Undercorrected Refractive Error in

Singaporean Chinese Adults

The Tanjong Pagar Survey
Seang-Mei Saw, MBBS, PhD,1,2,3,4 Paul J. Foster, PhD, FRCS (Ed),5,6
Gus Gazzard, MA(Cantab), FRCOphth,3,5,6,7 David Friedman, MD, MPH,8,9 Jocelyn Hee, BscOptom,2
Steve Seah, FRCS(G), FRCOphth2

Objective: To study the prevalence of undercorrected refractive error and associated sociodemographic
factors among Singaporean Chinese adults.
Design: Cross-sectional, population-based survey.
Participants: Singaporean Chinese adults aged 40 to 79 years (n ⫽ 1152).
Methods: The Singapore electoral register of Tanjong Pagar was used as a sampling frame, and disproportion-
ate, stratified, clustered, random sampling was performed. There were 1717 eligible adults and 1232 (71.8%)
participated. Analysis was performed among 1152 adults with complete habitual and best-corrected visual acuity
data.
Main Outcome Measure: Undercorrected refractive error was defined as improvement of better eye visual
acuity of at least 2 lines or more with best possible refractive correction.
Results: The age- and gender-adjusted rate of undercorrected refractive error standardized directly by age
and gender was 17.3% (95% confidence interval, 15.0, 19.5). Undercorrected refractive error rates were more
common in older adults who had completed fewer years of education and in those who had cataract. People who
did not wear spectacles tended to have poorer vision.
Conclusions: The undercorrected refractive error rate among Singaporean Chinese is relatively common com-
pared with data from other populations. Ophthalmology 2004;111:2168 –2174 © 2004 by the American Academy of
Ophthalmology.

Undercorrected refractive error has been found to be one of
the leading causes of visual impairment in recent years.1–5
As a consequence, the correction of refractive errors in
developed and developing countries is one of the main
priorities of the Vision 2020: The Right to Sight initiative of
the World Health Organization.6 In Australia, the Victoria
Visual Impairment Project found that the prevalence rate of
undercorrected refractive error in 4735 participants age 40
years and older was 10%.1 Data from Mexican Americans
aged 40 years and older in the Proyecto VER in Arizona
showed that 73% of visual impairment in that population
was the result of undercorrected refractive error.3 Similarly,
68.9% of visual impairment was explained by undercor-
rected refractive error in a study of 3441 adults 60 years and
older in the Shatin area of Hong Kong.7
Data on the extent of undiagnosed and partially cor-
rected refractive error and their associated risk factors in
urban Asian environments, areas where “outbreaks” of
myopia exist, are sparse.8 Despite available refractive
services and affordable spectacle lenses, the undercorrec-

9
Originally received: March 22, 2004. Department of International Health, Johns Hopkins Bloomberg School of
Accepted: May 26, 2004. Manuscript no. 240216. Public Health, Baltimore, Maryland.
1
Department of Community, Occupational and Family Medicine, National Supported by the National Medical Research Council, Republic of Singapore,
University of Singapore, Republic of Singapore. and the British Council for the Prevention of Blindness. Dr Friedman is a
2
Singapore National Eye Centre, Republic of Singapore. Research to Prevent Blindness (New York, New York) Robert E. McCormack
3 Scholar and an American Geriatrics Society (New York, New York) Jahnigen
Singapore Eye Research Institute, Republic of Singapore. Scholar.
4
Department of Ophthalmology, National University of Singapore, Re- The authors have no proprietary interests.
public of Singapore.
5 Reprint requests to Steve Seah, FRCS(G), FRCOphth, Singapore National
Department of Epidemiology and International Eye Health, The Institute
Eye Centre, 11 Third Hospital Avenue, Singapore 168751, Republic of
of Ophthalmology, London, United Kingdom.
Singapore.
6
Glaucoma Research Unit, Moorfields Eye Hospital, London, United Kingdom.
Correspondence to Seang-Mei Saw, MBBS, PhD, Department of Commu-
7
Department of Ophthalmology, St. Thomas Hospital, London, United Kingdom. nity, Occupational and Family Medicine, National University of Singapore,
8
Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, Johns 16 Medical Drive, Singapore 117597, Republic of Singapore. E-mail:
Hopkins University, Baltimore, Maryland. cofsawsm@nus.edu.sg.

