Secondary Logo

Journal Logo

Epidemiology of Myopia

Wu, Pei-Chang MD, PhD; Huang, Hsiu-Mei MD, MS; Yu, Hun-Ju MD; Fang, Po-Chiung MD; Chen, Chueh-Tan MS

The Asia-Pacific Journal of Ophthalmology: November/December 2016 - Volume 5 - Issue 6 - p 386–393
doi: 10.1097/APO.0000000000000236
Review Article
Free

Myopia is not a simple refractive error, but an eyesight-threatening disease. There is a high prevalence of myopia, 80% to 90%, in young adults in East Asia; myopia has become the leading cause of blindness in this area. As the myopic population increases globally, the severity of its impact is predicted. Approximately one fifth of the myopic population has high myopia (≥−6 diopters), which results in irreversible vision loss such as retinal detachment, choroidal neovascularization, cataracts, glaucoma, and macular atrophy. The increasing prevalence of school myopia in the past few decades may be a result of gene-environment interactions. However, earlier school myopia onset would accompany faster myopia progression and greater risk of high myopia later in life. Recently, there have been effective interventions to delay the onset of myopia, such as outdoor activity and decreasing the duration of near work. Hyperopia (≤0.5 diopters) is a predictor of myopia. Pharmacological agents and optic interventions such as low-concentration atropine and orthokeratology may slow progression in myopic children. Novel surgeries and anti–vascular endothelial growth factor drugs could deal with some myopic complications. From available evidence, the prevention, control, and treatment of myopia seem to be promising. However, to reduce the impact of myopia in future decades, more work and effort are still needed, including that by governments and intercountry eye health organizations.

From the Department of Ophthalmology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China.

Received for publication September 21, 2016; accepted September 24, 2016.

P.C.W. received grants from the Bureau of Health Promotion, Department of Health, Taiwan (PARPG8B0051; PARPG8B0141).

The authors have no conflicts of interest to declare.

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Reprints: Chueh-Tan Chen, MS, Department of Ophthalmology, Kaohsiung Chang Gung Memorial Hospital, 123, Dapi Rd, Niaosong District, Kaohsiung, 88301, Taiwan, Republic of China. E-mail: chuehtan@hotmail.com.

Myopia is a very common refractive error in the general population. Most people look at it as a simple refractive error that can be corrected by spectacles or refractive surgeries. In fact, myopia is an ocular disease characterized by an abnormally elongated eyeball, which cannot be rescued by optical lenses or refractive surgeries. Its severity can even result in blindness. The prevalence of myopia is increasing and has become an important issue in public health.1–3 In Taiwan and Singapore, the prevalence of myopia is 20% to 30% among 6 to 7 year olds and as high as 84% in high school students in Taiwan.2,4 The myopia progression rate in East Asian children is high [nearly −1 diopter (D) per year], and approximately 24% of the myopic population become high myopes as adults.2,5–7

Recently, myopia has become a significant public health problem. One of the complications of myopia, myopia maculopathy, has become a leading cause of untreatable visual loss in East Asia.8–10 It is also the third cause of blindness in Copenhagen, Rotterdam, and the Latino population in Los Angeles. High myopia is mostly defined as refraction greater than −6 D. Because of ocular elongation resulting in ocular tissue thinning and degeneration, it is highly associated with sight-threatening conditions. The complications of myopia include presenile cataracts, glaucoma, retinal detachment, myopic choroidal neovascularization (CNV), foveoschisis, staphyloma, macular atrophy, and blindness.11–13 Studies have shown that myopia progresses faster when children present with myopia at a younger age.14,15 Once myopia occurs in school-aged children, it progresses quickly until early adulthood, when it slows down.16–18 Early onset of myopia in childhood is associated with high myopia in adult life.19–21 Therefore, it is very important to stop or control myopia progression in myopic children from a young age.

Myopia has a great impact on public health and socioeconomic well-being.22,23 It is a condition of social, educational, and economic consequences. Blindness caused by myopia is a burden for patients, their families, and society. It is important to develop public policies and interventions to prevent patients from developing high myopia and associated visual impairment.

Myopia is the increase in axial length and the thinning of the sclera that may be due to both reduced collagen synthesis and increased collagen degradation.24,25 Animal studies in chickens, tree shrews, marmosets, rhesus monkeys, and guinea pigs revealed that blurred vision is caused by form deprivation, minus lens rearing, and peripheral refraction with hyperopic defocus resulting in myopic development.26,27 Animal studies not only can develop possible treatments for myopia but also can help to clarify the findings from epidemiological studies, such as light with outdoor activity and peripheral refraction with orthokeratology.27–29

Back to Top | Article Outline

BASIS AND DEFINITION OF MYOPIA

The normal development of emmetropization is hyperopia approximately +2 D in newborns and infants. The hyperopia decreases rapidly to approximately +1 D during the first 2 years.30,31 During the period of 2 to 14 years of age, the hyperopia decreases slowly to emmetropia. The eyeball grows rapidly in early childhood from 18 mm of axial length at birth to 23 mm at 3 years of age.32 Because of a 1-mm increase in axial length being correlated with a 2- to 3-D myopic shift, the refraction during this period is compensated by corneal flatting and thinning of the lens. The mean axial length of adults is 24 mm; therefore, there is only a 1-mm increase during the period from 3 to 13 years of age. Axial length has a very strong correlation with refractive status. Myopia usually results from an eye with longer axial length mostly due to the elongated vitreal chamber.33 Myopia is an abnormal condition breaking the emmetropization process.34 The myopic refraction will progress rapidly during onset from an early age and continue progression until early adulthood.

The most common definition of myopia is spherical equivalence −0.5 D or greater. The criterion standard for measurement of refractive error is cycloplegic refraction,35–37 especially in children. Children have strong accommodative responses leading to “pseudomyopia” during examination.38 However, if there is no cycloplegic examination for children, the refraction might be overestimated by approximately −1 to −2 D.39,40 High myopia is commonly defined as refraction of −6 D or greater. Some studies define high myopia as −5 D or greater.23,33 Myopia could also be defined as having an axial length greater than 24 mm, and high myopia defined as greater than 26 mm.41,42

Back to Top | Article Outline

PREVALENCE OF MYOPIA IN CHILDREN

The prevalence of myopia in children varies in different areas and countries. The myopia onset during childhood can be roughly calculated from the prevalence of different age populations. The higher prevalence of younger age groups would lead to a greater burden and severity of myopia in adulthood due to myopia progression in childhood leading to high myopia.

