OPTOMETRY

I GUESTEDITORIAL I Why is there an epidemic of myopia?

Clin Exp Optom 2003; 86: 5: 273-275

Theodore Grosvenor OD PhD FAA0 Adjunct Professor, Pacific University College of Optometry

This issue of Clinical and Experimental Optometry publishes several papers that were originally presented to two international conferences on myopia, the 9th International Conference on Myopia held in Hong Kong and Guangzhou, China, held in November last year and the International Myopia Workshop held in Australia in April 2002. The organisation of regular conferences focused solely on myopia recognises that the prevalence of myopia is so high as to make it an epidemic for which solutions must be found. Before discussing why there is an epidemic of myopia, it will be helpful to define the word epidemic and then to provide evidence that an epidemic of myopia exists.

ard deviations, of the expected number of cases. In the literature concerning the prevalence of myopia in various populations, terms such as epidemic and endemic have been used only during the past several years and only in Asian countries. In Myopia Updates II, published in 1998, Chen, Lin and ShihS began their report by saying: Myopia is a hyperendemic eye disease in Taiwan, showing a rapid increase in p-evalence since the early 1950s.

Evidence for an epidemic of myopia

In recent years, many studies of the prevalence of myopia have been reported in Asian countries, including Taiwan, Singapore and Hong Kong. Most of these studies have been concerned with myopia during childhood, while others have been concerned with myopia in adults.

cent at age six and 84 per cent at ages 16 to 18 years. In their discussion of these results, Lin and Shih5 commented: In Taiwan, myopia was not a p o b h some 50 years ago and maybe it still is of no special issue in many countries. In Asia, however, especially in Japan, Taiwan, Hong Kong and Singapore, myopia has been a big problem recently. In a study involving primary school children in Singapore, Saw and co-workers6 found myopia prevalences of 28 per cent at age six years, increasing to 44 per cent at age nine years. To put these percentages into perspective, consider how they compare to prevalences of two per cent at age six years and five per cent at age nine found in Orinda, California. In a longitudinal study of Hong Kong children, Edwards8 reported that the prevalence of myopia increased from 10 per cent at age seven to almost 60 per cent by the age of 12 years.

What is an epidemic?
The term epidemic is derived from the Greek word epidemios, which means prevalent. Merriam-Webster defines epidemic as: Affecting or tending to affect a dispropwtionately large number of individuals within a population, community orregion at the same time. Robert Newcomb,2 immediate past president of the American Academy of Optometry, has stated that for a disease to qualify as an epidemic: The number of diagnosed cases in a given period of time must be in excess, by two stand-

Myopia during childhood

Lin and colleagues4 described an islandwide survey of myopia among school children in Taiwan, conducted between 1983 and 1986, involving more than 10,000 children. On the basis of the results of cycloplegic retinoscopy and automated refractometry, they found that the prevalence of myopia increased from four per cent at age six years to 80 per cent at age 17 to 18 years.4Twelve years later, Lin and Shih5 reported the results of a more recent island-wide survey, in which the prevalence of myopia had increased to 12 per
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Myopia in adults
In a study of 1,232 Chinese adults in Singapore, ages 40 to 81 years, Wong and associate~ found ~ myopia of 0.50 D or more in 39 per cent of subjects. Goh and Lamlo reported on a study of myopia in young adults in Hong Kong, conducted by optometrists at The Hong Kong Polytechnic University. They found that 72 per cent of adults between the ages of 19 and 39 years were myopic lo but in a study of older adults, 40 to 65 years of age, Lam and colleagues reported a prevalence of myopia of only 29 per cent. However, some low

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myopes tend to become emmetropic or even hyperopic in their later years due to a hyperopic shift. Data were tabulated from Peter Skeates' optometric practice in New Zealand'* and indicate that a hyperopic shift would not be likely to account for an age-related difference in myopia prevalence as great as the 43 per cent (from 72 per cent to 29 per cent) found in the Hong Kong studies. In a study of 135Hong Kong medical students, Gold~chmidt~~ found that 95 per cent were myopic. This is 23 per cent greater than the 72 per cent found by Goh and Lamlofor 19 to 35-year-old adults, who presumably were not medical students.

