Myopia: Causes, Prevention, and Treatment of an Increasingly Common Disease (2024)
Chapter: Front Matter
Consensus Study Report
NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
This activity was supported by contracts between the National Academy of Sciences and the American Academy of Optometry; the American Optometric Association; the Health Care Alliance for Patient Safety; the Herbert Wertheim School of Optometry & Vision Science, University of California, Berkeley; Johnson & Johnson Vision; the National Eye Institute (HHSN263201800029I/75N98022F00005); Reality Labs Research; Research to Prevent Blindness; and the Warby Parker Impact Foundation. Support for the work of the Board on Behavioral, Cognitive, and Sensory Sciences comes from the National Science Foundation (Award 2234961), the National Institutes of Aging, the American Psychological Association, and the National Aeronautics and Space Administration. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
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COMMITTEE ON FOCUS ON MYOPIA: PATHOGENESIS AND RISING INCIDENCE
K. DAVINA FRICK (Co-Chair; she/her/hers), Johns Hopkins Carey Business School
TERRI L. YOUNG (Co-Chair; she/her/hers), University of Wisconsin–Madison
AFUA O. ASARE (she/her/hers), University of Utah
DAVID BERSON (he/him/his), Brown University
RICHARD T. BORN (he/him/his), Harvard School of Medicine
JING CHEN (she/her/hers), Rice University
JEREMY A. GUGGENHEIM (he/him/his), Cardiff University
ANTHONY N. KUO (he/him/his), Duke University
DAPHNE MAURER (she/her/hers), McMaster University
J. ANTHONY MOVSHON (he/him/his), New York University
DONALD O. MUTTI (he/him/his), The Ohio State University
MACHELLE T. PARDUE (she/her/hers), Emory University
RAMKUMAR SABESAN (he/him/his), University of Washington
JODY ANN SUMMERS (she/her/hers), University of Oklahoma
KATHERINE K. WEISE (she/her/hers), University of Alabama at Birmingham
Study Staff
MOLLY CHECKSFIELD DORRIES (she/her/hers), Study Director
DANIEL J. WEISS (he/him/his), Board Director
TINA M. WINTERS (she/her/hers), Program Officer
J. ASHTON RAY (she/her/hers), Senior Program Assistant
NOTE: See Appendix B, Disclosure of Unavoidable Conflict of Interest.
BOARD ON BEHAVIORAL, COGNITIVE, AND SENSORY SCIENCES
ELIZABETH A. PHELPS (Chair; she/her/hers), Harvard University
RICHARD N. ASLIN* (he/him/his), Yale University
WILSON S. GEISLER* (he/him/his), The University of Texas at Austin
MICHELE GELFAND* (she/her/hers), Stanford University
MARA MATHER (she/her/hers), University of Southern California
ULRICH MAYR (he/him/his), University of Oregon
KATHERINE L. MILKMAN (she/her/hers), University of Pennsylvania
DON OPERARIO (he/him/his), Emory University
DAVID E. POEPPEL (he/him/his), New York University
KARL W. REID (he/him/his), Northeastern University
MO WANG (he/him/his), University of Florida
DUANE WATSON (he/him/his), Vanderbilt University
Staff
DANIEL J. WEISS (he/him/his), Board Director
___________________
* Member, National Academy of Sciences
Reviewers
This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by THOMAS D. ALBRIGHT, Salk Institute for Biological Studies, and EVE J. HIGGINBOTHAM, Perelman School of Medicine, University of Pennsylvania. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
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Contents
2 Myopia and the Human Eye: A Primer
3 Understanding Myopia and Its Prevalence
Divergent Prevalence in Children by Age and Ethnicity
Lifestyle and Urbanization: Potential Causes of Divergent Prevalence
PREVALENCE OF MYOPIA IN THE UNITED STATES
Adult Population-Based Prevalence
Pediatric Population-Based Prevalence
LESSONS FROM THREE REGIONS: THE INUIT, AUSTRALIA, AND ISRAEL
Lessons from the Inuit, Australia, and Israel
CURRENT STANDARD CLINICAL ASSESSMENTS AND DIAGNOSTIC TECHNOLOGIES
Clinical History and Standard Eye Exam
DIAGNOSTICS AND ASSESSMENTS IN CLINICAL RESEARCH
Pupillometry to Assess Rods, Cones, and Intrinsically Photosensitive Retinal Ganglion Cells (ipRGCs)
DIAGNOSTICS FOR ASSESSING THE ENVIRONMENT
OTHER ASSESSMENT AND DIAGNOSTIC TECHNOLOGIES
5 Onset and Progression of Myopia
GENETIC FACTORS ASSOCIATED WITH MYOPIA
Genes Associated with Myopia and Refractive Error Development
Near Work—Re-examining a Classic Risk Factor for Myopia
Distinguishing Electronic Devices
Optical Features of Electronic Devices
The Nature of the Problem and Its Distal Causes
How Does Spending Time Outdoors Protect Against Myopia?
