Science & technology
Ophthalmology
The eyes have it
An epidemic of myopia is storing up health problems, particularly in East Asia
I n the early 1980s  Taiwan’s  army  real­
ised it had a problem. More and more of
its conscripts seemed to be short­sighted,
meaning  they  needed  glasses  to  focus  on
distant objects. “They were worried that if
the worst happened [ie, an attack by China]
their  troops  would  be  fighting  at  a  disad­
vantage,”  says  Ian  Morgan,  who  studies
myopia at Australian National University,
in Canberra. An island­wide study in 1983
confirmed  that  around  70%  of  Taiwanese
school  leavers  needed  glasses  or  contact
lenses to see properly.
These days, that number is above 80%.
But happily for Taiwan’s generals, the mil­
itary  disparity  has  disappeared.  Over  the
past few decades myopia rates have soared
across  East  Asia  (see  chart 1,  overleaf).  In
the  1960s  around  20­30%  of  Chinese
school­leavers  were  short­sighted.  These
days they are just as myopic as their cous­
ins  across  the  straits,  with  rates  in  some
parts of China running at over 80%.
Elsewhere on the continent things are
even worse. One study of male high­school
leavers  in  Seoul  found  97%  were  short­
sighted. Hong Kong and Singapore are not
012
ing  in  myopia  was  associated  with  a  67%
far  behind.  And  although  the  problem  is
worst in East Asia, it is not unique to it. Re­
liable numbers for America and Europe are
harder to come by. But one review article,
published in 2015, claimed a European rate
of  between  20%  and  40%—an  order  of
magnitude higher than that which people
working in the field think is the “natural”,
background rate.  about children’s eyesight, says Dr Morgan.
Don’t be short-sighted about this
For most of those affected, myopia is a life­
long, expensive nuisance. But severe myo­
pia can lead to untreatable vision loss, says
Annegret  Dahlmann­Noor,  a  consultant
ophthalmologist at Moorfields Eye Hospi­
tal, in London. A paper published in 2019
concluded  that  each  one­dioptre  worsen­
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The Economist June 11th 2022 77
increase in prevalence of myopic maculo­
pathy, an untreatable condition that caus­
es blindness. (A dioptre is a measure of a
lens’s  focusing  power.)  In  some  parts  of
East Asia, 20% of young people have severe
myopia,  defined  as  ­6  dioptres  or  worse
(see chart 2, overleaf). “This is storing up a
big problem for the coming decades,” says
Kathryn  Rose,  head  of  orthoptics  at  the
University of Technology, Sydney.
All that, in turn, is beginning to attract
official  attention.  In  2018  Xi  Jinping,  Chi­
na’s  president,  made  controlling  child­
hood  myopia  a  national  priority.  Crack­
downs  on  the  country’s  private­tutoring
and video­games industries, which began
in 2021, were partly motivated by worries
The governments of Taiwan and Singapore
are likewise trying to do something about
the matter. “I think it’s fair to say that pub­
lic health is starting to wake up to myopia
as a problem,” says Dr Dahlmann­Noor. 
Most  myopia  is  caused  by  misshapen
eyeballs.  A  properly  working  eye  focuses
incoming  light  precisely  onto  the  retina,
the  light­sensitive  surface  at  the  back  of
the eyeball (see picture above). In a myopic
eye, by contrast, the eyeball is distorted in a
way that causes the light to end up focused
short of the retina. Sufferers can see nor­
mally  up  close,  but  distant  objects  are
blurred. And the condition tends to be pro­
gressive,  with  vision  worsening  through­
out childhood and adolescence, before sta­
bilising in adulthood.
 78 Science & technology
Clear as daylight
Myopia, estimated prevalence at age 20, %
Hong Kong
Singapore
South Korea
Taiwan
1938 50 60 70 80 90 2000
Source: “The epidemics of myopia: Aetiology and prevention”,
by Ian Morgan et al., Progress in Retinal and Eye Research, 2017
For  decades,  researchers  had  thought
myopia was mostly genetic. It runs in fam­
ilies, and genomic studies have turned up
several  gene  variants  which  increase  the
risk  of  developing  the  condition.  There
were  early  hints,  though,  that  this  could
not be the whole story. A study of Inuit in
Alaska, published in 1969, found that myo­
pia  was  virtually  unknown  in  those  mid­
dle­aged or older, but that rates were above
50%  in  older  children  and  young  adults.
Such a change is much too fast to be purely
genetic,  and  it  had  happened  just  as  the
study  participants  had  begun  to  adopt  a
more settled, Westernised way of life. But
the results went against the dogma of the
day, says Dr Morgan, and were ignored.
The spike in East Asia, which occurred
as places there industrialised, was harder
to dismiss. Short­sightedness is stereotyp­
ically  an  affliction  of  the  bookish,  and  a
procession  of  studies  has  confirmed  a
strong, reliable link with education. “The
more  educated  you  are,  and  the  higher
your grades, and the more you participate
in  after­school  classes  and  tutorials—the
more likely you are [to be myopic]”, says Dr
Morgan. And an intriguing study on ortho­
dox Jewish children in Israel, in the 1990s,
confirmed the link with long school hours.
It  showed  that  boys—who  receive  inten­
sive religious education in addition to the
normal  curriculum—were  more  myopic
than their sisters, who do not.  Outdoor 120”, which encouraged schools to
Since there is no obvious way in which
learning sums, spelling or even the Talmud
could cause short­sightedness directly, the
assumption  was  that  education  was  a
proxy  for  something  else.  One  possibility
is the popular notion (raised by Johannes
Kepler, a German astronomer who himself
needed glasses, more than 400 years ago)
that myopia is linked to too much close­in
work, such as reading and writing.
