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Epidemiology of Myopia

Article in Epidemiologic Reviews · February 1996

DOI: 10.1093/oxfordjournals.epirev.a017924 · Source: PubMed

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Epidemiologic Reviews Vol. 18, No. 2
Copyright © 1996 by The Johns Hopkins University School of Hygiene and Public Health Printed in U.S.A.
All rights reserved

Epidemiology of Myopia

Seang-Mei Saw,1 Joanne Katz,2 Oliver D. Schein,3 Sek-Jin Chew,4 and Tat-Keong Chan 5

INTRODUCTION holes and tears, as well as retinal detachment. Methods

Myopia is the state of refraction in which parallel of correction of myopia are not without complications,
rays of light are brought to focus in front of the retina including corneal infections due to contact lens wear
of a resting eye (1). Myopia is measured by the spher- and corneal scarring and persistent corneal haze from
ical power in diopters of the diverging lens needed to refractive surgery (5).
focus light onto the retina, which can be expressed as The public health and economic impact of myopia,
the spherical equivalent or refraction in the least my- the most common eye condition in the world, is enor-
opic meridian (2, 3). The clinical correlates of myopia mous. In the United States, the cost of correcting
include blurred distance vision, eye rubbing, and refractive errors with spectacles or contact lenses is
squinting. estimated to be 2 billion dollars per year (6). The
military spends large amounts of money on pilot train-
Myopia has been classified as either physiologic or

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ing, but pilots may not be able to continue flying if
pathologic. Physiologic myopia occurs due to an in-
they develop myopia. Thus, myopia is a condition with
crease in the axial diameter of the eye over that which
social, educational, and economic consequences.
is attained by normal growth. Pathologic myopia is
caused by an abnormal lengthening of the eyeball, and Over the past few decades, there has been an in-
is often associated with thinning of the scleral wall (1). crease in the prevalence of myopia in some popula-
Another classification is based on age of onset. Con- tions, leading to growing concern among the public
genital, or infantile, myopia occurs at birth, with a and the scientific community. The Chinese and Japa-
reported prevalence in the full-term newborn varying nese appear to have had escalations of myopia rates.
from 0.0 to 24.2 percent. This variability is due to There is no well established or universally accepted
technical difficulties in measuring refraction in new- treatment for the prevention of myopia onset or pro-
borns (4). School myopia occurs at approximately gression.
7-17 years of age and stabilizes by the late teens or This review will summarize the descriptive epide-
early twenties. Both school and adult-onset myopia are miology of myopia, possible risk factors for myopia,
mainly the result of idiopathic causes, while congen- and the interventions available to prevent the onset and
ital myopia is often associated with other abnormali- progression of myopia. The limitations of the existing
ties. research will be addressed, as well as suggested direc-
tions for further research.
Severe myopia may be associated with myopic mac-
ular degeneration, cataract, glaucoma, peripheral reti-
DEFINITION OF MYOPIA IN EPIDEMIOLOGIC
nal changes (such as lattice degeneration), and retinal
STUDIES
Received for publication January 4,1996, and accepted for pub- Different studies have adopted different definitions
lication July 16, 1996. of myopia. The most common definitions are a refrac-
Abbreviation: NHANES, National Health and Nutrition Examina-
tion Survey. tive error greater than 0.25 diopter and a refractive
1
Department of Epidemiology, School of Hygiene and Public error greater than 0.50 diopter. The lack of uniform
Health, The Johns Hopkins University, Baltimore, MD. criteria has led to difficulties in comparing prevalence
2
Department of International Health, School of Hygiene and
Public Health, The Johns Hopkins University, Baltimore, MD. rates in different studies. Cross-sectional and cohort
3
Dana Center for Preventive Ophthalmology, Wilmer Eye Insti- studies use different criteria for defining persons as
tute, The Johns Hopkins Hospital, Baltimore, MD. myopic. All studies should specify the definition of
4
Singapore Eye Research Institute, Singapore National Eye Cen-
ter, Singapore. myopia used and the range of refractive error of the
5
Department of Ophthalmology, National University Hospital, subjects in the study.
Singapore. The accuracy and reliability of ophthalmologic and
Reprint requests to Dr. Joanne Katz, Department of International
Health, School of Hygiene and Public Health, The Johns Hopkins refractive examinations is crucial in epidemiologic
University, 615 North Wolfe Street, Baltimore, MD 21205. studies. The "gold standard" for measurement of re-

175
176 Sawetal.

fractive error in children is cycloplegic refraction (1). In Scandinavia, most of the studies were not
Cycloplegia is the act of paralyzing the muscles of population-based (10). Myopia prevalence was re-
accommodation in the eye. Usually, cyclopentolate ported to be 50.3 percent among 133 medical students
hydrochloride eye drops are instilled, which provides in Norway (11). In Sweden, the prevalence of myopia
cycloplegia lasting for 1 hour. Cycloplegic refraction among 2,616 Swedish conscripts aged 20 years was
is especially important in children and infants, as they 8.9 percent. These studies defined myopia as more
have strong accommodative responses which may lead than 0.25 diopter, and no cycloplegia was used. Ap-
to "pseudomyopia" (7). However, often cycloplegic proximately 20.5 percent of 21,000 Icelanders re-
refraction is not used for the diagnosis of myopia in fracted with cycloplegia in 1975 were myopic, defined
children and young adults. Thus, myopia rates may be as more than 0.5 diopter (10).
overestimated in the determination of refractive error In Asia, there is currently a high prevalence of
in these studies. myopia, especially among the Chinese and Japanese.
As early as the 1930s, Rasmussen (12) estimated a
PREVALENCE AND DEMOGRAPHIC PATTERNS prevalence of myopia of approximately 70 percent in
There is considerable geographic variation in the China; however, the refraction procedures were not
reported prevalence of myopia (table 1). It is difficult clearly described. A total of 4,000 schoolchildren aged
to compare prevalence rates between countries based 6-18 years were refracted with cycloplegia in an
on previous studies; the definitions of myopia are not island-wide survey in Taiwan in 1983. There was an
uniform, and refraction may have been performed increasing prevalence of myopia with age, from 4
without cycloplegia. Prevalence studies are not all percent at age 6 years to 40 percent at age 12 years,
population-based, with some studies being conducted more than 70 percent at age 15 years, and more than

