Rakhee Shah

Purpose: This study aimed to retrospectively analyse two datasets to investigate the correlation between progressive myopia and astigmatism focusing on the influence of the type of astigmatism on myopia progression in children undergoing myopia management with Defocus Incorporated Multiple Segments (DIMS) spectacle lenses. Patients and Methods: Retrospective right eye data from two anonymised datasets were obtained for analysis: an Asian paediatric population, and a Caucasian paediatric population. Participants’ refractive error at baseline was classified into one of four categories: spherical, with-the-rule (WTR), oblique or against-the-rule (ATR) astigmatism. Myopia progression was evaluated by the change in Spherical Equivalent Refraction (SER) and Axial Length (AL) between baseline and follow-up visits. Results: Retrospective analyses were conducted on right eye data from 265 children (160 Asian & 105 Caucasian). Linear Mixed Models (LMM) analysis of the combined datasets (n = 184) demonstrated a statistically significant main effect of astigmatism type on longitudinal patterns on SER change (p < 0.001), interaction between time and astigmatism was not significant (p = 0.07). In contrast, the LMM resulted in no statistically significant main effect of the astigmatism types on AL change (p = 0.06). The interaction term between time and astigmatism type also did not reveal a statistically significant effect on AL change (p = 0.21). This indicates that the trajectory of myopia progression over time was comparable across all groups despite initial differences at baseline. Analyses revealed that WTR-astigmatism was associated with the least myopia progression and ATR-astigmatism was associated with the greatest progression in this study. The presence of astigmatism at baseline did not significantly affect myopia progression in children wearing DIMS spectacles. Conclusion: The type of astigmatism affected myopia progression. Participants with WTR-astigmatism wearing DIMS spectacles showed less myopia progression compared to participants with oblique or ATR-astigmatism. Long-term investigations in participants with different types of astigmatism undergoing myopia management are required to better understand the relationship between progressive myopia and astigmatism type.

Purpose: Scotland has comprehensive vision screening at age 3.5–5.5 years, with ~85% participation (40,000–50,000 episodes annually). Orthoptists deliver the screening, including presenting vision and tests for binocular vision anomalies (BVAnom). The aims were to investigate (1) changes in the prevalence of BVAnom, 2013–2022 and (2) whether less comprehensive screening of solely presenting vision would detect BVAnom. Methods: Data from eight Scottish Health Boards were available for 2013–2014, 2014–2015, 2015–2016, 2020–2021 and 2021–2022. Binocular vision tests included cover test, ocular motility (OM) and additional tests (near point of convergence, 20Δ base out, pass/fail stereopsis). Data were analysed to determine the prevalence of various BVAnom and adequacy of screening if based solely on vision. Results: From 2013 to 2022, there was a statistically significant increase in prevalence of exotropia (including intermittent; r ² = 0.983, p = 0.001) and of any strabismus (including intermittent; r ² = 0.887, p = 0.02), with strabismus prevalence ~2% in 2020–2022. Prevalence of OM anomalies remained stable ( r ² = 0.364, p = 0.28). The prevalence of BVAnom for each year studied, consecutively, was 3.02, 3.78, 3.83, 4.87, 4.89% ( r ² = 0.930, p = 0.008). If vision screening had been confined to presenting vision, 342–512 cases of BVAnom would have been missed each year, increasing over time ( r ² = 0.934, p = 0.007). Conclusions: In a large population of children in Scotland aged 3.5–5.5 years, the prevalence of BVAnom is increasing, especially exotropia. Many cases of BVAnom would not be detected by solely assessing presenting vision, highlighting the benefits of including binocular vision tests in vision screening. It is recommended that vision screening is repeated during the school years.

