EDUCATION AND MYOPIA IN 110,236 YOUNG SINGAPOREAN MALES KG AuEong, TH Tay, MK Lim ABSTRACT Computerised data of 110236 Singaporean males aged 15 025 (mean 17.75) years who underwent compulsory medical examination {from Aprit 1987 to January 1992 were used to estimate the prevalence and severity of myopia among young Chinese, Malay Indian ‘and Eurasian Singaporean males wth different educational levels. The prevalence and severity of myopia amongst the groups with diferent educational levels were compared. These groups were fairly well-matched for important known confounding factors such 15 age, sex, race and degree of urbanisation of place of residence. Our data showed a positive association between educational ‘atizinment and both he prevalence and severity of myopia. Both the prevalence of myopia andthe proportion of myopes with severe myopia were in general higher among those with more years of formal education. Keywords: education, intelligence, myopia, near work, visual acuity INTRODUCTION Cohn! was the first o observe an increased prevalence of ‘myopia among persons characterised by high intellectual abil- ties and academic achievement more than a century ago. Since then, many investigators including Goldschmidt, Teasdale et al®, Rosner and Belkin”, Gawron® and Dunphy et al® have prodiuced epidemiological evidences that are consistent wit Cohn's findings. Goldschmidt found the frequency of myopia of any degree ‘among male Danish army conscripts in 1964 was 5.7% among unskilled workers, and this increased steadily dough groups ih intermediate education 10 38.7% among men with grammar schol or university education. More recently Teasdale et al \whoslso studied young men being drafted for military service in Denmark, showed that myopes of all degrees had significantly higher educational levels and intelligence test scores than non- imyopes. A strong association of myopia with both years of school attendance and intelligence was also reported by Rosner and Belkin" in a nationwide study involving 157,748 Jewish ‘males aged 17 10 19 years, They found thatthe prevalence of ‘myopia was significantly higher in the more educated and more intelligent groups. Myopic military recruits were also shown by Gaweon' to have completed those who were not myopic. Inthe United States, Dunphy etal! found myopia to be more frequent in academic populations than among unselected populations of young men, “Myopia prevalence has also been found to be closely associ- ted with many other factors includingage®) sex, race™and degree of urbanisation of place of residencel™. To study the relationship between educational attainment and myopia, an Medical Clasiiation Centre Central Manpower Base Singapore Armed Forces Depot Read Camp Depot Road Singapore 0410 KG AuFong, MBBS Medical Officer PH Tay, MBBS, FRCS (Glas). FCOphth (UK), FAMS Ophinalmetopist, MK Litn, MBBS, FAMS, DAvMed, MSe (OM), MPH Chief Medien Officer 1 DrK-G An Bong Singapore Nations ye Centre 11 Third Hospital Avenue Singapore 0316 Correspondence 489 SINGAPORE MED J 1993; Vol 34: 489-492 attempt to match as closely at possibly the abovementioned variables will reduce the number of confounding factors and produce a more accurate picture of the relation ‘The relationship between educational attainment and myo pia among young Singaporean males has been previously ana- lysed in a study frst reported by Chew SI et all® and later expanded by Tay MTH et al". It was demonstrated that males ‘vith higher educational levels in general had higher myopia prevalence. However, the different educational groups were not stratified into the different major races and since the racial distibutionsof malesin the differenteducational groupsmay not be identical and myopia prevalence is closely related to race™”, some bias may be present due to over-representation of certain races in some ofthe educational groups. Comparing males ofthe same race wll eliminate this bias, This paper is part of a retrospective cross-sectional epide= ‘miological study of myopiain 110,236 young Singaporeanmales ‘who were examined from April 1987 to January 1992. The aszociation between race, culture and myopia in this cohort has been separately reported. This paper examines the relationship betsvecn educational attainment and myopia by comparing the prevalence and severity of myopiaamongst groups with different educational eelsafter they have been matched forage, sex, race and degree of urbanisation of place of residence. SUBJECTS AND METHODS Al Singaporean males are called up for a compulsory