ARVO 2014 Annual Meeting Abstracts
209 Myopia - going beyond the near-work hypothesis
Monday, May 05, 2014 8:30 AM–10:15 AM
S 320CD Paper Session
Program #/Board # Range: 1268–1274
Organizing Section: Clinical/Epidemiologic Research
Program Number: 1268
Presentation Time: 8:30 AM–8:45 AM
Myopia prevalence in Europe: cohort effect of increasing
prevalence not fully explained by higher educational levels
Christopher J. Hammond. Ophthalmology, King’s College London,
London, United Kingdom.
Purpose: To examine the prevalence of myopia in Europe,
investigate whether it is becoming more common, and to explore
whether this can be explained by increasing levels of education.
Methods: Refractive error data were analysed from 13 population-
based cohorts of the E3 Consortium, collected between 1990 and
2012. Mean spherical equivalent (SE) of the two eyes was calculated.
Participants reporting cataract, retinal detachment or laser refractive
surgery were excluded. Myopia was defined as ≤-0.75 D and high
myopia as ≤-6 D. Sequential random effect meta-analyses were
performed with age stratification. Geographical differences were
examined according to the United Nations Geoscheme. The effects
of birth year and education level were investigated, stratifying
participants into primary (<16 leaving education), secondary (16-19)
or higher education (≥ 20).
Results: SE was available for 58,999 subjects with median cohort
ages 44-78 years, 57.9% female and minimal ethnic variation (99%
European ancestry). Overall myopia prevalence was 23.8% (95%
CI 19.3–28.4) with high myopia affecting 2.1%. Myopia was more
common in younger subjects; 42.3% (95% CI 38.7-45.9) aged
20-30 years, compared to 29.0% (95% CI 24.8-33.2) aged 50-60.
Prevalence of myopia did not differ by geographical area. A cohort
effect for rising myopia prevalence was apparent; in those aged 55-60
born between 1930-39, 22.6% (95% CI 20.2-25.0) were myopic,
increasing to 25.4% (95% CI 23.9-26.9) if born between 1940-49 and
to 33.0% (95% CI 30.3-35.7) if born between 1950-59. Education
level and birth year both affected myopia prevalence [Figure 1];
compared to a reference group of primary education and 1930-39
birth year, participants with higher education had a two-fold increase
in myopia prevalence and a three-fold increase in those with higher
education and born between 1950 and 1959.
Conclusions: A quarter of subjects in population-based cohorts
across Europe are myopic, higher in younger subjects. There appears
to be a cohort effect of increasing myopia prevalence. Education is
strongly associated with myopia and education levels have risen,
but the length of time in education does not fully explain the cohort
effect. Further research is required to investigate if the cohort effect is
explained by changes in educational experience and other factors.
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at pubs@arvo.org.
Myopia prevalence by birth year and education in subjects aged 45-
65
Commercial Relationships: Christopher J. Hammond, None
Support: MRC Clinical Trainee Research Fellowship (Dr K
Williams)
Program Number: 1269
Presentation Time: 8:45 AM–9:00 AM
Migration and Acculturation are associated with Refractive
Errors in a Multiethnic Cohort in the United States: the Multi-
Ethnic Study of Atherosclerosis
Chen Wei Pan1, 2, Sharon Chua3, Ronald Klein4, Barbara E. Klein4,
Mary Frances Cotch5, Ching-Yu Cheng2, 3, Tien Y. Wong2, 3. 1School of
Public Health, Soochow Univeristy, Suzhou, China; 2Singapore Eye
Research Institute, Singapore, Singapore; 3Saw Swee Hock School
of Public Health, National University of Singapore, Singapore,
Singapore; 4School of Medicine and Public Health, University of
Wisconsin, Madison, WI; 5National Eye Institute, Bethesda, MD.
Purpose: To assess the impact of factors related to migration and
acculturation (country of birth, age at migration and language spoken
at home) on refractive errors in the US.
Methods: A total of 5365 adults (2083 Whites, 1464 Blacks, 1175
Hispanics and 643 Chinese) aged 45 to 84 years living in the U.S
participated in the study. Information regarding acculturation level
including country of birth, age at migration and language spoken at
home were collected from interviews. Non-cycloplegic refraction
was performed in both eyes of all participants using an autorefractor
(NIDEK ARK-760 Autorefractor). Myopia was defined as spherical
equivalent of -1.0 diopters (D) or less in the right eye while hyperopia
was defined as SE of 1.0 D or more. Multivariate logistic regression
model was used to estimate the association between the acculturation
variables and myopia.
