1040-5488/100/7710-0549/0 VOL. 77, NO. 10, PP.

549554
OPTOMETRY AND VISION SCIENCE
Copyright 2000 American Academy of Optometry

ORIGINAL ARTICLE

Factors Related to the Progression of Myopia in

Singaporean Children
SEANG-MEI SAW, MBBS, MPH, PhD, MD, F. JAVIER NIETO, MHS, PhD, JOANNE KATZ, ScD,
OLIVER D. SCHEIN, MD, MPH, BRIAN LEVY, OD, MSc, and SEK-JIN CHEW, FRCS, PhD
Department of Community, Occupational, and Family Medicine, National University of Singapore, Faculty of Medicine, Singapore (S-
MS), Departments of Epidemiology (FJN) and International Health (JK), Johns Hopkins University School of Hygiene and Public Health,
Baltimore, Maryland, Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine,
Baltimore, Maryland (ODS), Global Biological and Clinical Research, Bausch & Lomb, Rochester, New York (BL), and Singapore Eye
Research Institute, Singapore (S-JC)

ABSTRACT: Purpose: To examine the possible factors related to the progression of myopia in Singapore children.
Methods: One hundred fifty-three Singapore children aged 6 to 12 years were recruited to participate in a concurrent
cohort study of the risk factors for the progression of myopia. Socioeconomic status, outdoor activity, and near-work
activity were documented in a face-to-face clinic interview. The changes in cycloplegic subjective refraction and
autorefraction were ascertained with the use of a Nidek ARK 900 over a 2-year period. Results: The average rate of
progression of myopia as measured by subjective refraction was 0.59 D per year (95% confidence interval 0.52,
0.66). Younger children and children who were more myopic at the beginning (refractive error worse than 2.0 D)
of the study had higher myopia progression rates. Conclusions: Myopia progression was faster for younger children and
for children who had more severe myopia at baseline. Socioeconomic status and near-work activity were not related
to myopia progression. (Optom Vis Sci 2000;77:549554)

Key Words: reading, subjective refraction, cohort, epidemiology

M
yopia is a seemingly benign ocular disorder. However,
severe myopia is associated with potentially blinding
conditions such as pigmentary degeneration, retinal de-
tachment, myopic macular degeneration, cataract, and glaucoma.1
The economic costs of correction for myopia with spectacles and
contact lenses as well as the costs of optometry visits amount to
billions of dollars per year.2 Myopia is an especially important
public health problem in Asian countries such as Taiwan, Japan,
Hong Kong, and Singapore, where myopia rates are high and have
been increasing over the past few decades.35
Environmental and genetic factors have both been postulated to
cause myopia.510 The near-work hypothesis is substantiated by
animal studies, which suggest that visual cues determine axial
length, and cross-sectional studies of near work and myopia.1117
Several studies have found an association between socioeconomic
status, education, academic achievement, and myopia.8 10
To address these issues, a cohort study was undertaken to deter-
mine the progression of myopia in preteen myopic Singaporean
children and the possible factors related to the progression of my-
opia in schoolchildren.
MATERIALS AND METHODS
Study Population
Three hundred eleven children aged 6 to 12 years were volun-
teers recruited to participate in a randomized clinical trial of the
effect of rigid contact lenses on the progression of myopia in Sin-
gapore children. A concurrent cohort study of the risk factors for
myopia progression, which was nested in the randomized clinical
trial, included 153 children who were randomized to the standard
treatment (spectacles). The children were volunteers from all parts
of the island recruited by several press releases and from the Re-
fraction Clinic of the School Health Services from March 1996 to
May 1997. The research protocol was approved by the Committee
on Human Research, Johns Hopkins University School of Hy-
giene and Public Health. The Ethics committee, Singapore Na-
tional Eye Center, also approved this study.
Eligible children had myopia of 1.0 to 4.0 D (sphere) with
no other ocular or medical condition or previous contact lens wear.
Children with astigmatism of more than 2.0 D were also ex-
cluded from the study. Informed consent was obtained after the