6 Myopia Pathogenesis: From Retinal Image to Scleral Growth
KEY FINDINGS FROM ANIMAL MODELS OF EMMETROPIZATION AND MYOPIA,
Open and Closed-loop Control of Eye Growth
The Role of the Eye’s Optics in Emmetropization
Ocular Component Characteristics Before, During, and After Myopia Onset
Importance of Optical Contributions to the Retinal Image
AN IMPROVED FRAMEWORK FOR STUDYING THE ROLE OF THE RETINAL IMAGE IN REGULATING EYE GROWTH
A Triangle of Interacting Factors
Computational Models of Retinal Image Formation and Visual Encoding
RETINAL CELLS AND CIRCUITS REGULATING EYE GROWTH
The Retina’s Central Role in Myopia Pathogenesis
Retinal Cells and Circuits Encoding Light Intensity
Dopamine as a Stop Signal for Refractive Eye Growth
Dopaminergic Amacrine Cells and ipRGCs—Irradiance-coding Cells and Circuits
Diverse Roles of the ON Pathway in Luminance Coding and Myopia Development
Evidence for Neural and Ocular Cell Populations in Eye-growth Regulation
Retinal Mechanisms for Encoding Defocus
Evidence for Choroidal Involvement
Chemical Mediators in the Retina-to-Sclera Signaling Cascade
CIRCADIAN RHYTHMS AND THE REGULATION OF POSTNATAL OCULAR GROWTH
Molecular Regulation of Ocular Circadian Rhythms
7 Current and Emerging Treatment Options for Myopia
CURRENT TREATMENT OPTIONS FOR MYOPIA
Surgical Treatments for Myopia
TREATMENT OPTIONS TO MITIGATE SIDE EFFECTS OF AN AXIALLY ENLONGATED EYE
Surgical Treatments for Retinal Effects of Myopia
Pharmaceutical/Nutraceutical Treatments for Retinal Effects of Myopia
HISTORY OF MYOPIA PROGRESSION WITHOUT INTERVENTION
Longitudinal Studies on Growth of the Human Eye and Myopia Progression
CURRENT TREATMENT OPTIONS FOR SLOWING MYOPIA PROGRESSION
How Myopia Progression Occurs: A Recap
OPTICAL TREATMENT TO SLOW HUMAN EYE GROWTH
Early Theories on Optical Mechanisms
CORNERSTONE HUMAN STUDIES ON SLOWING THE GROWTH OF THE HUMAN EYE
The Correction of Myopia Evaluation Trial (COMET)
The Bifocal Lenses in Nearsighted Kids (BLINK) Study
CURRENT OPTICAL TREATMENTS FOR MYOPIA PROGRESSION AVAILABLE IN THE UNITED STATES
PHARMACOLOGICAL TREATMENTS FOR MYOPIA PROGRESSION
Early Theories on Pharmaceutical Mechanisms
CORNERSTONE ATROPINE STUDIES FOR MYOPIA PROGRESSION
Atropine Treatment of Myopia (ATOM) Study
Atropine Treatment of Myopia 2 (ATOM 2) Study
Low-Concentration Atropine for Myopia Progression (LAMP) Study
CURRENT PHARMACEUTICAL TREATMENTS AVAILABLE IN THE UNITED STATES
CONTEMPORARY SYSTEMATIC REVIEWS AND GLOBAL PERSPECTIVES
Cochrane Living Systematic Review and Meta-Analysis
International Examples of the Effects of Outdoor Time
Optical Strategies for Mitigating Myopia Progression
Structural and Surgical Strategies for Mitigating Myopia Progression
Key Elements in the Decision to Pursue Myopia Control Treatment Options
Ideal Characteristics of Treatments
WHY DON’T MYOPIA TREATMENTS WORK BETTER FOR CONTROLLING MYOPIA PROGRESSION?