Results: Participants born in the US were more likely to have
myopia (odds ratio [OR]: 1.28; 95% confidence interval [CI]: 1.03,
1.61) and less likely to have hyperopia (OR: 0.70; 95% CI: 0.58,
0.85) than those born outside the US, while controlling for age,
gender, race/ethnicity, education, cataract and height. Participants
who spoke English at home had a higher prevalence of myopia
(OR: 1.77; 95% CI: 1.36, 2.32) and a lower prevalence of hyperopia
(OR: 0.67; 95% CI: 0.54, 0.84) compared with those who spoke a
non-English language. For participants born outside the US, those
who migrated to the US before the age of 20 had a higher prevalence
of myopia (OR: 2.44; 95% CI: 1.69, 3.57) and a lower prevalence
of hyperopia (OR: 0.62; 95% CI: 0.44, 0.86) compared with those
who migrated after the age of 20. When stratified by race/ethnicity,
the trends were similar among Chinese, Blacks and Hispanics with
higher acculturation level in the US being associated with a higher
prevalence of myopia. The association was not found in Whites due
ARVO 2014 Annual Meeting Abstracts
to the small numbers of White participants who were born outside the
US (n=138) or who did not speak English at home (n=32).
Conclusions: Myopia is more while hyperopia is less common
among new immigrants with higher acculturation levels in the US.
These findings suggest that country-specific environmental factors
may affect the onset and progression of refractive errors in diverse
populations.
Commercial Relationships: Chen Wei Pan, None; Sharon Chua,
None; Ronald Klein, None; Barbara E. Klein, None; Mary
Frances Cotch, None; Ching-Yu Cheng, None; Tien Y. Wong,
None
Program Number: 1270
Presentation Time: 9:00 AM–9:15 AM
Longitudinal change in ocular biometry: relationship to
refractive development in children and adolescents
Kathryn A. Rose1, Amanda N. French1, Paul Mitchell3, Ian G.
Morgan2, 1. 1Discipline of Orthoptics, University of Sydney,
Lidcombe, NSW, Australia; 2Research School of Biological
Sciences, Australian National University, Canberra, ACT, Australia;
3
Department of Ophthalmology, Westmead Millennium Institute,
University of Sydney, Sydney, NSW, Australia.
Purpose: To establish the relationship of change in refraction
over a period of 5-6 years with changes in ocular biometric and
anthropometric measures.
Methods: Sydney Myopia Study participants aged 6 and 12 years
were re-examined 5-6 years later in the Sydney Adolescent and
Vascular Eye Disease Study (SAVES). Axial length (AL), anterior
chamber depth (ACD) and corneal radius (CR) were measured using
the IOLMaster (Carl Zeiss, Germany). Spherical equivalent refraction
(SER) in dioptres (D) was calculated from cycloplegic autorefraction
(cyclopentolate 1%; Canon RK-F1) and myopia was defined SER
≤-0.50D. All measures, including height and weight, were established
at baseline and follow-up using the same methodology. Ethnicity was
defined by self identified origin of both parents.
Results: Complete longitudinal refractive data was available for 2059
children; 863 with an average age of 12.8 years at follow-up and
1196, mean age 17.2 years. There was significant change in SER from
baseline to follow-up for both cohorts and for all biometric measures,
including AL/CR (p<0.0001). Change in height was not correlated
with shift in SER in either cohort when stratified by ethnicity. In
a multivariate model adjusted for height and ethnicity, change in
SER was significantly associated with change in AL and AL/CR
(p <0.0001) in both the younger and older cohorts. CR marginally
flattened (0.05, 0.02mm, younger and older cohorts respectively).
The power of the cylindrical component of SER marginally decreased
(0.02D, p = 0.039) in the younger but not older cohort, however,
for those with myopia compared to those without, there was an
increase in the cylindrical power for those with baseline (p=0.001)
and incident myopia (p<0.0001) in the older cohort and only baseline
myopia in the younger cohort (p=0.017). In both cohorts, myopia
remained significantly associated with change in cylindrical power on
multivariate analysis (p<0.0001).
