The Increasing Burden of Myopia in Israel

among Young Adults over a Generation

Analysis of Predisposing Factors
Yinon Shapira, MD,1,* Michael Mimouni, MD,1,2,* Yossy Machluf, PhD,3,4 Yoram Chaiter, MD, MSc,3
Haitam Saab, MD,3 Eedy Mezer, MD1,2

Purpose: To determine the trends in prevalence of myopia in Israeli young adults over approximately a
generation, as well as associated factors and variation in the impact of these factors on myopia prevalence in this
region over time.
Design: Retrospective, cross-sectional study.
Participants: One hundred four thousand six hundred eighty-nine consecutive persons 16 to 19 years of age
born between 1971 and 1994 who had not yet enlisted in the Israeli Army but had completed the medical profiling
process.
Methods: Using data collected at a north Israel recruitment center, the prevalence of myopia over time was
estimated, and a polynomial regression analysis was performed to assess significance of nonlinear trends.
Associations of demographic and socioeconomic factors with myopia were assessed, and trends over time were
analyzed using a factorial logistic regression.
Main Outcome Measures: The primary outcome measure was factors associated with the prevalence of
myopia over time. The secondary outcome measure was a description of the change in prevalence of myopia over
time.
Results: The prevalence of myopia increased 1.284-fold over 24 years from 20.4% among participants born
between 1971 and 1982 to 26.2% among participants born between 1983 and 1994. A quite similar increase was
observed among males (from 17.9% to 22.7%, respectively) and females (from 23.9% to 30.8%, respectively).
The factors found to be associated with myopia were as follows: more recent date of birth, female gender, more
years of education, being the eldest child, non-Israeli ethnic origin, and urban residence. However, there were
significant trends over time in the effects of some of these factors, most notably an attenuation of the difference
between participants of different religions in the recent birth-years period. Most of these associations and trends
were observed in both males and females separately, with some gender-specific variations. Immigrants from
Ethiopia who were raised in Israel were highly more likely to demonstrate myopia than those who arrived at an
older age.
Conclusions: This study demonstrated an increase in the prevalence of myopia and the possible associa-
tions of urbanization- and higher education-related factors among several subpopulations and the risk for myopia
developing. Ophthalmology 2019;-:1e10 ª 2019 by the American Academy of Ophthalmology

Supplemental material available at www.aaojournal.org.

Uncorrected myopia is a frequent cause of visual
impairment in the world,1 with significant socioeconomic
consequences.2 The cost of providing refractive
correction presents a major challenge in many parts of
the world, especially developing countries. The
prevalence of myopia has risen dramatically,3 having
reached nearly 90% in urban East Asia4 and roughly
40% in Western countries.5 In the United States, the
prevalence of myopia has doubled in the last 30 years,5
and myopia is now considered an epidemic6 and a
major public health concern.7 In Israel, the prevalence
of myopia among young military candidates was
reported to have increased by nearly 40% between 1990
and 2002.8
High myopia, of 6 diopters (D) or more,9 has been
reported to be a leading cause of blindness, affecting up to
3% of the population worldwide.10 High myopia is
associated with many ocular comorbidities, with more
than 60% demonstrating peripheral vitreoretinal pathologic
features11 associated with higher rates of rhegmatogenous
retinal detachment.1,12 In addition, participants with
myopia are predisposed to both posterior subcapsular and
nuclear cataracts13 with a higher nuclear density,14
glaucoma,15 choroidal neovascularization,16 and others,17

ª 2019 by the American Academy of Ophthalmology https://doi.org/10.1016/j.ophtha.2019.06.025 1