Populations having very little myopia

At the other extreme, a team of researchers from the University of Auckland, headed by Leon Garner, has reported very low prevalences of myopia among Melanesian children in VanuatuL4J5 and Sherpa children in Nepal.I6In the first of two surveys of Melanesian children in Vanuatu, involving 977 children aged six to 17years, Garner and colleague^'^ found that only 1.3 per cent of the children had myopia of -0.50 D or greater. In the second survey, reported three years later and involving 788 children with ages six to 19 years, the prevalence of myopia was a higher 2.9 per ~ e n t .I' was ~ able to take part in the second survey, in Port Vila, Vaunatu's largest city and it was a very interesting experience. Reading is of very little importance in Vanuatu as there is a minimum of commerce and little or no industry other than agriculture. There is no electricity in residential areas, so most, if not all, reading must be done while in school. The school day in Vanuatu is short and children spend their after-school hours working in the family garden, attending to the chickens and pigs and fishing in the local streams. The only children who remain in school after age 12 or 13 are those whose parents plan for them to further their education in Australia or New Zealand. Although the low prevalence of myopia among Vanuatu children may be partially due to genetic influences, the role of the

environment is strikingly obvious. Garner and co-worken"j compared the prevalences of myopia for 270 Sherpa children and 555 Tibetan children, seven to 17years of age, living in Nepal. The prevalence of myopia for the Sherpa children was three per cent, comparable to that found for the Melanesians in Vanuatu and the prevalence for Tibetan children was 22 per cent, which is within the range typically found in North America and Europe. Sherpa and Tibetan children share a common genetic background: the Sherpas migrated to Nepal from Tibet over a period of centuries, whereas the Tibetans arrived in Nepal more recently as refugees, due to the Chinese involvement in their country. Garner and colleaguesI6emphasised that the Sherpa children live in an isolated village in the Himalayas, with a low-stress life-style and an absence of electric power, television and pollution; whereas the Tibetan children live in the modern city of Kathmandu with a stressful school atmosphere and, of course, the use of computers. I consider this study to be of extreme importance, inasmuch as the genetic background is similar for the Sherpa and Tibetin children, while the environmental differences are so obvious.

Why is there an epidemic of myopia in Asia?

Possible factors that may contribute to an epidemic of myopia in Asia but not in North America or Europe are stress-the stress of everyday life and the stress in relation to the need to achieve-and, in some areas, the necessity to read the Chinese characters could add to the stress. There is no doubt that everyday life can be more stressful in Taiwan, Singapore or Hong Kong than in a typical city in Europe or North America. The role of stress as a cause of myopia in Taiwan was discussed by Lin and colleagues: who commented: 'In Taiwan, most school children are placed f stress by the highly comunder a great deal o petitive entrance examination. Thqr spend, on average, more then 10 hours in reading and studying every day. Such a long period of nearwork possibly creates the significantly higher myopia prevalence in Chinese school children. It s e m that when all members of a
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population are exposed to a high-risk environment, genetic susceptibility becomes less important as compared with environmental factors. ' In a discussion at the Myopia Workshop in Copenhagen, which I was fortunate to attend in 1987, Lin commented that in Taiwan, parents are determined to enroll their children not only in the best university or the best secondary school but also in the best kindergarten. When I attended a conference at The Hong Kong Polytechnic University in 1999, I was aware of the 'closeness' that one feels in downtown Hong Kong, as when walking the few blocks from the hotel where I stayed to the university. I found that 1could get a feeling of 'distance' only by walking along the waterfront. One of the Polytechnic University faculty members made the observation that this 'closeness' may have something to do with the high prevalence of myopia: you seldom have a chance to completely relax your accommodation. I remember reading, many years ago, that Chinese children were forced to spend many hours each day, learning to read the very complicated Chinese characters. However in a recent e-mail exchange, Maurice Yap informed me that the issue of the Chinese characters is far from simple. Quoting Professor Yap: For a start, English is the medium of instruction in most schools in Singapore. As you know, Singapore is just as good at producing myopes as Taiwan (Chinese characters). In Hong Kong, we have some schools teaching in English ... So ... back to square one!'