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on convenient select groups of individuals with limited 75 percent at age 18 years (13). Three studies carried
generalizability. The prevalence of myopia varies with out in Singapore showed varying myopia rates: 24.9
time and the age of the study population. percent in 10-year-old Chinese children, 63 percent in
From data gathered on 7,401 persons aged 12-54 university freshmen aged 19 years, and 82 percent in
years in the National Health and Nutrition Examina- medical students (14-16). However, the definitions of
tion Survey (NHANES) in 1971 and 1972, the preva- myopia differed. Various surveys in India have found
lence of myopia in the United States was estimated to myopia prevalences ranging from 6.9 percent to 19.7
be 25 percent (8). However, the exact criteria for percent (17, 18). The techniques used for refraction
myopia in this survey were not clearly defined. This and the definition of myopia used were often not
population-based survey did not include cycloplegic mentioned in the studies conducted in Asia.
refraction (thereby probably overestimating the rate In agricultural countries, the prevalence of myopia
and degree of myopia), and the nonparticipation rate has been low. There have been several population-
was 30 percent. A more recent population-based sur- based studies. On the South Pacific island of Vanuatu,
vey in Beaver Dam, Wisconsin, of 4,926 adults be- 788 Melanesian children aged 6-19 years were exam-
tween the ages of 43 and 84 years showed a decreasing ined and refracted without cycloplegia. Only 2.9 per-
prevalence of myopia with age, from 43.0 percent in cent were found to be myopic by 0.5 diopter or more
the age group 43-54 years to 14.4 percent in subjects (19). In the Solomon Islands, an ophthalmic survey
above the age of 75 years (9). Myopia was defined as conducted in 1966 found that only 0.8 percent of the
more than 0.5 diopter; however, there was no mention study population from the islands of Bougainville and
of whether cycloplegia was used. Malaita were myopic by 0.25 diopter or more. No

TABLE 1. Summary of selected studies of myopia prevalence

Study Population- Sample Cycloplegic Myopia Age Prevalence

oounuy (ref. no.) based? size refraction? definition (years) (%)

Solomon Islands Verlee (20) Yes 512 No >0.25 diopter 1-69 0.8
Vanuatu Grosvenor(19) Yes 788 No >0.5 diopter 6-19 2.9
Sweden Str6mberg (cited by No, conscripts 2,616 No >0.25 diopter 20 8.9
Fledelius (10))
Iceland Sveinsson (23) No, spectacle 21,000 Yes >0.5 diopter 1-89 21
/MrtCI iftC

United States Sperduto et al. (8) Yes 7,401 No 12-54 25

Norway Midelfart et al. (11) No, medical 133 No >0.25 diopter 21-33 50.3
students
Taiwan Lin et al. (13) Yes 4,000 Yes 6-18 75 at age
18 years

Epidemiol Rev Vol. 18, No. 2, 1996

 Epidemiology of Myopia 177

cycloplegic refraction was done on the 512 subjects Incidence and progression of myopia
(20). There is a lack of adequate data on the incidence of
Myopia not only shows regional variation in prev- myopia from population-based cohort studies. Over a
alence but also exhibits country-specific differences in 10-year period, the incidence of myopia among Israeli
secular trends as well. A possible reason for the in- pilots was 7.4 percent in 991 pilots with 20/20 vision
crease in myopia rates in many countries is the in- in each eye upon entry into the profession and 22.5
crease in formal education, with more time being spent percent in 221 pilots with 20/25 vision in one eye upon
on closeup work, in the past few decades. The preva- entry into the profession (26). The results of this study
lence of myopia has increased over the past several are only generalizable to populations of pilots in Is-
decades in Singapore and Japan (21, 22). Similarly, rael, who are varied ethnically (European, North Af-
the prevalence of myopia in Iceland increased from rican, Asian). This is also a very unusual definition of
3.6 percent in 1935 to 20.51 percent in 1975 (23). The myopia; it is unclear how 20/25 vision relates to re-
Iceland study included the use of cycloplegic refrac- fractive error.
tion and the same myopia definition of more than 0.5 Longitudinal studies have found that myopia stops
diopter over the 50-year period. increasing earlier in females than in males, and that
Sex and race also affect the distribution of myopia. mean cessation ages range from 14.44 to 15.28 years
The 1971 and 1972 NHANES data showed that prev- for females and 15.01 to 16.66 years for males (27).
alence rates were higher in females than in males and Lin et al. (28), however, showed that even after pu-
higher in whites than in blacks in the United States (8). berty, myopia continues to progress slowly, and the
Several other studies have found a slightly higher increase in axial length is the main component in
preponderance of myopia in females (9, 21). Certain myopia progression. Both Goss (29) and Chew et al.

