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Which Environmental Factors Potentially Reduce the Progression of Childhood Myopia?

Divya Jagadeesh, PhD, Postdoctoral Research Fellow

BHVI

Increasing time outdoors at least one hour per day may reduce the risk of developing myopia by 45%.

Over the years, many risk factors have been considered for myopia and range from individual characteristics such as sex, ethnicity, parental myopia, height, and intelligence, to environmental factors, such as near work, time outdoors, sleep, diet, socioeconomic status, etc. Of the various risk factors, time outdoors and near work remain the most significant factors that appear interrelated to other factors. The protective effect of time outdoors has been consistent and gaining acceptance, whereas the link between near work and myopia has been weak.

Time Outdoors

The following factors are considered to play a role in the protective effect of time outdoors.

High illumination1-6

Spending more time outdoors during the day allows bright light to reach the retina and stimulates dopamine release that may reduce eye growth.1,2,4  Elevated light levels are said to trigger the intrinsically photosensitive retinal ganglion cells and activate retinal dopaminergic pathways.6 In animal models, daily exposure with high light levels of 40,000 lux prevented the onset of form-deprivation myopia and halted progression in chicks.3,7 Similarly, high light levels ~25,000 lux also inhibited form-deprivation myopia in rhesus monkeys.1,5

Pupillary miosis and increased depth of focus8

Distance viewing would result in less image blur and decreased peripheral hyperopic defocus, thus delaying myopia’s onset.

Ultraviolet (UV) light exposure9

Exposure to violet light (360 to 40 nm) (1) upregulated the myopia suppressive gene (EGR1) in chicks, and (2) violet light transmitting contact lenses suppressed progression in myopic children.

Spectral composition of the light10

In chicks, there was less form-deprivation myopia when exposed to UV and blue light compared to white light, red light, or when kept in a dark room.

Optical infinity/uniform dioptric space11

Outdoor environment with far viewing results in less dioptric difference between elements and may aid in an effective emmetropization process and therefore may prevent the onset of myopia.

Recommendations

A meta-analysis12 of 17 studies, including samples with multiple ethnicities, summarized that spending less than 13 hours a week outdoors is a risk factor for myopia development. Increasing time outdoors at least one hour per day may reduce the risk of developing myopia by 45%. A randomized clinical trial based in China showed that increasing time outdoors by at least 40 minutes per day decreased onset of myopia in school children by 9% in three years.13  Yet another study conducted in Taiwan showed that spending 80 minutes per day outdoors reduced the onset of myopia by 9% in 1 year.14  Importantly, even with sun protection (e.g., goggles, hats, etc.), the light levels outdoors were above the threshold luminance required for preventing the occurrence of myopia.15

The current recommendations are for a minimum of two hours per day with adequate sun protection, e.g., wearing hats, sunglasses while engaging in outdoor activities.

Less Time on Near Work

The evidence is inconsistent, but spending excessive time on near-based activities such as reading, writing, or screen time are considered risk factors of development/progression of myopia.16-19

Accommodation20,21

Although earlier studies reported that myopic children and adults have higher accommodative lag21,  there has been no association between myopia progression and accommodative lag. It appears that accommodative lag associated with myopia may be a consequence rather than a causative factor.20

Retinal Image Quality22

In adult myopes, retinal image quality while performing near tasks was studied. It concluded that a negative spherical aberration causing central and peripheral image degradation might stimulate eye growth.

Contrast23-27

Reading for prolonged hours without breaks may induce contrast adaptation to the high contrast letters being viewed.23 Contrast adaptation was hypothesized to be associated with the development of myopia. Some studies24-26found that contrast adaptation was higher in myopes when compared to emmetropes and hence recommended frequent breaks between reading hours to eliminate the contrast adaptation effects. A study investigating the role of contrast polarity and myopia showed that reading conventional black text on white paper overstimulated retina OFF pathways. It caused choroidal layer thinning, which is a biomarker associated with myopic refractive error. Conversely, white letters on a black background simulated retina ON pathways and may help in inhibiting myopia.27

Recommendations

Maintaining closer distance (<30 cm) while reading and continuous readings > 30 minutes were risk factors of myopia development in children.28 Therefore, avoiding a closer reading distance and taking frequent breaks while reading can be practiced to keep myopia at bay.