Published by Elsevier Inc. ISSN 0161-6420/19
 Ophthalmology Volume -, Number -, Month 2019
all of which may be detrimental to visual function or may
lead to permanent vision loss.
Both genetic and environmental factors are involved in
the development of myopia.18 Myopia-related heterozygous
mutations,19 inherited retinal dystrophies,20 and high-risk
genetic loci21 have been reported. However, genome-wide
association studies have shown that less than 5% of
genetic variability of refractive error can be explained by
identified genetic variants.22 A strong case has been made
for the importance of environmental influences in driving
the current epidemic prevalence rates of myopia.23,24
Environmental factors that have been reported include lit-
tle time spent outdoors,25,26 extended near work,27,28 season
of birth,29 maternal smoking during pregnancy,30 birth
order,31 number of years of education,24,32 and study
habits.33 The exact interplay between environmental factors
leading to increase in the prevalence and severity of myopia
remains a subject of intense research.1,7,34,35
Large databases have been used in a broad range of
ophthalmic research studies into disease surveillance, trends,
causes, and outcomes.36 Large population studies over an
extended period have provided sufficient power to study
small effect sizes and long-term events and trends.36
Therefore, the purpose of the current study was to identify
factors associated with myopia and to investigate the
influence and interplay of these factors over time on the
prevalence of myopia.
Methods
Israeli Defense Forces Medical Corps Institutional Review Board
approval was obtained, and this research adhered to the tenets of
the Declaration of Helsinki. The study relies on computerized
anonymous database. No identifying information exists in the
database that was used for analysis.
Study Participants
The Israeli National Military Service Act requires all 17-year-old
Israelis to undergo medical profiling at a regional recruitment
center. At the end of this process, a medical profile and appropriate
Functional Classifications Codes are assigned to each recruit and
stored in a computerized database. Functional Classifications
Codes describe the medical status and are similar to the Interna-
tional Classification of Diseases coding. The medical process and
its outcomes have been described previously in detail.37
The computerized database of the northern recruitment center of
Israel was used for this study, previously shown to possess a
stringent, high-quality medical process and reliable medical data.37
The study population consisted of consecutive conscripts 16 to 19
years of age who were born between 1971 and 1994 and who
completed the medical profiling process between 1988 and 2011,
as previously described by the authors.38
There are several populations in Israel that may be underrep-
resented in this study because of military service exemption:
females who are married, pregnant, mothers, or of any minority;
religious orthodox Jewish populations; and males of certain
minorities (only Druze and Circassian males are obliged to service
by law, whereas males of other minorities can volunteer). The
authors describe in detail the Israeli Defense Forces’ service law,
populations that are exempt from service, and representativeness of
the study population in the supplementary materials of their pre-
vious publication.39
2
Data Collection
Each participant throughout the study years underwent uncorrec-
ted distance visual acuity testing using a standard calibrated pro-
jected Snellen chart examination. Visual acuity testing was carried
out by a selected group of skilled medical technicians who were
trained by experienced staff ophthalmologists and the staff of
attending physicians. The training was based on specific and
detailed protocols that were published by the Israeli Defense
Forces Medical Corps. Care was taken to adhere to the protocol
and to use the same principles and methods over the years by all
technicians. Participants who could read all the letters but 1 from
the 1.0 (6/6) line, that is, who had a visual acuity score of better
than 6/6e1 without optical correction were assumed to have a
refractive error of 0 D (emmetropia). Of 104 689 young adults in
this study, 78 476 demonstrated uncorrected distance visual acuity
of 6/6e1 or better and thus were assumed to be emmetropic. The
remaining participants with an uncorrected distance visual acuity
of 6/6e2 or worse were referred to undertake automated non-
cycloplegic refraction (Speedy K, Nikon Corp., Tokyo, Japan;
KR-8000 and KR7000S, Topcon, Tokyo, Japan; and earlier
models) followed by a subjective refraction validation using a
standard Snellen chart for determination of best-corrected visual
acuity. This was carried out by either a certified optometrist or an
ophthalmologist.
The computerized medical database of all eligible recruits
was reviewed, and the relevant data were extracted, including
birth year, age at presentation, gender, spherical equivalent
refractive error, ethnic origin, country of birth, immigration sta-
tus, religion, residential environment, education level, socioeco-
nomic status (recording began from the year 1982 onward), birth
order, number of children in family, and the season at the time
of birth.
Data Analysis
Myopia and high myopia were defined as spherical equivalent of
e0.5 D or less and spherical equivalent of e6.0 D or less,
respectively, in at least 1 eye (excluding antimetropia, i.e., hy-
permetropia in one eye and myopia in the other eye). Data were
analyzed with StatSoft Statistica software version 10 (StatSoft,
Tulsa, OK). Time trend regression analyses of the general
prevalence of myopia were conducted for 5 relatively equally
spaced periods (1971e1975, 1976e1980, 1981e1985,
1986e1990, and 1991e1994), and this grouping was constructed
a priori to ensure that the analysis would not be driven by data.
A year-by-yearebased time trend analysis was performed as
well. A polynomial regression analysis was performed to assess
significance of nonlinear trends. Graphs are presented with their
corresponding regression lines, respective equations, R2 values,
and P values. A chi-square test was used for comparison of
proportions.
To identify trends over time in the effect of the available
baseline parameters on the prevalence of myopia, a factorial
logistic regression was conducted. Specifically, interaction effects
between each of the available baseline parameters (including
gender, religion, education years, number of children in family,
birth order, ethnic origin, immigration status, residential environ-
ment, and season of birth) and the birth year on the prevalence of
myopia (i.e., the dependent factor) were analyzed. To that end, a
birth-year stratification was categorized by 2 equal periods of 12
years (1971e1982 vs. 1983e1994), each containing a comparable
number of participants (51 496 vs. 53 193). The same analysis was
conducted separately for males and for females.
All factors reaching a P value of less than 0.1 in a univariate
analysis (for differences between the categories of the factor in the
 Shapira et al 
Myopia among Israeli Young Adults
Figure 1. Graph showing the prevalence of myopia by birth year among young adults in northern Israel.
general prevalence of myopia) were included in a multiple logistic
regression analysis to test for their independent effects on the
likelihood of myopia. For all analyses, a 2-sided P value of less
than 0.05 was considered statistically significant.
Results
The study population consisted of 104 689 young adults born be-
tween 1971 and 1994. The mean age was 17.4
0.6 years (median,
17.3 years; range, 16e19 years), and 58% were males. Myopia was
detected in 24 431 participants (23.3%), comprising 12 267 myopic
males (20.3%) and 12 164 myopic females (27.5%).
As shown in Figure 1 (Fig S1, available at www.aaojournal.org, for
corresponding year-by-year data analysis), the prevalence of myopia
increased steadily over a period of 24 years of birthdfrom 18%, to
21%, to more than 25%damong young adults born from 1971
through 1975, from 1976 through 1980, and later birth year categories,
respectively (R2 ¼ 0.98; P < 0.0001). The late 1970s and early 1980s
seemed to be when the prevalence increased substantially, with smaller
increases and some stabilization more recently. The prevalence of
myopia was 20.4% in the population born between 1971 and 1982,
with a 1.284-fold (28.4%) increase to 26.2% (P < 0.0001) in the
population born between 1983 and 1994. A quite similar increase
(Fig 1) was observed among males (from 17.9% to 22.7%,
respectively) and females (from 23.9% to 30.8%, respectively).
Sociodemographic Factors
The prevalence of myopia in young adults born during the earlier
period of 1971 through 1982 versus the more recent years of 1983
through 1994, stratified by various sociodemographic factors, is
presented in Table 1 (Table S1, available at www.aaojournal.org,
depicts a corresponding substratification by gender). A higher
prevalence of myopia among females compared with males was
observed in both birth-year periods (P < 0.0001), and the in-
crease in the prevalence of myopia was similar for both genders in
the more recent birth-year period (P ¼ 0.10, for trend). A relatively
lower prevalence of myopia was found among Arab participants of
all persuasions (Christian, Druze, Muslim, and Bedouin) compared
with Jewish participants in both birth-year periods (P < 0.0001).
However, the increase in the prevalence of myopia rose much more
steeply among those of Arab descent compared with those of
Jewish decent (P ¼ 0.001, for trend).
A greater percentage of participants who attained higher edu-
cation of 12 years or more demonstrated myopia in both birth-year
periods (P < 0.0001). The association between myopia and the
number of years of education did not change significantly over
time (P ¼ 0.09, for trend). Of note, a substantial increase was
found in the proportion of the sample with higher levels of edu-
cation over the birth years; from 1971 through 1975, only
approximately 72% of the population had completed 12 years or
more of education, and this proportion increased to 88%, 92%,
93%, and 85% in the following years (1976e1980, 1981e1985,
1986e1990, and 1991e1994, respectively). Furthermore,
throughout all years, a higher proportion of females attained 12
years or more of education when compared with males. Namely,
the proportion in females versus males was 81% versus 66%
(P < 0.0001), 93% versus 84% (P < 0.0001), 96% versus 89%
(P < 0.0001), 96% versus 91% (P < 0.0001), and 87% versus 84%
(P ¼ 0.0001) from 1976 through 1980, 1981 through 1985, 1986
through 1990, and 1991 through 1994, respectively.
Fewer children in the family during childhood was associated
significantly with a higher prevalence of myopia in both birth-year
periods (P < 0.0001 and P ¼ 0.01, respectively). However, this
difference diminished during the recent birth-year period compared
with the earlier period, in fact exhibiting a sharper rise in the rate of
myopia among those with a greater number of siblings (P < 0.0001,
for trend). This trend was similar among males and among females.
Similarly, the prevalence of myopia during both periods was
significantly higher among participants who were raised as an
only child (P < 0.0001 and P ¼ 0.01, respectively). However,
the increase in the prevalence of myopia was least notable in
participants who were an only child (þ10%), whereas the largest
rise occurred in the group who grew up as middle children
(þ34%; P ¼ 0.001, for trend). This trend was similar among
males and among females.
3
 Ophthalmology Volume -, Number -, Month 2019

