SURVEY OF OPHTHALMOLOGY VOLUME 29. NUMBER 2.

SEPTEMBER-OCTOBER 1984

PERSPECTIVES IN REFRACTION
MELVIN L. RUBIN, EDITOR

Night Myopia
G. MARION HOPE, Ph.D., AND MELVIN L. RUBIN, M.D.

Department of Ophthalmology, Uniuersitv of Florida College Of Afrdicine. J. Hillis hfiller Health Center.
Gainesrille. Florida

Abstract.*Although the phenomenon of night myopia has been recognized for two centuries, its
causes are still not fully understood. Early studies implicated spherical aberration and accommo-
dation, but the degree to which either contributed was not clearly established. More recently,
laser speckle techniques to measure myopia have allowed the collection ofdata on large subject
populations and it appears that night myopia represents a tendency [or accommodation to
approximate the dark focus as low luminance levels degrade the clarity of the retinal image. In
this article, the authors review the past and present literature on night myopia and related
anomalous myopias. and describe techniques for their evaluation and correction. (Surv Opb-
thalmol 29: 129 136, 1984)

Kev words.
II
accommodation l dark focus l instrument myopia l laser speckle l

myopia l night myopia l space myopia . spherical aberration

P
eople have a tendency to become nearsighted rected it by using minus lenses to improve his own
whenever the light level of their environment is astronomical observations at night.+ Borish and
substantially reduced. This phenomenon is Duke-Elder4 also cite other reports made prior to
called night (or nocturnal) myopia and has been Lord Rayleighs apparently independent rediscov-
recognized for almost 200 years. Over the last 15 ery? in 1883.10
years our understanding of it has increased dramati- During the century following Rayleighs descrip-
cally, but even now we still cannot fully explain its tion, numerous papers on night myopia appeared,
cause. In any event, it has recently begun to attract most searching for its basic cause. Initially, Ray-
attention as a clinical entity that can be easily man- leigh suggested that the phenomenon stemmed from
aged. In this article we will review what is known the spherical aberration of the eye that became
about night myopia and describe the more recent manifest when the pupil was dilated, a hypothesis
findings as they relate to deciding when and how to that was later elaborated on by others.16,7,?,8 Their
prescribe corrective lenses for it. reasoning was based on the fact that the outer zones
of the eyes optical system have greater optical pow-
Early Literature er than the central region. Under daylight (phot-
The first description of night myopia has been epic) conditions the pupil is constricted, so the cen-
erroneously attributed to Lord Rayleigh.,,25,33 Ac- tral-most zone of the cornea and lens is favored.
tually, it was Maskelyne a century earlier (1789) Under scotopic conditions the pupil dilates, so rays
who first reported the phenomenon and how he cor- refracted by the more peripheral optical zones pro-
129
130 Surv Ophthalmol 29(2) September-October 1984 HOPE AND RUBIN

