spectaclewearerswas2.3Dincontrastwith1.3Dforcontactlenswearers(p<0.05).

51Nomajor
adverseeventswerenoted.However,inamorerecentandlargerrandomisedclinicaltrialofrigid
contactlenseswith383Singaporechildrenaged612yearsover2years,therewasnosignificant
differencesintherateofprogressionofmyopiaoraxiallengthinthetwogroups(KatzJetal,
submittedforpublication)

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ORTHOKERATOLOGY
Thetechniqueknownasorthokeratologyhasbeenpractisedfordecades:thecorneaisflattenedby
fittingprogressivelyflatterrigidcontactlensesuntilthecornealshapeissufficientlyalteredtoachieve
myopiareduction.52Thetemporaryalterationofcornealshapeandhencecorrectionofmyopiaallows
forperiodsofclearunaidedvisionduringthedaywithouttheuseoflenses,butrequiresconstantuseof
retainerlens,

Inthe3yearHoustonstudyofrigidgaspermeablecontactlenses,100myopicchildrenaged813
yearswerefittedwithParapermoxygenpluscontactlensesandwerecomparedwith20spectacle
wearers.Theaverageprogressionofmyopiawassignificantlydifferent:0.48Dperyearforrigid
contactlenswearerscomparedwith1.53Dperyearforspectaclewearers.50However,theallocation
oftreatmentwasnotrandomised.Itwasalsoobservedthatapproximatelyhalfoftheeffectofrigidgas
permeablecontactlenseswasduetotransientcornealflattening.Inanonrandomisedstudyof45rigid
contactlenswearersand45spectaclewearersinSingapore10yearoldchildren,themeanincreasein
myopiaovera3yearperiodof
polymethylmethacrylate(PMMA)hardcontactlenses,thusalteringtheshapeofthecornea. 49
However,therewerehypoxiarelatedcornealchanges.Newrigidgaspermeablelenseswithhigh
oxygenpermeabilityareasuitableandsaferalternative.45Thepotentialmechanismsofactionofrigid
contactlensesincludetransientflatteningofthecornea,andimprovedqualityoftheretinalimagewith
reducedperipheralimageblur.Perhapsrigidcontactlensesmayevenretardaxialelongation.
However,thepermanenceofthesemechanismsofactionisstillunknown.
Ininfantprimateswearingminuscontactlenses,compensatoryoculargrowthmayleadtofunctional
myopia.38,39Alargenumberofreportsontheefficacyofvarioustypesofcontactlenses(silicone
acrylatecontactlenses,hydrophiliccontactlenses,hydrogellenses)werenotrandomised,hadsmall
samplesizes,andhighdropoutrates.4047Inarandomisedclinicaltrialoftheefficacyofsoftcontact
lensesin175childrenbyHornerandassociatesintheUnitedStates,therewasnosignificantdifference
intherateofprogressionofmyopiabetweenthecontactlens(0.36Dperyear)andcontrolgroup
(0.30Dperyear).48
Morrisonin1956fitted1021myopicchildren(79years)flatterthantheflattestcurvaturewith

reductionoftheprogressionofmyopia(meanmyopiaprogression1.19Dperyearinmultifocalgroup
versus1.40Dperyearinsinglevisiongroup)in227myopicchildrenaged612yearsafter1
years.34TheCorrectionofMyopiaEvaluationTrial(COMET)isalargeongoing3yearmulticentre
randomised,doublemaskedtrialevaluatingtheeffectofprogressiveadditionlensesversussingle
visionlensesin469myopicchildren(sphericalequivalentbetween1.25and4.50D)aged611
yearsintheUnitedStates.35,36Theresultsfromthistrialmayprovidenewevidencefortheefficacyof
multifocallenses.

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CONTACT LENSES
ContactlenseshavealonghistoryofuseasopticalcorrectionsincetheirintroductionbyEugenFickin
1888.37Contactlensesmayincreaseperipheralvision,providecosmeticbenefits,andpromotemore
outdooractivity.However,potentialcomplicationsofcontactlensuseincludeallergicconjunctivitis,
cornealinfiltrates,andinfectivekeratitis,andcontactlenshygienecompliancemaybeaproblemin
lessresponsiblechildren.

