Int Ophthalmol
DOI 10.1007/s10792-015-0091-5
ORIGINAL PAPER
Influence of indoor and outdoor activities on progression
of myopia during puberty
Veysi Öner . Asker Bulut . Yavuz Oruç .
Gökhan Özgür
Received: 10 March 2015 / Accepted: 26 May 2015
Ó Springer Science+Business Media Dordrecht 2015
Abstract The purpose of this study was to investi-
gate whether time spent on indoor and outdoor
activities or the other possible risk factors including
age, gender, parental history, and initial refraction was
associated with progression of myopia, during puberty.
Fifty eyes of 50 myopic children aged 9–14 years were
enrolled in the study. The parents were interviewed to
determine the amounts of time in hours per day spent
on reading and writing, using computer, watching TV,
and outdoor activities (i.e., sports, games, or being
outdoor with no activities) on an average day. The
annual myopia progression rate (diopters per year) was
calculated for each subject and was used in the
statistical analyses. The mean initial age of the subjects
was 10.9 ± 1.5 (ranging from 9 to 14) years. The mean
follow-up period was 33.3 ± 10.3 (ranging from 17 to
55) months. There was a significant increase in the
mean myopia value of the subjects after follow-up
period (p \ 0.001). The mean daily time spent on
reading and writing and initial refraction value were
independently associated with annual myopic progres-
sion rate. On the other hand, age, gender, parental
myopia, and the mean daily times spent on computer
use, watching TV, and outdoor activities had no
correlations with annual myopia progression rate. The
V. Öner (&)
A. Bulut
Y. Oruç
G. Özgür
Department of Ophthalmology, Recep Tayyip Erdoğan
University Medical School Education and Research
Hospital, Rize, Turkey
e-mail: veysioner@gmail.com
present study showed that myopia progression was
associated with time spent on reading and writing and
initial refraction value, during puberty. However,
myopia progression was not associated with parental
myopia, age, gender, and daily times spent on using
computer, watching TV, and outdoor activities.
Keywords Myopia progression
Reading and
writing
Computer use
Watching TV
Outdoor
activities
Introduction
Myopia is the most common cause of visual impairment
worldwide [1, 2]. Although myopia is rare in early
childhood, its prevalence rises gradually to 25–80 % in
young adults [3, 4]. Myopia has been found to be
associated with genetic factors [5]. Nevertheless, the
increasing prevalence of myopia in the world makes it
difficult to explain without taking environmental factors
into account [6, 7]. The daily amounts of time spent on
reading, watching TV, using computer, and outdoor
activities have been suggested as environmental factors
associated with onset of myopia [8, 9].
Several previous studies have also investigated the
influence of near work and outdoor activities on
progression of myopia after its onset. It has been
reported that less physical activity and more time spent
on reading were associated with accelerated myopia
123

progression rate in university students [10, 11]. On the
other hand, other studies have found no relationship
between myopia progression rate and hours spent on
near work or outdoor activities in children aged 6–12
and 7–9 years [12, 13].
Recently, it has been shown that children have peak
spherical equivalent or axial length velocity related to
growth spurts in puberty [14, 15]. In the present study,
we aimed to investigate whether time spent on indoor
(reading and writing, using computer, and watching
TV) and outdoor (i.e., sports, games) activities or the
other possible risk factors including age, gender,
parental history, and initial refraction was associated
with progression of myopia, during puberty.
Methods
Fifty eyes of 50 children, aged 9–14 years, who had
-0.25 diopter or more myopia were enrolled in the
study. The right eye of each subject was used for the
analyses. The age range of the study subjects was
decided according to the puberty ages of Turkish
children [16]. The subjects who would be in puberty
during follow-up period were chosen. Subjects who
had any eye disorder reducing best-corrected visual
acuity (i.e., cataract, corneal scar), astigmatism higher
than 2 diopter, and amblyopia were excluded. All
subjects and parents were informed about the study
and they consented to contribute. The study was in
accordance with the Tenets of the Declaration of
Helsinki and was approved by the Local Ethics
Committee.
Each subject underwent ophthalmological standard
examination including determination of refractive
error, measurement of visual acuity (by Snellen
charts), slit-lamp examination, and funduscopy. The
refractive error value was calculated via the spherical
equivalent by an ophthalmologic examination after a
cycloplegic refraction test. Cycloplegia was made by
administration of one drop of cyclopentolate 1 % for
three times (with 5 min intervals). Refractive error
measurement was performed by an autokeratorefrac-
tometer, at least 30 min after the last drop of
cyclopentolate 1 %. The results of the autokeratore-
fractometer were used to decide the distance refractive
error.