Conclusions: Change in refraction was significant associated with
change in AL and AL/CR, while the change in CR though statistically
significant was clinically insignificant. General growth including
height was not associated with change in SER. An increase in the
cylindrical component of refraction was significantly associated with
existing myopia at all ages and with incident myopia in the older
cohort.
Commercial Relationships: Kathryn A. Rose, None; Amanda N.
French, None; Paul Mitchell, None; Ian G. Morgan, None
Support: Australian NHMRC Grants APP1034329, 512530, 253732
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at pubs@arvo.org.
Program Number: 1271
Presentation Time: 9:15 AM–9:30 AM
Outdoor exposure determines axial length already at the age of 6
years: The Generation R Study
Jan Roelof Polling1, 2, Willem Tideman1, Vincent W. Jaddoe3, Albert
Hofman3, Caroline C. Klaver1. 1Ophthalmology, Erasmus MC,
Rotterdam, Netherlands; 2Orthopics & Optometry, University of
Applied Sciences Utrecht, Utrecht, Netherlands; 3Epidemiology,
Erasmus MC, Rotterdam, Netherlands.
Purpose: Myopia is predominantly caused by increase of the
eye ball’s axial length in childhood. Various studies reported an
association between time spent outdoors, near work, and risk of
myopia in children. The aim of this study was to investigate whether
environmental exposures already influence axial length in children
who are just learning to read.
Methods: The Generation R Study is a multi-ethnic population-
based birth-cohort study in Rotterdam, the Netherlands, which
includes a total of 6690 children. Visual acuity (LEA charts) and
axial length (IOL master) were obtained at the research center at
age 6. Cycloplegic refraction was evaluated in those with LogMAR
acuity > 0.1 and in those already receiving ophthalmologic care.
Data on ethnicity, time spent outdoors and near work activities were
obtained by questionnaire. In groups varying in duration of time
spent outdoors (<1 hour, 1-2 hours, or >2 hours per day) and near
work (<15 min, 15-30 min and >30 min per day) we investigated
the association with axial length using linear and logistic regression
analysis adjusting for age, gender, ethnicity and height.
Results: The prevalence of myopia was 1.9% (129 children), and
varied from 0.9% in Dutch to 3.2% in non-western immigrants. Axial
length ranged from 19,27 mm to 25,05 mm with a median of 22,35
(SD 0,73). 4059 children completed the questionnaires. Time spent
outdoors was significantly associated with axial length (22,41 mm for
< 1 hr. outdoors vs. 22,33 mm for > 2 hrs., P<0.001). Playing outside
< 1 hrs./day increased the risk of more than average axial length by
34% (OR 1.34, 95% CI 1,14-1,58). Time spent on near work was not
significantly associated with axial length (P=0.14).
Conclusions: Time spent outdoors already influences axial length in
children who have just started to read. Parents of children at risk of
myopia progression should be made aware of the protective effect of
outdoor exposure in very young children.
Commercial Relationships: Jan Roelof Polling, None; Willem
Tideman, None; Vincent W. Jaddoe, None; Albert Hofman, None;
Caroline C. Klaver, None
Program Number: 1272
Presentation Time: 9:30 AM–9:45 AM
INCREASED OUTDOOR TIME REDUCES INCIDENT
MYOPIA – THE GUANGZHOU OUTDOOR ACTIVITY
LONGITUDINAL STUDY
Ian G. Morgan1, 2, Fan Xiang3, Yangfa Zeng2, Jincheng Mai4, Qianyun
Chen2, Jian Zhang2, Kathryn A. Rose5, Mingguang He2. 1Research
School of Biology, Australian National University, Canberra, ACT,
Australia; 2Zhongshan Ophthalmic Center, Sun Yat-sen University,
Guangzhou, China; 3National Centre for Epidemiology and
Population Health, Australian National University, Canberra, China;
4
Student Health Care Institute, Guangzhou CIty Department of
Education, Guangzhou, China; 5Discipline of Orthoptics, University
of Sydney, Sydney, NSW, Australia.
Purpose: To determine whether increased time outdoors reduces
incident myopia in a school-based cluster-randomised three year trial.
