High Myopia and Glaucoma Susceptibility

The Beijing Eye Study

Liang Xu, MD,1 Yaxing Wang, MD,1 Shuang Wang, MD,1 Yun Wang, MD,1 Jost B. Jonas, MD2

Objective: To evaluate whether marked myopia, compared with moderate myopia and low myopia, is
associated with a higher prevalence of glaucomatous optic nerve damage.
Design: Population-based cross-sectional study.
Participants: Four thousand four hundred thirty-nine of 5324 subjects 40 years or older were invited to
participate (response rate, 83.4%). The group was stratified according to refractive error into high myopia
(myopia ⬎ ⫺8 diopters [D]), marked myopia (⬍⫺6 to ⫺8 D), moderate myopia (⬍⫺3 to ⫺6 D), low myopia (⬍⫺0.5
to ⫺3 D), emmetropia (⫺0.5 to ⫹ ⬍2 D), and hyperopia (⬎⫹ 2 D) subgroups.
Methods: Morphologic assessment of optic disc monoscopic photographs.
Main Outcome Measures: Morphologic optic disc parameters and intraocular pressure (IOP).
Results: For 4319 (97.3%) subjects (8484 eyes), optic disc photographs were evaluated. Prevalence of
glaucomatous optic nerve atrophy as defined by the glaucomatous optic nerve head appearance did not vary
significantly (P ⫽ 0.77; odds ratio [OR], 1.2; 95% confidence interval [CI], 0.38 –3.81) between the highly myopic
group and the group with marked myopia. In both refractive groups combined, glaucoma frequency seemed to
be higher (P ⫽ 0.075; OR, 2.28; 95% CI, 0.99 –5.25) higher than in the group with moderate myopia; it was
significantly (P ⫽ 0.001; OR, 3.5; 95% CI, 1.71–7.25) higher than in the group with low myopia; significantly
(P⬍0.001; OR, 7.56; 95% CI, 3.98 –14.35) higher than in the group with emmetropia; and significantly (P ⫽ 0.005;
OR, 4.23; 95% CI, 1.57–11.45) higher than in the group with hyperopia. Glaucoma frequency did not vary
significantly between the hyperopic group and the emmetropic group (P ⫽ 0.17), the group with low myopia
(P ⫽ 0.83), and the group with moderate myopia (P ⫽ 0.32). Intraocular pressure did not vary significantly
(P⬎0.10) between any of the subgroups. Similar results were obtained for the frequency of glaucoma defined as
glaucomatous optic disc appearance and visual field defects. In binary logistic regression analysis, presence of
glaucoma was significantly associated with the myopic refractive error (P⬍0.001), age (P⬍0.001), and IOP
(P⬍0.001).
Conclusions: Marked to high myopia with a myopic refractive error exceeding ⫺6 D may be a risk factor
associated with glaucomatous optic neuropathy. Ophthalmology 2007;114:216 –220 © 2007 by the American
Academy of Ophthalmology.

Findings from hospital-based studies and population-based
investigations are inconclusive concerning the role of my-
opia as a risk factor for chronic open-angle glaucoma. In the
Barbados Eye Study and the Blue Mountains Eye Study,
myopic subjects compared with hyperopic subjects showed
a significantly higher prevalence of glaucomatous optic
nerve damage.1,2 These observations were in agreement
with hospital-based studies in which axial myopia was
reported to be a risk factor for glaucomatous optic neurop-
Originally received: July 24, 2005.
Accepted: August 4, 2006. Manuscript no. 2005-1011.
1
Beijing Institute of Ophthalmology, Beijing Tongren Hospital, Capital
University of Medical Science, Beijing, China.
2
Department of Ophthalmology, Faculty of Clinical Medicine Mannheim,
University of Heidelberg, Mannheim, Germany.
The authors have no commercial or proprietary interest in the products or
companies mentioned in the article.