vide the bulk of the light responsible for image for- dictory results and similarly contradictory conclu-
mation.,. Moreover, the Stiles-Crawford effect,* sions. Other experiments designed to test the in-
which enhances the effectiveness of the light trans- fluence of accommodation used photographic
mitted through the center of the pupil, is absent or measurements of the Purkinje images reflected from
reduced in scotopia. Thus, in reduced illumination the lens surfaces to determine how much change
there is a reduction of the role of the central optical occurred in the lens curvature with decreasing illu-
zone, and the peripherally refracted light is greatly mination,R,, but these results were also contradic-
favored I.1625
tory, with one group finding no change in lens cur-
Competing hypotheses were also published. vature for three of four subjects and two other
These proposed that accommodation,tg, and groups finding + 0.8 and + 1.25 D of change.73J0
chromatic aberration, were also important causes From these experiments, the degree to which either
ofnight myopia. Chromatic aberration results in the spherical aberration or accommodation contributes
shorter wavelengths being focused in front of the to night myopia in any particular individual was not
retina. Since in the dark, adapted eye the special clearly established, though neither etiologic possi-
sensitivity of the retina is also shifted toward the bility was clearly eliminated.
shorter wavelengths, the eye becomes most myopic Other, more speculative hypotheses were also
for those wavelengths that are most affective in stim- proposed. These involved forward lens movement
ulating the retina. The other hypothesis, accommo- and increased lens sphericity secondary to pupil di-
dation, was also shown to be plausible. It proposed lation and forward vitreous pressure, recession of
that under low light levels (luminances) the eye does the retina due to emptying of choroidal vascula-
not relax its accommodation as one might expect, ture, and the presence of off-axis imagery. The
but actually undergoes active accommodation - it first two of these have been accorded only passing
is in focus for a position somewhere between the far mention in reviews and no experimental attention.
point and near points - or, alternatively, that the The off-axis hypothesis suggested that, under sco-
true resting state of the relaxed accommodative topic conditions, best-vision potential resides at
mechanism is not for a focus at infinity but for some more peripheral retinal loci, which are myopic rela-
intermediate position., 30.33~4g~5 Different versions of tive to the central retina. Evidence does support
this hypothesis imputed different reasons for the the contention that refractive correction of the pe-
accommodation. ripheral retina is different from that of the fovea,>
The chromatic aberration (CA) hypothesis was but we know that night myopia is present for fovea1
apparently supported by calculations and measure- vision, so peripheral refraction differences cannot
ments of the amounts of chromatic aberration pres- explain night myopia. In general, then, none of
ent in the eye., Careful studies with monochro- these speculative hypotheses is likely to account for
matic light indicated, however, that only about 0.3 night myopia. In fact, all have been discounted by
to 0.4 D is really present, although values between reviewers and researchers.
0.25 and 0.75 D have been reported. In retrospective overview of work from this early
The main controversy about the cause of night period, a number of interesting features about night
myopia - and much of the early research - cen- myopia are evidenk. The range of myopia in a large
tered on the relative roles of spherical aberration number of reports is broad - 0.0 to 6.0 diopters 1
and accommodation. Measurements of each of and there is much individual variation. However,
these in dim light were made during complex ex- most reports were on small numbers of subjects and
periments that artificially manipulated pupil size sometimes the same subjects were used repeatedly,
and accommodation. The results were contradic- often with the experimenters themselves as subjects.
tory. Some researchers found that cycloplegic Thus, much of the controversy and contradiction
agents (paralyzing accommodation) reduced night could have resulted from sampling error and sam-
myopia, thereby proving an accommodative con- pling bias. Z Moreover, the amount of night myopia
tribution; others found the opposite, proving that in a given individual was difficult to measure with-
the myopia was due to spherical and chromatic out inducing accommodation, which, of course,
aberration 14.16.17,33.49.50
E
ven in absolute presbyopes, strongly affected the variable being measured! Bor-
experiments manipulating pupil size yielded contra- ish, in a survey of 24 studies reported between 1893
and 1967, noted that almost all used methods which
stimulated accommodation. This was a major error
*Light rays that enter the eye near the pupillary center strike the since accommodation has been clearly implicated as
cone photoreceptors head-on and are thereby more effectively ab- one of the causes. Today it seems naive to believe
sorbed. Those rays entering the eye near the pupillary margins strike
that a phenomenon with such marked individual
the photoreceptors obliquely and so do not stimulate the cones as
effectively. The rods are not normally subject to this effect. variation could be caused by a single mechanism.
NIGHT MYOPIA 131