theprogressiveadditionlensmustbefittedveryhightofacilitatetheuseofthesegmentforreading.In
aclinicaltrialconductedbyLeungandBrowninHongKong,22childrenwereassignedtowear
progressivelenseswith+1.50Daddition,14tolenseswith+2.00Daddition,and32tosinglevision
lenses.Themeanprogressionrateofmyopiawas3.73Dforthechildrenassignedto+1.50D
additions,3.67Dforchildrenwearing+2.00Dadditions,and3.67Dforchildrenwearingsingle
visionlenses(p<0.001).However,theassignmentwasnotrandom:subjectswithevencaserecord
numberswereplacedintheprogressivelensesgroup,whilesubjectswithoddcaserecordnumbers
wereplacedinthesinglevisionlensesgroup.19ATaiwaneserandomisedclinicaltrialbyShihand
colleaguesshowedanonsignificantreductionoftheprogressionofmyopia(meanmyopiaprogression
1.19Dperyearinmultifocalgroup
Whenmyopiaisnotcorrected,lackofaclearvisualimagemayleadtoformdeprivationmyopia.11
Conversely,correctingachildsmyopiawithnegativelensesmayresultincompensatoryaberranteye
growthandthedevelopmentofmyopia.10Animalexperimentshaveshownthatcompensatorychanges
intheaxiallengthofaneyemayoccurinresponsetoerrorsignalsfromlensinduceddefocus.10,12Ina
nonrandomisedclinicaltrialevaluatingparttimedistancespectaclewearintheUnitedStates,43
myopeswerecategorisedintofourtreatmentgroups:(a)fulltimespectaclewear,(b)wearfordistance
viewingandthenaswitchtofulltimewear,(c)wearfordistanceviewingonly,and(d)nonwear.Over
aperiodof3years,therewerenosignificantdifferencesinrefractiveshiftsasmeasuredbynon
cycloplegicdistance
Whenmyopiaisnotcorrected,lackofaclearvisualimagemayleadtoformdeprivationmyopia.11
Conversely,correctingachildsmyopiawithnegativelensesmayresultincompensatoryaberranteye
growthandthedevelopmentofmyopia.10Animalexperimentshaveshownthatcompensatorychanges
intheaxiallengthofaneyemayoccurinresponsetoerrorsignalsfromlensinduceddefocus.10,12Ina
nonrandomisedclinicaltrialevaluatingparttimedistancespectaclewearintheUnitedStates,43
myopeswerecategorisedintofourtreatmentgroups:(a)fulltimespectaclewear,(b)wearfordistance
viewingandthenaswitchtofulltimewear,(c)wearfordistanceviewingonly,and(d)nonwear.Over
aperiodof3years,therewerenosignificantdifferencesinrefractiveshiftsasmeasuredbynon
cycloplegicdistance
Myopiaisclassifiedinasimplemanneras
i)simple
ii)pathological
SimpleMyopiaisnotprogresivebeyondtheamountincludedwithinnormaldevelopment;isassociated
withgoodvisionandrequiresnotreatmentexceptopticalcorrection.
PathologicalMyopiaontheotherhandisadegenerativemyopiaaccompaniedbychangesinthe
posteriorsegmentoftheeyeballwithlengtheningofAPaxisoftheglobe.Besides,theaxial
pathologicalmyopia,thereareothertypesofmyopiaduetodefectsinthecurvatureofcorneaandlens
andduetodrauma.Today,IwillconfinemyremarksonlytopathologicalaxialMyopia.
Thepathologicalmyopiashowsdegenerativechangesintheposteriorpole.Thusitcanbenamedas
degenerativemyopia(DukeElder).Itmayoccurasanindependentdevelopmental(congenital)

conditionorinassociationwithotherocculardiseasesorgeneraldisease.
VonJeagerfirstdescribedcongenitalmyopiain1855.Sincethenanumberofcaseshavebeen
reported.Majorityofcongenitalmyuopiasremainstationary.Someprogressfurtherleadingto
detachmentoftheretina.Visionisgoodinsomecases,whileinothersitissubnormal.
beinducedareformdeprivationandopticaldefocus.Formdeprivationmyopiacanbeinducedbythe
applicationoftranslucentoccludersovertheanimalseyes.Localretinaleffectsmayoccurandthe
resultantscleralgrowthmodulatedbychemicalssuchasdopamine,growthfactors,andmuscarinic
antagonists.79Negativespectaclelensesinchicksinducecompensatoryaxialelongationandmyopia.10
Suitabletherapeuticmodalitiessuchaspharmacologicalinterventionsandopticalcorrectivedevices
thatmayretardtheprogressionofmyopiainmyopicindividualshavebeenreported.The
overwhelmingmajorityofthesereportshavebeencitedinoptometryandnotophthalmologyjournals.
Theopticalcorrectionofmyopiaandoptimalstrategiestopreventtheprogressionofmyopiahavebeen
developedandprescribedlargelybyoptometrists.Ontheotherhand,issuesregardingthecausesand
preventionofmyopiahaveonlygainedinterestamongophthalmologistsintherecentdecade.The
objectiveofthis

