C L I N I C A L A N D E X P E R I M E N T A L
OPTOMETRY
The prevalence of anisometropia and its associated factors in an adult
population from Shahroud, Iran
Clin Exp Optom 2013; 96: 455459
Elham Mohammadi* MD MSc
Hassan Hashemi* MD
Mehdi Khabazkhoob* MSc
Mohammad Hassan Emamian MD PhD
Mohammad Shariati|| MD
Akbar Fotouhi MD PhD
* Noor Ophthalmology Research Centre, Noor Eye
Hospital, Tehran, Iran
Farabi Eye Hospital, Tehran University of Medical
Sciences, Tehran, Iran
Shahroud University of Medical Sciences,
Shahroud, Iran
|| Department of Social Medicine, School of
Medicine, Tehran University of Medical Sciences,
Tehran, Iran
Department of Epidemiology and Biostatistics,
School of Public Health, Tehran University of
Medical Sciences, Tehran, Iran
E-mail: afotouhi@tums.ac.ir
Submitted: 1 July 2012
Revised: 20 September 2012
Accepted for publication: 16 October 2012
Key words: anisometropia, cross-sectional, Iran, refractive errors
Anisometropia, different refractive errors
between two eyes of an individual, can
cause some clinical problems, such as ani-
seikonia, possible spectacle intolerance and
binocular defects. Other important conse-
quences of anisometropia are strabismus
and ambylopia.1
Although there are many studies that
have reported refractive errors, including
anisometropia, in the last two decades, few
have reported this ophthalmic disorder
specifically.28 For instance, Shih and col-
leagues9 among Taiwani schoolchildren,
Hashemi, Fotouhi and Mohammad8 and
Hashemi and colleagues10 among people
in Tehran, Tong and colleagues11 among
Singaporean schoolchildren and Wu and
2013 The Authors
Clinical and Experimental Optometry 2013 Optometrists Association Australia
RESEARCH PAPER
DOI:10.1111/cxo.12045
Background: The aim of this study was to evaluate the prevalence of anisometropia in an
urban adult population in the north of Iran.
Methods: This cross-sectional study was conducted among the 4064-year-old population
in Shahroud, Iran. Random cluster sampling was applied to select 6,311 people. Following
an interview, optometric and ophthalmologic examinations, including objective non-
cycloplegic refractions, were carried out. The prevalence of anisometropia was reported
according to non-cycloplegic refraction and with cut-off points of 0.50, 1.00, 2.00 and 3.00 D.
Results: Of the sampled people, 5,190 (82.2 per cent) took part in the study. After
considering exclusion criteria, data from 4,918 participants were included in the final
analysis. Most participants were female (57.6 per cent) and the average age (with standard
deviation) was 50.7 6.2 years. The prevalence of anisometropia with cut-off points of
0.50, 1.00 and 2.00 D were 23.1 (95%CI: 22.024.3), 7.7 (95%CI: 7.08.4) and 3.2 per cent
(95%CI: 2.73.7), respectively. The prevalence of severe anisometropia (3.00 D or more)
was 1.9 per cent (95%CI: 1.52.3). The odds ratio (OR) of anisometropia was 1.06 times
higher for every year of increasing age. The OR of anisometropia in participants with cataract
was 2.78 times more than in those without (p < 0.001). Anisometropia was more frequent
among participants with unilateral cataract (21.7 per cent) compared to those with bilateral
cataract (13.4 per cent). Anisometropia of 1.00 D or more was significantly more prevalent
among myopic participants compared to hyperopic participants (13.8 versus 12.7 per cent,
p < 0.001) and there was a stronger association between anisometropia and myopia (OR =
2.93) than hyperopia (OR = 2.23). With increasing educational level, the prevalence of
anisometropia decreased significantly (p < 0.001). The prevalence of aniso-astigmatism of
1.00 D or more was 11.1 per cent (95%CI: 10.211.9).
Conclusion: In the present study, the prevalence of anisometropia in Iran was not negligible;
however, it is less than in Eastern Asia. Myopia, cataract, age and educational level were
associated with anisometropia.
colleagues1 among older adults in Myanmar, sometropia. For instance, in some studies
specifically reported this disorder. In addi- associations between gender and age
tion, many studies were conducted mainly with anisometropia have been reported,
among children and adolescents, partly while other studies have not found this
because of its recognised severe outcomes association.17,19,20 One of the probable
at these ages.1217 reasons for major differences between risk
Generally, the reported prevalence of ani- factors regarding anisometropia is the small
sometropia ranges from 1.6 per cent in Aus- number of studies which have specifically
tralia to 35.5 per cent in Myanmar, partly due reported this disorder.
to the age groups sampled.1,18 According to Considering the small number of
the Tehran eye study, which is one of the few studies of anisometropia all over the
population-based studies in Iran to evaluate world, especially in the Middle East region
anisometropia, the prevalence of this disor- and Iran, the aim of the current study
der among five- to 86-year-old participants was to evaluate the prevalence of ani-
was 6.1 per cent.10 sometropia and its related biological and
In addition, different studies have environmental factors in an urban popula-
reported different risk factors for ani- tion in Iran.
Clinical and Experimental Optometry 96.5 September 2013
455
Anisometropia in Shahroud, Iran Mohammadi, Hashemi, Khabazkhoob, Emamian, Shariati and Fotouhi
Age 0.5 dioptre 1 dioptre 2 dioptre 3 dioptre
% (95%CI) % (95%CI) % (95%CI) % (95%CI)
4044 years 18.3 (15.820.7) 5.2 (3.86.6) 2.5 (1.63.5) 1.2 (0.51.8)
4549 years 17.9 (15.919.9) 4.8 (3.76.0) 1.7 (1.02.4) 1.0 (0.51.6)
5054 years 22.4 (20.124.7) 7.7 (6.29.2) 3.3 (2.34.4) 2.2 (1.33.1)
5559 years 29.7 (26.832.6) 11.1 (9.013.2) 4.6 (3.36.0) 2.6 (1.63.6)