Purpose: To review literature on anisometropia, concentrating on diagnostic criteria, contemporary prevalence and progression with regard to the changing distribution of refractive errors in many countries. Also, to consider anisometropia with respect to myopia and hyperopia control, regions/race/ethnicity, effects on visual function and associated conditions. Methods: Scoping review based on searches of PubMed, Embase and Cochrane databases. Results: Various diagnostic criteria have been used for anisometropia, most commonly a SER difference ≥1.00 D. Anisometropia is more common in people with higher refractive errors, and therefore, its prevalence changes with the frequency distribution of refractive errors. Anisometropia is traditionally mostly associated with hyperopia, and this is still the case in some populations. In East and South-East Asia, the rapid increase in myopia has resulted in increased anisometropia. This is associated with impaired stereopsis and binocularity, as well as increased rates of strabismus and amblyopia. When anisometropia is corrected with spectacles, there is an increased risk of spectacle non-tolerance arising from aniseikonia (different image sizes in each eye) and prismatic effects. Contact lenses alleviate most of the problems associated with anisometropia, but are under-prescribed for this condition. The increased association between anisometropia and myopia has led to trials of myopia control interventions, which show promise for reducing anisometropia in myopic cases. However, since myopia in one eye is often a precursor of bilateral myopia, the likelihood of pre-myopia in the non-myopic eye should be considered. Conclusions: The association between anisometropia and the magnitude of refractive error means that in populations with a high prevalence of myopia, anisometropia has largely become a feature of that refractive error, in contrast to the traditional association with hyperopia. This has important implications for myopia control. Vision screening and/or routine professional eye care are recommended because anisometropia is under-diagnosed.

Background: The predominant theory, underlying most optical myopia control interventions, is that relative peripheral hyperopic defocus (RPHD) is a cause of myopia progression. However, interventions that reduce RPHD only slow myopia progression on average by ~50%, so other factors are likely to be involved. Objective: To explore the literature on accommodation and binocular coordination as possible factors in myopia development and progression. Methods: PubMed was searched for relevant keywords in September 2025. Non-human and non-English reports were excluded. Results: (1) Concerning myopia onset, the CLEERE study found changes in the interaction between accommodation and convergence (increasing AC/A ratio) from four years before myopia onset. This is thought to indicate compromised accommodation, supported by reduced positive relative accommodation before myopia onset in other longitudinal studies. (2) Regarding myopia progression, the magnitude of accommodative lag is not strongly correlated with rate of myopia progression. The validity of clinical measurements of accommodative lag has been questioned. Tests of eye alignment during near vision show a more convergent posture (esophoria) in some myopes around the time of myopia onset, probably secondary to increased AC/A ratio. If compromised accommodation and/or near esophoria are relevant to myopia progression, prescribing a near addition should be helpful. However, myopia control trials of bifocal and progressive addition lens spectacles show poor efficacy. Despite early indications of greater efficacy in cases with higher accommodative lag and/or near esophoria, poor treatment effects in this sub-group were subsequently found. Nonetheless, some individual cases with symptomatic convergence excess esophoria are likely to benefit from bifocal spectacles for symptomatic relief. Conclusion: Although accommodative dysfunction seems likely to play some role in myopia onset, accommodative and binocular factors are unlikely to be major causal factors in myopia progression. An additive risk factor risk-resilience model is presented and suggestions are made for further research. Plain Language Summary: Myopia (short-sightedness) has become much more common in recent years, and is predicted to affect half the world’s population by 2050. Treatments are available that slow the progression of myopia by approximately 50% on average, including special spectacle lenses, contact lenses, and eye drops. To better understand why these approaches are not 100% effective we need to know more about the various factors that may play a causal role in myopia. The purpose of this review is to assess the evidence for two such factors: the ability to focus close to (ocular accommodation) and to use the two eyes as a team (binocular coordination). The review reveals research that has found abnormalities in ocular accommodation several years before a child develops myopia. However, there is less evidence that myopia or binocular coordination play a role during myopia progression. A risk-resilience model of myopia is presented. This highlights various factors that may play a causal role in myopia and others that may protect some children against developing myopia.

