This article was originally published in a sponsored newsletter.

It’s the pickle jar theory for me. In the world of myopia management, we have spent the last decade focused on the big rocks: Which techniques? How are they employed? How effective are they? With these big rocks in the proverbial jar, attention can turn to some of the pebbles and sand that will fill in a more complete understanding of the field (e.g., strength of add, length of treatment, specialized and optimized lens designs, as well as higher-order aberrations [HOAs]). The thing is, the more that is uncovered in the realm of aberrations, the more convincing it is that HOAs deserve a more outsized space in the jar of myopia management than previously suspected.

Let’s start with the fact that HOAs are important not only for retinal image quality¹ and visual function,² but also for myopia management.^3,4 That much has meaningful agreement in the scientific community. Nearly every study on the matter shows a significant association between greater HOAs and decreased axial elongation.⁵ Rates and impacts of HOAs vary based on pupil size, age, and contact lens designs, but the conclusion of these studies is clear: HOAs considerably impact eye growth by a mechanism that is presently unknown.^6-8

These HOAs are meaningfully increased by at least two-thirds of our myopia management triad: orthokeratology and multifocal soft contact lenses (that includes spectacles too, for inquiring minds).⁵ So if HOAs impact growth and myopia control techniques impact HOAs, it seems to follow that HOAs have an outsized role to play in the management of our myopic patients.

One compelling theory on the underlying mechanism is that these aberrations provide a retinal signal for growth and improved image quality.⁹ Put simply, the eye responds to this type of higher-order blur by growing in a compensatory direction for better vision.⁹

Here's the great news: This area appears to be rife with opportunity. Whether it’s in orthokeratology or multifocal contact lenses, practitioners are already shifting around magnitudes of HOAs, increasing them inherently by performing the technique.¹⁰Imagine a world in which evidence-based approaches to optimizing the design—that is, to adjust our spherical, comatic, trefoil, and beyond to maximize the effect on axial length—improves not only image quality, but also boosts the overall effectiveness of the technique. In other words, keep doing what is already being done. What cosmic kismet.

Practical chairside changes are few now but will be forthcoming as the evidence begins to elucidate the details. How exactly do HOAs help to slow axial growth and how can this effect be maximized? Is measurement of ocular HOAs a new standard of care in the management of myopic patients? Is the modulation of HOAs in the service of reducing ocular growth synergistic to maximizing retinal image quality? There are many more pebbles to be added to our understanding, but one thing is for sure: HOAs will take up a lot more room in the jar moving forward.

References

1. Collins MJ, Buehren T, Iskander DR. Retinal image quality, reading and myopia. Vision Res. 2006 Jan;46:196-215.

2. Yang Y-R, Zhao J-L, Xiao F, Zhao H-X, Dai Y. Effect of high-order aberrations on pattern-reversal visual evoked potentials. Vision Res. 2019 Aug;161:52-59.

3. Hiraoka T, Kotsuka J, Kakita T, Okamoto F, Oshika T. Relationship between higher-order wavefront aberrations and natural progression of myopia in schoolchildren. Sci Rep. 2017 Aug;7:7876.

4. Lau JK, Vincent SJ, Collins MJ, Cheung S-W, Cho P. Ocular higher-order aberrations and axial eye growth in young Hong Kong children. Sci Rep. 2018 Apr;8:6726.

5. Lau JK, Vincent SJ, Cheung S-W, Cho P. Higher-Order Aberrations and Axial Elongation in Myopic Children Treated With Orthokeratology. Invest Ophthalmol Vis Sci. 2020 Feb;61:22.

6. Carkeet A, Velaedan S, Tan YK, Lee DYJ, Tan DTH. Higher order ocular aberrations after cycloplegic and non-cycloplegic pupil dilation. J Refract Surg. 2003 May-Jun;19:316-322.

7. Brunette I, Bueno JM, Parent M, Hamam H, Simonet P. Monochromatic aberrations as a function of age, from childhood to advanced age. Invest Ophthalmol Vis Sci. 2003 Dec;44:5438-5446.

8. Kang P, Gifford P, Swarbrick H. Can manipulation of orthokeratology lens parameters modify peripheral refraction? Optom Vis Sci. 2013 Nov;90:1237-1248.

9. Buehren T, Iskander DR, Collins MJ, Davis B. Potential higher-order aberration cues for sphero-cylindrical refractive error development. Optom Vis Sci. 2007 Mar;84:163-174.

10. Huang Y, Li X, Ding C, et al. Comparison of peripheral refraction and higher-order aberrations between orthokeratology and multifocal soft contact lens designed with highly addition. Graefes Arch Clin Exp Ophthalmol. 2022 May;260:1755-1762.