Incidence and Progression of Myopia in Early Adulthood
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JAMA Ophthalmology | Original Investigation
Incidence and Progression of Myopia in Early Adulthood
Samantha Sze-Yee Lee, PhD; Gareth Lingham, PhD; Paul G. Sanfilippo, PhD; Christopher J. Hammond, MD;
Seang-Mei Saw, MBBS, PhD; Jeremy A. Guggenheim, PhD; Seyhan Yazar, PhD; David A. Mackey, MD
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IMPORTANCE Myopia incidence and progression has been described extensively in children. Supplemental content
However, few data exist regarding myopia incidence and progression in early adulthood.
OBJECTIVE To describe the 8-year incidence of myopia and change in ocular biometry in
young adults and their association with the known risk factors for childhood myopia.
DESIGN, SETTING, AND PARTICIPANTS The Raine Study is a prospective single-center cohort
study. Baseline and follow-up eye assessments were conducted from January 2010 to August
2012 and from March 2018 to March 2020. The data were analyzed from June to July 2021.
A total of 1328 participants attended the baseline assessment, and 813 participants attended
the follow-up assessment. Refractive information from both visits was available for 701
participants. Participants with keratoconus, previous corneal surgery, or recent
orthokeratology wear were excluded.
EXPOSURES Participants’ eyes were examined at ages 20 years (baseline) and 28 years.
MAIN OUTCOMES AND MEASURES Incidence of myopia and high myopia; change in spherical
equivalent (SE) and axial length (AL).
RESULTS A total of 516 (261 male [50.6%]) and 698 (349 male [50.0%]) participants without
myopia or high myopia at baseline, respectively, were included in the incidences analyses,
while 691 participants (339 male [49%]) were included in the progression analysis. The
8-year myopia and high myopia incidence were 14.0% (95% CI, 11.5%-17.4%) and 0.7%
(95% CI, 0.3%-1.2%), respectively. A myopic shift (of 0.50 diopters [D] or greater in at least
1 eye) occurred in 261 participants (37.8%). Statistical significance was found in longitudinal
changes in SE (−0.04 D per year; P < .001), AL (0.02 mm per year; PResearch Original Investigation Incidence and Progression of Myopia in Early Adulthood
T
he global myopia epidemic is well reported1,2 and the
rate of myopia-associated complications is expected to Key Points
similarly rise as younger generations with high myopia
Question How common is myopia progression and onset during
prevalence approach middle age and older age.3,4 Myopia typi- early adulthood?
cally develops and progresses fastest during childhood, and
Findings In a cohort study of 691 young adults from a general
it has been reported that myopia stabilizes (defined as change
population, significant increases were observed over the 8-year
of less than 0.5 diopters [D]) at around age 15 to 16 years.5,6
study period in myopia and axial length by 0.04 diopters per year
However, longitudinal studies involving university students and 0.02 mm per year, respectively. Of the 526 participants
have demonstrated that myopia may progress and even start without myopia at baseline, myopia incidence from age 20 to
to develop during young adulthood. In 118 university stu- 28 years was 14%.
dents who were observed for 3 years in Portugal7 (mean age,
Meaning In this study, there was a high incidence of myopia and
21 years at baseline), prevalence of myopia and hyperopia in- prevalence of myopia progression in the third decade of life.
creased by 5% and decreased by 9%, respectively, while mean
spherical equivalent decreased by 0.3 D. Another study in
Norway8 found a 3-year myopia incidence of 33% among uni- Australia’s Human Research Ethics Committee. All partici-
versity students (mean age, 21 years at baseline), with mean pants were given a full explanation of the nature of the study
spherical equivalent decreasing by 0.6 D. Similar longitudi- and provided written informed consent prior to participating
nal findings were reported in university students in Denmark9 in each follow-up assessment. No incentives were provided
and the US.10,11 for participation, apart from reimbursement of parking fees for
With the modern emphasis on education, a known risk fac- the visit.
