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Visual impairment in adults: Refractive disorders and

presbyopia
Author: Shahzad I Mian, MD
Section Editor: Matthew F Gardiner, MD
Deputy Editor: Jane Givens, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Mar 2020. | This topic last updated: Oct 28, 2019.

INTRODUCTION

Refractive errors and presbyopia are common, correctable causes of impaired vision throughout the
world.

The normal eye creates a clear image by bending (refracting) light in order to focus it onto the retina.
Refractive errors occur when a component of the eye's optical system fails to focus the optical image.
Presbyopia ("aging sight") is a non-refractive error that also affects visual acuity. Presbyopia occurs
when the lens loses its normal accommodating power and can no longer focus on objects viewed at
arm's length or closer.

This topic will cover the epidemiology, diagnosis, and treatment of refractive errors and presbyopia in
adults. Refractive errors in children and laser refractive treatment are discussed separately. (See
"Refractive errors in children" and "Laser refractive surgery".)

FUNCTIONAL ANATOMY OF THE EYE

The eye's ability to focus is dependent on the eye's optical system, which consists of two refractive
surfaces working in tandem: the cornea and the crystalline lens (figure 1).

The refractive power of the eye and of corrective lenses is measured in diopters, where a diopter is
the reciprocal of the focal length measured in meters. The focal length is the distance from a lens to
its focus or focal point.
The cornea is the more powerful refractive element, accounting for two-thirds of the eye's refractive
power. The lens provides the remaining one-third, for a total refractive power of 60 diopters (D).

The cornea has a fixed amount of refractive power while the lens can vary its power by altering its
shape [1]. Accommodation is the term used to describe this change in lens shape, which can
increase the power of the lens to enable the eye to focus on objects at arm's length or closer.

PATHOPHYSIOLOGY

Refractive errors are a developmental disorder. There are causes of adult-onset refractive errors,
such as cataracts, diabetes, and alteration in shape of the eye, which are not discussed in this
section. The developing eye in childhood through early adulthood maintains focus on the retina by a
process known as emmetropization. This process involves detection of a blurred image on the retina
with subsequent diffusion of signals into the outer layers of the eye, including the choroid and sclera
(figure 1). This results in alteration of the size of the eye in order to maintain clear vision throughout
development [2]. Emmetropization is accomplished by modulating scleral growth and choroidal
thickness. With refractive errors, the emmetropization process goes awry for reasons that remain
largely unknown.

Cellular and/or physiologic mechanisms are thought to cause retinal defocusing with resulting altered
axial length and myopia during the developmental process. In addition, eye growth is sensitive to an
individual's visual experience. The mechanisms thought to cause retinal defocusing include [3,4]:

● Form deprivation, which can lead to alterations in the ocular lens system, with elongation of the
visual axis
● Excessive accommodation
● Scleral stretching (secondary to increased intraocular pressure)
● Autonomic deficits during accommodation

DEFINITIONS

Emmetropia (normal refraction) describes the refractive state in which parallel light rays emanating
from an object located 20 feet or more from the eye form a focused image on the retina of an eye that
has not accommodated. (figure 2 and movie 1). Ametropia refers to the refractive state in which the
image is not focused on the retina.

Abnormal refraction (ametropia) — Refractive disorders are ametropic states in which the eye is
unable to bring light rays emanating from an object viewed from a distance into clear focus on the
retina, without the aid of a refractive device (eg, spectacles, contact lenses). Myopia, hyperopia, and
astigmatism are the three ametropic states. They are caused by abnormalities in the axial length
(distance from the posterior corneal surface to the retina) of the eye or in the shape of the cornea.

Myopia — Myopia ("nearsightedness") is a common refractive disorder in which the axial length of
the eye is either too long or the refractive power of the eye's optical system is too great (generally due
to corneal protrusion resulting in steep corneal curvature). The image is focused in front of the retina
(figure 3 and movie 2). This results in blurred distance vision unless optical correction is achieved
with a refractive device. A refractive device can provide a more concave surface which reduces the
excessive focusing power of the eye's optical system (movie 3).

Hyperopia — Hyperopia ("farsightedness") is a refractive disorder in which the axial length of the
eye is too short or the power of the eye's optical system is insufficient (due to a flat cornea) to
produce a focused image on the retina. The image is focused behind the retina (figure 4 and movie
4). Hyperopia is corrected with a refractive device that provides a more convex refracting surface in
order to increase the deficient focusing power of the eye's optical system (movie 5).

