1 Article Title

2 Prevalence of refractive error in Mexican population, 2014–2015: Map of

3 Visual health project.
4
5 Francisco Gomez-Alvarez1, Abraham Campos-Romero1,, Humberto Gomez-Campaña1,

6 Adrian Canizalez-Roman2,Jorge Velazquez-Roman2, Héctor Flores-Villaseñor2, Javier J.

7 Martinez-Garcia2,3, Joel Murillo-Llanes4, Secundino Muro-Amador2, Jaime Sanchez-

8 Cuen2,5, Ana Irineo-Cabrales2

10 (1)Salud Digna para Todos, I.A.P., 80000 Culiacán Sinaloa, México1;

11 (2)Research unit, School of Medicine, Autonomous University of Sinaloa, 80246 Culiacan

12 Sinaloa, Mexico2;

13 (3)Pediatric Hospital of Sinaloa, 80200 Culiacan Sinaloa, Mexico3;

14 (4)Department of Gastroenterology, Hospital Regional, ISSSTE, 80230 Culiacán, Sinaloa,

15 México5; Coordinación de Enseñanza e Investigación, HGR No. 1.

16

17 Key words: Prevalence, refractive error, hyperopia, myopia, astigmatism, Visual Healt.

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20 ABSTRACT

21 Objective: To determine the prevalence of refractive conditions in the Mexican population

22 that visited primary care optometry clinics in fourteen state of Mexico. Methods: A

23 retrospective cross-sectional study of patients examined at the optometry clinics (in

24 fourteen state) of Salud Digna para Todos, I.A.P between 2014 and 2015. Subjects

25 considered had best corrected visual acuity by standardized subjective refraction of 20/40

26 or better. The refractive errors were classified by the spherical equivalent (SE): sphere+½

27 cylinder. Myopia was classified as a SE>−0.50 D, hyperopia as a SE>+0.50 D, and

28 emmetropia as a SE between −0.50 and +0.50, both included. Astigmatism equal or higher

29 than 0.25 D in minuscylinder form was used. Results: A total of 676,856 subjects were

30 selected and ranged in age from 6 to 90 years. The estimated prevalence (95%, confidence

31 interval) among all subjects was hyperopia 18.8% (48.0-55.0), emmetropia 36.5% (30.5-

32 37.2), myopia 22.3% (12.1-17.2) and astigmatism 12.1% (68.8-73.3). Hyperopia was more

33 common in females than males although the difference was not statistically significant.

34 The prevalence of any clinically important refractive error was higher in males (61.2%)

35 than in females (58.3%; p=0.0003).The mean spherical equivalent values was hyperopic

36 until 70 y/o and decreased slightly as the population ages. From fourteen states that

37 collected information, Aguascalientes population (77.5%) had more frequent refractive

38 error, and Guanajuato population (52.4) had less frequent refractive error. Conclusion:

39 Myopia is the most common refractive error and prevalence seems to increase among the

40 young population (10 to 39 years old), but Hyperopia increase among the aging population

41 (40 to 80 years old) who visited the clinics. The prevalence of refractive error presented

42 here show variability in different geographical areas of Mexico. Further programs and

43 studies must be developed to address the refractive errors needs of the Mexican population.
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44 INTRODUCTION

45 Refractive error is recognized as one of the most important causes of correctable visual

46 impairment (Munoz et al., 2000;Munoz et al., 2002;Chia et al., 2004;Evans and Rowlands,

47 2004) worldwide (WHO, 2004;2015), accounting for nearly 80% of the visual impairment

48 in persons aged 12 years and older in the United States (Vitale et al., 2006).

49 Visual impairment from uncorrected refractive errors can have immediate and long-term

50 consequences in children and adults, such as lost educational and employment

51 opportunities, lost economic gain for individuals, families and societies, and impaired

52 quality of life (WHO, 2004;2015).

53 The prevalence of refractive errors in adults and school children worldwide varies

54 considerably in several countries. For example in children, the prevalence of myopia is

55 relatively low in the United States (U.S.) with a range of 4-19% (depending on age and

56 ethnicity) (Chen et al., 1996;Munoz et al., 2002;Vitale et al., 2006;Vitale et al., 2008;Qiu et

57 al., 2014), but much higher in Greece (Mavracanas et al., 2000) at 37%, and highest of all

58 in Taiwan (Shih et al., 2009) with a range of 12-85%, depending on age. In Latin America,

59 a great variance has also been observed with a lower prevalence of myopia in Brazil (4-6%)

60 (Salomao et al., 2008a;Salomao et al., 2008b;Salomao et al., 2009), and a higher prevalence

61 in Chile (3-19%) (Maul et al., 2000).

62 The prevalence of visual impairment due to uncorrected refractive error in adults and

63 children has not been previously studied in Mexico. The goal of this study was to examine

64 refractive errors in Mexican adults and children. To our knowledge, this is the first report of

65 refractive error in Mexican population in several setting.