The parents were interviewed to determine the
amounts of time in hours per day spent on reading and
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Int Ophthalmol
writing, using computer, watching TV, and outdoor
activities (i.e., sports, games, or being outdoor with no
activities) on an average day. Both week and weekend
days were included to analyses. After the first
examination and questionnaire, the subjects were
examined every 6 months. The annual myopia pro-
gression rate (diopters per year) was calculated for
each subject and was used in the statistical analyses.
Parental history of myopia was also noted.
Statistical analyses
Statistical analyses were carried out by SPSS version
16.0. The distribution of variables was checked with
Kolmogorov–Smirnov test. Quantitative variables
were given as mean ± standard deviation. Categorical
variables were given in percentage. Pearson correla-
tion coefficients were used to assess relations between
the variables. Multiple linear regression analyses were
carried out to evaluate the independent influence of the
possible risk factors on annual myopia progression
rate (confidence interval (CI): 95 %). A p \ 0.05 was
considered as statistically significant.
Results
The mean initial age of the study subjects was
10.9 ± 1.5 (ranging from 9 to 14) years. The mean
follow-up period was 33.3 ± 10.3 (ranging from 17 to
55) months. The mean indoor and outdoor activity
times and refraction measurements of the study
subjects are given in Tables 1 and 2. There was a
significant increase in the mean myopia value of the
study subjects after follow-up period (p \ 0.001).
Table 3 shows the results of correlation analyses
(Pearson correlation coefficients) between the mean
daily times spent on activities and annual myopia
progression rate. The mean daily time spent on reading
Table 1 The times spent on indoor and outdoor activities of
the study subjects (mean ± SD)
Activity Time (minutes/day)
Reading and writing 130.0 ± 86.0 (20–420)
Using computer 90.6 ± 92.8 (0–360)
Watching TV 125.7 ± 65.0 (0–300)
Outdoor activities 80.4 ± 60.1 (30–240)
Int Ophthalmol

Table 2 The refraction measurements of study subjects had no correlations with annual myopia progression
(mean ± SD) rate.
Measurement SE value (diopters) The outcomes of multiple linear regression analysis
evaluating the independent influence of the possible
Initial refraction -1.8 ± 1.3 risk factors on annual myopia progression rate are
The last refraction -2.8 ± 1.6 given in Table 4. The mean daily time spent on
Total myopia progression -0.9 ± 0.8 reading and writing and initial refraction were inde-
Annual myopia progression (per year) -0.3 ± 0.2 pendently associated with annual myopia progression
SE spherical equivalent rate (b1 = -0.379, p1 = 0.017 and b2 = 0.345,
p2 = 0.030, respectively). However, the other possi-
ble risk factors including age, gender, parental history,
Table 3 Correlation analyses between the mean daily times and the mean daily times spent on computer use,
spent on activities and the mean annual myopia progression watching TV, and outdoor activities were not associ-
rate ated with annual progression rate of myopia.
Activity Myopic progression per year (SE)
Correlation coefficient (r) p value
Discussion
Reading and writing -0.362 0.010
Using computer -0.074 0.612 The current study demonstrated that time spent on
Watching TV -0.018 0.899 reading and writing and initial refraction value were
Outdoor activities -0.041 0.766 associated with myopia progression during puberty.
However, there was no relation between myopia
Significant p value is given in bold
progression and age, gender, parental history, and
SE spherical equivalent
times spent on using computer, watching TV, and
outdoor activities.
and writing had a negative correlation with annual Myopia has been found to be associated with
myopic progression rate (r = -0.362, p = 0.010) individual educational levels and close-work jobs
(Fig. 1). On the other hand, the mean daily times spent [17]. Therefore, near work has been suggested as an
on computer use, watching TV, and outdoor activities environmental risk factor for the development of
myopia [8, 18]. Although accommodation and con-
vergence during prolonged near work have been
suggested as the mechanisms for the development of
myopia, strong associations between accommodation
and myopia have not been found [19]. Forced
hyperopic defocus has been demonstrated as an
influential stimulus for eye growth in experimental
studies [17]. Therefore, hyperopic defocus induced by
accommodative lag has been considered as another
mechanism to explain the relation between near work
and myopia. It has been shown that myopic children
have higher accommodative lag compared with em-
metropic children [17].
In the present study, we investigated the effects of
daily times spent on reading and writing, using
computer, and watching TV, separately, on myopia
progression. Our results showed that although the daily
reading and writing time was related with myopia
Fig. 1 Correlation between the mean annual myopia progres-
sion rate and the mean daily time spent on reading and writing in progression, time spent on using computer and watch-
the study subjects ing TV had no correlation with myopia progression.

