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CLINICALANDEXPERIMENT AL Optometry 

DIUNDANG REVIEW 

Myopic anisometropia: karakteristik mata dan pertimbangan etiologi 


Clin Exp Optom 2014; 97: 291-307 DOI: 10,1111 / cxo.12171 
Stephen J Vincent PhD Michael J Collins PhD Scott A Baca PhD Leo G Carney DSc Lensa Kontak dan Laboratorium Sekolah 
Visual Optik of Optometry dan Vision Ilmu Queensland University of Technology, Brisbane, Queensland, Australia E-mail: 
sj.vincent@qut.edu.au 
© 2014 Penulis Clinical and Experimental Optometry 97,4 Juli 2014 Clinical and Experimental Optometry © 2014 dokter mata 
Asosiasi Australia 291 anisometropia merupakan contoh yang unik dari perkembangan mata, di mana dua mata seorang individu 
, dengan latar belakang genetik yang identik dan tampaknya tunduk pada pengaruh lingkungan yang identik, dapat tumbuh 
asimetris untuk menghasilkan kesalahan tive refrac- berbeda secara signifikan. Ulasan ini memberikan gambaran tentang 
penelitian meneliti rabun pia anisometro-, karakteristik mata yang mendasari kondisi dan faktor-faktor etiologi potensial yang 
terlibat. Berbagai faktor mekanik dibahas, termasuk struktur kornea, tekanan intraokular dan pasukan yang dihasilkan selama 
dekat pekerjaan yang dapat berkontribusi untuk pengembangan anisomyopia. Potensi mekanisme visual dipandu pertumbuhan 
mata yang tidak sama juga dieksplorasi, termasuk pengaruh Silindris, akomodasi, tingkat tinggi aberra- tions dan respon 
choroidal untuk pengalaman visual diubah. Hubungan antara visi teropong, dominasi mata dan pembiasan asimetris juga 
dianggap, bersama dengan review dari kontribusi genetik terhadap etiologi anisometropia rabun. Meskipun Dikirim: 17 
September 2013 
sejumlah besar penelitian ke dalam karakteristik biomekanik, struktural dan 
optik Revisi: 28 Januari 2014 
dari mata anisometropic, masih belum ada teori pemersatu, yang memadai 
menjelaskan bagaimana dua Diterima untuk publikasi: 14 Februari 2014 
mata dalam sistem visual yang sama tumbuh endpoint yang berbeda. 
Kata kunci: anisometropia, miopia, biometrik mata, pertumbuhan mata, bias error 
Studi  sebelumnya  dari kedua hewan dan manusia telah menunjukkan bahwa kesalahan bias sangat ditentukan oleh panjang aksial 
dan  bahwa  pertumbuhan  mata  dipengaruhi  oleh  pengalaman-  ence.1  visual  yang  Meskipun  ada  bukti  menyarankan  pengaruh 
genetik  dalam  perkembangan  kesalahan  bias  (dalam  miopia  tertentu), 2,3 itu sekarang umumnya diterima bahwa environ- faktor 
mental,  seperti  di  dekat  work4-6  dan  activity7  luar  ruangan  juga  memainkan  peran  yang  signifikan;  Namun,  saat ini belum ada 
teori  tunggal  yang  memadai  menjelaskan  mekanisme  fisiologis  yang  mendasari  perkembangan  miopia.  Hipotesis  umum 
diusulkan  mekanisme  potensial  yang  mengarah  ke  pengembangan  miopia  termasuk  yang  mana  cal  mechani-  atau  faktor  optik 
mempromosikan berlebihan pertumbuhan mata aksial. 
Anisometropia  rabun  atau  anisomyopia  biasanya  didefinisikan  sebagai  perbedaan  antara  mata  di  rabun  bola  kesalahan  bias 
setara  dengan  1,00  D  atau  lebih  (biasanya  karena  asimetri  interocular  dalam  panjang  aksial)  8 adalah kondisi bias yang unik, di 
mana  sesama  mata  seorang  individu  telah  tumbuh  dua  titik  akhir  yang  jelas  berbeda.  Penyelidikan  anisometropia  dalam 
penelitian miopia (yaitu, membandingkan lebih 
matarabun  dengan  sesama  mata  relatif  kurang  rabun  dalam individu yang sama) memungkinkan untuk wawasan berpotensi baru 
ke  dalam  mekanisme  yang  mendasari  pengembangan  kesalahan  bias,  karena  memungkinkan  untuk  trol  con lebih besar variabel 
pembaur  seperti  usia  dan  jenis  kelamin,  minimalisasi  variasi  antar-subjek  dalam  faktor  ronmental  genetik  dan  gus  dan  dengan 
demikian  memberikan  sensitivitas  meningkat  dalam  mendeteksi subjek antara- (mata) perbedaan dalam variabel antar est. tujuan 
dari  ini  review  adalah  untuk  meringkas  literatur  mengenai  rabun  anisometro-  pia  (terutama  non-amblyopic  anisometro-  pia), 
dengan  fokus  khusus  pada  optik  (misalnya  akomodasi  dan  tingkat  tinggi  penyimpangan)  dan  karakteristik  mekanik  (misalnya, 
struktur  kornea,  tekanan  intraokular  dan  pasukan  yang  dihasilkan  selama  dekat  pekerjaan)  dari  anisomyopia,  yang  dapat 
memberikan wawasan lebih jauh ke asal-usul kesalahan bias rabun s. 
PERUBAHAN anisometropia SELURUHHIDUP 
studiBanyak telah meneliti lence preva- dan besarnya anisometropia pada 
berbagai  tahap  sepanjang  hidup.  Figure1  (berdasarkan  data  dari  population9  klinis  besar)  menggambarkan  perubahan  khas 
diamati  dari  anak  usia  dini  sampai  usia  yang  lebih  tua.  Penurunan  prevalensi  pia  anisometro-  terjadi  selama  masa  bayi  dan 
peningkatan  sepanjang  masa  dan  dalam  kelompok  usia  yang  lebih  tua.  Perubahan  besarnya  anisometropia  mengikuti  tren  yang 
sama,  dengan  perbedaan  interocular  1,00  D  atau  lebih  (atau  asimetri  panjang  aksial  lebih  besar  dari  0.3mm)  berada  di  luar 
jangkauan  khas  anisometropia  diamati  di  semua  usia  (0.00  untuk  0.75D)  .  Hipotesis  yang  terkait  dengan  mekanisme  yang 
mendasari yang mengatur perubahan yang berkaitan dengan usia seperti di sometropia ani- dibahas di bagian berikut. 
Masa bayi dan anisometropia amblyopic Subjek anisometropia amblyopic berada di luar cakupan makalah ini (untuk review lihat 
Barrett dan colleagues10); Namun, dalam sub-kelompok anisometropes amblyopic perubahan refraksi hyperopic, astig- 
anisometropes matic dan Strabismic melakukan 
 
karakteristik okuler dari anisometropia Vincent, Collins, Baca dan Carney 
50.00 
0.50 
masih relatif stabil dari waktu ke waktu, sedangkan sesama mata non-amblyopic cenderung untuk menjalani pergeseran rabun 
selama pemuda. Hal ini menunjukkan bahwa visi yang jelas dan mungkin accommoda- aiportemosi 
40.00 
0.40 
tion (yang terganggu pada amblyopia17,18) diperlukan untuk emmetropisation sukses dan berpotensi juga untuk pengembangan 
na 
30.00 
RES etulosbanaemfoecnelav er P 
20.00 
10.00 0 0,30 
miopia. Disfungsional atau dikompromikan visi mata bin- juga dapat terkait dengan devel-opment asimetris rabun bias 
0,20 
kesalahan. 

Non-amblyopic dimasa kanak-kanak 


anisometropia 
0,10 
Beberapa  studi  longitudinal  telah  meneliti  perkembangan  anisometropia  selama  masa  kanak-kanak  dan  biasanya  melaporkan 
peningkatan 