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67 MATERIALS AND METHODS

68 Design

69 This study is a retrospective cross-sectional study to estimate the prevalence of refractive

70 errors in children and adults living in Mexico who visited at the optometry clinics (in

71 fourteen state) of Salud Digna para Todos, I.A.P between 2014 and 2015, for

72 comprehensive eye exam. Refraction information from those patients was selected

73 retrospectively for the study: A total of 676,856 subjects were selected and ranged in age

74 from 6 to 90 years of either gender. Each patient obtained and completed a consent, and use

75 of information authorization form during the registration process. Ethical approval was

76 obtained from the ethics committee of the School of Medicine, Autonomous University of

77 Sinaloa.

78

79 Refractive Error Criteria

80 The refractive assessment was based on subjective refraction with visual acuity assessment

81 using a Snellen chartat 20 feet (6 m). Subjects considered had best corrected visual acuity

82 by standardized subjective refraction of 20/40 or better at 20 feet (6 m) in both eyes. The

83 refractive errors were classified by the spherical equivalent (SE): sphere+½ cylinder.

84 Myopia was classified as a spherical equivalent>−0.50 D, hyperopia as a spherical

85 equivalent>+0.50 D, and emmetropia as spherical equivalent between −0.50 and +0.50.

86 Astigmatism in minus cylinder form was used. Astigmatism against the rule (ATR) was

87 defined as axis 90◦±30◦, astigmatism with the rule (WTR) from 0◦to 30◦and 150◦to 180◦and

88 oblique astigmatism (O) 31◦to 59◦and 121◦to 149◦.All refractive errors were obtained at the

89 time of the visit using a phoropter with a range from −20.00 D to +20.00 D and cylinder

90 range −0.25 to −6.00 D. Since the refractive error between right and left eye was similar
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91 (r=0.87; P>0.05) the right eye was selected for analysis. Patients with documented history

92 of cataract extraction (pseudophakia oraphakia), refractive surgery or other corneal/ocular

93 surgery, amblyopia or any ocular disease were excluded from the study. Descriptive

94 statistics was used for data analysis. A significance level of P<0.05 was used with a 95%

95 confidence. The statistical analysis program SPSS V20 (SPSS Inc.,Chicago, IL) was used

96 to perform the calculations.

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102 RESULTS

103 Prevalence of refractive errors by age and sex.

104 Sample distribution by age and sex is shown in Table 1. Distribution of refractive errors

105 among total population (from 6 to 90 years old) revealed that 24.8% (95% CI, 24.7-24.9)

106 had myopia, 21.0% (95% CI, 20.9-21.0) had hyperopia and 13.5 (95% CI, 13.4-13.5) had

107 astigmatism. The prevalence of emmetropic among total population was 40.6% (95% CI,

108 30.5-37.2). Fig. 1, shows the distribution of refractive errors (myopia, hyperopia and

109 astigmatism) by age group. With increasing age, there is an increase in prevalence of

110 hyperopia. Myopia decreases during aging with a small increase at 70. The prevalence of

111 any clinically important refractive error was higher for those between ages from 50-59

112 (63.5%) and 60-69 (64.9%) years than between ages from 6-9 years (48.5%; p=0.0003).

113 The prevalence of myopia between genders was more common in males (27.5) than

114 females (23.4 %) (p = 0.256, table I). Hyperopia was more frequent in females (21.9 %)

115 than males (19.3%) (p= 0.052). Astigmatism is more frequent in males (14.4%) than

116 females (13.0 %) (p= 0.052). Emmetropia was more frequent in females (41.7%) than

117 males (38.8%) (p = 0.030, table I). In general, the prevalence of any clinically important

118 refractive error was higher in males (61.2%) than in females (58.3%; p=0.0003).

