Nearwork-Induced Transient Myopia in Preadolescent

Hong Kong Chinese

James Stuart Wolffsohn,1 Bernard Gilmartin,1 Roger Wing-hong Li,2
Marion Hastings Edwards,2 Sandy Wing-shan Chat,2 John Kwok-fai Lew,2 and
Bibianna Sin-ying Yu2

PURPOSE. To compare the magnitude and time course of near- than emmetropes or hyperopes, a phenomenon described as
work-induced transient myopia (NITM) in preadolescent Hong nearwork-induced transient myopia (NITM).2 Ciuffreda and
Kong Chinese myopes and emmetropes. Wallis2 found that the initial accommodative inaccuracy aver-
METHOD. Forty-five Hong Kong Chinese children, 35 myopes aged approximately 0.35 D overaccommodation in both their
and 10 emmetropes aged 6 to 12 years (median, 7.5), monoc- early-onset (EOMs, n ⫽ 13) and late-onset (LOMs, n ⫽ 11)
ularly viewed a letter target through a Badal lens for 5 minutes myopic groups. Neither the emmetropic group (n ⫽ 11) nor
at either 5.00- or 2.50-D accommodative demand, followed by the hyperopic group (n ⫽ 9) exhibited significant NITM. The
3 minutes of viewing the equivalent target at optical infinity. myopic groups, however, were distinguished by differences in
Accommodative responses were measured continuously with a the time taken subsequently to reach a stable optimum level of
modified, infrared, objective open-field autorefractor. Accom- accommodation for distance vision. LOMs were found to take
modative responses were also measured for a countercondi- almost twice as long to reach optimum distance accommoda-
tion: viewing of a letter target for 5 minutes at optical infinity, tion levels than EOMs (i.e., 63 seconds versus 35 seconds), and
followed by 3 minutes of viewing the target at a 5.00-D accom- the authors proposed that the consequent retinal defocus and
modative demand. The results were compared with tonic ac- degradation in retinal image contrast were sufficient to trigger
commodation and both subject and family history of refractive compensatory blur-driven growth of the posterior vitreous
error. chamber. The proposal is supported by a body of work on
myopia in animals that indicates that even modest levels of
RESULTS. Retinal-blur– driven NITM was significantly greater in retinal defocus, encompassed by depth of focus, can be suffi-
Hong Kong Chinese children with myopic vision than in the cient to induce ocular growth.3
emmetropes after both near tasks, but showed no significant Both myopic groups in the study by Ciuffreda and Wallis2
dose effect. The NITM was still evident 3 minutes after viewing were drawn from a sample of adult optometry students with a
the 5.00-D near task for 5 minutes. The magnitude of NITM mean age of approximately 24 years. The authors suggested
correlated with the accommodative drift after viewing a distant that the continuing propensity to NITM shown in these indi-
target for more than 4 minutes, but was unrelated to the viduals represents an inherent characteristic that, earlier in life,
subjects’ or family history of refractive error. induces temporary myopia after exposure to sustained near-
CONCLUSIONS. In a preadolescent ethnic population with known work. In EOM the exposure produces derailment of a prepro-
predisposition to myopia, there is a significant posttask blur- grammed pattern of ocular growth in the developing eye. In
driven accommodative NITM, which is sustained for longer than LOM, where ocular growth due to emmetropization has
has previously been found in white adults. (Invest Ophthalmol slowed or ceased before the onset of myopia,4,5 the derailment
Vis Sci. 2003;44:2284 –2289) DOI:10.1167/iovs.02-0373 is more directly attributable to nearwork exposure. Ciuffreda
and Wallis2 showed clearly that white adults with early- or

