Pediatrics

A Prevalence Study on Myopia Among School

Going Children in a Rural Area of South India
K Rajendran*, Mohammed Haneef, Kailas Chandrabhanu, Krishnamoorthy#, Manil Muhammed$, Ratheesh T Pillai

Abstract
Introduction: Myopia or short sightedness is a type of refractive error in which parallel rays coming from infinity are focused in
front of retina when accommodation is at rest. It is a vision condition in which close objects are seen clearly, but objects farther
away appear blurred. Myopia occurs if the eyeball is too long or cornea has too much curvature. Myopia is a common vision
condition affecting nearly 30% of population. It occur more frequently among school children aged between 8 and 12 years.
Because the eye continues to grow during childhood, it typically progresses until about age 20. Aims and objectives: This study
aimed at finding the prevalence of myopia among the students aged 10-12 years of a school in a rural area of Kollam and the
influence of environmental factors, indoor activities like reading, computer games and outdoor activities and genetic factors in
development of myopia. Materials and methods: Study population included students of a nearby school. Students of age >10
years were considered, so students of 5th, 6th and 7th standard students were selected. Each of the division was considered as
one strata and simple random sample of clusters had been selected from each standard. All the students of the selected division
were selected to sample. Thus, a total of 68 students from that school were taken for the study. The study setting was in a rural
area in Kollam district of Kerala. Results: Snellens chart along with unilateral vision blinders were used for evaluating vision.
Details of factors influencing were obtained using a pretested questionnaire in a pilot study. The prevalence of myopia in school
children of rural community in Kollam was found to be 51.47% in which a group of hidden myopic of 43.1% were discovered.

Keywords: Myopia, refractive error, diopter

yopia is a refractive error, which means that

the eyes do not bend or refract light properly
to a single focus to see images properly.
In myopia, close objects look clear but distant objects
look blurred. It is an eye focusing disorder, not an eye
disease. Myopia is inherited and is often discovered in
children when they are between the ages 8 and 12 years
old. During the teenage years, when the body grows
rapidly, myopia may become worse. Between the ages
20 and 40, there is usually little change. Myopia can
also occur in adults.1 The incidence of myopia with in
sampled population often rises with age, country, sex,
race, ethnicity, occupation environment and other factors.
The prevalence of myopia has been reported as high as
70-90% in some Asian countries.1-3

*Professor and Haed, Dept. of Pediatrics

Professor and Head, Dept. of Ophthalmology
Professor, Dept. of Pediatrics
#Assistant Professor, Dept. of Ophthalmology
$Assistant professor, Dept. of Pediatrics
Associate Professor
Azeezia Institute of Medical Sciences and Research Center
Meeyannoor, Kollam, Kerala
Address for correspondence
Azeezia Institute of Medical Sciences and Research Center
Meeyannoor, Kollam - 37, Kerala
E-mail: medicalcollge@azeezia.com

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Indian Journal of Clinical Practice, Vol. 25, No. 4, September 2014

In India, up to 41% of adult population is myopic to 1D

and up to 80% to 0.5D. Myopia occurs more frequently
below the age of 20 years. Risk of myopia is increased
particularly in those children who have a reading habit,
increased indoor activities and family history. Close
reading at a distance <30 cm and continuous reading
for >30 minutes and in a low illumination adds upon
the progression of myopia. The risk of development of
myopia further increases with the habit of reading in
supine position.3
There is an increased incidence of myopia among
students. Alteration in visual power is common in age
group 10-12 years. Students are found to be associated
with lot of near work and prolonged accommodation.
So, we were keen to observe risk factors that increase
the incidence of myopia in this age group. Myopia is
more common in children who are constantly engaged
in indoor activities like watching TV, computer, mobile
and videogames. Incidence of myopia is more in
children who watch TV and use computer in a low
illumination. Lower levels of outdoor activities in
children increase the risk of myopia. Unhealthy reading
habits like reading in supine position at a distance
>30 cm and in a low illumination. Genetics also play an
important role in development of myopia.

Pediatrics
Myopia is a common vision condition affecting nearly
30% of population. It occur more frequently among
school children aged between 8 and 12 years. Because
the eye continues to grow during childhood, it typically
progress until about age 20. However, myopia may also
develop in adult due to visual stress or health condition
such as diabetes.2-5

Visual acuity was tested using Snellen`s chart. All

students were interviewed by using self-administered
questionnaire. Students were placed 6 m from Snellens
chart and asked to read the chart. Each eye was tested
separately. From the findings of this, students were
grouped as myopic and nonmyopic. This is to correlate
the habits and their myopic stage.