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127 Table 1. Prevalence of refractive errors in the population of Mexico by age and sex
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Myopia Hyperopia Astigmatism
Age N n(≤- % (95 % CI) n(≥+1D) % (95 % CI) n(≥D) % (95 % CI)
0.75D)
6-9 29710 5795 19.5 (19.0-19.9) 2755 9.3 (8.9-9.6) 5848 19.7 (19.2-20.1)
10-19 106602 43605 40.9 (40.6-41.2) 3965 3.7 (3.6-3.8) 16771 15.7 (15.5-15.9)
20-29 99509 43204 43.4 (43.1-43.7) 2041 2.1 (1.9-2.1) 15949 16.0 (15.8-16.2)
30-39 79384 26552 33.4 (33.1-33.7) 5430 6.8 (6.6-7.0) 12196 15.4 (15.1-15.6)
40-49 112129 22011 19.6 (19.4-19.8) 22932 20.5 (20.2-20.6) 15992 14.3 (14.0-14.4)
50-59 123598 13328 10.7 (10.6-10.9) 52303 42.3 (42.0-42.5) 12869 10.4 (10.2-10.5)
60-69 79940 7119 8.9 (8.7-9.1) 37720 47.2 (46.8-47.5) 7044 8.8 (8.6-9.0)
70-79 36148 4840 13.3 (13.0-13.7) 12764 35.3 (34.8-35.8) 3533 9.8 (9.4-10.0)
80-90 9836 1606 16.3 (15.6-17.0) 2197 22.3 (21.5-23.1) 1067 10.8 (10.2-11.4)
Gende
r
Female 444953 104258 23.4 (23.1-23.5) 97456 21.9 (21.7-22.0) 57906 13.0 (12.9-13.1)
Male 231903 63802 27.5 (27.3-27.6) 44651 19.3 (19.0-19.4) 33363 14.4 (14.2-14.5)
Total 676856 168060 24.8 (24.7-24.9) 142107 21.0 (20.9-21.0) 91269 13.5 (13.4-13.5)
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132 CI; Confidence Interval
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167 Figure 1. Prevalence of refractive error by age groups. Frequency of hyperopia increases with aging with a small decrease
168 toward 70. Myopia decreases during aging with a small increase at 70 (Chi-square; p < 005).
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170 Prevalence of refractive error in different geographical areas of the country.

171 Myopia was most prevalent in Aguascalientes (42.5%), D.F. (36.0%) and Puebla State

172 (35.6%), compared with Sinaloa (18.6%), Nayarit (18.7%) and Sonora State (20.6%, table

173 II and Fig. 2). Prevalence of hyperopia was higher for Sinaloa (29.2%), Sonora (26.9%) and

174 Nayarit state (26.4%) than for Mexico State (8.8%), Guanajuato (10.9%) and Puebla

175 (13.5%, table II and Fig. 2). Prevalence of astigmatism varied little by State. However,

176 astigmatism was more prevalent in Aguascalientes (20.4%), Puebla (18.9%) and Queretaro

177 state (18.6%) than in Sinaloa (11.0%), Nayarit (11.7%) and Coahuila state (12.3%,

178 p<0.0001, table II and Fig. 2). Emmetropia was most prevalent in Guanajuato (47.6%),

179 Jalisco (47.4%) and Michoacan States (46.8%), compared with Aguascalientes (22.5%),

180 Federal District (30.8%) and Puebla states (32%, table II and Fig. 2). Prevalence of any

181 clinically important refractive error was highest for Aguascalientes (77.5%), D.F. (69.2%)

182 and Puebla states (68.0%) and it was lowest for Guanajuato (52.4%), Jalisco (52.6%) and

183 Michoacan states (53.2%). The prevalence of refractive error presented here (Table 2 and

184 Fig. 2), show variability among the proportions of emmetropics, myopia, hyperopia and

185 astigmatism in different geographical areas of the country.

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189 Table. Prevalence of refractive error in different geographical areas of the country.
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State Refractive error
N Emmetropia % CI Myopia % CI Hyperopia % CI Astigmatism % CI
Sinaloa 148914 61450 41.3 27670 18.6 43437 29.2 16357 11.0
Baja California 133133 49536 37.2 35707 26.8 28915 21.7 18975 14.3
Jalisco 83142 39439 47.4 17587 21.2 14982 18.0 11134 13.4
Sonora 74598 29911 40.1 15401 20.6 20062 26.9 9224 12.4
Guanajuato 58162 27657 47.6 16576 28.5 6317 10.9 7612 13.1
D.F. 41747 12855 30.8 15041 36.0 6578 15.8 7273 17.4
Coahuila 34017 15440 45.4 8991 26.4 5387 15.8 4199 12.3
Edo. Mexico 26225 11652 44.4 8138 31.0 2308 8.8 4127 15.7
Nayarit 24343 10513 43.2 4556 18.7 6432 26.4 2842 11.7
Aguascalientes 18762 4221 22.5 7968 42.5 2741 14.6 3832 20.4
Queretaro 13531 4555 33.7 4440 32.8 2019 14.9 2517 18.6
Durango 8868 4054 45.7 2314 26.1 1351 15.2 1149 13.0
Puebla 8127 2598 32.0 2893 35.6 1101 13.5 1535 18.9
Michoacán 3287 1539 46.8 778 23.7 477 14.5 493 15.0
Total 676856 275420 40.7 168060 24.8 142107 21.0 91269 13.5
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194 MAP OF VISUAL HEALT MÉ XICO
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219 Figure 2. % of Prevalence of refractive error in the different state population. Frequency of
220 hyperopia increases with aging with a small decrease toward 70. Myopia decreases during
221 aging with a small increase at 70 (Chi-square; p < 005).
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222 DISCUSSION

223 .

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225

227
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