Astigmatism — Astigmatism ("lack of a pinpoint" in Greek) refers to the refractive condition in

which a warped corneal surface causes light rays entering the eye along different planes to be
focused unevenly (movie 6). The patient reports blurred vision at all viewing distances. Unlike myopia
and hyperopia, which are corrected by spectacles containing a spherical surface, astigmatism is
corrected by spectacles containing a cylindrical optical surface (movie 7). A spherical lens is a device
with optical symmetry which can either converge or scatter light rays, while a cylindrical lens does not
have optical symmetry. One meridian (a closed curve on the surface of a sphere) in the cylindrical
lens is more curved than the opposite meridian. Soft (toric) or rigid gas permeable contact lenses can
also be used to correct astigmatism. Contact lenses are discussed in detail separately. (See
"Overview of contact lenses".)

Presbyopia — Presbyopia ("aging sight") is a non-refractive error that also affects visual acuity.
Presbyopia occurs when the lens loses its normal accommodating power and can no longer focus on
objects viewed at arm's length or closer. As such, it is not considered an ametropic state, but rather
one in which the normal physiologic function of lens accommodation has been lost.

In youth, the eye is able to easily accommodate or increase the curvature of the lens by contracting
the ciliary muscle (figure 1). The ciliary muscle surrounds the lens and is connected to it by zonular
fibers. The normally taut zonular fibers stretch the lens and keep it from assuming a fully rounded
state. The desire to focus on reading material automatically stimulates ciliary smooth muscle
contraction, which loosens the zonular fibers and allows the lens to become more rounded. In the
fully rounded state, the lens provides the additional refractive power needed to bring reading material
into focus.

During the natural aging process, the crystalline lens loses its elasticity and therefore its ability to
become more rounded when the zonular fibers loosen their grip. Presbyopia usually begins after age
40 when patients start to appreciate the inability to focus on objects at reading distance. In patients
with presbyopia, the eye's focusing power for reading is lost progressively and fully by age 65 years.

EPIDEMIOLOGY

The prevalence and risk factors associated with myopia are well-described. The epidemiologic data
for other refractive errors have been less studied.

Prevalence — Refractive disorders are common, affecting approximately one-third of persons age
≥40 years in the United States and Western Europe [5]. Worldwide, a total of 123 million people are
estimated to be visually impaired from uncorrected refractive errors, of whom approximately four
million are blind (as defined by best-corrected visual acuity <20/400) [6].

Prevalence rates vary depending on the type of refractive error, with myopia and astigmatism being
the most common.

● Myopia – The global prevalence of myopia was estimated at 23 percent in 2000 and is increasing
[7]. The prevalence of myopia is increasing in the United States and Europe [8,9]. In the United
States, the prevalence of myopia from between 1971 and 1972 to between 1999 and 2004 nearly
doubled among persons age 12 to 54 years (25 versus 42 percent) [8]. In Europe, myopia
prevalence is higher among more recent birth decades; age-standardized myopia prevalence is
18 percent in those born between 1910 and 1939 compared with 23.5 percent among those born
between 1940 and 1979 [9]. This difference, in part, may reflect changes in education and
consequent demands for close-up tasks such as reading, population shifts, and changes in the
classification of myopia. (See 'Risk factors' below.)

The prevalence of myopia decreases with increasing age, from about 40 percent in adults age 20
to 59 years to about 20 percent in adults age ≥60 years [10]. The decrease in myopia may be
secondary to progressive cataract formation. In contrast to childhood-onset myopia where the
degree of myopia tends to worsen rapidly, the degree of myopia stabilizes in late adolescence
and is subject to a slow rate of myopic change after age 20.

Prevalence rates of myopia also vary by race and ethnicity. In the United States, Caucasians
have the highest rates of myopia, followed by African Americans, then Hispanic Americans [10].
Worldwide, the prevalence of myopia is especially high among Asians [11-13].
 ● Hyperopia – In contrast to myopia, the prevalence of hyperopia increases with age, from 1 to 2
percent in those age 20 to 59 years to 10 percent in those age ≥60 years [10].

● Astigmatism – Similar to hyperopia, the prevalence of astigmatism increases with age from
approximately 25 percent among adults age 20 to 59 to 50 percent among adults age ≥60 years
[10].

