Myopia may be influenced by near work and indoor eye usage, with Jose-Manuel Alonso, PhD

Patients with myopia exhibit visuomotor function deficits driven by ON and OFF retinal pathways during lens accommodation, which may explain why myopia increases with maximized accommodative pupil constriction and decreases with activities that reduce it.¹

Data from a recent study by the State University of New York (SUNY) College of Optometry highlighted a mechanistic explanation for the various factors that contribute to myopia progression, including near work, dim indoor lighting, and treatments such as atropine drops, multifocal lenses, and time spent outdoors, all of which individually influence myopia progression. The central mechanism behind all of it, according to these data, is the constriction of the pupil.²

“When you constrict the pupil, the amount of light that’s entering the eye is also reduced,” Jose-Manuel Alonso, PhD, a professor in the department of biological and vision sciences at SUNY Optometry, and a member of the investigative team, told HCPLive^® in an exclusive interview. “And what we saw is that this constriction, this reduction in pupil size, increases over time. Your pupil is larger when you start reading, for example, than after 20 minutes of reading, and this constriction becomes very pronounced when you have myopia.”

Alonso and colleagues examined the contribution of the ON and OFF pathways to visual accommodation by measuring visuomotor responses to defocused light and dark stimuli. Patients were asked to fixate on a small square monocularly presented through an electrically tunable lens. The lens induced a defocus of around 5 D in the fixating eye, and the patients could bring the square to focus by increasing the crystalline lens’s power, simulating accommodation.¹

This accommodation constricted the pupils of both eyes, making the occluded eye turn inward as if the stimulus was approaching the patient. The difference in horizontal gaze between the fixing and occluded eyes provided a measurement of accommodative eye vergence. Patients were first shown the stimuli defocused, then at focus, and then removed from the display altogether to provide a resting period.¹

A total of 34 patients were enrolled in the trial: 13 were emmetropic, and 21 were myopic. All patients had normal binocular vision and no history of general systemic or ocular disease. Best-corrected visual acuity was 20/20 or better across all patients.¹

Investigators observed that introducing optical defocus increased accommodative eye vergence, which returned to baseline after the defocus was removed. This was consistent across both light and dark stimuli, driving the ON and OFF pathways. Alonso and colleagues observed this increase in both individual patients and average patient values.¹

The background luminance was the same for light and dark stimuli, indicating that changes in accommodative eye vergence are mediated by contrast rather than luminance. When the contrast rose from 1% to 100%, accommodative eye vergence also rose by roughly 3 to 6 times in both emmetropes and myopes with light stimuli (median/mean ± SD for 1% vs 100% contrast: 1.81°/1.80° ± 1.50° vs 6.66°/6.26° ± 2.48°; P = .0002 for emmetropic patients and 2.11°/2.12° ± 1.33° vs 6.71°/7.35° ± 3.07° for myopic patients; P = 6 × 10^–5, Wilcoxon test) and dark stimuli (median/mean ± SD for 1% vs 100% contrast: 2.41°/2.07° ± 1.51° vs 6.12°/5.97° ± 2.71°, P = .0002 for emmetropic patients and 1.94°/2.05° ± 1.20° vs 6.78°/7.12° ± 2.73° for myopic patients; P = 6 × 10^–5, Wilcoxon test).¹

Investigators noted a difference in baseline eye vergence at focus between emmetropic patients and myopic patients, which was significantly larger in myopic patients (median/mean ± SD: 8.21°/9.14° ± 4.50° vs 4.07°/5.64° ± 3.24°; P = .013, Wilcoxon test). Due to the change in accommodative eye vergence being similar, the maximum vergence at 100% contrast was also larger in myopic patients (median/average ± SD: 12.77°/13.64° ± 4.84° vs 8.21°/9.46° ± 4.30°; P = .018, Wilcoxon test). Alonso and colleagues determined that the difference in vergence is mostly due to baseline differences.¹

Additionally, the occluded eye of most patients with myopia (17 of 21) was turned nasally rather than temporally at focus during the first 10 stimulus trials. This indicated that the baseline eye vergence is larger than the trigonometric prediction in esophoria and smaller in exophoria. The bias toward esophoria was approximately 6 times more pronounced in myopic patients than in emmetropic patients (median/mean ± SD −3.5°/−4.3° ± 4.6° in myopes vs 0.6°/−0.5° ± 3.8° in emmetropic patients; P = .019, Wilcoxon test).¹

Alonso and colleagues believe these findings explain why myopia is associated with visuomotor defects, and why low light and near work exacerbate the effects of myopia while outdoor time reduces them.¹

“If you get things very close, the near reflex becomes stronger, and you make the problem worse,” Alonso said. “With time, the pupil constriction becomes stronger and stronger––if you take a break, then you will recover from this temporal potentiation of the reduction in light that you’re getting through the pupil.”

Editor’s Note: Alonso reports no relevant disclosures.

References

1. Maharjan U, Rahimi-Nasrabadi H, Poudel S, et al. Human accommodative visuomotor function is driven by contrast through ON and OFF pathways and is enhanced in myopia. Cell Rep. Published online February 17, 2026. doi:10.1016/j.celrep.2026.116938

2. New research suggests myopia is driven by how we use our eyes indoors. News release. State University of New York College of Optometry. February 17, 2026. Accessed February 19, 2026. https://www.eurekalert.org/news-releases/1116071