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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 .. 111

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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 - V11 1X X1 1 3 8 23 36 43 45 62 89 93 97

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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. X1 9 12 13 15 16 18 31 32 41 51 52 53 66 67 69 73 77 79

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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. ~ X11 87 88 33 34 34 48 55 58 63 71 81 83 86