pre enlistment medical examination and clasification at an appro- priate age. There isno sereening of any form prior tothe meshcal ‘examination, The vast majority of males are medically examined at 171018 years of age (mean age 17.75 years) although theirage ‘may range from 15 to 25 years. ‘A standardised ophthalmic examination is done forall sub {ects as part of the medical examination. This includes the determination of monocular unaided distance visual acuity for Doth eyes using the Snellen’s cart at six metres. ‘The computerised data of all subjects who were examined from April 1987 to January 1992 were retrieved and reviewed. Only the resulis for the right eye were analysed. Although refractions for right and left eyes may differ, they are known 10 be highly correlated. All subjects except those with impaired ‘unaided vision which could not be corrected by refraction were includedin thi study. This made up total of 110,236males. This sample represents almos! the entire male Singaporean population ‘ho were required to report for medical examination from April 1987 to January 1992 and may therefore be considered to be fairly representative of the general population of young. ‘Singaporean males in that age group.Asall subjects with impaired unaided vision notcorrected by refraction were excluded from this study, the cause of impaired lunaided vision of all males in this study is ametropia. Since ‘myopia has an overwhelming preponderance over hyperopia in this age group inthe local context, the estimated prevalence rate ‘of myopia can be taken tobe very close tothe prevalence rate of ‘ametropia in this study. Unaided visual acuity of 6/12 or better was considered adequate. Myopia was defined as unaided visual acuity of 6/18 or ‘worse in this study. Unaided visual acuity af worse than 6/60 was used as an indicator of severe myopia. “The highest level of education attained at the time of exami- nation of all subjects was determined and classified into one of the following categories in approximately increasing order of educational attainment: i) NFE No formal education ii) PRI” Have bogun but not completed 6 to 8 years of primary education iii) PSLE Passed the Primary School Leaving Examina- tion ie successfully completed 6 108 years of primary education iv) SEC Have begun but not completed 4 years of seconilary education Passed the General Certificate of Education 1N’ Level Examination ie successfully com= pleted 4 years of secondary education Passed the General Certificate of Education “0! Level Examination ie successfully co pleted 4 to 5 years of secondary education assed the General Certificate of Education A’ Level Examination ie successfully com- pleted 2 t03 years ofpre-universty education Successfully completed a 3 year diploma Successfully completed 3t0 years of univer- sity education ‘The different educational groups were fairly well-matchedin ‘each ofthe following factors a Age ‘The prevalence of myopia varies with age, Myopia is rare among infants of industrialised countries. However, in a birth cohort, it increases in prevalence and severity through the end of adolescence ad then stabilises". Although the age range of our ‘sample is from 15 10 25 year, the vast majority of males were examined at 17 t0 18 years of age and this small age range ‘minimises any variation in myopia prevalence that may occur v) GCE'N' vi) GCE'0 vil) GCE'A' viii) DIP ix) UNIV b) Sex Some studies have found females to have a slightly higher myopia prevalence than males. Since only males ae included inthis study, gender is nota confounding factor in our analysis. ©) Race Race is an expression of genetic constitution” and has heen shown to be a major inflvence in myopia prevalence observed amongstthe different races inthis stady cohort", Of the 110,236 males in our study, there were 88,315 (80.1%) Chinese, 12,854 (11.74%) Malays and 8,138 (7.4%) Indians (Table 1), The bulk of the 929 0.85%) males of other races were Eurasians. Comparison amongst groups with the same racial background removes ‘confounding factor. 