Myopia and Myopic Progression Among Schoolchildren:

A Three-Year Follow-Up Study

Olavi Pcirssinen* and Anna-Liisa Lyyraf

Purpose. To discuss the factors that might explain the rate of myopic progression and the
degree of myopia after a 3-year follow-up among schoolchildren with myopia.
Methods. Myopic progression among 238 schoolchildren was followed up in a randomized
clinical trial of myopia treatment. The associations between the explanatory factors and myo-
pic progression and thefinalvalue of the spherical equivalent after the follow-up were studied
by analysis of variance and regression analysis.
Results. Myopia progressed faster among girls than boys. According to the regression models
for the boys, 25% of the variation of myopic progression and 57% of the final spherical
equivalent could be explained by initial spherical equivalent, age at receiving first spectacles,
time spent on sports and outdoor activities, and on reading and close work. Among the girls,
30% of myopic progression could be explained by age at receiving first spectacles, time spent
on reading and close work, and reading distance. Similarly, 49% of the final spherical equiva-
lent could be explained by age at receiving first spectacles, initial spherical equivalent, time
spent on reading and close work, and reading distance. The rest of the variations could not be
explained by the variables measured in this study.
Conclusions. The factors with the most significant relationships to myopic progression were
sex, age of onset, and degree of myopia at the beginning of the follow-up. Myopic progression
and final myopia were related to time spent on reading and close work and to reading distance
but not, however, to accommodation stimulus. Invest Ophthalmol Vis Sci 1993; 34:
2794-2802.

JMyopia is a common refractive error in the literate gence,7 or both have most often been advanced as the
countries. It is clear that there is a hereditary influence reasons for these relationships.
on the different components of the refractive ele- Our previous report on a 3-year follow-up study
ments of the eye.1 However, the influence of various of myopia treatment showed that myopic progression
external factors on myopia and on its progression is among schoolchildren could not be prevented with the
still under discussion.23 That myopia is related to edu- use of bifocals or by avoiding spectacles in reading and
cation and the higher.occupational groups would seem close work.8 The same report showed a relationship
to be clearly established.45 Accommodation,6 conver- between myopic progression and time spent on read-
ing and close work, and also between myopia and
reading distance. Progression was also faster among
Frtnn the * Department of Ophthalmology, Central Hospital of Central Finland, and
the ^Department of Statistics, University ofJyvaskyla, Jyviiskyla, Finland. the girls than among the boys.
This study was supported by a grant from the Academy of Finland. We thank also
the instrnvientarium Corporation for sharing the costs of bifocal lenses.
This article deals with the factors that might ex-
Submitted for publication October 23, 1992; accepted January 12, 1993. plain the rate of myopic progression as well as the
Propriety interest category: N.
Reprint requests: Olavi Pdrssinen, Kannaksenkatu 5, SF-40600, Jyviiskyla,
degree of myopia after a 3-year follow-up among myo-
Finland. pic schoolchildren by using multivariate statistical

Investigative Ophthalmology & Visual Science, August 1993, Vol. 34, No. 9
2794 Copyright © Association for Research in Vision and Ophthalmology