Methods: Twelve primary schools were chosen from those monitored
annually for uncorrected visual acuity by the Guangzhou Student
Health Bureau. The schools were stratified by recent visual acuity
ARVO 2014 Annual Meeting Abstracts
data into 6 strata. One school from each stratum was randomly
allocated to the control and intervention arms. All Year 1 classes in
each school were enrolled in the study. Schools in the intervention
arm had an additional 45 minute outdoor activity class at the end of
each day. Control schools followed their normal activities. Parent
information campaigns were conducted in the intervention schools.
Cycloplegic refraction and axial length were measured at baseline
and annually, for three years. Myopia was defined as spherical
equivalent refraction of ≤ -0.5D. Results were adjusted for the
cluster-sampling design using mixed models.
Results: At baseline, the two arms were not significantly different
in prevalence of myopia or mean spherical equivalent. Over three
years, incident myopia, the primary outcome measure, was 39.5%
in the control arm, compared to 30.4% in the intervention arm - a
23.0% reduction in cases of incident myopia (p<0.001). Small but
statistically significant reductions were seen in myopic shift in mean
spherical equivalent refraction. Less axial elongation was also seen
in the intervention group, but this difference was not statistically
significant. The intervention group reported an increased amount of
time outdoors, outside of school hours (82.7 vs 61.0 minutes per day,
p<0.0001), in addition to their additional outdoor time at school.
Conclusions: These results provide proof of principle that increasing
the amount of time that children spend outdoors through the school
system can decrease the number of children who become myopic.
The estimated total difference in time outdoors between arms was
66.7 minutes per day (p<0.0001). The effect size is small, but
epidemiological evidence suggests a dose-response relationship
between protection and time outdoors. We therefore recommend
that myopia control programs based on increased time outdoors be
developed in primary schools, at least in countries with currently high
prevalence rates for myopia, with evidence-based mandatory targets
for the amount of time children spend outdoors.
Commercial Relationships: Ian G. Morgan, None; Fan Xiang,
None; Yangfa Zeng, None; Jincheng Mai, None; Qianyun Chen,
None; Jian Zhang, None; Kathryn A. Rose, None; Mingguang He,
None
Support: State Key Laboratory of Ophthalmology, Sun Yat-sen
University, China and National Natural Science Foundation of China
Clinical Trial: NCT00848900
Program Number: 1273
Presentation Time: 9:45 AM–10:00 AM
Myopia is associated with lower Vitamin D status in young adults.
Alex W. Hewitt1, 2, Seyhan Yazar2, Lucinda J. Black3, Charlotte M.
McKnight2, Jenny Mountain3, Wendy H. Oddy3, Minas T. Coroneo4,
Robyn Lucas5, 3, David A. Mackey2. 1Centre for Eye Research
Australia, Melbourne, VIC, Australia; 2Centre for Ophthalmology and
Vision Science, University of Western Australia; Lions Eye Institute,
Perth, WA, Australia; 3Telethon Institute for Child Health Research,
Centre for Child Health Research, University of Western Australia,
Perth, WA, Australia; 4Department of Ophthalmology, University
of New South Wales, Sydney, NSW, Australia; 5National Centre for
Epidemiology and Population Health, Australian National University,
Canberra, ACT, Australia.
Purpose: Myopia is a complex disease caused by a combination of
genetic and environmental factors. Outdoor activity has previously
been shown to be protective against the development of myopia. The
aim of this study was to investigate the association between myopia
and Vitamin D status in young adults.
Methods: A cross-sectional analysis of 946 of individuals
participating in the 20-year follow-up of the Western Australian
Pregnancy Cohort (Raine) Study was performed. Ethnicity, parental
myopia and education status were collected by self-reported
©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at pubs@arvo.org.
questionnaire. A comprehensive ophthalmic examination was
performed, including post-cycloplegic autorefraction and conjunctival
UV autofluorescence photography. A blood sample collected was
analysed for 25-hydroxyvitamin D3 (25(OH)D3) concentrations.
Mann Whitney U test was used to evaluate the association between
serum 25(OH)D3 concentrations and prevalence of myopia as well as
multivariable logistic regression adjusting for potential confounders.
Myopia was defined as mean spherical equivalent ≤ -0.5 diopters.
Results: Myopic participants (n=221; 23.4%) had lower 25(OH)
D3 concentrations compared to non-myopic participants (p=0.003).