● Presbyopia – It is estimated that, in 2015, there were 1.8 billion people with presbyopia
worldwide. Approximately 826 million of those had uncorrected or undercorrected vision [14]. In
the United States, presbyopia is the most common cause of visual impairment due to aging of
the "baby boomer" generation, the 76 million Americans born between 1946 and 1964 [15].

Risk factors — There are several different risk factors for myopia which have been well-documented
[16-33], whereas less data are available for other refractive errors [34-36].

● Myopia — The development of myopia is associated with higher education levels and
intelligence test scores, as well as occupations requiring close-up tasks of high accommodative
demand (eg, reading, writing, computer work) [37]. Known causes include:

• Genetic – Multiple studies have shown that hereditary factors are associated with the
development of myopia [16,17]. Lack of complete concordance between myopia and
monozygotic twins, as well as between generations in families, suggests a polygenic
inheritance model.

• Reading – An association in children between myopia and prolonged reading or reading at

close range is well-documented [18,19]. Continuous hyperopic defocusing that occurs during
prolonged periods of reading may lead the emmetropization mechanism to increase the axial
length of the eye, leading to myopia [20].

• Medications – Myopia can develop rapidly following use of certain medications. Sulfa-
derived medications (eg, sulfamethoxazole, topiramate) and diuretics (eg, furosemide,
acetazolamide) can induce transient myopia through forward displacement and thickening of
the lens by relaxation of the zonules [21]. Cholinergic medications (eg, neostigmine,
pilocarpine) can also result in accommodative spasm with subsequent transient myopia.
Withdrawal of the medication usually results in complete resolution of myopia [22].

• Diabetes mellitus – Transient refractive changes in patients with diabetes mellitus are well-
documented [23,24]. Alterations in serum osmolarity secondary to changes in blood glucose
levels can cause an influx of osmotic fluid into the lens with subsequent lens swelling and a
transient increase in refractive power or myopia. As a result, patients with type I or type II
 diabetes often present with transient blurred vision, particularly those with poorly controlled
glucose.

The prevalence of myopia is higher in diabetic patients compared with non-diabetic patients
[25]. Patients with diabetes who have poorly controlled hemoglobin A1C are also more likely
to have myopia due to lenticular changes.

• Trauma – Ocular trauma can cause forward displacement of the lens with subsequent
myopia.

Scleral laceration repair and use of scleral encircling elements in retinal detachment repair
can temporarily deform the globe, inducing astigmatism and myopia. In cases where this
deformation continues postoperatively, the increased axial length leads to persistent myopia
[26].

• Excessive accommodation – Patients with pathologically excessive accommodation may

have "accommodative spasm." The symptoms may include double vision and myopia.
Anxiety and patient behaviors (forced excessive convergence by focusing on a near object)
are common causes, but traumatic brain injury and parasympathomimetic medications can
also lead to excessive accommodation [27,28].

• Increased intraocular pressure – Although the rate of myopia progression may be associated
with increased intraocular pressure [29], data from the Correction of Myopia Evaluation Trial
have shown no correlation between intraocular pressure and myopic progression [30].

• Maternal factors – Myopia is associated with greater maternal age at birth and maternal
smoking during pregnancy [38].

• Light exposure – The role of light exposure in the development of myopia is unclear. After
adjusting for confounders, children who spend more time in outdoor activities have a lower
prevalence of myopia [31,39]. Persons who are near-sighted have higher serum melatonin
levels, suggesting a role for light exposure and circadian rhythm in the myopic growth
mechanism [40]. Results are mixed as to whether night lights (dim light left on during sleep)
are associated with development of myopia [32,33].

● Hyperopia — Several risk factors may lead to a posterior shift of the crystalline lens or
shortening of the eye's axial length and result in hyperopia. These include ocular trauma, mass
effect of an orbital tumor posterior to the retina, scleral inflammation with subretinal thickening,
and surgical removal of the crystalline lens without replacing it with a synthetic intraocular lens.
 Anticholinergic medications (eg, oxybutynin, scopolamine) exert parasympatholytic effects on the
ciliary muscle, decreasing accommodation and inducing hyperopia. Patients treated for
hyperglycemia who have a rapid decrease in blood glucose levels experience transient
hyperopia that can last for several weeks [34,35].