Back to Top | Article Outline

Asian Populations

In Taiwan from 1983 to 2000, the prevalence of myopia in 7 year olds increased from 5.8% to 21.0%. Among 12 year olds, the prevalence increased from 36.7% to 61.0%. Among 15 year olds, the prevalence increased from 64.2% to 81.0%. Among 16 to 18 year olds, the prevalence increased from 74% to 84% in 2000.43 The difference in prevalence may reflect secular trends over time. In Singapore, the prevalence of myopia was 11.0% in Chinese children aged 6 to 72 months,44 29.0% in 7 year olds, 34.7% in 8 year olds, and 53.1% in 9 year olds.4 In Hong Kong, the myopia prevalence was 17.0% in children younger than 7 years, which increased to 37.5% in 8 year olds and 53.1% in children older than 11 years.45 In Korea, the prevalence of myopia by age group was 50% in 5 to 11 year olds, 78% in 12 to 18 year olds, and 45.7% in high school students.46 In China, the prevalence of myopia in urban children ranged from 5.7% in 5 year olds, 30.1% in 10 year olds, and increased to 78.4% in 15 year olds.47 In rural children, almost no 5 year olds, 36.8% of 13 year olds, 43.0% of 15 year olds, and 53.9% of 17 year olds were found to be myopic.48,49 In India, urban children had a myopia prevalence of 4.7%, 7.0%, and 10.8% in 5, 10, and 15 year olds, respectively. In rural children, it was 2.8%, 4.1%, and 6.7% in 7, 10, and 15 year olds, respectively.50,51 In Nepal, urban children had a myopia prevalence of 10.9%, 16.5%, and 27.3% in 10, 12, and 15 year olds. In rural children, it was 1.2% in 5 to 15 year olds.52,53

Back to Top | Article Outline

Non-Asian Populations

In Australia, the myopia prevalence was 1.4% among 6 year olds.54 Among 12-year-old children, the overall myopia prevalence was 11.9%, which was lower among white European children (4.6%) and Middle Eastern children (6.1%) and higher among East Asian (39.5%) and South Asian (31.5%) children.55 In the United States, the prevalence of myopia was 4.5% in 6 to 7 year olds and 28% in 12 year olds in a predominantly white population.56 In another study, Asians had the highest prevalence (18.5%), followed by Hispanics (13.2%) in 5 to 17 year olds. African Americans (6.6%) and whites (4.4%) had the lowest.57 In Chile, the prevalence of myopia was 3.4% in 5 year olds and 19.4% and 14.7% in 15-year-old boys and girls, respectively.58 In England, the prevalence of myopia was 2.8% in 6 to 7 year olds and 17.7% in 12 to 13 year olds.59 In Sweden, the prevalence of myopia was 49.7% in 12 to 13 year olds.60 In Greece and Bulgaria, the prevalence of myopia (noncycloplegic) was 37.2% and 13.5% in 10 to 15 year olds, respectively.61 In South Africa, the prevalence of myopia was 3% to 4% in 5 to 13 year olds, 6.3% in 14 year olds, and 9.6% in 15 year olds.62

Back to Top | Article Outline

INCIDENCE OF MYOPIA IN CHILDREN

In China, the annual incidence of myopia in 7-year-old children was approximately 10% to 14%.63 In Taiwan, the annual incidence of myopia in 7 to 12 year olds was 8% to 18%.64 In Australia, the annual incidence of myopia in 12 and 17 year olds was 2.2% and 4.1%, respectively.65 The annual incidence rates of myopia in East Asian children were much higher than those in white European children.

Back to Top | Article Outline

PREVALENCE OF MYOPIA IN ADULTHOOD

The prevalence of myopia in adulthood is more stable because myopia onset is far less than that of childhood. However, the prevalence in the senior population could be overestimated because of lenticular cataracts inducing refractive myopia.

In Taiwan, a study of male military conscripts aged 18 to 24 years reported that the prevalence of myopia was 86.1%.66 The Shihpai Eye Study in Taiwanese adults older than 65 years found a myopia prevalence of only 19.4%.67 In China, the prevalence of myopia was 22.9% in the Beijing Eye Study (aged 40–90 years).68 In Japan, the prevalence was 41.8% for myopia in younger adults.69 In India, the prevalence was 34.6% in those 40 years or older.70 In Singapore, the prevalence rates in Singaporean Chinese, Malay, and Indian adults older than 40 years were 38.7%, 26.2%, and 28.0%, respectively.7,71,72 The difference in the prevalence reflects interethnic variation. In Bangladeshi and Pakistani adults older than 30 years, the prevalence of myopia was 23.8% and 36.5%, respectively.73,74 In Indonesia, the prevalence was 48.1% in adults older than 21 years.75 In Mongolia, the prevalence was 17.2% in adults older than 40 years.76

In the United States, the prevalence of myopia was 33.1% in adults 20 years or older.77 In the United Kingdom, the prevalence was 49% in adults aged 44 years. In Norway, the prevalence was 35.0% in adults aged 20 to 25 years.78 In Australia, the prevalence was 15.0% in adults aged 40 to 97 years.79

Back to Top | Article Outline

Prevalence of High Myopia

The prevalence of high myopia can be estimated at approximately 20% to 24% of the myopia prevalence in adults.23,43 Early onset of myopia is the most important predictor of high myopia later in life.80 Myopia prevalence is considerably high, especially in Asian countries with myopia epidemics. In college freshmen in Taiwan, high myopia increased from 26% among all types of myopia in 1988 to 40% in 2005.81 According to a national investigation, the prevalence of high myopia (>−6 D) in those 18 years of age increased from 10.9% in 1983 to 21% in 2000.11 A review estimated that in 2050 half of the global population (5 billion people) would be myopic, and one fifth of those (1 billion) would be considered highly myopic (>−5 D).8

Back to Top | Article Outline

PROGRESSION OF MYOPIA

After myopia onset, progression is fast in children. Younger children have greater myopia progression, and younger age is a significant risk factor for high myopia in the future.14,15 In general, myopia progression in Asian children is faster than in Western children.82 Previous studies showed progression of nearly −1 D per year in myopic Asian schoolchildren.5,6 In Finland, the myopia progression rate was −0.93 D annually in 8 year olds and −0.52 D in 13 year olds.83 Myopia progression declines with age and stabilizes after puberty.84 However, for adults with high myopia, because of the thin sclera, myopia will still progress with axial length elongated.85

Back to Top | Article Outline

RISK FACTORS

Decades ago, myopia prevalence was low, and it was primarily considered to be due to genetic factors, such as a very young child having high myopia within a highly myopic family showing the inheritance of myopia.86 Recently, because of myopia prevalence rapidly increasing in schools, there is debate regarding whether the cause of myopia is due to genetic or environmental factors.87,88 School myopia with low myopia onset is considered to be mainly determined by environmental risk factors.89 There might be some interaction between the 2 components. Myopia is also considered as a genetic susceptibility to environmental risk factors, meaning the genes responsible for growth of ocular components may be influenced by the environment in a person with low myopia.90,91

Back to Top | Article Outline

Genetics

There are 2 groups of myopia. One is congenital myopia or infantile-onset myopia, and the other is school myopia or juvenile-onset myopia. According to evolution, children with congenital or infantile poor vision could not survive in ancient times alongside the children with congenital myopia. Therefore, the genes for congenital myopia were not widely inherited, and the prevalence of congenital myopia is low, approximately 4% to 6%.92 The low prevalence in the global population is similar to other diseases of poor vision in early childhood, such as amblyopia and strabismus.