6064 years 36.0 (31.940.1) 13.9 (11.116.7) 5.5 (3.57.5) 3.4 (1.94.9)
Men 25.8 (23.827.7) 8.6 (7.49.8) 3.8 (3.04.6) 2.0 (1.42.6)
Women 21.2 (19.722.7) 7.1 (6.18.0) 2.8 (2.23.4) 1.8 (1.32.3)
Total 23.1 (22.024.3) 7.7 (7.08.4) 3.2 (2.73.7) 1.9 (1.52.3)
Table 1. Prevalence of anisometropia with cut-off points of 0.50, 1.00, 2.00 and 3.00 D
stratified by gender and age group
METHODS
Examination
Optometric examinations, including near
The Shahroud Eye Cohort Study is a and far visual acuity and objective non-
population-based prospective study and this cycloplegic refractions measured by retinos-
paper reports a cross-sectional study based copy were undertaken by optometrists.
on its first phase. This study was conducted Severity of lens opacity was estimated by
to evaluate the prevalence and magnitude comparison with standard photographs (the
of anisometropia in one of the urban areas lens opacities classification system III, LOCS
in Iran as well as the association among III) and was classified into cortical, posterior
anisometropia and age, gender, cataract, capsular and nuclear opacities.21
myopia and educational level.
Definitions
Participants Spherical equivalent (SE) equals the spheri-
This cross-sectional study was conducted cal error plus half of the cylindrical error.11
among an urban population in Shahroud In this study, cylindrical error was defined
in 2009. According to the census in 2006 by a negative number. Persons with a spheri-
the population of this city was 133,835 and cal equivalent of -0.50 D or more in one eye
among them 28,779 were between 40 and were considered myopic, while those greater
64 years of age. The strategy of the study than +0.50 were hyperopic. Between these
followed a stratified cluster sampling proce- two limits, subjects were considered emme-
dure with proportional allocation within tropic.11 In addition, the anisometropia
strata and 300 clusters were randomly was the absolute value of the difference in
selected, each containing 20 people. The spherical equivalent between right and left
Shahroud population in Irans health-care eyes.
system is covered by nine health-care
centres, which were the strata for this study.
The number of clusters related to each of Statistical analysis
the centres was decided mainly based on the In the current study, the prevalence of ani-
population covered by the centre. For each sometropia was reported with 95% confi-
cluster, interviewers approached the index dence intervals (CI). Estimation of CI was
household, which was specified through the carried out by considering cluster sampl-
random selection of clusters and was contin- ing design effect. Association between the
ued for 20 people by proceeding systemati- prevalence of anisometropia and related
cally in a clockwise direction from the index risk factors was defined by logistic regression
household within the cluster. During the analysis. To find the association between
face-to-face interview, trained nurses asked anisometropia and some factors, linear
the participants about age, gender, educa- regression was applied. Odds ratios (OR)
tion, medical and drug history, as well as and p-values were calculated using simple
ophthalmologic history. and multiple logistic regression.
Clinical and Experimental Optometry 96.5 September 2013
456 Clinical and Experimental Optometry 2013 Optometrists Association Australia
Ethical considerations
The Ethics Committee of Shahroud Medi-
cal Sciences University approved the study
which was conducted in accord with the
tenets of the Helsinki Declaration and an
informed consent was obtained from all the
participants.
RESULTS
Of 6,311 people who were recruited,
5,190 individuals participated in the study
(response rate: 82.2 per cent). After consid-
ering exclusion criteria, including previous
cataract surgery, aphakia or pseudophakia
and missing refractive data in at least one
eye, the final analysis in this article was run
according to objective and non-cycloplegic
refractive data of 4,918 participants, which
was measured by retinoscopy. The mean age
(and standard deviation) of the examinees
was 50.7 6.2 years and 2,834 individuals
were women (57.6 per cent).
The prevalence rates of anisometropia
equal to or more than 0.50, 1.00, 2.00 D were
23.1 (95%CI: 22.024.3), 7.7 (95%CI: 7.0
8.4) and 3.2 per cent (95%CI: 2.73.7),
respectively. About 1.9 per cent had ani-
sometropia of 3.00 D or more. A summary
of the prevalence of anisometropia by
certain variables and different cut-off points
is demonstrated in Table 1; associations are
summarised in Table 2.
There was no significant gender differ-
ence in the prevalence of anisometropia
of 1.00 D or more (p = 0.066); however,
as evident in Table 1, anisometropia of
1.00 D or more increased from 5.2 per cent
in the 4044-year-old group to 13.9 per cent
in the 6064-year-old group (p < 0.001).
The OR of anisometropia equal to or greater
than 1.00 D increased 1.06 times for every
year of increasing age (95%CI: 1.03
1.09).
Anisometropia of 1.00 D or more was
significantly more prevalent among myopic
participants compared to hyperopic partici-
pants (13.8 versus 12.7 per cent, p < 0.001).
The overall prevalence of antimetropia
was 0.61 per cent (95%CI: 0.390.82). The
prevalence of anisoastigmatism of 1.00 D or
more was 11.1 per cent (95%CI: 10.211.9)
and after adjustment for cataract, it
increased with increasing age (OR = 1.03 for
every year of increasing age, p < 0.001) and
no significant inter-gender difference was
detected (p = 0.350).
In participants with and without cataract,
the prevalence rates of anisometropia of
2013 The Authors
 Anisometropia in Shahroud, Iran Mohammadi, Hashemi, Khabazkhoob, Emamian, Shariati and Fotouhi

