576679

research-article2015
RSH0010.1177/1757913915576679Myopia and daylight in schoolsMyopia and daylight in schools

Peer Review

Myopia and daylight in schools: a neglected aspect of public health?

Myopia and daylight in schools: a

neglected aspect of public health?

Authors
Abstract
Richard Hobday
Independent Researcher
A century ago, it was widely believed that high levels of daylight in classrooms could prevent
myopia, and as such, education departments built schools with large windows to try to stop
children becoming short-sighted. This practice continued until the 1960s, from which time
myopia was believed to be an inherited condition. In the years that followed, less emphasis
was placed on preventing myopia. It has since become more common, reaching epidemic
Corresponding author: levels in east Asia. Recent research strongly suggests that the amount of light children get as
Richard Hobday, they grow determines whether they will develop short sight; however, evidence that daylight in
8 Springvale, Cwmbran, classrooms prevents myopia is lacking. Given the rapid increase in prevalence among school
NP44 5AZ, UK
Email: ra.hobday@virgin.net
children worldwide, this should be investigated.

Keywords
school design; myopia; Introduction
rickets; vitamin D; daylight
Over the last 50 years, myopia, or short-
sightedness, has increased among children and is
now a global public health problem. The most
dramatic rise has been in Hong Kong, Taiwan,
Singapore, China’s cities and elsewhere in east
Asia. In some cases, 80%–90% of children
leaving secondary school are short-sighted, and
of these, some 10%–20% have high myopia and
so are at risk of blindness in later life.1 In the
United States, the prevalence of myopia has
increased among people aged 12 to 54
years by more than 60% since the 1970s.2 The
cost of correcting the disorder with spectacles,
contact lenses and laser vision correction may total
more than US$3.8 billion annually.3 Worldwide, it
has been estimated that US$269 billion in
productivity was lost in 2007, and 158 million
people had impaired vision because of uncorrected
myopia and other refractive errors.4 This article
examines historical and current evidence regarding
the influence of daylight in reducing the onset and
progression of myopia, with particular reference to
school buildings.
Methods
Studies on school lighting and the non-visual
effects of daylight were drawn from literature
collected during previous research. Then a two-
level approach was used to select English
language papers across various databases
including PubMed. First, research studies were
identified using the term school related to
eyesight in children in combination with the terms,
including health, hygiene, lighting, myopia, sight,
vision, prevalence, prevention and aetiology. No
limit was placed on date of publication. Resulting
abstracts were then screened for eligibility and,
where necessary, full articles assessed. They were
then cross-referenced to identify further relevant
publications and search terms.
Myopia: nature or nurture?
Myopia is the result of abnormal axial lengthening
of the eye, which makes light focus ahead of the
retina rather than onto it, therefore blurring
distance vision.5 Low to modest degrees of
myopia are referred to as ‘school’ or ‘simple’
myopia.5 Some short-sighted children can
develop high myopia, and in such cases,
excessive elongation of the eye increases the risk
of visual loss through retinal detachment, early
onset glaucoma, cataract and degenerative
changes in the macula and other retinal tissue.6
However, not all highly myopic eyes develop the
pathological form of the condition. Visual