In univariable analysis, the prevalence of myopia decreased with
increasing serum 25(OH)D3 concentrations (OR 0.88; 95CI% 0.82 –
0.94; p <0.001 per 10 nmol/L increase). After adjusting for potential
confounders, including age, sex, ethnicity, parental myopia, education
status and sun-exposure, individuals in the highest tertile of serum
25(OH)D3 concentrations were less likely to be myopic that those in
the lowest tertile (OR 0.60; 95%CI 0.40-0.91; p=0.015).
Conclusions: The prevalence of myopia decreased in association
with increasing serum 25(OH)D3 concentration. Individuals with
higher vitamin D status were at decreased risk of myopia. Further
studies are warranted to investigate whether higher serum 25(OH)D3
concentration is protective against myopia or whether it is acting as
an indicator of sun exposure.
Commercial Relationships: Alex W. Hewitt, None; Seyhan
Yazar, None; Lucinda J. Black, None; Charlotte M. McKnight,
None; Jenny Mountain, None; Wendy H. Oddy, None; Minas T.
Coroneo, None; Robyn Lucas, None; David A. Mackey, None
Support: National Health and Medical Research Council and The
Ophthalmic Research Institute of Australia.
Program Number: 1274
Presentation Time: 10:00 AM–10:15 AM
Myopia and skin cancer are inversely correlated: Results of the
Busselton Healthy Ageing Study
David A. Mackey1, Maria Franchina1, Seyhan Yazar1, Michael
Hunter2, 3, Adam Gajdatsy1, Jean-Louis deSousa1, Alex W. Hewitt1, 4.
1
Centre for Ophthalmology and Visual Science, Lions Eye Institute,
University of Western Australia, Perth, WA, Australia; 2Busselton
Population Medical Research Institute, Department of Respiratory
Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia;
3
School of Population Health, University of Western Australia, Perth,
WA, Australia; 4Centre for Eye Research Australia, Royal Victorian
Eye and Ear Hospital, University of Melbourne, Melbourne, VIC,
Australia.
Purpose: Spending time outdoors, with the associated ultraviolet
(UV) irradiation, is a well-established risk factor for developing
skin cancer. In contrast, outdoor activity is protective against
myopia. We sought to determine the distribution of refractive error
amongst individuals previously diagnosed with basal cell carcinoma,
squamous cell carcinoma or cutaneous melanoma.
Methods: The Busselton Healthy Ageing Study is a cross-sectional
survey of individuals born between 1946-1964 living in the coastal
community of Busselton, located in the south-west of Western
Australian. Our cohort included 2023 participants of the Busselton
Healthy Ageing Study. Participants completed a questionnaire
including their previous medical and ocular history. Refractive error
was measured by cycloplegic autorefraction using the Nidek ARK-
510A (NIDEK Co.Ltd, Japan).
Results: Complete data were available for 1928 participants (mean
age 56.3 years, range 45.5-66.4 years, 53.5% male) of Northern
European ancestry. Of these, 146 (8%) had a previous history of skin
cancer. Median spherical equivalent (SE) was +0.44 D (IQR: -0.06,
+1.13) in the skin cancer group and +0.38 D (IQR: -0.31, +1.00) in
ARVO 2014 Annual Meeting Abstracts

the control group (p=0.05). In a regression model adjusted for age,

sex and education, the odds of being non-myopic was 2.35 (95%CI:
1.42 - 4.11) times higher in the skin cancer group than controls
(p=0.001). For every 1.00 D increase in mean SE, the odds of
having skin cancer increased by factor of 1.18 (95%CI: 1.04 - 1.34)
(p=0.01).
Conclusions: These findings support the hypothesis that spending
time outdoors lessens an individuals’ risk for developing refractive
error. However, recommendations to increase outdoor activity in
childhood to prevent myopia must also take into account the harmful
effects of UV radiation and increased risk of skin cancers.
Commercial Relationships: David A. Mackey, None; Maria
Franchina, None; Seyhan Yazar, None; Michael Hunter, None;
Adam Gajdatsy, None; Jean-Louis deSousa, None; Alex W.
Hewitt, None

©2014, Copyright by the Association for Research in Vision and Ophthalmology, Inc., all rights reserved. Go to iovs.org to access the version of record. For permission
to reproduce any abstract, contact the ARVO Office at pubs@arvo.org.