Optometry and Vision Science, Vol. 77, No. 10, October 2000
550 Myopia Progression in Singaporean ChildrenSaw et al.
study was explained to each parent and verbal consent obtained
from each child during the first screening eligibility visit. The
length of follow-up of the 153 children was 13 to 40 months.
Sample Size Estimations
Assuming a Type I error rate of 0.05, power of 0.8, the sample
size required to detect a 25% difference in myopia progression
rates for children who are exposed to the risk factor compared with
children who are not exposed was 130, and the SD for refractive
error was 0.50 D.
Near-Work Activity Measured by the
Questionnaire
An in-person interview was conducted in either English or Chi-
nese during the first screening clinic visit by the same examiner
(SMS). The parents were interviewed exclusively in this study. A
pretested questionnaire was used and the interview lasted about 15
min (available from the authors). The response rate was 100%.
The parents were asked to recollect the amount of time in hours per
day spent on near-work activities on an average day. The types of
near-work activity assessed include reading and writing, computer
use, and playing video games. Questions on the amount of near
work during an average school term weekday, school term week-
end, before examinations, and during the school holidays were
asked separately. The primary analysis was conducted with raw
near work hours using school weekday hours. Near work at school
performed by the 153 children was estimated with a school diary
filled by out a subgroup of the 153 children (n 119) from more
than 100 different schools during one school session (about 6 h per
day in the morning or afternoon). All parents of the 153 children
were interviewed, but only 119 participants completed the school
diary. The average estimate of near-work activity for the 119 chil-
dren of each age was used to estimate near-work activity for the
remaining children of similar ages in the study. Thus, raw near
work hours was obtained by adding the hours spent at home and
the hours spent at school on near work during a school weekday.
A secondary analysis was conducted with weighted near work
time. Weighted time was obtained using the scheme: total near
work on school weekdays (home near work plus school near work)
was weighted by 0.5, school weekends (home near work) by 0.2,
examination time (home near work plus school near work) by 0.1,
and school holidays (home near work) by 0.2. This weighting
scheme was based on the proportion each time period contributed
to the entire school year. For example, in a typical school year, the
school terms are altogether 8.5 mo (70%), examinations 1 mo
(10%), and vacation time 2.5 mo (20%). For the 8.5-month
school term (70% of the school year), weekdays amount to 5 of 7
days and weekends to 2 of 7 days. Thus, 50% of the entire school
year is school weekday time, and 20% school weekend time. Ad-
ditionally, the distance of paper from the eyes while the child was
writing was measured (in centimeters) using a ruler at the clinic
site.
Reproducibility of Near-work Activity Measures
The parents of 30 volunteer children in the cohort study were
asked to complete the questionnaire in the same fashion twice over
Optometry and Vision Science, Vol. 77, No. 10, October 2000
a 2-week period, and the intraclass correlation coefficient for total
near-work activity was 0.87 (95% confidence interval,
0.85 0.91).18 The parents of consecutive participants were se-
lected over a 2-day period.
Other Lifestyle Factors
Information on other confounders such as sex, age, and outdoor
activities (number of hours per week of outdoor activity) were also
obtained. Socioeconomic status was evaluated by father and moth-
ers education (no formal education, primary, secondary, preuni-
versity or diploma or tertiary); housing type (one- or two-room
apartment, three- or four-room apartment, five-room apartment,
private housing); and total monthly family income (all categorical
variables). Information on parental history of myopia was obtained
from the interview by asking one parent whether any of the childs
parents were near-sighted.
Refractive Outcomes
Cycloplegic refractive error measurements were documented ev-
ery 6 months. The refractive examinations were conducted 30 min
after the third drop of 1% Cyclogyl Ophthalmic solution was
instilled, whereby one drop of cycloplegic solution was adminis-
tered at 5-min intervals for a total of 15 min. Myopia was recorded
in increments of 0.25 D. The primary outcome is the change in
cycloplegic subjective refraction. Cycloplegic autorefraction mea-
surements were also measured with the Nidek ARK 900 (Nidek
Co. Ltd, Tokyo, Japan), where the average of three measurements
per eye was taken. We used the Generalized Estimating Equations
(GEE) to evaluate change in refractive error measurement (spher-
ical equivalent) every 6 months. Additionally, we measured the rate
of myopia progression (difference between final and initial refrac-
tive error measurement) annualized to produce diopters per year of
change in refraction. Even though the length of follow-up varied
for the 153 children, we included all 153 children in our study
analysis.
Statistical Analysis
The major outcome of the analysis of change in refraction was
based on mean equivalent sphere (sphere power half cylinder
power). The mean refractive error (spherical equivalent) change
per year as measured by subjective refraction and autorefraction
was evaluated for children of different gender, age, age of first
spectacle wear, astigmatism, and different socioeconomic status.
We studied the relationship between myopia progression and near-
work activity using the raw, unweighted hours of near work, as well
as weighted time on near work. We wanted to study the longitu-
dinal trend in refractive error, but because each visit is highly
correlated, the generalized estimating equation (GEE) method was
used to model the outcome, which was the change in refractive
error (spherical equivalent) at each 6-month visit (difference be-
tween refractive error at each visit and the baseline refractive error)
as a function of the risk factors.19 Only data from the right eye was
presented because the results from right and left eyes were similar.
Both univariate and multivariate analyses were performed using
Stata Version 5.0 (Stata Corporation, College Station, TX).
 Myopia Progression in Singaporean ChildrenSaw et al. 551