Studying the association with educational

Crude OR p-value Adjusted OR p-value level showed that anisometropia with 1.00 D
(95% CI) (95%CI) cut-off point decreased with higher educa-
tional level (p < 0.001). The prevalence of
Age group
anisometropia of 1.00 D or more was 10.1
4044 years 1 per cent among uneducated participants,
4549 years 0.93 (0.641.36) 0.700 and 4.8 per cent among participants with
5054 years 1.51 (1.062.16) 0.024 an academic degree (OR = 0.96 for every
5559 years 2.28 (1.573.3) <0.001 educational year, p < 0.001). The results
6064 years 2.94 (2.034.27) <0.001 <0.001 of a multivariate logistic regression analysis
showed that in the presence in the model
Gender
of age, gender, educational level, myopia
Male 1 and cataract, there was a significant positive
Female 1.24 (0.991.55) 0.066 association between the prevalence of ani-
Cataract 2.79 (2.063.77) <0.001 1.94 (1.392.69)* <0.001 sometropia and age, cataract and myopia.
Bilateral cataract 1.94 (1.322.85) 0.001
Unilateral cataract 3.60 (2.425.38) <0.001 Magnitude of anisometropia
Myopia 2.93 (2.373.62) <0.001 3.35 (2.664.21)* <0.001 The mean anisometropia was 0.41 D
Hyperopia 2.23 (1.802.75) <0.001 (95%CI: 0.390.42). The results of linear
Educational level (school year) 0.95 (0.930.98) <0.001 0.96 (0.940.98) 0.001 regression showed that anisometropia was
0.06 D more among men than women (p =