Correspondence to Dr J. Jonas, Universitäts-Augenklinik, Theodor-
Kutzer-Ufer 1-3, 68167 Mannheim, Germany. E-mail: Jost.Jonas@augen.ma.
uni-heidelberg.de.
athy.3–11 Randomized clinical trials have revealed varying
results suggesting that myopia may or may not be a risk
factor or predictive factor for the development and progres-
sion of glaucomatous optic nerve damage.12–16 These stud-
ies did not differentiate between marked to high myopia
and low to moderate myopia. Clinical studies and histo-
morphometric investigations showed, however, that the
optic nerve head appearance varies between subjects with
high marked to high myopia and subjects with low to
moderate myopia.17–20 It was, therefore, the purpose of the
present investigation to reevaluate whether the prevalence
of glaucomatous optic nerve damage differs between eyes
with marked to high myopia versus eyes with low to mod-
erate myopia, emmetropia, or hyperopia.
Patients and Methods
The Beijing Eye Study is a population-based cross-sectional study
in Northern China. It was carried out in 4 communities in the urban
district of Haidian in the North of Central Beijing and in 3 commu-
nities in the village area of Yufa of the Daxing District south of

216 © 2007 by the American Academy of Ophthalmology ISSN 0161-6420/07/$–see front matter
Published by Elsevier Inc. doi:10.1016/j.ophtha.2006.06.050
 Xu et al 䡠 Are Highly Myopic Eyes More Glaucoma Susceptible?
Beijing. The study has been described in detail recently.21–25 The
Medical Ethics Committee of the Beijing Tongren Hospital had
approved the study protocol, and all participants had given in-
formed consent according to the Declaration of Helsinki. At the
time of the survey in 2001, the 7 communities had a total popu-
lation of 5324 individuals aged ⱖ 40 years, all of whom were
given offers to accept the eye examination. In total, 4439 individ-
uals (2505 women) participated in the eye examination, corre-
sponding to an overall response rate of 83.4%. The study was
divided into a rural part (3946 eyes, 1973 subjects; 1143 women)
and an urban part (4932 eyes, 2466 subjects; 1362 women). Mean
age was 56.20⫾10.59 years (median, 56 years; range, 40 –101
years).
All examinations were carried out in the communities, either in
schoolhouses or in community houses. After receiving informed
consent, uncorrected visual acuity was measured (Snellen charts)
in a distance of 5 m. Automatic refractometry (Auto Refractometer
AR-610, Nidek Co., Ltd, Tokyo, Japan) was performed, if uncor-
rected visual acuity was ⬍ 1.0. Visual field examinations were
performed by frequency-doubling perimetry using the screening
program C-20-1 (Zeiss-Humphrey, Dublin, CA).26,27 Intraocular
pressure was measured using a noncontact pneumotonometer
(CT-60 computerized tonometer, Topcon Ltd., Tokyo, Japan) by
an experienced technician. Three measurements were taken, and
the mean of the 3 measurements was taken for further statistical
analysis. If the measurements were ⬎ 25 mmHg, tonometry was
repeated. A slit-lamp examination was carried out by an ophthal-
mologist. During the slit-lamp examination, the anterior chamber
depth was assessed using van Herick’s method. The pupil was
dilated using tropicamide once or twice, until the pupil diameter
was at least 6 mm. Digital photographs of the cornea and retroil-
luminated photographs of the lens were taken using the Neitz
CT-R camera (Neitz Instruments Co., Tokyo, Japan). The degree
of nuclear cataract was scored using the cataract grading system of
the Age-Related Eye Disease Study.28 The degree of cortical lens
opacification and posterior subcapsular lens opacification was as-
sessed on photographs taken under retroillumination as described
in the Age-Related Eye Disease Study. Monoscopic photographs
(on film) of the macula and optic disc were taken using a fundus
camera (Type CR6-45NM, Canon Inc., Lake Success, NY). Past
history of eye diseases, eye trauma, diabetes, mellitus, hyperten-
sion, and any ophthalmologic care the participant received were
recorded. Additional information was obtained on family income.
The optic disc slides were projected, and we examined the
qualitative parameters “shape of the neuroretinal rim,” with special
respect to the inferior–superior–nasal–temporal rule and to the
presence of neuroretinal rim notches; “occurrence of optic disc
hemorrhages”; “presence of localized defects in the retinal nerve
fiber layer”; “decreased diffuse visibility of the retinal nerve fiber
layer”; and “occurrence of marked diffuse thinning or focal thin-
ning of the retinal arteries in the peripapillary region.”29,30 Optic
disc photographs were additionally digitized and the optic disc
structures were measured by outlining the borders of the optic disc,
optic cup, peripapillary scleral ring, and ␣ and ␤ zones of peri-
papillary atrophy border on the computer screen. The optic disc
was defined as all the area inside of the peripapillary scleral ring.