Why should we be concerned about the epidemic of myopia?

More than 30 years ago, Sorsby reported that myopia was the fourth greatest cause of blind registrations in England and Wales" and for blindness occurring between the ages of 50 and 59 years, myopia was the most frequent cause of b1indness.l" The majority of the blindness was due to chorioretinal degeneration, with a relatively small minority being due to retinal detachment. More recently, in a discussion of vision impairment due to myopia, Flede1iuslg concluded:

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In the developed countries, myopia is surpassed only by diabetes as a basic disorder in the vision impairment statistics for those aged 30-60 years. In addition to the increased risk o f retinal degeneration and detachment ... cataract and glaucoma are also r e h a n t .
Fledelius19 also made the point that soft contact lens wear a n d refractive surgery are occasional causes of vision impairment. In his eye clinic, he h a d seen longstanding severe cases of keratitis among soft contact lens wearers, some of which were due to Acanthomoeba infections. As for refractive surgery, FledeliusIq said:

In a n article i n US News and World Repmt, Katy Kellyz1 said that although parents had been told that it was their responsibility t o prepare t h e i r children f o r a multi-tasking, technologydriven future: A growing number of educatms, child de-

velopment experts and eye doctors are beginning to speak out against early computer use, especially when it is coupled with regular television watching.

I a m reminded o f Henry Hofstetters paperzzentitled Aims i n optometric education, published more than 50 years ago,
i n which he described the optometrist as the general practitioner in t h e field of vision. As such, we optometrists should be using our influence t o prevent and, where it already exists, to reverse t h e epidemic of myopia.

Though clearly the exception, corneal scarring or a permanent haze may also be present f refractive surgery. aJer various types o

Should we expect an epidemic of myopia i n North America, A u s t r a l i a or New Zealand?

The literature o n myopia contains numerous reports of t h e relationship between reading and myopia. In a recent review of many of these reports, David GossZ0 commented:

REFERENCES
1. Merriam-Websters Collegiate Dictionary. Merriam-Webster Online. 2003. 2. Newcomb RD. Preface. In: Grosvenor T, ed. The Myopia Epidemic: Nearsightedness, Vision Impairment and Other Vision Problems. Ferndale, WA: Twenty Twenty Publications, 2002. 3. Chen C-J, Lin L LK, ShihY-F.Epidemiological studies on multiple risk factors for mycpia in T a i m : geneenvironment interaction. In: Lin LLK, Shih Y-F, Hung PT, eds. Myopia Updates 11. Proceedings of the 7th International Conference on Myopia, 1998. Tokyo: Springer-Verlag,2000: 17-20. 4. Lin L L K , Chen CJ, Hung PT, Ko LS.Nationwide survey among schoolchildren in Taiwan. In: Fledelius HC, Goldschmidt E, eds. The MyopiaWorkshop 1986. Acta Ophthalmol Scand Suppl185,1988 6 6 3436. 5. Lin L LK, Shih Y-F. Morbidity of myopia among schoolchildren in Taiwan. In: Lin L L K, Shih Y-F, Hung PT, eds. Myopia Updates 11. Proceedings of the 7th International Conference on Myopia, 1998. Tokyo: Springer-Verlag, 2000: 7-9. 6. Saw SM, Chua WH, Wu HM et al. Design and initial results of the Singapore myopia cohort study. In: Thorn F, Troilo D, Gwiazda J, eds. Myopia 2000: Proceedings of the VIII International Conference on Myopia. Boston: New England College of Optometry and Schepens Eye Institute, 2000: 4 1 0 . 7. Blum HL, Peters HB, Bettman JW. Vision Screening in Elementary Schools: The Orinda Study. Berkeley: University of California Press, 1959. 8. Edwards MH. The development of myopia in Hong Kong children between the ages
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Today it is generally accepted that visual input somehow guides refactive development, and that near work contributes to myopia deuelopment. In 1989, a National Academy of Sciences working group ... reached the conclusion that doing near work places one at risk for myopia .
Recent studies continue to support that conclusion. Although there does not appear to b e any evidence of a marked increase i n the prevalence of myopia in English-speaking populations during the past several years, the conditions leading to such an increase are becoming increasingly obvious: 1. Some public school officials are suggesting that reading instruction should begin a t an earlier age; for example, in preschool o r kindergarten, rather than i n Grade 1. 2. Children are u n d e r increasing pressure to perform well o n yearly standardised tests, beginning during t h e primary school years. 3. Infants and children are spending more time indoors, being entertained by television a n d c o m p u t e r games, r a t h e r than being involved in outdoor play.