School myopia might not be caused mainly by genetics. In Taiwan between 1983 and 2000, the myopia prevalence of 7 year olds increased up to 7 times, and that for 12 year olds increased up to 2.4 times.43 A similar trend was reported in the United States between 1971 and 2004; over 30 years, the myopia prevalence in 12 to 17 year olds increased 2.6 times (from 12% to 31.2%).3 In Finland over 20 years, the prevalence rate almost doubled in 14 to 15 year olds.93 In Hong Kong, the odds of having myopia in grandparents’ are far less than for parents’ and children’s generations (0.06, 0.26, and 0.35, respectively). The genome change of a certain population would not be as quick as within several decades. A dramatic increase in the prevalence of myopia in the generation of Alaskan Eskimos first exposed to compulsory education and a “Westernized” environment during their childhood was observed.94,95 This suggests that environmental factors might contribute more in the development of myopia. However, the distribution of myopia differs among races and ethnic groups, and studies on parents with myopia and comparative studies in twins also support the notion that hereditary factors partly influence juvenile myopia development.96,97 Therefore, regarding the increase in myopia prevalence worldwide, the theory of gene-environment interaction suggests that a certain number of individuals may be genetically susceptible to myopia if exposed to certain environmental factors.

Previously, molecular genetic studies were obtained predominantly from family linkage analyses, families with 2 or more individuals with 6 D or more of myopia, and candidate gene studies.98,99 Recently genome-wide association studies and whole-exome sequencing studies have been conducted.100–103 Some genetic associations have been successfully replicated in populations, but some have not. More than 20 chromosomal loci and 100 gene variants have been reported to be associated with myopia.

Back to Top | Article Outline

Near Work

Near work activities, such as reading, writing, and computer use, have been suggested to be possibly responsible for the remarkable increase in the prevalence of myopia.104,105 Cohort studies showed that schoolchildren with incident myopia performed significantly more near work and had a greater increase in axial length.106,107 A meta-analysis shows that more time spent on near work activities was associated with higher odds of myopia. The odds of myopia increased by 2% for every 1 diopter-hour more of near work per week.108 Therefore, near work is a strong important risk factor of myopia. The severity of risk is according to the intensity, such as duration of continued reading and distance to the near objects.109 Because near work is inevitable for learning, breaks of certain durations and preventing close reading may reduce the risk of near work.

Back to Top | Article Outline

Screens of Computers and Handheld Devices

There has been a dramatic increase in the use of computers and mobile phones in recent years. Increased screen time may be associated with the development of myopia.66,110 Computer use induces asthenopia, but there is still no clear evidence of association with myopia development. Because of the long duration of looking at screens and blue light emission from LED screens, the risk of myopia development and blue light ocular hazards should be serious concerns, especially in children.111

Back to Top | Article Outline

Educational Stress

In the East, the educational system and stresses are different from the West. Eastern parents pay a lot of attention to the academic performance of children and encourage more time spent on near work. In contrast, Western parents pay more attention to physical education and encourage more outdoor activities. This difference might partly contribute to the high prevalence of myopia in the East.112–114 Morgan and Rose115 proposed that the extensive use of after-school tutorials and increasing educational loads are associated with high prevalence rates of myopia. An association with additional tutorial classes has also been reported in Singapore and Taiwan.116–118

Back to Top | Article Outline

PROTECTIVE FACTORS

Outdoor Activity

Outdoor activity has recently been recognized as a protective factor for myopia.119 It may even overcome the risk factor of myopic parents if children spend enough time outdoors per week.120 A meta-analysis showed that more time spent on outdoor activities was associated with lower odds of myopia. The odds of myopia decreased by 2% for every additional hour of time spent outdoors per week.121

The mechanism through which outdoor activity can help prevent the onset of myopia is still unclear. Brighter light might be a possible mechanism to protect against myopia.122,123 The “light-dopamine” theory is accepted as a possible mechanism. Increased light intensity during time spent outdoors can stimulate the retina to release dopamine, which could inhibit axial elongation of the eyeball.124–126 Myopia protection seems to be mainly from visible light, not UV light. Therefore, myopia prevention from time spent outdoors should be compatible with avoidance of UV exposure.

The outdoor activity, effective duration, frequency, and light intensity are still under investigation. There may be a threshold of 10 to 14 hours spent outdoors per week to prevent myopia onset.120,127 Intermittent bright light suppresses myopia more than continuous bright light in chickens.128 A randomized trial of schoolchildren in China showed that 40 minutes per day of outdoor activity decreased myopia onset by 9% after 3 years. In Taiwan, an interventional study showed that 80 minutes per day of intermittent outdoor activity decreased myopia onset by 9% after 1 year.

Back to Top | Article Outline

Hyperopia

One of the best ways to predict future myopia is based on cycloplegic refractive error. Children with +0.75 D (or more) of hyperopia are less likely to become myopic.129,130 After myopia onset, the myopic shift is triggered, and the progression rate is approximately −1 D per year. Therefore, +0.75 D hyperopia or more might indicate less risk of myopia onset in the next year. A small study in Taiwan showed that 54% of premyopic children become myopic after 1 year.131

Back to Top | Article Outline

SUGGESTIONS TO ELIMINATE THE IMPACT OF MYOPIA

Prevention of Myopia Onset

For nonmyopic children, an annual cycloplegic refraction examination is suggested to monitor the baseline hyperopia refraction before myopia onset. Children should be encouraged to develop habits to reduce environmental risk factors, such as decreasing nonnecessary near work or increasing near work breaks, and strengthen protective factors, such as daily outdoor activities up to 2 hours per day. By delaying myopia onset as late as possible to the end of adolescence, high myopia status should seldom occur in adulthood.