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 Myopic Progression 2795

methods. We also attempted to identify those factors PEK camera.9 At the end of the follow-up period the
that would discriminate the fastest and slowest rates of axial dimensions were measured by a Storz a-scan with
myopic progression. The possible relationships be- a soft probe.
tween reading and myopia are also discussed. A questionnaire was used to determine the use of
spectacles by the children's parents. The children were
divided into two groups according to whether one or
MATERIALS AND METHODS both parents or neither parent had spectacles for dis-
tant vision. The questionnaire at the end of the follow-
Myopic progression (final spherical equivalent [SFE] up asked for the average, amount of time spent daily to
— initial SFE) among myopic schoolchildren was fol- the nearest half hour separately on reading and on
lowed for a 3-year period as a part of a clinical trial of other types of close work outside school, separately for
myopia treatment.8 Schoolchildren from the third and both school days and weekends. The mean number of
fifth grades of lower comprehensive school (mean age hours spent daily on close work was calculated from
10.9 years), with no previously prescribed spectacles those four estimates so that the values for school days
for myopia, were considered for inclusion in the study. were multiplied by five and those for weekends by two,
Two hundred forty children were randomly allocated and the different types of near work added together
to one of three treatment groups: full corrected spec- and divided by seven. The mean number of hours
tacles to be used continuously, only for distant vision, spent daily on outdoor activities was calculated like-
or in the form of bifocals with +1.75 D add. Before wise. In this report only the refraction values of the
randomization the children were invited to participate right eye are used. Because the differences between
in a follow-up study of myopia and all agreed. The the treatment groups in myopic progression and in the
research followed the tenets of the Declaration of Hel- final SFE (spherical equivalent at the end of the fol-
sinki. Informed consent was obtained after the nature low-up) of the right eye were statistically non-signifi-
and the possible consequences of the study were ex- cant, the treatment groups are mainly treated as a
plained to the participants. The research was ap- whole. Materials and methods have been published in
proved by the institutional human experimentation earlier reports. 810
committee. The 3-year follow-up proved possible for
238 children. Cycloplegic refraction was performed Statistical Methods
annually. Reading distance was measured during each The comparisons of means for myopic progression
annual examination using a Clement Clark accommo- and final SFE between the sexes, between treatment
dometer. The average value of the accommodation groups and between parent groups (according to
stimulus was calculated from annual measurements of whether parents wore spectacles for distant vision)
reading distances and the refraction values. Myopic were made using analysis of variance. Analysis of vari-
progression and the way of wearing spectacles were ance was also used to make the comparisons of the
accounted for in these calculations. The following for- mean values of myopic progression with regard to sex
mulae were used to calculate accommodation stimulus and to different groups concerning time spent on
between two control visits: reading and close work, reading distance, and time
Continuous use: ACC = (100/Rj + 100/R2):2 + spent outdoors. The degree of myopic progression
(SFD2 - SFD,):2 and final SFE were explained by age, initial SFE, time
Distant use: ACC = (100/R, + 100/R2):2 + (SFD2 spent on reading and close work, time spent on out-
+ SFD,):2 door activities, and average reading distance. These
Bifocals: ACC = (100/R, + 100/R2):2 + (SFD2 - relationships were examined by constructing regres-
SFD,):2-1.75, sion models separately for boys and girls. These mod-
where ACC = accommodation stimulus, Rj and R2 = els were estimated and tested using the LISREL 7 soft-
reading distances in two consecutive visits, SFDj and ware program (Scientific Software, Mooresville, IN).11
SFD2 = spherical equivalents of the right eye in two Comparisons of the refraction-related variables and
consecutive visits. selected background variables between the slowest
The average reading distance and accommodation and the fastest progressing groups were made by Stu-
stimulus for the whole follow-up period was calculated dent's tf-test. Comparisons of the relative proportions
from the consecutive values for annual reading dis- of the sex, treatment, and parent groups between the
tance and accommodation stimulus. slowest and the fastest progressing groups were made
Intraocular pressure was measured annually using using x2-test. For the longitudinal examination of myo-
Haag Streit applanation tonometry. Keratometry pic progression at the four measurement points the
readings were measured at the beginning and at the growth curves were constructed for boys and girls sep-
end of the study using a Wesley Jessen System 2000 arately using Generalized Multivariate Analysis of Vari-

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 2796 Investigative Ophthalmology & Visual Science, August 1993, Vol. 34, No. 9

TABLE l.Comparisons of the Means for Myopic Progression and Final Spherical
Equivalent (SFE)
Myopic Progression Final SFE
Parents Treatment
Sex Group Group Mean SD (n) Mean SD (n)

Boys One or both Continuously -1.62 0.84 (19) -3.11 1.29 (19)
Only distant -1.69 1.07 (21) -3.04 1.48 (21)
Bifocals -1.49 0.78 (22) -3.11 1.07 (22)
Neither Continuously -1.30 0.85 (18) -2.80 1.12 (18)
Only distant -1.55 0.88 (16) -2.88 0.95 (16)
Bifocals -1.33 0.37 (15) -2.53 0.64 (15)
Girls One or both Continuously -1.77 0.96 (25) -3.16 1.11 (25)
Only distant -2.23 1.03 (23) -3.64 1.17 (23)
Bifocals -2.12 1.11 (20) -3.55 1.25 (20)
Neither Continuously -1.28 0.94 (14) -2.70 0.95 (14)
Only distant -1.47 0.84 (13) -2.68 0.72 (13)
Bifocals -1.91 1.03 (16) -3.40 1.49 (16)
Source of Variation F df P F df P

Main Effects 4.513 4 0.002 3 .572 4 0.008

Sex 7.147 1 0.008 4 .408 1 0.037
Parent group 6.393 1 0.012 7.442 1 0.007
Treatment group 1.925 2 0.148 0 .938 2 0.393
Comparisons were performed by three-way analysis of variance among boys and girls in two groups of parents regarding their wearing of
spectacles for distant vision and in the three treatment groups.