T he association between the onset and development of

myopia and sustained nearwork has figured in the research
literature for many years1 and has instigated a variety of exper-
late-onset myopia, measured under binocular, free-space, nat-
ural viewing conditions, were susceptible to accommodative
nearwork aftereffects, even in the presence of normal-distance
imental protocols to compare pre- and posttask measures of blur-related feedback.2
oculomotor function. Of particular interest has been the find- Of special relevance to the present study is the subsequent
ing that immediately after a period of sustained nearwork, report by Ciuffreda and Thunyalukul6 on a group of children
myopes are less able to accommodate accurately for distance aged 4.7 to 9.9 years. The study demonstrated that juvenile
myopes (n ⫽ 10) were more susceptible to NITM than em-
metropes (n ⫽ 10) and further, that subjects in each refractive
group who exhibited an initial NITM, sustained the effect
From the 1Neurosciences Research Institute, School of Life and throughout a 2-minute posttask period. That NITM is more
Health Sciences, Aston University, Birmingham, United Kingdom; and
the 2Centre for Myopia Research, Faculty of Health and Social Sciences,
sustained in children than in adults was attributed by the
The Hong Kong Polytechnic University, Hong Kong, China. authors to differences in sympathetic innervation and/or sen-
Supported by Grant A436 from the Centre for Myopia Research, sitivity to blur. It was further postulated that NITM in conjunc-
Area of Strategic Development, The Hong Kong Polytechnic Univer- tion with the decreased blur-driven accommodative response
sity. Johnson & Johnson (Hong Kong) Ltd. kindly provided disposable at near associated with newly developed myopia in children
contact lenses. may lead to a time-integrated cumulative retinal defocus that
Submitted for publication April 15, 2002; revised October 4 and triggers axial elongation.
December 17, 2002; accepted January 16, 2003. The observation that the ability to detect blur is reduced in
Commercial relationships policy: N. adults with myopia7 has been examined recently in a cohort of
The publication costs of this article were defrayed in part by page
charge payment. This article must therefore be marked “advertise-
20 children (aged 8 –12 years), with or without myopic vision,8
ment” in accordance with 18 U.S.C. §1734 solely to indicate this fact. for two different black and white targets (text and scenes) and
Corresponding author: James S. Wolffsohn, Neurosciences Re- illumination conditions. There was no correlation between
search Institute, School of Life and Health Sciences, Aston University, blur thresholds and refractive error magnitude, refractive error
Birmingham B4 7ET, UK; [email protected]. progression (over the previous year), or contrast sensitivity.

Investigative Ophthalmology & Visual Science, May 2003, Vol. 44, No. 5
2284 Copyright © Association for Research in Vision and Ophthalmology

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 IOVS, May 2003, Vol. 44, No. 5 Accommodative Hysteresis in Hong Kong Chinese 2285