Copyright © Royal Society for Public Health 2015 Month 201X Vol XX No X l Perspectives in Public Health  1
SAGE Publications
ISSN 1757-9139 DOI: 10.1177/1757913915576679
 Peer Review
Myopia and daylight in schools: a neglected aspect of public health?
impairment can affect young people’s
self-perception, educational attainment
and career choices, while the elderly are
at increased risk of isolation and poor
health.7,8
It is 400 years since Johannes Kepler
gave the first accurate explanation of
myopia – he noted that short sight was
more common among young people
who do a lot of close work.9 Myopia has
since become the subject of a lengthy
`nature versus nurture’ debate. A century
ago, short sight was believed by some to
be strictly inherited, and there was no
definite evidence that school attendance
damaged children’s eyesight.10
Meanwhile, others argued that the
environment in which children were
educated was the most important factor:
they called for a reduction of close work
in schools and more light, open spaces
and playgrounds.11 Environmental
influences were thought to be important
until the 1960s, when medical opinion
changed in favour of genetic
determinism.12
The Aetiology Of School
Myopia
Despite investigation for more than a
century, the cause or causes of school
myopia have been elusive. Many theories
have been put forward to explain the
aetiology of myopia, and it has been
linked to bad hygiene, bad lighting, close
work, too much exertion or tubercular
infection.13 The history of school myopia
has parallels with another childhood
disease, rickets. Widely considered to be
either hereditary, or a result of
environmental conditions, rickets became
a common condition in England during
the 17th century, and reached epidemic
proportions in northern Europe and North
America. The remedy proved elusive until
the 1920s, when clinical work
demonstrated that lack of exposure to
sunlight, resulting in vitamin D deficiency,
was the determining factor in the
development of rickets.14 Myopia, like
rickets, appears to be a seasonal
condition which gets worse in the winter.15
Some forms of rickets are hereditary.16
Similarly, a parental history of myopia is a
significant risk factor for both the onset
2  Perspectives in Public Health l Month 201X Vol XX No X
and progression of myopia in children.17
However, the rise of myopia during the
second half of the 20th century does not
appear to be genetic, just as the rise in
rickets was not. Gene pools in human
populations do not change so rapidly.18
While genetic variation may decide who
is most affected, it is the environment in
which children grow up that appears to
be the major factor.18,19
Recent findings have revived a theory
current in the 1890s,20 that school
children who engage in higher levels of
outdoor activity have lower levels of
myopia.21 Epidemiological evidence now
suggests it is the amount of time spent
outdoors that reduces the risk of children
becoming myopic. This is irrespective of
the amount of exercise they take,
whether or not their parents are myopic
or how much close work they do.22
Children who engage in outdoor activity
for more than 14 hours per week
significantly reduce their risk of becoming
myopic.23 A Taiwanese study has
reported a 50% reduction in new cases
of myopia when school children were
made to go outdoors during
breaktimes.24 Another trial in Guangzhou,
China found that participation in an
additional outdoor class after school
each day was associated with a
reduction in myopia onset.25
However, it is not yet clear whether
time outdoors also regulates the
progression of myopia in children who
already have the condition.22 Also, the
precise biological mechanism, or
mechanisms, through which outdoor
activity influences the development of
myopia in children is still a matter of
debate. The strongest hypothesis is that
light is the most important environmental
factor in myopia:22 bright light stimulates
the release of the retinal transmitter
dopamine, which is known to inhibit axial
growth of the eye.26 Children who
experience lower ambient light levels
appear to be at greater risk of myopia
progression. A recent Danish study found
significant correlations between the
hours of available daylight and eye
elongation and myopia progression. Due
to the northern latitude of Denmark, there
are marked seasonal variations in
ambient light levels, and both eye
elongation and myopia progression
appeared to decrease with longer days
and to increase with shorter days.27
Differences in the development of
myopia may be explained by the
protective effect of time spent outdoors
in bright light: studies of individual
exposure to sunlight support the
hypothesis that bright light has a
protective effect,28 and animal studies
suggest that low light levels indoors may
be a risk factor for developing myopia.29
They also show that bright light can slow
myopia progression.30 However, the
intensity, spectral composition and the
amount needed for this protective effect
in humans are not yet known.26,31
Although there are similarities between
the aetiologies of myopia and rickets with
regard to solar radiation, the action
spectra appear to differ. Rickets develops
in children who do not get regular
exposure to ultraviolet radiation and so
cannot synthesise vitamin D in their skin.14
Vitamin D levels are lower among children
in heavily populated, urban settings than
in rural ones.32 Similarly, children living in
cities and urban areas are at a higher risk
of developing myopia when compared
with their peers growing up in rural
environments.1 A study of Korean
adolescents has found an association
between vitamin D levels and myopia: low
vitamin D status was related to more
severe myopia among the participants,
being most evident in adolescents with
high myopia.33 However, vitamin D
deficiency may only be a risk marker for
myopia. For example, when rickets was
the most common disease among
children in towns, it was not accompanied
by an epidemic of short-sightedness.11
Therefore, high vitamin D levels may act
as a proxy for the other biological
consequences of sun exposure that
prevent myopia.34 In animal experiments,
the protective effect of high-intensity
ambient light has been demonstrated
both with daylight exposure and with
ultraviolet-free lights.29 This suggests that
it is visible light that prevents myopia
rather than ultraviolet radiation.
Myopia is a multi-factorial condition,
and there may be other potential
contributors to its onset and progression.
There are optical differences between the