Back to Top | Article Outline

Controlling Myopia Progression

For myopic children, progression is fast, and controlling myopia progression is important to prevent high myopia later in life. Annual cycloplegic refraction should be performed to determine the effect of myopia control. During this period, maintaining good lifestyle habits is not enough to slow myopia progression. Near work and outdoor activities had little meaningful clinical effects on the rate of myopia progression.64,132,133 In addition, the optic correction of spectacles can assist only temporarily in clearing vision in children. However, the manipulations of optic correction in spectacles, including undercorrection, full correction, multifocal or bifocal, are all unable to inhibit myopia progression.84,134,135

A meta-analysis shows that only atropine or orthokeratology can significantly slow myopia progression.135 Bifocal soft contact lenses might have potential but are still under investigation. However, the adverse effects of the 2 proven effective treatments should be decreased as much as possible. For atropine treatment, the concern of phototoxicity from pupil dilation can be solved by using low-concentration atropine, which achieves similar myopia-controlling effects as high concentrations.136–138 For orthokeratology treatment, the greatest concern is microbial infection, inducing corneal ulcers.139–142 During initial wearing of the corneal reshaping lens, superficial keratitis is common. Frequent prompt follow-up and topical antibiotics are often necessary. Hygienic care of orthokeratology lenses and the storage case to decrease microbial load are important.143–146 Because of corneal reshaping resulting in difficulty of accurate refraction detection, annual axial length measurement to monitor myopia control is necessary.

Back to Top | Article Outline

Treatment for Complications

There have been recent advances in the treatment of complications of myopia. In presenile cataracts of myopia, phacoemulsification or femtosecond laser–assisted cataract surgery can achieve good results.147 Nonetheless, myopia is a significant risk factor for complications such as posterior capsule rupture and development of retinal detachment after cataract or Nd:YAG capsulotomy.148–150 Myopia is a known risk factor for glaucoma. A meta-analysis found myopia as a risk factor for glaucoma, with a pooled odds ratio of 1.92 and concluded that progressively higher myopia increases the likelihood of glaucoma.151 However, the diagnosis of glaucoma is still challenging.152,153 Early detection with prevention is important but is often overlooked.

Myopic CNV is the leading cause of CNV in young adults and results in poor visual outcomes after long-term follow-up.154 Recently, intravitreal injection of anti–vascular endothelial growth factor has become the first-line therapy for myopic CNV and overall achieves good visual outcomes.155 Myopia is a well-known risk factor for retinal detachment. It often presents with severe forms of retinal detachment, such as macular hole retinal detachment (MHRD) or giant retinal tears. Aside from traditional surgeries such as scleral buckling and/or vitrectomy for MHRD, there are several novel methods to assist in retinal attachment, such as inverted internal limiting membrane insertion, lens capsule flap, and internal limiting membrane reposition covered by autologous blood.156–159 For myopic staphyloma–accompanied complications such as foveoschisis or fovea detachment, vitrectomy and/or macular buckling might achieve certain positive results.160

Macular atrophy in myopia often develops in cases of extremely high myopia or myopia with older age. Because of retinal and choroidal degeneration, there is still no good way to treat or prevent this development. However, there is a new international classification to facilitate communication, which helps compare findings from clinical trials and epidemiological studies, to accelerate the development of possible treatments.161

Back to Top | Article Outline

CONCLUSIONS

The tide of myopia is coming along with the consequences it will bring. Not only is the treatment of myopia complicated, but also prevention is more important. Although the mystery of myopia is still shrouded, evidence-based medicine helps us more clearly identify the risk factors, protectors, and treatments. Outdoor activity is a simple, free, and effective method to prevent myopia onset. Widespread outdoor activity is recommended to overcome the large amount of near work in the coming era of handheld devices. Low-concentration atropine and orthokeratology make school myopia controllable. Anti–vascular endothelial growth factor is becoming the choice for myopic CNV treatment. However, there are still many incurable myopia complications. Epidemiology shows us that myopia has become the leading irreversible cause of blindness in East Asian countries, and it will be in more countries in the future. Intercountry organizations for eye health, such as the World Health Organization or Asia-Pacific Academy of Ophthalmology, are encouraged to raise awareness of the threat of myopia and organize committees to establish guidelines for myopia prevention and treatment.

