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MYOPIA: PRE#LE~CE AND
PASSION
Irking Group on Myopia Prevalence and Progression
Co~htee on V6lon
Common on Beb-~r~ and
Social Sciences and Education
Natlon~ Rese~cb Council
Natlon~ Academy Press
~shlugton, D.C. lg89
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NOTICE: The project that is the subject of this report was approved by the Governing
Board of the National Research Council, whose members are drawn from the councils of the
National Academy of Sciences, the National Academy of Engineering, and the Institute of
Medicine. The members of the committee responsible for the report were chosen for their
special competences and with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to procedures
approved by a Report Review Committee consisting of members of the National Academy
of Sciences, the National Academy of Engineering, and the Institute of Medicine.
The National Academy of Sciences is a private, nonprofit, self-perpetuating society
of distinguished scholars engaged in scientific ant} engineering research, dedicated to the
furtherance of science and technology and to their use for the general welfare. Upon the
authority of the charter granted to it by the Congress in 1863, the Academy has a mandate
that requires it to advise the federal government on scientific and technical matters. Dr.
Frank Press is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of
the National Academy of Sciences, as a parallel organization of outstanding engineers.
It is autonomous in its administration and in the selection of its members, sharing with
the National Academy of Sciences the responsibility for advising the federal government.
The National Academy of Engineering also sponsors engineering programs aimed at meeting
national needs, encourages education and research, and recognizes the superior achievements
of engineers. Dr. Robert M. White is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences
to secure the services of eminent members of appropriate professions in the examination
of policy matters pertaining to the health of the public. The Institute acts under the
responsibility given to the National Academy of Sciences by its congressional charter to
be an adviser to the federal government and, upon its own initiative, to identify issues of
medical care, research, and education. Dr. Samuel O. Thier is president of the Institute of
Medicine.
The National Research Council was organized by the National Academy of Sciences
in 1916 to associate the broad community of science and technology with the Academy's
purposes of furthering knowledge and advising the federal government. Functioning in
accordance with general policies determined by the Academy, the Council has become the
principal operating agency of both the National Academy of Sciences and the National
Academy of Engineering in providing services to the government, the public, and the scien-
tific and engineering communities. The Council is adrn~nistered jointly by both Academies
and the Institute of Medicine. Dr. Frank Press and Dr. Robert M. White are chairman and
vice chairman, respectively, of the National Research Council.
This project was sponsored by the U.S. Air Force School of Aerospace Medicine.
ISBN 0-309-04081-7
Library of Congress number 89-62773
Printed in the United States of America
First Printing, August 1989
Second Pnnung, September 1989
Third Printing, May 1990
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WORKING GROUP ON MYOPIA
PREVALENCE AND PROGRESSION
ANTHONY J. ADAMS (Chair), School of Optometry, University of California, Berkeley
WILI,IAM R. BAI,DWIN, College of Optometry, University of Houston
TRYING BlEDERMAN, Department of Psychology, University of Minnesota
BRIAN J. CURTIN, Manhattan Eye and Ear Clinic, New York
SHELDON M. EBENHOLTZ, Institute for Vision Research, State University of New
York, New York
DAVID A. GOSS, College of Optometry, Northeastern State University
GEORGE B. HUTCHISON, Harvard School of Public Health
JOHANNA M. SEDDON, Massachusetts Eye and Ear Infirmary, Boston
JOSHUA WALLMAN, Department of Biology, City University of New York
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COMMITTEE ON VISION
ANTHONY J. ADAMS (Chair), School of Optometry, University of California, Berkeley
TRYING BlEDERMAN, Department of Psychology, University of Minnesota
RANDOLPH BLAKE, Cresap Neuroscience Laboratory, Northwestern University
ROBERT BOYNTON (NAS), University of California, San Diego
ANNE B. FULTON, Children's Hospital, Boston
DONALD HOOD, Department of Psychology, Columbia University
CHRIS A. JOHNSON, Department of Ophthalmology, University of California, Davis
JAMES LACKNER, Provost, Brandeis University
SUZANNE MCKEE, Sm~th-Kettlewell Eye Research Foundation, San Francisco
AZRIEL ROSENFELD, Center for Automation Research, University of Maryland
ROBERT SHAPI.EY, Department of Psychology, New York University
LOUIS SILVERSTEIN, Honeywell, Inc., Phoenix, Arizona
PAMELA EBERT FLATTAU, Study Director
CAROL METCALF, Administrative Secretary
1V
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Foreword
The Committee on Vision is a standing committee of the National Research Council's
Commission on Behavioral and Social Sciences and Education. The committee provides
analysis and advice on scientific issues and applied proble~rm involving vision. It also
attempts to stimulate the further development of visual science and to provide a forum in
which basic and applied scientists, engineers, and clinicians can interact. Working groups of
the committee study questions that may involve engineering and equipment, physiological
and physical optics, neurophysiology, psychophysics, perception, environmental effects on
vision, and treatment of visual disorders.