RESULTS
The mean and median follow-up periods of the study for the
153 children were 28 and 27.7 months, respectively. Children
with longer follow-up times had similar ages but were more likely
to be male. Table 1 shows the characteristics of the study popula-
tion. There were 92 boys and 61 girls in the study. The mean age
of the children was 8.5 years. Thirty-nine (25.7%) of the childrens
fathers had tertiary education and 51 (33.3%) lived in private
housing. In contrast, 9.4% of Singapore men had tertiary educa-
tion and 15.4% lived in private houses.20 One hundred and one
(66%) of the fathers were myopic and 100 (65.4%) of the mothers
were myopic. These prevalence rates were higher than the preva-
lence rate of 38.7% in Singapore adults above 40 years.21 The
median raw near-work activity was 5.8 h/day (range, 0.5 to 10.9). FIGURE 1.
Fig. 1 shows the distribution of the change in right eye subjec- Change in right eye subjective refraction spherical equivalent per year
tive refraction per year, whereby the rate of progression of myopia for the children in the study, Singapore, 1996 to 1999.
was greater than 0.5 D per year in 88 (55.4%) children. Fig. 2
shows the distribution of the change in right eye autorefraction per

TABLE 1.
Characteristics of 153 Singaporean children aged 6 to 12
years who participated in the cohort study of the factors
related to the progression of myopia, 1996 to 1999
Mean SD N (%)

Age at first clinic visit (years) 8.5 1.4

Gender
Male 92 (60.1)
Female 61 (39.9)
Fathers education
No formal education 0 (0.0)
Primary 11 (7.3) FIGURE 2.
Secondary 50 (32.9)
Change in right eye autorefraction spherical equivalent per year for the
Preuniversity or diploma 52 (34.2) children in the study, Singapore, 1996 1999.
Tertiary 39 (25.7)
Mothers education
No formal education 3 (2.0) year and 91 (57.2%) children had a rate of progression of myopia
Primary 5 (3.3) greater than 0.5 D per year. The mean changes in subjective
Secondary 84 (55.3) refraction per year and autorefraction per year for children with
Preuniversity or diploma 44 (29.0) different characteristics at baseline were presented in Table 2. The
Tertiary 16 (10.5) average change in subjective refraction for total subjects was 0.59
Housing D per year (0.56 D per year in boys, and 0.66 D per year in
One/two room apartment 2 (1.3) girls). Younger children had faster rates of myopia progression as
Three/four room 46 (30.1) measured by subjective refraction (p 0.0001) and autorefraction
apartment
(P 0.0001). The average change in refractive error for children
Five room apartment 54 (35.3)
whose initial refractive error was 2.0 D or more was 0.65 D per
Private housing 51 (33.3)
Total family income per year compared with 0.56 D per year for those whose initial
month (1.6 Sin$ 1 refractive error was less than 2.0 D. This was statistically signif-
US$) icant for the change in autorefraction readings (p 0.0001). The
2000 16 (10.5) changes in refractive error per year for children with different base-
20015000 64 (41.8) line astigmatism measures, incomes, and types of housing were
5000 73 (47.7) similar.
Father with myopia Table 3 presents the regression coefficients and 95% confidence
Yes 101 (66.0) intervals of the generalized estimating equation (GEE) models that
No 52 (34.0) model the difference in refractive error at each 6-month visit and
Mother with myopia
the baseline visit with the different covariates of interest including
Yes 100 (65.4)
No 53 (34.6)
age, gender, raw near work, total weighted near work time, raw
reading and writing hours, total weighted reading and writing

Optometry and Vision Science, Vol. 77, No. 10, October 2000
552 Myopia Progression in Singaporean ChildrenSaw et al.