Adjusted for age, cataract, gender and myopia 0.014) and it increased with increasing age
CI: confidence interval, OR: odds ratio (p < 0.001). After age adjustment, there was
no difference between men and women
with regard to the magnitude of anisome-
Table 2. Simple and multiple logistic regression analyses of anisometropia of 1.00 tropia. Figure 1 demonstrates the mean ani-
dioptre or more and independent variables, age, gender, cataract, myopia and hyperopia sometropia by amount of refractive error.
In addition, when educational level
increased, the magnitude of anisometropia
5 decreased, which could also be found after
age adjustment. In a multivariate logistic
regression model in the presence of age,
95% CI Anisometropia (dioptre)

4
gender and spherical equivalent, there was a
significant positive association between age
3
and spherical equivalent with anisometropia
(p < 0.001), while there was no association
2 between this variable and gender.
The average anisocylindrical value in this
1
study was 0.42 0.63 D, which increased
significantly with increasing age (p < 0.001).

DISCUSSION
-1
< -4

-4 to -3

-3 to -2

-2 to -1

-1 to -0.5

-0.5 to 0.5

0.5 to 1

1 to 2

2 to 3

3 to 4

>4

The current study is one of the few

population-based studies performed to
evaluate the prevalence and associated
Spherical equivalent (dioptre) determinants of anisometropia in the
Middle East region.
Figure 1. Mean anisometropia by amount of refractive errors in
the least ametropic eye Prevalence
The prevalence of anisometropia with a
1.00 D cut-off point, which means ani-
1.00 D or more were 16.9 and 6.8 per cent, tively (OR = 1.9, p < 0.001 for bilateral sometropia equal to or more than 1.00 D in
respectively (p < 0.001). In addition, the cataract; OR = 3.6, p < 0.001 for unilateral this study was 7.7 per cent, while the preva-
prevalence of anisometropia of at least cataract). After adjusting for cataract, the lence of anisometropia with 0.50 D cut-off
1.00 D in those with unilateral and bilateral OR for different age groups remained sig- point was 23 per cent. Considering the fact
cataract was 21.7 and 13.4 per cent, respec- nificant (p < 0.001). that most of the studies have focused on