Peripapillary chorioretinal atrophy was divided into a peripheral
alpha zone and a central beta zone at the optic disc border.29 –31
The ␣ zone was characterized by an irregular hypopigmentation
and hyperpigmentation and intimated thinning of the chorioretinal
tissue layer. On its outer side it was adjacent to the retina, and on
its inner side it was in touch with a zone characterized by visible
sclera and visible large choroidal vessels (␤ zone), or with the
peripapillary scleral ring, respectively. Features of the inner zone
(␤ zone) were marked atrophy of the retinal pigment epithelium
and of the choriocapillaris, good visibility of the large choroidal
vessels and the sclera, thinning of the chorioretinal tissues, and
round bounds to the adjacent ␣ zone on its peripheral side and to
the peripapillary scleral ring on its central side. If both zones were
present, the ␤ zone was always closer to the optic disc than alpha
zone. The method has been described in detail previously.24,29 –31
The optic disc assessment was carried out by a single examiner
(YW) after a training period in which optic disc photographs of
about 900 subjects had been examined and discussed together with
2 glaucoma specialists (LX, JBJ). In a second step of the exami-
nation, in the case of doubt, optic disc photographs were reas-
sessed by a panel (including LX and JBJ). In a third step of the
examination, the optic disc photographs of all eyes with suspicious
optic nerve heads, of all highly myopic eyes, of all eyes with an
intraocular pressure ⬎ 21 mmHg and of all eyes with a visual field
loss or a visual acuity of ⬍ 0.50 were separately re-reviewed by
JBJ and coworkers.
To examine the relationship between high myopia and glau-
coma, 2 different glaucoma definitions were applied. In the defi-
nition of optic disc glaucoma, the only criterion for glaucoma was
a glaucomatous appearance of the optic disc. Absolute criteria for
a glaucomatous appearance of the optic nerve head, each of which
were sufficient for the diagnosis of glaucoma, were a notch in the
neuroretinal rim in the temporal inferior region and/or the temporal
superior region, so that the inferior–superior–nasal–temporal rule
was not fulfilled (in eyes with an optic cup sufficiently large to
allow an assessment of the neuroretinal shape); a localized retinal
nerve layer defect which could not be explained by any other cause
than glaucoma; and an abnormally large cup in relation to the size
of the optic disc.29,30 Relative criteria for the diagnosis of a
glaucomatous appearance of the optic nerve head were if the
neuroretinal rim was markedly thinner in inferior disc region
compared with the superior disc region, even if the smallest part of
the neuroretinal rim was located in the temporal horizontal disc
region; a diffuse decrease in the visibility of the retinal nerve fiber
layer (particularly in eyes with small optic discs), if the back-
ground pigmentation of the eye allowed an assessment of the
retinal nerve fiber layer and if there were no other reasons than
glaucoma for retinal nerve fiber layer loss; a marked diffuse
thinning and/or focal thinning of the retinal arteries if there were
no other reasons than glaucoma for retinal vessel thinning; and an
optic disc hemorrhage, if there were no other reasons for a disc
bleeding, such as retinal vessel occlusions. If none of the absolute
glaucoma criteria were positive, at least 2 relative criteria had to be
positive, including a suspicious neuroretinal rim shape in eyes with
an optic cup large enough for the assessment of the rim shape; or
at least 2 relative criteria had to be positive including the occur-
rence of a optic cup in a small optic disc which usually would not
show cupping. The height of intraocular pressure and presence of
visual field defects were no criteria for the diagnosis of optic disc
glaucoma. In the definition of perimetric glaucoma, the optic disc
seemed glaucomatous and the visual field showed defects, which
could be explained by no other disease than glaucomatous optic
neuropathy. A visual field defect was defined as any abnormal test
point in the frequency doubling perimetry if the rate of false-positive
results was ⱕ 0.33, and if the rate of fixation loss was ⱕ 0.33.