Myopiahasbeenknownformorethan2000yearsandwasfirstdescribedbytheancientGreeks.1,2
However,despitetherecordeduseofconvexlensesforpresbyopiainthelate13thcenturyinFlorence,
Italy,thecorrectionofmyopicrefractiveerrorhadtoawaitthedevelopmentofconcavelensesinthe
mid16thcentury.
Myopiamaybeclassifiedasschoolmyopiaoradultonsetmyopia.3Schoolmyopiadevelops
duringtheschoolageandstabilisesaround1517yearsofage,whileadultonsetmyopiadevelopsin
youngadults.Theaetiology,pathogenesis,andtreatmentofmyopiahavebeenhotlydebatedinthe
ophthalmiccommunityfordecades.4Thereareseveraltheoriesonthemechanismofdevelopmentof
myopiaarisingfromdisruptionoftheemmetropisationprocess.Emmetropisationisachievedwhenthe
opticalpoweroftheeyematchestheaxiallength,resultinginafocusedimageofadistantobjectonthe
retinawithoutaccommodativeeffort.5Ithasbeenproposedthatoveractingintraocularmusclesmay
resultinexcessiveaccommodationandinfluenceemmetropisation.6Thetwobasicmechanismsby
whichanimalmyopiamay

Previous studies have evaluated the efficacy of several interventions

to decrease the progression of myopia. These include devices that
alter the perception of the visual environment and pharmacological
treatments. There is no conclusive evidence thus far that alteration
of the pattern of spectacle wear, bifocals, ocular hypotensives, or
contact lenses retards the progression of myopia. Several
randomised clinical trials have demonstrated that the rate of
progression of myopia is lower in children given atropine eye drops
than those given placebo. However, atropine is associated with
short term side effects such as photophobia and possible long term
adverse events including light induced retinal damage and cataract
formation. Other more selective antimuscarinic agents such as
pirenzipine are presently being evaluated. Further well conducted
randomised clinical trials with large sample sizes and adequate
follow up designed to evaluate treatments to retard the progression
of myopia should be conducted, since the identification of an

effective intervention may have a greater public health impact on

the burden and morbidity from myopia than the few treatments
currently available.

INTRODUCTION
Optometrists, through their clinical education, training, experience,
and broad geographic distribution, have the means to provide
effective primary eye and visison care for a significant portion of the
American public and are often the first health care practitioners to
diagnose patients with myopia.
This Optometric Clinical Practice Guideline for the Care of the
Patient with Myopia describes appropriate examination and
treatment procedures for myopia and contains recommendations for
diagnosis and management of myopia. This Guideline will assist
optometrists in achieving the following goals:
1.

Accurately diagnose the different types of myopia

2.

Improve the quality of care rendered to patients with myopia

3.

Inform and educate parents, patients, and other health care

practitioners about the options of correction, control, or reduction
of myopiaDecrease visual morbidity related to higher degrees of
myopia.

Tellyourdoctorrightawayifanyoftheseunlikelybutserioussideeffectsoccur:signsofinfection
(e.g.,fever,persistentsorethroat),troublebreathing,unusualtiredness,swellingankles/feet,
burning/painful/frequenturination,decreasedsexualinterest/ability,hairloss,musclecramps/pain,See
alsoWarningsection.
Beforetakingitraconazole,tellyourdoctororpharmacistifyouareallergictoit;ortootherazole
antifungals(e.g.,ketoconazole);orifyouhaveanyotherallergies.Thisproductmaycontaininactive
ingredients,whichcancauseallergicreactionsorotherproblems.Talktoyourpharmacistformore
details.
Beforeusingthismedication,tellyourdoctororpharmacistyourmedicalhistory,especiallyof:liver
disease(orhistoryofliverdiseasewithotherdrugs),kidneydisease,heartdisease(e.g.,coronaryartery
disease,heartvalvedisease,congestiveheartfailure),severelungdisease(e.g.,chronicobstructive
pulmonarydisease
s

Tunikavaskularis(lapisuvea)merupakanlapisantengahbolamataterdiri
ataskhoroid,badansiliarisdaniris.

Tunikaneuralis(lapisretina)merupakanlapisandalambolamataterdiriatasretina.

Howtouseitraconazole
ReadthePatientInformationLeafletprovidedbyyourpharmacistbeforeyoustart
takingitraconazoleandeachtimeyougetarefill.Ifyouhaveanyquestions,consult
yourdoctororpharmacist.