● Astigmatism — Risk factors for astigmatism are largely unknown but may be related to genetic
and/or developmental factors [36].

CLINICAL CONSEQUENCES

Daily functioning — Several observational studies have shown that refractive errors are associated
with limitations in instrumental activities of daily living (IADLs), falls, decreased ability to drive or work,
and depression [41-45]. In one cohort study of noninstitutionalized older adult subjects, visual
impairment was associated with limitations in ADLs, one-fifth of which were estimated to be
preventable by use of best optical correction [41].

Although visual correction may improve ability to read and perform other tasks, it does not appear to
reduce risk or rate of falls among older adults. In one randomized trial, visual correction including new
eyeglasses, glaucoma management, and cataract surgery led to an increased rate of falls compared
with usual care [46], possibly related to an adjustment period needed to adapt to new corrective
eyeglasses, and a less sedentary lifestyle.

Associated eye disorders — Refractive errors have also been associated with other ocular
pathology [47-52].

High degrees of refractive error (myopia >6.0 diopters [D], hyperopia >3.0 D, astigmatism >3.0 D) are
associated with pathologic ocular changes [47]. Highly myopic patients have an increased incidence
of retinal thinning, peripheral retinal degeneration, retinal detachment [48], cataract [49], and
glaucoma [50,51]. Among patients with myopic refractive errors of 1 to 3 D, more than half of non-
traumatic retinal detachments are attributable to myopia [48]. (See "Retinal detachment" and
"Cataract in adults" and "Open-angle glaucoma: Epidemiology, clinical presentation, and diagnosis"
and "Angle-closure glaucoma".)

Hyperopia is associated with ocular pathology but to a lesser extent than myopia. Hyperopia is
associated with angle-closure glaucoma, age-related macular degeneration, and cataracts [52,53].
(See "Age-related macular degeneration: Clinical presentation, etiology, and diagnosis".)

SCREENING AND DIAGNOSTIC TESTS

There is no consensus on how and when to perform routine screening of visual acuity. Different
organizations have different recommendations:

● The US Preventive Services Task Force states that there is insufficient evidence to assess the
benefits and harms of screening for impaired vision in adults aged 65 and older without vision
problems [54].

● The Canadian Task Force on the Periodic Health Examination recommends against screening in
primary care settings for impaired vision in community-dwelling adults aged 65 and older without
risk factors for impaired vision [55].

● The American Academy of Ophthalmology (AAO) recommends comprehensive eye

examinations by ophthalmologists for adults with no symptoms or risk factors [56], although there
is little evidence supporting this recommendation.

Visual screening tests are recommended in children, which is discussed separately. (See "Vision
screening and assessment in infants and children", section on 'Vision screening'.)

There are a variety of visual charts to examine visual acuity, although few data are available showing
superiority of one method over another [57]. The Snellen eye chart is considered one of the clinical
standards for evaluating visual acuity and can be used in the primary care setting (figure 5) [58].
Patients should have their vision examined at 20 feet and while reading. While there is no explicit
evidence regarding appropriate cutoffs for referral, patients with unexplained vision loss in either eye
should be referred to an eye specialist for further evaluation.

Although refractive errors may be suspected on history of visual blurriness or by visual acuity testing,
diagnosis of all refractive disorders is confirmed with use of a phoropter by the eye specialist. A
phoropter is an instrument containing different lenses used to bring the focus of objects onto the
retina (picture 1). In addition to diagnosis, a phoropter is also used to measure severity of refractive
error for prescribing corrective lenses.

A retinoscope and pinhole occluder are additional devices that can be used to assess refractive error
by an eye specialist. A retinoscope is an objective measure of refractive error that is not dependent
upon patient response (picture 2). The retinoscope projects a beam of light into the patient's eye
through the pupil. Through the peephole in the scope, the observer sees a light reflex coming from
the patient's pupil. By observing the behavior of the reflex under certain conditions, the observer can
objectively determine the refractive error of the patient's eye.

A pinhole occluder may also be used as a screening tool for refractive errors (picture 3). The occluder
is a simple way to focus light, as in a pinhole camera, temporarily removing the effects of refractive
errors such as myopia. Because light passes only through the center of the eye's lens, defects in the
shape of the lens (errors of refraction) have no effect while the occluder is used. This can allow
estimation of the maximum improvement in a patient's vision that can be attained by lenses to correct
errors of refraction. Squinting works similarly to a pinhole occluder, by blocking light through the outer
parts of the eye's lens.