Table 1. Prevalence of Myopia in Young Adults Born from 1971 through 1982 versus 1983 through 1994 Stratified by Sociodemographic
Factors

Prevalence of Myopia, No./Total No. (%)

Parameter Categories Participants Born 1971e1982 Participants Born 1983e1994 % Change* P Valuey
Gender Males 5408/30 186 (17.9) 6859/30 198 (22.7) þ26 0.10
Females 5093/21 310 (23.9) 7071/22 995 (30.8) þ29
P valuez <0.0001 <0.0001
Religion Jewish 10 027/46 576 (21.5) 12 791/46 359 (27.6) þ28 0.001
Other 279/1342 (20.8) 651/2968 (21.9) þ5
Christians 25/304 (8.2) 18/120 (15.0) þ83
Druze 121/2029 (6.0) 94/1060 (8.9) þ48
Muslims 15/344 (4.4) 49/587 (8.3) þ93
Bedouins 34/901 (3.8) 93/1106 (8.4) þ115
P valuez <0.0001 <0.0001
Socioeconomic statusx High NA 306/1074 (28.5) NA
Medium NA 7505/26 836 (28.0)
Low NA 1577/6152 (25.6)
P valuez 0.001
Education (no. of yrs) 1e6 462/2748 (16.8) 4/40 (10.0) e40 0.09
7e9 144/1349 (10.7) 133/830 (16.0) þ50
10e11 692/5014 (13.8) 763/4026 (19.0) þ38
12 9205/42 403 (21.7) 13 030/48 261 (27.0) þ24
P valuez <0.0001 <0.0001
No. of children in family 1 388/1566 (24.8) 820/2992 (27.4) þ10 <0.001
2e3 4077/19 045 (21.4) 6328/24 705 (25.6) þ20
4e5 4193/20 974 (20.0) 5224/19 460 (26.8) þ34
6 1843/9922 (18.6) 1558/6034 (25.8) þ39
P valuez <0.0001 0.01
Birth order Only child 388/1566 (24.8) 820/2992 (27.4) þ10 0.001
First born 3453/15 811 (21.8) 3910/14 484 (27.0) þ24
Middle child 4421/22 990 (19.2) 5113/19 766 (25.9) þ34
Last born 2239/11 139 (20.1) 4087/15 949 (25.6) þ27
P valuez <0.0001 0.01

Boldface indicates statistical significance. P values in the third and forth columns (from the left) relate to differences between categories in each birth-year
period (either 1971-1982 or 1983-1994) and P value in the sixth column refers to significance of trend between the periods.
NA ¼ not available.
*Percent change in the prevalence of myopia per parameter category from 1971 through 1982 to 1983 through 1994.
y
Binomial logistic regression for the interaction effect between the tested parameter and the birth year (on the prevalence of myopia).
z
Chi-square test for differences between the categories of the tested parameter (in the prevalence of myopia).
x
Socioeconomic status available only from 1982 onward.

Ethnic or Environmental Factors
The prevalence of myopia in young adults born from 1971 through
1982 in comparison with those who were born from 1983 through
1994, stratified by ethnic or environmental factors, is presented in
Table 2 (Table S2, available at www.aaojournal.org, depicts a
corresponding substratification by gender). Ethnic variations in
myopia prevalence were more pronounced among males
(Table S2); participants of Israeli descent (of all religious
backgrounds) showed the lowest prevalence of myopia compared
with participants whose families originated abroad throughout all
birth years (P < 0.0001). However, although the highest increase
over time in the prevalence of myopia occurred in male
participants of Israeli descent, among males and among females
there seemed to be a sharper increase among participants of
African and Asian descent when compared with participants of
American, European, and the former Soviet Union descent
(P < 0.0001, for trend among males and that among females).
Native Israelis (of all religious and ethnic backgrounds) showed
a lower prevalence of myopia compared with immigrants in the
earlier birth-year period (P < 0.0001) but showed an (proportional)
increase of more than 3 times that of the immigrants, reaching a
higher prevalence in the recent birth-year period (P ¼ 0.001).
Among males, living in an urban residential area was associated
with a significantly higher prevalence of myopia in both birth-year
periods (Table S2; P < 0.0001). Among females, this urbanerural
gradient was evident only in the recent birth-year period (Table S2).
None of the seasons of birth were associated
significantly with myopia (P > 0.05), with a similar rate of
increase in the prevalence of myopia over time for all the sea-
sons (P ¼ 0.11, for trend). This was evident among males and
among females.
The effect of ethnic origin, place of birth, and immigration status
was analyzed further, as presented in Table 3. Among native Israelis,
there was a significant difference in the pooled (i.e., all birth years
included) prevalence of myopia among participants of different
ethnic origins. The highest prevalence was noted among Israel-born
participants of former Soviet Union origin, followed by Israel-born
participants of Ethiopian origin, followed by native Israelis of Israeli
origin (P < 0.0001). Participants of Ethiopian origin who immigrated
to Israel after the age of 7 years showed a 2-fold lower prevalence of

4
 Shapira et al 
Myopia among Israeli Young Adults

Table 2. Prevalence of Myopia in Young Adults in Northern Israel Born in 1971 through 1982 versus 1983 through 1994 Stratified by
Ethnicity and Environmental Factors

Prevalence of Myopia, No./Total No. (%)

