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Medical Forum / General / Vision / June 2005Pseudo-myopia
We were talking about pseudomyopia with Dr. Stacy and I wanted to ask out here, what exactly is pseudomyopia is and what kind of therapy is suggested to treat this condition. A website says; Overuse of the eyes for close work in poor or glaring light can also cause pseudomyopia. * As with other types of accommodative anomalies, a vision therapy program for accommodative excess usually requires 12 to 24 office visits if no home therapy is done. * Again, if the patient does exercises at home, the improvement will be seen much more quickly, usually 8 to 12 weeks. * In cases of pseudomyopia and accommodative excess, vision therapy is aimed at reducing excessive accommodative effort and improving accommodative control. * Procedures similar to those used in treating accommodative infacility may be used. * In addition, general relaxation therapy techniques may be of benefit.  SignaturePV2 Yasar, M U.S. ARMY AH-64D "Armt Dawg" A Co/602d ASB/2ID/EUSA - South Korea Thursday, 02 Jun 2005 / 13:43:08 Korea Standard Time (+0900) Pseudo-myopia is caused by excessive ciliary muscle tone, which causes an increase in accommodation, which causes the crystalline lens to have more plus power. A myopic eye is simply an optical system with plus power. A plus system is neutralized with a minus lens. Whatever causes a relaxation of the ciliary muscle decreases pseudo-myopia. This is one valid use for a plus lens or a bifocal. Excess accommodation can be measured by performing a cycloplegic refraction, in which the ciliary muscle is paralyzed. If the cycloplegic refraction results in less minus (i.e. the eye has less plus power), then the excess is termed the pseudo-myopic component. Since accommodation declines with age, the eye becomes less plus. All pseudo-myopes become less myopic with age. Many pseudo-myopes are also esophoric, which means that their excessive accommodation causes increased convergence. One of the old bifocal studies Otis likes to cite was actually done on myopic patients with esophoria. There have been a few later studies of bifocals for myopes with esophoria with similar results. Most myopes, however, are not esophoric, because their myopia is caused by elongation of the posterior chamber of the eye. Numerous studies have confirmed this by using ultrasound to measure the anterior-posterior length. The accommodative component of myopia is seldom very large. Because any population of myopes will contain a small percentage of pseudo-myopes, anecdotal success stories involving relaxation techniques such as Bates, plus lenses, etc., have always and will continue to occur. For example, a person who acquires one diopter of myopia or so in adulthood is a prime candidate for pseudo-myopia. I have seen any number of those improve spontaneously when they leave the workforce to have children, and are no longer sitting at the computer all day. If a 4 diopter myope loses one diopter of myopia by using eye relaxation techniques, that person will become an enthusiastic promoter of such techniques. Unfortunately, getting rid of those remaining 3 diopters is not going to be quite so easy. DrG This makes perfect sense about all these theories, Bates to begin with... Thanks for the message Doc. SignaturePV2 Yasar, M U.S. ARMY AH-64D "Armt Dawg" A Co/602d ASB/2ID/EUSA - South Korea Thursday, 02 Jun 2005 / 21:23:46 Korea Standard Time (+0900) [the doc's excellent explanation of pseudomyopia snipped] >If a 4 diopter myope loses one diopter of myopia by using eye >relaxation techniques, that person will become an enthusiastic promoter >of such techniques. Unfortunately, getting rid of those remaining 3 >diopters is not going to be quite so easy. Bear in mind that younger people have more accommodation than older people. This means that a 20 year old *could theoretically* have as much as 10 diopters of pseudomyopia that could be uncovered/"released" with cycloplegia and/or relaxation exercises. Again, this doesn't mean their myopia is being cured; only that their PSEUDOmyopia is being treated. Here's a _guideline_ of accommodative amplitudes vs. age. The original page was http://www.tedmontgomery.com/the_eye/index.html --> select "Crystalline Lens" on the left --> scroll to "Accommodation" on the right Age Amplitude of Accommodation 5 16.00 diopters 10 14.00 diopters 15 12.00 diopters 20 10.00 diopters 25 8.50 diopters 30 7.00 diopters 35 5.50 diopters 40 4.50 diopters 45 3.50 diopters 50 2.50 diopters 55 1.75 diopters 60 1.00 diopter 65 0.50 diopter 70 0.25 diopter 75 0.12 diopter To the docters here: Have you studied why eyes become elongated? My observation tells me that most people are not born with elongated