TREATMENT

The decision to treat refractive disorders depends on the individual patient's symptoms and needs.
Treatment is aimed to improve visual acuity, visual comfort (eg, visual distortion, polycoria, decreased
stereopsis), and other visual function (eg, color discrimination, motion detection, peripheral vision).

First-line treatments include corrective lenses, such as glasses and contact lenses, or refractive
surgery.

Corrective lenses — Corrective lenses work by altering the overall power of the lens system of the
eye. Concave lenses for myopia act to weaken the lens system, or reduce its power in diopters.
Convex lenses for hyperopia act by strengthening the lens system, or increasing its power in diopters.
Cylindrical lenses are used to correct astigmatism.

Presbyopia is treated with use of convex lenses as "reading glasses" or in combination with a
correction for distance viewing in which the lenses may be lined (bifocals, trifocals) or unlined
(multifocals, progressive).

Spectacles, or glasses, are the most common method of treating refractive errors, followed by contact
lenses. (See "Overview of contact lenses".)

The use of overnight contact lens use (orthokeratology) and low-dose atropine in children may be
effective in slowing progression of mild to moderate degrees of myopia [59,60].

Interpreting the prescription — By convention, lenses that increase divergence and decrease
the eye's focusing power are considered "minus" lenses; lenses that increase convergence and
increase focusing power are considered "plus" lenses. Accordingly, myopic refractive error is
corrected with concave ("minus", "divergent") lenses (movie 3), and hyperopia is corrected with
convex ("plus", "convergent") lenses (movie 5). Astigmatism is corrected by cylindrical lenses which
even out the eye's focusing power (movie 7).

In spectacle prescription notation, the first number is the refractive power, also known as the sphere.
A minus number indicates a concave lens; a plus number indicates a convex lens. The second
number denotes the cylinder, which corrects any astigmatic component. The "x" that follows the
astigmatism power denotes the axis (in radial degrees) of the cylinder. Spectacle prescriptions are
then written in increments of 0.25 diopters (D). For example, a prescription for a patient with myopia
and astigmatism may read -4.50 + 2.50 x 090 and a prescription for a patient with hyperopia and
astigmatism may read +3.25 + 1.50 x 180.

OD signifies the right eye (oculus dexter in Latin). OS signifies the left eye (oculus sinister). OU
signifies both eyes (oculi uterque).

Surgical correction — The most common surgical procedure performed to correct refractive errors
is laser in situ keratomileusis (LASIK). Overall outcomes with LASIK are favorable, leading to rapid
recovery of vision and minimal pain after surgery. Other corneal surgical procedures include
photorefractive keratectomy (PRK), and laser epithelial keratomileusis (LASEK). Laser refractive
procedures are discussed in detail elsewhere. (See "Laser refractive surgery".)

Intraocular lens implants, similar to those used to correct vision with cataract surgery, can correct high
degrees of myopia. However, intraocular lens implants can result in cataract formation, increased
intraocular pressure, and damage to the cornea over time. Thus, lens implants are not routinely
recommended for correction of refractive errors.

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The
Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and
they answer the four or five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer short, easy-to-read
materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for patients
who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-
mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Age-related vision loss (The Basics)" and "Patient
education: Open-angle glaucoma (The Basics)" and "Patient education: Presbyopia and
refractive errors (The Basics)")

SUMMARY AND RECOMMENDATIONS

 ● Refractive errors occur when a component of the eye's optical system fails to focus an optical
image onto the retina. The optical system consists of two refractive surfaces working in tandem:
the cornea and the crystalline lens (figure 1). (See 'Functional anatomy of the eye' above.)

● Refractive errors include myopia (nearsightedness), hyperopia (farsightedness), and astigmatism

(abnormal corneal shape). Presbyopia (aging sight) is a non-refractive error that occurs when the
lens loses its normal accommodating power. (See 'Definitions' above.)

● Abnormalities in refraction are common, affecting one-third of persons age ≥40 years in the
United States and Western Europe. Worldwide, uncorrected refractive errors are a common
cause of poor visual acuity and blindness. (See 'Epidemiology' above.)

