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Current Eye Research

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Family history and reading habits in adult-onset myopia

Rafael Iribarren; Guillermo Iribarren; Maria M. Castagnola; Alejandra Balsa; Mario
R. Cerrella; Alejandro Armesto; Andrea Fornaciari; Toms Pfrtner
First Published on: 01 November 2002
To cite this Article: Iribarren, Rafael, Iribarren, Guillermo, Castagnola, Maria M.,
Balsa, Alejandra, Cerrella, Mario R., Armesto, Alejandro, Fornaciari, Andrea and
Pfrtner, Toms , (2002) 'Family history and reading habits in adult-onset myopia',
Current Eye Research, 25:5, 309 - 315
To link to this article: DOI: 10.1076/ceyr.25.5.309.13494
URL: http://dx.doi.org/10.1076/ceyr.25.5.309.13494

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Current Eye Research

2002, Vol. 25, No. 5, pp. 309315

0271-3683/02/2505-309$16.00
Swets & Zeitlinger

Family history and reading habits in adult-onset myopia

Rafael Iribarren1, Guillermo Iribarren1, Maria M. Castagnola1, Alejandra Balsa1, Mario R. Cerrella1, Alejandro Armesto1,
Andrea Fornaciari2 and Toms Pfrtner 3
Depto. de Oftalmologa, Centro Mdico San Luis, Buenos Aires; 2Facultad de Ciencias Jurdicas, Universidad del Salvador,
Buenos Aires; 3Laboratorio Pfrtner-Cornealent, Buenos Aires, Argentina
1

Abstract
Purpose. A retrospective study was developed to evaluate
risk factors in adult-onset myopia.
Methods. Subjects included were 25 to 35 years old. There
were 116 non-myopic subjects in the control group and 66
myopic subjects with first lens prescription at age 17 or later.
Subjects received a questionnaire about academic achievement, daily hours of reading during years of study, and family
history of myopia.
Results. The level of academic achievement was similar for
myopic and non-myopic groups in this sample. Myopia was
associated with family history (c2 = 6.131, p 0.013) and
with daily hours of reading during years of study (c2 = 3.904,
p 0.048). According to multiple logistic regression analysis, the correlation of myopia with family history adjusted
for daily hours of reading remained significant (p 0.005),
whereas the correlation with daily hours of reading adjusted
for family history was not significant (p 0.061).
Conclusions. After multivariate analysis, adult-onset myopia
was significantly associated only with family history of
myopia.
Keywords: adult-myopia; family history; nearwork

Introduction
Many papers have been published18 regarding prevalence,
evolution and risk factors of myopia development in children
and teenagers, because affected young people can be easily
located and followed through the years. Those studies have
clearly shown that myopia prevalence increases during child-

hood,24 and that family history5,79 and near-work5,7,1015 are

risk factors associated with myopia development. It has
also been reported that myopia prevalence is greater in
the city than in the countryside24,16,17 and that myopia is
associated with high family income and higher academic
achievement.1825
Population studies2531 have showed that myopia prevalence increases with age as new cases are developed, reaching a maximum in young adulthood. Recent work in Norway
by Kinge et al.,3233 and in Denmark by Fledelius26,34 clearly
showed the development of many new cases of myopia after
18 years of age. These new, adult-onset cases could account
for 50% of the prevalence in adulthood. Parssinenn in
Finland35 and Midelfart et al. in Norway36 obtained similar
data. Biometric studies32,3742 have shown that adult-onset
myopia is associated with increased axial length like youth
onset myopia. At least some of adult-onset myopes could
continue increasing refractive error in their late thirties.43
Recent studies have shown that myopia in adults increases
in association with intense nearwork.3233,42 On the other
hand, Bullimore et al.44 did not find any association of
myopia progression with near-work in a group of adult
contact lens users. No studies could be found concerning
family history in this type of myopia. The present retrospective study was developed to evaluate family history of
myopia and the amount of reading hours in subjects with
adult onset myopia.