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ethnic groups, such as Asians and Jews, have a higher (30) have reported that a greater amount of myopia at
prevalence of myopia, whereas Africans and African the initial examination age is associated with a greater
Americans have a low myopia prevalence rate (8). In rate of progression. In a study of Finnish schoolchil-
Hawaii, the prevalence of myopia varies among the dren by Parssinen and Lyyra (31), myopia progressed
different ethnic populations: 17 percent in Chinese, 13 faster in girls than in boys, in children with an earlier
percent in Koreans, 12 percent in Japanese, and 12 age of onset of myopia, and in children who had more
percent in Caucasians (24). In a Taiwanese survey, severe myopia at initial examination. All of these
where the eyes of children in one school were re- studies have a potential bias in that they examined
fracted under cycloplegia, the prevalence of myopia populations that self-referred for spectacle or contact
among the purely aboriginal children was 13 percent, lens correction of myopia (i.e., perhaps only certain
compared with 30 percent in the Chinese children types of people seek help when they first start to
(25). become myopic, while others wait longer before seek-
The prevalence of myopia changes considerably ing correction of their myopia).
with age. Newborns are usually hyperopic. In subse-
quent years, the ocular axis elongates, with thinning of
the lens and flattening of the cornea, which leads to RISK FACTORS FOR MYOPIA
emmetropia in children by age 8-10 years (22). When Both environmental and genetic factors have been
myopia occurs, it usually develops between the ages of associated with the onset and progression of myopia.
6 and 14 years. Thereafter, the prevalence of myopia The use-abuse theory states that closeup work causes
remains relatively constant between the ages of 12 and myopia, as seen in the higher prevalence of myopia
54, as reported in the US NHANES data (8). There is among persons who are more highly educated and are
a decreasing prevalence of myopia with increasing age in white collar occupations. The genetic theory, on the
after age 40 years (9). other hand, is based on the belief that natural individ-
To facilitate appropriate comparisons of the preva- ual variation in eye growth will produce myopia in
lence of myopia across different populations, studies certain individuals (3). The mechanisms underlying
should be population-based, have similar definitions the environmental and genetic factors, and the nature
of myopia, refract children under cycloplegia, and of the interaction between the two factors, is not
report findings by age. This will allow researchers to certain. Educational level, intelligence, certain person-
compare prevalence rates across geographic bound- ality traits, and socioeconomic status have all been
aries. Similarly, studies of secular trends in myopia associated with myopia. Premature and low-
rates and the sociodemographic characteristics of my- birth-weight infants have a higher risk of developing
opia should have the same definitions of myopia and myopia later in life (32-34). The effects of malnutri-
should include refraction by cycloplegia. tion and height on myopia are poorly substantiated

Epidemiol Rev Vol. 18, No. 2, 1996

178 Saw et al.

(35-37). The strongest evidence for an environmental The exact mode of inheritance and possible genetic
cause is the effect of closeup work on the onset and markers for myopia have not been identified. Not all
progression of myopia. observations, such as the increase in myopia preva-
lence in Taiwan, Singapore, and Hong Kong, can be
Family history explained solely by genetic causes. There may be an
interaction between genetic and environmental factors
There is a greater prevalence of myopia in children
wherein some individuals have a genetic predisposi-
of myopic parents than in children of nonmyopic par-
tion such that they are more susceptible to environ-
ents (38, 39). Genetic studies of myopia have mainly
mental influences causing myopia. More conclusive
been twin studies, pedigree studies, and studies of
and well-designed studies of family pedigrees of indi-
familial correlation. Family studies by Sorsby et al.
viduals with high myopia that use genetic markers
(40) and Keller (41) demonstrated significant parent-
associated with myopia must be conducted. The mark-
child correlations. However, it is difficult to separate
ers for collagen metabolism, intelligence, and retinal
hereditary factors from environmental factors such as
neurotransmitters could provide clues to the location
similar work patterns in parents and their children
of possible myopia genes.
(41). Initial cross-sectional results of the Orinda Lon-
gitudinal Study of volunteer schoolchildren showed
that before the onset of myopia, the children of myopic
parents had longer eyes, suggesting a possible hered- Education and intelligence
itary predisposition to myopia. However, early envi- Several cross-sectional studies in Denmark, Israel,
ronmental factors may also have led to longer eyes the United States, and Finland have shown a higher
(42). The role of heredity is postulated to be more prevalence of myopia among individuals with higher