● Assessment of visual acuity in the primary care setting can be performed with a standard Snellen
chart. Patients with visual acuity less than 20/25 in either eye have impaired visual acuity and
should be referred to an eye specialist for further evaluation. (See 'Screening and diagnostic
tests' above.)

● Treatments for refractive errors include glasses, contact lenses, and refractive surgery. (See
'Treatment' above and "Laser refractive surgery".)

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REFERENCES

1. Subcommittee AAoOBaCS. Section 3: Clinical Optics. San Francisco, CA: American Academy
of Ophthalmology, 2008.

2. Lawrence MS, Azar DT. Myopia and models and mechanisms of refractive error control.
Ophthalmol Clin North Am 2002; 15:127.

3. Wallman J, Winawer J. Homeostasis of eye growth and the question of myopia. Neuron 2004;
43:447.

4. Chen JC, Schmid KL, Brown B. The autonomic control of accommodation and implications for
human myopia development: a review. Ophthalmic Physiol Opt 2003; 23:401.

5. Kempen JH, Mitchell P, Lee KE, et al. The prevalence of refractive errors among adults in the
United States, Western Europe, and Australia. Arch Ophthalmol 2004; 122:495.
 6. Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. Br J Ophthalmol 2012;
96:614.

7. Holden BA, Fricke TR, Wilson DA, et al. Global Prevalence of Myopia and High Myopia and
Temporal Trends from 2000 through 2050. Ophthalmology 2016; 123:1036.

8. Vitale S, Sperduto RD, Ferris FL 3rd. Increased prevalence of myopia in the United States
between 1971-1972 and 1999-2004. Arch Ophthalmol 2009; 127:1632.

9. Williams KM, Bertelsen G, Cumberland P, et al. Increasing Prevalence of Myopia in Europe and
the Impact of Education. Ophthalmology 2015; 122:1489.

10. Vitale S, Ellwein L, Cotch MF, et al. Prevalence of refractive error in the United States, 1999-
2004. Arch Ophthalmol 2008; 126:1111.

11. Resnikoff S, Pascolini D, Mariotti SP, Pokharel GP. Global magnitude of visual impairment
caused by uncorrected refractive errors in 2004. Bull World Health Organ 2008; 86:63.

12. McCarty CA, Livingston PM, Taylor HR. Prevalence of myopia in adults: implications for
refractive surgeons. J Refract Surg 1997; 13:229.

13. Krishnaiah S, Srinivas M, Khanna RC, Rao GN. Prevalence and risk factors for refractive errors
in the South Indian adult population: The Andhra Pradesh Eye disease study. Clin Ophthalmol
2009; 3:17.

14. Fricke TR, Tahhan N, Resnikoff S, et al. Global Prevalence of Presbyopia and Vision
Impairment from Uncorrected Presbyopia: Systematic Review, Meta-analysis, and Modelling.
Ophthalmology 2018; 125:1492.

15. Rosenbloom AA Jr. New aged and old aged: impact of the Baby Boomer. Optometry 2003;
74:211.

16. Dirani M, Chamberlain M, Shekar SN, et al. Heritability of refractive error and ocular biometrics:
the Genes in Myopia (GEM) twin study. Invest Ophthalmol Vis Sci 2006; 47:4756.

17. Dirani M, Shekar SN, Baird PN. Evidence of shared genes in refraction and axial length: the
Genes in Myopia (GEM) twin study. Invest Ophthalmol Vis Sci 2008; 49:4336.

18. Saw SM, Chua WH, Hong CY, et al. Nearwork in early-onset myopia. Invest Ophthalmol Vis Sci
2002; 43:332.
19. Ip JM, Saw SM, Rose KA, et al. Role of near work in myopia: findings in a sample of Australian
school children. Invest Ophthalmol Vis Sci 2008; 49:2903.

20. Mutti DO, Mitchell GL, Hayes JR, et al. Accommodative lag before and after the onset of
myopia. Invest Ophthalmol Vis Sci 2006; 47:837.

21. Bovino JA, Marcus DF. The mechanism of transient myopia induced by sulfonamide therapy.
Am J Ophthalmol 1982; 94:99.

22. Drug-induced myopia. Prescrire Int 2003; 12:22.

23. Duke-Elder WS. CHANGES IN REFRACTION IN DIABETES MELLITUS. Br J Ophthalmol

1925; 9:167.