eyes. Myopia becomes more severe gradualy with time. My question is: have you considered the long time in pseudomyopia, or long time in the environment which caused the pseudomyopia at the first place, may cause the eyes to elongate? and if it is so, then eliminate the original cause (such as change the environment) should prevent the myopia from further down. Besides, since children are still growing, after the environment change, the children's eyes may even reverse the shape to round again during the growth. I know a treatment is to treat the result, but prevention is to look at the cause. I am sure there are many scientists are studying this, becuase myopia, just like obesity, is becoming an issue for our human's wellbeing. Another question: what do doctors do for the children who are pseudomyopia and esophoric? Since you can detect this, do you tell these children that using plus or bifocal may help them, or do you simplely give them minus lenses without telling them this? In my past experience, no doctors ever told me that my daughter was esophoric and gave any advice on bifocals or plus. Even after I found a behavior OD to help my daughter, the doctors she saw before still strongly discouraged us. Now, my daughter is about -1.5 in both eyes, (coming from -4.00 two years ago when she was five), and still improving. I contributes this to her dedicated vision therapy and environment change. ( we use plus with all her near work.) May be, to some doctors, my daughter is just a patient with a illness which is not so common that does not worth their effort to treat her, but to herself and her parents, it worths every effort to save her vision. I think this alone makes a big difference in judging what treatments worth or not worth the effort. Something to think about. Thanks for reading. Yan > [the doc's excellent explanation of pseudomyopia snipped] > [quoted text clipped - 35 lines] > 70 0.25 diopter > 75 0.12 diopter Yes, I have studied myopiagenesis. Recent research shows that myopia happens even when no accommodation occurs or can occur, as in a denervated eye. Also, pirenzepine, a selective muscarinic antagonist, can block eyeball elongation without having any effect on accommodation. Current thinking is that a blurred image triggers axial elongation. A few questions for you, now. Was or is your daughter esophoric? Did your daughter receive a cycloplegic refraction at age 5? DrG First, thank you for the reply. Now I will answer your questions. Yes, my daughter was diagnosied as esophoric by her behavior OD, and we have been under her VT treatment since then. My daughter had cycloplegic refraction at age 4, and she was prescribed -2.5 both eyes at that time. That was a horrific experience for my daughter. So at age five she refused to take the cycloplegic, then her doctor did the "number 1 or number 2" kind of testing and prescribed -4 for both eyes. I was almost in tears at the docter's office, and begging the doctor for any help, because I knew my daughter was not born nearsighted, and at age five with -4, she would have real health problem later, but no, her doctor never, ever mentioned anything about the plus or bifocal, only said it was genetic and wearing glasses all the time. Looking at my daughter today, I feel so lucky that we did not give up so easy. Yes, it is true that the reversal process takes time, but it worths the effort because the alternative is that my daughter will be severely nearsighted for the rest of her life. I still do not understand why her doctors never told us anything about her esophoric and prevention. Either they never bothered to check her for this, or they knew it but just did not want to treat her. I think either way is acceptable, at least to me. Thanks. Yan Something seems off here. Could you post some visual acuity data for her? Especially unaided or uncorrected... > First, thank you for the reply. Now I will answer your questions. > [quoted text clipped - 21 lines] > > Yan At age 4, she was -2.5 with acuity 20/80, at age 5, she was -4 with 20/200. These are all unaided vision. By the way, I meant to type "either way are unacceptable" in my last messge. Thanks. Yan Dear Yan, cc: Our friend, "You Idiot". It is amazing that an "behaviorial" optometrist would not even MENTION the use of the plus -- before the minus! I can't believe it. At the very minimum he should have at least refered you to Steve Leung's site www.chinamyopia.org For true PREVENTION information. It may be too late for your daughter -- but I hope not! I think ALL ODs who identify themselves as "behaviorial" should discuss this preventive alternative -- with you making the final decision. In the future, I would ask the question about the effect that the minus lens has on the natural