Disclaimer: For all the general public and specialists, some technical knowledge might be required.
Let en-light our blog, pick our sunglasses and let´s talk about the influence of outdoor time on the onset, development as well as progression of myopia. Besides, as far as 100 years ago (1), some studies started to conjecture about ambient light and its impact on the development of the eye. Starting to be considered as plausible public action to stop myopia prevalence increase, especially in those areas with high risk of development such as East Asia, the topic triggered interest again.
For more in-depth treatment of the issue of outdoors effect we should keep in mind different terms such as time exposure and light intensity, because many factors could contribute to this “shielding effect“.
During the last years a large number of research studies investigated the hypothesis that time spent outdoors protects against the development and progression of myopia.
Since the beginning of this hypothesis, all researches pointed to this direction. Earlier, it was shown in chickens (2) and children that ambient light plays an important role at compensation of myopic defocus and onset of myopia. While at early stages in humans, it was though that physical activity could have a major input, Rose et al (3) showed that light conditions where the key.
To get a better overview on this matter we should introduce the sentence scientific evidence.
But what´s evidence?
In a scientific environment, there is no place for believes, and the evidence relies in the studies published and their repeatability. If we want to grade the evidence they give, we do so according to the type of article, as following pyramid illustrates.
As pointed out by the pyramid, meta-analysis are the highest source of evidence in science. And a recent meta-analysis from Xiong et al, 2017 (4), analyzed over 25 studies and they concluded that time outdoors prevent the development, but has no effect on slowing progression of eyes that are already myopic.
Other studies that looked into the possible use of longer outdoor hours to prevent myopia (5) as public policies, concluded that an extra hour could have greater impact on the onset and development of myopia in children between 5 to 8 years. Similar recommendation were given by He et al 2015,(6) where they claimed that 45 min of outdoor activities for schools in China could prevented myopia onset.
“Although research about understanding the exact mechanism is still underway, based on current results approximately 3 hours of outdoor activity during a day may be considered protective against myopia.”
Since the earliest studies on myopia, several theories about its etiology have been enunciated, but nowadays we can mainly forge them into two flowlines: genes (1,2) and environment (3).
Scientific data and experience indicate that there is a very complex mixture of factors and both lines seems to be important.
However, there is no clear answer to why myopia is developed. Only in the last decades, there is an increased understanding about development and onset of myopia, that is, more detailed knowledge of what, how, when, where and why myopia develops.
Simplifying, the answers to these questions may be found in the following factors:
There is a genetic predisposition to myopia in some individuals but it often requires of environmental help to being developed. Higher concordances in myopia prevalence have been found between monozygotic twins than in dizygotic ones, and even more linked than child-parent relationships.(4) Furthermore, it appears that Han ethnicity is more prone to develop Myopia. (5)
However, as genetic factors can take a large shot, we would explain them in deep in another article.
Genetic Myopia (Not available yet)
The educational level have been correlated with myopia quite soon. Already in 1892, Hermann Cohn stated that the prevalence of myopia is related to the educational level (6).
Following this trend, we can find this study from Morgan et al, in Inuits, that reveals the same correlation.(7)
This educational level by itself, is not the original cause of myopia, and we should discern between the conglomerate factors that define it. Which seems to be related with more myopia development, as proposed, more indoor activity, near work activities…(8)
Near work and eye accommodation
It has been described that myopic children show higher degrees of accommodative lag (you are focusing on one object, but your eyes actually focus on a point behind it). This accommodative mismatch produces hyperopic retinal blur, which could provide a stimulus for myopic eye growth. (9)
There are still many unanswered questions and details to resolve about myopia-accommodation link. For this reason it is necessary to carry out more longitudinal and randomized research trials to confirm that near work is a real risk factor for myopia development. (10)
Accommodation and Myopia (Not available yet)
Animal studies have shown that the peripheral retina plays an important role in determining eye growth, moreover there appears to be different theories (11) about how it works in humans, for more information, refer to the following article.