Parameter Categories Participants Born 1971e1982 Participants Born 1983e1994 % Change* P Valuey
Ethnic origin Africa 3168/15 630 (20.3) 4634/16 615 (27.9) þ37 <0.0001
Former Soviet Union 1538/6900 (22.3) 2529/9967 (25.4) þ14
Israel 801/6647 (12.1) 1262/6971 (18.1) þ50
Europe 2756/12 301 (22.4) 2421/9135 (26.5) þ18
America 439/1822 (24.1) 555/2105 (26.4) þ10
Asia 1700/7737 (22.0) 2434/8039 (30.3) þ38
Oceania 11/44 (25.0) 21/61 (34.4) þ38
Other 88/415 (21.2) 74/300 (24.7) þ17
P valuez <0.0001 <0.0001
Immigration status Native Israelis 9154/45 552 (20.1) 11 477/43 332 (26.5) þ32 <0.0001
Immigrants 1347/5944 (22.7) 2453/9861 (24.9) þ10
P valuez <0.0001 0.001
Residential environment Urban 5699/26 153 (21.8) 7596/26 326 (28.9) þ33 0.001
Rural 4802/25 343 (18.9) 6334/26 867 (23.6) þ25
P valuez <0.0001 <0.0001
Season of birth Autumn 2618/13 167 (19.9) 3459/13 193 (26.2) þ32 0.11
Winter 2495/12 423 (20.1) 3453/13 029 (26.5) þ32
Spring 2570/12 469 (20.6) 3465/13 256 (26.1) þ27
Summer 2818/13 437 (21.0) 3553/13 715 (25.9) þ24
P valuez 0.11 0.74

Boldface indicates statistical significance.

*Percent change in the prevalence of myopia per parameter category from 1971 through 1982 to 1983 through 1994.
y
Binomial logistic regression for interaction effect between the tested parameter and the birth year (on the prevalence of myopia).
z
Chi-square test for differences between the categories of the tested parameter (in prevalence of myopia).

myopia when compared with participants of Ethiopian origin who
were either born in Israel or who immigrated to Israel before the age of
7 years (P < 0.0001). In contrast, participants of former Soviet Union
decent showed a relatively homogenous prevalence of myopia
(Table 3). However, a smaller prevalence of myopia was noted among
participants who immigrated to Israel before the age of 7 years
compared with those who either were born in Israel or immigrated
to Israel after the age of 7 years (P < 0.0001).
Independent Predictive Value of Baseline
Factors on Prevalence Myopia
All factors reaching a P < 0.1 level of significance in a univariate
analysis (for differences between the categories of the factor in the
general prevalence of myopia) were included in a multiple logistic
regression analysis (excluding socioeconomic status, which was
not recorded before 1982) to test for their effects on the likelihood
of myopia. The included categorical factors, namely, the birth year,
ethnic origin, immigration status, residential environment, educa-
tion years, birth order, religion, and gender, all maintained their
independent significant predictive value regarding the likelihood of
myopia (Table S3, available at www.aaojournal.org, for the
regression analysis details).
Specifically, birth year maintained its significant predictive
value for the odds of myopia, with an increasing gradient from an
odds ratio (OR) of 1.18 (95% confidence interval [CI], 1.12e1.24)
in the birth years 1976 through 1980 and up to an OR of 1.67 (95%
CI, 1.58e1.77) in the birth years 1991 through 1994 versus the
birth years 1971 through 1975, respectively. In comparison with
participants of Israeli ethnic background, all ethnicities except for

Table 3. Prevalence of Myopia in Young Adults in Northern Israel Stratified by Ethnic Origin, Place of Birth, and Age at Immigration

Ethnic Origin Categories Prevalence of Myopia, No./Total No. (%) P Value*

Israel Birth: Israel 2009/13 443 (14.9) <0.0001
Ethiopian Birth: Israel and Origin: Ethiopia 135/667 (20.2)
Birth: Ethiopia and Immigrated at the age of 0e7 yrs 91/422 (21.6)
Birth: Ethiopia AND Immigrated at the age of >7 yrs 38/373 (10.2)
P valuey <0.0001
Former Soviet Union Birth: Israel and Origin: former Soviet Union 1142/4823 (23.7)
Birth: former Soviet Union and Immigrated at the age of 0e7 yrs 1060/3987 (26.6)
Birth: former Soviet Union and Immigrated at the age of >7 yrs 1919/8333 (23.0)
P valuey <0.0001

*Chi-square test for differences in the prevalence of myopia between the Israeli-born categories of the 3 ethnic origin groups (Israel vs. Ethiopians vs. former
Soviet Union).
y
Chi-square test for differences in the prevalence of myopia between the categories of each of the ethnic groups (Ethiopians or former Soviet Union),
respectively.