eye, i.e., does the eye's refractive status go "down" when you place a minus lens on it. The question is simple --and the answer would be revealing as to the "attitude" of the OD. If he says, absolutly NO, there is no relationship between visual-enviroment and the refractive state of the eye -- then find another OD who actually pays attention to the scientifc-experimental data itself. If he agrees with that statement, and further states that his own children are wearing the plus-for-prevention, then you have found the RIGHT OD to assist your child with prevention. I wish the best for your young daughter. Best, Otis >Dear Yan, > >cc: Our friend, "You Idiot". > >It is amazing that an "behaviorial" optometrist would not even >MENTION the use of the plus -- before the minus! I imagine, if there were any evidence that it worked, a behavioral optometrist would. Can you do your part for humanity and help to generate that evidence?? >I can't believe it. At the very minimum he should have >at least refered you to Steve Leung's site > >www.chinamyopia.org > >For true PREVENTION information. [edit] true PREVENTION theories . . . as yet unproven. >It may be too late for your daughter -- but I hope not! > >I think ALL ODs who identify themselves as "behaviorial" >should discuss this preventive alternative -- with >you making the final decision. . . . and, once its proven (if it ever is), I imagine they will. >In the future, I would ask the question about the >effect that the minus lens has on the natural eye, [quoted text clipped - 14 lines] >have found the RIGHT OD to assist >your child with prevention. I would ask him if he believes that a "box camera" works on an "input" vs. "output" basis, but from a "scientific," not a "medical" standpoint. If you get thrown out of the OD's office, *then* you know you've found a smart practitioner. Getting back *in* that office might be a challenge, but.... >I wish the best for your young daughter. Ignore Otis. Listen to Dr. Leukoma and the other OD/MDs on this site and your daughter will be fine. Ignore me, too. I've just been on this NG a *long* time. Given enough grief, the charlatans have *always* gone away. We're just not there with OSB yet. Sigh.... Dear Otis, Maybe I did not write very clear, please forgive my English, it's only my second language. What I meant was that the behavior OD, with who my daughter has been with since she was five, diagnosed her "esophoric", prescribed her with bifocals, and doing VT with her since then. We are very happy with the behavior OD, because under her care, my daughter's vision has changed from -4 to -1.5, and still improving. She did not mention plus though. The plus lens was my idea, a conclusion from many months' study. The complains I have are for the opthomologists my daughter had seen before we switched to her current behavior OD. From reading this board, it seems that the eye doctors know that bifocal and plus may help esophoric children. This is very difficult for me to understand why my daughter's eye doctors (the two opthomologists we had before) did not ever mentioned this to us because my daughter was esophoric. One reason I can think of is that the doctors think the esophoric myopies are small percentage among the myopia population therefore not worth single them out and help them. This is really, really sad, because to me, my daughter is a whole person. The bifocal and plus may not work for 99% myopies, but it just may work for my daughter, the 1%. How can doctors do not even tell my daughter that she may have a chance to save her vision? Really cannot understand this! Thank you for caring about my daughter's vision. She is in very good hands now, and we are very happy. We are still doing the VT, and specially very strict on her visual environment, such as lighting, reading time, and using plus with near work. In my experience, the environment factor is extremely important, more important than anything else. Without controlling the environment, you cannot really control the myopia progress. Maybe that is why those "controlled studies" do not really mean much, because who knows how these children used their eyes? Some may read two hours without resting, some may read in dim light. Some may not read much. Some may read with extremely high concentration (eyes do not even blink, like me), some may read with wondering mind.....Everyone's threshold is diffrent, that have a lot to do with genes and overall health. Same amount of near work may be perfectly ok to one person but may make another nearsighted. Just like the diet plans, they all work or not. I had a roomate while I was in college, she ate much more and exercised much less than me, but never gain any weight. Should I draw a conclusion that food and exercise have