Beatnik Picnic

Myopia - Doing Something About It

Nico Bea -
[!info] This is the sixth in a series of posts about the epidemic of myopia (nearsightedness), my personal experience with it, and what people are doing about it. The fifth part is "Myopia - The Search for Help"

finding and trying something to treat progression

These are some of the possible options I became aware of when looking for something I could try in order to hopefully slow or stop my own progression. They come with a large disclaimer that most or all clinical trials for various treatments and preventatives have only been done in children, so while they are legal for adults, they are "off-label". As discussed before, the mechanisms that cause axial elongation and worsening myopia in adults may not be the same as those in children, limited numbers of researchers are currently investigating this. So in the meantime that leaves the rest of us normal people to use our best guesses in cooperation with our practititioners. This overview will also perhaps be useful for those with myopic children interested in various options to prevent further myopia.

the first and oldest intervention: off-label atropine

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The initial suggestion made to me was for atropine eye drops. Atropine is a compound that some optometrists first started trying around 20 years ago and has been shown to help. There is still no official and corporate produced pre-packaged variety of this treatment in the USA, so it is up to individual optometrists to special order it in the concentration they desire from special compounding pharmacies.

I have thought that if you'd like to explain atropine to a child (one who enjoys fantasy and sci-fi), you'd say it's like a potion for your eyes: you take it at the beginning of the day and hope it helps you over time, though it may have unintended effects, and it wears off or diminishes a while. We may think of the polyjuice potion from Harry Potter or Ent-Draught from Lord of the Rings.

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There were a few things that made me feel uncomfortable with this. The main one being it is known to have a side-effect of pupil dilation and increased daytime blurriness. I also generally felt odd about the idea of putting that substance into my eye for an indeterminate period of time.

specialty contact lenses

This as opposed to the main other type of specialty treatment that had seen success in children: specialty contact lenses. I mentioned Coopervision misight earlier, but this lens 1) did not at the time extend to my prescription range and 2) did not have any astigmatism coverage. This left two other possible avenues: the commercially-produced NaturalVue Multifocal, or custom lenses such as those produced by SpecialEyes or gas-permeable or scleral lenses. With custom lenses, there may be additional issues caused by fitting complexities or by the interaction of the material with my dry eyes. An aside - I forgot to mention earlier that optometrists had identified that I likely have early onset meibomian gland dysfunction caused by previous use of Isotretinoin/Accutane - another topic for another time. But this complicated things.

I'm not sure what all the words here mean, but the images can give even a normal person an idea of which different lenses have different distributions of prescription powers throughout. It is captioned: Radial power profile and color power map of lenses analyzed; for a better comparison between different designs, the radial power profiles were plotted removing the labeled lens power from the raw data. Note that the power profiles are not plotted using the same dioptric scale. Source here.

It is noteworthy that the specialty lenses do not all have the same type of optic designs. Most of them work on the basis of creating myopic peripheral defocus, countering the hypothesized mechanism for myopia progression mentioned earlier. A non-comprehensive list of the lenses I know of, and subjective layperson impressions of them:

coopervision misight

This is the most common, and one of the first lenses to market. It's a daily lens, It uses a "concentric ring" design to provide alternating rings of the typical prescribed distance (minus) power and defocus (plus power). They recently expanded the range of available powers, to attempt to be able to help patients who already have higher degrees of myopia. A variant is being developed that uses the most contemporary high-oxygen-transmissibility lens materials (silicon hydrogel polymers) It cannot correct astigmatism. More info here.

**NaturalVue Enhanced Multifocal / Menicon Bloom Day**

https://vtivision.com/practitioner/products/enhanced-multifocal/

This is a bit of an outlier in some good ways. Rather then a "concentric ring" design, it has gradually increasing plus power from the center of the lens outward. This is considered an EDOF or extended depth of focus design. I believe this is the class of design more typically found in the lens implants given to cataract patients when their natural lens they are born with fails. The manufacturer says this creates peripheral blur and a "virtual pinhole aperture", which may result in several additional benefits:

  • correcting some astigmatism
  • offloading some acommodation/focusing to the brain instead of the eye
  • having clearer vision across several distances and reduction in "halos" and discrete focus zones usually found with multifocal contact lenses The lens was designed in part by a former engineer who became fascinated with the eye and light and retrained as an optometrist. The lens can also be used to treat presbyopia (the focusing trouble that many people get as they age). It is marketed outside the US as Menicon Bloom Day. The lens material is a less recent but still modern material.