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significant in persons with higher degrees of myopia. educational levels (53-56). Other studies have shown
In a study of 258 myopic patients, the percentage of an association between myopia and intelligence and
parents with myopia was 15 percent for those with socioeconomic status (57-60).
myopia of less than 1.00 diopter versus 55 percent for Refractive error and intelligence have been com-
patients with myopia of more than 7.00 diopters (43). pared in various studies, with inconsistent results. Pos-
Different modes of Mendelian inheritance, includ- itive associations were found in Ohio and in Auckland,
ing autosomal dominant, autosomal recessive, and New Zealand, when the California Test of Mental
sex-linked, have been suggested by different authors Maturity and the Otis Self-Administered Test, respec-
(44, 45). In a study conducted in Hawaii of 185 fam- tively, were used to evaluate intelligence (59, 60).
ilies with both parents of Japanese ancestry and of 192 However, no relation was found when the Stanford-
families with both parents of European ancestry, seg- Binet Test was used in Ohio or when the Raven Matrix
regation analysis was performed (46). The results Test was used in Auckland (59, 60).
showed that there was little evidence for a Mendelian Ashton (61), in Hawaii, measured the effects of both
mode of genetic inheritance. closeup work and intelligence on the onset of myopia.
Past twin studies have not defined the mode of Although no association between myopia and closeup
inheritance but have provided evidence to support the work was found, a relation between school achieve-
heritability of myopia. Accurate classification of zy- ment and myopia was noted. The results of this study
gosity and the comparison of monozygotic and dizy- may have been affected by the crude measure of
gotic twin populations of similar characteristics are closeup work (number of books and magazines read
important considerations in the design of twin studies per month), refraction without the use of cycloplegia,
(47). Similar results have been obtained from twin and the cross-sectional nature of the study.
studies conducted in the United Kingdom, Finland, Questions about the validity of intelligence testing
Taiwan, and Shanghai, where there were higher con- and the omission of information on other confounding
cordance rates of myopia in monozygotic twins than in factors, such as closeup work, socioeconomic status,
dizygotic twins (48-51). In a study of Chinese twin and educational level, limit conclusions from previous
pairs (52), there was a higher concordance rate of studies of intelligence and myopia (57-60). Hirsch
myopia (92.2 percent) for monozygotic twins with (59) noted that intelligence test scores could be influ-
concordant close-work habits (differences of less than enced by the amount of reading a child does or that a
1 hour per day spent studying and reading) than for more intelligent child might read more and thus be-
monozygotic twins (79.3 percent) with discordant come more myopic. Educational level and intelligence
close-work habits. The authors concluded that there are strongly related to amount of closeup work and are
was significant additive interaction between zygosity probably not independent risk factors but surrogates
and close-work habits. for closeup work.

Epidemiol Rev Vol. 18, No. 2, 1996

 Epidemiology of Myopia 179

Closeup work implicated as a risk factor for the onset of myopia (8).
Closeup work encompasses tasks of high accommo- The mechanisms for myopia onset and progression
dative demand, such as reading, writing, computer may be similar, and the association between closeup
work, and close television viewing. It has been sug- work and myopia progression can provide evidence
gested that the side-to-side movement of the eyes for the causation of myopia onset.
during reading has a different effect on myopia than
does close work without similar eye movement, such
Cross-sectional prevalence studies
as sewing (31). The incidence of myopia increases at
the time children start attending school, and this sug- Cross-sectional studies conducted in Newfoundland
gests that closeup work may be a cause of the devel- and Hong Kong have found positive associations be-
opment of myopia (62). The increase in myopia prev- tween closeup work and the prevalence of myopia
alence observed in Hong Kong, Taiwan, Japan, and (72-74). The odds ratio for myopia in subjects who
Singapore over the past few decades suggests an en- attended school in the Hong Kong study was 1.7 (95
vironmental risk factor, since the gene pool has not percent confidence interval 1.0-3.0). However, refrac-
changed. There has been an increase in educational tion was measured without cycloplegia in these stud-
attainment over the past several decades, with an ac- ies. The measures of closeup work were crude and
companying increase in myopia incidence, in coun- were obtained from questions on the amount of read-
tries such as the United States (63). However, these ing and writing done. The effects of different types of
observations have generally been ecologic rather than closeup work, such as reading or watching television,
epidemiologic. An increased prevalence of myopia is and variations in levels over time were not assessed.
observed in certain occupations, such as microscopy, Moreover, the studies did not account for variations in

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sewing, and carpet weaving, that require a large the amount of closeup work by age, or the distances
amount of time spent in closeup work (64). However, used for various tasks.
it is difficult to separate cause from effect; the study of An interesting study was conducted in Israel in
persons in select occupational groups who spend large which orthodox schoolboys of identical ethnic back-
amounts of time on close work may be part of a ground had a myopia prevalence of 81.3 percent, as
selection process whereby individuals with myopia compared with 27.4 percent among boys from general
may prefer these occupations. Further evidence for the schools (myopia was defined as more than 0.50 diop-
close-work hypothesis is the higher prevalence of my- ter; cycloplegic refraction could not be performed on
opia among college graduates, with a higher number all subjects) (75). The authors of this study attributed
of new cases in the college years, compared with other this increased myopia in orthodox males to their
adults in the same age group (65). In 1964, Sato (66) unique study habits, and to the fact that the printed
noted a higher incidence of myopia among US grad- letters in the commentaries studied may be as small as
uates after they studied Chinese in universities. 1 mm in height. In addition, there was a large differ-
In the native populations of the Arctic regions of ence in the amount of time spent reading and writing
Alaska and Canada there has been a notable increase at school. The girls in the orthodox schools had rates
in myopia in the younger generation. There is little of myopia comparable to those of girls in the non-
parent-child correlation in refractive error, but a orthodox schools. Again, the big difference was in the
sibling-sibling correlation now exists. The prevalence amount of closeup work, which was much less for
of myopia was much higher in young persons com- girls than for boys in the orthodox schools. However,
pared with older individuals among Alaskan Eskimos, individual estimates of the amount of closeup work
Canadian Inuit, members of a Labrador community, were not obtained.
Yupik Eskimos, and American Indians in Ontario (67-
71). The increase in myopia incidence in Arctic re-
gions has coincided with the establishment of compul- Cohort studies
sory schooling after World War II and with an increase Parssinen et al. (76) reported a faster rate of pro-
in exposure to closeup work. Intermarriage with gression of myopia among children who spent a
whites could also be contributing to a genetic change greater amount of time on closeup work. Refractive
in the predisposition to myopia. However, a homoge- error was measured annually with cycloplegia. A
nous change in refractive error in different populations questionnaire was designed to determine the amount
suggests that intermarriage is unlikely to be contrib- of time spent on closeup work to the nearest half hour,
uting substantially to the rising incidence of myopia with information obtained on closeup work done on
and, more importantly, Caucasians do not have very both weekends and school days, as well as details on
high rates of myopia. Thus, closeup work has been reading distance.