besarnya perbedaan interocular di 0-9 
10-19 20-29 30-39 40-49 50-59 
60 -69 70-79 80-89 90-99 
refraksi dengan usia, yang sebanding Umur (tahun) 
ke peningkatan myopia (Gambar 2). Ia telah mengemukakan bahwa Gambar bias divergen 1. Prevalensi dan besarnya 
anisometropia sepanjang hidup (berdasarkan 
kesalahan antara sesama 
mata selama Data masa kanak-kanak dari sebuah studi klinis besar lebih dari 85.000 pasien, termasuk myopes, 
terkait dengan 
pengembangan dan progres- hyperopes, amblyopes dan kasus pathology9 mata). Bar hitam mewakili 
sion miopia adalah hasil dari 
prevalensi kegagalan berarti mutlak bola anisometropia refraksi setara dengan 1,00 D atau 
internal (antara mata) 
homeostatis lebih (sesuai dengan kiri sumbu y). Garis putus-putus mewakili besarnya rata-rata mutlak bola 
anisometropia refraksi setara, untuk semua pasien termasuk isometropes dan anisometropes (sesuai dengan y-sumbu 
kanan). Prevalensi dan besarnya anisometropia bervariasi secara signifikan dari waktu ke waktu. 
mekanisme yang mengatur simetris mata growth.24 disengaja sepihak Intervensi yang optik pada anak-anak, 25-28 yang 
menghasilkan pertumbuhan mata asimetris (dibahas secara rinci nanti) menunjukkan bahwa visi yang lokal mekanisme 
tergantung juga mungkin memainkan peran memberikan beberapa wawasan mengenai mengembangkan- 
sejumlah penelitian juga telah diamati 
dalam pengembangan 
anisometropia di ment kesalahan bias asimetris. 
bahwa perubahan refraksi dari waktu ke waktu bervariasi 
muda. Abrahamsson dan 
colleagues11 diikuti 
antara amblyopic dan non-amblyopic 
The study29 membujur Ojai 
diikuti 310 astigmatic satu-year-olds (1.00D atau 
mata strabismic13,14 dannon-strabismic15 
pengembangan biasanak-anak 
dari lebih di satu mata) selama tiga -tahun periode 
anak-anak, dengan mata non-amblyopic typi- 
usia enam sampai 17 tahun. 
Dari 359 anak-anak dengan di dan mengamati bahwa sejumlah besaranisome- 
Callymenjalani signifikan lebih besar 
setidaknya 22 bias titik waktu 
(lebih dari satu 11 untuk tropia dapat mengurangi masa bayi. Aniso- 
pergeseran rabun. Caputo dan colleagues16 
12 periode tahun), 2,5 persen 
metropia maju bertahan di 46 persen dari 
retrospektif perubahan 
anisometropia rabun (1.00D 
atau bayi lebih anisometropic seluruhstudi 
refraksicycloplegic dari 46 muda rabun 
bola setara refraksi). Pada 
periode pertama ini, dan sekitar 25 persen dari 
anisometropes, lebih dari setengah dari mereka memiliki 
studi meneliti pengembangan 
non anak-anak ini dikembangkan amblyopia. Dalam 
sebuah gangguan gerakan mata. Para penulis 
anisometropia rabun amblyopic 
selama penelitian lain, Abrahamsson dan Sjöstrand12 
mengamati bahwa mata kurang rabun pada 
masakanak-kanak, Hirsch 
menyatakan bahwa'. . . teori apapun retrospektif meneliti perubahan 
pemeriksaan awal menjadi lebih rabun 
untuk pengembangan miopia 
harus menjelaskan pembiasan 20 anak-anak yang telah ditandai 
dari waktu ke waktu, sedangkan mata lebih rabun 
bagaimana dua mata di individu 
mencapai anisometropia yang berbeda dari 3.00D atau lebih pada satu 
(sering dengan amblyopia atau strabismus) 
menyatakan bias, karena tahun 
kedua mata mengakomodir usia. Tiga puluh persen dari anak-anak ini 
memiliki refraksi relatif stabil selama 
tanggal dan bertemu sama, 
menerima mengalami peningkatan besarnya 
pembangunan. 
pengaruh hormonal yang sama, 
melakukan anisometropia mereka (mean 1.4 D) dan opment 
Singkatnya, pada anak usia dini, anisome- 
tugas yang sama dan memiliki 
banyak kesamaan lain. amblyopia oped antara usia tiga sampai 
tropia biasanya menurun selama emme- 
Parssinen20 mengikuti 
perubahan refrac- 10 tahun. Anisometropia menurun di 
tropisation (penguranganneonatal 
tiondari 238 anak-anak rabun 
berusia sembilan sampai tersisa 70 persen dari anak-anak selama 
kesalahan bias ke arah emmetropia sampai 
11 tahun selama periode tiga 
tahun dan menemukan waktu. Setengah dari anak-anak ini memilikisignifikan 
copertumbuhan mata -ordinated) dengan opment 
anisometropia yang tetap stabil 
di penurunan anisometropia (mean 3,00 D) 
ngunan dari teropong koordinasi. Ketika 
67 persen, meningkat 27 persen 
dan dan tidak berkembang amblyopia; Namun, 
anisometropia berlangsung di luar tiga tahun 
menurun dalam enam persen 
dari mata pelajaran. Sebagai bagian lain dari kelompok ini mengalami 
usia, biasanya menghasilkan amblyopia.meningkat 
Miopia dari waktu ke waktu 
(berarti bola hanya penurunan ringan pada anisometropia 
kesalahan bias mata amblyopic (associ- 
setara refraksi berubah dari 
-1,43 (mean 1.2 D) tapi semua anak-anak ini opment 
diciptakan dengan anisometropia hyperopic, strabis- 
ke -3,06 D), besarnya 
amblyopia oped bola. 
mus atau disfungsional penglihatan binokular) 
setara anisometropia meningkat dari 
Clinical and Experimental Optometry 97,4 Jul 2014 © 2014 Penulis 292 Clinical and Experimental Optometry © 2014 Asosiasi 
dokter mata Australia 
 
okuler karakteristik anisometropia Vincent, Collins, Baca dan Carney 
0,75 
Studi Parssinen (1990) Yamashita et al (1999)) D (aiportemo adalah na 
Pointer dan Gilmartin21 retrospektif meneliti perubahan longitudinal pada tion refrac- dari populasi yang sedikit lebih tua berusia 
enam sampai 19 tahun. Mereka membandingkan tingkat perubahan bias di 21 anisometropes rabun unilateral (satu mata rabun, 
sesama emmetropic mata) untuk kontrol 0,50usia-cocok 
kelompokb  myopes  ilateral.  Laju  perkembangan  di  mata  rabun  dari  anisometropes  tidak  berbeda  secara  signifikan  dari  tingkat 
pengembangan di myopes bilateral, situs oppo- tren dari yang dilaporkan oleh Tong dan colleagues.22 
Baru-baru  ini,  Deng  dan  Gwiazda19  meneliti  perubahan  anisometropia  selama  studi  tudinal  longi-  anak-anak  dari  usia  enam 
bulan  ke  12  sampai  15  tahun.  Besarnya  anisometropia  meningkat  dari  waktu  ke  waktu  dan  dikaitkan  dengan  peningkatan  baik 
kesalahan  bias  rabun  dan  hyperopic.  Hal  ini  menunjukkan  bahwa  mekanisme selain exces- pertumbuhan mata sive selama masa 
kanak-kanak  dapat  mempromosikan  pengembangan  anisometropia  (misalnya  perubahan  penglihatan  binokular  atau  dominasi 
mata). 
Besarnya anisometropia pada anak-chil- dengan akomodasi aktif bisa bervariasi tergantung pada metode yang digunakan untuk 
menilai  kesalahan  bias.  Namun,  ada  bukti  yang  menunjukkan  bahwa  penggunaan  cycloplegia  selama  penentuan  kesalahan  bias 
memiliki  pengaruh  minimal  pada  besarnya  dan  prevalensi  (kurang  dari  satu  persen  ence  berbeda-  prevalensi  antara cycloplegic 
dan teknik non-cycloplegic) dari pia anisometro- di baik children30 dan adults31 dari berbagai kesalahan bias. 
Singkatnya,  prevalensi  dan  magni-  tude  dari  anisometropia  biasanya  meningkat  terus  sepanjang  masa  untuk  dewasa  muda 
dalam  hubungan dengan usia (Gambar 2) dan peningkatan rabun atau astigmatic kesalahan bias. Perubahan anisometropia selama 
masa  kanak-kanak  berkorelasi  dengan  perubahan  asimetris  panjang  aksial  antara  sesama  mata.  Bukti  mengenai  tingkat 
pengembangan rabun di com- anisometropic dikupas untuk isometropic mata adalah bertentangan. 

Rabun pada usia dewasa 


anisometropia 
Sementara  anisometropia  menurun  selama  tahun-tahun  awal  kehidupan  (mungkin  melalui  emmetropisation  dan  pengembangan 
penglihatan  binokular)  dan  meningkat  selama  hood  anak-  dan  remaja  (terkait  dengan  perkembangan  miopia),  seluruh  usia 
pertengahan (sekitar 30 sampai 50 tahun) pra tersebut valensi dan besarnya anisometropia 
© 2014 Penulis Clinical and Experimental Optometry 97,4 Juli 2014 Clinical and Experimental Optometry © 2014 Asosiasi 
dokter mata Australia 293 
Pointer & Gilmartin (2004) Tong et al (2006) Deng & Gwiazda (2012) 
RES etulosbanae M 
0.25 
0.00 
0 5 10 15 
20 Umur (tahun) 
Gambar  2.  Gabungan  data  dari  studi  longitudinal  anisometropia  non-amblyopic  sepanjang  masa  dan adolescence.19-23 
peningkatan  kecil  tapi  signifikan  dalam  besarnya rata-rata mutlak bola anisometropia pembiasan setara diamati dengan 
bertambahnya  usia,  yang  terkait dengan perkembangan rabun dan astigmatic kesalahan bias. Padat garis mewakili garis 
fit dan putus-putus jalur terbaik 95 per interval keyakinan persen. 
0,30-0,51 D. kesalahan bias awal, 
namun, ada berkekuatan positif yang signifikan atau sumbu astigmatisme dan 
jenis 
korelasi antara besarnya koreksi tontonan (visi tunggal atau 
anisometropia bola dan astigmatic. The bifocal) tidak terkait dengan perubahan 
perbedaan interocular di Silindris bisa di anisometropia; Namun, 
mengembangkan- yang 
menjadi faktor yang berkontribusi terhadap ment pengembangan anisometropia 
berkorelasi dengan 
dari anisometropia bola atau mungkin con- peningkatan myopia. Para penulis 
nyarankan- 
urutan pertumbuhan mata asimetris. gested bahwa semakin besar gangguan di 
Dalam sebuah studi longitudinal tiga tahun emmetropisation, karena baik 
genetik 
hampir 2.000 anak-anak di Singapura faktor umur atau lingkungan, semakin 
besar 
tujuh sampai sembilan tahun, Tong dan potensi colleagues22 untuk asimetri 
panjang okular 
ditemukan mean bola setara aniso- untuk mengembangkan. 
metropia sedikit meningkat dari waktu ke waktu dari Dalam kohort didominasi 
emmetro- 
0,29 D pada awal menjadi 0,44 D di studi komplemen pic anak sekolah Jepang 
(awal berarti 
tion. Kurang dari empat persen dari anak-anak memiliki bola setara refraksi 0,91 
D), 
anisometropia dari 1.00 D atau lebih pada awal. Yamashita, Watanabe dan 
Ohba23 juga 
Of anak-anak ini dengan 1,00 D atau lebih mengamati bahwa bola anisometropia 
anisometropia, 5,1 persen mengalami peningkatan relatif stabil selama lima 
tahun 
di anisometropia minimal 0,50 D, sedangkan periode (berarti sekitar 0,25 D ) 
dari 
3,4 persen mengalami penurunan minimal 0,50 D. usia enam sampai 11 tahun. 
Selama masa studi, 
Perubahan anisometropia berkorelasi anisometropia tetap stabil di 84 per 
dengan perubahan panjang aksial antar-mata. persen dari anak-anak, sementara 
di 16 persen yang 
Dibandingkan dengan anak-anak isometropic, masing-masing berkekuatan 
meningkat atau menurun dengan 
mata anak-anak anisometropic memiliki usia. Perbedaan interocular di 
tingkat yang lebih tinggi dari perkembangan miopia tetapi besarnya 
astigmatisme juga stabil 
perubahan anisometropia dari waktu ke waktu adalah dari waktu ke waktu 
(berarti sekitar 0.32D); 
serupa di antara kedua kelompok. 
 