environment indoors and the one
outdoors. Pupillary constriction outdoors
in bright light could have a protective
effect as this increases depth of focus,
decreases blur and thus could slow eye
growth.22 Indoors, during close work,
sub-optimal accommodation, or
accommodative lag, leads to hyperopic
defocus on the retina which, in turn, has
a major influence on eye growth.
However, it is not yet clear whether high
accommodative lag appears before or
after the onset of myopia. It is also
unclear whether reduced
accommodation due to more distance
viewing outdoors leads to decreased
axial elongation of the growing eye.22
Over time, attitudes towards the
condition have changed markedly.
Myopia in all its forms, whether moderate
or high, used to be considered a
pathological condition, and measures
were put in place to try and prevent it in
children.35,36 Moderate myopia is now
often considered to be benign, even
though it increases the health risk from
ocular diseases.37 Myopia is the most
common eye disorder in children, yet it
and prevention of it have attracted less
research interest than it merits.
Myopia is usually corrected with
spectacles or contact lenses. Another
approach is refractive surgery; however,
this is not suitable for children. There is
some evidence that wearing hard
contact lenses at night can slow the
progress of myopia, and two drugs,
atropine and pirenzepine, slow myopia
but have frequent side effects or limited
availability. Many other measures have
also been proposed, aiming to slow
myopia progression, but few have
undergone rigorous scientific testing.38
Daylight In The Classroom
Daylight is solar radiation visible to the
human eye either directly as sunlight, or
indirectly as diffuse skylight. Vision in
daylight conditions is generally better
than under artificial lighting, which does
not provide the variability or spectrum
that daylight does. Light is the most
prominent time cue or zeitgeber for the
human circadian system, and, within the
built environment, sunlight is a stronger
Myopia and daylight in schools: a neglected aspect of public health?
zeitgeber than artificial lighting.39
Maintaining synchronised circadian
rhythms has a range of positive health
effects, and daylighting is associated
with some of them.
The relationship between daylighting
and myopia came to prominence in 1869,
when the German pathologist Professor
Rudolf Virchow identified myopia as the
single most harmful effect of school
attendance.40 Virchow reached this
conclusion having studied the work of his
compatriot, the ophthalmologist Dr
Hermann Cohn. Cohn had measured the
eyesight of 10,060 school children, and
Virchow was alarmed by Cohn’s findings,
which he believed to be both accurate
and decisive. They showed myopia
among school children was progressive:
not only did the proportion of short-
sighted children increase with the number
of years spent at school but the degree of
myopia also rose.41 In gymnasia, or high
schools, Cohn reported the percentages
of myopia from the first year of
attendance to the sixth, finding that more
than half of the children he examined in
the highest classes were myopic.40
Cohn also investigated the effects of
school lighting on myopia. In his book
Hygiene of the Eye in Schools, he devoted
two chapters to lighting; believing this to
be of the highest importance in preventing
myopia.42 Cohn had examined the
eyesight of children in 20 elementary
schools and found the incidence of
myopia varied from 1.8% to 15.1%. He
compared the light levels in the
classrooms with the number of short-
sighted children in them and concluded
that schools increase the prevalence of
myopia if the surrounding buildings darken
the interior. The narrower the street in
which classrooms were situated, the lower
the level on which lessons took place, and
the taller the houses opposite, the more
numerous the cases. Schools in streets of
‘crushing narrowness’ had the highest
rates. Cohn recorded between four and
five times more myopia in elementary
schools in towns than in village schools.
There were no photometers available to
Cohn, so his measurements were based
on the actual performance of the eye
when reading under different lighting
conditions. He concluded that window
Month 201X Vol XX No X l Perspectives in Public Health  3
Peer Review
areas in classrooms should be at least
one-fifth the floor area, which was double
those of some he measured. Cohn stated
there could never be too much light in a
school, as long as heating and glare from
the sun were controlled, and ideally,
daylight should be admitted from above
via glass roofs.42
Cohn found the number of short-
sighted children increased with the grade
of the school and the length of time they
studied. He was undecided on the
question of the heredity of myopia.
Based on his own research, and that of
others, he believed the transmission of
the tendency to myopia was highly
probable. However, in many cases,
heredity was not the cause. Significantly,
Cohn wrote that parents had a right to
demand that their children, who were
compelled by law to attend school,
should not suffer injury to their health by
doing so.42 Cohn’s work on eyesight
provided the impetus for improving
conditions in schools generally.
At the beginning of the last century,
high levels of daylight in classrooms were
one of a number of measures thought to
prevent myopia, and some eye specialists
campaigned for what they referred to as
‘ocular hygiene’ in schools.They stated
that children had to learn how to see
properly, without straining their eyes, if
they were to preserve their eyesight.43
There were ‘sight saving classes’ for
children with severe myopia, and special
schools were set up to try to save their
eyesight from further decline and
blindness.44,45 Good daylighting was a
priority in such schools, and it also
became so within mainstream education.
Some schools had windows that folded
back along one wall, opening onto
terraced areas and verandahs for lessons
outside.46 Such ‘open-air’ schools were
part of a campaign to tackle childhood
diseases: the part played by sunlight in
myopia progression was not known, but
children suffering from defective vision
were thought to benefit from it.47
Designing Schools For