Indeed, the consensus of reviews of this early litera- tion occurs, and the speckle is seen as moving in the
ture indicates that several factors are involved: ac- same direction as the real surface.
commodation, spherical aberration, and chromatic One important feature of speckle movement is
aberration, I 1.ii.,11Xl1 contribute to night myopia, that, since the speckles are generated by the interfer-
but in differing degrees in different individ- ing wavefronts at the plane of the photoreceptors,
ua,s,I,?i,ii.il they are always in focus; that is, the presence of
refractive error will not influence their clarity. And,
Recent Literature since changes in accommodative power are not nec-
Within the last 20 years, most research on night essary to improve image sharpness, the speckle pat-
myopia has included the use of laser speckle to tern should not stimulate accommodation. Note
help measure the myopia. The discovery that laser then. that 1) the direction of speckle movement can
speckle could indicate the type and amount of ame- be used to indicate the refractive state ihypermetro-
tropia was made by Rigdon and Gordon in 1962 pia, emmetropia or myopia) of the eye relativ,e to the
and was confirmed by Oliver in 1963. Simply stat- plane ofstationarity, and 2) the determination ofthe
ed, when light from a laser is reflected from a granu- refractive state is presumed to be free from the influ-
lar surface, a speckled pattern becomes visible. Ifan ence of accommodation.
observer looking at this pattern moves his head, the Henry Knoll was apparently the first to devise
speckles seem to move. They move in the direc- an instrument to measure ametropia using speckle
tion of the head movrement if the eye is hypermetro- movement as a marker. This instrument provided a
pit for the distance to the scattering surface; they moving surface with a variable axis. Using it to
move opposite to the head movement if the eye is study night myopia, Knoll found 0.125 to 0.75 D of
myopic for this distance. If the retina is optically myopia in six sub.jects. Hennessy and Leibowitz
conjugate with the surface, the pattern remains sta- demonstrated empirically that the speckle stimulus
tionary (or exhibits random or boiling motion). does not influence accommodation, and confirmed
Thus, correcting the refractive error with spectacle the theoretical prediction. Later they incorporated
or contact lenses will neutralize the patterns move- the speckle generator into a Badal optometer,H. an
ment... One can also use a moving surface to instrument used for the objective determination of
induce speckle mov~ement, and this is just as effec- refractive error. Laser optometers have figured
tive as a moving head; in the former, however, the prominently in most of the recent research on night
apparent motion is in the opposite direction for ei- myopia and related phenomena. Leibowitz and
ther type of ametropia. Owens also correlated the far-point in darkness
We now understand why this phenomenon oc- (which they called the darxl~~fbcus)with the far-points
curs. The coherent laser light is reflected from many under high and medium luminances and found that
direrent spots on the granular (diffusing) surface. the far-point moves progressively nearer as lum-
The reflected wavefronts enter the eye and interfere inance decreases. Thus, hoth the far-point and
optically (constructively and destructively) in the amount of night myopia will vary with the light
plane of the retinal photoreceptors. This generates lev,el.
the light and dark spots seen as speckle. The The relative ease with which night myopia can
optical and mathematical considerations that ex- now be measured has allowed the collection of data
plain how the movement relates to the degree of on large subject populations. Leibowitz and
ametropia are complex and beyond the scope of this Owens reported on 59 subjects showing a range of
discussion, but conceptually these technical analy- myopia from 0.37 to 2.89 D. In a second report
ses define a plane of stationarity-,,,. that takes expanded to 124 subjects these same authors found
into account the geometry of the incident and re- a range from 0.0 to 4.0 D myopia (mean = 1.7 1 D.?
flected laser light and the observers position rela- s.d. = 0.72). In a third paper, they reported on 220
tive to the moving reflecting surface. When the eye subjects j having a range from 0.4 D hypero@ to 4.0
is focused at this plane, the interfering wavefronts D myopia (mean = + 1.52, s.d. = 6.77 D). They
on the retina are not translated into motion as the emphasized the high variability between subjects
points on the reflective surface are translated in real and felt that this accounted for the inconsistency in
space. When the eye is focused beyond this plane the earlier literature.Li In a study of over 300 eyes,
(hyperopia), the interfering wavefronts move across Epstein et al used a laser-Badal optometer to meas-
the retina in the same direction as the actual surface ure myopia under scotopic and mesopic adaptation
movement in real space and are thus perceived as (luminance values not specified). They found a
moving in the direction opposite to the real surface range from 1.0 D hypermetropia to 3.2 D myopia
movement. In myopia, when the eye is focused clos- under mesopic adaptation and from slight hyperme-
er than the plane of stationarity, the reverse situa- tropia (0.5 D) to 5.1 D myopia under scotopic con-
132 Surv Ophthalmol 29(2) September-October 1984 HOPE AND RUBIN

ditions. Mershon and Amersonz6 measured night contrast reduction.7,l0.9,20,2,23,4