Epidemiol Rev Vol. 18, No. 2, 1996

180 Sawetal.

Occupational studies show a greater role in myopia development than equa-

Rapid industrialization and modernization has led to torial areas. Recent studies have shown strong evi-
many workers' spending more time on closeup work dence that objects viewed nearby may cause the eye to
with video display terminals and to children's using elongate further than it does during normal growth to
video display terminals for computer-aided instruction maximize the sharpness of images on the retina. This
and video games, as well as increased television growing eye thus elongates and becomes myopic (85).
watching (77). Studies of persons in occupations in- In a study by Hung et al. (86) in Houston, Texas,
volving long hours of closeup work, such as textile refractive errors such as myopia were induced in mon-
workers and visual display unit workers, show that the keys by lenses. There was resultant compensating eye
prevalence of myopia is higher in these occupations growth that reduced the effect of refractive errors
(78, 79). These studies often compare groups of people produced by the spectacle lenses. This experiment
with different educational levels and socioeconomic supports the hypothesis that lens wearing affects the
status; such comparisons are difficult. growth of the eye and that myopia progression may be
There is a growing belief that both genetic and hastened by focusing on close objects when wearing
environmental factors, such as closeup work, play a minus lenses, but this has not been demonstrated in
part in the onset of myopia. Refraction is possibly a humans. Further research is needed to bridge the gap
product of both genetic and environmental factors, between animal models and human eye physiology.
with the environment modifying the genetically deter-
mined development of the eye. Other risk factors
Other risk factors that have been explored as possi-
bly contributing to myopia onset and progression in-

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Biologic theories for closeup work
clude prematurity, low birth weight, height, personal-
The growing eye of a child is sensitive to visual cues ity, and malnutrition. There is strong evidence for a
that could determine axial length and whether the eye link between prematurity and low birth weight and
grows in the direction of myopia or hyperopia (80). myopia, but unconvincing evidence for any associa-
There are several theories which attribute closeup tion between myopia and height, personality, or mal-
work to the increase in axial length that causes myo- nutrition.
pia. One of the most widely held theories is the ac- Past studies have reported a greater prevalence of
commodation theory, wherein there is an increase in myopia later in life in premature infants as compared
pressure in the posterior part of the eye during accom- with full-term infants (32-34). Myopia is especially
modation which is poorly resisted by the sclera, re- common in premature infants with retinopathy of pre-
sulting in increased ocular length (63). Although in- maturity, which is caused by excessive exposure to
traocular pressure plays a role in normal eye growth oxygen during the first few weeks of life (1).
during development, there has been no documented Eye size may be linked to body stature, with taller
increase in intraocular pressure in myopic eyes. None- individuals having longer axial lengths. Several stud-
theless, defective accommodation may cause retinal ies have shown that myopic individuals are taller than
image defocus, which is increasingly regarded as a key nonmyopic individuals (35, 87). However, this differ-
factor in myopia development (81). ence is often explained by a difference in socioeco-
Animal research showed that monkeys whose vision nomic status. A Finnish case-control study by Teikari
was restricted to a distance of 18 inches (46 cm) by (35) showed that myopic persons were significantly
drapes became myopic, and cage-reared animals had a taller than nonmyopic persons. However, refractive
higher prevalence of myopia than their wild counter- status was not directly examined, and height informa-
parts (82). This supports the association of closeup tion was obtained indirectly from a questionnaire.
work with increased accommodation and myopia. Ex- There have been several studies which investigated
periments by Raviola and Wiesel (83) showed that the association between personality and myopia. Early
monkeys with unilaterally surgically closed eyelids studies showed that myopic individuals may be more
who were reared in lighted environments developed introverted, reflective, self-confident, dominant, and
axial myopia in the closed eye and none in the other, sedentary than nonmyopic individuals (57, 58), while
open eye. This could be due to visual form depriva- other studies, such as a cross-sectional study by
tion, as animals with sutured lids who are reared in the Bullimore et al. (88), did not find any association
dark do not become myopic. Another theory (84) between personality and myopia. These personality
postulates that the printed page provides an impover- attributes of myopic individuals may be associated
ished stimulus for nonfoveal retinal neurons, which with other risk factors such as intelligence and large
have large receptive fields. Posterior poles of chicks amounts of time spent on closeup work.

