Vision impairment in university students

·Investigation·

The prevalence of vision impairment and refractive

error in 3654 first year students at Tianjin Medical
University
Xue-Ying Shi, Yi-Feng Ke, Nan Jin, Hong-Mei Zhang, Rui-Hua Wei, Xiao-Rong Li

Tianjin Medical University Eye Hospital, Tianjin Medical well correction in myopia subjects were 82.73%, 84.39%
University Eye Institute & Tianjin Medical University School and 15.61%, respectively.
of Optometry and Ophthalmology, Tianjin 300384, China ● CONCLUSION: We present a high prevalence of refractive
Co-first authors: Xue-Ying Shi and Yi-Feng Ke errors and high rates of under correction refractive error
Correspondence to: Rui-Hua Wei and Xiao-Rong Li. among first year university students. These results may
Tianjin Medical University Eye Hospital, Fukang Road 251, help to promote vision protection work in young adults.
Nankai District, Tianjin 300384, China. [email protected]; ● KEYWORDS: vision impairment; refractive error; corrective
[email protected] status; myopia; first year university students
Received: 2018-03-17 Accepted: 2018-06-05 DOI:10.18240/ijo.2018.10.19

Abstract Citation: Shi XY, Ke YF, Jin N, Zhang HM, Wei RH, Li XR. The
● AIM: To determine the prevalence of vision impairment prevalence of vision impairment and refractive error in 3654 first
(VI) and refractive error in first year university students at year students at Tianjin Medical University. Int J Ophthalmol
the Tianjin Medical University. 2018;11(10):1698-1703
● METHODS: This is a cross-sectional observational cohort
study of VI and refractive error among first year university INTRODUCTION
students at the Tianjin Medical University. The first year
university students were involved in this study and
were given a detailed questionnaire including age, birth
V ision impairment (VI) is the main factor that hampers
people’s daily activities and quality of life. According
to the World Health Organization (WHO), an estimated 253
date, and spectacle wearing history. A standardized million people live with VI and 217 million have moderate to
ophthalmologic examination including visual acuity (VA), severe VI. Uncorrected or under-corrected refractive error is
slit-lamp examination, non-cycloplegic auto-refraction, the leading causes (53%) of VI and the second cause (21%)
objective refraction, fundus photography, and examination of blindness globally[1]. Moreover, approximately 19 million
of their spectacles were recorded. children and adolescents 5 to 15y of age suffer from VI, and
● RESULTS: A total of 3654 participants were included in approximately 12 million children have a VI due to refractive
this study. Totally 3436 (94.03%) individuals had VI in this error, especially myopia [2]. VI due to refractive error has
population. Totally 150 (4.10%) individuals had VI due to become a common social and public health problem in young
ocular disease, including amblyopia, congenital cataract, people globally.
retinal atrophy or degeneration, strabismus, congenital Recently, some studies reported the prevalence of myopia
nystagmus, refractive surgery orthokeratology. Totally surpassed 90% in university students[3] in China compared
3286 (89.93%) subjects had VI due to refractive error. with 60% among 12-year-old after primary school[4], 80% at
Only 218 (5.97%) students were emmetropia. Moreover, 16-year-old after junior high school[5]. The high prevalence
refractive error was the main cause for the VI (95.63%). of myopia in university students attracted our sight. As far as
Totally 3242 (92.52%) students were myopia and the we know, over 72% of myopia aged over 18 years old in East
prevalence of mild, moderate, and high myopia subgroup Asians lived in China[6]. The prevalence of myopia was high
was 27.05%, 44.35%, and 21.26% respectively. Totally 44 in Chinese adolescents and increased as age increased[7]. This
(1.29%) subjects were hyperopic. The rates of uncorrected adolescent myopia not only is simply refractive error but also
visual acuity (UCVA), presenting visual acuity (PVA) can progress to high myopia and pathologic myopia[8], which
and best corrected visual acuity (BCVA) which better finally leads to irreversible vision loss[9]. Adolescent myopia
than 20/20 in both eyes were 5.65%, 22.32% and 82.13% has become a remarkable public health problem in Chinese
respectively. The rates of correction, under correction and young people, especially in university students[3,10-11].