Materials and methods

As recommended by Grosvenor45 we divide myopes into
youth-onset and adult-onset according to the age at which

Received: July 15, 2002

Accepted: November 20, 2002
Correspondence: Rafael Iribarren, Depto. de Oftalmologa, Centro Mdico San Luis, San Martn de Tours 2980, (1425) Buenos Aires,
Argentina. Tel/Fax: 54-11-4801-8050, E-mail: rafael@ar.inter.net

Downloaded By: [informa internal users] At: 16:02 5 July 2007

310

R. Iribarren et al.

their symptoms begin. This study was conducted in a

Caucasian population of diverse national origins, resident in
Buenos Aires, Argentina. These subjects of both sexes are
participants in prepaid health-care plans and belong to
a well-educated social class having high and medium
family incomes. We followed the tenets of the Declaration of
Helsinki. Subjects for the study were every consecutive
patient between 25 and 35 years of age who came for vision
examination in an ophthalmologists office from July to
November 2001, minus exclusions as detailed below. The
same five ophthalmologists performed all the ophthalmic
examinations. All subjects gave informed consent for the
investigation. They first received a questionnaire with the following questions: 1) How many years have you spent studying at University (after High School)?, 2) How many hours
a day, on average, did you spend reading in those study
years?. Then, myopia was defined with an indirect statement, as the need of lenses for far distance at a young age.
Finally, questions 3) and 4) queried whether father and
mother were myopic (possible answers were yes, no
or dont know). For testing the reliability of these last
two questions, a similar questionnaire was administered to
another group of 59 consecutive subjects who bought contact
lenses at an opticians shop. With the same definition of
myopia, this time we queried each subject whether he was
myopic, with the same three possible answers. Then, the lens
prescription (spherical equivalent) was registered, and thus
the accuracy of the responses was checked.
After each subject answered the four questions, the ophthalmologist (AA, AB, MC, MMC, RI), blind to the answers,
performed the ophthalmic examination. If the patient already
used lenses, a lensometer (Topcon) was used to measure
them for comparison with the actual refraction. Visual acuity
(VA) was obtained using projected Snellen optotypes at 3
meters distance (Topcon). If the patient did not have any previous correction, and reached a VA of 20/25 or better with
either eye, the examiner performed a fogging technique with
a +1 diopter lens to find latent hyperopia. If the patient then
perceived a slight blur in the 20/25 letters he was classified
in the control group; on the other hand, if he did not perceive
blur under fogging or said that he saw better, he was not
included in the study. Patients who were already using positive lenses for reading at this young age were considered
hyperopic and were not included. Also excluded were subjects with astigmatism greater than one diopter, those with
anisometropia greater than one diopter, those who presented
any form of strabismus, and those with best corrected VA
lower than 20/25 in either eye.
If the subject was myopic or could not see the 20/25 VA
line with either uncorrected eye, the examiner used the usual
subjective method to assess distance refractive state, with
trial frame, prescribing the least negative correction necessary to obtain 20/25 visual acuity in each eye. Myopia was
defined as having a myopic error of at least -0.75 diopters
(spherical equivalent) in either eye. The examiner asked the
myopic subjects at what age had they begun using lenses for

far distance. Adult-onset myopia was considered as the one

with onset at age 17 years or later, so 26 myopic subjects who
had their first prescription before age 17 years were excluded.
Thus, 116 subjects remained in the control group and 66
subjects in the myopic group. There were 78 females and
104 males. Both groups were matched by sex (c2 = 0.42,
p 0.52) and age (t-student test, p 0.66).
Regarding family history, subjects were considered positive if they answered that they had either one or two myopic
parents, subjects who answered no with regard to both
parents were considered negative, and subjects who answered
dont know with regard to both parents were considered
dont know responses as well as the ones who answered
no for one parent and dont know for the other.
The myopic and control groups were compared with
respect to family history, hours of reading and years of study.
As presence or absence of myopia is a dichotomous variable,
the continuous exposure variables (hours of reading and
years of study) were converted into dichotomous variables
(i.e., values above or below the median) to perform Chisquare univariate analysis. Then, multivariate analysis (logistic regression) was performed for the significant variables.
The median values for the sample were 6 years of study and
4 hours a day spent reading.

Results
There were 5 hyperopes and 54 myopes in the group of 59
contact lens buyers used for validating the family history
questionnaire. There were no dont know responses to
the question whether they were myopic or not. The myopes
reported their myopic condition accurately after reading our
definition of myopia, because we confirmed the presence of
myopic refractions in 53 out of 54 of them. The 5 hyperopes
were also accurate, as they all answered they were not myopic.
The mean age of onset of myopia for subjects in this study
(n = 66) was 22.06 4.15 years. Figure 1 displays the frequency of each age of myopia onset. The median refractive
error for the myopic group was -1.75 diopters for the right
eye (Fig. 2, range from -0.75 to -5.50). Table 1 shows the
results of univariate analysis. Myopia was found to be associated significantly with family history and with the number
of daily hours of reading, but the years of study were similar
in both groups (Fig. 3).
Regarding the question about family history, the incidence
of dont know responses was low: 18.1% in the control
group, and 4.55% in the myopic group (Fig. 4). The rate
of dont know responses was 11.3% for the whole
sample. A positive family history was present in 50% of the
myopic subjects in contrast with 26.72% of the control group
(Fig. 4).
The myopic group recalled, on average, almost one more
daily hour of reading than the control group (Fig. 5). As
myopia was found to be associated significantly with family
history and hours of reading, multiple logistic regression

Years of Study

Number of subjects

6
5
4
3
2
1
0
17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

9
8
7
6
5
4
3
2
1
0

311

8.11

7.91

5.72

5.68

3.34

3.45

Controls

Myopes

Age of first lens prescription

Figure 1. Number of subjects for each reported age of first lens

prescription, in years.
35

Figure 3. Average number of years of University study for both

myopic and control groups (standard deviations are represented by
the vertical bars).