Intraocular pressure was no criterion for the diagnosis.
Statistical analysis was performed using a commercially avail-
able statistical software package (SPSS for Windows, version 13.0,
SPSS, Chicago, IL). The data are given as mean values ⫾ standard
deviation. Chi-square tests were used to compare proportions.
Logistic regression was used to investigate the associations of the
binary dependent variable “presence of glaucoma” with the con-
tinuous or categorical independent variables, such as age, gender,
and intraocular pressure. Confidence intervals were presented. All
P-values were 2-sided and were considered statistically significant
when the values were ⬍ 0.05.
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 Ophthalmology Volume 114, Number 2, February 2007

Results Intraocular pressure did not vary significantly (P⬎0.20) be-

From the 4439 individuals, readable optic disc photographs and
refractometry data were available for 4342 (97.8%) subjects. In a
second step, aphakic and pseudophakic eyes were excluded so that
eventually 4319 (97.3%) subjects (8484 eyes) with 1905 (44.1%)
subjects from the rural region and 2414 (55.9%) subjects from the
urban region entered the statistical analysis. The mean age was
55.8⫾10.3 years (median, 56 years; range, 40 –90 years), and the
mean refractive error was – 0.34⫾2.17 diopters (median, 0 diopt-
ers; range, ⫺20.9 to ⫹7.9 diopters).
Stratifying the study population according to refractive error
and including all eyes into the statistical analysis revealed, that the
frequency of optic disc glaucoma did not vary significantly (P ⫽
0.81; odds ratio [OR], 1.21; 95% confidence interval [CI], 0.47–
3.12) between the highly myopic group and the group with
marked myopia (⬍ ⫺6 to – 8 diopters; Table 1). In both
refractive groups combined, the frequency of optic disc glau-
coma seemed to be higher (P ⫽ 0.083; OR, 1.84; 95% CI,
0.97–3.50) than in the group with moderate myopia (⬍ ⫺3 to
⫺6 diopters); it was significantly (P⬍0.001; OR, 3.00; 95% CI,
1.69 –5.30) higher than in the group with low myopia (⬍ ⫺0.50
to –3 diopters); significantly (P⬍0.001; OR, 5.50; 95% CI,
3.31–9.15) higher than in the group with emmetropia (⫺0.50 to
⬍ ⫹2.0 diopters); and significantly (P ⫽ 0.001; OR, 3.79; 95% CI,
1.77– 8.12) higher than in the group with hyperopia (ⱖ ⫹2.0
diopters). Correspondingly, the frequency of glaucoma was highly
significantly higher in the combined group of marked myopia and
high myopia compared with the combined group of the remaining
eyes (P⬍0.001; OR, 4.13; 95% CI, 2.62– 6.49).
The frequency of optic disc glaucoma did not vary significantly
between the hyperopic group and the emmetropic group (P ⫽ 0.26;
OR, 1.45; 95% CI, 0.78 –2.72), the group with low myopia (P ⫽
0.62; OR, 0.79; 95% CI, 0.40 –1.56), and the group with moderate
myopia (P ⫽ 0.07; OR, 0.49, 95% CI, 0.23–1.02). In a binary
logistic regression analysis with the presence of glaucomatous
optic nerve damage (optic disc glaucoma definition) as dependent,
and with refractive error, age, and intraocular pressure as indepen-
dent variables, presence of glaucoma was significantly associated
with the myopic refractive error (P⬍0.001), age (P⬍0.001), and
intraocular pressure (P⬍0.001).
tween any of the subgroups (Table 1). The same held true if eyes
with an intraocular pressure ⬎ 40 mmHg were excluded.