Alternative Theories for Mechanisms
Mechanisms of Optical Treatments and Their Limitations
Theories on Contributions of ON/OFF Pathway Dysfunction to Myopia Progression
COST-EFFECTIVENESS OF TREATMENTS
Financial Burden and Cost-Effectiveness of Interventions
8 Identifying Children with Myopia and the Links to Treatment: Methods and Barriers
MODELS FOR IDENTIFYING AND TREATING MYOPIA
VISION CARE POLICIES IN THE UNITED STATES
BARRIERS TO ACCESSING VISION HEALTH SERVICES IN CHILDREN
CONTEXTUAL BARRIERS TO ACCESSING VISION HEALTH SERVICES IN CHILDREN
Contextual Barriers to Vision Screening
Contextual Barriers to Vision Screening in Pediatric Primary Care
Contextual Barriers to Vision Screening in Schools and Communities
Contextual Barriers to Comprehensive Eye Exams and Treatment
BARRIERS TO RESEARCH TO ACCESS TO PEDIATRIC VISION SCREENING, COMPREHENSIVE EYE EXAMS, AND TREATMENT
Lack of Data Collection for Surveillance
Ethical Concerns Regarding the Conduct of Randomized Trials in Children
Poor Representation of Ethnic and Minority Populations
STRATEGIES RECOMMENDED TO OVERCOME BARRIERS
Offering Parental Opt-outs Rather than Consent
School Visits to Promote Parental Consent
Improved Vision Screening Criteria for Myopia
Integrated Data Systems to Improve Surveillance of Children with Myopia
INNOVATIVE APPROACHES TO ADDRESS BARRIERS TO VISION CARE SERVICES
9 Implications for Stakeholders and an Agenda for Future Research
OPHTHALMOLOGISTS, OPTOMETRISTS, OTHER CLINICIANS, AND PROFESSIONAL SOCIETIES
INDIVIDUALS WITH MYOPIA AND PARENTS/CAREGIVERS OF CHILDREN WITH OR AT RISK OF DEVELOPING MYOPIA
POLICY-MAKING AGENCIES AND ORGANIZATIONS AT THE STATE AND LOCAL, FEDERAL, AND GLOBAL LEVELS
Local and State Developments of Health and Departments of Education
RESEARCHERS AND FUNDING AGENCIES
Factors that Contribute to the Onset and Progression of Myopia
Boxes, Figures, and Tables
BOXES
3-1 Higher Prevalence of Myopia but Same Rate of Progression
4-1 Diagnostic Technologies for Children
5-1 Earlier Onset of Myopia Typically Means Higher Amounts of Myopia
5-2 Are the Mechanisms Regulating Normal Eye Growth and Myopia Eye Growth the Same?
5-3 Genome-Wide Association Studies (GWAS)
7-1 Optical Corrections and Refractive Surgery Do Not Alter Risk for Myopia Complications
7-2 What Is the Role of Astigmatism in Myopia Development and Treatment Options?
