Korean J Ophthalmol 2016;30(3):214-224

http://dx.doi.org/10.3341/kjo.2016.30.3.214
pISSN: 1011-8942 eISSN: 2092-9382

Original Article

Refractive Errors in Koreans: The Korea National Health and

Nutrition Examination Survey 2008-2012
Tyler Hyungtaek Rim1, Seung-Hyun Kim2, Key Hwan Lim3, Moonjung Choi1, Hye Young Kim4*,
Seung-Hee Baek5*; Epidemiologic Survey Committee of the Korean Ophthalmological Society
1
The Institute of Vision Research, Department of Ophthalmology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
2
Department of Ophthalmology, Korea University College of Medicine, Seoul, Korea
3
Department of Ophthalmology, Ewha Womans University School of Medicine, Seoul, Korea
4
Department of Ophthalmology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
5
Department of Ophthalmology, Kims Eye Hospital, Myung-Gok Eye Research Institute, Konyang University College of Medicine, Seoul, Korea

Purpose: Our study provides epidemiologic data on the prevalence of refractive errors in all age group 5 years
in Korea.
Methods: In 2008 to 2012, a total of 33,355 participants aged 5 years underwent ophthalmologic examina-
tions. