Six-year cumulative treatment effect and treatment efficacy of a dual focus myopia control contact lens.

PURPOSE: Accumulated axial growth observed during a 6-year clinical trial of a dual focus myopia control contact lens was used to explore different approaches to assess treatment efficacy. METHODS: Axial length measurements from 170 eyes in a 6-year clinical trial of a dual focus myopia control lens (MiSight 1 day, CooperVision) were analysed. Treatment groups comprised one having undergone 6 years of treatment and the other (the initial control group) having 3 years of treatment after 3 years of wearing a single vision control lens. Efficacy was assessed by comparing accumulated ocular growth during treatment to that expected of untreated myopic and emmetropic eyes. The impact of treatment on delaying axial growth was quantified by comparing the increased time required to reach criterion growths for treated eyes and survivor analysis approaches. RESULTS: When compared to the predicted accumulated growth of untreated eyes, 6 years of treatment reduced growth by 0.52 mm, while 3 years of treatment initiated 3 years later reduced growth by 0.19 mm. Accumulated differences between the growth of treated and untreated myopic eyes ranged between 67% and 52% of the untreated myopic growth, and between 112% and 86% of the predicted difference in growth between untreated myopic and age-matched emmetropic eyes. Treated eyes took almost 4 years longer to reach their final accumulated growth than untreated eyes. Treatment increased the time to reach criterion growths by 2.3-2.7 times. CONCLUSION: Estimated growth of age-matched emmetropic and untreated myopic eyes provided evidence of an accumulated slowing in axial elongation of 0.52 mm over 6 years, and the treated growth remained close to that expected of emmetropic eyes. Six years of dual focus myopia control delayed the time to reach the final growth level by almost 4 years.

Myopia Control Dose Delivered to Treated Eyes by a Dual-focus Myopia-control Contact Lens.

PURPOSE: This study examined the optical impact of a DF contact lens during near viewing in a sample of habitual DF lens wearing children. METHODS: Seventeen myopic children aged 14 to 18 years who had completed 3 or 6 years of treatment with a DF contact lens (MiSight 1 Day; CooperVision, Inc., San Ramon, CA) were recruited and fit bilaterally with the DF and a single-vision (Proclear 1 Day; CooperVision, Inc.) contact lens. Right eye wavefronts were measured using a pyramidal aberrometer (Osiris; CSO, Florence, Italy) while children accommodated binocularly to high-contrast letter stimuli at five target vergences. Wavefront error data were used to compute pupil maps of refractive state. RESULTS: During near viewing, children wearing single-vision lenses accommodated on average to achieve approximate focus in the pupil center but, because of combined accommodative lag and negative spherical aberration, experienced up to 2.00 D of hyperopic defocus in the pupil margins. With DF lenses, children accommodated similarly achieving approximate focus in the pupil center. When viewing three near distances (0.48, 0.31, and 0.23 m), the added +2.00 D within the DF lens treatment optics shifted the mean defocus from +0.75 to -1.00 D. The DF lens reduced the percentage of hyperopic defocus (≥+0.75 D) in the retinal image from 52 to 25% over these target distances, leading to an increase in myopic defocus (≤-0.50 D) from 17 to 42%. CONCLUSIONS: The DF contact lens did not alter the accommodative behavior of children. The treatment optics introduced myopic defocus and decreased the amount of hyperopically defocused light in the retinal image.

Catastrophe optics theory unveils the localised wave aberration features that generate ghost images.

Monocular polyplopia (ghost or multiple images) is a serious visual impediment for some people who report seeing two (diplopia), three (triplopia) or even more images. Polyplopia is expected to appear if the point spread function (PSF) has multiple intensity cores (a dense concentration of a large portion of the radiant flux contained in the PSF) relatively separated from each other, each of which contributes to a distinct image. We present a theory that assigns these multiple PSF cores to specific features of aberrated wavefronts, thereby accounting optically for the perceptual phenomenon of monocular polyplopia. The theory provides two major conclusions. First, the most likely event giving rise to multiple PSF cores is the presence of hyperbolic, or less probably elliptical, umbilic caustics (using the terminology of catastrophe optics). Second, those umbilic caustics formed on the retinal surface are associated with certain points of the wave aberration function, called cusps of Gauss, where the gradient of a curvature function vanishes. However, not all cusps of Gauss generate those umbilic caustics. We also provide necessary conditions for those cusps of Gauss to be fertile. To show the potential of this theoretical framework for understanding the nature and origin of polyplopia, we provide specific examples of ocular wave aberration functions that induce diplopia and triplopia. The polyplopia effects in these examples are illustrated by depicting the multi-core PSFs and the convolved retinal images for clinical letter charts, both through computer simulations and through experimental recording using an adaptive optics set-up. The number and location of cores in the PSF is thus a potentially useful metric for the existence and severity of polyplopia in spatial vision. These examples also help explain why physiological pupil constriction might reduce the incidence of ghosting and multiple images of daily objects that affect vision with dilated pupils. This mechanistic explanation suggests a possible role for optical phase-masking as a clinical treatment for polyplopia and ghosting.

Long-term Effect of Dual-focus Contact Lenses on Myopia Progression in Children: A 6-year Multicenter Clinical Trial.

SIGNIFICANCE: Treatment of myopic children with a dual-focus soft contact lens (DFCL; MiSight 1 day) produced sustained slowing of myopia progression over a 6-year period. Significant slowing was also observed in children switched from a single vision control to treatment lenses (3 years in each lens). PURPOSE: This study aimed to evaluate the effectiveness of DFCLs in sustaining slowed progression of juvenile-onset myopia over a 6-year treatment period and assess myopia progression in children who were switched to a DFCL at the end of year 3. METHODS: Part 1 was a 3-year clinical trial comparing DFCLs with a control contact lens (Proclear 1 day) at four investigational sites. In part 2, subjects completing part 1 were invited to continue for 3 additional years during which all children were treated with MiSight 1 day DFCLs (52 and 56 from the initially treated [T6] and control [T3] groups, respectively). Eighty-five subjects (45 [T3] and 40 [T6]) completed part 2. Cyclopleged spherical equivalent refractive errors (SEREs) and axial lengths (ALs) were monitored, and a linear mixed model was used to compare their adjusted change annually. RESULTS: Average ages at part 2 baseline were 13.2 ± 1.3 and 13.0 ± 1.5 years for the T6 and T3 groups, respectively. Slowed myopia progression in the T6 group observed during part 1 was sustained throughout part 2 (mean ± standard error of the mean: change from baseline SERE [in diopters], -0.52 ± 0.076 vs. -0.51 ± 0.076; change in AL [in millimeters], 0.28 ± 0.033 vs. 0.23 ± 0.033; both P > .05). Comparing progression rates in part 2 for the T6 and T3 groups, respectively, indicates that prior treatment does not influence efficacy (SERE, -0.51 ± 0.076 vs. -0.34 ± 0.077; AL, 0.23 ± 0.03 vs. 0.18 ± 0.03; both P > .05). Within-eye comparisons of AL growth revealed a 71% slowing for the T3 group (3 years older than part 1) and further revealed a small subset of eyes (10%) that did not respond to treatment. CONCLUSIONS: Dual-focus soft contact lenses continue to slow the progression of myopia in children over a 6-year period revealing an accumulation of treatment effect. Eye growth of the initial control cohort with DFCL was slowed by 71% over the subsequent 3-year treatment period.

Time-course of the visual Impact on presbyopes of a low dose miotic.

PURPOSE: To examine the pupil and visual impact of a single early morning drop of a low concentration miotic. METHODS: Pupil size, refraction, visual acuity (VA), near reading performance and intraocular pressure were monitored for 8 h at a wide range of light levels following bilateral instillation of single drops of 0.1% brimonidine tartate in 19 early presbyopes (40-50 years) and 11 mature presbyopes (>50 years). RESULTS: Pupil miosis did not alter distance VA or refraction. Significant pupil miosis peaked at 1-2 h after dosing, which expanded the depth of focus of mature presbyopes with the mean improvement in near logMAR VA of -0.15, -0.07 and -0.03, at 20, 200 and 2000 lux, respectively. One hour after instillation, near reading speed improved by 21, 24 and 5 words per min for text size commonly seen in US newspaper and cellphone text messages, 18, 21 and 19 words per min for text size of grocery labels and 12, 13 and 30 words per min for text size of over-the-counter medications at light levels of 20, 200 and 2000 lux, respectively. No such improvements in near VA and near reading speed were observed in the young presbyopes having some residual accommodation. Most of the pupil miosis remained 8 h after instillation, whereas near VA improvements disappeared after 4 h. CONCLUSION: Low dose miotics can enhance near vision in presbyopic subjects while retaining high quality distance vision over a wide range of light levels. Significant improvements in near vision were observed only during the 1-2 h period after dosing when miosis peaked.

Resolution acuity across the visual field for mesopic and scotopic illumination.

We investigated the classical question of why visual acuity decreases with decreasing retinal illuminance by holding retinal eccentricity fixed while illumination varied. Our results indicate that acuity is largely independent of illuminance at any given retinal location, which suggests that under classical free-viewing conditions acuity improves as illumination increases from rod threshold to rod saturation because the retinal location of the stimulus is permitted to migrate from a peripheral location of maximum sensitivity but poor acuity to the foveal location of maximum acuity but poor sensitivity. Comparison with anatomical sampling density of retinal neurons suggests that mesopic acuity at all eccentricities and scotopic acuity for eccentricities beyond about 20° is limited by the spacing of midget ganglion cells. In central retina, however, scotopic acuity is further limited by spatial filtering due to spatial summation within the large, overlapping receptive fields of the A-II class of amacrine cells interposed in the rod pathway between rod bipolars and midget ganglion cells. Our results offer a mechanistic interpretation of the clinical metrics for low-luminance visual dysfunction used to monitor progression of retinal disease.

The Impact of IOL Abbe Number on Polychromatic Image Quality of Pseudophakic Eyes.

PURPOSE: The human eye exhibits large amounts (2.5 diopters) of longitudinal chromatic aberration (LCA). Its impact on polychromatic image quality, however, has been shown experimentally and by computer modeling to be small or absent. We hypothesized that modest changes in pseudophakic LCA created by higher and lower Abbe number materials will have little or no impact on polychromatic image quality in pseudophakic eyes. MATERIALS AND METHODS: Using published chromatic and monochromatic aberration data from pseudophakic eyes and higher and lower Abbe number materials (37 and 55), we computed monochromatic point spread functions for 21 wavelengths across the visible spectrum. After weighting by either the RGB spectra of a liquid crystal display or by a flat white spectrum, they were weighted by the human spectral sensitivity function (Vλ) before being added to generate polychromatic PSFs. RESULTS: In the absence of monochromatic aberrations, the reduced LCA due to higher Abbe number intraocular lens (IOL) materials resulted in a reduction of 0.08 diopters in the mean defocus generated by LCA. At the retinal plane, the higher Abbe number pseudophakic model produced improvements in polychromatic modulation transfer functions (MTFs) similar to those generated by a 0.05 diopter reduction in spherical defocus. When monochromatic aberrations were added to make the model more representative of actual pseudophakic eyes, the differences in image quality became sub-threshold for human vision or disappeared completely. CONCLUSION: The anticipated gains in polychromatic image quality from employing higher Abbe number IOL materials with reduced LCA do not materialize in plausible aberrated models of pseudophakic eyes.

Optical and imaging properties of a novel multi-segment spectacle lens designed to slow myopia progression.

PURPOSE: High sampling density optical metrology combined with pupil- and image-plane numerical analyses were applied to evaluate a novel spectacle lens containing multiple small zones designed to slow myopia progression. METHODS: High-resolution aberrometry (ClearWave, www.lumetrics.com) was used to sample wavefront slopes of a novel spectacle lens, Defocus Incorporated Multiple Segments (DIMS) (www.hoya.com), incorporating many small, positive-powered lenslets in its periphery. Using wavefront slope and error maps, custom MATLAB software ('Indiana Wavefront Analyzer') was used to compute image-plane point-spread functions (PSF), modulation transfer functions (MTF), simulated images and power distributions created by the dual-focus optic for different pupil sizes and target vergences. RESULTS: Outside of a central 10 mm zone containing single distance optical power, a hexagonal array of small 1 mm lenslets with nearest-neighbour separations of 0.5 mm were distributed over the lens periphery. Sagittal and curvature-based measures of optical power imperfectly captured the consistent +3.50 D add produced by the lenslets. Image plane simulations revealed multiple PSFs and poor image quality at the lenslet focal plane. Blur at the distance optic focal plane was consistent with a combination of diffraction blur from the distance optic and the approximately +3.50 D of defocus from the 1 mm diameter near optic zones. CONCLUSION: Converging the defocused beams generated by the multiple small (1 mm diameter) lenslets to a blurred image at the distance focal plane produced a blur magnitude determined by the small lenslet diameter and not the overall pupil diameter. The distance optic located in between the near-add lenslets determines the limits of the optical quality achievable by the lens. When compared to the optics of a traditional concentric-zone dual-focus contact lens, the optics of the DIMS lens generates higher-contrast images at low spatial frequencies (<7 cycles per degree), but lower-contrast at high spatial frequencies.

Accommodative Behavior, Hyperopic Defocus, and Retinal Image Quality in Children Viewing Electronic Displays.

SIGNIFICANCE: The prevalence of myopia and use of electronic displays by children has grown rapidly in recent years. We found that children viewing electronic displays, however, experience hyperopic defocus levels similar to those previously reported for other stimuli. PURPOSE: This study aimed to compare accommodative behavior of nonmyopic and myopic children viewing a computer screen or mobile phone. METHODS: Accommodative behavior was examined in 11 nonmyopic and 8 myopic children (11.32 ± 2.90 and 14.13 ± 2.30 years, respectively; P = .04; refractions, +0.51 ± 0.51 and -2.54 ± 1.29, respectively) using an open-field autorefractor (Grand Seiko) at target vergences from -0.25 to -5.00 D. Different size (scaled or nonscaled) and type (text or movie) stimuli were presented on an LCD monitor (distant) or an iPhone (near), with subjects viewing monocularly or binocularly in an illuminated or dark room. RESULTS: At the typical reading distances (20 and 33 cm), all 19 children exhibited some amount of accommodative lag. Stimulus type had little impact on accommodation. However, slightly but statistically significant lower slopes were observed (Bonferroni-corrected significance level of P ≤ .01) for low room lighting (0.96 vs. 0.91; t test, t = 3.88; P = .003), nonscaled targets (0.99 vs. 0.92; t test, t = 4.28; P = .001), and monocular viewing (0.99 vs. 0.90; t test, t = 4.0; P = .002) in the nonmyopic group only. When viewing nonscaled stimuli binocularly (natural viewing), the means and standard deviations of accommodative lags (averaged across room lights on and off, and text and movie) were generally larger for the nonmyopes at all distances and were largest at 33 cm (0.73 ± 0.18 D for the nonmyopes and 0.49 ± 0.23 for the myopes; t test, t = 2.62; P = .01). CONCLUSIONS: Generally small (≤0.50 D) amounts of hyperopic defocus are present in children binocularly viewing handheld electronic devices (nonmyopes slightly more than myopes). Modern electronic devices do not expose children to unusually high levels of hyperopic defocus.