8-1 Other Childhood Visual Problems Besides Myopia That Deserve Attention
8-3 10 Clinical Practices to Improve Vision Care Access, Adherence, and Continuity
8-4 Adherence with Wearing Prescribed Glasses Is Low
FIGURES
2-1 Relative frequency (%) of refractive errors in newborns and infants, 11 Relationship
2-2 between axial length and (de)focus
2-3 Correction of nearsighted defocus with a concave-shaped diverging lens
2-4 Components of the eye discussed in this report
3-1 Illustration of an eye with astigmatism and one with perfect optical balance
3-3 Myopia prevalence in northern native communities 1950–2010, by age
3-5 The prevalence of myopia of −0.5D or more in Israeli army recruits from 1971 to 1994
4-1 Fundus photograph images of (A) pathologic myopia and (B) normal fundus
4-3 Illustrations of different eye shapes (exaggerated to illustrate the concept)
4-4 Optical coherence tomography (OTC) images of the choroid
4-5 Example of a commercially available pupillometer being used clinically
5-1 Growth curves for height, axial length and refractive error in mice and humans
5-2 Manhattan plot from a Genome-Wide Association Studies (GWAS) analysis
5-7 iPad screen distance feature
5-8 Vergence-accommodation conflict
5-10 A simple control systems model of emmetropization
5-11 Spectral composition of sunlight at approximately sea level
5-12 Spectral composition of indoor lighting
5-13 Effects of longitudinal chromatic aberration
5-14 Refractive power (in diopters [D]) required to render far objects in focus
5-15 Refractive power (in diopters [D]) required to render near objects in focus
5-16 Dioptric error generated when viewing a near or distant visual scene
5-17 Origin of the ON and OFF pathways in the retina
6-1 Plot of the evolutionary emergence of vertebrate animals on earth
6-2 Changes in the cornea (a), lens (b), and ocular globe (c) with normal eye growth
6-3 Axial elongation, relative to myopia onset and by age of onset
6-4 Onset of myopia is a discrete event
6-5 A framework for studying the role of the retinal image in regulating abnormal eye growth
6-6 A flowchart of ISETBio computational model of early vision
6-7 Rod:cone ratio vs. retinal eccentricity
6-8 Shape and orientation of blur in the periphery in different refractive groups
6-9 Polychromatic point-spread functions in the nasal visual field in different refractive groups
6-10 Distinct retinal neurons and synaptic circuits encoding luminance and image motion
6-11 Creep rate of tree shrew scleral strips
6-12 Changes in scleral proteoglycan synthesis during visually guided ocular growth
7-5 Myopia control soft contact lens designs
7-8 Frequency of the term “myopia” in research titles, by year, 1842–2024
7-9 Cochrane Review of treatment effect of myopia
7-10 Schematic of the Defocus Incorporated Multiple Segments (DIMS) in the Hoya MiYOSMART lens
7-11 Illustration of longitudinal chromatic aberration in the eye
8-1 Vision assessment requirements by state for children
8-2 Contextual factors that influence access to vision health services
8-3 Peek-Powered Program features
TABLES
3-2 Methods for Detecting and Measuring Myopia
3-3 Ways to Report Myopia When Evaluating Prevalence and Their Feasibility
3-4 Studies of U.S. Prevalence of Myopia
5-2 Previous Findings on Lockdown-Related Increases to Children’s Screen Time
5-3 Integral of Light Exposure
5-4 Effect of Raising Different Animals Under Narrow-Band Illumination
6-1 Differences Between the Foveocentric and Retinocentric Views of Refraction
7-1 Treatment Options for Myopia: Optical, Surgical, and Pharmaceutical/Nutraceutical
8-3 Periodicity Schedule for Vision Assessment in Infants, Children, and Young Adults
Preface
The committee was charged with assessing the state of knowledge regarding the mechanistic understanding of myopia pathogenesis and identifying the causes of myopia’s increased prevalence and the knowledge gaps and barriers to progress. The committee developed a research agenda over the course of the study process. For each of the report’s chapters, the committee reviewed relevant areas of empirical research across multiple disciplines related to myopia; for instance, epidemiology, biology, physiology, optics, public health, and technology. The data underscore that the refractive error shift towards myopia noted in multiple global populations has risen to epidemic proportions. The increasing prevalence of myopia seen in urban Asia is now happening in the United States as well, although the United States lacks rigorous data collection on refractive errors. The evidence points strongly to environmental factors as the most influential, but there is also evidence of genetic contributions, particularly those that interact with the environment.
Even though there is existing and ongoing research in this field, the committee identified numerous critical gaps. There is a pressing need to understand the causal mechanisms underlying myopic eye growth in order to develop more effective treatments to slow myopia progression or prevent its onset altogether. In addition, more evidence-based research is needed on what produces sustainable, equitable, nimble ocular health assessment and effective treatments that can be adapted and applied across all communities. In addition to filling the gaps, the committee envisioned an aspirational research agenda that could help facilitate a future line of transformational and groundbreaking work that pushes the field forward in ways it identified as innovative, necessary, and challenging.
