The Global Need for Refractive Correction

JD Silver, DN Crosby, MG Douali, GE MacKenzie, MD Plimmer

The Centre for Vision in the Developing World, University of Oxford, England

Abstract Corrected vision in the developed world

The simplest way to get an estimate of the global need for corrective eyewear is to look at what fraction of a developed world
population wears or has some form of vision correction, and then extrapolate. This fraction is about one half to two thirds of the
population for the USA, Western Europe, Japan etc. This figure is interesting because it is for populations where access to vision
correction is in effect not significantly limited by access to professionals or money. In countries where access to eyewear and eyecare
professionals is not limited i.e. the US, the UK, Europe,
Another way of looking at the problem is to take a “typical” distribution of refractive error, and use a theoretical correspondence Japan etc., between 50% and 70% of the population
between refractive error and achievable acuity. Choosing a pupil diameter then leads to a minimum size “focus” of, for example, a have some form of vision correction1,2.
distant point object on the retina, by simple optics. Interestingly, for an emmetrope, the minimum “spot” is a diffraction pattern of the
pupil, but once some defocus is introduced, we get a situation where the “spot” on the retina can be found to reasonable accuracy – for
a given pupil diameter – by simple geometric optics. Choosing a pupil diameter, using a “typical” distribution of refractive error, and These are populations where one might assume that
setting an acuity criterion, then enables us to estimate the fraction of that population who will be able to see to that acuity. most of those that “need” vision correction have it.

A WHO working group which studied the need for corrective eyewear concluded in 1987 that “the sight of one-fifth of the population
could be improved by the use of spectacles, including the sight of about 10% of schoolchildren”. Using the procedure we suggest here,
that estimate can be interpreted in terms of an implied acuity criterion in that study.

Optical limitations for the resolving ability of the eye Effect of diffraction on image formation in the emmetropic eye Magnitude of refractive error
0D 1D 2D

• If the eye were perfect one would expect to get a nice

sharp image on the retina. In reality this does not happen
for two reasons:

1. diffraction of light by the pupil margin

8 mm
2. the defocus produced by ametropia

Diffraction
Effect of defocus and diffraction on image formation in the 20/20
• If one observes a point source , the extent of the blurred myopic eye
image arising from diffraction depends upon the pupil
diameter (d) and the wavelength of light λ (Rayleigh
criterion: 1.22 λ/d)
Pupil diameter

• Thus, for an emmetropic eye with a pupil diameter of 4mm,

and yellow light (wavelength 590nm), the minimum spot
size on the retina corresponds to an angular resolution of a
little over half a minute of arc. Detail finer that this cannot 5 mm
be resolved.

Defocus 20/20
• If the eye is ametropic the degree of blurring – and hence
The relationship between the magnitude of ametropia and
the subject’s best achievable acuity – is determined by visual acuity for different pupil sizes (Smith,1991)
defocus. There is thus a relationship between refractive
error and visual acuity*
8mm
5mm

Relationship between visual acuity and refractive error 2mm

• It is also clear from simple “ray optics” that the amount of 2 mm

blur of the image on the retina is determined by the iris
diameter – as well as the magnitude of the subject’s
myopia3.
20/20
• It follows that for any given population, if we know the
distribution of refractive error, we know in principle the
distribution of achievable acuity. •The bigger the refractive error the more blurred image
*this relationship does not necessarily hold for individuals with an amplitude of
accommodation sufficient for hyperopia
•This blurring occurs more quickly for larger pupil diameters

How to estimate the global need

What about presbyopes?
To estimate the need for refractive correction, we need

1. A distribution of refractive error

2. An assumed pupil diameter The method of relating refractive error to visual acuity
3. An acuity criterion
can also be applied to presbyopes

• An acuity criterion is appropriately defined in relation to a specific Given that the focal length of the presbyopic eye is
task
fixed, the vast majority of presbyopes need corrective
• We can conveniently use driving as such a task in which case it is eyewear
the vehicle licensing authorities that set the criterion
• For example, in the US one is required by law to read a standard
sized number plate which corresponds to a visual acuity of at least
If we assume everyone over the age of 45 is presbyopic,
2 minutes of arc (20/40 Snellen acuity)4-6.
this alone implies that in excess of one fifth of the
• Distributions of refractive error vary from one population to another
world’s population requires vision correction
and as yet there are no complete global statistics for adults
• For children, however, there has been a large population based
study of 38,000 subjects in several countries7-15.
• One can use this data to estimate:

1. the percentage of myopes not satisfying the acuity criterion (9%)

2. the percentage of hyperopes not satisfying the acuity criterion or, Conclusion
in the case of children*, an arbitrary refractive error criterion (1D
hyperopia) criterion (30%)
Given the 20/40 visual acuity criterion, and excluding non-
presbyopic adults, the table above indicates that at least
33% of the world’s population could benefit from vision
*where the amplitude of accommodation is sufficient to compensate for some correction Population in People requiring
degree of hyperopia age group vision correction
(millions) (millions)
Although the distribution of refractive error in the non-
Children
presbyopic adult population (approximately 3.1 billion (age < 16 years) Myopic 1,830 165 (9%)
people) is currently unknown, a conservative estimate of
Hyperopic ≈ 650 (30%)
the need for vision correction in this age group would be
30% (930 million). This corresponds to 14% of the world’s Non-presbyopic adults
3,154 Unknown
(16 ≥ age > 45 years)
References population.
Presbyopes
1,720 > 1,380 (> 80%)
• National Centre for Social Research and University College London. Department of Epidemiology and Public Health, Health Survey for England, 2001. 2nd Edition. Colchester, Essex: UK Data Archive, June 2004. SN: 4628. (age ≥ 45 years)
•
•
Global Eyeglasses Market (2005). Eyeglasses MCP-2532: A global strategic business report. Global Industry Analyst, April 2008.
Smith G (1991). Relation between spherical refractive error and visual acuity. Optometry and Vision Science 68 (8) 591-598.
Our final estimate for the global need for vision correction
•
•
New York State Department of Motor Vehicles, Eye Test Report for Medical Review Unit, MV-80L, 2007.
California Department of Motor Vehicles, Report on Vision Examination, DL-62, 2007.
is at least 47%. This figure is in fair agreement, but still Total > 2,195
•
•
Royal College of Ophthalmology Guidelines, Visual Standards for Driving, 1996.
Goh PP, Abqariyah Y, Pokharel GP, Ellwein LB. Refractive error and visual impairment in school-age children in Gombak District, Malaysia. Ophthalmology 2005;112:678–685.
lower than, the fraction of people known to be wearing
•
•
Negrel AD, Maul E, Pokharel GP, et al. Refractive Error Study in Children: sampling and measurement methods for a multi-country survey. Am J Ophthalmol 2000;129:421– 426.
Zhao J, Pan X, Sui R, et al. Refractive Error Study in Children: results from Shunyi District, China. Am J Ophthalmol 2000; 129:427–435.
corrective eyewear in the developed world.
• He M, Zeng J, Liu Y, et al. Refractive error and visual impairment in urban children in southern China. Invest Ophthalmol Vis Sci 2004;45:793–799.
• Pokharel GP, Negrel AD, Munoz SR, Ellwein LB. Refractive Error Study in Children: results from Mechi Zone, Nepal. Am J Ophthalmol 2000;129:436–444.
•
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Maul E, Barroso S, Munoz SR, et al. Refractive Error Study in Children: results from La Florida, Chile. Am J Ophthalmol 2000;129:445–454.
Murthy GV, Gupta SK, Ellwein LB, et al. Refractive error in children in an urban population in New Delhi. Invest Ophthalmol Vis Sci 2002;43:623–631.
We suggest that a further global study should be carried
•
•
Naidoo KS, Raghunandan A, Mashige KP, et al. Refractive error and visual impairment in African children in South Africa. Invest Ophthalmol Vis Sci 2003;44:3764 –3770.
He M, Huang W, Zheng Y, Huang L, Ellwein LB. Refractive Error and Visual Impairment in School Children in Rural Southern China. Ophthalmology 2007;114:374–382.
out on adults so as to refine the estimate presented here.