100%

30
Number of Subjects

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Family history and reading habits in adult-onset myopia

80%

no family history

25

60%

20
15

40%

10

20%

0%

with family
history
'don't know'
response

controls

0
-4.75 to - -3.75 to - -2.75 to - -1.75 to - -0.75 to 5.5
4.5
3.5
2.5
1.50
Diopters of Spherical Equivalent (right eye)

Figure 2. Number of subjects for each refractive interval in

diopters (myopic group only).

myopes

Figure 4. Percentage of subjects with no family history of myopia

in white, and with at least one myopic parent in gray, for both
myopic and control groups (note the small rate of dont know
responses).

Table 1.
Univariate analysis
Family history vs. myopia
Daily hours of reading
vs. myopia
Years of study vs. myopia

c2

p-value

6.131
3.904

0.013
0.048

Significant
Significant

0.211

0.646

Not significant

analysis was performed. Table 2 shows that family history

adjusted for daily hours of reading remained significant, but
daily hours of reading adjusted for family history, lost significance. Therefore, the most important finding in this study
is a significant association of adult onset myopia with family
history of myopia.

Discussion
The people enrolled for this retrospective study came to a
general Ophthalmologic practice office with vision-related

Figure 5. Average number of reading hours during the study years

for both myopic and control groups (standard deviations are represented by the vertical bars).

symptoms such as headaches, for vision screening or lens

prescription. Most of our patients are older than 40 years of
age, with presbyopia and cataract as their main problems. It
took five months to gather this group of consecutive young
subjects among our patients. In Buenos Aires city, schoolaged children with refractive errors usually go to pediatric

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312

R. Iribarren et al.
Table 2.
Multivariate analysis
Family history adjusted for
daily hours of reading
Daily hours of reading adjusted
for family history

Odds-ratio

95% CI

p-value*

2368

(2.14.6)

0.005

Significant

1692

(0.93.23)

0.061

Not significant

* p-value obtained from multiple logistic regression.

ophthalmologists and remain with them as they grow older,

whereas adult-onset myopes usually go to general ophthalmologists when they need lens prescription. This may be the
reason why we found more adult-onset myopes than earlyonset myopes in our sampling.
Fledelius has shown that myopes remember accurately the
age of their first lens prescription.46 It is possible that we
found a high incidence of adult myopia because of delayed
reporting of lens prescription in subjects who develop
myopia slowly and begin lens use after a year or two of symptoms onset. The fact that some myopes in this sample had a
mean spherical equivalent greater than -3.75, and therefore
could be youth-onset myopes who had remained uncorrected
until they were adults, would be consistent with this possibility. However, some adult onset myopes can develop great
amounts of myopia, as indicated by the three subjects with
adult-onset myopia of more than -9 diopters included in the
study of Fedelius.46 In fact, the 10 most myopic subjects in
the present study had an average onset age of 19.7 years and
were 29.7 years old on average when interviewed. They could
easily have developed 4 diopters of myopia in ten years, at a
rate less than -0.50 diopters a year.
The sample has a high level of education (on average 6
years of study at the University). Since many epidemiological studies1825 have shown a higher prevalence of myopia
among well-educated people, we expected to confirm this in
our study, but no significant difference in years of study was
found between the two groups. This can be due to the fact
that the sample belongs to a high-income well-educated
population and not a general one, where one would expect
different levels of education. However, there was a significant difference in the amount of daily hours of reading
during University time: myopes read for more time than
non-myopes. This has been found previously in myopic
children7,11,1314 and military conscripts.5
Retrospective questionnaires are not very reliable because
of recall bias. But the subjects in this study were 25 to 35
years old, so they could remember easily what had happened
during their recent study years. The number of University
study years can be considered a reliable answer. On the contrary, the question about the average number of daily hours
of reading in study years, is likely to be a major source of
bias in this study. Subjects may blame their myopia on near
work, and this could lead to bias in the retrospective report-