Back to Top | Article Outline

REFERENCES

1. Liang YB, Wong TY, Sun LP, et al. Refractive errors in a rural Chinese adult population: the Handan Eye Study. Ophthalmology. 2009;116:2119–2127.
2. Lin LL, Shih YF, Hsiao CK, et al. Epidemiologic study of the prevalence and severity of myopia among schoolchildren in Taiwan in 2000. J Formos Med Assoc. 2001;100:684–691.
3. Vitale S, Sperduto RD, Ferris FL 3rd. Increased prevalence of myopia in the United States between 1971–1972 and 1999–2004. Arch Ophthalmol. 2009;127:1632–1639.
4. Saw SM, Carkeet A, Chia KS, et al. Component dependent risk factors for ocular parameters in Singapore Chinese children. Ophthalmology. 2002;109:2065–2071.
5. Shih YF, Chen CH, Chou AC, et al. Effects of different concentrations of atropine on controlling myopia in myopic children. J Ocul Pharmacol Ther. 1999;15:85–90.
6. Tan DT, Lam DS, Chua WH, et al. One-year multicenter, double-masked, placebo-controlled, parallel safety and efficacy study of 2% pirenzepine ophthalmic gel in children with myopia. Ophthalmology. 2005;112:84–91.
7. Wong TY, Foster PJ, Hee J, et al. Prevalence and risk factors for refractive errors in adult Chinese in Singapore. Invest Ophthalmol Vis Sci. 2000;41:2486–2494.
8. Hsu WM, Cheng CY, Liu JH, et al. Prevalence and causes of visual impairment in an elderly Chinese population in Taiwan: the Shihpai Eye Study. Ophthalmology. 2004;111:62–69.
9. Iwase A, Araie M, Tomidokoro A, et al. Prevalence and causes of low vision and blindness in a Japanese adult population: the Tajimi Study. Ophthalmology. 2006;113:1354–1362.
10. Xu L, Wang Y, Li Y, et al. Causes of blindness and visual impairment in urban and rural areas in Beijing: the Beijing Eye Study. Ophthalmology. 2006;113:1134. e1–1134.e11.
11. Pruett RC. Complications associated with posterior staphyloma. Curr Opin Ophthalmol. 1998;9:16–22.
12. Saw SM, Gazzard G, Shih-Yen EC, et al. Myopia and associated pathological complications. Ophthalmic Physiol Opt. 2005;25:381–391.
13. Saw SM. How blinding is pathological myopia? Br J Ophthalmol. 2006;90:525–526.
14. Gwiazda J, Hyman L, Dong LM, et al. Factors associated with high myopia after 7 years of follow-up in the Correction of Myopia Evaluation Trial (COMET) cohort. Ophthalmic Epidemiol. 2007;14:230–237.
15. Saw SM, Tong L, Chua WH, et al. Incidence and progression of myopia in Singaporean school children. Invest Ophthalmol Vis Sci. 2005;46:51–57.
16. Adams AJBW, Biederman I, Curtin BJ, et al. Myopia: Prevalence and Progression. Washington, DC: National Academy Press; 1989:45–46.
17. Tan NW, Saw SM, Lam DS, et al. Temporal variations in myopia progression in Singaporean children within an academic year. Optom Vis Sci. 2000;77:465–472.
18. Goss DA, Winkler RL. Progression of myopia in youth: age of cessation. Am J Optom Physiol Opt. 1983;60:651–658.
19. Braun CI, Freidlin V, Sperduto RD, et al. The progression of myopia in school age children: data from the Columbia Medical Plan. Ophthalmic Epidemiol. 1996;3:13–21.
20. Jensen H. Myopia in teenagers. An eight-year follow-up study on myopia progression and risk factors. Acta Ophthalmol Scand. 1995;73:389–393.
21. Liang CL, Yen E, Su JY, et al. Impact of family history of high myopia on level and onset of myopia. Invest Ophthalmol Vis Sci. 2004;45:3446–3452.
22. Zheng YF, Pan CW, Chay J, et al. The economic cost of myopia in adults aged over 40 years in Singapore. Invest Ophthalmol Vis Sci. 2013;54:7532–7537.
23. Holden BA, Fricke TR, Wilson DA, et al. Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmology. 2016;123:1036–1042.
24. McBrien NA. Regulation of scleral metabolism in myopia and the role of transforming growth factor-beta. Exp Eye Res. 2013;114:128–140.
25. McBrien NA, Gentle A. Role of the sclera in the development and pathological complications of myopia. Prog Retin Eye Res. 2003;22:307–338.
26. Schaeffel F, Feldkaemper M. Animal models in myopia research. Clin Exp Optom. 2015;98:507–517.
27. Hung LF, Ramamirtham R, Huang J, et al. Peripheral refraction in normal infant rhesus monkeys. Invest Ophthalmol Vis Sci. 2008;49:3747–3757.
28. Ashby R. Animal studies and the mechanism of myopia—protection by light? Optom Vis Sci. 2016;93:1052–1054.
29. Norton TT. What do animal studies tell us about the mechanism of myopia—protection by light? Optom Vis Sci. 2016;93:1049–1051.
30. Mayer DL, Hansen RM, Moore BD, et al. Cycloplegic refractions in healthy children aged 1 through 48 months. Arch Ophthalmol. 2001;119:1625–1628.
31. McBrien NA, Barnes DA. A review and evaluation of theories of refractive error development. Ophthalmic Physiol Opt. 1984;4:201–213.
32. Benjamin B, Davey JB, Sheridan M, et al. Emmetropia and its aberrations; a study in the correlation of the optical components of the eye. Spec Rep Ser Med Res Counc (G B). 1957;11:1–69.
33. Morgan IG, Ohno-Matsui K, Saw SM. Myopia. Lancet. 2012;379:1739–1748.
34. Flitcroft DI. Is myopia a failure of homeostasis? Exp Eye Res. 2013;114:16–24.
35. Curtin BJ. The Myopias: Basic Science and Clinical Management. Harper and Row: Philadelphia, PA; 1985.
36. Khurana AK, Ahluwalia BK, Rajan C. Status of cyclopentolate as a cycloplegic in children: a comparison with atropine and homatropine. Acta Ophthalmol. 1988;66:721–724.
37. Manny RE, Hussein M, Scheiman M, et al. Tropicamide (1%): an effective cycloplegic agent for myopic children. Invest Ophthalmol Vis Sci. 2001;42:1728–1735.
38. Mutti DO, Zadnik K, Egashira S, et al. The effect of cycloplegia on measurement of the ocular components. Invest Ophthalmol Vis Sci. 1994;35:515–527.
39. Zhao J, Mao J, Luo R, et al. Accuracy of noncycloplegic autorefraction in school-age children in China. Optom Vis Sci. 2004;81:49–55.
40. Fotedar R, Rochtchina E, Morgan I, et al. Necessity of cycloplegia for assessing refractive error in 12-year-old children: a population-based study. Am J Ophthalmol. 2007;144:307–309.
41. Meng W, Butterworth J, Malecaze F, et al. Axial length of myopia: a review of current research. Ophthalmologica. 2011;225:127–134.
42. Percival SP. Redefinition of high myopia: the relationship of axial length measurement to myopic pathology and its relevance to cataract surgery. Dev Ophthalmol. 1987;14:42–46.
43. Lin LL, Shih YF, Hsiao CK, et al. Prevalence of myopia in Taiwanese schoolchildren: 1983 to 2000. Ann Acad Med Singapore. 2004;33:27–33.