Aims/Purpose: Myopia arises primarily due to excessive axial elongation and is associated with an increased risk of ocular complications and visual impairment, particularly in high myopia. Although astigmatism may have implications on refractive development, the role of astigmatism in myopic eye growth and the effectiveness of myopia control strategies is unclear. Methods: A scoping review was conducted in March 2025 and updated in August 2025, using MEDLINE and PubMed to explore myopia prevalence and onset, progression and astigmatism (Aim 1) and myopia control and astigmatism (Aim 2). Literature was initially screened by title, abstract and finally by the relevance of the full manuscript. Results: A total of 1004 studies were identified; 26 duplicates were removed; 911 were excluded following title screening and 20 were excluded following abstract screening. A total of 47 studies were included (Aim 1 = 30, Aim 2 = 17), with most conducted in Asia ( n = 31). A higher prevalence of astigmatism was associated with myopia. Myopia progression and astigmatism may be related, although there is limited research on the effects of uncorrected astigmatism on the course of myopia. Additionally, there is limited research regarding the influence of astigmatism on the effectiveness of myopia control strategies, with conflicting findings between studies. Conclusions: Myopia progression and astigmatism may be interdependent. However, a causative role of astigmatism in promoting myopia is unclear. The diverse range of study designs and methodologies impairs the comparability of findings. Prospective research in children of differing ethnicities with a range of astigmatism is required to determine if astigmatism influences the effectiveness of myopia control interventions. This would provide an evidence base to inform clinical decision‐making and management plans for myopic children with astigmatism, particularly in non‐Asian populations where research is limited.

Aim To evaluate and compare the efficacy of combination treatment using 0.025% atropine and Defocus Incorporated Multiple Segments (DIMS) spectacle lenses to 0.025% atropine and single vision (SV) spectacle lenses in slowing myopia progression in children with myopia. Methods Randomised controlled trial conducted on children aged 4–16 years with myopia between −1.00D and −6.00D and astigmatism ≤2.00D. Children were randomly allocated into two groups: 0.025% atropine and SV spectacle lenses treatment group (group A), and 0.025% atropine and DIMS spectacle lenses treatment group (group B). Cycloplegic spherical equivalent refraction (SER) and axial length were measured at baseline, 6 and 12 months. Results 102 patients completed the 12-month follow-up: n=49 in group A, mean age 9.50±2.78 years and n=53 in group B, mean age 9.90±2.47 years. At 12 months, the mean AL±SD change was 0.18±0.16 mm in group A and 0.07±0.16 mm in group B (mean difference: 0.11, 95% CI: 0.05 to 0.17; p≤0.001). Mean SER±SD progression at 12 months was −0.19±0.42D and −0.09±0.35D in groups A and B, respectively (p=0.13). 39.6% of children in group B had no axial elongation over 12 months compared with 12.2% of the children in group A (p=0.002). Conclusions Combination treatment with 0.025% atropine and DIMS spectacle lenses is more effective in controlling axial elongation than 0.025% atropine with SV lenses. Although not significant, SER differences between groups were lower in group B. These findings support a potential additive effect of the two treatments.

Purpose: Scotland has comprehensive child vision screening at age 3.5–5.5 years of age, with ~85% participation (40,000–50,000 screening episodes annually). Orthoptists deliver the screening, including presenting vision, cover test and other tests. Screening failures are referred for eye examinations, including cycloplegic refraction. The study aims to report refractive error data from these examinations (~5000–6000 annually) for 3 years before and 2 years following the COVID‐19 pandemic, and to investigate correlations between myopia and socio‐economic factors. Methods: Right eye data from eight Scottish health boards (HB) are reported for spherical equivalent refraction (SER) for the years 2013–14, 2014–15, 2015–16, 2020–21 and 2021–22. Associations were investigated between the proportion of the sample in each HB with myopia and the proportion of the population in each HB with different levels of deprivation index, classification on a rural/urban continuum and dwelling type. Results: Refractive error frequency distributions revealed a myopic shift in SER over the 5 years. Median SER (interquartile range) in 2013–14, 2014–15, 2015–16, 2020–21 and 2021–22 was +1.38 D (+0.50 to +2.75), +1.38 D (+0.25 to +2.63), +1.38 D (+0.50 to +2.75), +1.13 D (+0.25 to +2.25) and +1.25 D (+0.38 to +2.25), respectively. The increase in myopia was statistically significant in each of the last 2 years compared with each of the first 3 years ( p < 0.0005). The proportion of myopes (≤−0.50 D) increased from r ² = 0.94, p = 0.006). Associations between the proportion of children in each HB with myopia and: (1) deprivation index was low and not statistically significant; (2) the proportion of the population in the most urban environments was high ( r ² = 0.79; p = 0.003); (3) the proportion of dwellings that were flats/apartments was also high ( r ² = 0.83, p = 0.002). Conclusions: In this predominantly Caucasian population, the proportion of children with myopia has increased post‐COVID. A strong association exists between myopia and living in flats/apartments and urbanicity, but not with a deprivation index.