nothing to do with weight control? No, of course not. It just means that her threshold is higher than mine, maybe her body does not absorb food as efficient as mine etc...For the unfortunate me, I just have to watch what I eat and do my exercise to keep healthy. Same analogy to the vision health. Sometimes you may hear someone tells you that near work has nothing to do with myopia because he or she reads just as much as you do and still 20/20, then you know that logic is frauded. Unfortunately, vision helth is a little bit more "abstract" than weight health. Anyway, thank you. Yan Sorry a typo, I meant to say "then you know that logic is flawed." Yan Dear Yan, It is regrettable that your daughter was over-prescribed for her myopia. As a parent, you exercised your right to get a second "professional" opinion, with good results. It is indeed rare for a child of 4 to present with 2.5 diopters of myopia. As far as Otis goes, I doubt that he cares not a whit for your daughter, or anybody else, for that matter. Even though your daughter is being helped by her optometrist, Otis still finds fault. There are reasons why these things happen from time to time. but to condemn the process because of one incident is a bit irrational. Let's just say that I probably would have done some things differently. DrG > As far as Otis goes, I doubt that he cares not a whit for your > daughter, or anybody else, for that matter. I disagree with you here. Fakes and charlatans are easier to deal with. People with the "true faith", who very much believe in what they are doing, are far more dangerous. I believe that Otis very much wants to save the world, and especially the children, from myopia. ObSadChildrenStory: My son played Little League. It was a miserable experience, he was just terrible at baseball, and the parents were way too competitive. The coaches and umps were great, although we were just lucky. We were very happy after three years of this when he was too old to play anymore. Then, my daughter announced that she wanted to play in Little League! Now, girls were finally allowed to play. I would guess that about 10% or less of the players were girls, now it looks more like 5% or less. My daughter was even a worse baseball player than my son. It would have been horrible. My wife kept trying to convince her to play girl's softball. She was resistant. She had been drug to innumerable Little League games where her brother played, and had never seen girl's softball. Finally my wife got the idea of taking her to see a girl's softball game. Well, my daughter is a *very* social person, and I suspect that that was most of why she wanted to join Little League (especially back then, she wanted to join *everything*). Once she saw the girl's softball game, she was hooked. There were all her little friends from soccer, Girl Scouts (or whatever it was called at that age) and school. That was ten years ago, but I still walk by the LIttle League field (and the soccer field) several times a day while out walking for exercise. Yesterday I heard yelling coming from the Little League field, so stopped to see what was happening. A coach was yelling at the top of his lungs at the umpire. He yelled for about five minutes, and had three basic lines: "I'm just trying to save the kids from embarrassment", "You're out of control" and "This is just unbelievable". What a role model for the kids! If I had been on his team, I would have: been terribly embarrassed about seeing my coach yelling at the umpire, realized full well who was in control and who wasn't (the umpire never raised his voice, and mostly just stood there) and realized full well what was unbelievable. He threw in a few more phrases, like "I'm just trying to save the kids from embarrassment, and you throw me out of the game" and "You don't care for the kids. You couldn't care less. Well, *I* care about these kids.". He also asserted his right as a coach to turn off the scoreboard any time he felt like it, which is why the umpire threw him out of the game. What's my point? I think that the coach and Otis sincerely believe that they are doing the best for the kids. SignatureDan Abel Sonoma State University AIS dabel@sonic.net I don't deny that Otis probably thinks that his ideas are monumentally important, but that is quite a different motivation than altruism. Note how he makes frequent reference to the fact that he has done some "arm twisting" of his own relatives in order to get them to see the light. I wonder what they would have to say about that? A quick visit to his website should convince you that Otis was thwarted from his true mission in life, that of becoming a pilot, because of what he calls staircase myopia induced by the malpractice of the optometric community. He