Elsevier

Survey of Ophthalmology

Volume 48, Issue 5, September–October 2003, Pages 515-543
Survey of Ophthalmology

Public health and the eye
Epidemiology of refractive errors and presbyopia

https://doi.org/10.1016/S0039-6257(03)00086-9Get rights and content

Abstract

Limitations in existing studies of the epidemiological aspects of refraction are attributed to both technical and statistical procedures. Early influences of ocular parameters on refraction are identified accordingly as prematurity and may or may not be involved. Attention is paid to familial and genetic influences, and infants and toddlers are examined as a group separate from schoolchildren and teenagers, who are likely to have experienced significant periods of near work. The effects of sex and geographical distribution are considered both for younger and older age ranges. Special attention is paid to anisometropia, which is shown—apparently for the first time—to increase appreciably among presbyopes. The connection between refractive errors and ocular pathologies is reviewed, and possible means of preventing early onset myopia are examined. Presbyopia is addressed with reference to its geographical distribution and hypothetical links to accommodation insufficiency.

Section snippets

Ocular parameters including ethnic variations

The variation with age of ocular parameters relevant to an understanding of age-related changes in refraction has been reviewed.192., 193. Earlier data were based largely on in vivo and in vitro material of Caucasian origin. The advent of ultrasonography has reduced reliance on in vitro measurements, although earlier difficulties linked to an uncertainty regarding the values of the refractive indices pertaining to the various components still persist. Also there has appeared a welcome interest

Genetic influences, sex differences, and familial correlations

The completion of the details of the human genome leaves no room for doubt but that the genetics of refraction and its anomalies will become known. Indeed, two loci for high myopia (<−6D) have now been identified, located on chromosomes 12q21–23 and 18p11.31, respectively.204 The type of myopia was not linked to near-work (see below), as the average age of onset was 5.9 years, the mean refractive error being −9.5 D. However, on a medico-social scale the priority of solving the genetic problem

Prematurity

The careful pioneering work by Fledelius48 has shown that refractive anomalies present at the birth of low-birth-weight children may persist for many years.49 Myopia may affect some 18% of them.153 When one considers that, even in a relatively advanced country, such as the United Kingdom, the prevalence of low birth weight babies is about 6%, the fraction of the total population that is myopic on that score is about 1%: this is not far from an epidemic.36 However, this argument is dwarfed by

Infants and toddlers

Schooling involves near work and therefore has been implicated in the etiology of acquired myopia. Consequently the epidemiology of refractive errors is in the first instance properly focused on pre-school children.

The causes of infant myopia are still being investigated, but, in view of the attention given during the last decade or so to long-term intra-uterine influences,14 it is worth noting that maternal hypertension, preeclampsia and renal disease are liable to lead to a baby's myopia

Phenomenology

The association of myopia, developing in the years leading up to puberty and beyond, with close work is now generally accepted. It finds its physiological basis in the observation that the axial lengths of eyes aged 18–22 years change by 0.06 mm and 0.1 mm during accommodation of 3 D and 8 D, respectively.175 Myopia thus appears to be linked to repeated and/or prolonged accommodation, and we shall see later that this view forms the basis of proposed remedies. In this connection it is

Late-onset myopia

Whereas Goss64 quotes the average annual increase in childhood myopia in Europe and the U.S. as being 0.5 D, it would seem that the late onset involves a slower progress. This was tracked in Norwegian university students with a mean age of 20.6 years:98 over a 3-year period the mean refractive change was −0.5 D (p = 0.0001), that is, three times as slow: this fits comfortably into an extrapolation of Table 7 to an age of 20.5 years. There was a significant relation between the degree of acquired

Age and sex

The description of age-related changes in refraction by Saunders170 has the advantage over all the others in that it provides a graphical frame-work with which to compare other studies. Fig. 8 shows the initial, infant hypermetropia being reduced as a result of emmetropization to zero at an age of ∼14 years in the sample studied. A progression to myopia reaches a maximum around the 30s, and then regresses toward hypermetropia, the maximum of which is reached in the 70s.52 The subsequent change

Refraction and pathology

While it is clear that this topic could be the subject of a review on its own, it would not be right to ignore it altogether, if only to hint at some of the difficulties facing it. Two examples must suffice to illustrate this. As we shall see in a moment, myopia is conventionally seen as a risk factor for primary open-angle glaucoma (POAG). Yet it can also appear as a familial factor in primary angle-closure glaucoma (PACG),76 and PACG is also prevalent among Chinese with a high prevalence of

Prevention

We previously noted that two gene loci for high myopia have been discovered, as a result of which the condition has been described as multigenic: if they should turn out to be the only ones, the condition would probably be called digenic. However, the links between high myopia and associated conditions are still tentative, and we shall have to wait for the situation to be resolved.

In the meantime, concern about the various undesirable sequelae of myopia has not abated, and, with regard to

Presbyopia

Because presbyopia is of relatively minor socio-medical urgency, few population-based study appear to have been published on either the age-related prevalence or incidence of accommodative failure. Therefore, there is no substantial basis for an epidemiology of presbyopia. The risk, in later life, of falling prey to the condition of being unable to focus sharply on near-by objects, such as the printed page, is 100%. There are a few isolated reports of people aged 60 years or more who claim to

Conclusion

It is appropriate that a review of the epidemiology of refractive errors should end with a pointer at Vision 2020, a global initiative200 promoting the elimination of avoidable blindness. In industrially developed countries the idea that refraction could be involved with avoiding blindness may appear strange. Nonetheless Vision 2020 stresses that there are five treatable conditions responsible for 75% of the world's blindness, and refractive errors are one of them. Thus the non-availability of

Summary

  • 1.

    In the immediate future, a distinction may have to be made between programs designed to address vision correction for developing and developed countries, respectively. The former need first aid to bring corrected vision to a level of at least 25% normal, that is, 20/80 or 6/15. Such countries also need ready help with presbyopic corrections.

  • 2.

    With regard to industrially more advanced countries, several studies suggest that the degree and prevalence of early onset myopia can be reduced worldwide

Method of literature search

I used Medline and Science on the Internet (the last 30 years). I had access to the library of the Institute of Ophthalmology (University of London), the journal shelves and lists of contents of which I combed. I possess an extensive collection of reprints, and also referred to the extensive bibliographies in my books. I used abstracts of Japanese papers, but ensured that I fully understood the relevant accompanying graphs. The search words used were related to ocular refraction, presbyopia,

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    The author reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.

    This work has not been funded by anyone.

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