Mark'ennovy Mylo

The Brien Holden Vision Institute of Australia researched a class of lens designs which seem to sit somewhere between the concentric ring designs and continuous EDOF design of NaturalVue. They don't manufacture lenses but rather license their design out to several firms, the first being Mark'ennovy. The Mylo lens is not a daily, but monthly lens. Some evidence suggests this design is not as effective as others, some suggest it is on par with others. But it does come with toric parameters for astigmatism.

Euclid Be Free day

A relatively new daily lens for the american market, using the Brien Holden design mentioned above. Its available Rx powers are not yet as extensive as some other designs. This is marketed by Mark'ennovy in Europe.

SEED 1-Day Pure

Available in parts of Europe and Japan, manufactured by a Japanese company, it uses a similar Brien Holden design. There are not clinical trials or retrospective studies for this specific lens in myopia control, but there are for similar or identical brien holden designs.

Synergeyes ID and Duette

A custom hybrid lens (part gas-permeable in the center, part soft lens on the outer part), this is another multifocal lens that uses a different Brien Holden design.

Tiedra Esencia

A 90 day lens which seems primarily for Spain, but possibly elsewhere in Europe. Information on this lens is harder to come by.

Johnson and Johnson Abiliti 1-day

Another concentric ring design like misight, it is not yet available in The US, but widely in Canada. It is specifically targeted to smaller child-sized eyes.

SwissLens Relax

A European lens, it uses a distinct multifocal design and is one of the only designs if not the only design I'm aware of that is also available in a RGP (rigid gas-permeable) format.

DISC 1-Day

A lens mainly for the chinese market, developed in Hong Kong, which can treat eyes with high minus powers

SpecialEyes Multifocal

Another custom lens, multi-month replacement schedule, and was an early player to fill gaps left by other lenses. Has a more traditional "zonal" design with discrete focus zones.

Other Off-Label Lenses

The pioneer of myopia control lenses was off-label use of coopervision Biofinity and Proclear lenses used in the BLINK trial by researcher Jeff Walline and others. This was an off-label use of a lens that was the first proven soft-lens treatment that reduced myopia control. Others followed, including Thomas Aller and others with Acuvue Vistakon bifocal in the CONTROL trial For most cases, use of these lenses would likely be superseded by use of coopervision misight or acuvue abiliti 1-day instead.

Another look at some of these various lenses is found here. I believe the "Cheng et al" design is abiliti 1-day, and the "Sankaridurg" designs are the Brien Holden Vision Institute designs.

A specialty lens, in our fantasy metaphor may be thought of more like an amulet or shield - something that aids and protects for the duration of while it is worn, and whose effects generally don't wear off. Like the invisibility cloak from Harry Potter or Mithril armor from Lord of the Rings.

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Naturalvue multifocal was probably the most suitable for me

Returning for a moment to my personal history. Dr. Adams suggested to me, if not atropine, then NaturalVue multifocal. However, there were still complications with this lens - one being that we did not know if my dry eyes would tolerate the older lens material, and two being that it did not have astigmatism parameters, so the provider believed that it would also be necessary for me to wear spectacles over the contact lenses.

Through quite a bit of investigation, some conversations with other providers, and some exchanges with the lens vendor's medical officer (who kindly responded to several inquiries), I determined that because of special characteristics of the lens's design, there was a chance that the lens could indeed correct astigmatism without additional eyeglasses needed on top.

This, along with a few other considerations I'd had at the OD office I'd been visiting, meant it was time to seek out a new provider. And because most of the clinical trials have been in children, some informed speculation or synthesis of the current state of things would continue to be useful. To that end, I engaged in correspondence with several folks including a world-leading expert who lectures on this topic and has aided in lens designs, a few professors at optometry schools, and a telemedicine consult with a provider who'd written publicly about his experiences using this lens for this purpose.

This was not a straightforward process - some practitioners or researchers had different takes on what could be a good idea to try, ranging from one well-regarded provider somewhat aggressively telling me the problem was in my head, to some saying "couldn't hurt to try", to others urging me to be as aggressive as possible in pursuing one or more treatments that have only anecdotal evidence. I tried to find a middle way. There's also the psychological aspect of questioning myself when hearing the varying inputs. Had I done things wrong? Did I care too much? There may be a future update in more detail on this.