myopia (dark focus) in right and left eyes of 22 men An important question addressed only recently is,
and 17 women and found no differences between how stable over time is an individuals dark focus
eyes of an individual or between genders. (or night myopia)? Leibowitz measured three sub-
The controversy that fostered much of the early jects twice daily over eight days and found little
research into the causes of night myopia has largely variability (generally less than 1 .O D), except in two
dissipated; nevertheless, there is still some recent instances, where the individuals were being subject-
work directed toward etiology, where the relative ed to psychological stress. At these times there were
roles of aberration (chromatic and spherical) and significant shifts in the dark focus beyond the sub-
accommodation have been reexamined. Epstein6 jects normal range. 22 Miller measured the dark fo-
measured mesopic and night myopia in two unilat- cus in 2 1 subjects twice weekly over three weeks, the
eral aphakes. In the normal eyes, he found 0.73 and weeks not being necessarily consecutive.28 He found
1.22 D of night myopia, but in the aphakic eyes, less a range of 0.39 D to 4.45 D myopia (m = 2.76, s.d.
than 0.1D.6 The normal eyes each exhibited about = 0.36). Variations for individual subjects over 12
half the myopia in the mesopic state than was exhib- measures (2-3 weeks) ranged from 0.08 D to 2.92 D,
ited in scotopia, but no such difference was found in with a mean of 1.07 D for all subjects. Correlations
the aphakic eyes. Epstein felt that his results sup- between first and second tests, 7.5 to 12.5 hours
ported accommodation as the primary basis for apart, and first and last tests, 14 to 24 days apart,
night myopia.6 But since removal of the lens also were high (coefficient r of 0.948 and 0.852, respec-
removes the primary contributor to spherical aber- tively). Mershon and Amersonz6 conducted a simi-
ration,6.7 the latter effect cannot be ruled out. lar study on 39 subjects, with retesting immediately
Leibowitz and Owens found that as the luminance and after one week. Their test-retest correlation co-
was reduced, the far point (focus for a distant tar- efficients were 0.91 and 0.81 for the immediate and
get) approached the dark focus; in addition, my- one-week conditions, respectively. Epstein et al
driasisper se had no effect on either the dark focus or measured myopia under scotopic and mesopic con-
the accommodation for the distant target. Raymond ditions (in six eyes of three subjects) at three times
et al investigated the accommodation-stimulating- on the same day and once a day on three days and
effectiveness of the size and contrast aspects of a found variations from about 0.1 to 0.5 D in some
grating pattern containing alternating light and subjects. Owens and Higgins36 measured the dark
dark bands. (Grating patterns are usually specified focus of live subjects periodically over 10 to 12
in terms of spatial frequency - the number of light/ months. Their plots of dark focus measures over
dark pairs (cycles) per degree of visual angle.) They time for individual subjects (Figs. 3 and 4 in refer-
found that, for any given spatial frequency (bar ence 36) clearly demonstrate that the dark focus is
width), approximately ten times as much contrast highly stable over long periods, but shortterm vari-
between dark and light bands was required to stim- ations can be dramatic in some individuals. One of
ulate accommodation as was required to just see the their subjects showed a swing of almost 5.0 D over
pattern. 41Their findings imply that night myopia is one month, while several others varied less than 1 .O
due to the loss of contrast that results from lumi- D over the entire period of 10 to 12 months.
nance reduction, rather than to low luminanceperse. There are four major features of the temporal
Hennessy et allo found through the use of artificial stability of the dark focus. (1) Statistically, when
pupils that, since small pupil size largely determines dealing with averages of many measurements on an
the image quality and expands the depth offield, the individual or on a group, the mean dark focus is
small pupils reduce the need to accommodate and remarkably stable over long periods of time. (2) In
permit the eyes to assume a basic accommodative any individual, however, dramatic shortterm vari-
level that approaches the dark focus, regardless of ations from the mean dark focus (up to 5 D) are not
the actual stimulus distance. When the artificial pu- uncommon. (3) Individuals differ in the variability
pil was made as small as 0.5 mm, accommodation exhibited. (4) Variability can be induced by nonvi-
was fixed at the dark focus. These and other ex- sual factors, such as psychological stress.
periments led Leibowitz and his coworkers to con-
clude the following: (1) the dark focus represents an
Night Myopia and Related Phenomena
intermediate resting state of the accomodative The renewed interest in night myopia and its ac-
mechanism, and (2) night myopia represents a ten- commodative resting point has uncovered relation-
dency for accommodation to approximate the dark ships between night myopia and other phenomena
focus as the clarity of the retinal image (that is, the of temporary myopia, e.g., instrument myopia and
stimulus to accommodation} is degraded by low lu- space (empty-field) myopia. Leibowitz and Owens
minance levels - probably because of attendant compared space, instrument, and night myopia and
NIGHT MYOPIA 133

