²

Intermittent exotropia (IXT) has also been associated with a higher prevalence of myopia - 50% of children with IXT are myopic by age 10 and 90% are myopic by age 20.⁵

Read more about this in How to identify and manage pre-myopes.

In myopia control studies of progressive addition spectacle lenses (PAL), children with esophoria in single vision spectacle control groups were found to progress more quickly,⁶ and children with a larger baseline accommodative lag in the PAL groups showed statistically greater treatment effect.⁷

If we have a child with normal binocular vision, PALs may not show much of a myopia control effect. But in the presence of esophoria and/or accommodative lag, PALs can show modest treatment effects. Overall, though, bifocals seem to be more effective than PALs across various BV presentations.⁸ Learn more in When to prescribe spectacles for myopia control. 

The most effective spectacle lens options for myopia control are the new designs with lenslets or diffusion technology, and research has shown that these do not modify binocular vision. This means that the myopia treatment elements of the lens design are not seen by the eye as an 'add' power, as for a PAL or bifocal spectacle lenses. Read more in The next generation - DIMS, H.A.L.T. and DOT spectacle lenses for myopia control.

Three key research papers are relevant here. Firstly, fitting bifocal soft contact lenses to myopic children with esophoria at near, where the add was chosen to neutralize the associated phoria, resulted in a 70% reduction in axial elongation over twelve months compared to single vision soft contact lens wearing controls.⁹

Secondly, children with lower baseline accommodative amplitude have shown a 56% better myopia control response to orthokeratology contact lens wear compared to normal accommodators, in a two year study. Study participants were separated by the mean accommodative amplitude into 'below average' and 'above average' accommodators. The children with 'below average' accommodation showed the bigger improvement in their amps in OK wear (around 4D more, compared to around 1D for the above average accommodators) and the better myopia control effect.¹⁰

Finally, a study investigating a soft contact lens designed with positive spherical aberration for myopia control (think of it as a type of 'distance centred' multifocal) showed that children wearing this lens relaxed their accommodation compared to a single vision control lens.¹¹ This reduction in accommodative response was correlated with a reduced myopia control effect in the test lens, but no such association was found in the control (single vision) lens. This study was the first to link accommodation with myopia control efficacy in soft contact lenses, with the relationship in OrthoK indicated previously.

Overall, this appears to indicate that accurate vergence and accommodation are important factors in achieving the best possible treatment effect from soft contact lens designs and orthokeratology fit for myopia control.

If you want to deep-dive into the science on this, check out this research summary entitled Spherical aberration, accommodation and multifocal soft contact lenses. If you're interested in the clinical side of this, check out Which multifocal soft lens? Efficacy and visual function.

To comprehensively customize treatment for your patient, managing their binocular vision can influence visual comfort as well as myopia control efficacy. We know that:

• Esophoria and accommodative lag are likely to be improved in orthokeratology wear.^12,13
• Multifocal contact lenses may also cause a small exophoric shift but may slightly increase accommodative lag depending on their design.^14,16
• The dual focus concentric contact lens design (MiSight) appears not to alter accommodation or phoria.^15-17
• The new generation of myopia controlling spectacle lenses (eg. DIMS Hoya MiyoSmart) and H.A.L.T technology (Essilor Stellest) also don't alter binocular vision function.^18,19
• Exophoria and accommodative lag can worsen when changing the myope (especially the higher myope) from spectacles to contact lenses.²⁰

Why does this matter? Firstly symptoms of binocular vision problems can be confused with dry eye symptoms - this has been shown in young adult myopic CL wearers.²¹ This could be extrapolated to children; although the link between binocular vision disorders and reduced reading speed and comprehension could be more concerning.^22,23 Secondly, if a child does not accommodate normally through a multifocal contact lens, it could influence the ideal optics required for myopia control efficacy.²⁴

Here's the complicated part. There is a wealth of research on the links between binocular vision disorders, myopia onset and progression, and interactions with myopia control treatments. Despite this, there is no clear association between altering these binocular vision conditions and myopia progression. What does this mean? That we should manage binocular vision to ensure our patients have good visual comfort, but can't draw the line specifically to how this will impact their myopia progression.²⁵

Learn more about how to factor binocular vision into your prescribing decisions - for both visual comfort and myopia control efficacy - in Selecting an option: Clinical Decision Trees.

Myopia has long been associated with inaccurate and insufficient accommodative behaviour at near and increased accommodative convergence in comparison to emmetropes.^4,26-27 Detecting these conditions in both the at-risk emmetrope and myopic child can reveal the picture of myopia progression risk, and their management could provide added benefit to myopia control treatment.

Binocular vision status is additionally relevant to visual comfort, to ensure children have functional skills for reading and schoolwork and acceptance of their correction, and to avoid dry eye-type symptoms in young adults. 

If binocular vision function is normal, then selecting a myopia control option is uncomplicated - choose the best treatment that you have available, that suits the child and family. If binocular vision is abnormal, though, managing this as well as managing myopia may require different strategies.

• How to measure accommodative lag

• Binocular Vision Fundamentals - assessing accommodative facility

• Binocular Vision Fundamentals - assessing vergence

• Binocular vision - easier than you think (one hour lecture)

• Measuring near lag of accommodation

• Specs To Contacts - What Happens To BV?

• Spherical Aberration, Accommodation And Multifocal Soft Contact Lenses (Science review)

Check out my online course Binocular Vision Fundamentals, which starts with my two-system approach to BV assessment and diagnosis. Stepping through understanding of the accommodation and vergence systems, the course then covers clinical tests, diagnostic criteria, prescribing and management. Once this foundation is set, it moves onto clinical communication and the importance of BV in myopia management. Always with a laser sharp focus on the clinical applications.

Included are video examples of assessment techniques and chairside infographic summary downloads to reference in practice.

You can enroll on the first two modules for free, with the full course priced at US$140 if you decide to continue. Reduced course fees by 30% and 50% are available by application for practitioners residing in lower income countries - check out the course page for more information.