123

Table 4 Multiple linear regression analysis evaluating the association between possible risk factors and annual myopia progression
rate (Dependent variable: annual myopia progression rate)
Covariates Unstandardized
coefficient (B)
Age (years) 0.054
Gender 0.021
Parental history -0.003
Initial refraction 0.0679
Time spent on reading and writing (h/d) -0.001
Time spent on computer use (h/d) 0.000
Time spent on watching TV (h/d) 0.000
Time spent on outdoor activities (h/d) 0.000
Significant p values have been given in bold
CI confidence interval
These three activities have different effects on the
suggested mechanisms (accommodation, convergence,
and accommodative lag) to explain the relation between
near work and myopia. Reading and writing are
performed with relatively lower light levels and
small-sized words compared with computer use which
is related with flashing images. In addition, different
working distances are used for these viewing activities.
These dissimilarities among the activities cause differ-
ent accommodative patterns and, as a result, might
affect myopia progression differentially [20].
The results of previous studies investigating the
association between myopia progression and near
work are conflicting. Saw et al. [13] have found no
correlation between near work and myopia progression
in children aged 6–12 years. Tan et al. [21] reported
that there were no statistically significant correlations
between myopia progression and near work in children
aged 7, 9, and 12 years, after a follow-up period of one
year. In another study, Saw et al. showed that there was
no relationship between axial elongation and reading in
myopic children aged 7–9 years [12]. On the other
hand, Parssinen et al. [19] found that myopic progres-
sion was associated with time spent on reading and
close work in schoolchildren with a mean age of
10.9 years. It can be speculated that the different age
groups might cause the contradictory results. Our
results were in accordance with the study by Parssinen
et al. [19]. We believe that it might be because of the
similar age ranges of study populations.
We failed to find an association between outdoor
activities and myopia progression during puberty. The
results of previous studies investigating association
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Int Ophthalmol
Standardized 95 % CI p value
coefficient (b)
0.284 -0.004 to 0.113 0.068
0.032 -0.179 to 0.221 0.834
-0.005 -0.174 to 0.168 0.970
0.345 0.008 to 0.149 0.030
-0.379 -0.002 to 0.000 0.017
-0.089 -0.001 to 0.001 0.550
0.027 -0.001 to 0.002 0.859
0.037 -0.001 to 0.002 0.791
between outdoor activities and myopia are also
conflicting. Although several previous studies have
found an association between outdoor activities and
the onset of myopia [9, 22], Jones-Jordan et al. [23]
have reported no significant correlation between
outdoor activities and the rate of myopia progression,
in accordance with our results.
In the present study, multiple regression analysis
showed that the severity of myopia at the beginning of
the study was also independently associated with
progression of myopia. In accordance with our results,
Parssinen et al. [19] and Saw et al. [13] have found that
myopia progression was faster for children who had
severe initial myopia values. On the other hand, we
could not find a relationship between the parental
myopia and annual progression rate. Similarly, Huang
et al. [24] reported that there was no association
between parental myopia and progression of myopia
in school children aged 7–9 years. Conversely, Lee
et al. [25] displayed an association between parental
myopia and myopia progression in subjects aged
18–24 years. The conflicting results might be due to
the different age ranges of the study populations.
In the current study, subjects who were aged
between 9 and 14 years were chosen. The mean
follow-up period was 33.3 ± 10.3 months. Therefore,
although we did not examine the sex characters or the
hormone levels of the subjects, we considered that
subjects should be in the puberty period, which was
determined for Turkish population previously [16],
during follow-up period. However, lacking examina-
tions of the sex characters or hormone level measure-
ments is the limitation of the study.
Int Ophthalmol
Puberty is a dynamic period of growth which is
characterized by rapid alterations in body size, shape,
and composition [16]. It has been suggested that
environmental factors have significant effects on
height and adolescent growth [26]. According to our
results, it can be speculated that eye growth might be
more vulnerable to environmental factors including
reading and writing during the puberty period.
In conclusion, our study displayed that myopia
progression was associated with time spent on reading
and writing and initial refraction value, during puberty.
However, myopia progression was not associated with
parental myopia, age, gender, and daily times spent on
using computer, watching TV, and outdoor activities.
Compliance with ethical standards None of the authors has
conflict of interest with the submission. No financial support was
received for this submission. All subjects and parents were
informed about the study procedure and informed consents were
obtained. The study was in accordance with the Tenets of the
Declaration of Helsinki and was approved by the Ethics
Committee of Recep Tayyip Erdogan University Medical School.