5
 Ophthalmology Volume -, Number -, Month 2019
Oceania slightly increased the odds of myopia. The OR ranged
from 1.08 (95% CI, 1.01e1.15) for African descendants and up to
an OR of 1.27 (95% CI, 1.16e1.40) for participants of American
descent. Immigrants showed slightly lower odds (OR, 0.93; 95%
CI, 0.88e0.99) for myopia when compared with native Israelis.
Rural residence predicted lower odds for myopia (OR, 0.83; 95%
CI, 0.80e0.85). The number of years of education showed an
increasing gradient for the odds of myopia, with an OR of 0.67
(95% CI, 0.58e0.76) for 7 to 9 years of education and up to an OR
of 1.16 (95% CI, 1.03e1.30) for more than 12 education years
versus 12 education years. Being a middle child (OR, 0.94; 95%
CI, 0.91e0.98) or a last-born child (OR, 0.89; 95% CI, 0.85e0.93)
decreased the odds of myopia when compared with first-born
participants. In comparison with Jewish participants, all other
religious backgrounds decreased the odds of myopia. The OR
ranged from 0.30 (95% CI, 0.23e0.39) for Muslims and up to an
OR of 0.45 (95% CI, 0.33e0.63) for (Arab) Christians. Finally,
females showed a higher likelihood of myopia (OR, 1.32; 95% CI,
1.28e1.36).
High Myopia
Of 24 431 persons with myopia in the study population, 1725
(7.1% of those with myopia; 1.65% of the entire study population)
showed high myopia (e6 D). In the birth years 1971 through
1975, the prevalence of high myopia was 1.38%, and it was 1.65%,
1.69%, 1.80%, and 1.67% in the years 1976 through 1980, 1981
through 1985, 1986 through 1990, and 1991 through 1994,
respectively (P ¼ 0.002 for trend; see Fig S2, available at
www.aaojournal.org). Overall, in the birth years 1971 through
1982, the prevalence of high myopia was 1.54%, and it rose to
1.75% during the birth years 1983 through 1994 (P ¼ 0.009).
All factors included in the multiple logistic regression analysis
to test for their effects on the likelihood of myopia (Table S3) were
retested in a multiple logistic regression analysis for their effects on
the likelihood of high myopia (Table S4, available at
www.aaojournal.org). For this end, the dependent variable
constituted all those with e6 D or less of myopia versus the
entire nonmyopic population. Birth year, residential environment,
education years, birth order, religion, and gender were
independent significant predictors of high myopia. However,
ethnic origin and immigration status were not significant
predictors of high myopia (see Table S4 for regression analysis
details).
Discussion
This study assessed the prevalence of myopia as well as
high myopia in young adults in northern Israel over a
generation and identified associated factors and their in-
fluence over time using a large dataset. Uncorrected
myopia is a leading cause of vision impairment world-
wide and imparts an economic burden on the individual
and the state, especially in low-income countries.2 High
myopia significantly increases the risk of associated
blinding ocular conditions. Hence, identifying such
factors is an essential building block in locating high-
risk populations that are more likely to require interven-
tion.24 In addition, via identification of modifiable risk
factors, light may be shed on the pathophysiologic
features of myopic development that remain
incompletely understood today.40
6
The prevalence of myopia has increased over time
worldwide. In a recent systematic review, Holden et al3
reported that the estimated prevalence of myopia ranged
between 3.2% (East Africa) and 46.1% (high-income Asia
Pacific) in 2000 and increased to 4.9% and 48.8%,
respectively, in 2010. Based on additional estimates, the
prevalence of myopia in North America (28.3%e34.5%),
Western Europe (21.9%e28.5%), and Australia (19.7%e
27.3%) increased by approximately 25% to 50% during
this period.3 In the current study of young adults in
northern Israel, the prevalence of myopia increased from
18% to 26% over 2 decades (1988e2011). This estimate
is supported by the study of Bar Dayan et al,8 who
reported a similar increase in the prevalence of myopia
from 20.3% in 1990 to 28.3% in 2002. The prevalence of
myopia in Israel seems to be somewhere between its
prevalence in North Africa and the Middle East and in
European countries as estimated by Holden et al. Indeed,
most participants in this study were of North African
ethnicity, followed by the former Soviet Union, Asia, and
Europe. According to a recent publication, myopia
numbers are expected to rise worldwide to 5 billion
persons with myopia and 1 billion persons with high
myopia by 2050.3
In this study, female gender was associated with myopia
(OR, 1.32; 95%, CI 1.28e1.36) and high myopia (OR, 1.26;
95% CI, 1.14e1.40). This finding supports the findings of
previous studies.41,42 In a large study of Israeli-born con-
scripts, Mandel et al41 reported that female gender was
associated significantly with myopia (OR, 1.14). In their
systematic review, Rudnicka et al42 reported that although
white and East Asian women were twice as likely to be
myopic than their male counterparts by the age of 18
years, there was a lack of evidence or no clear differences
between genders in the other investigated ethnicities
(South Asian as well as Hispanic and Latino) after
adjusting for age, environmental setting, and year of
survey. In the aforementioned study, the association
between female gender and myopia increased as the
participants aged from 7 to 18 years. However, Hashemi
et al43 reported that in Western Iran, myopia was
associated significantly with male gender (OR, 3.1). In the
current study, most baseline parameters exhibited a similar
risk for myopia in both males and females, as well as a
similar interaction with the time factor. Furthermore, the
regression analysis incorporating all baseline factors
(including gender) confirmed the independent effect of
these factors on the likelihood of myopia. Nonetheless, the
stratification by gender revealed noteworthy gender
differences. In concurrence with the aforementioned previ-
ous reports, ethnic variations were evident between males
and females both in the prevalence of myopia as well as in
its trend over time. Also, gender variations were observed
with respect to the influence of living in an urban versus
rural environment.
Given the current findings and the variability in the re-
ports on the association of gender and prevalence of myopia
from various regions of the globe, it may be that the rela-
tionship between gender and myopia is complicated and
may be affected by additional factors such as education
 Shapira et al 
Myopia among Israeli Young Adults
(accounted for in the current study) and outdoor activities or
overall exposure to light (not accounted for directly in the
current study), as well as other influences.44
In the current study, we revealed a strong correlation
between higher education and the prevalence of myopia as
well as high myopia. Throughout the study years, a strong
association between myopia and the number of years of
education was found, and this association did not change
significantly over time. Interestingly, the proportion of the
population with higher levels of education increased sub-
stantially, in fact corresponding with the substantial increase
in myopia prevalence evident in the early 1980s. This could
be a contributing factor to the increase in myopia prevalence
over time, although the relationship between myopia and
education has remained the same. Furthermore, a signifi-
cantly higher percentage of women attained 12 years or
more of education compared with men throughout the study
years. This may be an important factor that could explain
partially the higher prevalence of myopia in women in the
current study. The association between education and both
socioeconomic status and myopia has been well estab-
lished,32 and often it is difficult to analyze each factor
independently.24 Lack of outdoor activities45,46 and a high
amount of near-work activities47,48 both have been
suggested as possible mediators.
A plethora of data supports the association between
urban (vs. rural) residency and myopia.3,49,50 This is most
likely because of less outdoor activity and more indoor
activity while growing up in an urban region, further
confounded by increased near-work activity, all of which
have been shown to be associated with urban environs.49
Indeed, in the current study, living in an urban residential
area was highly significantly associated with a greater
prevalence of myopia as well as high myopia. In addition,
a relatively lower prevalence of myopia (and high
myopia) was found among participants of Arab descent
when compared with Jewish participants, with the
prevalence of myopia rising more sharply among Arabs in