2168 © 2004 by the American Academy of Ophthalmology ISSN 0161-6420/04/$–see front matter
Published by Elsevier Inc. doi:10.1016/j.ophtha.2004.05.032
 Saw et al 䡠 Undercorrected Refractive Errors in Singapore
tion of refractive error still may remain a public health
problem in Asian cities. The present study was designed
to evaluate the prevalence of undercorrected refractive
error and associated risk factors in middle-aged and
elderly Chinese adults in Singapore.
Materials and Methods
The Tanjong Pagar Study was a population-based eye survey
among Singaporean Chinese adults aged 40 to 79 years in 1997
and 1998. The study methodology has been described else-
where.9 –13 Tanjong Pagar is an area situated in the central part of
Singapore and consists of a community that includes socially and
economically diverse groups that are largely representative of the
general Singaporean population. Because registration and voting
are legal requirements for all Singaporean citizens aged 21 years
and older, the electoral register of Tanjong Pagar was used as the
sampling frame. Two thousand names (13% of 15,082) were
sampled using disproportionate, stratified, clustered, random sam-
pling with more weight given to the older age groups: 500 people
were drawn from each of the 4 age strata, 40 to 49 years, 50 to 59
years, 60 to 69 years, and 70 to 79 years. Forty-six persons had
died, 235 persons had moved away from the study area since its
beginning, and 2 persons had severe illness; thus, there were 1717
eligible participants. The overall participation rate was 71.8%
(1232 of 1717). Analysis was performed on 1152 adults, because
habitual or best-corrected right or left eye data could not be
obtained for 80 adults. There were 526 men (45.7%), and the mean
age was 59.4 years (standard deviation, 11.1). Informed written
consent was obtained from all participants, and the study proce-
dures followed the tenets of the Declaration of Helsinki. Ethics
committee approval from the Singapore National Eye Center was
obtained.
Eye Examinations
Details of the eye examination in the research eye clinic or home
have been described in detail in prior reports.9 –13 Habitual visual
acuity (VA) of the right and left eye first was determined using
logarithm of the minimum angle of resolution charts (The Light-
house, Long Island City, NY) at 4 m with distance spectacle
correction, if any. For clinic subjects, the test began reading at the
0.3 line. If they were unable to read more than 3 letters on the 0.3
line, they would read the line above and continue this process until
they could read at least 3 or more letters. They proceeded to the
next line each time they read 3 or more letters correctly. The VA
was recorded as the last line where 3 or more letters were read
correctly. If they read fewer than 3 letters on any line, the line
above would be recorded as the VA. Conversion of logarithm of
the minimum angle of resolution to Snellen equivalent readings
were performed to allow direct comparisons of clinic and home
visit data. Refractive error was assessed using the handheld au-
torefractor (Retinomax K-plus; Nikon, Tokyo, Japan). Manual
subjective refraction then was attempted to refine vision, and the
best-corrected VA was documented. An ophthalmologist graded
lens opacity using a slit lamp according to the modified Lens
Opacity Classification System III.13 Glaucoma was identified by
assessment of visual field and examination of the optic disc.9
For those who did not attend the clinic visits (n ⫽ 91), domi-
ciliary examinations were conducted. Habitual VA of the right and
left eye was assessed using a Snellen chart. If the VA was less than
6/12, pinhole VA measurements were performed (best-corrected
visual acuity). Data on general demographic variables such as
completed level of education were obtained from face-to-face
interviews conducted in either English or Chinese. The interview-