490 © Degree of urbanisation of place of residence Some studies have suggested an association between myopia and the degree of urbanisation of place of residence”. The popula: tion of Singapore can be considered homogenous in this respect since Singapore is a very small country and is almost wholly urbanised, RESULTS 1) Estimated prevalence rate of myopia ‘The estimated prevalence rates of myopia amongst the Chinese, Indians, Malays and Eurasians with different educational levels are as shown in Tables If, I, 1V and V. The rates for all males regariless oftheir race by educational levels are as shown in ‘Table VI. twill be noted that in general, the myopia prevalence rate ‘was higher among groups with higher educational levels (Tables 1, IL, IV and V). Within each racial group, myopia prevalence ‘was lowestin males with noformaledcation except in Eurasians ‘where the NFE group was very small. Myopia prevalence rate rose steadily from the groups with no formal education through roups with intermediate educational levels to those with GCE ‘A’ eve, diploma and university education in whom the rates were highest. For example, among Chinese males, 16.4% of ‘those with no formal education were myopic (Table HD. The rate for those with PSLE and GCE 'N’ and 'O" level education were 21,36, 35.0% and 48.3% respectively. Those with GCE'A’Iével tnd university education had 68.0% and 66.2% myopia preva lence rates respectively. 2) Kstimated prevalence of severe myopia and proportion of _myopes with severe myopia Using unaided visual acuity of worse than 6/60 38 an indicator of severe myopia (and excluding ether ocular pathology), the est ‘mated prevalence rate of severe myopia was in general higher among the more educated groups (Tables Il, I, IV and V). The proportion of myopes with severe myopia was also generally higher among the more educated groups (Tables IL. II, and 1V). Forexample,32.5%of all Chinese myopes who began butdid not complete primary education (PRI group) had unaided visual acuity of worse than 6/60 (Table I). This proportion was 33.9%, 46.7% and 53.1% for those with PSLE and GCE'N and’'O' evel education respectively. The highest proportions were found among those with GCE ‘A’ Jevel and university education with {63.3% and 64.64 respectively. Interestingly, althoughithe preva: Tenee ates ofboth myopiaand severe myopiain the Chinese NFE group were lower than the corresponding rates in the PRI and PSLE groups, the proportion of myopes with severe myopia in the NFE group was higher thanthatin he lattertwo groups (Table 1), The trendamong Eurasians was not clear because ofthe small ‘numbers ofmyopesin some ofthe educational groups (Table V). distribution of ingaporean males ‘Number Percentage Aisibution (%) Chinese 88,315 801 Malay 12.854 Y Indian 8.138 74 Others 29 08 Total 110,236 100.0‘Tabled Myopia among young Chinese Singaporean ‘Table V — Myopia among young Eurasian Singaporean, ‘males by educational attainment ‘males by edueational attainment yori ‘Severe mya Myopia ‘Severe myopia dvcaiona! © No) ————— —————————___Edweafonal No,_|§ ———— ———_____ atainment No, Pewlence No, Preilence Peceageof attainment No, Prevalence No, Prevalence Perestge of ® (8) nyones (6) @ (6) —_myopes 8) Ne we ids SSC Ne > 2m2 0 O ° PRL TM 16H 21 69 BS PRL 9 62 9 oO 0 PSLE 686 149 213 Bl 12 PSLE 39 m2 38D SEC Sos 37 286 hLDA SEC &B m3 9 22 oD GCEN 4563 15% 350 M767 GcEN 6 16 BS GCEO 26523 1280 483 GAN SH SB GEO 30 110 31403 SS GCEN 208M 1416S 68D 8968 BD ce B BQ 7 Be a6 DP Taam 7984 S20 ASM BT ST Die 7 2 HR 610 1355 UNIV 2aH4 L618 662 2s ots UNIV. 3 69 BS 65 Tata WSIS GAN AS DIN RSS Tol mm TTR SID ‘Table IIL - Myopia among young Malay Singaporean ‘males by educational attainment ‘Table VI--_Myopia among young Singaporean males of all races by educational attainmen Myopia ‘Severe myopia Myopia ‘Severe myopia vcationd No, | ———— ————__Eitucatonal___ No, |§ ———— stint No, Prevalence No. Prevalence Peenigeof ——aanment No, Prevalence No, Prowlence Perentge of ©, )__myopss (8) ) (8) myopes() Nie me 3109 83 NE Wa 1 166 71289 2194 mH BSL 38D PRI uo 298 189 656 9 1598 1 B27 3 SLE. gail 19% 192 S80 62323 59 1st 1488 SEC G76 1736 258 706-105-407 1s 3 240698 693 2100 3038819 4467 1288 885051338 35925 15061 M477 28S Ia @ 4970 Me 24000 15,715. 652 ms a6 5S BS 46 1 RD 55 14399 8342 519 me Sa as 49 9a UN 2678 1738_ 649 as as aM MM MS 1295 RT wal ‘O36 4876442 Ba SMA ‘Table LV ~ Myopia among young Indian Singaporean males by educational attainment Myopia Severe myopia Eicon! — No, ———_____ atanment No, Prevlense No. Prevalence Percentage of ) () __myopes Tm % WS OM RO SR 99 MB ISB TB 6 MS 166 | SOM 2 190 1993 ous m3 2 2S WS BA WS MN V9 798 467 4568S 36 I) 1366 9 Sad M6 OT S00 Si 20s wd LT TA DISCUSSION "The fact that there is an association between the prevalence and severity of myopia and educational levels does not necessarily imply a cause-and-effect relationship as each of these may ‘correlate with some common but unidentified factors ‘One factor which may correlate with both myopia and ‘education is near