Epidemiol Rev Vol. 18, No. 2, 1996

 Epidemiology of Myopia 181

There is no evidence that specific vitamin deficien- sured and appropriately adjusted for in studies exam-
cies are associated with myopia (57). The evidence for ining the association between myopia and closeup
nutritional causes for the onset of myopia has been work. There is no consistent evidence for height, per-
unconvincing, as past studies showing an association sonality, or malnutrition as risk factors for myopia.
have had methodological limitations. Studies in Afri-
can tribal people and Lebanese Arab infants showed INTERVENTIONS
that malnourished individuals had higher myopia rates
(36, 37). However, only limited conclusions may be Visual corrective aids, such as spectacles and con-
made, as the cross-sectional studies do not allow direct tact lenses, are established methods of correcting the
analysis of the temporal nature of the relation and defective distant vision arising from myopia. How-
there may be more proximal causes of myopia that are ever, to date, there has not been any convincing or
associated with nutrition that have not been examined. widely accepted method of preventing the onset of
In addition, there is a question as to why there would myopia or retarding the progression of myopia in
be an increase in myopia in Singapore, Taiwan, Japan, humans.
etc., at a time when people's diets were improving (in A variety of different methods to reduce the onset
terms of calories and protein content). If there is any and progression of myopia have been described. These
association, the attributable risk is probably very methods include visual training, biofeedback training,
small. the use of bifocal spectacles, contact lenses, the instil-
lation of atropine eyedrops, the instillation of beta-
NEEDS FOR FURTHER EPIDEMIOLOGIC blocker eyedrops, lowering of the intraocular pressure,
RESEARCH and surgery (89). Unfortunately, most of the results

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published have had limited validity. Some of the early
Currently, there is no conclusive evidence for any of intervention trials did not have a control group for
the myopia risk factors postulated above. Most of the comparison. Many clinical trials did not include ran-
observed associations have come from cross-sectional domization, thus allowing for selection bias by the
studies. There are very few cohort studies that have a investigators and participants. Furthermore, the treat-
sufficient sample size, accurate measurement of risk ment groups were not comparable with regard to mea-
factors, adjustment for possible confounding factors, sured confounding factors. The sample size and length
and measurement of the different refractive compo- of follow-up were often insufficient. In addition, large
nents in myopia development, which include refrac- numbers of dropouts were common, and a difference
tion by cycloplegia, axial length, and corneal curva- in myopia progression among subjects lost to
ture. There is a need for further well-designed follow-up may have led to biased conclusions. Mask-
epidemiologic studies to provide us with information ing of subjects is almost impossible, and it is difficult
on risk factors for myopia onset and progression. to mask the technicians who refract the subjects with
From our assessment of the available literature, we regard to intervention status. The trials discussed here
must make inferences about the relative importance of are limited to those that utilized controls, as shown in
the different risk factors in order to set directions for table 2.
further epidemiologic research. It appears that there is
an hereditary component of myopia, as seen in the
many familial correlation, twin, and pedigree studies Bifocal spectacles
that have been conducted. However, the exact mode of Bifocal spectacles have been postulated to slow the
interaction between genetic and environmental factors, progression of myopia by reducing accommodative
the relative contribution of genetic factors as opposed demand. Clinical trials on the effects of bifocals are
to environmental factors, and the nature of the genetic often not randomized, and there is no conclusive evi-
markers is unknown. Time trends showing increased dence for the effect of bifocals in the slowing of
myopia rates in many countries point to an environ- myopia progression (90). In 1975, Oakley and Young
mental cause for myopia. The most important environ- (91) conducted a clinical trial which assigned bifocals
mental risk factor for myopia appears to be closeup to volunteers and spectacles to subjects who refused to
work, for which several cross-sectional and cohort wear bifocals. The study population of 156 Native
studies have shown an association. Other risk factors, Americans and 441 Caucasians aged 6-21 years was
such as intelligence, academic achievement, socioeco- followed for 2-4 years, and an average of three cy-
nomic status, and educational level, are possible sur- cloplegic refractions were performed. The results
rogates for closeup work. Myopia also varies with age, showed a significant difference in the rate of progres-
sex, race, and gestational age at birth. All of the above sion of myopia of -0.04 diopter in the bifocal group
factors are potential confounders and should be mea- compared with —0.51 diopter in the control group. No

Epidemiol Rev Vol. 18, No. 2, 1996

182 Saw et al.

TABLE 2. Clinical trials of interventions to decrease the rate of progression of myopia

Study Intervention Result Limitations

(ref. no.)

Oakley and Young (91) Bifocal lenses Significant difference in annual rate of No randomization; investigators
myopia progression of -0.12 diopter measuring outcome not
in the bifocal group compared with masked
-0.38 diopter in the control group
Goss and Grosvenor Bifocal lenses No significant difference in myopia No randomization; refractive
(92) progression between different groups outcomes from medical
records
Grosvenor et al. (93) Bifocal lenses No significant difference in myopia Large number of dropouts
progression between different groups
Parssinen et al. (76) Bifocal lenses No significant difference in myopia
progression between different groups
Stone (94) Contact lenses Significant difference of annual myopia No randomization; refraction
progression of 0.1 diopter in contact measured without cycloplegia
lens wearers compared with 0.36
diopter in spectacle wearers
Andreo (95) Hydrophilic contact No significant difference in myopia No randomization
lenses progression in different groups
Grosvenor et al. (97) Gas-permeable contact Significant difference in annual myopia No randomization
lenses progression of 0.14 diopter in the
contact lens group versus 0.40
diopter in the spectacle group