ers were masked to the results of the eye examinations.
Definitions and Analysis
Undercorrected refractive error was defined as improvement of at
least 2 lines of better eye VA with best possible refractive correc-
tion. Refractive error was expressed as spherical equivalent (SE;
defined as sphere⫹half cylinder). Myopia was defined as an SE of
at least ⫺0.5 diopters (D), hyperopia as an SE of at least ⫹0.5 D,
and astigmatism as cylinder of at least ⫺1.0 D in any eye. Non-
spectacle wearers were defined as individuals without spectacle
correction at the clinic visit (i.e., adults who do not wear spectacles
or adults who have spectacles but do not wear them habitually).
Nonspectacle wearers with undercorrected refractive error were
defined as adults with an improvement of at least 2 lines of better
eye VA on best correction who do not have spectacles or who do
not wear spectacles habitually. Glaucoma (categories 1, 2, or 3)
was diagnosed according to the International Society of Geograph-
ical and Epidemiologic Ophthalmology scheme.14 Cataract in any
eye was defined as either Lens Opacity Classification System III
score of 4 or more for nuclear opalescence, 4 or more for nuclear
color, 2 or more for cortical cataract, or 2 or more for posterior
subcapsular cataract.13 Population prevalence rates of undercor-
rected refractive error were calculated by direct age and gender
standardization to the 1997 Singaporean Chinese population.15
Chi-square tests were used to compare proportions. Logistic re-
gression models were used to examine the relationship between
uncorrected refractive error and selected sociodemographic char-
acteristics. Odds ratios and 95% confidence intervals (CIs) were
presented. All P values were 2-sided and were considered statis-
tically significant when the values were less than 0.05. A sample
size of 1154 was needed to detect a prevalence rate of low vision
of 0.2 and an allowable difference of 0.02, assuming the type I
error, ␣, was 0.05. Statistical computation was conducted using the
commercially available software STATA version 8.0.16
Results
The age- and gender-adjusted rates of bilateral low vision (defined
by better eye habitual Snellen VA worse than 6/18 and 3/60 or
better) and blindness (defined as better eye Snellen VA worse than
3/60) were 5.3% (95% CI, 4.0, 6.6) and 0.5% (95% CI, 0.2, 0.7),
respectively. Undercorrected refractive error caused 66% of bilat-
eral low vision, but did not contribute to blindness. The distribu-
tions of better eye habitual VA and best-corrected VA are shown
in Figure 1. The mean better eye habitual and best-corrected
logarithm of the minimum angle of resolution VAs were 0.16
(median, 0.01) and 0.07 (median, 0.0), respectively. Table 1 de-
scribes the number of lines gained after refraction for spectacle and
nonspectacle wearers by age and gender. The proportion of adults
with 0 lines gained after refraction was higher in spectacle wearers
(66.8%) compared with nonspectacle wearers (49.1%; P⬍0.001),
but was similar in men (56.8%) and women (55.7%; P ⫽ 0.71).
Similarly, there were 28 nonspectacle wearers and only 3 spectacle
wearers who gained 5 or more lines (P⬍0.001), whereas 11 men
and 20 women gained 5 or more lines (P ⫽ 0.25).
The prevalence rates of undercorrected refractive error (im-
provement of at least 2 lines of better eye VA after refraction) are
depicted in Table 2. The age- and gender-adjusted rate (to the
Singaporean population older than 40 years) of undercorrected
refractive error was 17.3% (95% CI, 15.0, 19.5). The undercor-
rection of refractive error was 3 times more common in adults 70
years of age and older compared with adults 40 to 49 years of age
(P⬍0.001). The rates of undercorrected refractive error also in-
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 Ophthalmology Volume 111, Number 12, December 2004