Karakteristik mata dari anisometropia Vincent, Collins, Baca dan Carney 
50,00 
0,60 
signifikan pada prevalensi di usia yang lebih tua. Peningkatan diamati di kemudian hari mungkin terkait dengan regresi kontrol 
saraf dari teropong 0,50 
visi. Peningkatan prevalensi dan aiporte 
40,00 
besarnya anisometropia selama periode kehidupan biasanya terkait dengan Mosina 
30,00 
0,40 
onset dan perkembangan miopia adalah kepentingan tertentu, seperti memahami RES etulosbanaemfo 
mekanisme yang mendasari pengembangan 0,30 
anisometropia dapat memberikan wawasan 
20.00 
pengembangan miopia. 
GENETIKA DAN ANISOMYOPIA 
10.00 
0,10 
Sementara banyak penelitian telah menyelidiki pengaruh genetika pada ment mengembangkan- miopia (misalnya, studi keluarga, 
38,39 studi kembar, 2,3 identifikasi <20 20-29 30-39 40-49 
50-59>60 
lokus genetik di myopia40 tinggi), relatif sedikit Umur (tahun) 
studi telah meneliti heritabilitas 
Gambar 3. prevalensi dan besarnya anisometropia sepanjang hidup di miopia 
kesalahan bias anisometropic. Dalam sebuah studi silsilah awal, Goldschmidt41 investigasi (berdasarkan data dari studi klinis 
bias operasi candidates31). Bar hitam 
terjaga keamanannya 
keluarga segera 36 remaja mewakili prevalensi rata-rata mutlak bola anisometropia refraksi setara 
dengan myopia tinggi (lebih 
besar dari 6,00 D di 1,00 D atau lebih (sesuai dengan kiri sumbu y). Garis putus-putus merupakansatu 
salahmata), sembilan di 
antaranya memiliki moderat untuk besarnya rata-rata mutlak bola anisometropia refraksi setara, untuk rabun 
miopia unilateral parah 
(rata-rata 8,00 D, pasien hanya termasuk kedua isometropes (sesuai dengan y-sumbu kanan). 
kisaran  empat  sampai  14  D).  Tak  satu  pun  dari  saudara  kandung  dari  probands  anisometropic  ditampilkan  kesalahan  bias 
asimetris  signifikan. Juga, status bias orang tua bervariasi; dengan 55 persen menunjukkan emmetropia atau hyperopia rendah, 22 
persen  dengan  miopia  isometropic,  11  persen  dengan  anisometropia  rabun  dan  11  persen  dengan  antimetropia.  Berdasarkan 
temuan  ini,  Goldschmidt41  menyimpulkan  bahwa  unilateral  miopia  tinggi  tidak  'sesuai  dengan  sederhana,  modus  monomer 
warisan' dan berspekulasi bahwa faktor lingkungan juga dapat mempengaruhi simetri pembiasan antara sesama mata. 
Beberapa  penelitian  lain  telah  meneliti  silsilah  anisometropes  rabun,  dengan  temuan  yang  saling  bertentangan.  Ohguro  dan 
leagues42  kumpulkan  mengamati  pola  pewarisan  autosomal  dominan  dalam  laki-laki  muda  dengan  20  D  dari  anisomyopia. 
Baru-baru  ini,  Feng,  permen  dan  Yang43  melaporkan  pola  pewarisan  autosomal  resesif  dalam  keluarga  Cina  dengan 
anisometropia  rabun  sekitar  5,00  D.  Dalam  sebuah  studi  dari  48  anak  anisometropic,  Weiss44  melaporkan  bahwa  tiga  pasien 
wanita  memiliki  riwayat  keluarga  yang  kuat  dari  anisomyopia  dan  menyarankan  pola  warisan  resesif  x-linked  ada  dalam kasus 
unilateral aksial tinggi miopia. 
Beberapa laporan kasus monozigot muda dan kembar dizigot juga menyarankan bahwa genetika 
Clinical and Experimental Optometry 97,4 Jul 2014 © 2014 Penulis 294 Clinical and Experimental Optometry © 2014 dokter 
mata Asosiasi Australia 
0,20 
ecnelaver P 
0 0 
masih relatif stabil (Angka 1 dan 3). 
prevalensi anisometropia sampai usia tua ini mungkin berhubungan dengan 
stabilitas 
mata sehat tanpa patologi. pembiasan jarak selama periode ini 
Weale34 mengumpulkan data dari beberapa studi kehidupan dewasa; Namun, 
di kemudian hari (di luar 
memeriksa hubungan antara 60 tahun), ada peningkatan yang ditandai dalam 
prevalensi anisometropia dan usia dan prevalensi bias anisometropic 
diamati peningkatan perkiraan di errors.31-35preva- 
lencedari satu persen untuk setiap tujuh tahun Ia telah mengemukakan bahwa 
peningkatan 
kehidupan. Dia menyarankan bahwa asimetri di anisometropia pada orang 
dewasa yang lebih tua mungkin menjadihasil 
perkembangankatarak tidak bisa menjelaskan perkembangan katarak asimetris 
atauuni- 
peningkatan yang signifikandi anisometropia dan ekstraksi katarak lateral. Studi 
dibatasi 
menyarankan bahwa neuro-penuaan, atau break untuk pasien phakic masih 
mendemonstrasikan 
turun di penglihatan binokular mungkin memainkan peran dalam peningkatan 
dengan usia dan proporsi yang lebih tinggi dari 
asal-usul refraksi yang berbeda di anisometropia pada pasien dengan com- 
bilateral 
kemudian tahun. Sebuah studi terbaru menunjukkan bahwa dikupas untuk 
cataract32 unilateral dan anisome- 
prevalensi gangguan dari teropong visi tropia ditemukan secara signifikan terkait 
tidak meningkat secara signifikan di usia yang lebih tua dengan usia bahkan 
setelah pengendalian untukPres- 
groups.37 encedari cataract.36 
Singkatnya, prevalensi dan magni- Gambar 3 menggambarkanyang berkaitan 
dengan usia 
tudedari anisometropia bervariasi sepanjang hidup. perubahan besarnya dan 
prevalensi 
Studi populasi klinis besar atas anisometropia untuk kohort besarrabun 
berbagaikelompok usia dan mata pelajaran bias (calon bedah refraktif), 
kesalahan telah menunjukkan bahwa sementara anisometropia tidak termasuk 
kasus patologi, seperti unilateral 
adalah terkait dengan ametropia bola dan katarak eral (berdasarkan data dari 
Linke 
Silindris, juga secara independen associ- dan colleagues31). Meskipun studi ini 
memilikilebih sedikit 
ateddengan usia. Penurunan cepat dalam anisome- muda (kurang dari 20 tahun) 
dantua 
tropiadiamati selama tahun-tahun awal (lebih dari 60 tahun) mata pelajaran 
dibandingkan 
kehidupan, diikuti oleh peningkatan sejak kecil untuk analisis Qin dan 
colleagues9 
sampai dewasa. Anisometropia biasanya (Gambar 1), data menampilkan 
peningkatan 
yang stabil di masa dewasa tetapi meningkat signifi- 
 
karakteristik okuler dari anisometropia Vincent, Collins, Baca dan Carney 
30 
aenro 
aenro 
snelro 
snelro 
Lebih rabun 
EPR) 

25 
croiretn A 
croirets P 
iretn A d 
(o 
iretso P 
Kurang rabun 
htgn 
20 
1. ketebalan kornea Central 2. anterior kedalaman ruang ertsla 
15 
3. ketebalan Lens 4. kedalaman ruang Vitreous 
NGI S 
10 


Gambar  4.  Optical  koherensi  rendah  reflectometry  keluaran  A-scan  untuk  lebih  rabun  (  merah,  aksial  panjang  24,70 
mm,  refraksi  -2,75  /  -1,75  ×  5)  dan  kurang  rabun  (biru,  aksial  panjang  23,11  mm,  refraksi  pl  /  -0,25  ×  5)  mata  dari 
anisometrope  non-amblyopic  khas.  studi  biometrik  mata  anisometropic telah menunjukkan tingkat tinggi simetri antara 
dua  mata  untuk  langkah-langkah  struktur  segmen  anterior. dalam contoh khusus ini, tengah ketebalan kornea (1) (lebih 
501  m,  kurang  501  m),  anterior  kedalaman  ruang  (2)  (lebih  3,12  mm,  kurang  2,98  mm)  dan  ketebalan lensa (3) (lebih 3 
0,53  mm,  kurang  3,47  mm).  Dasar  biometrik  dari  anisomyopia aksial adalah perbedaan interocular di kedalaman ruang 
vitreous (4) (lebih 17,55 mm, kurang 16,15 mm). RPE: retina epitel pigmen. 
mungkin  memainkan  peran  dalam  etiologi  sedang  sampai  anisometropia  rabun  berat  (yang  sepatutnya  ximately  8,00  untuk 
10.00D).  Bayangan  cermin  (Sibling  1  refraksi:  RL  ∞  Sibling  2  refraksi:  LR)  atau  langsung  simetris  (Sibling  1  refraksi:  RL  ∞ 
Sibling  2  refraksi:  RL)  anisometropia  parah  telah  diamati  di  kedua  twins45-47  dan  non-kembar  saudara kandung. 48,49 tingkat 
tinggi  seperti  anisometropia  yang  Cally  typi-  karena  pembangunan  mata  abnormal  pada  mata  yang  terkena,  seperti  saraf  optik 
plasia  hipo,  45  makula  hypoplasia47  atau  coloboma48  atau  berhubungan  dengan  patologi  yang  signifikan  seperti  atrophy.50 
chorioretinal 
Sebaliknya,  Angi  dan  colleagues51  mengamati  dua  kasus  anisometropia  sumbang  pada  kembar  monozigot  muda  (yaitu, 
anisometropia  di  satu  kembar  saja).  Metries  Asym-  di  Silindris  bias  juga  diamati  di  setiap  terpengaruh  (anisometropic) kembar 
dengan  tingkat  yang  lebih  tinggi Silindris di mata lebih rabun. Para penulis berhipotesis bahwa perampasan visual yang asimetris 
akibat  astigmatisme  tidak  dikoreksi  selama  tahun-tahun  prasekolah  langsung  influ-  pengembangan  ences  dari  anisomyopia. 
Dalam  sepasang  kembar  monozigot  yang  lebih  tua  (berusia  62  tahun),  Dirani  dan  colleagues52also  diamati  signifi-  tidak  bisa 
sumbang anisometropia (8.00 D dari anisomyopia di satu kembar saja). Mengingat 
© 2014 Penulis Clinical and Experimental Optometry 97,4 Juli 2014 Optometry © 2014 Asosiasi dokter mata Clinical and 
Experimental Australia 295 