TABLE 2.
Sociodemographic factors and the change per year of cycloplegic subjective refraction and autorefraction for 153
children in our study, 1996 to 1999
Mean change per year for Mean change per year
subjective refraction for autorefraction

Mean SD Mean SD
Total subjects 0.59 0.44 0.60 0.41
Gender
Male 0.56 0.40 0.59 0.39
Female 0.66 0.42 0.60 0.51
Age (years at the start of the study)
7 and below 0.85 0.41 0.85 0.41
8 0.62 0.31 0.66 0.33
9 0.51 0.33 0.51 0.40
10 0.32 0.42 0.32 0.38
11 and above 0.36 0.24 0.20 0.29
Astigmatism (More than 0.5 D)
Yes 0.60 0.42 0.57 0.42
No 0.60 0.40 0.62 0.46
Initial refractive error
Less than 2.0 D 0.56 0.38 0.50 0.44
2.0 D or more 0.65 0.44 0.70 0.41
Total family income (1.6 Sin$ 1 US$)
$2000 per month 0.49 0.42 0.58 0.41
$2000 to $5000 per month 0.61 0.42 0.56 0.44
$5000 per month 0.63 0.41 0.62 0.46
Housing
One/two room apartment 0.49 0.17 0.80 0.20
Three/four room apartment 0.49 0.44 0.54 0.45
Five room apartment 0.74 0.41 0.70 0.42
Private housing 0.57 0.37 0.51 0.45

time, reading distance, outdoor activity, total combined family
income, type of housing, and parental history of myopia. All mod-
els adjust for age, gender, and parental history of myopia. Children
who were younger had higher rates of change in cycloplegic sub-
jective refraction for the different visits. Children with myopic
parents had larger changes in myopia rates. There were no statisti-
cally significant associations between cycloplegic subjective refrac-
tion change and total or raw near-work activity, reading and writ-
ing, reading distance, total combined family income, or type of
housing.
DISCUSSION
To our knowledge, this is one of the first concurrent cohort
studies conducted in Asia that studies detailed assessments of the
different environmental risk factors for the progression of myopia.
There are many factors that may contribute to the different indi-
vidual variations in myopia progression.22 Near-work activity may
be one factor related to myopia progression; objects that are viewed
nearby may cause the eye to elongate further to maximize the
sharpness of images on the retina.1213 A positive association has
been found for near-work activity and myopia in several cross-
sectional studies.5, 1517, 2324 There have also been positive corre-
lations between socioeconomic status and myopia.8 10
The average rate of progression of myopia as measured by cy-
cloplegic subjective refraction in the right eye was 0.59 D per
year, and 0.60 D per year as measured by autorefraction. These
rates are slightly higher than the average rates of progression of
myopia of 0.46 D in Hong Kong children aged 6 to 17 years,
0.41 D per year in men and 0.46 D in women aged 6 to 15
years in the United States, and 0.55 D per year in Finnish chil-
dren aged 7 to 15 years.2527 The age groups of the study popula-
tions vary and measurements of myopia progression rates may not
be exactly comparable. Younger children were found to have
higher myopia progression rates.2728 Children who were more
myopic at the beginning of the study were found to have more
rapid myopia progression rates.29 30 Similar results were found by
Braun et al., whereby younger children and children with more
than 1 D myopia at baseline were found to have faster myopia
progression.31
Socioeconomic status of the family as denoted by family income
or housing did not predict the rate of progression of myopia. Only
a small proportion of parents had completed primary education
(elementary school) only (11 fathers and 5 mothers), thus our
study population has a rather uniform socioeconomic status.
Therefore, our population may not be suitable for determining
possible modest associations between socioeconomic status and
myopia progression. There was also no relationship between out-
door activity and myopia progression.
Our study may not find a relationship between near-work ac-
tivity and the progression of myopia for several reasons (other than