found that all three had a resting position ap- condition that degrades the accommodative stimu-
proximating the dark focus. At least one common lus (such as by reducing contrast), renders it am-
feature eliciting both space and night myopia is the biguous (as inserting an intermediate screen) or
absence of (or degradation of) an accommodative reduces the effect of accommodation (as the pinhole
stimulus; that is, the viewed field is featureless. In effect of some optical instruments) results in a ten-
instrument myopia, however, the situation is differ- dency for accommodation to approach the level re-
ent, since the target being viewed is usually rich in quired by the plane of the dark focus. Under such
features. Here, the key factor - the effect of pupil circumstances, then, individuals tend to underac-
size on accommodation - was noted by Hennessy commodate for near objects and overaccommodate
et al. Progressively smaller artificial pupils pro- for distant ones. The degree of this accommodative
duced accommodation that approached the dark bias is related to accommodative need and the
focus. This was attributed to the pinhole effect of the adequacy of the accommodative stimuli available.
artificial pupil, which, by greatly extending the Leibowitz and his coinvestigators have noted that
depth of field, reduced the importance of the eyes this condition has ramifications for a broad range of
focusing mechanism for determining retinal image clinical and research practices - from the use of
quality. Since in this case accommodation would small fixation targets to fix the level of accommoda-
have little or no effect on image quality and there is tion during vision assessment, to the use ofdarkened
little (or no) stimulus for the eye to accommodate, lanes during a refraction examination.
the eye assumes a resting focus. These authors also
pointed out that many optical instruments - espe-
Correction of Anomalous Myopia
cially light microscopes - have small exit pupils The correction of night myopia is as old as its
(simulating a pinhole) and hence induce instrument recognition. As mentioned, Maskelyne, in his 1789
myopia. report of the phenomenon, commented on his im-
In other words. night and space myopia appar- proved astronomical observations when he used mi-
ently both occur under the same condition - ab- nus corrective lenses. Some present-day textbooks
sence or degradation of accommodative stimuli - advocate the correction of night or space myopia by
while instrument myopia occurs under conditions of applying additional minus clip-on power over the
reduced need - when accommodation fails to im- normal distance correction, and suggest a given
prove the quality of the retinal image. In all three, amount of minus correction for all persons.~27~47
however, the accommodative mechanism tends to Richards found this arbitrary minus correction
assume a resting state at or near the dark focus.? made matters worse for many., If some correction
Leibowitz and Owens suggested the term anoma- is warranted, he advocates that a refraction be care-
lous myopias for the related phenomena, but the fully done at low luminances (0.1-0.3 foot-lamberts,
term needs broadening, since Johnson found that corresponding to country and urban night driving
night presbyopia is also related to the dark focus. conditions). Though Richards findings of poor sub-
As luminance was reduced, he found that the near jective improvement with arbitrary corrections are
point receded and approached the dark focus. Addi- consistent with recent data showing tremendous in-
tionally, Owens3 showed that when competing dividual variation in night myopia,j~20~~~23 we suggest
stimuli are present, such as when a distant object is that a low luminance eyechart is still not a perfect
viewed through a near surface that has texture (e.g., refracting target because it stimulates accommoda-
a screen or dirty window), there is an accommoda- tion, and thus may induce artifact in the refractive
tive bias toward the object closest to the dark focus. error measurement. Leibowitz has noted that most
Owens termed this the Mandelbaum effect and clinical tests utilize very high contrast targets,
showed that it exists for targets both closer and whereas the real world generally provides low con-
more distant than the dark focus, when the compet- trast stimuli (personal communication).
ing or screening surface is at the dark focus. Final- To extrapolate, a high contrast eyechart at low
ly, Owens and Leibowitz showed that a small fix- luminance does not properly mimic a low contrast
ation light in darkness, a situation common in vision world at low luminance. Thus, it should not be sur-
testing, does not fix accommodation. When 11 sub- prising that night myopia corrections based on con-
jects viewed fixation lights located 0.5 and 4.0 me- ventional refraction techniques - even at low lu-
ters away, their accommodative states were not as minances - have not been totally successful.
expected (i.e., 2 D and 0.25 D), but were virtually AS stated, night myopia seems to be a special case
identical to their individual dark focuses. of Leibowitz and Owens anomalous myopia,O
These investigations of phenomena related to where the dark focus - the focus assumed by the
night myopia indicate that there is an accommoda- eye in total darkness - is both the extreme of night
tive bias toward a resting state (dark focus). Any myopia and the resting state of accommodation
134 Surv Ophthalmol 29(2) September-October 1984 HOPE AND RUBIN