References:

1 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 2012; 53: 421-428.

2 Rose KA, Morgan IG, Ip J et al. Outdoor activity reduces the prevalence of myopia in children. Ophthalmology 2008; 115: 1279-1285.

3 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.

4 Ashby RS, Schaeffel F. The effect of bright light on lens compensation in chicks. Invest Ophthalmol Vis Sci 2010; 51: 5247-5253.

5 Wang Y, Ding H, Stell WK et al. Exposure to sunlight reduces the risk of myopia in rhesus monkeys. PLoS One 2015; 10: e0127863.

6 Norton TT, Siegwart JT, Jr. Light levels, refractive development, and myopia–a speculative review. Exp Eye Res 2013; 114: 48-57.

7 Karouta C, Ashby RS. Correlation between light levels and the development of deprivation myopia. Invest Ophthalmol Vis Sci 2014; 56: 299-309.

8 Flitcroft DI. Emmetropisation and the aetiology of refractive errors. Eye (Lond) 2014; 28: 169-179.

9 Torii H, Kurihara T, Seko Y et al. Violet Light Exposure Can Be a Preventive Strategy Against Myopia Progression. EBioMedicine 2017; 15: 210-219.

10 Wang M, Schaeffel F, Jiang B et al. Effects of Light of Different Spectral Composition on Refractive Development and Retinal Dopamine in Chicks. Invest Ophthalmol Vis Sci 2018; 59: 4413-4424.

11 Charman WN. Keeping the world in focus: how might this be achieved? Optom Vis Sci 2011; 88: 373-376.

12 Xiong S, Sankaridurg P, Naduvilath T et al. Time spent in outdoor activities in relation to myopia prevention and control: a meta-analysis and systematic review. Acta Ophthalmol2017; 95: 551-566.

13 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.

14 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.

15 Lanca C, Teo A, Vivagandan A, et al. The Effects of Different Outdoor Environments, Sunglasses and Hats on Light Levels: Implications for Myopia Prevention. Transl Vis Sci Technol 2019; 8: 7.

16 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.

17 Saw SM, Hong CY, Chia KS et al. Nearwork and myopia in young children. Lancet 2001; 357: 390.

18 Saw SM, Chua WH, Hong CY et al. Nearwork in early-onset myopia. Invest Ophthalmol Vis Sci 2002; 43: 332-339.

19 Saw SM, Chua WH, Wu HM et al. Myopia: gene-environment interaction. Ann Acad Med Singap 2000; 29: 290-297.

20 Mutti DO, Mitchell GL, Hayes JR et al. Accommodative lag before and after the onset of myopia. Invest Ophthalmol Vis Sci 2006; 47: 837-846.

21 Bullimore MA, Gilmartin B. The accommodative response, refractive error, and mental effort: 1. The sympathetic nervous system. Doc Ophthalmol 1988; 69: 385-397.

22 Sreenivasan V, Aslakson E, Kornaus A et al. Retinal image quality during accommodation in adult myopic eyes. Optom Vis Sci 2013; 90: 1292-1303.

23 Ohlendorf A, Schaeffel F. Contrast adaptation induced by defocus – a possible error signal for emmetropization? Vision Res 2009; 49: 249-256.

24 Yeo AC, Atchison DA, Lai NS et al. Near work-induced contrast adaptation in emmetropic and myopic children. Invest Ophthalmol Vis Sci 2012; 53: 3441-3448.

25 Diether S, Schaeffel F. Long-term changes in retinal contrast sensitivity in chicks from frosted occluders and drugs: relations to myopia? Vision Res 1999; 39: 2499-2510.

26 Yeo AC, Atchison DA, Schmid KL. Effect of text type on near work-induced contrast adaptation in myopic and emmetropic young adults. Invest Ophthalmol Vis Sci 2013; 54: 1478-1483.

27 Aleman AC, Wang M, Schaeffel F. Reading and Myopia: Contrast Polarity Matters. Sci Rep 2018; 8: 10840.

28 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.

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