Experimental Model of Far Temporal Field Negative Dysphotopsia Generated in Phakic Eyes.

Purpose: The axial separation between the iris and the intraocular lens (IOL) in pseudophakic eyes can cause rays originating from the far temporal field to miss the IOL, resulting in negative dysphotopsia (ND). We developed an experimental model to test the hypothesis that obstruction of rays from the far temporal field can generate ND and an accompanying loss of visual sensitivity in the far temporal field. Methods: The right eyes of 10 phakic subjects were fitted with soft contact lenses containing a 5.50-mm central clear zone and a 12-mm outer diameter opaque annulus. In three of the subjects, eyes were dilated with 1% tropicamide solution, and effective aperture diameters were determined optically (pupil camera) and psychophysically (narrow beam detection). Visual field extent (Goldmann bowl) and temporal and inferotemporal meridian sensitivities (Octopus perimeter) were measured. A wide-angle model was constructed to quantify the impact of the annular opacity on retinal illuminance. Results: All 10 subjects observed a dark crescent in the far temporal and inferotemporal fields. The opaque annulus reduced effective horizontal pupil diameters from 8 mm to 5.5 mm on-axis and from >2 mm to <1 mm at 90°. Perimetry revealed a 10° reduction in temporal and inferotemporal field extent and increasing loss of sensitivity beyond 70°. The wide-angle model confirmed significant vignetting (>50% beyond 70°), approaching zero retinal illuminance beyond 85°. Conclusions: Vignetting of rays originating from the far temporal field by axially separated apertures can create symptoms mirroring perceptual reports of negative dysphotopsia in symptomatic pseudophakic patients.

Impact of monovision on dynamic accommodation of early presbyopes.

PURPOSE: To examine the impact of monovision on dynamic changes in accommodation, pupil responses, spherical aberration and resultant image quality in early presbyopes. METHODS: Refractive state, pupil size and spherical aberration levels were monitored in nine early presbyopes who exhibited some accommodation (40-50 years, mean = 42 ± 2.37 years) using a Shack-Hartmann aberrometer as a binocularly viewed stimulus stepped closer (from 2 m to 40 cm), or farther (from 40 cm to 2 m). Comparison data from two fully presbyopic (i.e. non-accommodating) subjects (ages 46 and 61 years) and two young adults (ages 26 and 29 years) were also collected. Each subject was fit with four different refractive strategies: (1) both eyes corrected for 2 m, (2) both eyes corrected for 40 cm, (3) monovision with the measured right eye corrected for 2 m and, (4) monovision with the right eye corrected for 40 cm. Monochromatic image quality was quantified using the AreaMTF metric. RESULTS: When fit with monovision, the largest number of early presbyopes produce an accommodative response dominated by the right eye correction (distance or near) as the stimulus is abruptly changed from the retinal conjugate plane of one eye to that of the other eye. However, the accommodative responses in some early presbyopes were always dominated by the distance corrected eye, the near corrected eye, or by convergence. When the stimulus approached, the near corrected eye experienced high image quality only if there was no accommodative response. However, reduced image quality was observed if an accommodative response was initiated. Neither accommodation nor pupil response latencies were longer with monovision corrections compared with bilateral distance corrections (p > 0.05). In the early presbyopes, spherical aberration was reduced during near viewing, but primarily due to pupil miosis and not lens shape changes. CONCLUSION: As the stimulus was abruptly changed from the retinal conjugate plane of the distance corrected eye to that of the near corrected eye, most early presbyopes fit with monovision accommodated, which resulted in a decline, not an increase in image quality in the near corrected eye. These results reveal a non-optimal accommodative strategy in early presbyopes fit with monovision.

Correction of presbyopia: old problems with old (and new) solutions.

