Myopia

Friday, March 27th, 2015

East Asia is growing increasingly myopic — literally:

Sixty years ago, 10–20% of the Chinese population was short-sighted. Today, up to 90% of teenagers and young adults are. In Seoul, a whopping 96.5% of 19-year-old men are short-sighted.

Other parts of the world have also seen a dramatic increase in the condition, which now affects around half of young adults in the United States and Europe — double the prevalence of half a century ago. By some estimates, one-third of the world’s population — 2.5 billion people — could be affected by short-sightedness by the end of this decade.

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For many years, the scientific consensus held that myopia was largely down to genes. Studies in the 1960s showed that the condition was more common among genetically identical twins than non-identical ones, suggesting that susceptibility is strongly influenced by DNA. Gene-finding efforts have now linked more than 100 regions of the genome to short-sightedness.

But it was obvious that genes could not be the whole story. One of the clearest signs came from a 1969 study of Inuit people on the northern tip of Alaska whose lifestyle was changing2. Of adults who had grown up in isolated communities, only 2 of 131 had myopic eyes. But more than half of their children and grandchildren had the condition. Genetic changes happen too slowly to explain this rapid change — or the soaring rates in myopia that have since been documented all over the world (see ‘The march of myopia’). “There must be an environmental effect that has caused the generational difference,” says Seang Mei Saw, who studies the epidemiology and genetics of myopia at the National University of Singapore.

There was one obvious culprit: book work. That idea had arisen more than 400 years ago, when the German astronomer and optics expert Johannes Kepler blamed his own short-sightedness on all his study. The idea took root; by the nineteenth century, some leading ophthalmologists were recommending that pupils use headrests to prevent them from poring too closely over their books.

The modern rise in myopia mirrored a trend for children in many countries to spend more time engaged in reading, studying or — more recently — glued to computer and smartphone screens. This is particularly the case in East Asian countries, where the high value placed on educational performance is driving children to spend longer in school and on their studies. A report last year3 from the Organisation for Economic Co-operation and Development showed that the average 15-year-old in Shanghai now spends 14 hours per week on homework, compared with 5 hours in the United Kingdom and 6 hours in the United States.

Researchers have consistently documented a strong association between measures of education and the prevalence of myopia. In the 1990s, for example, they found that teenage boys in Israel who attended schools known as Yeshivas (where they spent their days studying religious texts) had much higher rates of myopia than did students who spent less time at their books4. On a biological level, it seemed plausible that sustained close work could alter growth of the eyeball as it tries to accommodate the incoming light and focus close-up images squarely on the retina.

Attractive though the idea was, it did not hold up. In the early 2000s, when researchers started to look at specific behaviours, such as books read per week or hours spent reading or using a computer, none seemed to be a major contributor to myopia risk5. But another factor did. In 2007, Donald Mutti and his colleagues at the Ohio State University College of Optometry in Columbus reported the results of a study that tracked more than 500 eight- and nine-year-olds in California who started out with healthy vision6. The team examined how the children spent their days, and “sort of as an afterthought at the time, we asked about sports and outdoorsy stuff”, says Mutti.

It was a good thing they did. After five years, one in five of the children had developed myopia, and the only environmental factor that was strongly associated with risk was time spent outdoors6. “We thought it was an odd finding,” recalls Mutti, “but it just kept coming up as we did the analyses.” A year later, Rose and her colleagues arrived at much the same conclusion in Australia7. After studying more than 4,000 children at Sydney primary and secondary schools for three years, they found that children who spent less time outside were at greater risk of developing myopia.

Rose’s team tried to eliminate any other explanations for this link — for example, that children outdoors were engaged in more physical activity and that this was having the beneficial effect. But time engaged in indoor sports had no such protective association; and time outdoors did, whether children had played sports, attended picnics or simply read on the beach. And children who spent more time outside were not necessarily spending less time with books, screens and close work. “We had these children who were doing both activities at very high levels and they didn’t become myopic,” says Rose. Close work might still have some effect, but what seemed to matter most was the eye’s exposure to bright light.

March of Myopia

Based on epidemiological studies, Ian Morgan, a myopia researcher at the Australian National University in Canberra, estimates that children need to spend around three hours per day under light levels of at least 10,000 lux to be protected against myopia. This is about the level experienced by someone under a shady tree, wearing sunglasses, on a bright summer day. (An overcast day can provide less than 10,000 lux and a well-lit office or classroom is usually no more than 500 lux.) Three or more hours of daily outdoor time is already the norm for children in Morgan’s native Australia, where only around 30% of 17-year-olds are myopic. But in many parts of the world — including the United States, Europe and East Asia — children are often outside for only one or two hours.

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