tor for myopia,12 myopia may continue to progress or onset dur-
ing young adulthood. With the rise in indoor jobs in the past Eye Examination
century13 and the increase in automation of many manual or The 20-year and 28-year follow-up assessments were con-
outdoor labor occupations,14 individuals are likely to spend less ducted from January 2010 to August 2012 and from March 2018
time outdoors, which could further drive myopia progression to March 2020, respectively.19,20 In brief, both eye examina-
during young adulthood,15-17 even after formal education is tions included conjunctival ultraviolet autofluorescence
completed. However, there are limited data in the literature (CUVAF) photography, ocular biometry (IOLMaster V.5; Carl
on myopia development or progression in young adulthood, Zeiss Meditec AG), postmydriatic autorefraction/keratom-
and often studies have been conducted in select populations. etry (Nidek ARK-510A; NIDEK), and lens thickness measure-
This study aimed to (1) describe the 8-year incidence of ment (Oculus Pentacam; OculusOptikgerate GmbH), among
myopia and high myopia and (2) examine the 8-year within- others. Autorefraction was performed at least 20 minutes af-
person change in refractive measures in young adults from ter instillation of 1 drop of tropicamide, 1%. CUVAF photogra-
a general population. Within both aims, we explored risk fac- phy is an objective method of measuring ocular sun exposure
tors for myopia development or progression during young and has a strong correlation with self-reported time spent out-
adulthood and tested the hypothesis that the 3 known major doors in adults.21 The same refraction and ocular biometric
risk factors of childhood myopia—higher level of education, measurement protocol and instrument models were used in
lower time spent outdoors, and parental myopia—are also both follow-up assessments.
associated with myopia development and progression during A participant was considered to have myopia or high myo-
young adulthood. pia if either or both eyes had a spherical equivalent of 0.50 D
or less or 6.00 D or less, respectively.22 A refraction shift was
defined as a change of 0.50 D or more in spherical equivalent
in either direction (myopic/hyperopic).
Methods
Study Sample Questionnaire
The Raine Study 18 has observed a cohort of participants In a self-administered questionnaire, participants indicated
since their prenatal periods in 1989 to 1991, when more than their highest level of education as (1) up to secondary school;
2900 pregnant women were recruited from the King Edward (2) vocational qualification (including technical college, vo-
Memorial Hospital and surrounding obstetric clinics in Perth, cational training, or other certification courses); (3) under-
Australia. From these women, 2868 offspring were born, form- graduate degree; or (4) postgraduate degree, and years of edu-
ing the original study cohort who are now in young adult- cation. Self-reported parental myopia, race, and ocular history
hood, and have since been undergoing a series of regular medi- were also obtained. Race was categorized as East Asian, White,
cal and health examinations. and others/mixed (Aboriginal Australian, South Asian, South-
At the 20-year follow-up (age 18 to 22 years), participants east Asian, Torres Straits Islander, or a combination of these
underwent their first Raine Study eye examination.19 Partici- with East Asian or White). East Asian participants were ana-
pants were invited to return for an eye examination at the lyzed in their category in view of the observed high preva-
28-year follow-up. All follow-up assessments of the Raine Study lence of myopia in this demographic.23 Ocular history infor-
were conducted in compliance with the Declaration of Hel- mation included previous operations and keratoconus. For
sinki and have been approved by the University of Western participants who had laser refractive surgery, we further asked
E2 JAMA Ophthalmology Published online January 6, 2022 (Reprinted) jamaophthalmology.com
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if they remembered their approximate refraction prior to
Figure. Sample Size for Incidence Analysis (Aim 1)
surgery (eg, what their contact lens prescription was prior
to surgery).
2868 Individuals in the original cohort
Statistical Analysis
For aim 1 (describing the 8-year incidence of myopia), partici-
1344 Attended 20-y follow-up 813 Attended 28-y follow-upa
pants were included in the analysis if they had postmydriatic
refraction data at both assessments and if they had no myo-
1328 With refraction data available 783 With refraction data available
pia at the 20-year follow-up (baseline). A similar process
was applied to obtain the 8-year incidence of high myopia.
Logistics regression was used to explore the risk factors of myo-
701 With refraction data available for
pia development, including sex, race, education, and ocular both follow-ups
sun exposure.
To address aim 2, all participants who had refraction data
at both follow-up assessments were included, regardless of 185 Excluded 18 Excluded
myopia status. Linear mixed-effect models were used with 177 Myopia at baselineb 7 High myopia at baseline
6 Keratoconus 6 Keratoconus
random intercept and slope for participants to account for the 3 Orthokeratology wear 3 Refractive surgery with
within-participant correlation between 2 eyes.24 In multivari- unknown prior refraction
2 Orthokeratology wear
able analyses, the main effects of sex, race, highest level of edu-
cation, CUVAF area (as an objective measure of ocular sun
516 Included in final sample for 683 Included in final sample for
exposure), and parental myopia as well as interaction effects myopia incidence analysis high myopia incidence analysisa
with age on refractive measures were evaluated.