Figure 1. Graph of presenting and best-corrected logarithm of the minimum angle of resolution (logMAR) visual acuity.

creased with age in both men and women. The age-adjusted
undercorrected refractive error rates were not different among men
(16.3%) and women (18.1%; P ⫽ 0.93). Undercorrected refractive
error rates were most common among adults with refractive error
of ⫹2.0 to ⫹3.0 D, followed by adults with ⫹3.0 D or more, ⫺1.0
to ⫺2.0 D, and ⫺2.0 to ⫺3.0 D (Fig 2).
The rates of undercorrected refractive error among spectacle
wearers (i.e., those spectacle wearers with inadequate corrective
lenses) and undercorrected refractive error among nonspectacle
wearers (i.e., adults who have undercorrected refractive error but
do not have spectacles or adults with undercorrected refractive
error who do not wear spectacles habitually) were 10.6% (95% CI,
7.9, 13.7) and 29.3% (95% CI, 26.0, 32.9), respectively. There
were 464 adults (40.4%) who wore spectacles. Spectacle wearers

Table 1. Distribution of Number of Lines Gained after Table 2. Prevalence Rates of Undercorrected Refractive Error
Refraction by Sociodemographic Factors
Number of Spectacle Nonspectacle Undercorrected
Lines Gained Total, n (%) Wearers, n (%) Wearers, n (%) Refractive Error, P Value
Men and women % (95% (chi-square
0 646 (56.2) 310 (66.8) 336 (49.1) Confidence test for
1 253 (22.0) 105 (22.6) 148 (21.6) n Interval) trend)
2 129 (11.2) 34 (7.3) 95 (13.9) Total 1152 21.7 (19.4–24.2)
3 68 (5.9) 11 (2.4) 57 (8.3) Age- and gender-adjusted* 17.3 (15.0–19.5)
4 22 (1.9) 1 (0.2) 21 (3.1) Both men and women
5 18 (1.6) 1 (0.2) 17 (2.5) 40–49 yrs of age 269 10.0 (6.7–14.3) ⬍0.001
6 or more 13 (1.1) 2 (0.4) 11 (1.6) 50–59 yrs of age 296 18.9 (14.6–23.9)
Total 1,149 (100.0) 464 (100.0) 685 (100.0) 60–69 yrs of age 326 26.4 (21.7–31.5)
Men 70 and older 261 31.0 (25.5–37.0)
0 299 (56.8) 121 (66.1) 178 (51.9) Men
1 110 (20.9) 41 (22.4) 69 (20.2) 40–49 yrs of age 121 8.3 (4.0–14.7) ⬍0.001
2 59 (11.2) 14 (7.7) 45 (13.1) 50–59 yrs of age 113 20.4 (13.4–29.0)
3 37 (7.0) 6 (3.3) 31 (9.0) 60–69 yrs of age 166 22.9 (16.7–30.0)
4 10 (1.9) 0 (0.0) 10 (2.9) 70 yrs and older 126 36.5 (28.1–45.6)
5 5 (1.0) 0 (0.0) 5 (1.5) All men 526 22.2 (18.8–26.0)
6 or more 6 (1.1) 1 (0.6) 5 (1.5) Men (age adjusted) 16.3 (13.0–20.0)
Total 526 (100.0) 183 (100.0) 343 (100.0) Women
Women 40–49 yrs of age 148 11.5 (6.8–17.8) ⬍0.001
0 347 (55.7) 189 (67.3) 158 (46.2) 50–59 yrs of age 183 18.0 (12.7–24.4)
1 143 (23.0) 64 (22.8) 79 (23.1) 60–69 yrs of age 160 30.0 (23.0–37.7)
2 70 (11.2) 20 (7.1) 50 (14.6) 70 yrs and older 135 25.9 (18.8–34.2)
3 31 (5.0) 5 (1.8) 26 (7.6) All women 626 21.2 (18.1–24.7)
4 12 (1.9) 1 (0.4) 11 (3.2) Women (age adjusted) 18.1 (15.1–21.3)
5 13 (2.1) 1 (0.4) 12 (3.5)
6 or more 7 (1.1) 1 (0.4) 6 (1.8)
Total 623 (100.0) 281 (100.0) 342 (100.0) *To the 1997 Singaporean Chinese adult population.