In order for the committee to perform its role effectively, it draws on experts from a wide
range of scientific, engineering, and clinical disciplines. The members of this working group
were chosen for their expertise in vision research, for their familiarity with epidemiological
approaches to the study of myopia, and for their knowledge of present-day approaches to
its assessment and treatment.
This report considers the issues surrounding the occurrence, progression, and pre-
dictability of myopia, with special emphasis on the 16-26-year-old population. The report
is based on an analysis of findings in the available literature and represents in itself an
important contribution to the literature base by virtue of the efforts of the working group
to identify and review only the most pertinent published research in this area. The observa-
tions and recommendations arising from the efforts of this working group will undoubtedly
be of considerable interest to vision scientists and clinicians alike.
Robert Sekuler, Past Chair
Committee on Vision
v
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Contents
PREFACE
TABLES AND FIGURES
SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS
1: INTRODUCTION
2: ANALYSIS OF THE PREVALENCE LITERATURE
3: ANALYSIS OF THE PROGRESSION LITERATURE
4: CONCLUSIONS AND RECOMMENDATIONS
APPENDIX A: The Biological Basis of Myopia
APPENDIX B: Review of the Prevalence Literature
APPENDIX C: Review of the Progression Literature
APPENDIX D: The Etiology of Myopia
APPENDIX E: Glossary
BIBLIOGRAPHY
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Preface
At the request of the U.S. Air Force School of Aerospace Medicine, the Committee on
Vision established the Working Group on Myopia Prevalence and Progression in 1984. The
working group was asked to address three questions:
What demographic and confounding variables must be evaluated in comparing
older myopia prevalence data with current data?
Are there variables by which changes in refractive error can be predicted for an
individual?
What agenda for future research would substantially increase our knowledge of
myopia prevalence and progression?
Myopia is commonly known as nearsightedness. A nearsighted individual, or myope,
sees near objects well but sees distant objects poorly. Prevalence estimates from the 1972
National Health and Nutrition Examination Survey of persons in the United States between
the ages of 12 and 54 years indicate that 25 percent were myopic.
Individual differences are also known to occur in the progression of myopia. Ophthalmic
clinicians widely acknowledge that once a youngster becomes myopic, he or she will most
likely become more myopic, and this increase in myopia will stop or slow down sometime in
the teenage years or later. There is, however, a great deal of individual variability in age at
which progression ceases.
In order to answer the questions put by the U.S. Air Force School of Aerospace Medicine,
the working group established as its goals:
the specification of classification criteria for the estimation of myopia prevalence;
the identification of some of the probable determinants of myopia prevalence;
a consideration of some of the factors contributing to the etiology of myopia;
the specification of the characteristics of myopia onset and its progression;
a review of the refractive changes in myopia progression in children and young adults;
and
the creation of a selected bibliography on myopia prevalence and progression.
To accomplish these goals, the working group developed a research plan to review
what is known about myopia. An extensive literature review was conducted. Over 500
articles were identified, the majority of which had been published in the last 40 years in
English-language journals. A significant number of articles in nineteenth century periodicals
were also identified. These articles were distributed to subgroups of the working group for
L'C
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analysis. In addition to the literature search, staff identified a limited number of published
research findings in languages other than English. This report builds on those analyses and
the discussion that took place at the meetings of the working group over a two-year period.