Participants who wore orthokeratology lenses or had a his- a
Fewer participants attended the 28-year follow-up partly because data
tory of cataract or corneal surgery were removed from the collection had to cease early because of the COVID-19 pandemic.
b
analyses. Participants with keratoconus, defined as having a Includes 5 with history of laser refractive surgery but known refractive error
Belin/Ambrósio enhanced ectasia display score of 2.6 or more prior to surgery.
in either eye based on Scheimpflug imaging25 at the 28-year
follow-up assessment, were additionally excluded. To maxi-
mize the sample size, we included participants who under- Among the 1344 participants who attended the baseline
went laser refractive surgery between ages 20 and 28 years by visit, there was no significant difference in race, baseline spheri-
adding their self-provided estimated presurgical spherical cal equivalent, axial length, or CUVAF area between those who
equivalent (if known) to their 8-year refraction data as ob- returned and did not return for the follow-up visit. However,
tained during the eye examination. However, these partici- there were more male participants than female participants
pants were removed from analyses with keratometry as the who did not attend the follow-up visit (male: did not attend,
outcome measure. Participants who were not able to provide 360 [53.9%] vs attended, 261 [48.9%]; P = .05).
or recall their estimated refraction data prior to surgery were
excluded. 8-Year Incidence of Myopia
All analyses were conducted using R version 3.6.2 (The After excluding participants who had no refraction data at base-
R Foundation for Statistical Computing Platform), and the level line or follow-up, those with myopia at baseline, keratoco-
of significance was set at P < .05. Because of the multiple com- nus, or recent use of orthokeratology contact lenses, a total
parisons in aim 2, the level of significance was set as P < .025 of 516 participants (50.6% male) were included in the myopia
for aim 2 with the Bonferroni correction, in consideration of incidence analysis (Figure). The cumulative 8-year myopia in-
the 2 main refractive outcome measures (spherical equiva- cidence was 14.0% (95% CI, 11.5%-17.4%), with 72 partici-
lent and axial length; this adjustment was not done for aim pants developing myopia. In univariable logistic regression,
1 as it only had 1 outcome measure). myopia incidence was significantly associated with female
sex, East Asian race (relative to White participants), less sun
exposure (as indicated by smaller CUVAF areas), and parental
myopia (Table 1). Participants who reported vocational train-
Results ing as their highest level of education had lower odds of inci-
Of 1344 participants who attended the baseline visit, 1328 dent myopia relative to those who reported up to secondary
had refractive data, including 342 participants and 19 partici- school. In the multivariable analyses, all these factors, except
pants with myopia and high myopia, respectively, giving for education, remained significantly associated with inci-
a prevalence of 25.8% (95% CI, 23.5%-28.2%) and 1.4% dent myopia (eAppendix in the Supplement).
(95% CI, 0.9%-2.2%). Of the 801 participants who attended Eyes with incident myopia had lower spherical equiva-
the follow-up, 783 had refractive data, included 260 partici- lent, longer axial lengths, and thinner lens at baseline (age 20
pants with myopia (prevalence, 33.2%; 95% CI, 30.1%- years) than those that did not become myopic (Table 2). There
36.7%) and 12 participants with high myopia (1.5%; 95% CI, was no significant difference in baseline corneal radius be-
0.9%-2.7%). tween groups (Table 2).
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Table 1. Risk Factors Associated With Incident Myopia Between Age 20 and 28 Years
No. (%)
Analyses
Developed myopia Univariable Multivariablea
All
Characteristic participants Yes No OR (95% CI) P value OR (95% CI) P value
No. 516 72 444 NA NA NA NA
Sex
Male 261 (50.6) 26 (36.1) 235 (90.0) 1 [Reference] NA NA NA
Female 255 (49.4) 46 (63.9) 209 (82.0) 1.99 (1.19-3.33) .009 1.81 (1.02-3.22) .04
Raceb
East Asian 6 (1.2) 3 (4.2) 3 (6.8) 6.63 (1.31-33.63) .02 6.13 (1.06-35.25) .04
White 458 (88.8) 60 (83.3) 398 (89.6) 1 [Reference] NA NA NA
Other/mixedc 52 (10.1) 9 (12.5) 43 (9.7) 1.39 (0.64-2.99) .40 1.45 (0.65-3.26) .55
Parental myopiab,d
None 373 (72.3) 40 (55.6) 333 (75.0) 1 [Reference] NA NA NA
1 Parent 102 (19.8) 24 (33.3) 78 (17.6) NA .001 .05
1.57 (1.03-2.38)c
Both parents 30 (5.8) 7 (9.7) 23 (5.2) 1.86 (1.28-2.70)c NA NA
No response 9 (1.7) 2 (1.4) 10 (2.3) NA NA NA NA
Highest educationb
Up to secondary school 96 (18.6) 17 (23.6) 79 (17.9) 1 [Reference] NA NA NA
Vocational training 158 (30.6) 14 (19.4) 144 (32.4) 0.45 (0.21-0.96) .04 0.57 (0.13-1.02) .22
Undergraduate degree 168 (32.3) 25 (34.7) 143 (32.2) 0.81 (0.41-1.60) .55 0.64 (0.31-1.32) .44
Postgraduate degree 77 (14.9) 15 (20.8) 62 (14.0) 1.12 (0.52-2.43) .77 1.00 (0.44-2.25) .80
No response 18 (3.3) 1 (1.4) 16 (3.6) NA NA NA NA
CUVAF area per 10-mm2 40.7 (21.6- 34 (14.8- 42.8 (23.3- 9.87 (9.78-9.97) .009 9.86 (9.76-9.97) .009
increase, median (IQR) 64.5) 52.7) 65.4)
c
Abbreviations: CUVAF, conjunctival UV autofluorescence; NA, not applicable; Other includes Aboriginal Australian, South Asian, Southeast Asian, Torres
OR, odds ratio. Strait Islander, or a combination of these with East Asian or White.