1 2 3 4 
5 10 15 20 25 
Axial panjang (mm) 
genetik  identik  dan  tidak  adanya  patologi  okular  atau  signifikan  tism  astigma-,  asimetri  bias antara kembar mungkin akibat dari 
faktor lingkungan, seperti trauma selama perkembangan embrio, cedera saat kelahiran atau penetrance.53 genetik plete incom- 
Sementara  bukti  yang  bertentangan  ada  dari  studi  keluarga  mengenai  warisan  anisometropia  rabun  (  yang  berpotensi 
menunjukkan  modus  multifaktorial  dari  Ance  inherit-),  sedang  sampai  anisometropia  hadir  parah  dari  usia  muda  tampaknya 
menjadi  hasil  dari  pengaruh  genetik  daripada  lingkungan.  Kasus  seperti  anisometropia  biasanya  berhubungan  dengan  kelainan 
struktural  unilateral  menyebabkan  berlebihan  elongasi  aksial;  Namun,  dengan  tidak  adanya  patologi  okular,  ada  kemungkinan 
bahwa  anisomyopia  adalah  hasil  dari  kombinasi  faktor  genetik  dan  lingkungan,  seperti  yang  abnormal  (asimetris)  pengalaman 
visual. 
Tidak ada studi telah secara khusus meneliti peran genetika dalam pengembangan tingkat yang lebih rendah dari anisometropia 
rabun,  yang  lebih  umum  ditemui;  Namun,  kemajuan  terbaru  dalam  pengujian  genetik,  yang  telah  memungkinkan  identifikasi 
lokus genetik Rous nume- terkait dengan errors54-57 bias rabun bisa memberikanbaru 
wawasanke dalam kontribusi genetik untuk anisometropic kesalahan bias. 
KARAKTERISTIK OCULAR OF anisometropia 
Pada  bagian  ini,  kita  membahas  perbedaan  anatomi  antara  sesama  mata  anisometropes  dan  berspekulasi  bagaimana  perbedaan 
tersebut  dapat  terjadi  atau  berpotensi  mempengaruhi  pengembangan  dan  perkembangan  anisomyopia.  Sejumlah  studi  telah 
meneliti  berbagai  elemen  struktural  mata  anisometropic  (Tabel  S1).  Secara singkat, dasar biometrik utama anisometropia adalah 
perbedaan antara mata panjang aksial, khususnya kedalaman ruang vitreous (Gambar 4). 
Tampaknya  ada  kontribusi  minimal  dari segmen anterior, termasuk ketebalan kornea, kedalaman ruang anterior atau ketebalan 
lensa  kristal  (kecuali  dalam  anisomyopia  lenticular  terkait  dengan  cataract66),  menunjukkan  anisometropia  yang  terutama 
asimetri  interocular  dalam  besarnya  atau  tingkat  pertumbuhan  mata  posterior.  Sejumlah  penelitian  telah  melaporkan  pada 
karakteristik  mata  di  amblyopia  anisometropic  dengan  asimetri  dalam  kesalahan  bias  juga  menjadi  terutama  aksial  dalam 
nature13  (tetapi  juga  dapat  melibatkan  perbedaan  interocular  di  ture70  yang  cornea67-69  atau  kristal  lensa  struc-)  dan  telah 
dikaitkan  dengan  tions  altera-  di  kepala  saraf  optik  morphology.71,72  Beberapa  perdebatan  masih  ada,  apakah  lebih 
tinggi-memesan penyimpangan berperan dalam asal-usulanisometropia.73-77 amblyopic 
pERTIMBANGAN mECHANICALiN ANISOMYOPIA 
Jika  faktor  mekanik  berkontribusi  anisometropic  pertumbuhan  mata,  maka  ences  berbeda-  dapat  terlihat  dalam  sifat-sifat 
biomekanik  antara  sesama  mata,  seperti  ketebalan  kornea,  hysteresis  kornea  atau  tekanan  intraokular  (TIO).  Bagian  ini 
merangkum  literatur  tentang  simetri  mata  antara-  faktor  biomekanik  di  anisometropia  dan  membahas  potensi  jalur  mekanis 
didorong dari asimetris aksial elongasi. 
Kornea Sebuah studi awal memeriksa simetri antara mata ketebalan kornea dengan pachometer digital elektronik 
mengungkapkan bahwa kedua epitel dan stromakornea 
 
karakteristik Oculardari anisometropia Vincent, Collins, Baca dan Carney 
ketebalan sama antara kedua 
Sebagai pengukuran TIO mungkin 
antara sesama mata mata rabun 
parah hyperopic dan anisome- rabun 
dipengaruhi oleh variabel seperti usia,darah 
anisometropes(sekitar 1-2 
mmHg), kiasan (berarti mutlak anisometropia 3,33 
tekanan, thickness85 kornea dan diurnal 
di, studi cross-sectional umum 
± 3,15 D; 1 sampai 2 um interoculartebal-kornea, 
variasi 86 banyak penelitian haruscom- 
anisomyopestidak mendukung 
perbedaan ness terkait IOP) 0,78 temuan ini telah 
dikupas mata lebih dan kurang rabun 
mekanismeekspansi aksial 
asimetris dikonfirmasi menggunakan lebihteknologi baru 
anisometropesuntuk mengendalikan 
individudunia. Sifat 
cross-sectional (tomografi koherensi optik, Oktober) di 
variasi, yang dapat mengacaukan hasil dalam 
studi di atas daun membuka 
tingkat parah possibil- dari anisomyopia (sekitar 
penelitian kohort banding menyelidiki 
ity yang baik jangka pendek 
(misalnya, 10 D, dengan kurang dari 3,0 um interocular dif- 
hubungan antara IOP danyang berbeda 
variasi diurnalatau IOP 
spikes93) atau ference lebih panjang ketebalan kornea pusat) 0,79 
kesalahan bias (misalnya, emmetropes 
fluktuasi jangka di IOP dapat 
bervariasi dalam Sementara ketebalan kornea muncul sangat 
dibandingkan dengan myopes usia yang sama) 
mata anisometropic. Meskipun 
tidak ada penelitian simetris antara sesama mata ani- 
(Tabel S2). 
secara khusus telah melaporkan 
perubahan sometropes, Xu dan colleagues79 mengamati 
Jika sebuah hubungan memang ada antara IOP 
IOP dari waktu ke waktu 
selama pengembangan pengurangan kecil tapi signifikan secara statistik 
dan elongasi aksial, salah satu mungkin berharap bahwa 
anisometropia, studi 
longitudinal dari kornea opment hysteresis (1.00 mmHg) di lebih 
IOP akan lebih tinggi dimata lebih rabun 
ngunanmiopia pada anak-anak 
telah gagal untuk mata rabun dari anisometropes berat (berarti 
dari anisometropes, setidaknya selama opment 
menemukan hubungan antara 
IOP dan aksial anisometropia lebih besar dari 10 D),suggest- 
ngunanatau perkembangan miopia; Namun, 
growth.94,95 ing sedikit 
perubahan dalammechani- kornea 
studi cross-sectionalmenggunakankedua sifat kal kontak. Histeresis juga 
berkurang dalam kondisi yang berhubungan dengan penipisan kornea seperti keratoconus maju atau mengikuti kornea laser yang 
bias surgery.80 Shen dan colleagues81also mengamati tingkat signifikan lebih rendah dari hysteresis kornea di myopes tinggi 
(bola setara refraksi lebih besar dari -9,00 D) dibandingkan dengan kelompok kontrol dari emmetropes dan myopes rendah 
dengan ketebalan kornea yang sama dan menyarankan bahwa struktur kolagen kornea dapat diubah dengan tingkat yang lebih 
tinggi miopia, mirip dengan perubahan komposisi scleral dan mekanika biome- diamati dalam myopia.82,83 tinggi Sebaliknya, di 
tingkat yang lebih rendah of myopic aniso- 
Clinical and Experimental Optometry 97.4 July 2014 © 2014 The Authors 296 Clinical and Experimental Optometry © 2014 
Optometrists Association Australia and non-contact applanation techniques have shown no significant differences in IOP 
between the fellow eyes of low to moderate level anisometropes (approximately 2.00 to 5.00 D).62,87,89–91 These studies 
suggest that axial elongation due to a simple IOP- induced expansion of the globe is unlikely to be involved in the development 
of axial anisomyopia. However, studies examining the symmetry of IOP in moderate to severe anisometropes (on average 
approximately 5.00 to 10.00 D anisomyopia)61,88 observed a slightly higher IOP (one to two mmHg) in the more myopic eye, 
which approached79 or reached61,88 statistical significance. An 
Mechanical effects of near work Since several epidemiological studies4,96–98 have reported an association between near work 
and myopia, it has been suggested that mechanical forces generated during near work such as those produced during conver- 
gence or ciliary muscle contraction could promote axial elongation. When near work is performed the eyes typically converge 
and accommodate to maintain clear, single binocular vision of near targets. Here, we consider potential mechanical pathways 
associated with convergence and accommo- dation in asymmetric myopia development. 
metropia (around 2.00 D) corneal biome- chanics appear to be unaltered between the 
isolated case report of unilateral chronic angle closure in a young female described a 
Convergence fellow eyes.62 
These studies suggest that 
marked myopic shift in the affected eye 
Forces exerted by the 
extraocular muscles changes in corneal structure or biomechan- 
(8.00D change in spherical equivalent 
during convergence are thought 
to have the ics appear to be limited to high levels of 
refraction over 11 years); however, the asym- 
potential to lead to changes in 
axial length.99 myopic anisometropia. 
metric change in refraction was primarily 
Bayramlar, Cekic and Hepson100 concluded 

Intraocular pressure 
due to altered corneal curvature (5.45 D 
that transient axial elongation associated interocular difference in mean corneal 
with near work is a result of 
convergence Another potential mechanical factor in 
power) and not axial elongation (0.4 mm 
rather than accommodation 
after observing myopia development is IOP. The role of IOP 
interocular difference).92 
significant vitreous chamber 
elongation in the development of myopia has been 
It may also be possible that anisometropia 
measured with ultrasonic 
biometry in young studied extensively in both animals and 
could develop through an IOP-dependent 
subjects following near fixation 
with and humans; however, the findings have been 
mechanism in the presence of symmetrical 
without cycloplegia. However, 
Read and col- equivocal. As myopia is primarily axial in 
IOP, if between-eye differences exist in 
leagues101 reported that axial 
length meas- nature, early theories proposed that raised 
scleral biomechanics. Lee and Edwards90cal- 
ured with partial coherence 
interferometry IOP was responsible for excessive inflation 
culated that the stress exerted upon the 
appears largely unchanged in 
adults both or elongation of the globe. Van Alphen84 
sclera was significantly higher in the more 
during and following a period 
of sustained demonstrated that increasing IOP in both 
myopic eyes of anisometropes compared to 
convergence. enucleated cat and 
human eyes resulted in 
the fellow eyes. The authors90 proposed that 
Recently, Ghosh and 
colleagues102 exam- significant axial elongation of the globe 
an interocular difference in scleral thickness 
ined the influence of gaze 
direction (nine without radial expansion. The author con- 
due to different rates of collagen synthesis 
different directions were 
examined) upon cluded that the tone of the ciliary muscle 
might result in asymmetric axial elonga- 
axial length during distance 
fixation and mediates the tension within the choroid and 
tion and the development of anisomyopia 
also found no significant change 
in axial subsequently the sclera, which in turn influ- 
despite symmetrical IOP. 
length with nasal gaze (that is, 
conver- ences expansion of the globe and leads to an 
While small, clinically insignificant dif- 
gence); however, a significant 
increase in increase in axial length. 
ferences in IOP have been detected 
axial length (relative to primary gaze) was 
 