the recent birth-year period (P ¼ 0.001). This may be
because of a large proportion of the Arab population in
Israel residing in rural areas and the increasing rate of
myopia reflecting urbanization and improvement in socio-
economic factors, including education in this population
sector.51 Recent interventional prospective studies have
shown that encouraging outdoor activity and exposure to
sunlight effectively prevents the development of
myopia.46,52,53 Animal studies have demonstrated that the
retina releases dopamine when exposed to higher levels of
luminance,54,55 leading to inhibition of increase in axial
length.56e60 Despite the apparent advantages of increased
time spent outdoors to increase exposure to light, it is still
unclear how much time is needed, and the potential
disadvantages, such as exposure to ultraviolet radiation in
countries with high levels of ultraviolet light, need to be
taken into account as well.46 Nevertheless, it is likely that
adequate sun protection, including sunglasses, hats, and
sunscreen, can be worn while outdoors to prevent adverse
effects of ultraviolet exposure, while still receiving the
benefits of such exposure to reduce the development of
myopia, given that it is light intensity and not ultraviolet
light wavelength that seems to be important.57,60
Sufficient evidence supports the association of ethnicity
with myopia.61e63 Given that less than 5% of variation in
refractive error is explained by genetics in genome-wide
association studies,22 it seems as though differences in
myopia risk between ethnic groups are more likely the
result of environmental exposure than genetics.
Participants of Ethiopian origin who immigrated to Israel
after the age of 7 years showed a 2-fold lower prevalence
of myopia when compared with participants of Ethiopian
origin who either were born in Israel or immigrated to Israel
before the age of 7 years (P < 0.0001). This may mirror the
transition from an agrarian way of life in Ethiopia to the
urban and highly westernized state of Israel.64 In contrast,
participants from the former Soviet Union demonstrated a
relatively homogenous prevalence of myopia regardless of
the age of immigration, leading us to speculate that this
depicts the high level of education and European urban
socioeconomic background of the immigrants from the
former Soviet Union.
This study underscores sociodemographic trends with
regard to their influence on the risk for myopia. However,
the effects of the season of birth, gender, or the number of
years of education did not alter over the years. However,
some sociodemographic factors attenuated with regard to
their effect on myopia prevalence. For example, Israeli
Arabs of different religions showed a catch-up trend with
the Jewish population, with an attenuated difference be-
tween the religions in the recent birth-year period. A similar
trend was evident for family structure, with both birth order
and the size of the family (number of children) exhibiting
less pronounced differences in myopia prevalence in the
recent birth-year period. Finally, a trend of an increasing
ruraleurban gradient in the prevalence of myopia was
found.
This study has several limitations, the first of which is its
retrospective nature. Second, a cutoff point of e0.5 D was
used to define myopia, and we did not distinguish between
the various levels of myopia (with the exception of a high-
myopia subanalysis that was conducted). Third, certain
populations, such as extra-orthodox males, are not repre-
sented in this cohort. They are characterized by a higher
prevalence and degree of myopia (in general and compared
with females), probably because of a high abundance of
myopia-related risk factors, including many hours of reading
inside closed and dim rooms.8,33,65 Fourth, participants who
showed an uncorrected visual acuity score of 6/6e1 were
assumed to have a refractive error of 0 D, and therefore,
some myopic participants may have been missed. However,
uncorrected visual acuity assessment has been shown to be a
sensitive method for detecting myopia.66,67 Fifth, we were
not able to assess or account for the influence of interre-
latedness between siblings in our analyses. Finally, this
study included participants from northern Israel, and there-
fore its findings may not be generalized to other geographic
areas. Interestingly, our group previously showed that an
attempt to include recruits from various centers throughout
Israel would have exposed the study to a wide variability in
7
 Ophthalmology Volume -, Number -, Month 2019
the process of physical and ophthalmic examinations con-
ducted at different centers.68 The aforementioned could
explain why Bar Dayan et al8 reported a greater increase
in myopia (approximately 40%) from 1990 to 2002 while
assessing multiple recruitment centers throughout Israel.
In summary, our study provides insights into the trends in
myopia and its potential association with sociodemographic
factors including immigration, education, and urbanization
among young adults in northern Israel over a generation.
Indeed, several factors were found to be associated in the
current study with a higher prevalence of myopia: female
gender, Jewish faith, more than 12 years of education, being
an only child, being the eldest child, more recent date of
birth, non-Israeli ethnic origin of the parents, as well as
growing up in an urban location. This study demonstrated
that the worldwide epidemic of myopia has invaded Israel
during the past decade. Although many people enjoy better
socioeconomic status and education in Israel as well as all
over the world, we have shown that the consequence may be
an increase in the global burden of myopia. Identifying these
causes may be the first step to providing future interventions
to prevent the progression of myopia.
References
1. Flitcroft DI. The complex interactions of retinal, optical and
environmental factors in myopia aetiology. Prog Retin Eye
Res. 2012;31(6):622e660.
2. Resnikoff S, Pascolini D, Mariotti SP, Pokharel GP. Global
magnitude of visual impairment caused by uncorrected
refractive errors in 2004. Bull World Health Organ.
2008;86(1):63e70.
3. Holden BA, Fricke TR, Wilson DA, et al. Global prevalence of
myopia and high myopia and temporal trends from 2000
through 2050. Ophthalmology. 2016;123(5):1036e1042.
4. Lin LL, Shih YF, Hsiao CK, Chen CJ. Prevalence of myopia
in Taiwanese schoolchildren: 1983 to 2000. Ann Acad Med
Singapore. 2004;33(1):27e33.
5. Vitale S, Sperduto RD, Ferris 3rd FL. Increased prevalence of
myopia in the United States between 1971e1972 and
1999e2004. Arch Ophthalmol. 2009;127(12):1632e1639.
6. Wolffsohn JS, Flitcroft DI, Gifford KL, et al. IMIdMyopia
Control Reports Overview and Introduction. Invest Oph-
thalmol Vis Sci. 2019;60(3):M1eM19.
7. Morgan IG, Ohno-Matsui K, Saw SM. Myopia. Lancet.
2012;379(9827):1739e1748.
8. Bar Dayan Y, Levin A, Morad Y, et al. The changing preva-
lence of myopia in young adults: a 13-year series of
population-based prevalence surveys. Invest Ophthalmol Vis
Sci. 2005;46(8):2760e2765.
9. Ohno-Matsui K, Lai TY, Lai CC, Cheung CM. Updates of
pathologic myopia. Prog Retin Eye Res. 2016;52:156e187.
10. Wong TY, Ferreira A, Hughes R, et al. Epidemiology and
disease burden of pathologic myopia and myopic choroidal
neovascularization: an evidence-based systematic review. Am
J Ophthalmol. 2014;157(1):9e25 e12.
11. Cheng SC, Lam CS, Yap MK. Prevalence of myopia-related
retinal changes among 12e18 year old Hong Kong Chinese
high myopes. Ophthalmic Physiol Opt. 2013;33(6):652e660.
8
12. Li X; Beijing Rhegmatogenous Retinal Detachment Study
Group. Incidence and epidemiological characteristics of
rhegmatogenous retinal detachment in Beijing, China.
Ophthalmology. 2003;110(12):2413e2417.
13. Wong TY, Foster PJ, Johnson GJ, Seah SK. Refractive errors,
axial ocular dimensions, and age-related cataracts: the Tanjong
Pagar Survey. Invest Ophthalmol Vis Sci. 2003;44(4):
1479e1485.
14. Praveen MR, Vasavada AR, Jani UD, et al. Prevalence of
cataract type in relation to axial length in subjects with high
myopia and emmetropia in an Indian population. Am J Oph-
thalmol. 2008;145(1):176e181.
15. Jonas JB, Aung T, Bourne RR, et al. Glaucoma. Lancet.
2017;390(10108):2183e2193.
16. Zhu Y, Zhang T, Xu G, Peng L. Anti-vascular endothelial
growth factor for choroidal neovascularisation in people with
pathological myopia. Cochrane Database Syst Rev. 2016;12:
1e67. CD011160.
17. Cho BJ, Shin JY, Yu HG. Complications of pathologic
myopia. Eye Contact Lens. 2016;42(1):9e15.
18. Wenbo L, Congxia B, Hui L. Genetic and environmental-
genetic interaction rules for the myopia based on a family