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 Saw et al 䡠 Undercorrected Refractive Errors in Singapore
Figure 2. Percent undercorrected refractive error by spherical equivalent
(in diopters [D]).
were more likely to be female (60.6% vs. 49.9%; P⬍0.001) and to
have completed tertiary education (13.8% vs. 3.8%; P⬍0.001). As
expected, adults with high myopia (SE of at least ⫺6.0 D) and high
hyperopia (SE of at least ⫹3.0 D) were most likely to wear
spectacles (Fig 3).
In a univariate assessment, the prevalence rate of undercor-
rected refractive error was 3 times lower in patients with tertiary
level education (10.0%) compared with no education (32.9%;
P⬍0.001) and 3 times lower in patients aged 40 to 49 years
(10.0%) compared with adults 70 years of age and older (31.0%;
P⬍0.001). Participants with cataract had higher rates of undercor-
rected refractive error (28.7%) compared with individuals without
cataract (16.0%; P⬍0.001). Adults with glaucoma had similar
rates (25.0%) compared with adults without glaucoma (21.6%;
P ⫽ 0.65). Adults who were currently driving had lower rates of
undercorrected refractive error (15.5%) compared with adults who
were not (23.1%; P⬍0.001). The undercorrected refractive error
rates were similar among adults with myopia, hyperopia, and
mixed refractive error (myopia in 1 eye and hyperopia in the other;
P ⫽ 0.60). Adults with astigmatism had higher rates of undercor-
Figure 3. Percent who habitually wear spectacles by spherical equivalent
(in diopters [D]).
rected refractive error (26.5%) compared with nonastigmatic
adults (17.5%; P⬍0.001).
A multiple logistic regression model was constructed with
undercorrected refractive error as the dependent variable and with
age, educational level, spectacle wear, and cataract as the explan-
atory covariates (Table 3). Adults who wore spectacles were less
likely (0.3 times) to have undercorrection of refractive error com-
pared with adults who did not wear spectacles, adjusting for age,
education, and cataract. The multivariate odds ratio of undercor-
rected refractive error in adults 70 years of age and older compared
with adults 40 to 49 years was 2.4 (95% CI, 1.4, 4.2), controlling
for education, spectacle wear, and cataract. The odds ratio of
undercorrected refractive error for tertiary education compared
with no formal education was 0.5 (95% CI, 0.2, 1.0), controlling
for age, spectacle wear, and cataract, but this relationship is only
of borderline significance (P ⫽ 0.06). The multivariate odds ratio
of undercorrected refractive error for adults with cataract was 1.5
(95% CI, 1.1, 2.1), after adjusting for age, educational level, and
spectacle wear. The association between driving status and under-
corrected refractive error did not remain after controlling for age,
educational level, spectacle wear, and cataract.
Discussion
The adjusted prevalence rate of undercorrected refractive error
is 17.3%, and undercorrected refractive error is a leading
contributing cause of bilateral low vision in Singaporean Chi-
nese persons aged 40 to 79 years. Undercorrected refractive
error rates are highest among adults who are older, have lower
educational levels, do not wear spectacles, and have cataract.
Refractive errors are a growing public health problem
worldwide. Myopia is of special interest in Asia because
the rates of myopia are among the highest in the world
(79.3% among 15 095 Singaporean military conscripts
aged 16 to 25 years).17 Although myopia is easily cor-
rectable with spectacles, there are still large numbers of
individuals with significant visual loss resulting from
undercorrected refractive error, and this is especially true
for older patients. Our finding that individuals older than
70 years of age are at high risk of undercorrected refrac-
tive error is particularly concerning. The elderly are more
prone to falls, and low vision has been documented to
increase this risk.18 –22 Although increased falling with
age is a multifactorial process—postural stability de-
clines with age because of vestibular changes,18 increas-
ing lower limb weakness,19 and poorer proprioception—
low vision greatly exacerbates this,20 and refractive blur
in particular can contribute to an excess risk of falls in the
elderly.21
Worldwide, approximately 110 million people had low
vision and 38 million people were estimated to be blind 1
decade ago.22 Recent population-based studies have intro-
duced a new classification of low vision defined as habitual
(rather than best-corrected) Snellen VA worse than 6/18 and
3/60 or better and blindness defined as VA worse than 3/60.
This has led to the wider recognition of undercorrected
refractive error as a leading cause of low vision in the
developed and developing world. In the Salisbury Eye Eval-
uation Study of 3821 adults aged 65 to 84 years in the
United States, undercorrected refractive error contributed to
one third of the causes of visual impairment,23 whereas
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 Ophthalmology Volume 111, Number 12, December 2004