Several studies have reported the association between outdoor time and lower likelihood of myopic refraction. The main idea behind this factor is the amelioration of myopia development due to the high levels of light (pupil construction, increased depth of focus, increased dopamine release).(12)
Following this trend of time spend outdoors, several authors claimed a relationship between Urban vs Rural and population density, where rural lifestyle with more time outdoors can be related to less myopic prevalence. Similar effect has been described to physical activity, the most the better to avoid myopia, but before claiming them to be truly related factors, a deeper understanding is required of outdoors as can be not risk “per se” if not only incentives for more outdoor time.(13)
The premature children are more predispose to develop refractive errors, such as Myopia.(14), and seems to have shallower anterior chambers.
As you have seen, myopia is a complex trait: several variables, factors and small details are involved on its development.
A small proportion of myopia are clearly inherited. These appear at an early age, and reach high values. However, the most common myopia occurs at school age, and does not reach these high values. In this type of nearsightedness, it seems that there may be a small genetic contribution, but environmental factors seem to be the most important, and this is what is contributing to the increase in myopia worldwide.
Based on the scientific findings, currently, myopia control is focused taking all these factors into account: genetics, outdoor exposure, new optical designs, pharmaceutical agents, etc.
(1) Goldschmidt E, Jacobsen N. Genetic and environmental effects on myopia development and progression. Eye. 2014;28(2):126-133. doi:10.1038/eye.2013.254.
(2) Mohamed Dirani, Matthew Chamberlain, Sri N. Shekar, Amirul F. M. Islam, Pam Garoufalis, Christine Y. Chen, Robyn H. Guymer, Paul N. Baird; Heritability of Refractive Error and Ocular Biometrics: The Genes in Myopia (GEM) Twin Study. Invest. Ophthalmol. Vis. Sci. 2006;47(11):4756-4761. doi: 10.1167/iovs.06-0270.
(3) Ramessur R, Williams KM, Hammond CJ. Risk factors for myopia in a discordant monozygotic twin study. Ophthalmic & Physiological Optics. 2015;35(6):643-651. doi:10.1111/opo.12246.
(4) Rong SS, Chen LJ, Pang CP. Myopia Genetics—The Asia-Pacific Perspective. Asia-Pacific J Ophthalmol. 2016;5(4):236-244. doi:10.1097/APO.0000000000000224.
(5) Chin MP, Siong KH, Chan KH, Do CW, Chan HHL & Cheong AMY. Prevalence of visual impairment and refractive errors among different ethnic groups in schoolchildren in Turpan, China. Ophthalmic Physiol Opt2015; 35: 263–270. doi: 10.1111/opo.12193
(6) Schaeffel F. Myopia V What is Old and What is New ? 2016;93(9):1022-1030.
(7) Morgan RW, Speakman JS, Grimshaw SE. Inuit myopia: an environmentally induced “epidemic”? Canadian Medical Association Journal. 1975;112(5):575-577.
(8) Morgan IG, Rose KA. Myopia and international educational performance. Ophthalmic Physiol Opt 2013; 33: 329–338. doi: 10.1111/opo.12040
(9) Gwiazda J, Thorn F, Bauer J, Held R. Myopic children show insufficient accommodative response to blur. Invest Ophthalmol Vis Sci. Mar 1993;34(3):690-694.
(10) Huang HM, Chang DST, Wu PC (2015) The Association between Near Work Activities and Myopia in Children—A Systematic Review and Meta-Analysis. PLOS ONE 10(10): e0140419. doi: 10.1371/journal.pone.0140419
(11) Atchison DA, Rose R. The Possible Role of Peripheral Refraction in Development of Myopia. 2016;93(9):1042-1044. doi:10.1097/OPX.0000000000000979.
(12) Ngo C, Saw SM, Dharani R, Flitcroft I. Does sunlight (bright lights) explain the protective effects of outdoor activity against myopia? Ophthalmic Physiol Opt. 2013;33(3):368-372. doi:10.1111/opo.12051.
(13) Guggenheim JA, Northstone K, McMahon G, et al. Time Outdoors and Physical Activity as Predictors of Incident Myopia in Childhood: A Prospective Cohort Study. Investigative Ophthalmology & Visual Science. 2012;53(6):2856-2865. doi:10.1167/iovs.11-9091.
(14) Quinn GE Dobson V Kivlin J . Prevalence of myopia between 3 months and 5 1/2 years in preterm infants with and without retinopathy of prematurity: Cryotherapy for Retinopathy of Prematurity Cooperative Group. Ophthalmology. 1998;105(7):1292–1300