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Previous studies on VI are mostly focused on children below Table 1 Causes of visual impairment n (%)
age 15, little is known about VI in university students (age Prevalence in the
Students with VI
Causes of VI population
18 and over). The survey of VI and refractive error in this (one or both eyes)
n=3654 (%)
population is limited. Our study presented detailed analysis Refractive error 3286 (95.63) 89.92
on the prevalence of VI and refractive error in a specific Amblyopia 36 (1.05) 0.99
population of first year university students at Tianjin Medical Congenital cataract 20 (0.58) 0.55
University (TMU). These results may help to promote vision Retinal atrophy or degeneration 24 (0.70) 0.66
Strabismus 10 (0.29) 0.27
protection work in young adults.
Congenital nystagmus 6 (0.17) 0.16
SUBJECTS AND METHODS
Surgery and orthokeratology 54 (1.57) 1.48
This study was approved by the Ethics Committee of Tianjin Total 3436 (100) 94.03
Medical University Eye Hospital, and adhered to the tenets
of the Declaration of Helsinki. Informed written consent was defined as a cylinder more than 0.50 D. Myopia was also
obtained from at least one parent of 71 students whose age was classified into mild, moderate, and high myopia as an SE of
less than 18y old. -0.50 to -3.00 D, -3.00 to -6.00 D, and more than -6.00 D,
Study Population Totally 3754 students from TMU were respectively.
registered for this study and 3654 students were finished all Statistical Analysis The statistical analysis were performed
examinations in this study from October 2016 to October using SPSS statistical package version 23.0 (IBM Corporation,
2017 (response rates 97.34%). Eventually, 3654 students were Armonk, NY, USA). All numerical data were given as the
involved in this study. mean±SD. The prevalence of refractive error between males
Examinations This study was done by a team consisting and females were compared using the Chi-square statistic. P
of one qualified ophthalmologist, two optometrists, and five value was two-side and considered significantly when P<0.05.
optometry assistants. A training course was conducted to RESULTS
ensure all questions would be asked under the same criteria The Prevalence of Vision Impairment Totally 3654
and a standard procedure was made for the whole outcome participants were involved in this study. Totally 3436 (94.03%)
recording during the study. subjects had VI in this population (Table 1). Totally 150
All participants were required to complete a questionnaire (4.10%) individuals had VI due to ocular disease, including
which contained personal information and spectacle wearing amblyopia, congenital cataract, retinal atrophy or degeneration,
habits. A regular ocular examination was performed using a strabismus, congenital nystagmus, refractive surgery or
slit-lamp and fundus ophthalmoscope (66 Vision Tech Co., orthokeratology. Totally 3286 (89.93%) subjects had VI due to
Ltd., Suzhou, China) to check ocular abnormalities. refractive error. Only 218 (5.97%) students were emmetropia.
Visual acuity (VA) was measured using a standard logarithmic Moreover, refractive error was the main cause for the VI
VA chart with Tumbling-E optotypes and the uncorrected (95.63%).
visual acuity (UCVA) was recorded. Best corrected visual The Prevalence of Refractive Errors Totally 3504 individuals
acuity (BCVA) and presenting visual acuity (PVA) was were involved in the refractive error analysis after eliminating
measured in all students. PVA refers to the daily present participants of ocular disease. This population included 1330
vision for student, PVA was recorded as follows: 1) if a person (37.96%) males and 2174 (62.04%) females. The mean
usually does not wear spectacles, then it takes naked eye age was 18.83±0.92y. In total 7008 eyes, the mean SE was
vision as PVA; 2) if a person usually wears spectacles where -4.11±2.49 D (Figure 1A) and the mean diopter of astigmatism
the spectacles are appropriate, it takes the vision wearing the was -0.66±0.64 D (Figure 1B). Table 2 showed the prevalence
spectacles as PVA; 3) if a person has spectacles barely wearing of different type of refractive errors. Totally 218 subjects
it, it takes naked eye vision as PVA. (6.22%) were emmetropia and it was significantly higher
An automatic refractometer (model KR 8900; Topcon, Tokyo, in males (7.97%) than females (5.15%) (Chi-square=6.616,
Japan) and a photometer (VT10; Topcon, Tokyo, Japan) was used P=0.018). Totally 44 subjects (1.26%) were hyperopia and
to measure the degree of the refractive error. Refractive errors there was no remarkably difference in males (1.80%) and
[spherical (S), cylinder (C), axis (α)] were recorded after three females (0.92%) (Chi-square=2.604, P=0.107). Totally 3242
repetitions. (92.52%) individuals were myopia. Moreover, the number of
Spherical equivalent (SE) was calculated according to the students who had mild myopia, moderate and high myopia
following formula: SE=S+C/2. Refractive errors were classified were 948 (27.05%), 1554 (44.35%) and 740 (21.12%),
according to SE. Emmetropia was defined as refractive error respectively. Female students had a higher prevalence in the
less than 0.50 diopter (D). Myopia was the SE degree <-0.50 D, myopia group (Chi-square=4.556, P=0.004) and the mild
Hyperopia was the SE degree >0.50 D. Astigmatism was myopia subgroup (Chi-square=4.871, P=0.027) comparing
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Figure 1 The distribution of refractive errors in the 3504 subjects A: The distribution of SE refraction (mean SE =-4.11±2.49 DS); B: The
distribution of astigmatism (mean astigmatism diopter =-0.66±0.64 DC).