hasn't quite forgiven them. After all, there is no way that such myopia could be hereditary. In his mind, the ends justify the means, even if the means are recruiting young, gullible myopes. He now apparently wants to practice optometry. Is that close? DrG Dear Yan, Esophoria is sometimes a sign of excessive accommodation, but not always. Most myopes do not show esophoria at near, because without their eyeglasses, they under-accommodate. Besides causing convergence, excessive accommodation may give a false "nearsighted" refraction, or pseudomyopia. This is why a cycloplegic agent should be used, always, with young children. Whether the esophoria was there initially is only speculation. It may not have been. Sometimes, the cycloplegic agent may not result in complete cycloplegia. Atropine was more commonly used in the past, but the effects last days. Perhaps it should be used more often. Interesting case, though. DrG >Sometimes, the cycloplegic agent may not result in complete >cycloplegia. Atropine was more commonly used in the past, but the >effects last days. Perhaps it should be used more often. Interesting >case, though. That's really the meat of *my* story, Doc. High hyperope/moderate astigmatism (OD: 8.44 -1.71; OS: 7.95 -1.92) Tenacious ciliary spasm. Commonly used cycloplegics only ever elicited an additional ~ 1-2d of hyperopia (over my standard ~+5d Rx), but a) the symptoms were always there, and b) I couldn't ever adapt to a (what was thought to be) full plus Rx. The spasm would return and I'd have pseudomyopia. Only four days of Atropine b.i.d. (at about age 34) "unlocked" my full hyperopia, indicating that I'd actually been about 4.5d over-minused (relative to a full cyclo Rx) for years. Too much load on *my* accommodative system. Also (presumably) resulted in an underestimation of my actual esotropia, indicating less surgical correction than would have been indicated if the acc. component had been fully eliminated. This was before the idea of Prism Adaptive Trials (though, if I had significant tonic accommodation, those results would have been inaccurate, too....) Now what I use is my Atropinised wavefront Rx. I can adapt to that in cl's; not in distance vision specs. Can't help wondering where I'd be now had I been hit with Atropine/Homatropine *somewhere* during those 20 years.... All Hail Atropine! > Only four days of Atropine b.i.d. (at about age 34) "unlocked" my full > hyperopia, indicating that I'd actually been about 4.5d over-minused [quoted text clipped - 3 lines] > correction than would have been indicated if the acc. component had > been fully eliminated. Being over-minused really means under-plussed in your case. (my clarification to avoid otis' thinking that someone actually put minus lenses on you). Either way, it would have resulted in an over-estimation of your actual esotropia, at least the non-accommodative portion thereof. This is because the excessive accommodation would increase the total strabismic angle, whereas full plus would relax out the accommodative part. w.stacy, o.d. >> Only four days of Atropine b.i.d. (at about age 34) "unlocked" my full >> hyperopia, indicating that I'd actually been about 4.5d over-minused [quoted text clipped - 6 lines] >Being over-minused really means under-plussed in your case. (my >clarification to avoid otis' thinking Hasn't happened yet >that someone actually put minus lenses on you). Oops. There was more. Sorry. >Either way, it would have resulted in an over-estimation of your actual >esotropia, at least the non-accommodative portion thereof. This is >because the excessive accommodation would increase the total strabismic >angle, whereas full plus would relax out the accommodative part. You're exactly right. I think they overestimated the non-accommodative part, but (perhaps) underestimated the eso- that could have been elicited via prism adaptive trials. Incidentally, patching isn't alleviating symptoms. I'll be switching eyes today (woo-hoo!) ;-) > Incidentally, patching isn't alleviating symptoms. I'll be switching > eyes today (woo-hoo!) ;-) So that probably eliminates vergence issues from your symptoms, meaning I think you could probably dispense with the prisms, unless that would give you diplopia. w.stacy, o.d. The above "amplitude of accommodation", i.e., stop-to-stop ignores depth-of-field effects which can increase the range of sharp focus by about 1 diopter or so -- in sunlight. Best, Otis That's a good observation. However, then the patient has no amplitude left over for reading. DrG As you pointed out -- it is an ill wind that does not blow some good. If he is -1.5 diopter myopic, then with depth-of-field he should be able to read with no glasses. Best, Otis |
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