44. Dirani M, Chan YH, Gazzard G, et al. Prevalence of refractive error in Singaporean Chinese children: the Strabismus, Amblyopia, and Refractive Error in Young Singaporean Children (STARS) Study. Invest Ophthalmol Vis Sci. 2010;51:1348–1355.
45. Fan DS, Lam DS, Lam RF, et al. Prevalence, incidence, and progression of myopia of school children in Hong Kong. Invest Ophthalmol Vis Sci. 2004;45:1071–1075.
46. Yoon KC, Mun GH, Kim SD, et al. Prevalence of eye diseases in South Korea: data from the Korea National Health and Nutrition Examination Survey 2008–2009. Korean J Ophthalmol. 2011;25:421–433.
47. He M, Zeng J, Liu Y, et al. Refractive error and visual impairment in urban children in southern China. Invest Ophthalmol Vis Sci. 2004;45:793–799.
48. He M, Huang W, Zheng Y, et al. Refractive error and visual impairment in school children in rural southern China. Ophthalmology. 2007;114:374–382.
49. Zhao J, Pan X, Sui R, et al. Refractive error study in children: results from Shunyi District, China. Am J Ophthalmol. 2000;129:427–435.
50. Dandona R, Dandona L, Srinivas M, et al. Refractive error in children in a rural population in India. Invest Ophthalmol Vis Sci. 2002;43:615–622.
51. Murthy GV, Gupta SK, Ellwein LB, et al. Refractive error in children in an urban population in New Delhi. Invest Ophthalmol Vis Sci. 2002;43:623–631.
52. Pokharel GP, Negrel AD, Munoz SR, et al. Refractive error study in children: results from Mechi Zone, Nepal. Am J Ophthalmol. 2000;129:436–444.
53. Sapkota YD, Adhikari BN, Pokharel GP, et al. The prevalence of visual impairment in school children of upper-middle socioeconomic status in Kathmandu. Ophthalmic Epidemiol. 2008;15:17–23.
54. Ojaimi E, Rose KA, Morgan IG, et al. Distribution of ocular biometric parameters and refraction in a population-based study of Australian children. Invest Ophthalmol Vis Sci. 2005;46:2748–2754.
55. Ip JM, Huynh SC, Robaei D, et al. Ethnic differences in refraction and ocular biometry in a population-based sample of 11–15-year-old Australian children. Eye (Lond). 2008;22:649–656.
56. Zadnik K. The Glenn A. Fry Award Lecture (1995). Myopia development in childhood. Optom Vis Sci. 1997;74:603–608.
57. Kleinstein RN, Jones LA, Hullett S, et al. Refractive error and ethnicity in children. Arch Ophthalmol. 2003;121:1141–1147.
58. Maul E, Barroso S, Munoz SR, et al. Refractive error study in children: results from La Florida, Chile. Am J Ophthalmol. 2000;129:445–454.
59. O’Donoghue L, McClelland JF, Logan NS, et al. Refractive error and visual impairment in school children in Northern Ireland. Br J Ophthalmol. 2010;94:1155–1159.
60. Villarreal MG, Ohlsson J, Abrahamsson M, et al. Myopisation: the refractive tendency in teenagers. Prevalence of myopia among young teenagers in Sweden. Acta Ophthalmol Scand. 2000;78:177–181.
61. Plainis S, Moschandreas J, Nikolitsa P, et al. Myopia and visual acuity impairment: a comparative study of Greek and Bulgarian school children. Ophthalmic Physiol Opt. 2009;29:312–320.
62. Naidoo KS, Raghunandan A, Mashige KP, et al. Refractive error and visual impairment in African children in South Africa. Invest Ophthalmol Vis Sci. 2003;44:3764–3770.
63. He M, Xiang F, Zeng Y, et al. Effect of time spent outdoors at school on the development of myopia among children in China: a randomized clinical trial. JAMA. 2015;314:1142–1148.
64. Wu PC, Tsai CL, Wu HL, et al. Outdoor activity during class recess reduces myopia onset and progression in school children. Ophthalmology. 2013;120:1080–1085.
65. French AN, Morgan IG, Burlutsky G, et al. Prevalence and 5- to 6-year incidence and progression of myopia and hyperopia in Australian schoolchildren. Ophthalmology. 2013;120:1482–1491.
66. Lee YY, Lo CT, Sheu SJ, et al. What factors are associated with myopia in young adults? A survey study in Taiwan military conscripts. Invest Ophthalmol Vis Sci. 2013;54:1026–1033.
67. Cheng CY, Hsu WM, Liu JH, et al. Refractive errors in an elderly Chinese population in Taiwan: the Shihpai Eye Study. Invest Ophthalmol Vis Sci. 2003;44:4630–4638.
68. Xu L, Li J, Cui T, et al. Refractive error in urban and rural adult Chinese in Beijing. Ophthalmology. 2005;112:1676–1683.
69. Sawada A, Tomidokoro A, Araie M, et al. Refractive errors in an elderly Japanese population: the Tajimi Study. Ophthalmology. 2008;115:363–370. e3.
70. Krishnaiah S, Srinivas M, Khanna RC, et al. Prevalence and risk factors for refractive errors in the South Indian adult population: the Andhra Pradesh Eye Disease Study. Clin Ophthalmol. 2009;3:17–27.
71. Saw SM, Chan YH, Wong WL, et al. Prevalence and risk factors for refractive errors in the Singapore Malay Eye Survey. Ophthalmology. 2008;115:1713–1719.
72. Pan CW, Wong TY, Lavanya R, et al. Prevalence and risk factors for refractive errors in Indians: the Singapore Indian Eye Study (SINDI). Invest Ophthalmol Vis Sci. 2011;52:3166–3173.
73. Bourne RR, Dineen BP, Ali SM, et al. Prevalence of refractive error in Bangladeshi adults: results of the National Blindness and Low Vision Survey of Bangladesh. Ophthalmology. 2004;111:1150–1160.
74. Shah SP, Jadoon MZ, Dineen B, et al. Refractive errors in the adult Pakistani population: the national blindness and visual impairment survey. Ophthalmic Epidemiol. 2008;15:183–190.
75. Saw SM, Gazzard G, Koh D, et al. Prevalence rates of refractive errors in Sumatra, Indonesia. Invest Ophthalmol Vis Sci. 2002;43:3174–3180.
76. Wickremasinghe S, Foster PJ, Uranchimeg D, et al. Ocular biometry and refraction in Mongolian adults. Invest Ophthalmol Vis Sci. 2004;45:776–783.
77. Vitale S, Ellwein L, Cotch MF, et al. Prevalence of refractive error in the United States, 1999–2004. Arch Ophthalmol. 2008;126:1111–1119.
78. Midelfart A, Kinge B, Midelfart S, et al. Prevalence of refractive errors in young and middle-aged adults in Norway. Acta Ophthalmol Scand. 2002;80:501–505.
79. Attebo K, Ivers RQ, Mitchell P. Refractive errors in an older population: the Blue Mountains Eye Study. Ophthalmology. 1999;106:1066–1072.
80. Chua SY, Sabanayagam C, Cheung YB, et al. Age of onset of myopia predicts risk of high myopia in later childhood in myopic Singapore children. Ophthalmic Physiol Opt. 2016;36:388–394.
81. Wang TJ, Chiang TH, Wang TH, et al. Changes of the ocular refraction among freshmen in National Taiwan University between 1988 and 2005. Eye. 2009;23:1168–1169.