of 7 and 12 years: A five-year longitudinal study. OphthalPhysiol Opt 1999; 19: 286294. 9. Wong TI, Foster PJ, Ng TP et al. The epidemiology of myopia in adult Chinese in Singapore. In: Thorn F, Troilo D, Gwiazda J, eds. Myopia 2000: Proceedings of the VIII International Conference on Myopia. Boston: New England College of Optometry and Schepens Eye Institute, 2000: 21-25. 10. Goh SH, Lam SY. Changes in refractive trends and optical components in Hong Kong Chinese aged 19-39 years. Ophthal Physiol Opt 1994; 1 4 378-382. 11. Lam S Y ,Goh SH, Tang YK, Tsui KK, Wong WC, Man TC. Changes in refractive trends and optical components in Hong Kong Chinese aged over 40 years. Ophthal Physiol Opt 1994; 14: 383388. 12. Grosvenor T, Skeates, PD. Is there a hyperopic shift in myopic eyes during the presbyopic years? Clin Exp Optom 1999; 82: 236243. 13. Goldschmidt E. Epidemiology of myopia: Scandanavia and Hong Kong experiences. In: Lin LLK, Shih Y-F, HungPT, eds. Myopia Updates 11. Proceedings of the 7th International Conference on Myopia, 1998. Tokyo: Springer-Verlag,2000: 2-12. 14. Garner LF, Kinnear R, KlingerJD, McKellar M. Prevalence of myopia in school children in Vanuatu. Acta OphthalmolScand 1985; 63: 323-326. 15. Garner LF, Kinnear R, McKellar J, Klinger JD, Hovander M, Grosvenor T. Refraction and its components in Melanesian schoolchildren in Vanuatu. AmJOptom Physio Opt 1988; 65: 182-189. 16. Garner LF, Owens H, Kinnear R, Frith MJ. Prevalence of myopia in Sherpa and Tibetan children in Nepal. Optom Vis Science 1999; 7 6 282-285. 17. Sorsby A. The Incidence of Blindness in England and Wales, 1948-1962. London: Her Majestys Stationery Office, 1966. 18. Sorsby A. The Incidence of Blindness in England and Wales, 1963-1968. London: Her Majestys Stationery Ofice, 1972. 19. Fledelius HC. Myopia and significant visual impairment: Global aspects. In: Lin LLK, Shih Y-F, HungPT, eds. Myopia Updates 11. Proceedings of the 7th International Conference on Myopia, 1998. Tokyo: SpringerVerlag, 2000: 31-37. 20. Goss DA. More evidence that near work contributes to myopia development. IndianaJ Optom 2002; 5: 11-13, 21. Kelly K. False promise: parking your child in front of a computer may seem like a good idea, but think again. US News and World Repwt Sept 25,2000. 22. Hofstetter HW.Aims in optometric education. JAmer Optom Assoc 1950; 22: 270.

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