Ocular characteristics of anisometropia Vincent, Collins, Read and Carney 
observed during inferior and infero-nasal 
stimuli during monocular fixation.108 While 
myopic than the injured eye for 
all trauma gaze directions. Importantly, axial elonga- 
the more myopic eye displayed a slightly 
patients and 2.76 ± 2.47 D for 
the subset of tion was only evident when the eye was 
greater change in axial length during 
'traumatic' anisometropes. A 
strong correla- turned to maintain fixation, rather than a 
accommodation compared to the less 
tion was observed between the 
extent of head turn, suggesting that the changes in 
myopic eyes for both the 2.50 D (three μm 
anterior chamber angle 
recession (that is, eye length were due to extraocular muscle 
greater) and 5.00D stimuli (four μm 
zero to 360 degrees) and the 
between-eye forces. Interocular differences in the size or 
greater), these interocular differences did 
asymmetry in refraction (r = 
0.60, p < 0.01) insertion points of the extraocular muscles, 
not reach statistical significance. Over time 
and axial length (r = -0.57, p < 
0.01). Follow- in particular those associated with conver- 
or for larger accommodative demands, it 
ing trauma, the majority of 
patients also dis- gence and downward gaze (that is, the 
may be possible that an asymmetric accom- 
played an asymmetry in 
accommodation. superior oblique and inferior rectus) or 
modative response could lead to transient 
Given that IOP was not 
significantly different asymmetric convergence in downward gaze 
axial length elongation of different magni- 
between the two eyes, the 
authors suggested (one eye converging more than the fellow 
tudes between the two eyes, potentially 
that 'traumatic cycloplegia' 
halted myopic eye) as a result of an abnormal head turn 
leading to axial anisometropia. 
progression in the injured eye 
compared could result in different forces transmitted 
If ciliary body forces or choroidal tension 
to the fellow eye, similar to the 
effect of between fellow eyes and an asymmetry in 
generated during accommodation cause 
atropine115 or pirenzepine.116 
This study transient axial length changes during near 
transient axial length changes following 
adds some weight to the theory 
that the work. 
near work and are related to longer-term 
ciliary body (or accommodation) 
is involved It has also been suggested that anisome- 
changes in ocular growth, then ciliary 
in asymmetric axial elongation; 
however, tropia may be related to facial structure, 
body (or ciliary muscle) thickness might be 
whether this is an optical or 
mechanical specifically the position of the orbits. Lateral 
larger in myopes compared to emmetro- 
mechanism (or a combination 
of the two) displacement of one orbit would induce an 
pes or larger in the more myopic eye of 
remains unclear. asymmetric 
convergence demand between 
anisomyopes relative to the fellow eye. This the two eyes, potentially causing 
greater 
finding has been reported in children mechanical stress on the eye further from 
(emmetropes compared to myopes)109 and 
OPTICAL FACTORS IN 
ANISOMYOPIA the vertical midline. Martinez103 noted that 
in cases of unilateral high myopia (mean anisometropes tended to have asymme- 
anisometropia 8.00 D);110 however, in a tric naso-pupillary distances; however, 
the 
recent study of anisometropes (1.00 D or interocular difference did not correlate 
with 
more of spherical anisometropia), ciliary the magnitude or sign of the 
between-eye 
muscle size was largely symmetrical between difference in refractive error. If 
convergent 
the two eyes (although slightly thinner in the muscle forces do play a role in the 
develop- 
more myopic eye).111 ment of anisomyopia, one might expect 
Factors other than ciliary body size may that in cases of unilateral esotropia, 
the 
influence the amount of force transmitted squinting eye would typically be 
myopic rela- 
to the posterior eye during accommoda- tive to the fixating eye; however, studies 
tion, such as the structural and biome- of strabismic children have found the 
oppo- 
chanical properties of the choroid and site to be true (the fixing eye becomes 
more 
sclera. Significantly thinner choroids have myopic relative to the squinting eye 
over 
been observed in myopic children com- time).13–15 
pared to emmetropes112 and in the more 

Accommodation 
myopic eyes of anisomyopic adults,64 which could promote unequal axial elongation (or Ciliary muscle contraction is associated 
with 
at least result in asymmetric biomechanical 
© 2014 The Authors Clinical and Experimental Optometry 97.4 July 2014 Clinical and Experimental Optometry © 2014 
Optometrists Association Australia 297 Numerous studies with animal models have shown that unilateral manipulation of visual 
input such as hyperopic defocus (via a spec- tacle lens) or form deprivation (via lid suture or diffuser) results in compensatory 
ocular growth (choroidal thinning and axial elon- gation to adjust the positio n of the retina) to achieve emmetropia in the 
experimentally treated eye.1,117,118This results in the develop- ment of anisometropia (or unilateral myopia). If anisomyopic 
ocular growth in humans is influenced by an interocular difference in visual experience, then asym- metries in optical properties 
(for example, corneal or total ocular higher-order aberra- tions) may be evident between the two eyes of anisometropes. 
small but significant increases in the eye's axial length. Various studies have docu- mented transient changes in axial length 
stress at the posterior globe) in the presence of symmetrical ciliary body structure and function. On the other hand, it has been 

Asymmetric visual experience and ocular growth using highly precise non-contact instru- 
suggested that a thicker ciliary muscle may 
Deprivation of form vision 
during infancy ments during104–106 or following107 periods 
restrict equatorial ocular growth (producing 
results in the most severe form 
of amblyopia. of accommodation; however, the magni- 
greater axial expansion) or result in poor 
Retinal image degradation due 
to ptosis,119 tude of axial elongation between myopic 
contractility leading to a reduced accommo- 
corneal scarring,120 congenital 
cataract121 or and emmetropic cohorts varies between 
dative response, both of which could initiate 
vitreous haemorrhage122 
typically leads to studies. 
axial elongation and the development of 
excessive axial elongation (form 
deprivation In two separate studies of anisomyopes, 
myopia.113 
myopia) and dense amblyopia. 
The magni- no significant difference was observed 
In a retrospective case series examining 
tude of myopia and thus 
anisometropia is between the two eyes with respect to tran- 
long-term complications of unilateral trau- 
related to the degree and age at 
the onset of sient changes in axial length following a 
matic hyphaema, Lin and Lue114 observed 
image degradation. 10-minute 
binocular reading task (2.50 D 
significant anisometropia (1.00 D or more) 
Similarly, studies have 
shown that deliber- accommodative demand) or during an 
in 44 per cent of their patients. On average, 
ate unilateral manipulation of 
the retinal accommodative task at 2.50 and 5.00D 
the unaffected eye was 1.23 ± 2.13 D more 
image in humans can alter axial elongation 
 
Ocular characteristics of anisometropia Vincent, Collins, Read and Carney 
between the two eyes. Cheung, Cho and 
was attributed to the constant peripheral 
ence in crystalline lens power 
(mean 4.25 ± Fan26 observed asymmetric ocular growth 
myopic defocus induced during all levels of 
0.48 D) and one as a result of an 
asymmetry in an 11-year-old myopic anisometrope 
accommodation. 
in corneal power (1.7D). Using 
more undergoing unilateral orthokeratological 
Recently, Read, Collins and Sander123 
sophisticated techniques 
(ultrasonography treatment in the more myopic eye. Over a 
examined the short-term change in axial 
and corneal topography), Kuo, 
Shen and two-year treatment period, the less myopic 
length and choroidal thickness in young 
Shen61 examined a larger 
cohort of older eye grew 0.34 mm (an increase in myopia 
adults following one hour of imposed 
antimetropes of similar 
magnitude (19 to 30 of approximately 1.00D) compared to 
monocular defocus. Using an optical 
years old, mean spherical 
equivalent refrac- the treated more myopic eye, which grew 
biometer, significant changes in axial length 
tion antimetropia 5.28 D) and 
found no sig- only 0.13 mm, suggesting that the corneal 
were observed, which corresponded to 
nificant differences between the 
two eyes for reshaping slowed myopic progression in the 
the direction of the induced defocus. 
anterior eye biometrics (corneal 
thickness treated eye. Similarly, in a contralateral 
Lens-induced hyperopic defocus (-3.00 D) 
and anterior chamber depth) but 
a signifi- design clinical trial of 26 children wearing 
and form deprivation (diffuser) both 
cant difference in axial lengths 
(mean an orthokeratology lens in one eye and a 
resulted in choroidal thinning and axial 
2.00 mm, 95 per cent CI 1.7 to 
2.5 mm) and conventional rigid gas-permeable lens in 
elongation, while lens-induced myopic 
concluded that the biometric 
basis of the fellow eye, Swarbrick and colleagues28 
defocus (+3.00 D) resulted in a thickening 
antimetropia is the interocular 
asymmetry in observed a significant interocular difference 
of the choroid and a decrease in axial 
axial length. in both ocular 
growth and refraction after 
length (only in the eye with the imposed 
Antimetropic ocular growth 
in the one year; the eye wearing the conventional 
defocus). This study suggests that the adult 
absence of amblyopia or 
pathology is an rigid gas-permeable lens was on average 0.09 
human visual system is capable of detecting 
intriguing refractive anomaly, 
perhaps even ± 0.17 mm longer and 0.57 ± 0.66 D more 
the direction of defocus and adjusting 
more so than anisomyopia, as 
the two eyes myopic than the fellow eye wearing the 
the position of the retina to minimise the 
within the one visual system 
have not only orthokeratology lens. 
imposed blur by altering the thickness 
developed markedly different 
refractive Phillips27 followed 13 11-year-old myopes 
of the choroid. Previous studies with young 
errors but in opposite directions 
from fitted with monovision spectacles (2.00 D or 
animals have shown similar short-term 
emmetropia. While the existing 
literature more) over a period of 30 months. Using 
changes in choroidal thickness occurring 
regarding antimetropia is 
limited (poten- dynamic retinoscopy, the author observed 
within minutes in response to defocus that 
tially due to its low prevalence, 
up to 0.1 per that all children accommodated to read 
precedes longer-term changes in ocular 
cent125,126), future research 
into antime- using the distance-corrected dominant 
growth. 
tropic ocular growth may 
provide valuable eye rather than the near-corrected eye. As 
These studies demonstrate that deliberate 
insights into retinal 
image-mediated asym- a result, the near-corrected eye received 
manipulation of the focal properties of 
metric ocular growth and the 
development myopic defocus for all levels of accommoda- 
the retinal image in young subjects has the 
of myopia. tion. Myopic 
progression was significantly 
potential to influence ocular growth and slower in the near-corrected eye 
compared to the fellow distance-corrected eye. All sub- jects developed anisometropia due to the interocular symmetry in 
vitreous chamber growth (interocular difference of 0.13 mm per year). When these subjects returned to conventional distance 
spectacle wear, the anisometropia reduced to baseline levels within 18 months. 
In  a  larger  study,  Anstice  and  Phillips25  examined  the  change  in  refraction  and  axial  length  in  40  young  non-anisometropic 
myopes  (11  to  14  years  old)  over  a  period  of  20  months,  while  wearing  a  different  design  of  soft  contact  lens  in  each  eye.  A 
single  vision  lens  was  worn  in  one eye and a multifocal lens (simultaneous vision— distance centre) was worn in the fellow eye. 
The mean increase in myopic progression (spherical equivalent and axial length) over 10 months was significantly reduced in the 
Clinical and Experimental Optometry 97.4 July 2014 © 2014 The Authors 298 Clinical and Experimental Optometry © 2014 
Optometrists Association Australia lead to changes in the refractive state of the eye. It follows that interocular differences in 
retinal focus may underlie anisomyopic ocular growth. 
A  recent  case  report  of  non-amblyopic progressive adult antimetropia124 (anisome- tropia in which one eye is myopic and the 
fellow  eye  is  hyperopic)  also  adds  weight  to  the  above  evidence  for  a  local  mechanism  of  ocular  growth  regulation  in  humans 
with  relatively  independent  control  in  each  eye.  In  this  particular  case,  the  increase in antimetropia was due to a combination of 
unilateral axial elongation in one eye and the gradual manifestation of latent hypero- pia in the fellow eye. 
Sorsby,  Leary  and Richards8 reported on the ocular characteristics of six antimetropic children (aged seven to 16 years). All of 
the children exhibited low hyperopia in one eye (1.00 to 2.00 D) and a moderate degree of 
Pupil size When considering the optical properties or image quality of the eye, an important factor to take into account is pupil 
size. Asymmetry in pupil size (anisocoria) or an interocular difference in the quality and size of the fundus reflex is often used as 
a screening technique for interocular differences in refractive errors or ocular misalignment in children;127 however, in a cohort 
of anisomyopic subjects,108 pupil dimensions were measured using digital photography and customised software and were found 
to be highly symmetrical between the more and less myopic eyes. Although the difference in pupil diameter between the more 
and less myopic eyes approached significance (more 3.53 mm and less 3.48 mm, p = 0.09) there was no correlation between the 
degree of physiological anisocoria and anisometropia. 
eyes wearing the multifocal lens (-0.44 ± 0.33 D and 0.11 ± 0.09 mm) compared to 
myopia in the fellow eye (mean absolute anitmetropia 4.93 ± 1.33 D). The origin of 
Corneal power the single vision 
lens (-0.69±0.38 D and 0.22 
the antimetropia varied substantially; three 
It is generally accepted that in 
an individual ± 0.10 mm). The reduction in myopia pro- 
cases of axial length asymmetry (mean 2.44± 
with no eyelid abnormalities, 
the two eyes gression associated with multifocal lens wear 
0.13 mm), two due to an interocular differ- 
display some degree of corneal symmetry 
 