In a similar manner, if only 1 randomly selected eye per subject
was taken for statistical analysis, the prevalence of optic disc
glaucoma did not vary significantly (P ⫽ 0.77; OR, 1.2; 95% CI,
0.38 –3.81) between the highly myopic group and the group
with marked myopia (Table 1). In both refractive groups com-
bined, frequency of optic disc glaucoma seemed to be higher
(P ⫽ 0.075; OR, 2.28; 95% CI, 0.99 –5.25) than in the group with
moderate myopia; it was significantly (P ⫽ 0.001; OR, 3.5;
95% CI, 1.71–7.25) higher than in the group with low myopia;
significantly (P⬍0.001; OR, 7.56; 95% CI, 3.98 –14.35) higher
than in the group with emmetropia; and significantly (P ⫽ 0.005;
OR, 4.23; 95% CI, 1.57–11.45) higher than in the group with
hyperopia. Correspondingly, the frequency of glaucoma was
highly significantly higher in the combined group of marked
myopia and high myopia compared with the combined group of
the remaining eyes (P⬍0.001; OR, 5.18; 95% CI, 2.98 –9.02). The
frequency of optic disc glaucoma did not vary significantly be-
tween the hyperopic group and the emmetropic group (P ⫽ 0.17;
OR, 1.79; 95% CI, 0.77– 4.22), the group with low myopia (P ⫽
0.83; OR, 0.83; 95% CI, 0.33–2.09), or the group with moderate
myopia (P ⫽ 0.32; OR, 0.54, 95% CI, 0.20 –1.48). In a binary
logistic regression analysis with the presence of glaucomatous
optic nerve damage (optic disc glaucoma definition) as depen-
dent, and with refractive error, age, and intraocular pressure as
independent variables, presence of glaucoma was significantly
associated with the myopic refractive error (P⬍0.001), age
(P⬍0.001), and intraocular pressure (P⬍0.001). Intraocular
pressure did not vary significantly (P⬎0.10) between any of the
subgroups (Table 1). The same held true if eyes with an intraocular
pressure ⬎ 40 mmHg were excluded.
The prevalence of glaucoma using the definition of perimetric
glaucoma (glaucomatous appearance of the optic disc and visual
field defects) was 7 of 119 (5.9%; 95% CI, 1.6 –10.2) in the highly
myopic group and 6 of 92 (6.5%; 95% CI, 1.4 –11.7) in the group
with marked myopia. There was no significant difference between
these groups (P ⫽ 1.00; OR, 1.15; 95% CI, 0.37–3.53). In both
refractive groups, frequency of perimetric glaucoma was signifi-
cantly (P ⫽ 0.025; OR, 2.63; 95% CI, 1.14 – 6.11) higher than in

Table 1. Frequency of Glaucomatous Optic Nerve Damage (“Optic Disc Glaucoma” with Structural Optic Disc Abnormalities;
“Perimetric Glaucoma” with Optic Disc Abnormalities Plus Frequency Doubling Perimetry Defects) in the Population of the Beijing
Eye Study Stratified According to Refractive Error

“Optic Disc Glaucoma” “Perimetric Glaucoma”

Frequency IOP Frequency IOP
Eyes (%; 95% CI) (mm Hg) (%; 95% CI) (mm Hg)
High myopia (⬍⫺8 diopters) 122 10 (8.2%; 3.3–13.1) 19.1⫾10.1 7 (5.7%; 1.6–9.9) 18.3⫾11.9
Marked myopia (⬍⫺6 to ⫺8 diopters) 92 9 (9.8%; 3.6–16.0) 20.4⫾2.5 6 (6.5%; 1.4–11.7) 20.3⫾1.8
Moderate myopia (⬍⫺3 to ⫺6 diopters) 417 21 (5.0%; 2.9–7.1) 17.0⫾3.7 10 (2.4%; 0.9–3.9) 18.9⫾3.9
Low myopia (⬍⫺0.5 to ⫺3 diopters) 1206 38 (3.2%; 2.2–4.1) 24.6⫾14.4 27 (2.2%; 1.4–3.1) 22.7⫾12.4
Emmetropia (⫺0.5 to ⫹ ⬍2 diopters) 6208 108 (1.7%; 1.4–2.1) 19.2⫾5.8 63 (1.0%; 0.8–1.3) 19.9⫾6.5
Hyperopia (ⱖ⫹ 2 diopters) 439 11 (2.5%; 1.0–4.0) 17.3⫾3.7 6 (1.4%; 0.3–2.5) 18.3⫾4.5