82. Donovan L, Sankaridurg P, Ho A, et al. Myopia progression rates in urban children wearing single-vision spectacles. Optom Vis Sci. 2012;89:27–32.
83. Mantyjarvi M. Refraction Changes and Vision Disorders in Finnish School Children. Kuopio, Finland: Publ of the University of Kuopio Medicine; 1986:48–49.
84. Medina A. The progression of corrected myopia. Graefes Arch Clin Exp Ophthalmol. 2015;253:1273–1277.
85. Saka N, Ohno-Matsui K, Shimada N, et al. Long-term changes in axial length in adult eyes with pathologic myopia. Am J Ophthalmol. 2010;150:562–568. e1.
86. Guggenheim JA, Kirov G, Hodson SA. The heritability of high myopia: a reanalysis of Goldschmidt’s data. J Med Genet. 2000;37:227–231.
87. Mutti DO, Zadnik K, Adams AJ. Myopia. The nature versus nurture debate goes on. Invest Ophthalmol Vis Sci. 1996;37:952–957.
88. Goldschmidt E. The mystery of myopia. Acta Ophthalmol Scand. 2003;81:431–436.
89. Morgan I, Rose K. How genetic is school myopia? Prog Retin Eye Res. 2005;24:1–38.
90. Goldschmidt E. The importance of heredity and environment in the etiology of low myopia. Acta Ophthalmol. 1981;59:759–762.
91. Saw SM, Katz J, Schein OD, et al. Epidemiology of myopia. Epidemiol Rev. 1996;18:175–187.
92. Curtin BJ. The pathogenesis of congenital myopia. A study of 66 cases. Arch Ophthalmol. 1963;6:166–173.
93. Parssinen O. The increased prevalence of myopia in Finland. Acta Ophthalmol. 2012;90:497–502.
94. Young FA, Leary GA, Baldwin WR, et al. The transmission of refractive errors within Eskimo families. Am J Optom Arch Am Acad Optom. 1969;46:676–685.
95. Young FA, Leary GA, Baldwin WR, et al. Refractive errors, reading performance, and school achievement among Eskimo children. Am J Optom Arch Am Acad Optom. 1970;47:384–390.
96. Mutti DO, Mitchell GL, Moeschberger ML, et al. Parental myopia, near work, school achievement, and children’s refractive error. Invest Ophthalmol Vis Sci. 2002;43:3633–3640.
97. Chen CJ, Cohen BH, Diamond EL. Genetic and environmental effects on the development of myopia in Chinese twin children. Ophthalmic Paediatr Genet. 1985;6:353–359.
98. Young TL, Metlapally R, Shay AE. Complex trait genetics of refractive error. Arch Ophthalmol. 2007;125:38–48.
99. Rong SS, Chen LJ, Pang CP. Myopia genetics—the Asia-Pacific perspective. Asia Pac J Ophthalmol (Phila). 2016;5:236–244.
100. Zhang Q. Genetics of refraction and myopia. Prog Mol Biol Transl Sci. 2015;134:269–279.
101. Tideman JW, Fan Q, Polling JR, et al. When do myopia genes have their effect? Comparison of genetic risks between children and adults. Genet Epidemiol. September 9, 2016. [Epub ahead of print].
102. Fan Q, Guo X, Tideman JW, et al. Childhood gene-environment interactions and age-dependent effects of genetic variants associated with refractive error and myopia: the CREAM Consortium. Sci Rep. 2016;6:25853.
103. Hysi PG, Wojciechowski R, Rahi JS, et al. Genome-wide association studies of refractive error and myopia, lessons learned, and implications for the future. Invest Ophthalmol Vis Sci. 2014;55:3344–3351.
104. Saw SM, Chua WH, Hong CY, et al. Nearwork in early-onset myopia. Invest Ophthalmol Vis Sci. 2002;43:332–339.
105. Ip JM, Huynh SC, Robaei D, et al. Ethnic differences in the impact of parental myopia: findings from a population-based study of 12-year-old Australian children. Invest Ophthalmol Vis Sci. 2007;48:2520–2528.
106. French AN, Morgan IG, Mitchell P, et al. Risk factors for incident myopia in Australian schoolchildren: the Sydney Adolescent Vascular and Eye Study. Ophthalmology. 2013;120:2100–2108.
107. Woodman EC, Read SA, Collins MJ, et al. Axial elongation following prolonged near work in myopes and emmetropes. Br J Ophthalmol. 2011;95:652–656.
108. Huang HM, Chang DS, Wu PC. The association between near work activities and myopia in children—a systematic review and meta-analysis. PLoS One. 2015;10:e0140419.
109. 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;49:2903–2910.
110. Qian DJ, Zhong H, Li J, et al. Myopia among school students in rural China (Yunnan). Ophthalmic Physiol Opt. 2016;36:381–387.
111. Behar-Cohen F, Martinsons C, Vienot F, et al. Light-emitting diodes (LED) for domestic lighting: any risks for the eye? Prog Retin Eye Res. 2011;30:239–257.
112. Chen H. Parents’ attitudes and expectations regarding science education: comparisons among American, Chinese-American, and Chinese families. Adolescence. 2001;36:305–313.
113. Qin DB, Chang TF, Han EJ, et al. Conflicts and communication between high-achieving Chinese American adolescents and their parents. New Dir Child Adolesc Dev. 2012;2012:35–57.
114. Saw A, Berenbaum H, Okazaki S. Influences of personal standards and perceived parental expectations on worry for Asian American and white American college students. Anxiety Stress Coping. 2013;26:187–202.
115. Morgan IG, Rose KA. Myopia and international educational performance. Ophthalmic Physiol Opt. 2013;33:329–338.
116. Saw SM, Wu HM, Seet B, et al. Academic achievement, close up work parameters, and myopia in Singapore military conscripts. Br J Ophthalmol. 2001;85:855–860.
117. Tan GJ, Ng YP, Lim YC, et al. Cross-sectional study of near-work and myopia in kindergarten children in Singapore. Ann Acad Med Singapore. 2000;29:740–744.
118. Hsu CC, Huang N, Lin PY, et al. Prevalence and risk factors for myopia in second-grade primary school children in Taipei: a population-based study. J Chin Med Assoc. June 24, 2016. [Epub ahead of print].
119. Rose KA, Morgan IG, Ip J, et al. Outdoor activity reduces the prevalence of myopia in children. Ophthalmology. 2008;115:1279–1285.
120. Jones LA, Sinnott LT, Mutti DO, et al. Parental history of myopia, sports and outdoor activities, and future myopia. Invest Ophthalmol Vis Sci. 2007;48:3524–3532.
121. Sherwin JC, Reacher MH, Keogh RH, et al. The association between time spent outdoors and myopia in children and adolescents: a systematic review and meta-analysis. Ophthalmology. 2012;119:2141–2151.
122. Ashby R, Ohlendorf A, Schaeffel F. The effect of ambient illuminance on the development of deprivation myopia in chicks. Invest Ophthalmol Vis Sci. 2009;50:5348–5354.
123. Smith EL 3rd, Hung LF, Huang J. Protective effects of high ambient lighting on the development of form-deprivation myopia in rhesus monkeys. Invest Ophthalmol Vis Sci;53:421–428.