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Perrigin et al. (98) Silicone-acrylate contact Significant difference in annual myopia No randomization; large number
lenses progression of 0.16 diopter in the of dropouts
contact lens group compared with
0.51 diopter in the spectacles group
Bedrossian (99) 1 % atropine eyedrops No myopia progression in 74% of Fellow eye used as control
atropine treated eyes versus 4%
of untreated fellow eyes
Kaoetal. (102) 1 % atropine ointment Significant difference in myopia No randomization
progression of 0.17 diopter in the
atropine group compared with 0.75
diopter in the control group
Hosaka (104) Labetalol and timolol Significant difference in myopia No randomization; small sample
eyedrops progression between eyes treated size
with labetalol and placebo but no
difference for eyes treated with timolol
and placebo
Jensen (105) 0.25% timolol maleate No statistically significant difference in Small sample size
myopia progression

masking was done, and this could have led to inves- elicited from past medical records. A randomized clin-
tigator bias wherein favorable refractive measure- ical trial (93) in Houston, Texas, placed subjects into
ments were made in the bifocal group. An analysis of three groups consisting of children wearing single-
three studies by Grosvenor et al., Roberts and Banford, vision lenses, +1.00 diopter added bifocals, or +2.00
and Goss showed decreased rates of progression of diopters added bifocals based on a table of random
myopia in patients with convergent strabismus who numbers. The mean increase of myopia in the 124
wore bifocals, but no difference in rates in patients participants was —0.34 diopter per year for the single-
with no strabismus or divergent strabismus who wore vision subjects, —0.36 diopter per year for the +1.00
bifocals (92). The Grosvenor and Goss (90) bifocal diopter added bifocal subjects, and —0.34 diopter per
study of 112 myopic patients from three optometry year for the +2.00 diopters added bifocal subjects.
practices in the central United States showed no sta- The differences in the rates were not statistically sig-
tistically significant difference in the rate of progres- nificant. There was a large number of dropouts, with
sion of myopia of —0.44 diopter per year for wearers only 124 of the 207 subjects remaining in the study
of single-vision spectacles and —0.37 diopter per year after 3 years. In Finland, a randomized clinical trial in
for wearers of bifocals. The treatment assignment was which children aged 8-13 years were assigned to the
not randomized, and refractive measurements were use of bifocal lenses, continuous use of single-vision

Epidemiol Rev Vol. 18, No. 2, 1996

 Epidemiology of Myopia 183

spectacles, or use of single-vision spectacles only for such as atropine to decrease ocular accommodation.
distant vision showed no significant difference be- Several past clinical trials did not randomize subjects,
tween rates of progression in the three groups (76). and dropout rates were high. The findings were often
equivocal and inconclusive (99-101). Bedrossian's
Contact lenses study (99) involving 75 subjects aged 7-13 years used
the other eye as a control. Bedrossian found that 112
Rigid contact lenses have been used in several clin- of the 150 atropine-treated eyes had no change or a
ical trials, as it is postulated that these lenses retard decrease in myopia, whereas in the control eyes, only
myopia progression by causing corneal flattening. One four had no change or a decrease in myopia. Kao et al.
of the first studies to assess' the possible effects of (102) studied the effect of 1 percent atropine ointment
contact lenses on the rate of progression of myopia on the progression of myopia in Taiwanese schoolchil-
was conducted by Stone in the London Refraction dren with myopia of more than —0.5 diopter. A total
Hospital, where 120 children were followed for 5 of 40 schoolchildren received 1 percent atropine oph-
years (94). However, the subjects were not random- thalmic ointment in both eyes every night for the
ized into contact lens and spectacle groups, and myo- duration of 1 year; 40 similarly myopic schoolchildren
pia was measured with noncycloplegic refraction. The wearing spectacles but not receiving atropine treat-
increase in myopia among the contact lens wearers ment served as controls. The authors found that 51.3
was 0.10 diopter per year as compared with 0.36 percent of the treated group showed no progression of
diopter per year for the spectacle wearers. Andreo (95) myopia, and only 10 percent showed progression of
studied a small sample of 56 patients who were wear- greater than 0.5 diopter. By contrast, in the control
ing spectacles or hydrophilic contact lenses over a group, 12.5 percent showed no myopia progression
period of approximately 12 months, and the results

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and 62.5 percent showed progression of greater than
showed no statistically significant difference in the 0.5 diopter.
rates of progression between the two groups. As with
Stone's study, the subjects were not randomized to the
Intraocular pressure reduction using beta-
two different groups. A study by Grosvenor et al. (96) blocking agents
used gas-permeable contact lenses in 100 myopic chil-
dren and compared them with another nonrandomized Intraocular pressure could be an important mediator
age-matched group of spectacle-wearers. They found of scleral stress, causing axial elongation of the eye-
an increase in myopia of 0.14 diopter in the contact ball and resultant myopia (103). On the basis of this
lens group compared with 0.40 diopter in the spectacle hypothesis, pharmacologic agents which lower the in-
group in this nonrandomized study. Grosvenor et al. traocular pressure may have an effect in retarding the
noted that upon discontinuation of contact lens wear, progression of myopia. Hosaka (104) conducted a
myopia progression increased. However, the reduction small study in which 20 Japanese children aged 6-14
in myopia progression was not accounted for entirely years were treated with 0.25 percent timolol maleate (a
by corneal flattening as measured by the keratometer. beta-blocker) twice daily, another 50 subjects were
The researchers concluded that the keratometer did not treated with 0.5 percent or 0.25 percent labetalol eye-
provide an accurate assessment of corneal flattening drops (another beta-blocker) twice daily, and other
from contact lens wear (97). However, another Hous- subjects were treated with placebo. With a short
ton study (98) fitted 100 children with silicone-acry- follow-up period of only 2-5 months, Hosaka found a
late contact lenses and made comparisons with 20 statistically significant difference in the progression of
spectacle-wearing children matched by age and initial myopia between the labetalol-treated eyes and the eyes
amount of myopia over a 3-year period. The myopia of treated with placebo, whereas no such difference was
the contact lenses wearers progressed at a statistically found in timolol maleate-treated eyes and placebo-
significantly slower rate of 0.16 diopter per year, com- treated eyes. Jensen (105), in a preliminary report
pared with 0.51 diopter per year in the spectacle wear- published in 1988, studied the effect of timolol mal-
ers. However, there was a large dropout rate, with only eate in the control of myopia in 9- to 12-year-old
56 of the original 100 children fitted with contact schoolchildren in Denmark. A total of 159 schoolchil-
lenses remaining in the study at the end of 3 years, and dren were randomly allocated to one of three groups:
there was no randomization of treatment assignments. a control group, a group with bifocal spectacles, and a
group with 0.25 percent timolol eyedrops instilled
twice daily. Timolol maleate was found not to have
Atropine eyedrops any statistically significant effect in slowing the pro-
Another putative method of myopia control is the gression of myopia in these schoolchildren (106).
daily instillation of a long-acting cycloplegic agent Thus, it can be inferred that there has been no conclu-

