Patterns of refractive change in myopic subjects during the incipient phase of presbyopia: a preliminary study

Purpose: Changes in refractive error are well documented over the typical human lifespan. However, a relatively neglected period of investigation appears to be during the late fourth decade; this is at the incipient phase of presbyopia (IP), where the amplitude of accommodation is much reduced and approaches the level where a first reading addition is anticipated. Significantly, informal clinical observation has suggested a low incidence of an unexpected abrupt increase in myopia during IP. Methods: We investigated this alleged myopic shift retrospectively by mapping the longitudinal refraction histories of normally-sighted 35-44 years old British White patients previously examined in routine optometric practice. The refractive trends in the right eyes of healthy myopic subjects (spherical equivalent refraction, SER <=-0.50 D: N = 39) were analysed relative to that point at which a first near dioptric addition was considered to be clinically useful. Results: A refractive change was evident in some subjects during IP; viz, an abrupt increase in myopic SER of between -0.50 and -0.75 D. These individuals (N = 8) represented 20% of the study population of myopic incipient presbyopes. Beyond the pivotal point of the first near addition the longitudinal refraction stabilized in these subjects. In contrast, and as the extent of the available longitudinal data would permit, the remaining myopic eyes maintained an approximately stable refractive trend throughout IP and beyond. Conclusions: The anatomical or physiological basis of this specific late (non-developmental) abrupt myopic refractive change is an intriguing issue. Axial (vitreous chamber elongation), corneal (contour) and lenticular (profile and index) power bases, alone or in concert, might be considered candidates for this hitherto unexplored refractive phenomenon. Although necessarily obtained under conventional conditions of central (0 deg) fixation, our data might also be a reflection of the recent recognition of the possible influence of the peripheral refraction upon the axial error. Consideration of this material provides an impetus for further research, including ocular biometry, a reappraisal of ciliary zonular functional anatomy, renewed investigation of the AC/A ratio, and the extent of a centripetal refractive influence on myopia development.