when there are no accommodative stimuli.20 The from the reports. *I9A second approach, somewhat
key to correction of these myopias, then, is the deter- more feasible in a clinic setting, utilizes a standard
mination of the dark focus. retinoscope in a completely darkened room. Under
Owens and Leibowitz35 and Post et aPg investigat- these conditions, Owens et al38 have shown that
ed the correction of night myopia and space (empty- retinoscopy performed at somewhere between 25
field) myopia, respectively, based on dark focus and 100 cm, and with the distance correction in place,
measures for individuals. Owens and Leibowitz yields a refractive error that correlates well (r =
found that night myopia was best corrected by an 0.86) with the dark focus. This procedure has since
amount equalling one-half the dioptric value of the been termed dark retinoscopy (Owens DA: per-
dark focus. This study explained why using an arbi- sonal communication) to distinguish it from near
trary minus lens power has not been fully successful retinoscopy2g which, though performed similarly
to correct night myopia. It established a relation- in a standard refraction procedure, produces differ-
ship between a successful correction and the dis- ent information. Dark retinoscopy is related to the
tance of the dark focus by showing that those with dark focus as follows:
very near dark focuses were consistently helped by
correction, while those with distant dark focuses Dark Focus = Dark Retinoscopy - 0.25D
received little or no practical benefit from correc- 0.64
tion.35 Post et al3g found that when correcting space
myopia it was best to choose a lens equal to the full With this relationship in hand, we agree with
value of the dark focus rather than l/2 the value, as Leibowitz and coworkers in suggesting that the cor-
for night myopia. Owens and Leibowitz35 verified rection for conventional night driving should be
their conclusions by field trials. They reported that one-half the dark focus estimate. A greater percent-
one subject in their field trials, when faced with bad age (up to the full value of the dark focus) should be
weather conditions that further degraded accommo- prescribed for space or empty-field conditions (e.g.,
dative stimuli, found the best correction to be a lens flying) .35.3g
whose power was dioptrically equal to the dark fo- Example: A myopic patient wears regular corrective spec-
cus. Since most reports have demonstrated that me- tacles of - 3 D. When he drives at night, he complains of
halos around lights and blurred vision. Retinoscopy in the
sopic conditions yield less myopia than scotopic
dark, performed at 50 cm with the distance correction in
conditions,jJ,35 one can expect that correction at place, indicates a refractive error of - 1.5 D after subtracting
night-driving luminances would be somewhat less the 2 D working distance equivalent. By the above formula,
than the full-dark focus value. Similarly, since space his dark focus is (- 1.5 - 0.25)/0.64 = -2.75 D. For con-
or empty-field myopia approximates the dark fo- ventional night driving, we have said that the correction
should be % the dark focus, so we should prescribe - 2.7512
CUS,~~this condition should require a stronger cor-
or about - 1.50 D. This can be supplied by a - 1.50 D clip-
rection than that required for standard night driv- on over the patients - 3 D spectacles or by a separate pair of
ing. And, if low luminance is combined with poor spectacles of -4.50 D power.
weather conditions (rain or fog), one would expect a Discerning readers have probably noticed that this calcu-
shift even closer toward the dark focus, as a result of lated night driving correction is essentially the same as the
dark retinoscopy error, so why not use the dark retinoscopy
the addition of conditions that simulate empty space
value of - 1.50 D directly? Indeed, the mathematics in-
(e.g., fog) or the Mandelbaum effect (e.g., rain). volved ,in calculating the dark focus are such that for dark
These would require a stronger minus correction for retinoscopy values less than about - 1.75 D, the difference
the greater amount of myopia induced. Thus, the between one-half the dark focus and the dark retinoscopy
correction of the anomalous myopias should always value itself will be less than 0.25 D, and so the dark retinos-
copy value can be used directly. In fact, Owens and Owens
be based on an individuals dark focus value as
have used this approach on some 50 patients with success
shown by experimental data on these phenomena. (D.A. Owens, personal communication). However, we
The most promising approach to the correction of would caution that for large dark retinoscopy values (>
night myopia requires that a patients dark focus be - 2.0 D), the discrepancy between the two can be significant.
determined. Then, some percentage of this value (or Also, if the full dark focus is to be prescribed for space my-
opia, it will not do to simply double the dark retinoscopy
the full value) should be prescribed. The amount
value, since this would double the discrepancy as well, and
would depend on the conditions under which the could suggest a prescription that significantly deviates from
correction will be used. But this leaves us with the the true full dark focus value.
practical question: How is the dark focus deter- This approach to correction of anomalous my-
mined in routine clinical practice? opia appears to be far superior to simply prescribing
Two methods are in vogue. The first requires gen- an arbitrary amount of minus correction, but there
eration of laser speckle. Although there are no com- are still several potential problems. First, even if the
mercial devices available, it is simple and inexpen- dark or resting focus can be accurately determined
sive to construct a laser Badal optometer directly and a correction derived from this value, it appears
NIGHT MYOPIA 135

