Is emmetropia the natural endpoint for human refractive development? An analysis of population-based data from the refractive error study in children (RESC)

Purpose: To determine the natural end-point for refractive development during childhood.

Methods: Cycloplegic (1% cyclopentolate) autorefraction was performed on 38, 811 children aged 5 and 15 in population-based samples at eight sites in the Refractive Error Study in Children (RESC). Refractions (right eye) were categorized as myopic (≤-0.5 D), emmetropic (>-0.5 to ≤+0.5 D), mildly hyperopic (>+0.5 to ≤+2.0 D and hyperopic (>+2.0 D).

Results: At five sites (Jhapa - rural Nepal, New Delhi - urban India, Mahabubnagar - rural India, Durban - semi-urban South Africa and La Florida - urban Chile), there was <20% myopia by age 15. Mild hyperopia was the most prevalent category at all ages, except for Mahabubnagar where emmetropia became the marginally most prevalent category at ages 14 and 15. At the other sites (Gombak - semi-urban Malaysia, Shunyi - semi-rural China and Guangzhou - urban China), there was substantial (>35%) myopia by age 15. At these sites, mild hyperopia was the most prevalent category during early childhood, and myopia became the predominant category later. In Gombak district and Guangzhou, emmetropia was a minor category at all ages, with myopia increasing as mild hyperopia decreased. In Shunyi district, emmetropia was the most prevalent category over the ages 11-14.

Conclusion: Emmetropia was not the predominant outcome for refractive development in children. Instead, populations were predominantly mildly hyperopic or substantial amounts of myopia appeared in them. This suggests that mild hyperopia is the natural state of refractive development in children and that emmetropia during childhood carries the risk of subsequent progression to myopia.