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Ocular Characteristics of Anisometropia

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Ocular Characteristics of Anisometropia Ocular characteristics of anisometropia Stephen J Vincent BAppSc (Optom) (Hons) Institute of Health and Biomedical Innovation School of Optometry Queensland University of Technology Brisbane Australia Submitted as part of the requirements for the award of the degree Doctor of Philosophy, 2011 Keywords Keywords Anisometropia Myopia Asymmetry Amblyopia Aberrations Dominance ii Abstract Abstract Animal models of refractive error development have demonstrated that visual experience influences ocular growth. In a variety of species, axial anisometropia (i.e. a difference in the length of the two eyes) can be induced through unilateral occlusion, image degradation or optical manipulation. In humans, anisometropia may occur in isolation or in association with amblyopia, strabismus or unilateral pathology. Non-amblyopic myopic anisometropia represents an interesting anomaly of ocular growth, since the two eyes within one visual system have grown to different endpoints. These experiments have investigated a range of biometric, optical and mechanical properties of anisometropic eyes (with and without amblyopia) with the aim of improving our current understanding of asymmetric refractive error development. In the first experiment, the interocular symmetry in 34 non-amblyopic myopic anisometropes (31 Asian, 3 Caucasian) was examined during relaxed accommodation. A high degree of symmetry was observed between the fellow eyes for a range of optical, biometric and biomechanical measurements. When the magnitude of anisometropia exceeded 1.75 D, the more myopic eye was almost always the sighting dominant eye. Further analysis of the optical and biometric properties of the dominant and non-dominant eyes was conducted to determine any related factors but no significant interocular differences were observed with iii Abstract respect to best-corrected visual acuity, corneal or total ocular aberrations during relaxed accommodation. Given the high degree of symmetry observed between the fellow eyes during distance viewing in the first experiment and the strong association previously reported between near work and myopia development, the aim of the second experiment was to investigate the symmetry between the fellow eyes of the same 34 myopic anisometropes following a period of near work. Symmetrical changes in corneal and total ocular aberrations were observed following a short reading task (10 minutes, 2.5 D accommodation demand) which was attributed to the high degree of interocular symmetry for measures of anterior eye morphology, and corneal biomechanics. These changes were related to eyelid shape and position during downward gaze, but gave no clear indication of factors associated with near work that might cause asymmetric eye growth within an individual. Since the influence of near work on eye growth is likely to be most obvious during, rather than following near tasks, in the third experiment the interocular symmetry of the optical and biometric changes was examined during accommodation for 11 myopic anisometropes. The changes in anterior eye biometrics associated with accommodation were again similar between the eyes, resulting in symmetrical changes in the optical characteristics. However, the more myopic eyes exhibited slightly greater amounts of axial elongation during accommodation which may be iv Abstract related to the force exerted by the ciliary muscle. This small asymmetry in axial elongation we observed between the eyes may be due to interocular differences in posterior eye structure, given that the accommodative response was equal between eyes. Using ocular coherence tomography a reduced average choroidal thickness was observed in the more myopic eyes compared to the less myopic eyes of these subjects. The interocular difference in choroidal thickness was correlated with the magnitude of spherical equivalent and axial anisometropia. The symmetry in optics and biometrics between fellow eyes which have undergone significantly different visual development (i.e. anisometropic subjects with amblyopia) is also of interest with respect to refractive error development. In the final experiment the influence of altered visual experience upon corneal and ocular higher-order aberrations was investigated in 21 amblyopic subjects (8 refractive, 11 strabismic and 2 form deprivation). Significant differences in aberrations were observed between the fellow eyes, which varied according to the type of amblyopia. Refractive amblyopes displayed significantly higher levels of 4th order corneal aberrations (spherical aberration and secondary astigmatism) in the amblyopic eye compared to the fellow non-amblyopic eye. Strabismic amblyopes exhibited significantly higher levels of trefoil, a third order aberration, in the amblyopic eye for both corneal and total ocular aberrations. The results of this experiment suggest that asymmetric visual experience during development is associated with asymmetries in higher-order aberrations, proportional to the magnitude of anisometropia and dependent upon the amblyogenic factor. This v Abstract suggests a direct link between the development of higher-order optical characteristics of the human eye and visual feedback. The results from these experiments have shown that a high degree of symmetry exists between the fellow eyes of non-amblyopic myopic anisometropes for a range of biomechanical, biometric and optical parameters for different levels of accommodation and following near work. While a single specific optical or biomechanical factor that is consistently associated with asymmetric refractive error development has not been identified, the findings from these studies suggest that further research into the association between ocular dominance, choroidal thickness and higher-order aberrations with anisometropia may improve our understanding of refractive error development. vi Contents Table of Contents Chapter 1: Literature Review ............................................................................... 1 1.1 Refractive error development ....................................................................... 1 1.1.1 Emmetropisation .................................................................................... 1 1.1.2 Biometric changes during emmetropisation ............................................ 2 1.1.3 Biometric basis of refractive errors .......................................................... 3 1.1.4 Altered visual experience during emmetropisation .................................. 4 1.1.4.1 Ocular pathology .............................................................................. 5 1.1.4.2 Refractive amblyopia ........................................................................ 6 1.1.4.3 Strabismic amblyopia........................................................................ 7 1.1.4.4 Form deprivation amblyopia ............................................................. 8 1.1.4.5 Treatment of amblyopia ................................................................... 8 1.1.5 Animal studies of refractive error development ...................................... 8 1.1.6 Retinal image manipulation in humans ................................................. 11 1.1.6.1 Orthokeratology ............................................................................. 11 1.1.6.2 Bifocal contact lenses ..................................................................... 12 1.1.6.3 Monovision .................................................................................... 14 1.1.7 Summary .............................................................................................. 16 1.2 Myopia development - aetiological factors .................................................. 18 1.2.1 Myopia development - optical factors ................................................... 20 1.2.1.1 Accommodation ............................................................................. 20 vii Contents 1.2.1.2 Higher-order aberrations ................................................................... 22 1.2.1.3 Variables that influence higher-order aberrations ........................... 23 1.2.1.4 Interocular symmetry of higher-order aberrations .......................... 25 1.2.1.5 Compensatory mechanisms ............................................................ 31 1.2.1.6 Higher-order aberrations and refractive error development ............ 31 1.2.2 Summary .............................................................................................. 38 1.3 Myopia development - mechanical factors .................................................. 39 1.3.1 Mechanical changes during near work .................................................. 39 1.3.1.1 Convergence .................................................................................. 39 1.3.1.2 Ciliary body forces .......................................................................... 40 1.3.2 Intraocular pressure ............................................................................. 42 1.3.2.1 Animal models ............................................................................... 42 1.3.2.2 Intraocular pressure and myopia in children ................................... 44 1.3.2.3 Intraocular pressure and myopia in adults ...................................... 47 1.3.3 Summary .............................................................................................. 49 1.4 Non-amblyopic anisometropia .................................................................... 50 1.4.1 Genetic influence .................................................................................
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