a d
Includes all variables in the table. OR with each additional parent with myopia.
b
Self-reported.
Table 2. Baseline (Age 20 Years) Ocular Measures According to Incident Myopia
Developed myopia, Group difference
median (IQR) statistical outcomea
Measure Yes No F statistic P value
Eyes, No. 122 925 NA NA Abbreviations: D, diopter; NA, not
applicable.
Spherical equivalent, D 0 (−0.13 to 0.25) 0.50 (0.25-0.75) F1,514 = 50.2Incidence and Progression of Myopia in Early Adulthood Original Investigation Research
Table 3. Refraction Shift Over 8 Years Among 691 Participants
Left eye, No. (%)
Refractive shifta Myopic shift No change Hyperopic shift
Right eye
Myopic shift 152 (22.0) 56 (8.1) 0
a
No change 53 (7.6) 361 (52.2) 45 (6.5) Myopic/hyperopic shift defined
as a change in refraction of
Hyperopic shift 0 10 (1.4) 14 (2.0)
0.50 diopters or more.
Table 4. Estimated Annual Change in Myopia-Related Parameters
Statistical outcomeb
a
Measure Estimate (97.5% CI) F statistic P value
All participants
Spherical equivalent −0.041 (−0.055 to −0.027) F1,1972 = 27.6Research Original Investigation Incidence and Progression of Myopia in Early Adulthood
applied to the general population, they provide evidence that over, higher level of education was not significantly associated
it is common for myopia to start developing after childhood with myopia incidence or progression. It is possible that some
and adolescence. other lifestyle habits, biological, or hormonal factors may me-
In our study of young adults from a general population, diate this age and sex interaction effect during young adult-
we found an 8-year incidence of 14% and that spherical equiva- hood, and this should be explored in further studies.
lent progressed by −0.04 D per year on average, with 38% of Over the 8 years of the study, there were crystalline lens
participants experiencing a myopia shift of 0.50 D or more thickening and axial elongation in this sample. The latter is par-
in at least 1 eye over 8 years, in contrast to a mean age of myo- ticularly concerning as it is strongly believed that longer axial
pia stabilization at approximately 15 years reported by the length increases the risk of myopia-related complications.46
Correction of Myopia Evaluation Trial.5 With younger genera- Fricke et al4 estimated that more than 55 million people (0.6%
tions increasingly pursuing postgraduate education,35 we may of the world population) will be visually impaired from my-
expect more at-risk young adults to develop myopia in their opic macular degeneration alone, including 18 million who will
20s or early 30s. Even in nonuniversity students or gradu- be blind, in the year 2050 if we do not implement interven-
ates, individuals are likely to start their first full-time occupa- tions to slow myopia progression. Similarly, Cheung et al3 pre-
tion in or just prior to their 20s (students are aged 17 to 18 years dict a retinal detachment epidemic as a consequence of a surge
when they leave school), and the rise in indoor occupations in prevalence of high myopia. Myopia management strate-
will inevitably result in the development or progression of gies targeting control of axial elongation should therefore be
myopia in a substantial proportion of the population. considered in young adults exhibiting myopia progression.