ing of near-work habits. To avoid this type of bias, Rah

et al.47 have initiated a prospective study with objective
measurement of near-work activity.
Although students may spend significant time at near
work other than reading, this was the only near-work
task measured in the present study because previous
studies7,34 have showed that reading was the principal
near-work activity associated with myopic progression in
students.
The question about family history of myopia was performed in as reliable a manner as possible: by asking about
myopia after defining it as the need of lenses for far distance at a young age. This kind of question usually has
low rate of dont know response, as shown in a previous
study (8.9%)48 as well as the present one (11.3%). In the
non-myopic group there was a higher rate of dont know
answers, perhaps because these subjects, who were not using
lenses, may not have understood their parents ametropias
(Fig. 4). The fact that most contact lens buyers correctly identified their myopic condition, further confirms the reliability
of reporting of family history by myopes in our population.
It is also possible that our subjects sometimes classified high
hyperopic parents as myopes, simply because they wore corrective lenses of some kind. This last type of bias should be
small, because the prevalence of high hyperopia is very low
(for example, <10% in 15 year-old children in Chile,4 with a
population similar to ours).
Another possible bias against finding an association of
myopia with reading habits in this study, is the fact that in
11 out of the 66 myopes the age of onset was older than 25
years, after the usual period of University study. Subjects in
this group had studied on average 6 years, and their myopia
did not begin until after their years of study had ended.
Besides, some of the youngest subjects in the control group
(now classified as non-myopes) could become myopic in
the near future as a result of genetic or environmental risk
factors. However, as Figure 1 shows, most subjects had
their myopia onset at the same years of study addressed by
the question about reading habits. Therefore, we found an
interesting and significant association between incidence of
myopia development and number of reading hours during the
same stage of life. This association lost significance when
controlling by parental history of myopia, indicating that
the association was due to genetic factors or early rearing

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Family history and reading habits in adult-onset myopia

conditions rather than hours of reading per se. Besides, the
difference between amount of reading by the groups in the
present study was only about 1 hour per day, which seems to
be rather small. It might, however, be of significance over a
long academic study period.
The lower limit proposed for myopia here (-0.75 diopters
spherical equivalent in either eye) is the same used by Zadnik
et al.,7 better for us than the reference value of -0.50 used in
many other myopia studies. In fact, among the 116 subjects
in the control group, 14 had a spherical equivalent of -0.50,
and five of them did not use lenses at all. On the other hand,
in the myopic group, every subject used lenses. In other
words, if we had used a mean spherical equivalent criterion
of -0.50 diopters, we would have included asymptomatic
subjects not using lenses. Future studies could address the
question about which spherical equivalent cut off has clinical relevance.
This study does not compare emmetropes with myopes,
because a small number of hyperopic subjects who could
escape detection by the fogging technique may have been
included in the control group. Family history of hyperopia
is protective against myopia development in children.49 It
is possible that the significance of the difference that we
observed, between family histories of control and myopic
groups, could have been enhanced by the inclusion of some
hyperopic subjects in the control group.
The present study shows that adult-myopia is associated
with family history and reading habits. Regression
analysis showed that the association was more robust
with family history, in a similar manner as Zadnik et al.7
found in children. Although this study does not prove the
hypothesis that reading is a causal factor in adult-myopia,
other prospective studies33,34,43 have provided support for it,
showing that intense nearwork is associated with the earliness of onset and rate of progression of myopia in adults.
Therefore, while it is likely that reading habits are a causal
factor in adult-myopia, genetic influences also must not be
overlooked.
Parental history of myopia has been associated with
myopia in children.79 It has been argued whether this is
an effect of shared genes or whether parents create a
special environment (for example, induce more reading) for
myopic children. The present study has found an association
between parental history and the development of myopia in
adults, for whom their parents habits have far less importance in creating their environment at the time of myopia
onset than when they were children. Therefore it is possible
that parental history represents the genetic aspect of this
disease.
Youth- and adult-onset myopia have been separated
because they could have somewhat different origins.45 The
values of refractive error are generally lower in adult-onset
than in youth-onset myopia,36,45 and myopia that develops
at a younger age stabilizes sooner.44 However, biometric
studies32,3742 have shown that both youth- and adult-onset
myopias are axial in origin, and the present study supports

313

the idea that both have similar risk factors. Therefore we conclude that both types of myopia may be similar in origin, with
similarly predominant roles for family history and genetic
factors.

Acknowledgments
The authors thank Leon B. Ellwein, National Eye Institute,
Bethesda, Maryland, for his comments and questions,
and William K. Stell, University of Calgary Faculty of
Medicine, Alberta, Canada, for his editorial comments on
the manuscript.

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