Table 2 The prevalence of refractive error in this study n (%)

Groups Total Male Female P
Emmetropia 218 (6.22) 106 (7.97) 112 (5.15) 0.018
Hyperopia 44 (1.26) 24 (1.80) 20 (0.92) 0.107
Myopia 3242 (92.52) 1200 (90.23) 2042 (93.93) 0.004
Mild myopia 948 (27.05) 320 (24.06) 628 (28.89) 0.027
Moderate myopia 1554 (44.35) 612 (46.02) 942 (43.33) 0.272
High myopia 740 (21.12) 268 (20.15) 472 (27.71) 0.437
Astigmatism 2248 (64.16) 864 (64.96) 1384 (63.66) 0.582

Table 3 Distribution of first year university students in UCVA, PVA, and BCVA n (%)
VA category UCVA Wearing spectacles PVA BCVA
≥ 20/20 both eyes 198 (5.65) 4 (2.02) 782 (22.32) 2878 (82.13)
≥ 20/20 one eye only 246 (7.02) 32 (13.01) 746 (21.29) 358 (10.22)
<20/20 to ≥20/25 better eye 152 (4.34) 34 (22.37) 1168 (33.33) 268 (7.65)
<20/25 to ≥ 20/40 better eye 306 (8.73) 166 (54.25) 438 (12.50) 0 (0.00)
<20/40 to ≥ 20/63 better eye 208 (5.94) 128 (61.54) 258 (7.36) 0 (0.00)
< 20/63 better eye 2394 (68.32) 2314 (96.66) 112 (3.20) 0 (0.00)
All 3504 (100.00) 2678 (76.43) 3504 (100.00) 3504 (100.00)

with male students. The prevalence of astigmatism was Table 4 Habits of spectacle wearing
64.16% and indicated no remarkable difference with gender Characteristic n (%)
(Chi-square=0.304, P=0.582). The frequency of changing spectacles
Visual Acuity Totally 198 (5.65%) students had a UCVA ≤1y 872 (32.57)
better than 20/20 in both eyes and 2394 (68.32%) students less 1-2y 1276 (47.65)
than 20/63 in the better eye. A total of 2678 students (76.43%) 2-3y 332 (12.42)
wore spectacles for vision correction. There were 782 (22.32%) >3y 198 (7.36)
individuals who had PVA better than 20/20 in both eyes and Habits of wearing spectacles
746 (21.29%) students had PVA better than 20/20 in one eye Wearing when need 966 (36.07)
only, while the PVA of 1168 (33.33%) students were between Wearing constantly 1712 (63.93)
20/25 and 20/20. The PVA of 112 (3.20%) students were worse Duration of wearing spectacles
than 20/63 in the better eye. After vision correction, 2878 <1y 228 (6.51)
(82.13%) students can achieve BCVA better than 20/20 in both 1-3y 562 (16.04)
eyes in 3504 subjects (Table 3). 3-5y 808 (23.06)
Habits of Spectacle Wearing Spectacles is one of the 5-8y 912 (26.03)
approaches for correction of refractive error. Table 4 showed 8-10y 122 (3.48)
habits of spectacle wearing in the students of our study. Among >10y 46 (1.31)

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Table 5 Correction status of students of myopia subjects n (%)

Groups Total Corrected Under correction Well corrected
Myopia 3242 (92.52) 2682 (82.73) 2736 (84.39) 506 (15.61)
Mild myopia 948 (27.05) 470 (49.58) 784 (82.70) 164 (17.30)
Moderate myopia 1554 (44.35) 1486 (95.62) 1296 (83.40) 258 (16.60)
High myopia 740 (21.12) 726 (98.11) 670 (90.54) 70 (9.46)