2013 The Authors Clinical and Experimental Optometry 96.5 September 2013
Clinical and Experimental Optometry 2013 Optometrists Association Australia 457
Anisometropia in Shahroud, Iran Mohammadi, Hashemi, Khabazkhoob, Emamian, Shariati and Fotouhi
anisometropia of 1.00 D or more, we used
this cut-off point to assess its correlation
with other factors.
Based on the age of the participants, the
prevalence of 1.00 D or more anisometropia
varies in different regions up to 35.5 per
cent in Myanmar.1 Moreover, in another
population-based study conducted among
1,361 Chinese participants who lived in
Taiwan and were aged 65 years or more, the
prevalence of anisometropia with cut-off
point of 1.00 D was 21.8 per cent.22
The Tehran Eye Study in Iran, which was
conducted among 4,354 participants, who
were between five and 86 years old, reported
that the prevalence of anisometropia with a
1.00 D cut off point was 6.7 per cent and was
8.4 per cent among participants 45 years and
older. By increasing age, the prevalence of
this ophthalmic disorder increased up to 30
per cent.10 In addition, in another study
in Mashhad in Iran the prevalence of ani-
sometropia was 10.7 per cent among partici-
pants 55 years or older.23
Comparison of the findings of the present
study with those in both the Tehran and
Mashhad eye studies with similar age groups,
reveals that the prevalence of anisometropia
does not vary widely in Iran and this ophthal-
mic disorder is relatively less common in
Iran compared to eastern Asian countries
such as China, Myanmar or Indonesia.1,5,24
We found no association between the
prevalence of anisometropia and gender,
which was in accordance with most other
findings;1,6,10 however, Bourne and col-
leagues study7 conducted among partici-
pants 30 years and older in Bangladesh, and
Quek and colleagues study25 carried out
among high school students in Singapore
both reported a higher prevalence of
anisometropia among female participants.
In terms of age, we found a significant
positive associations between this variable
and the prevalence of anisometropia in uni-
variate and multivariate logistic regression
analyses in the presence of gender, cataract
and myopia which was in agreement with
most of the other studies.2,3,57,10,19 In an
extensive review, Weale26 found that for
every seven-year increase in age, the preva-
lence of anisometropia increased one per
cent. In contrast, in the study conducted
among participants 40 years or older in
Myanmar by Wu and colleagues,1 there was a
significant association between age and ani-
sometropia in univariate analysis while no
association was found in a logistic regression
model in the presence of cataract and
Clinical and Experimental Optometry 96.5 September 2013
458
myopia. The reason for an increase in ani-
sometropia with increasing age remains
unclear. For instance, Weale26 contended
that the most common hypothesis, the
uneven progress of nuclear cataract between
the two eyes, might not be the main cause, as
the contents of the lenses do not change
simultaneously when the prevalence of
anisometropia increases.
There was a significant association
between cataract and prevalence of ani-
sometropia in the presence of age, gender
and myopia in a multivariate model and it
was 2.78 times more common in participants
with cataract. Moreover, the prevalence of
anisometropia in the current study was sig-
nificantly more common in participants with
cataract (bilateral or unilateral) compared
to those without. In the Blue Mountains Eye
Study conducted among 3,654 participants
50 years or older in Australia, the prevalence
of anisometropia in participants with bilat-
eral and unilateral cataract and without any
cataract, were 24.9, 18.2, 9.1 per cent, respec-
tively, which was not in line with our find-
ings.19 We found less prevalence among
participants with unilateral cataract com-
pared to those with bilateral cataract. Cata-
ract changes lens refractive index, which
consequently changes the refractive error
index. As in unilateral cataract, where
changes predominantly happen in one eye,
we hypothesised that the prevalence of ani-
sometropia might be highest among partici-
pants with unilateral cataract, and this was
supported by our findings. On the other
hand, in bilateral cataract, it is probable that
the progression or the type of haziness
is different in the two eyes and therefore,
the prevalence of anisometropia is greater
among them compared to individuals
without cataract. Overall, there are different
findings related to cataract; for example the
prevalence of anisometropia was reportedly
very high in Bangladesh in participants with
cataract while no association was found
between these two variables in Malays
in Singapore.4,7 Taking all the findings
together, it seemed that age, cataract and
myopia were independently associated
with anisometropia.
In the current study, anisometropia was
significantly more prevalent among myopic
participants, which was in accordance with
the findings of many other studies.23,8,19 For
example, the study of Wu and colleagues1
reported that the OR of anisometropia in
myopic individuals was 2.7 times more than
in non-myopics. The Tehran Eye Study also
Clinical and Experimental Optometry 2013 Optometrists Association Australia
found that anisometropia was more fre-
quent among myopic than non-myopic
participants (15.4 versus 8.9 per cent).10
As cataract causes severe myopia in the
elderly, the association between myopia
and anisometropia could be partly due
to the cataract. To control the effect of this
confounder, a logistic regression analysis
was run in the presence of gender, age, cata-
ract and myopia, which showed that the asso-
ciation remained significant even after
controlling for this confounder.
Observing a correlation between educa-
tional level and anisometropia is clearly in
agreement with previous studies.7 As the
educational level increased, the prevalence
of anisometropia decreased. One of the
probable reasons is that less educated
people in Shahroud belonged to the older
age groups, which highlighted the effect of
age in the prevalence of anisometropia.
Magnitude of anisometropia
In the current study, an association was
found between magnitude of anisometropia
and age which was in accordance with some
of the other studies. For instance, Xu and
colleagues3 and Guzowski and colleagues19
have also reported this association. In con-
trast, in the study conducted by Tong and
colleagues11 among schoolchildren in Singa-
pore, this association was not found.
In addition, like many other studies, we
found no association between severity of ani-
sometropia and gender. For instance, in the
study by Tonget and colleagues11 an associa-
tion was found between these two variables
among myopic children but not among
non-myopes.
We found an association between spheri-
cal equivalent and the magnitude of ani-
sometropia, which was in line with the
findings of other studies.3,19,27
Some of the strengths of the current study
were the large sample and high response
rate. One of the limitations of the study
was not evaluating the association between
corneal curvature and the difference of axial
length between two eyes with anisometropia.
CONCLUSION
The prevalence of anisometropia and its
severity in an urban population in Iran
should not be neglected. One of the impor-
tant and interesting findings of this study
was the independent association of age, cata-
ract and myopia with anisometropia. To
2013 The Authors
 Anisometropia in Shahroud, Iran Mohammadi, Hashemi, Khabazkhoob, Emamian, Shariati and Fotouhi
assess the magnitude of their influence
on anisometropia, the measurement of
corneal curvature and the difference in
the axial length between the two eyes
are recommended.
ACKNOWLEDGEMENT
This project was supported by Noor Oph-
thalmology Research Centre, Shahroud
University of Medical Sciences and Tehran
University of Medical Sciences.
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