Types of myopia

Students who are not having 6/6 vision for at least one
eye were considered as myopic.

Etiological classification: Axial myopia, curvature

myopia, positional myopia, index myopia and

myopia due to excessive accommodation.

Clinical classification: Congenital myopia, simple

myopia, pathological myopia and acquired myopia.

AIMS AND OBJECTIVES

This study aimed at finding the prevalence of myopia
among the students aged 10-12 years of a school in a
rural area of Kollam and the influence of environmental
factors, indoor activities like reading, computer
games and outdoor activities and genetic factors
in development of myopia and find the influence
of unhealthy reading habits like reading in supine
position, in low illumination at a near distance for
>30 minutes in development of myopia.
MATERIAL and METHODS
Study population included students of a school in
Kollam district, Kerala, India. Students of age >10
years were considered, so students of 5th, 6th and 7th
standard students were selected.
Sample size, n = 4PQ/L^2

= (4 60 40)/(12 12)

= 67

We selected 68 students to equalize the number of boys

and girls.
P = Prevalence rate; Q = 100-P
L = Allowable error of P (20%)

Sampling Technique
Each of the division was considered as one strata and
simple random sample of clusters had been selected
from each standard. Thus, we took 5th, 6th and 7th
standard students. Each standard consists of 3 divisions
each with 45-50 students. A division was selected at
random from all the classes. All the students of the
selected division were selected to sample. Thus, a total of
68 students from that school were taken for the study.

Results
From the study conducted, it was found that the
prevalence of myopia is 51.47%.
According to our study, the significant risk factors were:
Reading in supine position
Reading books at a distance >30 cm.
Watching TV in low illumination
Lower levels of outdoor activities

In a study of 68 students, we found that 35 students

were myopic. Among the 35 myopic students, 20 are
females and 15 are males (Figs. 1 and 2). We found that
only 10 students were using spectacles. The rest did not
use spectacles and had not approached the eye clinic
before. Twenty-five students were having undiagnosed
myopia. The cause of this hidden group was due to lack
of awareness or due to poor parental education and
lack of proper care and attention given to the children
and may be due to lack of healthcare facilities in the
community.
Most of the cases of myopia in children can be detected
in the school by the teachers, if they give proper attention
and care. A properly illuminated and ventilated class
is a necessity and the school environment should be
such that it helps in proper development of health of
the child. Here we found that, the class rooms were
not properly illuminated and ventilated and they were
also overcrowded. The student in the last row was
not able to see the blackboard due to the above-said
problem. Proper awareness guidelines and medical
camps should be conducted in school on myopia, so
as to prevent and also detect new cases of myopia
(Fig. 3 and 4).
After the interview, students were found to have many
risk factors which contribute to development of myopia
as well as many factors, which prevent the incidence.
In our study, we found that, girls were more myopic
than boys, it was true but our hypothesis was not
proved since p value is >0.05. In our study, we found

Indian Journal of Clinical Practice, Vol. 25, No. 4, September 2014

375

Pediatrics
Time spent for continuous
reading >30 minutes

35.5

35

33.5
33

33
32.5
32

No

Yes

No. of students

Females
Males

20

15

14

10

No

Myopic

Yes

Figure 2. Gender distribution of myopia.

Myopic (No)
Myopic (Yes)

14

14

No. of students

12
10
8
6

4
2
0
>4

2-4

No

Myopic

Yes

Time spent for continuous reading

19

15

Figure 1. Frequency of myopia.

20

Valid myopia

<2

Time spent for reading in a day (hours)

Figure 3. Frequency of myopia with reading duration.

that the relation between myopia and family history

had no significance. It may be because of number of
students having family history of myopia was less in
our study (Fig. 5). Indoor activities like watching TV
or looking at computer at a near distance of <30 cm

376

11

10

34

12

12

34.5

No. of students

No. of students

35

Time spent for continuous

reading <30 minutes

Indian Journal of Clinical Practice, Vol. 25, No. 4, September 2014

Figure 4. Relationship between myopia and continuous

reading.