Ocular developmental growth can be affected by visual diet (i.e., the various visual stimuli from the environment that enter the eye), so starting intentional (data-based) interventions earlier in life is better. There is a definite need to perform scientific and clinical assessments at an earlier age—ideally, prior to formal schooling. Earlier age of onset of myopia has implications for the likelihood of ocular morbidities associated with myopia and therefore impacts quality of life and lifestyle choices, with economic implications both individually and community-wide, as well as impacts on educational and vocational choices, opportunities, and productivity.
Developing communities will likely experience the most dramatic changes over the next few decades, and the most affected urban areas will experience higher patient concerns of ocular co-morbidities with associated impairment of visual acuity. Based on the evidence stated above, the committee encourages change now with increased outdoor time during daylight for young children and persistent outdoor activity throughout childhood and into young adulthood. With population health concerns, incremental adaptive changes have historically been shown to be the most effective.
Multiple stakeholders and implicated parties should recognize their responsibility and potential impact in affecting intentional and increased change to thwart the trend toward myopic
eye growth. There is a need to think big-picture and in nontraditional ways regarding partners to address this issue on multiple levels. The committee suggests greater attention to and offerings of competitive small to large multi-site research grants, and local screening and treatment provision efforts that are coordinated both statewide and nationwide, including collaborations with global health agencies. All efforts and data collection need to be harmonized so true comparisons can be made to detect refractive error and other visual disorder shifts in communities. The committee recommends greater efforts to customize therapies coordinated with evidence-based risk assessments. This will require multidisciplinary teams that might not directly study myopia but would have the tools and varied perspectives to approach the problem differently and more comprehensively.
Myopia, in our opinion, is indisputably a disease, and should be treated as such. At present, especially in the United States, it is generally considered a visual inconvenience. However, the impact on visual function and the risk for blinding complications later in life are significant. The increasing prevalence of myopia is an urgent issue that requires better awareness to attract the funding dollars needed for effective treatments, screening, and research study. Finally, the health impacts of this global myopic epidemic will be experienced unequally between and within countries, with the most vulnerable communities often suffering from the highest impact. Linked to this, inequality is also arguably fueling this crisis.
The committee desires to congratulate the National Academies of Sciences, Engineering, and Medicine’s Board on Behavioral, Cognitive, and Sensory Sciences (BBCSS) on recognizing the importance of this subject, as such an effort had not been performed since its 1989 report. Substantial changes in the human condition of myopia have occurred since then, along with substantive research to better understand these changes. A recalibration of our understanding of this ocular disorder and its impacts globally was long overdue.
We would like to thank our generous committee sponsors, the National Eye Institute, the American Academy of Optometry, the American Optometric Association, Health Care Alliance for Patient Safety, the Herbert Wertheim School of Optometry & Vision Science, University of California, Berkeley, Johnson & Johnson Vision, Reality Labs Research, Research to Prevent Blindness, and the Warby Parker Impact Foundation.
Molly Checksfield Dorries, the study director, demonstrated exceptional commitment in keeping the project on track. Tina Winters, program officer, provided guidance on all elements of the project, including ushering the report to publication. We also appreciate the efforts of Ashton Ray for her invaluable support. Special thanks to Kirsten Sampson Snyder for overseeing the review process, Bea Porter for her work on preparing the manuscript files, Marc DeFrancis for his adept editing skills, and Kim Halperin and Doug Sprunger for their strategic guidance on communications and development of dissemination materials.
We appreciate the commissioned paper authors who contributed enlightening and thought-provoking papers to the committee:
- Mark Bullimore, M.C. Optom, Ph.D., University of Houston (Animal Models of Myopia: Lessons for the Understanding of Human Myopia)
- Susana Marcos, Ph.D., University of Rochester Medical Center (Optical and Visual Diet in Myopia)
- Christopher Hammond, MA, MD, MRCP, FRCO, King’s College London and Katie Williams, OD, Ph.D., King’s College London (Perspectives on Genetic and Environmental Factors in Myopia, Its Prediction, and the Future Direction of Research)
- Joy Harewood, OD, FAAO, Dipl ABO, State University of New York (SUNY) College of Optometry; Melissa Contreras, OD, Marshall B. Ketchum University; Shelby Leach, OD, SUNY Optometry; Kristine Huang, OD, MPH, FAAO, Southern California College of Optometry, Marshall B. Ketchum University; and Jing Wang, PhD, SUNY Optometry (Access to Myopia: A Scoping Review)
- Safal Khanal, OD, Ph.D., FAAO, The University of Alabama at Birmingham School of Optometry; Síofra Harrington, Ph.D., Dublin Institute of Technology; Erin Tomiyama, OD, Ph.D., FAAO, Marshall B. Ketchum University (Treatment of Childhood Myopia).