Indeed, we observed an inverse association of increased
sun exposure, as quantified using CUVAF area with incident Strengths and Limitations
myopia. Similarly, previous studies36-40 have noted a protec- A main strength of the current study is the large sample of
tive effect of increased time outdoors against myopia, but find- community-based young adults, rather than recruiting partici-
ings on whether it reduces myopia progression have been con- pants from universities or myopic cohorts, as has been done in
flicting. The lack of association between ocular sun exposure previous studies on young adults.7,8,11,47,48 The Raine Study par-
and refractive measure change may also be partly owing to use ticipants have also been shown to be generally representative
of sunglasses or hats in some adults, which filters out inci- of the Western Australian population of the same age.49 How-
dent ultraviolet rays and thus is protective against enlarge- ever, this study has limitations. Our findings may not be gener-
ment of CUVAF area,41 while still allowing exposure to higher alizable to recent immigrants of Western Australia, which may
levels of outdoor lighting. comprise a higher proportion of people of East Asian decent than
Additionally, we did not find a significant association be- the current cohort. There was also a substantial proportion of
tween highest level of education with rate of change in refrac- participants who did not attend the follow-up eye examination.
tive measures. Instead, unmodifiable factors, such as race, sex, This was partly because we had to cease data collection early due
and parental myopia, appeared to have stronger associations to the COVID-19 pandemic. It is unclear how this may have af-
with the rate of change in refractive measures than environ- fected the incidence estimates. Participants with eye issues may
mental factors. be more likely to attend the eye examination, resulting in an over-
Women were more likely than men to develop myopia and estimation of myopia incidence, but these participants are also
had greater changes in refractive measures between ages 20 likely to have had more frequent optometrists visits and thus
and 28 years. Longitudinal studies on school-aged children in did not feel the need to attend the follow-up eye examination,
East and South Asian countries have similarly reported higher resulting in an underestimation of myopia incidence. We were
myopia incidence26,30,34 and faster myopia progression28,42 in also unable to ascertain whether there was a differential rate of
girls compared with boys. Likewise, the Correction of Myopia change within the follow-up period, for example, if progression
Evaluation Trial reported that myopia progressed faster in girls was faster during the early 20s than mid to late 20s.
than in boys, in terms of spherical equivalent but not axial
length.43 In previous studies involving children, the differen-
tial effect of sex on myopia progression and axial elongation may
be influenced by pubertal growth spurts,44 but this is unlikely
Conclusion
to be a factor in our young adult sample. Instead, this differ- Nonetheless, our findings provide evidence that myopia can
ence between young men and young women may reflect the start to develop and continue to progress during young adult-
modern societal push for higher education in girls and women, hood. The eye continues to elongate axially in some partici-
as reflected by the increasing proportion of women with higher pants during young adulthood, which may contribute to the
education than men,45 and a tendency for women to work in increased risk of myopia-related complications as these young
indoor-based occupations in Australia.45 However, the associa- adults reach middle and older age. Our findings highlight the
tions between female sex and myopia progression were signifi- need for research into myopia control methods in young adults
cant even after correcting for education and CUVAF area. More- in addition to those currently being researched in children.
ARTICLE INFORMATION Published Online: January 6, 2022. Author Affiliations: Centre for Ophthalmology and
Accepted for Publication: October 11, 2021. doi:10.1001/jamaophthalmol.2021.5067 Visual Science (incorporating Lions Eye Institute),
The University of Western Australia, Perth, Australia
E6 JAMA Ophthalmology Published online January 6, 2022 (Reprinted) jamaophthalmology.com
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Downloaded From: https://jamanetwork.com/ by a Chinese University of Hong Kong User on 01/09/2022Incidence and Progression of Myopia in Early Adulthood Original Investigation Research
(Lee, Lingham, Mackey); Centre for Eye Research Meeting Presentations: This paper was presented Increasing prevalence of myopia in Europe and the
Ireland, School of Physics, Clinical and Optometric at the 2021 Raine Annual Scientific Meeting; impact of education. Ophthalmology. 2015;122(7):
Sciences, Technological University Dublin, October 29, 2021; Perth, Australia. 1489-1497. doi:10.1016/j.ophtha.2015.03.018
Dublin, Ireland (Lingham); Centre for Eye Research Additional Contributions: We thank the 13. Wyatt ID, Hecker DE. Occupational changes
Australia, University of Melbourne, Royal Victorian Raine Study participants and their families, the during the 20th century. Monthly Lab Rev. 2006;
Eye and Ear Hospital, Melbourne, Australia Raine Study staff for study coordination, and 129:35.
(Sanfilippo, Mackey); Department of Twin Research the staff, students, and volunteers of the Genetics
& Genetic Epidemiology, King’s College London, 14. Frey CB, Osborne MA. The future of
and Epidemiology group of the Lions Eye Institute employment: how susceptible are jobs to
London, United Kingdom (Hammond); Singapore for assisting in the eye data collection.
Eye Research Institute, Singapore (Saw); Yong Loo computerisation? Technol Forecast Soc Change.
Lin School of Medicine, National University of 2017;114:254-280. doi:10.1016/j.techfore.2016.
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