exposed to risk from a myopic environment. Gene. 2017;626:
305e308.
19. Wang B, Liu Y, Chen S, et al. A novel potentially causative
variant of NDUFAF7 revealed by mutation screening in a
Chinese family with pathologic myopia. Invest Ophthalmol Vis
Sci. 2017;58(10):4182e4192.
20. Hendriks M, Verhoeven VJM, Buitendijk GHS, et al. Devel-
opment of refractive errorsdwhat can we learn from inherited
retinal dystrophies? Am J Ophthalmol. 2017;182:81e89.
21. Musolf AM, Simpson CL, Moiz BA, et al. Caucasian families
exhibit significant linkage of myopia to chromosome 11p.
Invest Ophthalmol Vis Sci. 2017;58(9):3547e3554.
22. Hysi PG, Wojciechowski R, Rahi JS, Hammond CJ. Genome-
wide association studies of refractive error and myopia, lessons
learned, and implications for the future. Invest Ophthalmol Vis
Sci. 2014;55(5):3344e3351.
23. Morgan I, Rose K. How genetic is school myopia? Prog Retin
Eye Res. 2005;24(1):1e38.
24. Morgan IG, French AN, Ashby RS, et al. The epidemics of
myopia: aetiology and prevention. Prog Retin Eye Res.
2018;62:134e149.
25. French AN, Ashby RS, Morgan IG, Rose KA. Time outdoors
and the prevention of myopia. Exp Eye Res. 2013;114:58e68.
26. Sherwin JC, Reacher MH, Keogh RH, et al. The association
between time spent outdoors and myopia in children and ad-
olescents: a systematic review and meta-analysis. Ophthal-
mology. 2012;119(10):2141e2151.
27. Huang HM, Chang DS, Wu PC. The association between near
work activities and myopia in childrenda systematic review
and meta-analysis. PLoS One. 2015;10(10):e0140419.
28. Mutti DO, Mitchell GL, Moeschberger ML, et al. Parental
myopia, near work, school achievement, and children’s
refractive error. Invest Ophthalmol Vis Sci. 2002;43(12):
3633e3640.
29. Ma Q, Xu W, Zhou X, et al. The relationship of season of birth
with refractive error in very young children in eastern China.
PLoS One. 2014;9(6):e100472.
30. Rahi JS, Cumberland PM, Peckham CS. Myopia over the
lifecourse: prevalence and early life influences in the 1958
British birth cohort. Ophthalmology. 2011;118(5):
797e804.
 Shapira et al 
Myopia among Israeli Young Adults
31. Guggenheim JA, McMahon G, Northstone K, et al. Birth order
and myopia. Ophthalmic Epidemiol. 2013;20(6):375e384.
32. Williams KM, Bertelsen G, Cumberland P, et al. Increasing
prevalence of myopia in Europe and the impact of education.
Ophthalmology. 2015;122(7):1489e1497.
33. Zylbermann R, Landau D, Berson D. The influence of study
habits on myopia in Jewish teenagers. J Pediatr Ophthalmol
Strabismus. 1993;30(5):319e322.
34. Holden B, Sankaridurg P, Smith E, et al. Myopia, an under-
rated global challenge to vision: where the current data takes
us on myopia control. Eye (Lond). 2014;28(2):142e146.
35. Warner N. Update on myopia. Curr Opin Ophthalmol.
2016;27(5):402e406.
36. Clark A, Ng JQ, Morlet N, Semmens JB. Big data and
ophthalmic research. Surv Ophthalmol. 2016;61(4):443e465.
37. Machluf Y, Pirogovsky A, Palma E, et al. Coordinated
computerized systems aimed at management, control, and
quality assurance of medical processes and informatics.
Int J Health Care Qual Assur. 2012;25(8):663e681.
38. Shapira Y, Machluf Y, Mimouni M, et al. Amblyopia and
strabismus: trends in prevalence and risk factors among young
adults in Israel. Br J Ophthalmol. 2018;102(5):659e666.
39. Machluf Y, Fink D, Farkash R, et al. Adolescent BMI at
northern Israel: from trends, to associated variables and
comorbidities, and to medical signatures. Medicine (Balti-
more). 2016;95(12):e3022.
40. Lee DC, Lee SY, Kim YC. An epidemiological study of the
risk factors associated with myopia in young adult men in
Korea. Sci Rep. 2018;8(1):511.
41. Mandel Y, Grotto I, El-Yaniv R, et al. Season of birth, natural
light, and myopia. Ophthalmology. 2008;115(4):686e692.
42. Rudnicka AR, Kapetanakis VV, Wathern AK, et al. Global
variations and time trends in the prevalence of childhood
myopia, a systematic review and quantitative meta-analysis:
implications for aetiology and early prevention. Br J Oph-
thalmol. 2016;100(7):882e890.
43. Hashemi H, Rezvan F, Beiranvand A, et al. Prevalence of
refractive errors among high school students in Western Iran.
J Ophthalmic Vis Res. 2014;9(2):232e239.
44. French AN, Morgan IG, Mitchell P, Rose KA. Patterns of
myopigenic activities with age, gender and ethnicity in Sydney
schoolchildren. Ophthalmic Physiol Opt. 2013;33(3):318e328.
45. Wu PC, Tsai CL, Wu HL, et al. Outdoor activity during class
recess reduces myopia onset and progression in school chil-
dren. Ophthalmology. 2013;120(5):1080e1085.
46. He M, Xiang F, Zeng Y, et al. Effect of time spent outdoors at
school on the development of myopia among children in
China: a randomized clinical trial. JAMA. 2015;314(11):
1142e1148.
47. Jones-Jordan LA, Sinnott LT, Cotter SA, et al. Time out-
doors, visual activity, and myopia progression in juvenile-
onset myopes. Invest Ophthalmol Vis Sci. 2012;53(11):
7169e7175.
48. Saw SM, Tan SB, Fung D, et al. IQ and the association with
myopia in children. Invest Ophthalmol Vis Sci. 2004;45(9):
2943e2948.
49. Guo Y, Liu LJ, Xu L, et al. Outdoor activity and myopia
among primary students in rural and urban regions of Beijing.
Ophthalmology. 2013;120(2):277e283.
50. Ip JM, Rose KA, Morgan IG, et al. Myopia and the urban
environment: findings in a sample of 12-year-old Australian
school children. Invest Ophthalmol Vis Sci. 2008;49(9):
3858e3863.
51. Shmueli D, Khamaisi R; Arab Communities of Israel and
Their Urbanization. Israel’s Invisible Negev Bedouin: Issues of
Land and Spatial Planning. Cham, Switzerland: Springer In-
ternational Publishing; 2015.
52. Wu PC, Chen CT, Lin KK, et al. Myopia prevention and
outdoor light intensity in a school-based cluster randomized
trial. Ophthalmology. 2018;125(8):1239e1250.
53. Ngo CS, Pan CW, Finkelstein EA, et al. A cluster randomised
controlled trial evaluating an incentive-based outdoor physical
activity programme to increase outdoor time and prevent
myopia in children. Ophthalmic Physiol Opt. 2014;34(3):
362e368.
54. Ashby R. Animal studies and the mechanism of myopia-
protection by light? Optom Vis Sci. 2016;93(9):1052e1054.
55. Ashby RS, Schaeffel F. The effect of bright light on lens
compensation in chicks. Invest Ophthalmol Vis Sci.
2010;51(10):5247e5253.
56. Ashby R, McCarthy CS, Maleszka R, et al. A muscarinic
cholinergic antagonist and a dopamine agonist rapidly increase
ZENK mRNA expression in the form-deprived chicken retina.
Exp Eye Res. 2007;85(1):15e22.
57. Ashby R, Ohlendorf A, Schaeffel F. The effect of ambient
illuminance on the development of deprivation myopia in
chicks. Invest Ophthalmol Vis Sci. 2009;50(11):5348e5354.
58. Feldkaemper M, Schaeffel F. An updated view on the role of
dopamine in myopia. Exp Eye Res. 2013;114:106e119.
59. Smith 3rd EL, Hung LF, Arumugam B. Visual regulation of
refractive development: insights from animal studies. Eye
(Lond). 2014;28(2):180e188.
60. Smith 3rd EL, Hung LF, Huang J. Protective effects of high
ambient lighting on the development of form-deprivation
myopia in rhesus monkeys. Invest Ophthalmol Vis Sci.
2012;53(1):421e428.
61. Hyman L, Gwiazda J, Hussein M, et al. Relationship of age,
sex, and ethnicity with myopia progression and axial elonga-
tion in the correction of myopia evaluation trial. Arch Oph-
thalmol. 2005;123(7):977e987.
62. Wen G, Tarczy-Hornoch K, McKean-Cowdin R, et al. Prev-
alence of myopia, hyperopia, and astigmatism in non-Hispanic
white and Asian children: Multi-ethnic Pediatric Eye Disease
Study. Ophthalmology. 2013;120(10):2109e2116.
63. Ip JM, Huynh SC, Robaei D, et al. Ethnic differences in the
impact of parental myopia: findings from a population-based
study of 12-year-old Australian children. Invest Ophthalmol
Vis Sci. 2007;48(6):2520e2528.
64. Offer S. The socio-economic integration of the Ethiopian
community in Israel. International Migration. 2004;42(3):
29e55.
65. Ben-Simon GJ, Peiss M, Anis E, et al. Spectacle use and
reduced unaided vision in third grade students: a comparative
study in different educational settings. Clin Exp Optom.
2004;87(3):175e179.
66. Leone JF, Mitchell P, Morgan IG, et al. Use of visual acuity to
screen for significant refractive errors in adolescents: is it
reliable? Arch Ophthalmol. 2010;128(7):894e899.
67. Tong L, Saw SM, Chan ES, et al. Screening for myopia and
refractive errors using LogMAR visual acuity by optometrists
and a simplified visual acuity chart by nurses. Optom Vis Sci.
2004;81(9):684e691.
68. Chaiter Y, Machluf Y, Pirogovsky A, et al. Quality control and
quality assurance of medical committee performance in the
Israel Defense Forces. Int J Health Care Qual Assur.
2010;23(5):507e515.
9
 Ophthalmology Volume -, Number -, Month 2019