ance (GMANOVA) model.12 The estimation and test- groups, and between the two groups according to par-
ing of hypotheses for the growth curves and the calcu- ents' use of spectacles were studied by analysis of vari-
lations of confidence intervals were also computed ance (Table 1).
using the GMANOVA program.13 Myopic progression was significantly slower
among boys, and among those whose parents did not
RESULTS have spectacles for distant vision. The differences be-
tween the treatment groups (in the right eye) were not
The differences in myopic progression and final SFE significant. No interaction among these three explana-
between the boys and girls, between the treatment tory factors was found.

TABLE 2. Regression Models of Myopic Progression and Final SFE for Boys and Girls
Myopic Progression Final SFE

Boys Girls Boys Girls

Explanatory
Variable 0 (SE) P (SE) (SE) (SE)

Age 0.32* (.09) 0.40* (-09) 0.24* (.07) 0.34* (0.07)

Initial SFE 0.25f (.09) — 0.67* (.07) 0.51* (0.07)
Close work -0.16 (.09) -0.18J (.08) -0.12 (.07) -0.16J (0.07)
Outdoors 0.23f (.09) — 0.17J (.07) —
Reading distance — 0.18J (.09) — 0.15f (0.07)
N 108 113 108 113
R2 0.25 0.30 0.57 0.49
The explanatory variables used were: age at commencement of study (Age); initial spherical equivalent (SFE); daily time spent on reading
and close work (Close work); time spent on outdoor activities (Outdoors), and average reading distance during the follow up (Reading
distance). Only effective variables were included in the models. Estimates for regression coefficients /3 and their standard errors are in pa-
rentheses. N, number of observations. R2, determination coefficients.
* P< 0.001.
fP<0.01.
%P < 0.05.

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 Myopic Progression 2797
MYOPIC PROGRESSION (D) The correlations among the different explanatory
factors about certain living habits and myopic progres-
3 - sion and the final SFE were analyzed by constructing
regression models for boys and girls separately, in-
cluding age at the start of the study (age of receiving
GIRLS the first spectacles for myopia) and the initial SFE as
2 - p = 0.004
> BOYS control variables (Table 2).
The age of receiving first spectacles for myopia
. '
1 was significantly related to myopic progression and
1 -
f final myopia among both boys and girls. Similarly SFE
on receiving the first spectacles had a significant rela-
n n nrn tionship with final SFE and with myopic progression
1 i
among the boys.
s2.0 2.1-3.0 3.1-4.0 • 4.0 Time spent on reading and close work was asso-
TIME SPENT ON READING AND CLOSE WORK (h) ciated with a faster rate of myopic progression and a
higher degree of myopia at the end of the study, al-
though the association was slightly weaker among the
MYOPIC PROGRESSIONJ (D) boys. The amount of time spent outdoors was clearly
connected with myopic progression and final SFE
3 - among the boys, so that the greater the amount of time
spent outdoors, the lower was the rate of myopic pro-
gression and the degree of myopia at the end of the
follow-up. A shorter reading distance was clearly con-
2 _
nected with a faster rate of myopic progression and
•i a1 higher myopia at the end of the follow-up among the
"
girls.
1 GIRLS According to the regression models these factors
\ p= 0.003
BOYS
explained 25% of the variation in myopic progression
n n nn? among the boys and 30% among the girls, and 57%
n i and 49% of the variation in final SFE, among the boys
20-24.9 25-29.9 > 30 and the girls, respectively.
B READING DISTANCE (cm) We also compared the mean values of myopic pro-
gression with the factors characterizing habits of read-
ing and outdoor activities classified in four groups (Fig-
MYOPIC PROGRESSION (D) ure 1).
Figure la shows that when more time was spent on
3 -
reading and close work, myopia progressed faster (P =
0.003). Progression was significantly faster among the
girls than among the boys (P = 0.004). The figures
2 -
MYOPIC PROGRESSION (D)

BOYS
1 - GIRLS
-1

s2.0 2.1-3.0 3.1-4.0 >4.0 -2

TIME SPENT ON SPORTS AND OUTDOOR ACTIVITIES (h)

FIGURE l. Comparisons of the mean values of myopic pro- -3

gression with regard to sex and to (A) time spent on reading
and close work; (B) reading distance and (C) time spent out-
BEGINNING FIRST yr SECOND yr THIRD yr
doors. Results of two-way analysis of variance: P values for
differences among four groups on x-axis and between sex. FIGURE 2. Curves showing final spherical equivalent changes
Bars represent standard deviations. for boys and girls.