124. Ashby RS, Schaeffel F. The effect of bright light on lens compensation in chicks. Invest Ophthalmol Vis Sci. 2010;51:5247–5253.
125. Mao J, Liu S, Qin W, et al. Levodopa inhibits the development of form-deprivation myopia in guinea pigs. Optom Vis Sci. 2010;87:53–60.
126. French AN, Ashby RS, Morgan IG, et al. Time outdoors and the prevention of myopia. Exp Eye Res. 2013;114:58–68.
127. Rose KA, Morgan IG, Smith W, et al. Myopia, lifestyle, and schooling in students of Chinese ethnicity in Singapore and Sydney. Arch Ophthalmol. 2008;126:527–530.
128. Lan W, Feldkaemper M, Schaeffel F. Intermittent episodes of bright light suppress myopia in the chicken more than continuous bright light. PLoS One. 2014;9:e110906.
129. Zadnik K, Mutti DO, Friedman NE, et al. Ocular predictors of the onset of juvenile myopia. Invest Ophthalmol Vis Sci. 1999;40:1936–1943.
130. Zadnik K, Sinnott LT, Cotter SA, et al. Prediction of juvenile-onset myopia. JAMA Ophthalmol. 2015;133:683–689.
131. Fang PC, Chung MY, Yu HJ, et al. Prevention of myopia onset with 0.025% atropine in premyopic children. J Ocul Pharmacol Ther. 2010;26:341–345.
132. Scheiman M, Zhang Q, Gwiazda J, et al. Visual activity and its association with myopia stabilisation. Ophthalmic Physiol Opt. 2014;34:353–361.
133. Jones-Jordan LA, Sinnott LT, Cotter SA, et al. Time outdoors, visual activity, and myopia progression in juvenile-onset myopes. Invest Ophthalmol Vis Sci. 2012;53:7169–7175.
134. Cooper J, Schulman E, Jamal N. Current status on the development and treatment of myopia. Optometry. 2012;83:179–199.
135. Walline JJ, Lindsley K, Vedula SS, et al. Interventions to slow progression of myopia in children. Cochrane Database Syst Rev. 2011:CD004916.
136. Chia A, Lu QS, Tan D. Five-year clinical trial on Atropine for the Treatment of Myopia 2: myopia control with atropine 0.01% eyedrops. Ophthalmology. 2016;123:391–399.
137. Chia A, Chua WH, Cheung YB, et al. Atropine for the treatment of childhood myopia: safety and efficacy of 0.5%, 0.1%, and 0.01% doses (Atropine for the Treatment of Myopia 2). Ophthalmology. 2012;119:347–354.
138. Wu PC, Yang YH, Fang PC. The long-term results of using low-concentration atropine eye drops for controlling myopia progression in schoolchildren. J Ocul Pharmacol Ther. 2011;27:461–466.
139. Lee YS, Tan HY, Yeh LK, et al. Pediatric microbial keratitis in Taiwan: clinical and microbiological profiles, 1998–2002 versus 2008–2012. Am J Ophthalmol. 2014;157:1090–1096.
140. Watt K, Swarbrick HA. Microbial keratitis in overnight orthokeratology: review of the first 50 cases. Eye Contact Lens. 2005;31:201–208.
141. Young AL, Leung KS, Tsim N, et al. Risk factors, microbiological profile, and treatment outcomes of pediatric microbial keratitis in a tertiary care hospital in Hong Kong. Am J Ophthalmol. 2013;156:1040–1044. e2.
142. Chan TC, Li EY, Wong VW, et al. Orthokeratology-associated infectious keratitis in a tertiary care eye hospital in Hong Kong. Am J Ophthalmol. 2014;158:1130–1135. e2.
143. Lo J, Fang PC, Chien CC, et al. PCR analysis for assessment of bacterial bioburden in orthokeratology lens cases. Mol Vis. 2016;22:1–8.
144. Fang PC, Lo J, Chang TC, et al. Bacterial bioburden decrease in orthokeratology lens storage cases after forewarning: assessment by the DNA dot hybridization assay. Eye Contact Lens. February 8, 2016. [Epub ahead of print].
145. Lo J, Kuo MT, Chien CC, et al. Microbial bioburden of orthokeratology contact lens care system. Eye Contact Lens. 2016;42:61–67.
146. Kuo MT, Chien CC, Lo J, et al. A DNA dot hybridization model for assessment of bacterial bioburden in orthokeratology lens storage cases. Invest Ophthalmol Vis Sci. 2015;56:445–450.
147. Lam JK, Chan TC, Ng AL, et al. Outcomes of cataract operations in extreme high axial myopia. Graefes Arch Clin Exp Ophthalmol. 2016;254:1811–1817.
148. Lin JY, Ho WL, Ger LP, et al. Analysis of factors correlated with the development of pseudophakic retinal detachment—a long-term study in a single medical center. Graefes Arch Clin Exp Ophthalmol. 2013;251:459–465.
149. Sheu SJ, Ger LP, Ho WL. Late increased risk of retinal detachment after cataract extraction. Am J Ophthalmol. 2010;149:113–119.
150. Fritch CD. Risk of retinal detachment in myopic eyes after intraocular lens implantation: a 7 year study. J Cataract Refract Surg. 1998;24:1357–1360.
151. Marcus MW, de Vries MM, Junoy Montolio FG, et al. Myopia as a risk factor for open-angle glaucoma: a systematic review and meta-analysis. Ophthalmology. 2011;118:1989–1994.e2.
152. Chang RT, Singh K. Myopia and glaucoma: diagnostic and therapeutic challenges. Curr Opin Ophthalmol. 2013;24:96–101.
153. Hsu CH, Chen RI, Lin SC. Myopia and glaucoma: sorting out the difference. Curr Opin Ophthalmol. 2015;26:90–95.
154. Yoshida T, Ohno-Matsui K, Yasuzumi K, et al. Myopic choroidal neovascularization: a 10-year follow-up. Ophthalmology. 2003;110:1297–1305.
155. Wang E, Chen Y. Intravitreal anti–vascular endothelial growth factor for choroidal neovascularization secondary to pathologic myopia: systematic review and meta-analysis. Retina. 2013;33:1375–1392.
156. Chen SN, Yang CM. Lens capsular flap transplantation in the management of refractory macular hole from multiple etiologies. Retina. 2016;36:163–170.
157. Chen SN, Yang CM. Inverted internal limiting membrane insertion for macular hole–associated retinal detachment in high myopia. Am J Ophthalmol. 2016;166:211.
158. Lai CC, Chen YP, Wang NK, et al. Vitrectomy with internal limiting membrane repositioning and autologous blood for macular hole retinal detachment in highly myopic eyes. Ophthalmology. 2015;122:1889–1898.
159. Ortisi E, Avitabile T, Bonfiglio V. Surgical management of retinal detachment because of macular hole in highly myopic eyes. Retina. 2012;32:1704–1718.
160. Gohil R, Sivaprasad S, Han LT, et al. Myopic foveoschisis: a clinical review. Eye. 2015;29:593–601.
161. Ohno-Matsui K, Kawasaki R, Jonas JB, et al. International photographic classification and grading system for myopic maculopathy. Am J Ophthalmol. 2015;159:877–883.e7.

The best and most beautiful things in the world cannot be seen or even touched – they must be felt with the heart.

— Helen Keller

Figure

Figure

Keywords:

epidemiology; myopia

© 2016 by Asia Pacific Academy of Ophthalmology