We live in a three-dimensional world and the human eye can focus images from a wide range of distances by adjusting the power of the eye's lens (accommodation). Progressive senescent changes in the lens ultimately lead to a complete loss of this ability by about age 50, which then requires alternative strategies to generate high-quality retinal images for far and close viewing distances. This review paper highlights the biomimetic properties and underlying optical mechanisms of induced anisometropia, small apertures, dynamic lenses, and multi-optic lenses in ameliorating the visual consequences of presbyopia. Specifically, the advantages and consequences of non-liner neural summation leveraged in monovision treatments are reviewed. Additionally, the value of a small pupil is quantified, and the impact of pinhole pupil location and their effects on neural sensitivity are examined. Different strategies of generating multifocal optics are also examined, and specifically the interaction between ocular and contact or intraocular lens aberrations and their effect on resulting image quality are simulated. Interestingly, most of the novel strategies for aiding presbyopic and pseudophakic eyes (for example, monovision, multifocality, pinhole pupils) have emerged naturally via evolution in a range of species.

Validation of a Clinical Aberrometer Using Pyramidal Wavefront Sensing.

SIGNIFICANCE: Measurement of ocular aberrations is a critical component of many optical corrections. PURPOSE: This study examines the accuracy and repeatability of a newly available high-resolution pyramidal wavefront sensor-based aberrometer (Osiris by Costruzione Strumenti Oftalmici, Firenze, Italy). METHODS: An engineered model eye and a dilated presbyopic eye were used to assess accuracy and repeatability of aberration measurements after systematic introduction of lower- and higher-order aberrations with calibrated trial lenses (sphere +10.00 to -10.00 D, and astigmatic -4.00 and -2.00 D with axis 180, 90, and 45°) and phase plates (-0.57 to 0.60 µm of Seidel spherical aberration defined over a 6-mm pupil diameter). Osiris aberration measurements were compared with those acquired on a previously calibrated COAS-HD aberrometer for foveal and peripheral optics both with and without multizone dual-focus contact lenses. The impact of simulated axial and lateral misalignment was evaluated. RESULTS: Root-mean-square errors for paraxial sphere (corneal plane), cylinder, and axis were, respectively, 0.07, 0.11 D, and 1.8° for the engineered model and 0.15, 0.26 D, and 2.7° for the presbyopic eye. Repeatability estimates (i.e., standard deviation of 10 repeat measures) for the model and presbyopic eyes were 0.026 and 0.039 D for spherical error. Root-mean-square errors of 0.01 and 0.02 µm, respectively, were observed for primary spherical aberration and horizontal coma (model eye). Foveal and peripheral measures of higher- and lower-order aberrations measured with the Osiris closely matched parallel data collected with the COAS-HD aberrometer both with and without dual-focus zonal bifocal contact lenses. Operator errors of focus and alignment introduced changes of 0.018 and 0.02 D/mm in sphere estimates. CONCLUSIONS: The newly available clinical pyramidal aberrometer provided accurate and repeatable measures of lower- and higher-order aberrations, even in the challenging but clinically important cases of peripheral retina and multifocal optics.

Ricco's law and absolute threshold for foveal detection of black holes.

Visual detection of small black objects surrounded by a light background depends on background luminance, pupil size, optical blur, and object size. Holding pupil and optics fixed, we measured the minimum background luminance needed for foveal detection of small black targets as a function of target size. For all three observers, absolute threshold varied inversely with target area when disk diameter subtended less than 10' of visual angle. For target diameter ≥10', threshold remained constant at about 0.3 Td, which was also the absolute threshold for detecting light spots 10' or larger in diameter on a black background. These results are consistent with Ricco's law of spatial summation: a "black hole" is just detectable when the background luminance is sufficiently high for its absence inside the Ricco area to reduce 555 nm photon flux by 7500 photons/s, which is the same change needed to detect light spots on a black surround. These results can be accounted for by a differential pair of Ricco detectors, each about the size of the receptive field center of magocellular retinal ganglion cells when projected into object space through the eye's weakly aberrated optical system. Statistical analysis of the model suggests the quantum fluctuations due to internal, biological noise (i.e., "scotons") are a greater handicap than the photon fluctuations inherent in the light stimulus at absolute foveal threshold.