References
1. Zylbermann R, Landau D, Berson D (1993) The influence of
study habits on myopia in Jewish teenagers. J Pediatr
Ophthalmol Strabismus 30:319–322
2. Saw SM, Katz J, Schein OD, Chew SJ, Chan TK (1996)
Epidemiology of myopia. Epidemiol Rev 18:175–187
3. Gilmartin B (2004) Myopia: precedents for research in the
twenty first century. Clin Exp Opthalmol 32:305–324
4. Morgan I, Rose K (2005) How genetic is school myopia?
Prog Retin Eye Res 24:1–38
5. Teikari JM, O’Donnell J, Kaprio J, Koskenvuo M (1991)
Impact of heredity in myopia. Hum Hered 41:151–156
6. Vitale S, Sperduto RD, Ferris FL 3rd (2009) Increased preva-
lence of myopia in the United States between 1971–1972 and
1999–2004. Arch Ophthalmol 127:1632–1639
7. Parssinen O (2012) The increased prevalence of myopia in
Finland. Acta Ophthalmol 90:497–502
8. Lee YY, Lo CT, Sheu SJ, Lin JL (2013) What factors are
associated with myopia in young adults? A survey study in
Taiwan Military Conscripts. Invest Ophthalmol Vis Sci
54:1026–1033
9. Guggenheim JA, Northstone K, McMahon G, Ness AR,
Deere K, Mattocks C, Pourcain BS, Williams C (2012)
Time outdoors and physical activity as predictors of incident
myopia in childhood: a prospective cohort study. Invest
Ophthalmol Vis Sci 53:2856–2865
10. Kinge B, Midelfart A, Jacobsen G, Rystad J (2000) The
influence of near work on development of myopia among
university students. A three-year longitudinal study among
engineering students in Norway. Acta Ophthalmol Scand
78:26–29
11. Jacobsen N, Jensen H, Goldschmidt E (2008) Does the level
of physical activity in university students influence devel-
opment and progression of myopia?–a 2-year prospective
cohort study. Invest Ophthalmol Vis Sci 49:1322–1327
12. Saw SM, Chua WH, Gazzard G, Koh D, Tan DT, Stone RA
(2005) Eye growth changes in myopic children in Singa-
pore. Br J Ophthalmol 89:1489–1494
13. Saw SM, Nieto FJ, Katz J, Schein OD, Levy B, Chew SJ
(2000) Factors related to the progression of myopia in
Singaporean children. Optom Vis Sci 77:549–554
14. Wang D, Ding X, Liu B, Zhang J, He M (2011) Longitudinal
changes of axial length and height are associated and con-
comitant in children. Invest Ophthalmol Vis Sci 52:
7949–7953
15. Yip VC, Pan CW, Lin XY, Lee YS, Gazzard G, Wong TY,
Saw SM (2012) The relationship between growth spurts and
myopia in Singapore children. Invest Ophthalmol Vis Sci
53:7961–7966
16. Semiz S, Kurt F, Kurt DT, Zencir M, Sevinç O (2008) Pu-
bertal development of Turkish children. J Pediatr En-
docrinol Metab 21:951–961
17. Ip JM, Saw SM, Rose KA, Morgan IG, Kifley A, Wang JJ,
Mitchell P (2008) Role of near work in myopia: findings in a
sample of Australian school children. Invest Ophthalmol
Vis Sci 49:2903–2910
18. Goss DA (2000) Nearwork and myopia. Lancet 356:1456–
1457
19. Parssinen O, Lyyra AL (1993) Myopia and myopic pro-
gression among schoolchildren: a three-year follow-up
study. Invest Ophthalmol Vis Sci 34:2794–2802
20. Rose KA, Morgan IG, Ip J, Kifley A, Huynh S, Smith W,
Mitchell P (2008) Outdoor activity reduces the prevalence
of myopia in children. Ophthalmology 115:1279–1285
21. Tan NW, Saw SM, Lam DS, Cheng HM, Rajan U, Chew SJ
(2000) Temporal variations in myopia progression in Sin-
gaporean children within an academic year. Optom Vis Sci
77:465–472
22. Jones LA, Sinnott LT, Mutti DO, Mitchell GL,
Moeschberger ML, Zadnik K (2007) Parental history of
myopia, sports and outdoor activities, and future myopia.
Invest Ophthalmol Vis Sci 48:3524–3532
23. Jones-Jordan LA, Sinnott LT, Cotter SA, Kleinstein RN,
Manny RE, Mutti DO, Twelker JD, Zadnik K, CLEERE
Study Group (2012) Time outdoors, visual activity, and
myopia progression in juvenile-onset myopes. Invest Oph-
thalmol Vis Sci 53:7169–7175
24. Huang CY, Hou CH, Lin KK, Lee JS, Yang ML (2014)
Relationship of lifestyle and body stature growth with the
development of myopia and axial length elongation in
Taiwanese elementary school children. Indian J Ophthalmol
62(8):865–869
25. Lee YY, Lo CT, Sheu SJ, Yin LT (2015) Risk factors for and
progression of myopia in young Taiwanese men. Oph-
thalmic Epidemiol 22(1):66–73
26. Rogol AD, Roemmich JN, Clark PA (2002) Growth at pu-
berty. J Adolesc Health 31:192–200
123