24. Fledelius HC, Fuchs J, Reck A. Refraction in diabetics during metabolic dysregulation, acute or
chronic. With special reference to the diabetic myopia concept. Acta Ophthalmol (Copenh)
1990; 68:275.

25. Jacobsen N, Jensen H, Lund-Andersen H, Goldschmidt E. Is poor glycaemic control in diabetic

patients a risk factor of myopia? Acta Ophthalmol 2008; 86:510.

26. Trobe JD. Symptoms of Optical Disorders. In: Neurology of Vision, 1st ed, Oxford University Pre
ss, New York 2001.

27. Goldstein JH, Schneekloth BB. Spasm of the near reflex: a spectrum of anomalies. Surv
Ophthalmol 1996; 40:269.

28. Tijssen CC, Goor C, Van Woerkom TC. Spasm of the near reflex: functional or organic disorder.
Neuro-ophthalmology 1983; 3:59.

29. Mitchell P, Hourihan F, Sandbach J, Wang JJ. The relationship between glaucoma and myopia:
the Blue Mountains Eye Study. Ophthalmology 1999; 106:2010.

30. Hyman LG, Lilienfeld AM, Ferris FL 3rd, Fine SL. Senile macular degeneration: a case-control
study. Am J Epidemiol 1983; 118:213.

31. Rose KA, Morgan IG, Ip J, et al. Outdoor activity reduces the prevalence of myopia in children.
Ophthalmology 2008; 115:1279.

32. Saw SM, Wu HM, Hong CY, et al. Myopia and night lighting in children in Singapore. Br J
Ophthalmol 2001; 85:527.
33. Saw SM, Zhang MZ, Hong RZ, et al. Near-work activity, night-lights, and myopia in the
Singapore-China study. Arch Ophthalmol 2002; 120:620.

34. Furushima M, Imaizumi M, Nakatsuka K. Changes in refraction caused by induction of acute

hyperglycemia in healthy volunteers. Jpn J Ophthalmol 1999; 43:398.

35. Lin SF, Lin PK, Chang FL, Tsai RK. Transient hyperopia after intensive treatment of
hyperglycemia in newly diagnosed diabetes. Ophthalmologica 2009; 223:68.

36. Read SA, Collins MJ, Carney LG. A review of astigmatism and its possible genesis. Clin Exp
Optom 2007; 90:5.

37. Saw SM, Katz J, Schein OD, et al. Epidemiology of myopia. Epidemiol Rev 1996; 18:175.

38. Rahi JS, Cumberland PM, Peckham CS. Myopia over the lifecourse: prevalence and early life
influences in the 1958 British birth cohort. Ophthalmology 2011; 118:797.

39. McKnight CM, Sherwin JC, Yazar S, et al. Myopia in young adults is inversely related to an
objective marker of ocular sun exposure: the Western Australian Raine cohort study. Am J
Ophthalmol 2014; 158:1079.

40. Kearney S, O'Donoghue L, Pourshahidi LK, et al. Myopes have significantly higher serum
melatonin concentrations than non-myopes. Ophthalmic Physiol Opt 2017; 37:557.

41. Daien V, Pérès K, Villain M, et al. Visual impairment, optical correction, and their impact on
activity limitations in elderly persons: the POLA study. Arch Intern Med 2011; 171:1206.

42. Klein BE, Klein R, Lee KE, Cruickshanks KJ. Performance-based and self-assessed measures
of visual function as related to history of falls, hip fractures, and measured gait time. The Beaver
Dam Eye Study. Ophthalmology 1998; 105:160.

43. Ivers RQ, Mitchell P, Cumming RG. Sensory impairment and driving: the Blue Mountains Eye
Study. Am J Public Health 1999; 89:85.

44. Sherrod CE, Vitale S, Frick KD, Ramulu PY. Association of vision loss and work status in the
United States. JAMA Ophthalmol 2014; 132:1239.

45. Hong T, Mitchell P, Burlutsky G, et al. Visual impairment and depressive symptoms in an older
Australian cohort: longitudinal findings from the Blue Mountains Eye Study. Br J Ophthalmol
2015; 99:1017.
46. Cumming RG, Ivers R, Clemson L, et al. Improving vision to prevent falls in frail older people: a
randomized trial. J Am Geriatr Soc 2007; 55:175.