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 2798 Investigative Ophthalmology & Visual Science, August 1993, Vol. 34, No. 9

TABLE 3.
Comparisons of Annual Myopic Progression in Dioptes (D) Between Boys and Girls
Using Two-Tailed t-test
Boys Girls
t-test
Variable Mean (D) SD(n) Mean (D) SD(n) (P Value)
First year -0.56 0.41 (119) -0.79 0.51 (120) <0.001
Second year -0.46 0.36(119) -0.57 0.47(118) 0.038
Third year -0.43 0.44(119) -0.46 0.42(119) 0.618

were virtually the same when reading time only was where SFE is the expectation of the spherical equiva-
taken into account. lent of the right eye, t = 0 at the beginning of the study
Myopic progression was also faster among chil- and t = 3 at the final examination 3 years later. The
dren with a shorter reading distance (P = 0.002; Fig hypotheses suggesting identical and parallel curves for
lb). The difference between boys and girls was also both sexes were both rejected (P < 0.001), and the
significant (P = 0.003). Myopic progression was myopic progression among the girls was found to be
slightly slower when more time was spent on outdoor clearly faster.
activities, but the relationship was nonsignificant (Fig The graphs of the growth curves of SFE are shown
lc). Nevertheless, the difference between the boys and in Figure 2.
the girls was significant. There was a divergent trend between the boys and
The differences in the data in Figure 1 were tested the girls as well as a slight decrease in the rate of myo-
using the two-way analysis of variance. There were no pic progression. The annual progression among the
interactions between sex and these three explanatory girls was faster than that among the boys during the
variables. first 2 follow-up years but not thereafter (Table 3).
The longitudinal investigation of myopic progres- The amount of time spent on reading and close
sion during the 3-year period was carried out by fitting work was somewhat greater among the girls and the
the growth curve model for the SFE of the right eye amount of time spent outdoors was correspondingly
through the four time points separately for both sexes shorter. However, the differences in these variables
using the GMANOVA model. The second-order poly- could not fully explain the divergence in myopic pro-
nomials were obtained as the growth curve models for gression between the sexes.
the SFE; for the boys Different profiles of myopic progression emerged.
SFEt = -1.44 - 0.58t + 0.03t2 , t = 0,1,2,3, Among six boys and six girls myopic progression dur-
and for the girls ing the follow-up was 0.25 D or less. Conversely, seven
SFEt = -1.44 - 0.86t + 0.08t2 , t = 0,1,2,3, boys and seventeen girls had a myopic progression of

TABLE 4. Comparisons of Variables Connected With Refraction Between the Slowest and
Fastest Progressing Groups Using Two-Tailed t-test
Slow Fast
t-test
Variable Mean SD(n) Mean SD (n) (P Value)
Age at entering
the study (yr) 11.3 0.9 (60) 10.3 1.0(60) <0.001
Initial spherical
equivalent (D) -1.4 0.6 (60) -1.5 0.7 (60) 0.214
Myopic progression (D) -0.5 0.3 (60) -2.9 0.6 (60) <0.001
Initial corneal
refraction (D) 44.1 1.3(55) 44.1 1.4(55) 0.965
Final corneal
refraction (D) 44.2 1.3(35) 44.1 1.3(39) 0.751
Final anterior
chamber depth (mm) 3.67 0.38 (33) 3.78 0.35 (44) 0.166
Final lens
thickness (mm) 3.36 0.14(32) 3.36 0.20 (44) 0.843
Final axial
length (mm) 24.11 0.74 (38) 24.99 0.77 (46) <0.001

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 Myopic Progression 2799

TABLE 5. Comparisons of Selected There were no significant differences between the