I eventually settled into a prescription for the specialty lens I mentioned - NaturalVue Multifocal. Representatives from the company were very open and helpful in attempting to help me get the correct fit for the lens and also find a place to purchase it. The fitting process differs substantially from most typical contact lenses, and because of the unique design of the lens, there can be an adaptation period, as well as simple acceptance or acclimation to some of the drawbacks of the lens. I'll say more about my experience with that later.

For now, more about other treatment options.

specialty spectacles

These are eyeglasses whose lenses have special designs and may be based off similar hypotheses to specialty contact lenses

HoyaVision Miyosmart (DIMS and DIMS TED)

Not yet available in the USA, whereas version 2.0 DIMS TED is already being rolled out in Canada. DIMS is short for: , and rather than using concentric rings of defocus, it uses small dots grouped together in a defocus zone

Essilor Stellest (HALT)

I am not eager to promote Essilor due to their questionable monopoly practices in the spectacle and vision discount plan markets. That might be a post for another time but suffice to say I believe this French company contributes to far more expensive trips to the optometrist and optical shop in the USA than should be necessary.

That said, they are the first to market with a myopia control spectacle in the USA, which lags far behind every developed country in adoption of myopia control spectacle lenses. By the time these were available in the US in 2025, they'd already been available in Canada for years.

They work based on a similar premise of concentric-ring contact lens designs, alternating zones of minus and plus power. However, spectacle lenses do not follow the eye's movements like contact lenses. This design is called Highly Aspherical Lenslet or H.A.L.T. They are working toward a more effective Stellest 2.0 / HALT MAX

SightGlass (DOT)

This is the lone treatment I'm aware of that addresses contrast issues mentioned earlier. DOT is short for "diffusion optics technology" It seems to me it could be interesting if researchers try to combine this with other spectacle lens designs. It also seems appealing given that they have a simulator of using the lens on their site, which seems minimally different from regular vision. Although they were designed in the US, for some reason they're not available here yet.

source: SightGlass Vision

Zeiss MyoCare

It is my understanding that unfortunately this design is substantially inferior in efficacy to other designs.

A Gap: NO EDOF spectacle designs currently exist. They may not be possible to make, or perhaps they are considered similar enough to multifocal spectacles, which have not been shown to be effective in myopia control

More on various methods and their effectiveness, in this article aimed at clinicians, so tread carefully, and check in with a trusted professional.

orthokeratology ("ortho-k")

This is an option that is not available to me, because my eyes are already too long and corneas too altered. Orthokeratology works to reshape the cornea, the front surface of the eye, via special hard contact lenses that are worn overnight and removed during the day. I think of this like having a contact lens that temporarily does laser eye surgery for one night.

This was one of the earlier treatment methods available, long standing, and still in use. It has the bonus that no corrective lenses are required during the day. It may also be used by adults with low prescriptions who do not require myopia control but also do not wish to have laser eye surgery.

7-MX

This is a caffeine and chocolate metabolite that has been in use in Denmark for over a decade. Still, it has not been used in randomized control trials. There appear to have been some retrospective studies which show it having mixed effectiveness

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Scleral or Macular Reinforcement Surgery

This is an extreme and invasive intervention, which at this point seems reserved for patients with advanced stage myopia-related pathologies mentioned earlier. The operation carries risk of other sight-threatening issues, but may have beneficial effects including substantial reduction of sight-impairing symptoms of myopia-related conditions. This seems unlikely to be offered for most myopic children since there are so many less-invasive methods that are advancing quickly. It also seems less likely to be offered in adults since there may be emerging less-invasive alternatives emerging (RLRL and Scleral Cross-Linking, mentioned later).

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lifestyle interventions

One practitioner I spoke to gave me an analogy of a patient with heart disease - there are medications and devices, but there are also lifestyle interventions that may help like reducing sugar and salt intake. For myopia, I hinted at several of these earlier. However, there is still disagreement over which factors are causal and to what degree. These are general suggestions or inferences I've made from discussing with practitioners, but as usual, check with a trusted provider. The lifestyle interventions may include:

So there are a number of treatments, some that are variations on a theme. One hopes that additional treatments continue to be explored. In the next part, I'll say a bit about what treatments may be available in the near term.