47. Saw SM, Gazzard G, Shih-Yen EC, Chua WH. Myopia and associated pathological
complications. Ophthalmic Physiol Opt 2005; 25:381.

48. Risk factors for idiopathic rhegmatogenous retinal detachment. The Eye Disease Case-Control
Study Group. Am J Epidemiol 1993; 137:749.

49. Lim R, Mitchell P, Cumming RG. Refractive associations with cataract: the Blue Mountains Eye
Study. Invest Ophthalmol Vis Sci 1999; 40:3021.

50. Grødum K, Heijl A, Bengtsson B. Refractive error and glaucoma. Acta Ophthalmol Scand 2001;
79:560.

51. Wong TY, Klein BE, Klein R, et al. Refractive errors, intraocular pressure, and glaucoma in a
white population. Ophthalmology 2003; 110:211.

52. Ikram MK, van Leeuwen R, Vingerling JR, et al. Relationship between refraction and prevalent
as well as incident age-related maculopathy: the Rotterdam Study. Invest Ophthalmol Vis Sci
2003; 44:3778.

53. Verhoeven VJ, Wong KT, Buitendijk GH, et al. Visual consequences of refractive errors in the
general population. Ophthalmology 2015; 122:101.

54. US Preventive Services Task Force (USPSTF), Siu AL, Bibbins-Domingo K, et al. Screening for
Impaired Visual Acuity in Older Adults: US Preventive Services Task Force Recommendation
Statement. JAMA 2016; 315:908.

55. Wilson BJ, Courage S, Bacchus M, et al. Screening for impaired vision in community-dwelling
adults aged 65 years and older in primary care settings. CMAJ 2018; 190:E588.

56. Feder RS, Olsen TW, Prum BE Jr, et al. Comprehensive Adult Medical Eye Evaluation
Preferred Practice Pattern(®) Guidelines. Ophthalmology 2016; 123:P209.

57. Chou R, Dana T, Bougatsos C, et al. Screening for Impaired Visual Acuity in Older Adults:
Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.
JAMA 2016; 315:915.

58. Kniestedt C, Stamper RL. Visual acuity and its measurement. Ophthalmol Clin North Am 2003;
16:155.
 59. Lee YC, Wang JH, Chiu CJ. Effect of Orthokeratology on myopia progression: twelve-year
results of a retrospective cohort study. BMC Ophthalmol 2017; 17:243.

60. Gong Q, Janowski M, Luo M, et al. Efficacy and Adverse Effects of Atropine in Childhood
Myopia: A Meta-analysis. JAMA Ophthalmol 2017; 135:624.

Topic 6895 Version 41.0

GRAPHICS

Horizontal section of the eye

Representation of a horizontal section of the eyeball reveals its three coats: (1) external or
fibrous coat (sclera and cornea); (2) middle or vascular coat (choroid, ciliary body, and
iris); and (3) internal or retinal layer. The four refractive media are the cornea, the aqueous
humor in the anterior chamber, the lens, and the vitreous body.

Graphic 59910 Version 4.0

Normal vision

The eye's optical system focuses light on to the retina primarily due to the
shape of the cornea.

Graphic 81157 Version 1.0

Myopia with steep cornea

When the cornea is steep, light is focused in front of the retina resulting in
myopia.

Graphic 65268 Version 1.0

Hyperopia with flat cornea

A flat cornea focuses light behind the retina resulting in hyperopia.

Graphic 75265 Version 3.0

Snellen chart to test visual acuity

Graphic 50810 Version 2.0

Phoropter

A phoropter is an instrument containing different lenses used to bring the focus onto the
retina.

Graphic 66741 Version 2.0

Retinoscope

A retinoscope is used to get an objective measure of refractive error that is not

dependent upon patient response.

Graphic 55046 Version 2.0

Pinhole occluder

A pinhole occluder is a simple way to focus light, as in a pinhole camera,

temporarily removing the effects of refractive errors such as myopia in order to
assess visual acuity.

Graphic 66325 Version 2.0

Contributor Disclosures
Shahzad I Mian, MD Nothing to disclose Matthew F Gardiner, MD Other Financial Interest: Alcon
[Cataracts]. Jane Givens, MD Consultant/Advisory Boards (Partner): CVS Health/CVS Omnicare
[Pharmaceutical management of formulary decision-making].

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
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