the 2678 participants who wore spectacles, 1712 (63.93%) students and postgraduates from Donghua University were
subjects wore spectacles constantly, 966 (36.07%) students myopia in Shanghai and 19.5% of them were high myopia.
wore spectacles when necessary such as driving, reading and Wu et al[14] reported that the prevalence of about 80% for
studying. The number of students changing spectacles every myopia and 10% for high myopia in students aged 16 to 18y.
year was 436 (32.57%), the number of students for changing These results supported our discovery. University students
spectacles every 2, 3y and more than 3y were 1276 (47.65%), had remarkably myopia prevalence; it might be associated
332 (12.42%) and 198 (7.36%) respectively. Totally 228 with education levels[15]. Previous study[16] showed that higher
(6.51%) students worn spectacles less than 1y. The numbers of levels of school and post-school professional education
students wearing spectacles with 1-3y, 3-5y 5-8y, 8-10y were were associated with myopic refraction. University first year
562 (16.04%), 808 (23.06%), 912 (26.03%), 122 (3.48%), 46 university students were a special population which just
(1.31%) respectively. underwent a high-intensity of prolonged near work and less
Correction of Myopia In this survey, the definition of under outdoor activities. Recent studies supported the association
corrective myopia is that PVA could be improved by at least 2 of time spent outdoors with the incidence of myopia[17-18]. It
lines with subjective refraction compared with baseline. Table has been reported for years that near work can be associated
5 showed the correction status in 3242 myopia subjects in with myopia, though recent studies raised some doubts about
which 2682 (82.73%) individuals had corrected whereas 560 this association[19-20]. Therefore, prolonged near work and less
(17.27%) without corrected, while 2736 (84.39%) students outdoor activities may be the main risk factors that leads to
were under correction, only 506 (15.61%) students were well myopia in young university students.
corrected. The ratio of correction of mild, moderate and high We also found a slightly higher prevalence of myopia in female
myopia were 49.58%, 95.62% and 98.11%, respectively. first year university students. Some studies presented high
While the ratio of under correction in mild, moderate and high prevalence of myopia in female subjects. Females students
myopia were 82.70%, 83.40% and 90.54%, respectively. The spent more time on reading, doing near work[21]. The Shunyi
ratio of well correction in mild, moderate and high myopia Study conducted a semirural area in northern China, 36.7%
were 17.30%, 16.60% and 9.46%, respectively. male and 55% female subjects were myopic at the age of
DISCUSSION 15[22]. Nevertheless, other study[23] did not find any significant
Our study showed that the VI rate before vision correction difference for the prevalence of myopia on gender. Large-scale
among first year university students was 94.03%, but about studies need to confirm this result.
with 95.63% of VI was attributable to refractive error and Astigmatism, another major cause of correctable VI in the
mostly myopia. Refractive errors, especially myopia, had world, is divided into refractive astigmatism (RA) and corneal
become a major public health problem worldwide, especially astigmatism[24] that can be independently measured. The etiology
in Asia[12-13]. This study demonstrated high prevalence of of astigmatism is complex with gene[25] and environmental[26]
refractive errors and high myopia in young adults exposed to risk factors. Astigmatism is highly prevalent in school-age
high educational demands, though the sample investigated children and aged 21 to 30y old[27]. A study in Singapore[13]
was not representative of the young adult population as a showed that the prevalence of refractive astigmatism increased
whole. University students comprised a specific academic significantly from 41.4% of 15 085 young subjects aged around
excellent population. Therefore, the prevalence of myopia and 19y old in 1996-1997 to 50.9% of 28 908 young subjects aged
high myopia were probably high. This opinion was verified around 19y old in 2009-2010. NHANES Study analyzed 12
by our study. In our study, myopia was found in 92.52% of 010 participants aged 20y and over, it presented the prevalence
all participants, with high myopia occurring in 22.26% of all of astigmatism was 36.2% in USA[28]. While our study showed
participants. First year university students with emmetropia a higher prevalence (61.16%) of refractive astigmatism in
were very rare (6.22%). Other studies also found a high university first year university students comparing with
prevalence of myopia and high myopia in Chinese university Singapore (50.9%) and the USA (36.2%). This difference may
students. Sun et al[3] reported that 95.5% first year university be caused by the different aged population in each study.
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The refractive error is an avoidable VI. PVA is a crucial factor population size. The characteristics of only first year university
that affect the vision quality. As shown in Table 5, our study students subjects in one university also biased the results in
found that the PVA of most students was worse which was this population. Large-scale study and wide age range will
eventually affect their daily life. The under correction ratio was contribute to more accurate results.
remarkable in myopia subjects indicating a poor corrective Our study demonstrated high prevalence of refractive error and
status of university first year university students. Some worse high ratio of under correction in university first year university
corrected students did not realize their poor corrected VA can students. This study offered evidence on worse PVA of university
be further improved, that would make them feel frustrated students in TMU affected by refractive error. This result may
and affect their daily activities, such as job hunting, marriage help to promote vision protection work in young adults.
and specializations. Some studies in different age support ACKNOWLEDGEMENTS
this result. Wang et al[11] reported that among urban migrant Foundations: Supported by National Natural Science
children aged around 11y old in eastern China, there was a Foundation of China (No.81500745; No.81670875); the
high ratio of needing for spectacles (55.80%) and a very low Natural Science Foundation of Tianjin (No.16JCQNJC12700;
ratio of spectacle ownership (12.82%). He et al[29] showed that No.15JCZDJC34500).
the rate of wearing spectacles was low and the percentage of Conflicts of Interest: Shi XY, None; Ke YF, None; Jin N,
inaccurate prescriptions, among those who wore spectacles, None; Zhang HM, None; Wei RH, None; Li XR, None.
was high in schools for children in Shanghai, China. This REFERENCES
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