Daylight
By the 1930s, the daylighting of schools
was one of the most researched subjects
 Peer Review
Myopia and daylight in schools: a neglected aspect of public health?
in environmental design.48 However,
Cohn’s pioneering work on light and
visual health in schools does not appear
to have been validated. Half a century
after his proposals gained acceptance,
the basis for them was questioned –
school myopia had not been eradicated,
and it was not certain that it had become
less prevalent. This was difficult to
determine accurately because data were
scarce and their interpretation open to
dispute.49 Intensive research in schools
was proposed, and it was argued that
the best approach would be to study
children over a period of years, beginning
in infant schools.50 Yet, longitudinal
studies of this kind were not undertaken,
making it difficult to determine whether
Cohn’s insistence on good lighting in
schools was justified. Nevertheless, high
levels of natural light in classrooms
continued to be seen as a good form of
insurance against short sight. A British
Ministry of Works report from 1944 sums
up this precautionary approach:
The eye of a child is a growing eye,
and more susceptible to damage from
deficiencies of lighting than the mature
eye. Unsuitable and inadequate
lighting may leave its mark on any
child, effecting his comfort, efficiency,
and earning powers throughout his
life.51
The report includes an analysis of
daylight levels in a range of classroom
types and suggests ways in which
existing schools could be modified to
admit more light. It includes guidance on
designing for daylight and gives details of
measures to prevent overheating in
summer. The authors recognised sunlight
penetration could be problematic, but it
was also a valuable amenity, giving
‘warmth and pleasure’. They
recommended some sunlight should
enter classrooms in the winter months
and that it was better it did so in the
morning rather than in the afternoon.51
By the 1950s, high levels of natural
light became a statutory requirement in
British schools.52 At this time, the school
population was increasing, which, in turn,
necessitated a rapid school building
4  Perspectives in Public Health l Month 201X Vol XX No X
programme. During the late 1950s and
into the 1960s, guidance on daylighting
classrooms, such as that provided by the
Ministry of Works, was often ignored in
favour of simple rules of thumb. Daylight
design was based on the sky as the
main source of light. Large numbers of
schools from this period were grossly
over-glazed, incorrectly oriented and, as
a result, prone to overheating and glare
from the sun in the summer months and
under-heating in the winter.48 Their
unsatisfactory performance resulted in a
move away from daylight in schools
towards artificial lighting.48,52
By this time, the long-standing belief
that daylight could protect children’s
eyesight no longer informed school
design. There were a number of reasons
for this. During the 1950s, it was argued
that natural light in classrooms had no
health advantages over artificial lighting
from fluorescent lamps.53 In 1962, the
UK Medical Research Council published
a report, based on a study of twins,
which concluded that myopia was
overwhelmingly genetic. The only
outstanding question was whether the
environment had any role in myopia at
all.12 However, this influential research
was flawed,54 as the limited
environmental variation within twin pairs
means that such studies can
underestimate the impact of the
environment in myopia among the
general population.18 Nevertheless, from
this time onwards, there was a
consensus that myopia was mostly
inherited.
During the 1970s, there were changes
in educational thinking such that
individual and small-group teaching
became popular. Compact school
buildings with smaller windows started to
appear. In the United States, windowless
school designs were adopted: at one
stage, authorities in Florida passed a law
requiring all schools in the state to be air-
conditioned and windowless.52 However,
following the oil crisis in the 1970s, there
was renewed interest in getting natural
light and, in particular, sunlight into
schools, with the aim of reducing
dependence on fossil fuels. In Europe
and the United States, a number of
passive solar schools were built to this
end.52 Typically, they had large windows
on the southern facade to admit solar
radiation for heating, and smaller
windows on the north. The best of them
provided an environment which teachers
and pupils valued. A survey of such
schools in Hampshire, in the south of
England, found an improvement in
academic performance among pupils.
This appeared to be related to higher
levels of daylight in these schools
compared to the conventional designs of
the period and to the presence of
sunlight.55 In the absence of sunlight
penetration, lighting in buildings is
typically less than 1,000 lux, often in the
range of 100–500 lux. This is far lower
than the light levels experienced
outdoors during the daytime: on a clear
day in direct sun, more than 100,000 lux
is common, with about 15,000 lux in the
shade.56
Cohn defined the minimum level of
daylight needed to prevent myopia in
terms of the ratio of window to floor area.
Subsequently, the ‘Daylight Factor’
became the most commonly used
measure to quantify daylight in buildings.
In simple terms, this gives the
percentage of skylight outside a building
that is available indoors at a given point.
In 1945, when myopia was still a concern
for designers, school premises
regulations recommended a minimum
2% Daylight Factor in British schools and
suggested 5% where possible.52 By the
1990s, recommended illuminances in
classrooms had returned to comparable
levels. Daylighting was seen as a way to
reduce energy consumption in schools
and, thus, carbon emissions. Also,
natural light was believed to be beneficial
for learning and teaching. Guidance from
this period states that where possible, a
daylit space should have an average
Daylight Factor of 4%–5%.57
Conclusion
School lighting has undergone marked
changes over the last 150 years: from
small windows to large ones and from
windowless to passive solar buildings.
High levels of daylight were specified in