Background Variables Between the Slowest groups in corneal refraction at the beginning or at the
and Fastest Progressing Groups Using x2-test end of the follow-up. Of the axial dimensions at the
end of the follow-up only a greater total axial length
Slow Fast X2-test was observed in the faster progressing group. Table 5
Variable (%) (%) n (P Value) shows the other comparisons between the slowest and
Sex
the fastest progressing groups.
Boys 55 32 52 0.010 The faster progressing group contained more
Girls 45 68 68 girls, and the parents of the children in this group
Treatment group more often had spectacles for distant vision. The com-
Wearing spectacles parison did not show any significant differences be-
continuously 42 32 44
Wearing spectacles tween the treatment groups.
only for distant The faster progressing group had a shorter read-
vision 31 38 41 0.463 ing distance, but despite this their accommodation
Bifocals 27 30 34 stimulus in reading was less than in the slowest pro-
Parents' spectacles gressing group (Table 6).
for distant vision
One or both 49 69 67 0.028 Intraocular pressure seemed to be slightly higher
Neither 51 31 45 in the faster progressing quartile, although this differ-
ence was not statistically significant. Furthermore, the
time spent on reading or on both reading and close
work was longer, and the time spent outdoors shorter
more than 3 D. There was considerable variation in in the faster progressing group.
SFE at beginning of the follow-up in both the stable
(-0.38 D to -2.68 D) and the fastest progressing cases
(-0.38 D to -3.00 D). On the basis of the initial SFE DISCUSSION
we could not discriminate the stable from the fastest The subjects selected for this study consisted of a
progressing cases. rather visually homogenous group of schoolchildren
We then tried to ascertain which of the different receiving their first spectacles for myopia at beginning
variables would discriminate between the fastest and of the study. The age of the children on entering the
slowest progressing quartiles in this myopic child pop- study was also within narrow limits (mean 10.9 years,
ulation. The comparison groups consisted of the 60 range 8.8-12.8 years), thus imposing certain limita-
slowest and the 60 fastest progressing cases (Table 4). tions on interpretation of the results. Had the study
The fastest progressing group received their first included hyperopic and emmetropic cases, the varia-
spectacles approximately 1 year earlier than those with tion in the different explanatory factors used here
the slowest progression. At the beginning of the fol- would perhaps have been wider. However, even in the
low-up there were no significant differences between design of this study of myopic schoolchildren many
the groups in SFE although myopic progression was variables were found to be related to myopia and to its
about 2.4 D more in the fastest progressing quartile. progression.

TABLE 6. Comparisons of Selected Background Variables Between the Slowest and Fastest
Progressing Groups Using Two-tailed t-test
Slow Fast
t-test
Variable Mean SD(n) Mean SD (n) (P Value)
Reading distance (cm) 24.1 4.3 (56) 22.0 3.8 (58) 0.005
Accommodation stimulus (D) 1.5 0.9 (55) 0.3 1.2 (58) <0.001
Intraocular pressure (mm Hg)
At commencement to
the study 17.4 2.8 (58) 17.5 2.6 (60) 0.836
At the end of the study 15.6 2.2 (59) 16.4 2.5 (58) 0.085
Time spent on
reading (hours/day) 1.2 0.3 (58) 1.4 0.4 (60) 0.006
Time spent on reading
and close work (hours/day) 2.9 0.8 (58) 3.5 0.9 (60) 0.001
Time spent outdoors (hours/day) 3.2 1.4(60) 2.5 1.1 (60) 0.003

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 2800 Investigative Ophthalmology & Visual Science, August 1993, Vol. 34, No. 9