However, blur-detection ability showed significantly greater progressive myopia implies that they have a deficit in sympa-
individual variability in juvenile myopes, which led the authors thetic inhibition.
to suggest that subgroups may differ in ability to detect blur. The composite near response epitomizes the nature of au-
Further consideration of the role of retinal defocus is op- tonomic control. That is, a profound mediation of central and
portune after the recent important advances in theoretical peripheral processes to ensure an optimum balance between
modeling of the development of refractive error.9 –12 The In- internal and external demands on the organism and future
cremental Retinal Defocus Theory proposed by Hung and Ciuf- work is needed to elucidate further whether sympathetic con-
freda11 offers significant insight into the myopigenic nature of trol pervades the near vision complex as a whole or is re-
retinal defocus. The critical element of the theory, as it relates stricted to specific elements of the response.
to nearwork, is that the detection mechanism triggering ocular The purpose of this study was to determine the magnitude
growth does not depend on the sign of the retinal blur, but and time course of NITM induced solely by retinal blur with a
rather on the change in magnitude of blur during genetically variety of stimulus demands in preadolescent Hong Kong Chi-
programmed ocular growth—the rate of ocular growth being nese, a group that is particularly susceptible to environmental
dependent on the change in magnitude of retinal defocus, myopia and that is in the developing phase of myopia.21–23
regardless of how it is generated. Monocular viewing through a Badal optical system was used to
A compelling research question is how processing of retinal examine the steady–steady blur-driven component of accom-
defocus amalgamates with mechanisms of accommodative ad- modation and to allow control of proximal accommodation.
aptation and its neuropharmacologic control. Regarding the
former, a computer simulation model constructed by Hung and METHODS
Ciuffreda13 extended a previous adaptation model14 by adding
a proximal component,15 to provide a more realistic and com- Forty-five Hong Kong Chinese children aged 6 to 12 years participated
prehensive representation of the accommodation system and in the study. Thirty-five myopes (21 boys, 14 girls) of median age 8.0
to extend the model to NITM data. The adaptive gain (KA) was years (range, 6 –12), mean spherical equivalent refractive error (MSE)
used to modify the time constant of the controller and varia- ⫺3.41 ⫾ 0.99 D (range, ⫺1.63 to ⫺5.63 D), were recruited. All were
tions in KA (using the original Ciuffreda and Wallis data set2) habitual single-vision spectacle wearers, but had refraction fully cor-
were shown to be the principal determinant of variations in rected with hydrophilic daily disposable contact lenses for the pur-
NITM between refractive groups. Indeed, differences in ac- poses of this experiment (2-hydroxyethyl methacrylate [HEMA] lenses,
commodative gain between refractive groups were thought by 58% water content; Acuvue Dailies, Vistakon, Johnson & Johnson
Culhane and Winn16 to account for their finding, using closed- Vision Care, Jacksonville, FL). Owing to the high prevalence of myopia
loop dynamic accommodation measures, that late-onset young in Hong Kong Chinese children older than 8 years, the control em-
adult myopes have significantly longer reflex near–far response metropic sample was smaller in number (five boys, five girls; MSE
times after sustained 3-minute near tasks. ⫹0.00 ⫾ 0.23 D; range, ⫹0.50 to ⫺0.25 D) and slightly younger
In a recent study, using similar investigatory techniques, (median age, 7.0 years; range, 6 –10) than the myopic group. Subjects
Winn et al.17 present evidence to support proposals by several were not taking any medication and were prescreened to ensure that
groups (see review by Gilmartin18) that autonomic neurophar- they had no ocular disease or binocular vision abnormalities. Corrected
macologic modulation of accommodative adaptation and NITM visual acuity ranged from ⫺0.04 to 0.02 log minimum angle of resolu-
is a feasible putative control system for sustained near vision. tion (logMAR; average, 0.00 ⫾ 0.01), and astigmatism was less than
The principal systems concern the integration of parasympa- 1.25 D. Informed consent was obtained from a subject’s parent after
thetic and sympathetic innervation of ciliary smooth muscle, explanation of the nature and possible consequences of the study. The
such that sympathetic inhibition (through ␤2-adrenoceptors) is research adhered to the tenets of the Declaration of Helsinki and was
augmented by concurrent parasympathetic activity (through approved by institutional human experimentation committee of The
M3 cholinergic receptors). An anomaly in integration, say for Hong Kong Polytechnic University.
example by a deficit in inhibition, may thus predispose an The infra-red (IR) autorefractor (SRW-5000; Shin-Nippon Ophthal-
individual to abnormal postnearwork accommodative re- mic Instruments, Tokyo, Japan) was used to measure the accommoda-
sponses and possibly have etiological significance in the devel- tive state of the subject’s right eye throughout the experimental trials.
opment of myopia, although only approximately 30% of indi- The instrument provides an open field of view and quantifies accom-
viduals appear to have access to a sympathetic facility.19 Winn modation by image analysis of an IR ring of light, reflected from the
et al.17 used topical ␤-adrenoceptor antagonist drugs in five retina. Previous studies have shown that this system provides measures
young adult emmetropes to demonstrate inhibitory sympa- of high validity and repeatability in both adult24 and juvenile25 myopes.
thetic modulation of accommodation responses to dark room The autorefractor was modified to allow continuous recording of
open-loop or closed-loop conditions involving systematic step- accommodation, with a resolution of less than 0.01 D.26 Pupil size was
wise and sinusoidal changes in stimulus vergence. always greater than 3 mm, resulting in an approximately constant
Whereas the nature of autonomic control and sustained depth of focus.27
near vision has been addressed in several studies in young The visual axis of the infrared autorefractor was aligned with the
adults18 very few have involved children. In this regard, the right eye, with the left eye occluded. The subject viewed a row of
recent preliminary report by Chen et al.20 is of particular Arabic letters (⬎90% contrast), subtending 1 minute of arc (equivalent
relevance to the present study, as its purpose was to investi- to 0.00 logMAR), and was prompted at regular intervals to maintain
gate, in Hong Kong children (aged 8 –12 years), the effect of a fixation, focus, and attention on the letters. The letters were viewed
topical ␤ antagonist drug, timolol maleate (0.5%, 20 ␮L), on along the visual axis through a ⫹5.00-D Badal system, and the accom-
tonic accommodation measures, before and after playing a modative demand was changed instantaneously (i.e., in ⬍100 ms) using a
5-minute video game. The profile of posttask responses in the solenoid stepper motor. The Badal system ensured the same size and
30 children (10 emmetropes and 20 myopes, 5 with stable and contrast of the target, regardless of the accommodative demand. The
15 with progressing myopia) appeared to match those shown subject initially viewed the letter target, of luminance 20.0 cd/m2, located
in previous studies on young adults. The results showed that, 20 cm behind the Badal lens (i.e., imaged at optical infinity), and concur-
whereas timolol increased the magnitude of adaptation in sta- rent measures of the autorefractor IR measurement ring were recorded
ble myopes, it had no effect on adaptation in progressing dynamically, using a computer program (Labview; National Instruments,
myopia and had a counteradaptive effect in emmetropes. The Austin, TX), and statically, using the autorefractor’s preset internal cali-
absence of effect of timolol on adaptation in children with bration. All data are presented in relation to the subject’s baseline distance

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 2286 Wolffsohn et al. IOVS, May 2003, Vol. 44, No. 5