In 2022, the General Optical Council initiated a call for evidence concerning the Opticians Act. This consultation aimed to gather input and evidence relevant to potential modifications to the Opticians Act. One piece of research that was commissioned aimed to investigate the role of orthoptists in refraction. We invited a range of eye care practitioners to participate in an online virtual focus group. Focus group discussions were audio-recorded, transcribed, and thematically analysed. Two focus group discussions involving sixteen eye care professionals were completed. Findings confirm some orthoptists are already performing refraction tasks within the hospital eye service, primarily with young children using cycloplegic retinoscopy. Participants indicated that, at present, orthoptists refract on behalf of ophthalmologists who issue spectacle prescriptions based on the findings of the orthoptist’s refraction. Potential benefits of orthoptists undertaking refraction responsibilities were discussed including the ability to conduct retinoscopy in hospital paediatric clinics where services are in high demand and there is often a shortage of refraction appointments. This shift could lead to decreased NHS waiting times, fewer patient appointments, improved clinical decision-making, and facilitate the assessment of accommodative dysfunction. Overall, the group were positive towards orthoptists conducting refractions and issuing optical prescriptions but with specific conditions: limited to hospital settings, necessitating adequate postgraduate training, supervision by a hospital eye service consultant, and regular ocular health assessments. This study assessed the involvement of orthoptists in present and prospective refraction services, including their potential to legally issue optical prescriptions. The research outlined both the potential benefits and mitigating strategies to address concerns if orthoptists could issue optical prescriptions.

Background: Myopia and especially high myopia are recognised as major public health concerns. Although the prevalence of high myopia in young children is low, 10–20% of high school children in Asia have high myopia, with many still progressing, and one in three patients with high myopia develop visual impairment with age. Most participants in myopia control studies have low and moderate myopia; relatively little is known about myopia control in high myopia. Method: Literature searches were undertaken in MEDLINE and EMBASE to identify publications in English, investigating (Aim 1) the efficacy of myopia control strategies (environmental, pharmacological and optical) in high myopia (≤−6.00 D) and (Aim 2) the complications of high myopia using keywords. Outcomes included change in spherical equivalent refractive error (SE) and/or axial length (AL) to evaluate progression in high myopia. Results: Aim 1: Twelve studies were identified that reported the efficacy of optical and pharmacological (none on environmental) interventions on AL and SE for high myopia control. A statistically significant reduction in progression of SE and AL in high myopes was reported with 1% and 0.5% atropine. Defocus Incorporated Multiple Segment spectacle lenses had lower efficacy in slowing high myopia progression compared to moderate and low myopia. Ortho‐K lenses were equally effective in reducing myopia progression in low, moderate and high myopia. Aim 2: Myopic patients have an increased risk of myopic macular degeneration, retinal detachment, cataract and glaucoma, with the risk increasing with the level of myopia. Conclusions: High myopia has significant effects on quality of life, risk of pathological complications and vision impairment. Young children, excluding those with some syndromic associations, who are fast progressing moderate and high myopes require early intervention and close monitoring. Further research investigating the efficacy of myopia control strategies in highly myopic patients, both independently and through combination treatments, are necessary.