Psychophysical study of the optical origin of starbursts.

Starbursts seen around small bright lights at night have been attributed to optical scatter, diffraction, or aberrations. We manipulated pupil aperture and aberrations to investigate the entopic appearance of perceived starbursts. The impact of circular, annular, and wedge-shaped pupil apertures, and spherical aberration sign and magnitude were used to identify pupil sub-apertures responsible for each radial perceived starburst line. Local intensity distributions within the starbursts mapped onto unique sub-regions of the pupil of both phakic and pseudophakic eyes, consistent with the hypothesis that ocular aberrations are the cause of starbursts. In paraxially focused eyes, the size of starbursts is predicted by the amount of spherical aberration, and starburst orientation is either the same or 180 deg rotated from the pupil region that creates each starburst line. No starbursts are seen when the pupil diameter is smaller than 3 mm. Replacing the eye's natural lens with a radially symmetric and optically homogeneous intraocular lens reduced the observed number of starbursts by 50%. Geometrical optics modeling including the measured aberrations of an individual eye can reveal point spread function structure that captures some of the key elements of the entopic perceptions.

Small-pupil versus multifocal strategies for expanding depth of focus of presbyopic eyes.

PURPOSE: To compare the visually weighted image quality and depth of focus achieved with small-pupil and multifocal strategies for expanding depth of focus of presbyopic or pseudophakic eyes. SETTING: School of Optometry, Indiana University, Bloomington, USA. DESIGN: Computational modeling. METHODS: The visual Strehl ratio was computed from monochromatic optical transfer functions over a wide range of primary spherical aberration and defocus levels for pupil diameters ranging from 1.0 mm to 7.0 mm under high photopic light levels (retinal illuminance >900 trolands) and mesopic light levels (2 candelas/m2). RESULTS: Pupil miosis and added spherical aberration were effective at reducing the impact of spherical defocus. With high light levels at which Weber's law makes neural contrast sensitivity independent of retinal illuminance, small pupils (eg, 1.0 to 3.0 mm) generated higher peak image quality and more effective expansion of depth of focus than the small-pupil multifocal model. However, under low light levels at which the reduced retinal illuminance associated with pupil miosis lowered neural contrast sensitivity, the peak image quality was lower with small pupils (1.0 to 1.5 mm) at all aberration levels. Large pupils and high levels of spherical aberration were most effective at expanding the depth of focus under mesopic light levels. CONCLUSIONS: When reductions in retinal illuminance created by pupil miosis have no effect on neural contrast sensitivity, small pupils produced higher image quality and larger depth of focus than multifocal optics and large pupils. In general, the reverse was true under mesopic light conditions.

IMI - Clinical Myopia Control Trials and Instrumentation Report.

The evidence-basis based on existing myopia control trials along with the supporting academic literature were reviewed; this informed recommendations on the outcomes suggested from clinical trials aimed at slowing myopia progression to show the effectiveness of treatments and the impact on patients. These outcomes were classified as primary (refractive error and/or axial length), secondary (patient reported outcomes and treatment compliance), and exploratory (peripheral refraction, accommodative changes, ocular alignment, pupil size, outdoor activity/lighting levels, anterior and posterior segment imaging, and tissue biomechanics). The currently available instrumentation, which the literature has shown to best achieve the primary and secondary outcomes, was reviewed and critiqued. Issues relating to study design and patient selection were also identified. These findings and consensus from the International Myopia Institute members led to final recommendations to inform future instrumentation development and to guide clinical trial protocols.