work. Goldschmidt studied the relationship between myopia prevalence and different occupational catexo- ries which grouped subjects according tothe amount of near work performed. He found that those who performeda greater amount ‘of near work such as students and clerks had higher prevalence ‘of myopia than those who did a lesser amount of near work such as labourers, chauffeurs, farmers and fishermen, 491 11 js difficult if not impossible at the present moment 10 determine if near work induces myopia or hat myopic individu als choose to do near work. Iti possible that the gradual loss of efficient distance vision in myopes tends to concentrate the interests and energies of these individuals more and moreon near tasks, However, some investigators have implicated accommo- dation asa cause of myopia. Association of myopia with reading has been shown inthe United States population". One hypoth esis is that of the laying down of new lens fibres as the ciliary "muscle holds the lenssteady inthe accommodative position. This leads to a permanent increase in the convexity of the Tens surfocel®, There is also some evidence of increased vitreous pressure during secommodation which could cause the axial length of the globe to increase, ‘A rough indicator ofthe amount of near work done is the ‘nurnber of years of formal education atended. Its possible that those who are more educated, and hence exposed to more years ‘of formal education and its requirements for reading and close work, are more predisposed to the development and progression ‘of myopia than the less educated, The remarkable academic success ofthe myopic population has naturally raised questions regarding the association of myo pia and intelligence. A number of studies have demonstrated a ‘easurabledifference in the intelligence quotient (1Q) of persons with various refractive states?*!. Rosner and Belkin" showed strong association between the rate of myopia and intelligence in 137,748 male Jewish recruits aged 17 10 19 years. The prevalence rate of myopia in males with an 1Q of 80 oF less was 5,05. This rte became gradually higher with an increase in 1Q until it reached 27.3% among those with an 1Q of 128 or more.Among. 5,943 myopic and 9,891 non-myopie 18-year-old men being drafted for military service, Teasdale etal?) showed that :myopes of all degrees had significantly higher 1Qtest scores than rnon-myopes. Arealassociation betweenhigh IQ and myopia was also shown by Sofuerand Emery*inastudy on British members ‘of Mensa, the intemational society forthe highly intelligent, ‘Although IQ assessment was not performed on the subjects in our study, it is probable that those who achieved higher ‘educational levels were in general more intelligent and hence imeigenceis possible common fctorthat correlates with both myopia and educational attainment in our study, Given the hereditary background of myopia, scholarship reinforcement ‘was also more likely to be present at home. The myopic student more often has a similarly affected parent, often also of similar academic achievement, who would stress intellectual pursuits ‘and academic hobbies®. However, because both myopia and 1Q are to some extent inherited, there may be purely genetic exp nations forthe observed association, “Asthe genesis of myopia ishighly complex, further analyses are needed to explain how these various Factors and possibly other yet unidentified factors are related to one another and to myopia, CONCLUSION (ur data confirm findings from other studies that the prevalence and severity of myopia are associated with educational atain- ment. Itgoes further by confirming tis association afer suitably "matching the study groups for known confounding factors such sage, sex, race and degree of urbanisation of place of residence, {A variety of factors both genetic and environmental probably “underlie the reasons for this observ 42 ACKNOWLEDGEMENTS ‘Wethank Professor Arthur SMLim, Maj(D1) Liam Beng1inand ‘Professor Wallace $ Foulds fr their advice and support. We are also grateful to Ms Nithia Devan and Ms Tsai Meow Ling for their assistance, and to the past and present staf of the Eye Section, Medical Classification Centre, who performed the eye examinations. Revrnences 1 ht ely ate ahs a be penn ot in 2G One ely of myo: An piercing ay, At pala ‘S098 op ‘Section ove ant 966 BEST PEPE eee eee 5 Gen iemeanng mye comedy npn Duy ES Ming pag Asn ae psn Am pt tenes S88 7S. Ape ac vi Ach Oia 5040 wi Tm aioe nga i Sa An ‘pldalmologySprgis, Ics,Unied Ses of Amer: Toma. ta es At Oia ‘sro, eee