Ocular characteristics of anisometropia Vincent, Collins, Read and Carney 
(direct or mirror symmetry) with respect to 
compared to the less myopic eye over a 
be a suppression mechanism 
involved in the axes of astigmatism.128,129 A high degree 
6.0 mm analysis diameter. This finding lends 
eliminating the image from the 
eye with the of symmetry exists between two eyes for 
some support to the notion of an astigmatic 
higher accommodation demand. 
Con- corneal power in both isometropic130 and 
image-mediated mechanism associated with 
versely, Troilo, Totonelly and 
Harb149 sug- anisometropic eyes measured with kerato- 
the development of anisomyopia. 
gested that the binocular 
accommodative metry (that is, the central cornea)58–60,63 
It could also be argued that altered 
response in marmosets reared 
with imposed (TableS3). Although there is significant 
corneal shape may be a result of vision- 
anisometropic defocus was an 
average of the variability in corneal power in emmetropia 
dependent ocular growth rather than a 
two different demands rather 
than an aniso- and myopia,131 several studies have shown 
cause of development of myopia. Kee and 
accommodative mechanism or a 
response greater corneal power132–134and a less prolate 
Deng141 reported significant changes in 
driven by the lower of the two 
demands. corneal shape135 in myopes compared to 
corneal astigmatism following various visual 
Thus, interocular differences 
in the emmetropes. 
manipulations in young chicks, including 
accommodative demand (or 
response) Using videokeratoscopy, Vincent and col- 
form deprivation, hyperopic and myopic 
could provide a stimulus to 
asymmetric leagues62 observed small interocular differ- 
defocus. Small corneal differences observed 
ocular growth. Charman150 
postulated that ences between the flat and steep corneal 
between the eyes of anisometropic subjects 
the simple act of reading across 
a page meridians of two the eyes in a cohort of 
may be attributed to axial elongation (rather 
induces an unequal 
accommodative de- anisomyopes. The more myopic eyes exhib- 
than causing it) and subsequent alterations 
mand between the eyes (when 
not viewing ited more prolate corneas, in contrast to 
in scleral structure, which could impact 
directly along the midline), 
which increases previous studies, which have shown that 
upon the cornea at the limbus. 
as the working distance to the 
text is corneas tend to become less prolate with 
Together, these studies suggest that altera- 
decreased (or interpupillary 
distance increasing levels of myopia.136,137 The mean 
tions in corneal optics could potentially 
increases). If the eyes remain 
relatively refractive corneal power (average of the 
play a role in the development of myopia 
centred and stationary over the 
reading task, steep and flat corneal meridians) was also 
and anisometropia. Given the association 
the defocus experienced in one 
eye will also significantly greater (steeper) in the more 
between the progression of astigmatism and 
be experienced in the fellow 
eye in the oppo- myopic eyes, which is in contrast with previ- 
anisometropia during childhood and the 
site direction of gaze and each 
eye would ous biometric studies of anisometropic 
observation of higher levels of astigmatism 
receive the same amount of blur 
(averaged subjects8,58,61 and may be due to the more 
in the more myopic eye of anisometropic 
over time). When a head tilt or 
turn is accurate method used to assess the corneal 
twins, the relationship between astigmatism, 
adopted or any position in 
which the reading shape. 
retinal image quality and asymmetric ocular 
material is not centred in front of 
the eyes, Gwiazda and colleagues138 followed a 
growth requires further research. 
the accommodative demand for 
each eye cohort of children from the age of one year and observed that infantile against-the-rule 

Accommodation 
will again change. At a working distance of 10 cm, when reading on an A4 page, the astigmatism was associated with increased 
The accuracy of the accommodative 
interocular difference in 
accommodative myopia and astigmatism during childhood 
response and optical effects of accommoda- 
demand at the end of a line of 
text may reach (school age) and hypothesised that uncor- 
tion in various refractive error groups has 
up to 2.00 D.150 Therefore, 
viewing reading rected astigmatic errors during the emme- 
been investigated in detail.142 Typically a 
material at a short working 
distance (with a tropisation period may play a role in the 
greater lag of accommodation (under 
head tilt) may lead to hyperopic 
defocus development of myopia. 
accommodation during near work) has 
in one eye, assuming a consensual 
accommo- Buehren and colleagues139 also postulated 
been reported in myopes compared to 
dative response to the lower of 
the two that altered mid-peripheral corneal shape 
emmetropes.143–146It has been suggested that 
de mands. and optics due to lid 
pressure during 
hyperopic defocus associated with a lag of 
In a qualitative study, 
Childress, Childress reading might be a trigger for refractive 
accommodation may provide a cue to ocular 
and Conklin151 examined 
refractive error error development. Temporary corneal dis- 
growth and the development of myopia. 
types in a range of occupations 
and consid- tortions (changes in corneal astigmatism 
Numerous studies have explored the plau- 
ered the potential influence of 
specific or higher-order aberrations) resulting in 
sibility of aniso-accommodation in isome- 
work-related visual tasks (with 
respect to the hyperopic defocus or retinal image degra- 
tropic individuals. Koh and Charman147 
vertical midline) upon the 
development dation may lead to compensatory axial 
reported that during binocular viewing, 
of anisometropia. The authors 
questioned elongation. A similar mechanism could be 
when the eyes are presented with stimuli of 
participants regarding their 
typical visual proposed in the development of myopic ani- 
unequal accommodative demand, the eye 
demands, in particular the 
position of sometropia. A greater amount of peripheral 
which requires the least accommodative 
reading material and work 
instruments. In corneal flattening in one eye could result in 
effort to maintain clear focus of the target 
general, those who reported a 
habitual peripheral hyperopic defocus, triggering 
will control the accommodative response in 
reading posture centred on the 
vertical asymmetric axial elongation. 
both eyes. Marran and Schor148also observed 
midline displayed symmetrical 
refractive Vincent and colleagues140 investigated 
that when presented with unequal accom- 
errors (both spherical and 
astigmatic), while the change in corneal optics following a 
modative targets, subjects demonstrated 
individuals who placed reading 
material short reading task in young non-amblyopic 
aniso-accommodation to approximately 
to one side (due to office 
environment anisomyopes. The more myopic eye dis- 
one quarter of the interocular difference 
or job requirements) were more 
often played a small but significantly greater 
in demands. At a stimulus difference of 
anisometropic with the eye 
closer to the increase in against-the-rule astigmatism 
approximately 3.00D, there appeared to 
visual task usually the more myopic eye. 
© 2014 The Authors Clinical and Experimental Optometry 97.4 July 2014 Clinical and Experimental Optometry © 2014 
Optometrists Association Australia 299 
 