That  theory  remains  popular,  says  Dr
Rose, but evidence for it is mixed at best.
Instead,  the  dominant  hypothesis  now  is
that exposure to daylight is the main vari­
able. A study of Californian children, pub­
lished in 2007, found that time spent out­
012
doors was strongly associated with a lower
1 risk of myopia. Another paper, published
the following year by Drs Rose and Morgan
100 and their colleagues, followed more than
4,000 children in Sydney for three years
80 and came to a similar conclusion. The type
of activity—sports, walking, picnics—did
60 not seem to matter. Simply being outdoors
was the crucial point. The researchers
40 cross­checked the close­work hypothesis
and found that being outside drastically re­
20 duced the risk of short­sightedness, even
for children that did a lot of it.
0
This theory fits the data neatly. It ex­
11 plains why myopia seems, like diabetes
and heart disease, to be what doctors call a
“disease of affluence”—more common in
rich countries than poor ones—since eco­
nomic growth brings with it more educa­
tion,  and  therefore,  for  children,  more
time inside. It explains why rates are high
in East Asia in particular, says Dr Morgan,
since the ubiquity of private tutoring and
after­school  classes  mean  schoolchildren
there routinely work longer days than their
Western counterparts. Most South Korean
students,  for  instance,  attend  private  tu­
toring schools called hagwons in which les­
sons often stretch well into the evening.  both clear vision through the central part
Seeing the light
The  daylight­exposure  theory  is  also  bol­
stered by animal studies, in which that ex­
posure can be carefully controlled, and in
which  dimness  reliably  produces  short
sight. Researchers have a putative mecha­
nism, too. Exposure to bright light appears
to stimulate the production of dopamine, a
neurotransmitter, in the retina. Dopamine,
in turn, seems to help regulate the rate at
which the eye grows. Too little, and the eye
grows too long to focus properly.
Human trials, too, confirm the theory.
One of the biggest, led by Pei­Chang Wu of
the  Chang  Gung  University  College  of
Medicine,  in  Taiwan,  was  published  in
2020. It reported results from millions of
Taiwanese primary­school pupils who had
gone  through  the  school  system  between
2001 and 2015. In 2010 the government in­
stituted  a  programme  called  “Tian­Tian
take  pupils  outside  for  two  hours  a  day.
After it was implemented, rates of myopia
fell, slowly but steadily, from 49.4% in 2012
to 46.1% in 2015—reversing a decades­long
trend of rising rates.  Seoul (South Korea)
Exactly how much light is needed is un­
clear,  though  Dr  Morgan  reckons  10,000
lux is in the right ballpark. That is about as
much  as  you  might  get  in  the  shade  on  a
reasonably  sunny  day.  (Direct  sunlight  in
the tropics can exceed 100,000 lux.) Levels
indoors,  by  contrast,  rarely  exceed  1,000
lux. It is technically possible to light class­
rooms  to  10,000  lux,  notes  Dr  Rose.  But
even  with  led lighting,  she  says,  the
amount  of  heat  produced  would  require
The Economist June 11th 2022
specialist air conditioning, and the glare
might be enough to make reading tricky.
Researchers have also been working on
ways to slow myopia’s progression once it
has started. One is to use low doses of atro­
pine, a poisonous chemical found in dead­
ly nightshade—the juice of which was once
used by women to dilate their pupils, in or­
der to make themselves look more attrac­
tive. Another is specially designed “or­
tho­k” contact lenses, which are intended
to reshape the cornea while worn. (The
cornea is the front, transparent part of the
eye, which does most of the work of focus­
ing light on the retina; the eye’s so­called
lens is mainly for fine tuning.) These also
seem effective, though Dr Rose worries
about the side­effects from giving contact
lenses to children, since if misused they
can cause irreversible corneal scarring.
Sophisticated pairs of spectacles may
help, too. In 2020 the bmj published a Chi­
nese trial of “defocus incorporated multi­
ple segments” (dims) glasses. The lenses of
these have a central zone designed to cor­
rect the wearer’s sight, which is surround­
ed by hundreds of other small zones of dif­
ferent optical power. The idea is to provide
of the lens and deliberately distorted vi­
sion through the smaller zones, since
poorly focused vision is thought to signal
to the eye to slow its rate of growth. Wear­
ing dims glasses appeared to cut the rate of
myopic progression roughly in half.
Eyedrops, more sunlight and clever
glasses might be able to prevent or slow
myopia in future generations of school­
children. But by the time sufferers reach
adulthood, the condition is permanent.
This means that in some countries, a pub­
lic­health problem is already baked in. For
those with really serious myopia, says Dr
Rose, and who are at the highest risk of bad
complications, unhealthy changes in the
eye can start to occur when patients are in
their 40s. “And some of those are not in any
way treatable.” n
Look out! 2
Prevalence of myopia and severe myopia
in school-leavers, 2015 or latest available, %
Myopia Severe myopia
0 20 40 60 80 100
Guangzhou (China)
Taiwan
Shandong (China)
Jeju (South Korea)
Singapore
Ejina (China)
Source: “The epidemics of myopia: Aetiology and prevention”,
by Ian Morgan et al., Progress in Retinal and Eye Research, 2017