Blink artifacts were removed from the dynamic accommoda-

tive trace by removing data that were not within 2 D of the task
demand. To allow comparison with previous research, the
trace was averaged into 10-second intervals and the standard
deviation calculated (from approximately 350 dynamic read-
ings). Because the accommodative response is usually com-
plete in less than 1 second30 and the slow phase accommoda-
tive response is the principal component in NITM,12 the first
second of data after the stimulus changed distance was re-
moved from the analysis.
NITM, over the 3-minute posttask interval, was significantly
greater for each averaged interval in Hong Kong Chinese juve-
nile myopes than in emmetropes (F ⫽ 11.40, P ⬍ 0.001; Fig. 2).
NITM in myopes was significantly greater than the baseline
accommodative response for a distant target over the entire
3-minute posttask period (Table 1). There was no significant
NITM in accommodation after the near task in emmetropes
(Table 1). There was no significant reduction in NITM over the
3-minute posttask time interval after the 5.0- and 2.5-D task
demand (split-plot ANOVA, F ⫽ 1.10, P ⫽ 0.30; Fig. 3). There
was also no interaction between task demand, time after near
task, and refractive status (i.e., myopia versus emmetropia; P ⬎
0.50).
When the task condition was reversed so that subjects
viewed a distant target at 0.0 D accommodative demand for 5
minutes, followed by a near target at 5.0 D (Fig. 4), em-
metropes were better able to maintain their baseline accom-
modative response to the target at optical infinity than myopes
(Table 1). However, the lag for myopes was still smaller than
the magnitude of NITM after a near task. There was no signif-
icant difference between myopes and emmetropes in their
accommodative response to the subsequent near task com-
pared with baseline (unpaired t-test: P ⫽ 0.43). Therefore, the
accommodative response domain (i.e., the difference between
mean accommodative response for distance and near task) was
FIGURE 1. Example of typical data from an emmetrope (top trace) and significantly smaller for myopes than for emmetropes in all
a myope (bottom trace) viewing a letter target at 5.0-D accommodative three task conditions, but more so when a near target was
demand for 5 minutes, followed by optical infinity for 3 minutes. The viewed before rather than after the distant target (Table 2).
figure demonstrates the data analysis performed on the dynamic ac- The mean tonic accommodative level to the DoG target was
commodative trace. ⫹0.82 ⫾ 0.75 D in juvenile myopes and ⫹0.93 ⫾ 0.56 D in
emmetropes. The age of onset of myopia ranged from 6 to 10
accommodative state (0.0 D). The lead of accommodation, indicated by years (mean, 7.7 ⫾ 1.1). The mean reported parental refractive
the static autorefractor readings when the subject viewed the distant error for the myopic group was ⫺2.87 ⫾ 2.80 D, with 29%
target, is shown on the y axis of Figures 2– 4. emmetropic. The refractive error of 13% of grandparents was
Initially, accommodation was monitored dynamically while the not known, but of the remainder, the reported MSE was
subject viewed a 0.1 cyc/deg difference-of-gaussian target (DoG) at 25 ⫺0.43 ⫾ 1.71 D, with 82% emmetropes.
cd/m2 for 5 minutes placed at optical infinity to determine the tonic The relationships between the magnitude of NITM in myo-
accommodative level.28 Three trials were randomly allocated to each pic Hong Kong Chinese children and tonic accommodative
subject, with the test letters viewed for 5 minutes at one distance, after
which the accommodative demand of the target was instantaneously
changed to its new value and the target viewed for a further 3 minutes:
a near task at 5.0 D, followed by 3 minutes at 0.0 D; a near task at 2.5
D, followed by 3 minutes at 0.0 D; and a distance task at 0.0 D,
followed by 3 minutes at 5.0 D. The online analysis system monitored
both the position of the target and the corresponding accommodative
response, facilitating assessment of response latency characteristics.
Demographic data and details of family history of refractive error were
also collected for each subject.
Split-plot analysis of variance (StatView; SAS, Cary, NC)29 was used
to examine the differences in posttask NITM between the refractive
groups over time. Pearson’s product moment coefficient and stepwise
analysis were used to test the relationship between NITM, demo-
graphic data, and family history.

RESULTS FIGURE 2. Accommodative response to viewing a near stimulus at

5.0-D accommodative demand for 5 minutes, followed by 0.0 D for 3
Figure 1 shows an example of the raw data from a typical minutes. Dashed line: baseline accommodation to a distant target. n ⫽
myope (bottom trace) and a typical emmetrope (top trace). 35 myopes, 10 emmetropes. Error bars, 1 SEM.