Heredity progression but also on faster progression when

younger.
That heredity has an influence on refraction is obvi- Although the degree of myopia at the beginning
ous. In a recent study of 109 pairs of twins by Teikari was, on average, related to the rate of myopic progres-
et al, the heritability of myopia was 0.58 when myopia sion, this did not hold true in individual cases. In this
was considered a dichotomous variable.14 It can be study there were stable cases of myopia varying from
assumed that the effect of heredity on refraction is -0.38 D to -2.68 D. The distant vision of these chil-
similar to that of many other physiologic phenomena, dren had been tested by school nurses at 1- or 2-year
both in terms of direct influence and influence on sus- intervals at least twice before the commencement of
ceptibility to external factors. the study. Thus it can be supposed that their myopia
In a previous Finnish study the percentage of had developed during a few years and then stabilized.
myopes among those adults who wore spectacles for What halted their myopic progression remains to be
poor distant vision was 66%.15 Thus a higher fre- answered.
quency of myopia can be assumed in the case of those The relationship between faster myopic progres-
parents of the children in the current study who had sion and earlier onset of myopia may depend on a
spectacles for poor distant vision compared to those stronger hereditary influence and/or a stronger sus-
who did not have spectacles for this purpose. Al- ceptibility to external influences.
though this variable was apparently a rather weak vari-
able in the heredity of myopia, it nevertheless had a Living Habits
relationship both with myopic progression and final
myopia in this study. It is known that myopia is common among school chil-
dren and educated people,15 and less common among
Boys-Girls nonliterate populations.20 Myopia has also been shown
to be rare among occupational groups such as farmers
Myopic progression was significantly faster among the and fishermen.4 Further, restricted spaces have been
girls than the boys. Interestingly, the difference in the shown to increases myopia in animal experiments.21 In
rate of progression was significant only during the first our previous study of men aged between 33 and 37
2 years of the follow-up and remained approximately years, 77% of the subjects were correctly assignable as
the same thereafter. In the data studied by Goss, sex myopic by means of discriminant analysis taking into
did not have a great effect on the rate of progression account interest in reading, length of education, occu-
of childhood myopia.16 Perhaps this difference be- pational status, and body mass index.22 Richler and
tween the sexes is evident only at the beginning of Bear, respectively, using multiple regression coeffi-
myopia and when the onset of myopia is early. The cients, found an age-related relationship between myo-
variables used in this study could not fully explain the pia and near work.23
difference in myopic progression between boys and In this study the amount of time spent on reading
girls. It has been proposed that the progression of and on reading and close work and reading distance
myopia in children is related to the rate of their rate of were related to myopic progression and final SFE, al-
growth.17 Some of the difference in myopic progres- though there were clear differences between the boys
sion between the sexes might be explained by the and the girls.
faster maturation of girls at the ages studied. In this study there was also a slight negative corre-
lation among the boys between myopic progression
Age of Onset and Degree of Myopia and the amount of time spent on sports and outdoor
activities. It cannot be said whether the relationship
Earlier studies have shown that myopic progression is between slower progression rate and longer amounts
faster in the younger age groups. For example, in the of time spent outdoors was attributable to some effect
study by Mantyjarvi myopic progression was 0.93 D/yr of distant gazing or simply to being away from reading
in 8-year-olds and 0.52 D/yr in 13-year-olds.18 In the and close work.
Houston myopia control study there was also a more
rapid rate of progression among those who entered Accommodation, Convergence, and Eye
the study at an early age with a large amount of myo- Movements
pia.19 In the current study the rate of myopic progres-
sion was also related to the age of onset of myopia and What then might link myopia and reading and close
also independently to the degree of myopia at the be- work? Accommodation6 and convergence7 have been
ginning of the study. Thus the greater amount of myo- suggested as the reasons sons for the development of
pia in adulthood among those whose myopia begins myopia. If accommodation played a significant role in
earlier is not at least solely dependent on more years of myopic progression the feedback mechanism would

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 Myopic Progression 2801

probably halt the process when reading with under- also discriminated the fastest and slowest progressing
corrected glasses or without glasses. The results ob- myopes. The factors that had the most significant rela-
tained in the earlier report8 and from this study did tionships to myopic progression were sex, age of on-
not support the hypothesis of accommodation as a sig- set, and degree of myopia at the beginning of the fol-
nificant cause of myopia. As the matter of fact, in this low-up. In addition to having parents who had specta-
study the accommodation stimulus was smaller among cles for poor distant vision, more time spent on
the fastest progressing quartile than among the slow- reading and close work, and short reading distance but
est progressing quartile. The overall low accommoda- not high accommodation stimulus were all related to
tion stimulus values found here can be explained by myopic progression. Of the refractive elements of the
the study design as one third of the children were rec- eye, greater axial length was related to higher myopia.
ommended to do close work without spectacles and a It remains to be answered what, in addition to heredi-
second one third were prescribed bifocals. However, tary factors, could be the reason for greater axial
when a person with myopia reads without spectacles length and myopia, but we suggest that studies of myo-
small changes in reading distance cause a greater per- pia should be addressed in part to determine the me-
centage of changes in the amplitude of accommoda- chanical forces affecting the eye and sclera during
tion than when reading with spectacles, and we do not close work and especially when reading.
exactly know the effects of these changes.
The relationships between short reading distance Key Words
and myopic progression and final myopia found in this
study could support the hypothesis that convergence myopia, progression, reading distance, accommodation,
is one factor inducing myopia. Greene has supposed convergence
convergence, and specially the stress between the
oblique muscles, to be an important factor in myopic References
progression.7 However, in a previous Finnish study of
26- and 46-year-olds it was shown that education in- 1. Sorsby A, Benjamin B, Sheridan M. Refraction and its
creased the prevalence of myopia more than doing components during the growth of the eye from the
other kinds of precision close work.15 It can be sug- age of three. Medical Research Council, Spec Res Ser
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