classrooms for much of this period,
based on Cohn’s findings from the
1860s. When evidence emerged in the
1960s which seemed to show myopia
was inherited, this became the prevailing
orthodoxy for the next 40 years. It is only
recently that research into the influence
of daylight on the development and
progression of myopia has resumed.
The results of tests of intense ambient
lighting on laboratory animals suggest
that outdoor light levels are required to
prevent the onset of myopia. Yet, such
tests may not be fully representative of
childhood myopia.58 Also, the range of
illuminance values that affect refractive
development is not known.56 In which
case, the threshold at which light
protects children’s eyesight could be
lower than those outdoors.
The biological mechanism, or
mechanisms, in the eye that responds to
light and protects against myopia may
also do more than simply release retinal
dopamine.58 Light influences circadian
rhythms in the eye, and these may affect
ocular growth. So the protective effect
could be complex, and may depend on
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Month 201X Vol XX No X l Perspectives in Public Health  5
Peer Review
this can be done successfully.48
Researchers in China, where some
80% of children in cities now leave
school short-sighted, have recently
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whether large windows in classrooms
could help prevent myopia in school
children.61 Should clinical trials show
high daylight levels in classrooms have
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influence the onset and progression of
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Acknowledgements
The author is most grateful for the helpful
comments and insights provided by the
reviewers of this article.
CONFLICT OF INTEREST
None declared.
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