Subjects
High myopia (⬍⫺8 diopters) 70 7 (10.0%; 2.8–17.2) 19.9⫾11.4 5 (7.1%; 1.0–13.3) 20.4⫾13.8
Marked myopia (⬍⫺6 to ⫺8 diopters) 51 6 (11.8%; 2.6–20.9) 20.2⫾2.1 4 (7.8%; 0.2–15.5) 21.0⫾1.8
Moderate myopia (⬍⫺3 to ⫺6 diopters) 219 11 (5.0%; 2.1–7.9) 16.6⫾3.7 5 (2.3%; 0.3–4.3) 18.4⫾3.7
Low myopia (⬍⫺0.5 to ⫺3 diopters) 638 21 (3.3%; 1.9–4.7) 25.9⫾16.3 15 (2.4%; 1.2–3.5) 23.3⫾13.7
Emmetropia (⫺0.5 to ⫹ ⬍2 diopters) 3126 49 (1.6%; 1.1–2.0) 18.5⫾4.2 26 (0.8%; 0.5–1.2) 19.0⫾4.6
Hyperopia (⬎⫹2 diopters) 217 6 (2.8%; 0.6–5.0) 17.8⫾4.8 4 (1.8%; 0.04–3.7) 19.0⫾5.7
Total 4319

95% CI ⫽ 95% confidence interval; IOP ⫽ intraocular pressure in the glaucoma group (mean ⫾ standard deviation [SD]).

218
 Xu et al 䡠 Are Highly Myopic Eyes More Glaucoma Susceptible?
the group with moderate myopia; significantly (P ⫽ 0.005; OR,
2.82; 95% CI, 1.43–5.57) higher than in the group with low
myopia; significantly (P⬍0.001; OR, 6.31; 95% CI, 3.42–11.65)
higher than in the group with emmetropia; and significantly higher
(P ⫽ 0.002; OR, 4.67; 95% CI, 1.75–12.46) than in the group with
hyperopia. Intraocular pressure did not vary significantly (P⬎0.20)
between any of the subgroups (Table 1). The frequency of peri-
metric glaucoma did not vary significantly between the hyperopic
group and the emmetropic group (P ⫽ 0.46; OR, 1.35; 95% CI,
0.58 –3.14), the group with low myopia (P ⫽ 0.32; OR, 0.61; 95%
CI, 0.25–1.48), or the group with moderate myopia (P ⫽ 0.32; OR,
0.56, 95% CI, 0.20 –1.57). In a binary logistic regression analysis
with the presence of glaucomatous optic nerve damage (perimetric
glaucoma) as dependent, and with refractive error, age, and in-
traocular pressure as independent variables, presence of glaucoma
was significantly associated with the myopic refractive error
(P⬍0.001), age (P⬍0.001), and intraocular pressure (P⬍0.001).
If only 1 randomly selected eye per subject was taken for
statistical analysis, the group with high myopia and the group with
marked myopia did not vary significantly in the frequency of
perimetric glaucoma (P ⫽ 1.00; OR, 1.11; 95% CI, 0.28 – 4.34). In
both refractive groups, frequency of perimetric glaucoma was
significantly (P ⫽ 0.041; OR, 3.44; 95% CI, 1.13–10.51) higher
than in the group with moderate myopia; significantly (P ⫽ 0.008;
OR, 3.33; 95% CI, 1.42–7.79) higher than in the group with low
myopia; significantly (P⬍0.001; OR, 9.58; 95% CI, 4.39 –20.92)
higher than in the group with emmetropia; and significantly higher
(P ⫽ 0.016; OR, 4.28; 95% CI, 1.29 –14.20) than in the group with
hyperopia. The frequency of perimetric glaucoma did not vary
significantly between the hyperopic group and the emmetropic
group (P ⫽ 0.13; OR, 2.24; 95% CI, 0.77– 6.47), the group with
low myopia (P ⫽ 0.79; OR, 0.78; 95% CI, 0.26 –2.37), or the
group with moderate myopia (P ⫽ 1.00; OR, 0.80, 95% CI,
0.21–3.03). Intraocular pressure did not vary significantly (P⬎
0.50) between any of the subgroups (Table 1). In a binary logistic
regression analysis with the presence of glaucomatous optic nerve
damage (perimetric glaucoma) as dependent, and with refractive
error, age, and intraocular pressure as independent variables, pres-
ence of glaucoma was significantly associated with the myopic
refractive error (P⬍0.001), age (P⬍0.001), and intraocular pres-
sure (P⬍0.001).