Footnotes and Financial Disclosures

Originally received: December 3, 2018. The human ethics committees at the Israeli Defense Forces Medical Corps
Final revision: June 3, 2019. IRB/ethics committee approved the study. All research adhered to the tenets
Accepted: June 20, 2019. of the Declaration of Helsinki.
Available online: ---. Manuscript no. 2018-2719. No animal subjects were included in this study.
1
Department of Ophthalmology, Rambam Health Care Campus, Haifa, Author Contributions:
Israel.
Conception and design: Shapira, Mimouni, Machluf, Chaiter, Saab, Mezer
2
Bruce and Ruth Rappaport Faculty of Medicine, Technion, Israel Institute Analysis and interpretation: Shapira, Mimouni, Machluf, Chaiter, Saab,
of Technology. Mezer
3
Israel Defense Forces, Medical Corps, Israel. Data collection: Machluf, Chaiter
4
Shamir Research Institute, University of Haifa, Kazerin, Israel. Obtained funding: N/A
*Both authors contributed equally as first authors. Overall responsibility: Shapira, Mimouni, Machluf, Chaiter, Saab, Mezer
Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials Abbreviations and Acronyms:
discussed in this article. CI ¼ confidence interval; D ¼ diopter; OR ¼ odds ratio.
HUMAN SUBJECTS: Human subjects were not included in this study. It Correspondence:
relies on a computerized database in which subjects could not be identified. Michael Mimouni, MD, Department of Ophthalmology, Rambam Health
No identifying information exists in the database that was used for analysis. Care Campus, Haifa, Israel. E-mail: michael@intername.co.il.

10