may cause eye strain and reduced blinking rate, signs

of which include blurred vision and red or watery eyes.
About 5% of population is light sensitive, experiencing
discomfort from flickering light of specific frequency,
colors and patterns. Some students get headache from
spending excessive time in front of TV or computer.
To avoid some of these problems, it is advisable not to
watch TV in a dark room, to sit a little further from the
TV, to angle the computer screen straight ahead and
to use antiglare screen. Very close viewing of TV or
computer screen may slightly increase the temperature
of eye tissue due to electromagnetic radiation from
screen (Figs. 7 and 8).
Playing mobile games for long time induces greater
stress on the eye as mobile screen is so small and greater
stress is needed to play the game. Many of the parents
are not aware of these side effects that mobile phones
can make, so let their children to play with these for a
longer period of time.
Unhealthy reading habits have an influence in the
development of myopia. This was proved by our
study. Unhealthy reading habits followed by children
like reading in low illumination at a near distance and
for longer duration add on the progression of myopia.
It has been proposed that hyperopic defocus induced
by accommodative lag during near work stimulate
eye growth, since imposed hyperopic defocus is a
powerful stimulus for eye growth. Attempt to decrease
myopic progression by decreasing the need for
accommodation or accommodative lag by providing
clear vision over a range of viewing distance has
shown clinical significance. Reading in supine position

Pediatrics
Myopic (No)
18

17

10

15

12

10
5

Father, mother & siblings

1 1

Mother & siblings

Father & siblings

2
Father & mother

None

Siblings

1 1

Mother

23

20

Father

No. of students

No. of students

14
10

Watching TV distance <30 cm

25

16
12

Watching TV distance >30 cm

28

30

Myopic (Yes)

No

Yes

Myopic
Watching TV distance

Figure 7. Relationship between myopia and television

watching.
Myopic (No)
Myopic (Yes)

Family member wearing spectacle

30

Figure 5. Frequency of myopia with family history.

26

35

Reading distance >30 cm

32

Reading distance <30 cm

No. of students

30
25

21

20

22

20
15
8

10

5
14

15

10
5
0

No. of students

25

>3

1-2
<1
Computer duration (hours)

NA

Figure 8. Relationship between myopia and computer use.

1
No

3
1

Myopic

Yes

Reading distance

Figure 6. Relationship between myopia and reading

distance.

increases the chance of being myopic. Multiple reading

style increases the stress on eye muscles, to overcome
the stress they tend to read at a close distance.
A child who habitually reads while lying on left side
will probable develop more myopia in left side than
in right eye because the left eye is more closer to the
book and vice versa. The lengthening of eyeball that
results from the stretching allows reading to be done
with lens focusing effort and is the way of revealing
the stress of prolonged close work. The importance
of good lighting is that it causes the pupil to become
smaller, requiring less accommodation. Parents are not
properly aware of possible problems that can occur due
to unhealthy reading habits. It may possibly be due

to poor education and lack of health professionals to

properly guide them. Students who spent more time
for outdoor activities have less chances of development
of myopia because they spent less time for near work.
DISCUSSION
From our study, it was found that the prevalence
rate of myopia among the rural school children was
51.47%. Our study found some relationship between
environmental factors like indoor activities (watching
TV, computer, mobile phone playing, etc.) and low
levels of outdoor activities and unhealthy reading
habits with myopia.
It was found that prevalence of myopia was 8.6%
among school children in South India. In another study,
it was found that the prevalence of myopia increased
from 34% in 2,000 to 59% in 2005. In study 11, it was
found that 2,317 children in age group of 5-10 years
showed a prevalence of 14.02%. In study 13, it was

Indian Journal of Clinical Practice, Vol. 25, No. 4, September 2014

377

Pediatrics
found that 12,800 school children of age group 5-15 years
brought out a prevalence of 45.7%. But in our study, we
found that the prevalence is 51.47%. The reduction in
prevalence of myopia is due to regional variation and
due to the study conducted in rural area.1
It was found that there were no significant difference
in myopia between girls and boys among Indian school
children. In study 10, it was shown that prevalence of
myopia in school children was 65.03%. Prevalence of
myopia was more in females (60.7%) and less (39.3%)
in males. In study 12, prevalence of myopia among
girls was more than that of boys. According to our
study, there were no significant relationship between
sex and myopia (prevalence of myopia among girls is
57.17% and among boys is 42.83%). Our hypothesis is
true that the prevalence of myopia is more among girls
than boys. But, it was not proved because; now-a-days,
boys are more interested in indoor activities like playing
mobile games, computer, etc. than outdoor activities.2,3
The prevalence of myopia is 52-60%. It is associated
with increasing educational pressure combined with life
changes, which have reduced the time children spend
outside. In study 2, it was proved that higher levels of
outdoor activities were associated with more hyperopic
refraction and lower myopia in 12 years old students.
According to our study, we found that the prevalence
of myopia decreases with increasing levels of outdoor
activities. This may be due to higher outdoor activities
were associated with more hyperopic refractions and
lower myopia. Increased outdoor activities during
summer months decrease eye growth in children.4
A study on myopia among school children in India

was done by medical students of Al-Ameen Medical

College. In the study conducted from 2003 to 2006
among 549 students (279 boys and 270 girls), it was
found that prevalence of myopia was 8.6% among
school children in South India.1