Table 3. Multiple Logistic Regression Model of the Predictors of Undercorrected Refractive Error*

Crude Odds Ratio Multivariate† Odds

(95% Confidence Ratio (95% Confidence
n Interval) P Value Interval)‡ P Value
Age (yrs)
40–49 269 1.0 (referent) 1.0 (referent)
50–59 296 2.1 (1.3, 3.4) 0.003 1.7 (1.0, 2.8) 0.06
60–69 326 3.2 (2.1, 5.1) ⬍0.001 2.1 (1.2, 3.7) 0.006
70 and older 261 4.0 (2.5, 6.5) ⬍0.001 2.4 (1.4, 4.2) 0.002
Education level
No education 292 1.0 (referent) 1.0 (referent)
Primary (1–6 yrs) 464 0.6 (0.5, 0.9) 0.005 0.7 (0.5, 1.0) 0.03
Secondary (7–10 yrs) 305 0.3 (0.2, 0.4) ⬍0.001 0.4 (0.3, 0.7) ⬍0.001
Tertiary (11 yrs or more) 90 0.2 (0.1, 0.5) ⬍0.001 0.5 (0.2, 1.0) 0.06
Wore spectacles
No 685 1.0 (referent) ⬍0.001 1.0 (referent) ⬍0.001
Yes 464 0.3 (0.2, 0.4) 0.3 (0.2, 0.4)
Cataract
No 633 1.0 (referent) ⬍0.001 1.0 (referent) 0.02
Yes 519 2.1 (1.6, 2.8) 1.5 (1.1, 2.1)

Covariates in the model are age group, educational level, spectacle wear, and cataract.
*Defined as a gain of at least 2 lines in the logarithm of the minimum angle of resolution visual acuity chart.
†
Controlling for all other factors in the table.
‡
In diopters.

refractive error was one of the leading causes of blindness in
a population-based survey of 4284 adults 50 years or older
in rural Rajasthan, India.24
The adjusted undercorrected refractive error rates of
17.3% in Singaporean Chinese persons aged 40 to 80 years
are higher compared with those reported in other epidemi-
ologic studies. In addition, approximately 4.6% of our pop-
ulation had significant (gains of at least 4 lines after refrac-
tion) correctable visual loss. This could be attributed to the
high refractive error rates and lack of awareness of the need
for refractive examination check-ups in the general popula-
tion. Comparisons of undercorrected refractive error rates
across studies, however, are limited by differences in the
definition of undercorrected refractive error that vary from 1
line or more to 2 or more lines of improvement, sampling
strategies, participation rates, and the age ranges of the
study populations. In adults 40 years or older in Victoria,
Australia, the prevalence rate of undercorrected refractive
error with an improvement of 1 or more lines of VA with
refraction was 10%.1 In another Australian study (the Blue
Mountains Eye Study), 7.5% of 3654 adults aged 49 to 97
years had correctable visual impairment defined as visual
impairment less than 20/40 in the better eye that improved
after refraction to no impairment (20/40 or better).2
Factors leading to the need for a refractive examination
and optical correction to improve vision have not been well
investigated in prior epidemiologic studies. In the present
study, adults who are older, with lower education, who do
not wear spectacles, or who have cataract are less likely to
wear appropriate refractive correction. Comparable findings
were seen in Australia (the Victoria Visual Impairment
Project and the Blue Mountains Eye Study): increasing age,
lower educational levels, and absence of distance correction
were found to be the most important risk factors for under-
correction.1,2 Older individuals with lower education may
be less conscious of their health, less aware of correctable
visual disabilities associated with refractive error, and may
undertake less visually demanding tasks. The elderly also
may have lower visual distance expectations, may be less
aware of the need and availability of regular check-ups, and
may be less able to afford health care. Visual function may
not be remarkably impaired in affected individuals with less
than optimal correction of refractive error because visual
acuity readings may not be related directly to visual func-
tion. Singapore is a small city–state with excellent transport
facilities, and there are a large number of government and
private optometry and ophthalmic practices located in all
parts of the island. The accessibility of refractive care in
Singapore is much better than in developing countries in
Asia. However, certain segments of the population in Sin-
gapore may not be aware of the need to update spectacles
and may have less available access to refractive services.
In Singaporean Chinese, a significant proportion (29.3%)
of nonspectacle wearers have undercorrected refractive er-
rors. The possible reasons for undercorrected refractive
errors among nonspectacle wearers include the lack of
awareness of the need for refractive examination visits
among those who do not wear spectacles and unwillingness
to change their present lifestyle because vision was good in
the past or the refractive error may be small in magnitude.
Among adults with refractive error who are already wearing
spectacles, undercorrected refractive error may be a prob-
lem (10.6%) because there may be a lack of awareness of
the need for regular check-ups, poor access to health sys-
tems, or lack of affordability of health care, or they may
believe that their present prescription is adequate enough.
Adults diagnosed with cataract, but not patients with
glaucoma, are more likely to have undercorrected refrac-
tive error. Patients with cataract who have not undergone
surgery may be subject to more rapid changes in refrac-