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 IOVS, May 2003, Vol. 44, No. 5 Accommodative Hysteresis in Hong Kong Chinese 2287

TABLE 1. Mean Accommodative Level of Myopic and Emmetropic Groups while Performing the Tasks

Prechange Postchange

250–300 sec 1–60 sec 61–120 sec 121–180 sec

Myopes
5.0 to 0.0 D 4.35 ⫾ 0.63 0.47 ⫾ 0.46† 0.49 ⫾ 0.43† 0.52 ⫾ 0.44†
2.5 to 0.0 D 1.87 ⫾ 0.51 0.39 ⫾ 0.43† 0.44 ⫾ 0.46† 0.37 ⫾ 0.56†
0.0 to 5.0 D 0.30 ⫾ 0.56* 4.42 ⫾ 0.67 4.38 ⫾ 0.66 4.34 ⫾ 0.66
Emmetropes
5.0 to 0.0 D 4.62 ⫾ 0.43 0.19 ⫾ 0.58 0.20 ⫾ 0.43 0.10 ⫾ 0.45
2.5 to 0.0 D 1.96 ⫾ 0.65 0.12 ⫾ 0.42 0.03 ⫾ 0.34 0.03 ⫾ 0.53
0.0 to 5.0 D 0.06 ⫾ 0.60 4.44 ⫾ 0.38 4.40 ⫾ 0.26 4.42 ⫾ 0.40

Data are the mean ⫾ SD. Significance tested for distance viewing with respect to the baseline
accommodative response.
* P ⬍ 0.01.
† P ⬍ 0.001.

level, age-of-onset and magnitude of myopia, magnitude of sponse domain, is shown to be significantly reduced in myopes
parent and grandparent refractive error, and the drift in base- compared with emmetropes.
line accommodative level 50 seconds before the change in There is also substantial evidence for an association be-
accommodative demand (i.e., between 250 and 300 seconds) tween the onset of myopia and a decreased accommodative
were examined. Best subset regression analysis showed that response to retinal blur,7,8,33 an effect which, by inducing
30.2% of the variance in the magnitude of NITM could be regression of accommodation to an intermediate location,1
accounted for by a combination of all these features. However, may in part account for the significantly reduced accommoda-
most variance was accounted for by the drift in baseline ac- tive domain found in the juvenile myopes used in this study. In
commodative level (24.2%), followed by the age of onset of their comprehensive monograph on accommodation and my-
myopia (5.3%). opia, Ong and Ciuffreda34 identify retinal blur as the principal
component of NITM and consider its putative etiological role
in myopia. The mechanisms proposed in later work on NITM
DISCUSSION by Ciuffreda and Wallis35 may be especially relevant to the
juvenile myopes used in this study, as, given that it is a group
The study shows that preadolescent myopic Hong Kong Chi- characterized by rapidly progressing myopia and associated
nese children are significantly more susceptible than their increase in lag of accommodation at near, it may be particularly
emmetrope peers to blur-driven NITM induced by sustained susceptible to the time-integrated retinal defocus for both near
near vision. The magnitude of NITM found in the juvenile and distance hypothesized by the authors. Both sources of
myopes was of an order similar to that reported by Ciuffreda retinal blur have potential myopigenic effects, owing to the
and Wallis2 for white adults with early-onset myopia under authors’ further proposition that small amounts of retinal de-
binocular open-view natural viewing conditions. A distinguish- focus emanating from accommodative dysfunction in the my-
ing feature of NITM in the present study is, however, its opic eye, but not exceeding the eye’s depth of focus, may not
persistence and lack of dependence on the level of accommo- be sufficient to provide directional information, as blur defocus
dative demand of the near task. Regarding the latter and con- has no directional clues.36 The contribution of retinal blur to
sistent with a number of previous studies,31,32 myopes also reflex accommodation is equivocal, however. For example,
exhibited significantly greater lags of accommodation at near Kruger et al.37 have shown, measuring accommodation con-
than emmetropes and hence the composite profile of accom- tinuously under open-loop conditions, that both achromatic
modative response, expressed herein as accommodative re-

FIGURE 4. Accommodative response to viewing a distant stimulus at

FIGURE 3. Accommodative response to viewing a near stimulus at 0.0 D accommodative demand for 5 minutes, followed by a near task
2.5-D accommodative demand for 5 minutes, followed by 0.0 D for 3 of 5.0 D accommodative demand for 3 minutes. Dashed line: baseline
minutes. Dashed line: baseline accommodation to a distant target. n ⫽ accommodation to a distant target. n ⫽ 35 myopes, 10 emmetropes.
35 myopes, 10 emmetropes. Error bars, 1 SEM. Error bars, 1 SEM.

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