Epidemiol Rev Vol. 18, No. 2, 1996

184 Saw et al.

sive evidence that beta-blocking agents help to retard the development of myopia, while in populations
myopia progression. where closeup work is common, there is a high prev-
The available interventions are limited by their side alence of myopia and genetic factors do not have a
effects, and there has been inconclusive evidence from large influence (52).
present intervention studies. Atropine instillation may Over the past few decades, epidemiologic studies
occasionally result in side effects such as atropine have been mainly cross-sectional in nature, with poor
dermatitis, allergic reactions to atropine, and chronic documentation of the temporal relation between risk
pupillary dilation leading to cataract, and it has been factors and myopia. Confounding variables were not
reported that the myopia tends to resume at a faster examined, refraction was measured without cyclople-
rate once the eyedrops are withdrawn (107). Further- gia, and the different components of refraction, such as
more, the compliance rate is low, as the individual has axial length and corneal curvature, were not measured
to instill eyedrops daily over long periods of time and directly. The definition of myopia has varied widely,
is unable to read without bifocals if the drops are sample sizes have been insufficient, and longitudinal
instilled in both eyes. Beta-blocking agents need to be follow-up has been poor. Well-designed concurrent
instilled in the eye daily, with possible side effects and cohort studies with accurate instruments for measuring
a low compliance rate. The results of clinical trials closeup work, other risk factors, and refractive out-
using beta-blocking agents have not been conclusive. comes will provide us with further insights into the
Bifocals do not cause much discomfort for wearers. environmental causes of myopia. Closeup work is
However, the randomized trials of bifocals have not difficult to quantify, and much more study is needed to
showed any slowing of myopia progression. There obtain precise estimates of amounts and types of
was some slowing of myopia progression with the use closeup work and the environmental conditions under

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of contact lenses, but the trials were not randomized.
which closeup work is done. Future studies may ex-
Future research should be directed at interventions
amine the effects of reading English and Chinese
such as the use of rigid gas-permeable contact lenses,
characters, as well as the direction of eye movements,
with the emphasis on well-designed randomized clin-
whether vertical or right-to-left. Tools for closeup
ical trials with adequate sample sizes and accurate
work assessment, mainly questionnaires and diaries,
refractive measurements.
may be administered repeatedly over different time
periods in order to document seasonal variations in
closeup activities that result from factors such as
CONCLUSIONS school examinations or vacations. In children with
Myopia is an ocular condition with a high preva- active accommodation reflexes, refraction with cyclo-
lence in many parts of the world. The relative contri- plegia is essential. The availability of instruments for
bution of genetic and environmental factors to the biometric measurements of the eye will enable us to
development and progression of myopia is not fully better understand mechanisms of myopia onset and
understood (108). There are several questions that progression.
remain unanswered. To what extent does closeup work
Twin and familial correlation studies have sup-
contribute to the increased prevalence of myopia in
Japan, Taiwan, Hong Kong, Singapore, and the United ported the hypothesis of a genetic component of my-
States? Is the difference in myopia prevalence in dif- opia causation. However, the exact mode of inheri-
ferent ethnic groups due primarily to genetic factors or tance is uncertain, and marker studies have been few.
to environmental influences? How much of myopia is Further research should be directed at linkage-analysis
genetically determined, and how do environmental studies and the identification of myopia gene markers.
factors alter the onset and progression of myopia? Is A better understanding of the risk factors for myopia
closeup work an equal risk factor for both the onset would enable better public health interventions, such
and the progression of myopia? Is the age of onset of as health education efforts, to advise the public about
myopia important? Are there different risk factors for the types and circumstances under which closeup work
high and low myopia? could accelerate myopia onset and progression. Cohort
Recent studies have shown that a family history of studies examining the effects of changes in lighting,
myopia and closeup work are the two strongest risk types of closeup work, distance from reading material,
factors. The relation between closeup work and ge- or type sizes could provide a basis for specific closeup
netic factors, as well as the interaction between these work interventions in the future. Potential interven-
two variables, should be further studied. It has been tions for the prevention of the onset and progression of
suggested that in populations with little exposure to myopia should be subjected to rigorously performed
closeup work, genetic factors play an important part in randomized clinical trials.

Epidemiol Rev Vol. 18, No. 2, 1996

 Epidemiology of Myopia 185

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