In addition to the members of the working group, a number of people contributed in im-
portant ways to the success of the project. Carol Masters, Harvard School of Public Health,
provided extensive consultation on issues related to prevalence of myopia and is responsible
for much of the material presented in the review of the prevalence literature (Appendix
B). The working group is particularly grateful for her assistance. Wayne Shebilske, the
committee's study director through June 1985, planned the project and the initial phases of
the research plan. Pamela Ebert Flattau, the committee's study director after July 1, 1985,
provided important assistance in overseeing the effort and in preparing the working group's
report. Colonel Thomas Tredici, Brooks Air Force Base, and Constance Atwell, National
Eye Institute, provided valuable technical advice at the meetings of the working group.
Secretarial and administrative assistance were provided by Carol Metcalf and Gora
P. Lerma, for which the working group is grateful. Christine L. McShane, editor of the
Commission on Behavioral and Social Sciences and Education, helped improved the style
and clarity of the report.
Anthony ]. Adams, Chair
Working Group on Myopia
Prevalence and Progression
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Tables and Figures
TABLES
1 Myopia prevalence among children by age and gender, 1952.
2 Studies of myopia prevalence among adults in various populations, 1928-1950.
3 Myopia prevalence of various degrees among adults, 1928-1950.
4 Studies of myopia prevalence among children in Europe and the United States
1831-1980.
Studies of myopia prevalence among schoolchildren at different ages in the
United States, 1877-1932.
Studies of myopia prevalence among young adults by age and other variables,
1848-1953.
7 Studies of myopia prevalence among college students in the United States and
other countries, 1871-1985. 20
U.S. Naval Academy entrants who became myopic, 1956. 26
Hyperopic U.S. Air Force pilots and navigators who became myopic, 1983. 28
29
10 Myopic shift after 2.5 years in the U.S. Air Force Academy class of 1985.
11 Refractive error changes of 244 U.S. Naval Academy graduates who retained
20/20 acuity.
12 Mean refractive error change of U.S. Military Academy seniors who were
myopic at entry.
13 Percentage of eyes exhibiting conus at various refractive intervals.
B-1 Studies of myopia prevalence among Danish schoolchildren, 1884-1968.
B-2 Studies of myopia prevalence among Danish young men, 1882-1983.
B-3 Myopia prevalence among children and adults in the United States, 1924-1972.
C-1 Prevalence of myopia among schoolchildren in the Los Angeles area (Hirsch),
in Pullman, Washington (Young et al.) and in Ontario, Canada (Langer).
C-2 Mean amount of myopia at age 15-16 according to the age of onset.
C-3 Frequency distribution of rates of childhood myopia progression for patients
from five optometry practices in the central United States.
C-4 Average annual refractive error changes for two series of private practice patients.
C-5 Refractive error changes in submariners and national guardsmen.
C-6 Pilots and navigators who developed more than 0.25 D. of myopia by various
initial refractive error levels.
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C-7 Refraction and axial length and their changes from ages 1~18 in a sample
of Tow birthweight and full-term subjects.
C-8 Mean refractive error change and ocular dioptric components at age 18 in a
sample of low-birthweight and full-term subjects.
FIGURES
1 Mean myopic shift in spherical equivalent refractive error between the entrance
and third academic year exams (2.5 year period) for 664 eyes from the U.S.
Air Force Academy class of 1985.
Percentage of eyes in selected ranges of entering spherical equivalent (SPEQ)
refractive error with a myopic shift in SPEQ greater than or equal to selected
amounts for 994 eyes from the U.S. Air Force Academy class of 1985.
3 Percentage of eyes in each type of entering spherical equivalent (SPEQ) refractive
error showing either a 0.25 D. hyperopic or myopic shift or no shift in SPEQ
between entrance and third academic year exams (2.5 year period) for 994
eyes from the U.S. Air Force Academy Class of 1985.
B-1 Myopic errors by race.
B-2 NHANES data collection procedure.
B-3 Changes with age in proportion of subjects who are myopic in a comparison
of five studies.
C-1 Refractive error distributions for newborns based on the data of Cook and
Glasscock (1951) and for 6 to 8-year-olds from the data of Kempfet al. (1928~.
C-2 Examples of myopia progression in five males (A) and five females (B) from
north central United States private practice records.
C-3 Refractive error changes in individual pilots who developed myopia according to
age at beginning of employment and length of employment.
C-4 Examples of young adult myopia progression patterns based on the classification
system of Goss et al. (1985~.
C-5 Average annual changes in refractive components with respect to age.
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