likely that the correction will be appropriate only for the light intensity and thereby insure naturally di-
a limited set of conditions. Research indicates, for lated pupils. The use of such filters might allow
example, that a night driving correction may not be further refinement of the dark focus determination
sufficient for night driving during inclement weath- and its subsequent correction by incorporating any
er.j5 Additionally, the data suggest that as lumi- effects of both chromatic and spherical aberration
nance changes (whether from reductions in ambient into the measurements.
light or in the reflectivity of surroundings), the re- Although more research on the subject of charac-
quired correction is likely to change as well, since teristics and correction of the anomalous myopias is
the degree of myopia is a function of luminance., clearly in order, we do not have to wait. Basic re-
Studies of dark focus variation over time indicate search has already provided practical answers that
that many individuals exhibit considerable variabil- have dramatically improved the state-of-the-art.
ity over relatively short periods..2,6,28,36This is sig- We have at hand an empirical and rational basis for
nificant in two respects: 1) The dark focus deter- correcting anomalous myopias, although refracting
mined at a single sitting may be a poor indicator of clinicians should be alert to some residual diflicul-
the average value obtained over long periods, and 2) ties that might be expected when they prescribe for
even if one determined an average dark focus, the them. Clearly, a logically derived correction is in-
resultant correction can be expected to be appropri- deed valuable and should be prescribed whenever
ate for only those periods when the individuals dark symptoms related to night and the other myopias
focus is close to the average value. Also, Leibowitzs are evident.
data emphasize that emotional factors have a sig-
Acknowledgment
nificant effect on the dark focus. These studies sug-
gest that (1) several refractions on different days The authors wish to acknowledge with appreciation Drs.
H.W. Leibowitz, W.W. Dawson, Keith D. White and John
may be required to determine a representative dark
Guy, whose comments, criticisms and suggestions were ex-
focus, and (2) a second correction, at or near the full
tremely helpful in the development of this manuscript.
dark focus value, might be desirable for extreme
patient/environmental states. Thus, for the practi-
References
cal example above, the dark focus should be verified
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