This committee is grateful to all workshop presenters who provided the committee with valuable insight and expertise through presentations at public workshops: Martin Banks (University of California, Berkeley), BBCSS board member William Geisler (University of Texas at Austin), David Williams (University of Rochester), David Mackey (University of Western Australia), Daniel Ting (Singapore National Eye Centre), Pie-Chang Wu (Chang Gung University), Andrew Bastawrous (London School of Hygiene & Tropical Medicine & Peek Vision), Priya Morjaria (London School of Hygiene & Tropical Medicine & Peek Vision), Donna Fishman (National Center for Children’s Vision and Eye Health), Megan Collins (Johns Hopkins University), and Jessie Mandle (Healthy Schools Campaign).
It is our hope that this consensus study sets forth a research agenda, as directed by the committee’s Statement of Task, which states that the committee’s final consensus report will “identify and assess the current mechanistic understanding of myopia pathogenesis and the causes of its increased prevalence, to identify knowledge gaps and barriers to progress, and to develop a research agenda aimed at better understanding the biological and environmental factors that could explain its increasing incidence.”
K. Davina Frick, Co-Chair
Terri L. Young, Co-Chair
Committee on Focus on Myopia: Pathogenesis and Rising Incidence
Acronyms and Abbreviations
| AACO | American Association of Certified Orthoptists |
| AAFP | American Academy of Family Physicians |
| AAO | American Academy of Ophthalmology |
| AAP | American Academy of Pediatrics |
| AAPOS | American Association for Pediatric Ophthalmology and Strabismus |
| AMD | age-related macular degeneration |
| AREDS2 | Age-Related Eye-Disease Study 2 |
| ASD | autism spectrum disorder |
| AUC | area under the curve |
| BLINK | Bifocal Lenses in Nearsighted Kids |
| cCSNB | complete congenital stationary night blindness |
| CI | confidence interval |
| CLEERE | Collaborative Longitudinal Evaluation of Ethnicity and Refractive Error |
| CMS | Center for Medicaid and Medicare Services |
| COMET | Correction of Myopia Evaluation Trial |
| COMP | cartilage olimeric matrix protein |
| CVD | color vision deficiency |
| D | diopter |
| DA | dopaminergic amacrine |
| DAC | dopaminergic amacrine cell |
| DIMS | defocus-incorporated multiple-segment |
| ECM | extracellular matrix |
| EPSDT | Early and Periodic Screening, Diagnostic and Treatment |
| ERG | electroretinogram, electroretinography |
| FEM | fixational eye movement |
| ft | feet (measure) |
| GAC | glucagonergic amacrine cells |
| GWAS | Genome-wide association study |
| IMI | International Myopia Institute |
| IPL | inner plexiform layer |
| ipRGCs | intrinsically photosensitive retinal ganglion cells |
| IRBP | inter-retinoid binding protein |
| LASIK | laser in situ keratomileusis |
| LCA | longitudinal chromatic aberration |
| LIM | lens-induced myopia |
| m | meter |
| MRI | magnetic resonance imaging |
| MTF | modulation transfer function |
| OCT | optical coherence tomography |
| Opn | opsin |
| PRK | photorefractive keratectomy |
| PSF | point spread function |
| RCT | randomized controlled trial |
| RGC | retinal ganglion cell |
| RGP | rigid gas-permeable |
| RLRL | repeated low-level red light |
| RPE | retinal pigment epithelium |
| SCORM | Singapore Cohort Study of the Risk Factors for Myopia |
| SMILE | small-incision lenticule extraction |
| VEHSS | Vision and Eye Health Surveillance System |