Ocular characteristics of anisometropia Vincent, Collins, Read and Carney 
In a similar study, Harris152 investigated 
Recently, Lin and colleagues65 investi- 
pared the higher-order 
aberration profiles the association between the specific visual 
gated the magnitude of near work-induced 
between the two eyes of 
anisometropes, with demands of different musicians in a sym- 
transient myopia (NITM, a slight myopic 
conflicting results (Table S5). 
phony orchestra (that is, the effect of instru- 
shift in refractive error following near work) ment type on head tilt or turn and 
seat position relative to the conductor and sheet music) and their refractive errors. A number of musicians exhibited myopic and 
astig- matic anisometropia. Typically, the eye posi- tioned closer to the visual task at near displayed greater spherical myopia and 
less astigmatism compared to the fellow eye. The findings from these studies suggest a poten- tial role for asymmetric viewing 
during near work in the development of aniso- myopia; however, the underlying mecha- nism (for example, unequal 
accommodative demands, eyelid forces or asymmetric con- vergence) remains unknown. 
A  limited  number  of  studies  have  directly  examined  the  accommodative  response  in  myopic  anisometropes  (TableS4).  In an 
early  study,  Hosaka,  Matsudo  and  Chuang153  measured  the  monocular  amplitude  of  accommodation in a large cohort of aniso- 
metropes  (interocular  differences  of  1.00  D  or more and including some amblyopes) and a control group of isometropes. Ninety- 
seven  per  cent  of isometropes had an interocular difference in amplitude of accommodation of less than 2.00 D, com- pared to 69 
per  cent  in  the  anisometropic  cohort.  Of  the  anisometropic  subjects  with  an  interocular  difference  in  accommoda-  tion  greater 
than  0.50  D,  the  amplitude  of  accommodation  was  reduced  in  the  more  myopic  eye 70 per cent of the time; however, there was 
no significant correlation between the interocular difference in accommoda- tive amplitude and the magnitude of aniso- 
Clinical and Experimental Optometry 97.4 July 2014 © 2014 The Authors 300 Clinical and Experimental Optometry © 2014 
Optometrists Association Australia in the more and less myopic eyes of young anisomyopes (approximately 2.00 D aniso- 
metropia) during binocular viewing. On average, the more myopic eyes displayed a slightly greater level of transient myopia and 
a longer decay period to baseline refrac- tion, which reached statistical significance. A moderate correlation was also observed 
between the interocular difference in NITM and the magnitude of anisometropia (r = 0.31, p < 0.05). The authors suggested that 
interocular differences in ciliary body thick- ness110 may be related to the observed differ- ences in NITM between the fellow 
eyes; how- ever, for this relatively low level of aniso- myopia, ciliary body biometrics are similar between the more and less 
myopic eyes.111 
To  our  knowledge,  these  are  the  only  studies  to  directly  examine  the  interocular  symmetry  of  accommodation  in  aniso- 
myopia.  This  may  be  due  to  previous  research,  which  has  shown  a  symmetric  accommodative  response  between  the  eyes  of 
normal  subjects during both monocular155 and binocular156 viewing. It has been sug- gested that the dominant eye (traditionally 
the  preferred  eye  for  distant  sighting)  may  exhibit  different  accommodative  responses  to  the  fellow  non-dominant  eye.  In 
amblyopia,  the  non-dominant  (amblyopic)  eye  shows  impaired  accommo-  dation;76,157,158  however,  few  studies  have 
examined  the  role  of  ocular  dominance  and  accommodation  in  non-amblyopic subjects. Given the potential association between 
accommodation and development 
Corneal higher-order aberrations In non-anisometropic populations, there is a high degree of symmetry between the two eyes for 
measures of corneal aberra- tions.169,170 Plech and colleagues74 also observed that corneal higher-order aberra- tions were 
similar between fellow eyes in cases of unilateral amblyopia, including isometropic and anisometropic refractive errors. In a 
population of non-amblyopic anisomyopes, Vincent and colleagues62 found a high degree of interocular symmetry for corneal 
higher-order aberrations, which increased as the corneal analysis diameter increased. This suggests that the optical quality of the 
cornea is similar for the two eyes of myopic anisometropes, which does not support a model of development of myopia driven by 
corneal aberrations; however, these measurements were not taken during or following near work, which has been shown to alter 
corneal optics due to eyelid pressure. Using the same non- amblyopic anisomyopes, a further study140 was conducted to examine 
the symmetry of the change in corneal optics following a short-duration reading task. The changes in corneal higher-order 
aberrations following reading were not significantly different between the two eyes; however, the more myopic eyes exhibited a 
significantly greater increase in corneal against-the-rule astigma- tism, which resulted in a greater reduc- tion in image quality 
over a 6.00 mm pupil diameter. 
metropia. Seventeen subjects (mean age 21 ± 7 years) exhibited an interocular difference in accommodative response 
of myopia, the characteristics of accommo- dation between the dominant and non- dominant eyes are of interest with respect to 

Total ocular higher- order aberrations between 2.00 and 3.00 D but again, there 
refractive error development. 
A high degree of interocular 
symmetry was no clear evidence of a refractive error- accommodation interaction (that is, the 

Higher-order aberrations 
also exists for the total higher-order aberra- tions of the eye after correcting for more myopic eye showed a greater lag in 
Higher-order aberrations are optical imper- 
enantiomorphism (between eye 
mirror sym- only 50 per cent of these cases). 
fections of the eye (excluding defocus and 
metry) in various isometropic 
populations Xu and colleagues154 used an infrared 
astigmatism) that degrade retinal image 
during distance171–175 and 
near fixation.176 optometer to measure the interocular sym- 
quality and may influence ocular growth. 
Studies of chicks177,178 have 
reported a signifi- metry of the accommodative response in 20 
Although the unaccommodated eyes of 
cant increase in higher-order 
aberrations anisometropes with 2.50 to 7.00 D of spheri- 
myopes and emmetropes exhibit similar 
following monocular form 
deprivation cal anisometropia at a range of accommo- 
levels of aberrations,159,160 during or follow- 
and the development of myopia, 
and dative demands. The more myopic eyes 
ing near work, myopes tend to have higher 
recently Colletta, Marcos and 
Troilo179 exhibited a larger accommodative lag com- 
levels of aberrations in comparison to 
observed that experimentally 
form-deprived pared to the less myopic eyes for accommo- 
their emmetropic counterparts.161–163 Recent 
eyes of marmosets had 
significantly higher dative demands of 2.00, 3.00 and 4.00 D; 
studies suggest this may be due to differ- 
levels of the asymmetric 
aberration trefoil however, these differences did not reach sta- 
ences in the cornea or palpebral aperture 
compared to the fellow control 
eye. These tistical significance. 
morphology.162,164 Several studies have com- 
animal models suggest that interocular 
 
Ocular characteristics of anisometropia Vincent, Collins, Read and Carney 
Figure  5. Mirror symmetry of astigmatism and comparison of higher-order aberrations in a typical anisometropic subject 
(R:  -4.25/-1.75  ×15  and  L  -2.75/-1.75  ×170).  The  above  refractive  power  maps  (4  mm pupil) are generated from the total 
ocular  wavefront  for  Zernike  terms  up  to  the  eighth  radial  order:  4–6  (lower  order  terms,  A  and  B),  4–45  (lower  and 
higher-order  terms,  C  and  D)  and  7–45  (higher-order  terms  only,  E  and  F).  Cross-  sectional  studies  of  anisomyopes 
typically report similar levels of aberrations between the two eyes or slightly higher levels in the less myopic eye. 
asymmetries  in  higher-order  aberrations  may  be  a  result  of  asymmetric  visual  experi-  ence  and/or  ocular  growth,  rather  than  a 
cause. 
In  a  cohort  of  human  anisomyopes  (approximately  3.40  D  anisometropia), Kwan, Yip and Yap165 also observed signifi- cant 
interocular  symmetry  in  higher-order  aberrations;  however,  they  also  noted  signifi-  cantly  higher  levels  of  third-order  and total 
higher-order  aberrations  in  the  less  myopic  eye  compared  to  the  more myopic eye. Con- versely, more recent studies examining 
lower  levels  of  anisomyopia  (around  1.75  D  anisometropia)  have  found  a  high  degree  of  interocular  symmetry  (and  no signifi- 
cant interocular differences) in indivi- dual higher-order aberrations, third-order, 
© 2014 The Authors Clinical and Experimental Optometry 97.4 July 2014 Clinical and Experimental Optometry © 2014 
Optometrists Association Australia 301 
fourth-order and fifth-order aberrations or total higher-order aberrations62,166 (Table S5, Figure 5). Retrospective clinical 
studies of total higher-order aberrations in anisometropia also report a high degree of symmetry between the two eyes for almost 
all individual wavefront coefficients167 or a higher degree of interocular symmetry in anisometropes compared to 
isometropes.168 In summary, these studies (which gener- ally measured aberrations during distance fixation) do not support the 
hypothesis that increased aberrations (and hence reduced retinal image quality) in the unaccommodated eye play a role in the 
development of myopic anisometropia; however, this does not rule out the possibility that higher-order aberrations play a role in 
the  development  of  myopia  or  anisometro-  pia  during  or  following  near  work,  or  that  the  sign  of  the  aberrations  (for  example, 
relative  peripheral  hyperopia)  may play a role. Additionally, no longitudinal studies have currently been published examining the 
symmetry of higher-order aberrations in children during the development of myopia. 
THE POSTERIOR EYE IN ANISOMYOPIA 
Structural  alterations  of  the  posterior  eye,  such  as  staphyloma  and  optic  disc  abnor-  malities  are  often  associated  with  high 
myopia  and  excessive  axial  elongation.180  With  recent advances in posterior eye imaging (OCT), more subtle changes in retinal 
and  choroidal  thickness  have  also  been  observed  over a range of myopic refrac- tive errors (typically a thinning of the retina and 
choroid with increasing levels of myopia).181–183 
Retina While several studies have examined the interocular symmetry of retinal thickness in amblyopic anisometropia, few 
studies have examined retinal biometrics in myopic ani- sometropia. For lower levels of myopic ani- sometropia (1.50 to 3.00 D), 
there appear to be no obvious structural differences between the two eyes with respect to retinal thickness at the macula184 or in 
paramacular regions64 or the retinal nerve fibre layer thickness sur- rounding the optic nerve.185 Additionally, a recent study 
examining retinal character- istics in severe myopic anisometropia (approximately 10.00 D) found no signifi- cant differences 
between the two eyes for measures of foveal retinal thickness, but some retinal thinning was observed in the inferior and nasal 
paramacular regions in the order of 10 to 20 μm.186 
Logan  and  colleagues58calculated  the  pos-  terior retinal contour in Asian and Cauca- sian low myopic anisometropes of about 
2.00  D  (using  peripheral  refraction  coupled  with  corneal  curvature  and  axial length data) and observed an ethnic influence upon 
interocular  differences  in  the  shape  of  the  posterior  eye.  Caucasians  exhibited  between-eye  differences in axial length that were 
greater  nasally  compared  to  tem-  porally  in  the posterior retinal contour, while in anisometropes of Taiwanese- Chinese descent, 
the interocular difference in axial length was similar between corre- sponding nasal and temporal locations. 
 