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 Saw et al 䡠 Undercorrected Refractive Errors in Singapore
tive error because of the developing lens opacity itself
and also may visit ophthalmologists or update their spec-
tacle prescriptions less frequently. These findings are
consistent with the higher rates of undercorrected refrac-
tive error in adults aged 40 years or older with cataract in
the Visual Impairment Project in Melbourne, Australia.1
Undercorrected refractive error rates are similar in
myopes and hyperopes. In contrast, findings from the
Victoria Visual Impairment Project study showed higher
undercorrected refractive error rates among myopes
(11.1%) compared with hyperopes (7.5%).1 Astigmatism
left undercorrected also may decrease vision substan-
tially, and optimal full correction to enhance visual per-
formance is recommended. In our present study, 26.5%
of astigmatic adults are undercorrected.
Undercorrected refractive error is a common disorder
that should be easily rectified with the potential for overall
improvement of the visual status of the community. In
contrast, other common causes of low vision, including
cataract, glaucoma, and age-related macular degeneration,
are less readily treatable. In Singapore, accessibility to
health care should not be a problem, because the country is
small and the standard of health care generally is high.
Sliding-scale government subsidies for healthcare are avail-
able. Methods of correction using optical devices such as
spectacles or contact lenses are affordable to most, but cost
may continue to deter poorer sections of society from seek-
ing health care. Subsidy of spectacles could be considered
for the underprivileged, and affordable eye care should be
easily available. The public (especially the older and less
well educated) should be educated about the visual symp-
toms associated with undercorrected refractive error and the
need for regular screening and updated spectacles. Nation-
wide public health campaigns may be conducted to dissem-
inate appropriate messages through various methods, in-
cluding the distribution of health pamphlets, health talks,
and the mass media. Other approaches include the education
of optometrists, ophthalmologists, and primary care physi-
cians about the active diagnosis and remedial actions for
refractive care. Cataract patients should be seen regularly
and refractive errors assessed and corrected fully.
The strengths of our study include a population-based
sample from an area with endemic refractive errors. The
Tanjong Pagar study area is a central area in Singapore
generalizable to the general Singaporean population. Poten-
tial limitations include a fair participation rate of 71.8% and
the possibility that nonparticipants may have different rates
of undercorrected refractive errors. The rates of undercor-
rected refractive error also were not determined in the
minority ethnic groups, the Malays and Indians, and future
population-based studies could be designed to assess the
prevalence rates of undercorrected refractive errors among
minorities in Singapore. The undercorrection of near vision
also could be assessed.
In conclusion, undercorrected refractive error is a sizable
problem (17.3%) among Singaporean Chinese, especially in
older, less educated adults, nonspectacle wearers, and adults
with cataract. Strategies to improve the update of spectacles by
these populations likely will improve the overall visual func-
tion of this population.
References
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predictors of undercorrected refractive errors in the Victorian
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2. Foran S, Rose K, Wang JJ, Mitchell P. Correctable visual
impairment in an older population: the Blue Mountains Eye
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