Discussion
The prevalence of glaucomatous optic nerve damage was
significantly higher in the eyes with a myopic refractive
error exceeding ⫺6 diopters than in the remaining eyes. In
the hyperopic eyes, the emmetropic eyes and the eyes with
low to moderate myopia (myopic refractive up to ⫺6
diopters or less), the frequency of glaucoma did not vary
significantly (Table 1). It held true for both definitions of
glaucoma used. It suggests a higher glaucoma susceptibility
in eyes with marked to high myopia. It may fit with the
finding of a thinner lamina cribrosa in combination with a
secondary enlargement of the optic nerve head in highly
myopic eyes and with the pathophysiologic role the lamina
cribrosa may play in glaucoma.11,17,20,32–34 Interestingly,
the mean intraocular pressure was not significantly different
between the eyes with marked and high myopia and the
remaining eyes in the present study, although the frequency
of glaucoma was significantly higher in the eyes with
marked and high myopia (Table 1). One may infer that the
increased prevalence of glaucomatous optic nerve damage
in the highly myopic group might not have been due to a
higher level of intraocular pressure, but that other factors
might have played a role.
The present study agrees with preceding hospital-based
studies that have also suggested an association between
glaucomatous optic nerve damage and marked to high my-
opia, and with epidemiologic studies on non-Chinese pop-
ulations.1–11 The Blue Mountains Eye Study reported prev-
alence figures of glaucoma that ranged from 1.5% in
emmetropes to 4.4% in moderate to high myopes.2 The
Barbados Eye Study found that myopia increased the odds
of having glaucoma whereas hyperopia reduced the odds of
having glaucoma in black participants.1 The present study
also agrees with a Malmö eye survey, which was performed
on ⬎ 30 000 individuals as preparation of the Early Mani-
fest Glaucoma Trial.13,16 In the Malmö eye survey, the
prevalence of glaucoma increased with increasing myopia,
and the association between myopia and glaucoma was
strong at lower intraocular pressure levels, and weakened
gradually with increasing intraocular pressure.13 The results
of the present investigation may further elucidate the dis-
crepancies between some of the previous studies in which
myopia was, or was not, a predictive factor for glaucoma.35
If myopia is differentiated into marked or high myopia
beyond a myopic refractive error of ⫺6 diopters and into
low to moderate myopia, marked to high myopia may be a
risk factor for glaucoma, and low to moderate myopia may
not play a pronounced role for glaucoma. Correspondingly,
the low to moderate myopic group, the emmetropic group
and the hyperopic group did not vary significantly in the
prevalence of glaucoma in the present study.
There are limitations of the present study. A possible
source of bias is that highly myopic eyes usually show a
characteristic appearance of the optic nerve head with an
enlarged macrodisc, shallow cupping, a large myopic cres-
cent, and a bright fundus pigmentation. Although the exam-
iners were unaware of the refractive error at the time of the
optic disc analysis, the typical morphology of the highly
myopic optic disc might have made the examiners presume
that the eye was highly myopic. The optic disc assessment
was, therefore, only partially masked. Another limitation in
the design of the study is that biometry was not performed.
The use of the term myopia in the present study may mean
lenticular or index myopia, axial myopia, or a mixture of
both of these types of myopia. A further limitation of the
study may be that, assuming a low specificity for the optic
disc assessment, subjects with an abnormal visual field
examination could have been misclassified as glaucoma-
tous, leading to a falsely high frequency figure of glaucoma
in the study. Comparing the prevalence figures of glaucoma
in the Beijing Eye Study with previous population-based
studies shows, however, that the figures in the present
investigation are similar or even lower instead of being
higher than in other epidemiologic studies.1,2,36 – 41
In conclusion, the results of the present study suggest
that marked to high myopia with a myopic refractive error
exceeding ⫺6 diopters is associated with glaucomatous
optic neuropathy.
219
 Ophthalmology Volume 114, Number 2, February 2007
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