In a study conducted in Sydney, the relationship

school children in Kuala Lumpur children. In this

study among 749 students aged between 7-18 years
(49.7% boys and 50.3% girls), for right eye, 15.1%
of girls are myopic and 16.9% of boys were myopic.
For left eye 18.8% girls and 16.45% boys are myopic.
So, the prevalence was 16%. It was found that there
were no significant differences in myopia between
girls and boys among Indian school children.3
A

study on Myopia-major health issue among

school children in East Asia published by The Lancet;
it was found that the prevalence of myopia was
52-60% in school children in East Asia. It was
associated with increasing educational pressure
combined with life changes, which have reduced
the time children spend outside.4

A study on Prevalence of myopia in Taiwanese

school children was done by Dept. of

Ophthalmology, National Taiwan University. This
study was conducted from 2000 to 2005 among
school children aged between 16 and 18 years. It
was found that the prevalence of myopia increased
from 34% in 2000 to 59% in 2005.5

study on relationship of reading habit

and prevalence of myopia was conducted by
Dept. of Ophthalmology, Quassim University.
In this study undertaken from 2000 to 2003
among 320 students aged 7-12 years, it was
found that those who read book at a distance
>30 cm for >30 minutes in low illumination and
in supine position were more prone to develop
myopia. Prevalence was found to be 46%.6

A study on prevalence of myopia in children with

family history of myopia by Dept. of Ophthalmology,

Singapore University, it was found that children
with family history of myopia were more prone to
myopia.7

A study on Reading, writing, working on computer

or watching television and myopia by Dept. of

Ophthalmology, Pomeranian Medical University,
Poland among 5,865 school; it was proved that
myopia occurs more often in those who read and
write >2 hours/day, work 0.8 hours/day on computer
and watch TV >2 hours/day.8

between near, mid-working distance and outdoor

activities with prevalence of myopia was evaluated.
In the study conducted from 2003 to 2005 among
2,367 students, it was proved that higher levels
of outdoor activities were associated with more
hyperopic refraction and lower myopia in 12 years
old students. Students with higher levels of near
work and lower levels of outdoor activities had
the least hyperopic mean refraction (+0.27 D), 95%
confidence interval (CI), 0.02-0.52.2

In a study on prevalence of myopia in school children

A study was conducted in Kuala Lumpur; on

In study on prevalence of myopia in primary school

association between myopia and gender in Indian

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Indian Journal of Clinical Practice, Vol. 25, No. 4, September 2014

by Dept. of Community; National University of

Singapore, it was proved that prevalence of myopia
was more in the cities than in the countryside. The
prevalence of myopia in the city was 19.3% and
6.6% in the countryside.9
children of Qazuin University of Iran by Mohammed

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Lowers FPG & HbA1c

Sustained Improvement
In Glycaemic Control

2014

Delays Insulin Therapy

Pediatrics
Nijad, Shafaq Ali Rahmath and Mohammed Baraka
showed that prevalence of myopia in school
children was 65.03%. Prevalence of myopia was
more in females (60.7%) and less (39.3%) in males.10
CONCLUSION
It was found that the prevalence of myopia in school
children of rural community in Kollam was found to
be 51.47% in which a group of hidden myopic of 43.1%
were discovered. The main risk factors which add to
the incidence of developing myopia are reading books
at a distance less than 30 cm, reading in supine position
and watching TV in low illumination. Higher levels
of outdoor activities will decrease the development of
myopia. Further studies including other environmental
and genetic etiologic factors of myopia are expected.
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A new study by researchers from Massachusetts General Hospital noted that among cannabis-using

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drug addiction. The study was published in the Journal of Addiction Medicine.

An epidemiological study, published in the journal Epidemiology, has suggested that exposure to certain

phenols during pregnancy, especially parabens and triclosan, may disrupt growth of boys during fetal
development and the first years of life. Bisphenol A, however, was not associated with any definite
modification in growth.

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