Optometry and Vision Science, Vol. 77, No. 10, October 2000
 Myopia Progression in Singaporean ChildrenSaw et al. 553

TABLE 3.
Rate of change in cycloplegic subjective refraction readings as the response variable and the factors as the main exposures
of interest, adjusting for age, sex, and parental history of myopia using the generalized estimating equation (GEE model)
in a cohort study of Singaporean children, 1996 to 1999 (n 153).

Regression
95% CIa 2-sided p
coefficient

Age years 0.19 0.13, 0.25 0.0001

Gender
Males Reference Reference
Females 0.13 0.31, 0.05 0.16
Raw total near work hours per day on school weekday 0.023 0.18, 0.063 0.27
Weighted time on near work hours per day 0.013 0.023, 0.048 0.49
Raw total reading and writing hours per day on school 0.028 0.027, 0.083 0.32
weekday
Weighted time on total reading and writing hours per day 0.043 0.020, 0.11 0.18
Distance of eye from book while reading or writing 0.0087 0.0043, 0.022 0.19
Hours per week of outdoor activities 0.013 0.013, 0.04 0.33
Total combined family income Sin$ per month
$2000 Reference Reference
$2000$5000 0.049 0.36, 0.26 0.76
$5000 0.063 0.37, 0.24 0.69
Type of house
One or two room apartment Reference Reference
Three or four room apartment 0.32 0.45, 1.08 0.42
Five room apartment 0.11 0.65, 0.88 0.77
Private housing 0.36 0.41, 1.13 0.35
Number of parents with myopia
None Reference Reference
One 0.38 0.64, 0.11 0.005
Two 0.43 0.69, 0.18 0.001
a
95% confidence intervals CI based on the GEE robust estimates of the standard error.

the fact that such a relationship might not exist). An association of
near-work activity and myopia may represent a threshold effect
where, for example, virtually all the risk is assumed once the expo-
sure (near-work activity) exceeds 3 or 4 h. Near-work activity may
also be related to the onset rather than the progression of myopia.
This study conducted in Singapore has several unique advan-
tages. Cycloplegic refractions were determined by both autorefrac-
tion and subjective refraction in 153 myopic children. Further-
more, the optometrists who performed the refractive
measurements were masked to the different factors as measured in
the interview. There was no interviewer bias, because lifestyle fac-
tors were quantified prospectively before progression rates of my-
opia were ascertained. However, a limitation is that any changes in
near work cannot be associated with changes in myopia progres-
sion. The length of follow-up varied for each child. Children who
remained in the study for a longer period were more likely to be
male compared with children who left the study earlier. However,
the length of follow-up for each child did not determine myopia
progression, even after adjustment for gender. This study may have
limited generalizability, because the children participating in the
study are volunteers in a clinical trial with different socioeconomic
backgrounds compared with the Singapore population. However,
it is likely that the exposure-outcome relationship remains intact in
different populations.
In summary, younger children and children with higher degrees
of refractive error at baseline had faster myopia progression rates.
No definite relationship between socioeconomic status, near-work
activity, and myopia progression was found in preteen myopic
Singapore children who participated in a myopia clinical trial.
Migration studies, in which migrants may adopt certain lifestyles
of the new country, may provide us with some information on
both the environmental and genetic factors that may contribute to
myopia. The incidence of myopia may be determined in a large
cohort with a follow-up period of 3 to 5 years.
ACKNOWLEDGMENT
This study was supported by the Johns Hopkins Summer Epidemiology Pro-
gram and Bausch & Lomb, Inc, Rochester, New York. Dr. Saw was supported
by the National Medical Research Council-Shaw Foundation Research Fel-
lowship from October 1996 to May 1997.
Received January 19, 2000; revision received June 20, 2000.
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Seang-Mei Saw
Department of Community, Occupational and Family Medicine
National University of Singapore
16 Medical Drive
Singapore 117597
Email: cofsawsm@nus.edu.sg