Ocular characteristics of anisometropia Vincent, Collins, Read and Carney 

Choroid 
thickness may be a result of an active ocular 
the non-dominant eye is 
typically the more Until recently, choroidal thickness had not 
mechanism, similar to the response 
myopic eye or the eye with a 
greater level of been measured directly in anisometropic 
observed in monocular manipulation of 
astigmatism. eyes. Early studies 
estimated the interocular 
refractive error in animal models. symmetry of choroidal blood flow in 
anisomyopes by measuring the ocular pulse amplitude and the pulsatile ocular blood 
OCULAR DOMINANCE 

Retinal image quality and ocular dominance flow. Shih and colleagues89 observed that 
Several studies have investigated the associa- 
In anisometropic amblyopia, the 
dominant when anisometropia exceeded 3.00 D, there 
tion between ocular sighting dominance 
sighting eye is typically the eye 
with better was a significant interocular difference in 
(the preference for the visual input from 
visual acuity, although there 
may be excep- the ocular pulse amplitude (0.27 mmHg). 
one eye when viewing binocularly) and ani- 
tions in some cases with 
intermittent strabis- Similarly, Lam and colleagues91 found that 
sometropia (Table S6). In a cohort of adult 
mus.192 If visual acuity 
influences ocular in anisometropic subjects (greater than 
Asian myopes Cheng and colleagues188 
dominance in myopic 
anisometropia, one 2.00 D) both ocular pulse amplitude and 
observed that when the degree of anisome- 
might expect to see a significant 
difference pulsatile ocular blood flow were significantly 
tropia exceeded 1.75D, the dominant 
in acuity between the two eyes 
of aniso- lower in the more myopic eye of axial 
eye was always the more myopic eye and 
metropes or a greater difference 
in acuity anisometropes and the interocular differ- 
hypothesised that an aniso-accommodative 
between eyes with increasing 
levels of ences in ocular pulse amplitude and pulsa- 
response (due to unequal accommodative 
myopic anisometropia. In 
non-amblyopic tile ocular blood flow were both significantly 
demands during reading) may be responsi- 
myopic anisometropes, no 
significant differ- correlated with the interocular difference in 
ble for the dominant eye be ing more 
ence in visual acuity was 
observed between axial length. These studies suggest that 
myopic. Similarly, a study examining pre- 
the two eyes for either high 
(more than reduced choroidal blood flow is associated 
dominantly Asian myopic anisometropes 
1.75 D) or low levels of 
anisometropia (up to with increasing myopia. 
found that when the magnitude of anisome- 
1.75 D).62 Furthermore, total 
higher-order Vincent and colleagues64 directly meas- 
tropia exceeded 1.75 D, the more myopic 
monochromatic aberrations 
(which alter ured choroidal thickness in adult aniso- 
eye was almost always the dominant sighting 
the retinal image) were 
compared between myopes using OCT and observed significant 
eye (90 per cent of cases) and when aniso- 
the dominant and non-dominant 
eyes interocular differences proportional to the 
metropia exceeded 2.25 D the more myopic 
to examine if subtle optical 
differences degree of axial anisometropia. These differ- 
eye was always the dominant eye.62 This 
between the eyes might 
somehow influence ences (thinner choroid in the more myopic 
finding is in agreement with studies of young 
ocular dominance. The 
dominant and non- eye) were more apparent in Asian aniso- 
amblyopic strabismics, in which the fixat- 
dominant eyes displayed similar 
root mean metropes compared to Caucasians. This 
ing (dominant) eye typically undergoes a 
square error values for 
measurements of finding was consistent with the previous 
greater myopic shift during childhood com- 
higher-order aberrations taken 
during dis- posterior retinal findings of Logan and 
pared to the fellow amblyopic eye.13–15 
tance fixation. This does not 
point to an colleagues,58 as Asians displayed relatively 
Conversely, in a study of Asian children, 
obvious underlying optical 
reason (that is, symmetrical interocular differences in 
Chia and colleagues189 found no such asso- 
reduced retinal image quality) 
for the more choroidal thickness at corresponding nasal 
ciation. The authors reported that when ani- 
myopic eye typically being the 
dominant eye and temporal locations, while in Caucasians 
sometropia was greater than 1.50D, the 
for higher levels of 
anisometropia. choroidal thinning was limited to a region 
dominant eye was more myopic in only 56 
Some studies have reported 
that the non- nasal to the fovea of the more myopic eye. 
per cent of subjects. A large retrospective 
dominant eye has a significantly 
higher level Together, these studies suggest that some of 
study of over 10,000 patients screened 
of astigmatism compared to the 
dominant the structural changes in the eye associated 
for refractive surgery in Western Europe31 
eye, which increases with 
greater levels of with anisomyopia differ between Asian and 
(presumably a predominantly Caucasian/ 
anisometropia.31,189,193 
While this suggests Caucasian subjects. 
European cohort) also recently found that 
that image quality may play a role 
in the Since previous animal studies have shown 
in myopic anisometropia the dominant eye 
development of ocular 
dominance or aniso- an active choroidal mechanism to emme- 
is typically the eye with the lower refractive 
metropia, the cross-sectional 
nature of these tropise (by adjusting the position of the 
error. While these studies all employed 
studies prevents any firm 
conclusions retina) to imposed defocus118,187 and evi- 
similar techniques to deter mine ocular 
regarding the causal nature of 
this associa- dence for a similar mechanism has been 
dominance (variations of the hole-in-the- 
tion. One longitudinal study190 
examined reported in humans,123 it is possible that the 
card test191), differences in subject ethnicity 
the rate of development of 
myopia between choroid plays a role in the development of 
and age may account for some of the discrep- 
dominant and non-dominant 
eyes of young anisomyopia. As the above study64 was cross- 
ancies observed in the findings between the 
Asian myopes and concluded 
that sighting sectional it is unclear if the thinning of the 
studies. 
dominance has no influence 
upon refractive choroid in the more myopic eye was a cause 
In summary, cross-sectional studies of 
error development; however, 
this study or consequence of development of myopia; 
adult myopes (of predominantly Asian eth- 
included only isometropic 
children (mean however, modelling suggested that the 
nicity) have found that beyond a threshold 
anisometropia, 0.22 D; range 
zero to 1.00 D interocular differences observed were not 
level of anisometropia (1.75 to 2.25 D), the 
at initial examination) and 
excluded moder- accounted for by a simple passive stretching 
more myopic eye is typically the dominant 
ate myopes, astigmatic myopes 
and children of the globe. This supports the theory that 
sighting eye; however, studies of Asian chil- 
whose parents had myopia 
greater than the between-eye differences in choroidal 
dren or European adults have observed that 
-3.00 D, significantly reducing the likelihood 
Clinical and Experimental Optometry 97.4 July 2014 © 2014 The Authors 302 Clinical and Experimental Optometry © 2014 
Optometrists Association Australia 
 
Ocular characteristics of anisometropia Vincent, Collins, Read and Carney 
of including participants who may have 
explanation may be that ocular dominance 
and non-dominant eyes during 
the develop- developed anisometropia. 
is influenced by the development of aniso- 
ment of anisomyopia may provide further 

Accommodation, binocularity and ocular dominance 


© 2014 The Authors Clinical and Experimental Optometry 97.4 July 2014 Clinical and Experimental Optometry © 2014 
Optometrists Association Australia 303 metropia (particularly in Asian ethnicities). 
insight into the potential causal nature of Beyond a certain degree of 
anisometropia, 
this association. Characteristics of the domi- the more myopic eye may be 
favoured for 
nant eye during binocular near 
work may Studies measuring ocular changes of both 
near work during binocular vision due to the 
also help to explain the 
underlying mecha- eyes simultaneously during near tasks with 
reduced ocular accommodative demand 
nism, if ocular dominance 
influences the binocular viewing may provide insight into 
relative to the fellow eye, and thus it may 
development of myopic 
anisometropia. characteristics that influence ocular domi- 
dominate during binocular viewing. This 
An interocular asymmetry in 
choroidal nance. Yang and Hwang194 compared the 
could explain why there is a significant shift 
thickness has been observed 
that is propor- interocular equality of the accommodative 
to the more myopic eye as the dominant 
tional to the magnitude of 
anisomyopia. Pre- response in children with intermittent 
sighting eye when anisometropia exceeds 
vious animal studies have 
shown an active exotropia, without amblyopia or anisome- 
1.75D in adult Asian myopes but not 
choroidal mechanism to 
emmetropise to tropia. During monocular viewing, the 
children. 
imposed defocus118,187 and 
evidence for a dominant and non-dominant eyes of inter- 
Studies examining ocular dominance 
similar mechanism in humans 
has recently mittent exotropes both showed a small lag of 
and anisometropia have been cross-sectional 
been reported.123Given that the 
between-eye accommodation; however, during binocular 
and have employed a simple forced-choice 
differences in choroidal 
thickness cannot be fixation, a significant number of subjects 
method of determining sighting preference 
explained by a simple passive 
stretch model, displayed a greater lag of accommodation in 
(the hole-in-the-card test191). A longitudinal 
interocular differences in 
myopiagenic the non-dominant eye compared to the 
study into the ocular changes of dominant 
stimuli may be driving 
asymmetric develop- fellow dominant eye. This finding suggests 
and non-dominant eyes during the develop- 
ment of myopia. Therefore, a 
longitudinal a potential mechanism for the non- 
ment of anisometropia (using more sophis- 
study examining factors such as 
the dominant eye becoming more myopic (due 
ticated techniques to quantify ocular 
interocular symmetry of ocular 
biometry, to hyperopic defocus) compared to the 
dominance196) may provide further insight 
optical quality (including 
corneal and dominant eye, in cases of atypical ocular 
into the potential causal nature of this asso- 
total ocular astigmatism and 
higher-order alignment. 
ciation. Characteristics of the dominant eye 
aberrations) and changes in the 
choroid There is conflicting evidence regarding 
during binocular near work may help 
during childhood-adolescent 
development the association between the magnitude of 
explain the underlying mechanism, if ocular 
of myopia may provide 
important informa- myopic anisometropia and ocular domi- 
dominance influences the development 
tion regarding the development 
of asymmet- nance and its role, if any, in asymme tric 
of myopic anisometropia. Apart from one 
ric refractive errors. refractive 
development. The fact that the 
study of myopic children,189 the majority of more myopic eye is typically the 
dominant 
adult subjects examined in other cohorts eye in some cohorts with higher levels 
of 
were presumably established anisometropes myopic anisometropia62,188 seems 
counter- 
(that is, not developing anisometropia). As intuitive. In amblyopic eyes, the 
dominant 
such, we cannot rule out that visual acuity (or eye is the eye with better visual 
acuity, which 
the quality of vision) during development of 
ACKNOWLEDGEMENTS The authors thank Dr Fan Yi and Mr Stephen Witt for assistance in the translation of foreign texts. 
has experienced normal emmetropisation 
anisometropia plays a role in determining and has a lower degree of ametropia. 
Con- 
sighting dominance. versely, in non-amblyopic myopic anisome- tropia, initial 
reports suggested that the 
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SUPPORTING INFORMATION 
Additional Supporting Information may be found in the online version of this article at the publisher's website: 
Table S1. Summary of biometric studies of myopic anisometropia Table S2. Summary of cross sectional studies of IOP in 
anisometropic cohorts Table S3. Summary of cross-sectional studies of corneal power (or radius of curvature) in anisometropia 
Table S4. Summary of studies of accommo- dation in myopic anisometropia TableS5. Summary of studies of higher- order 
aberrations in anisometropia Table S6. Summary of studies of ocular sight- ing dominance and refractive error 
© 2014 The Authors Clinical and Experimental Optometry 97.4 July 2014 Clinical and Experimental Optometry © 2014 
Optometrists Association Australia 307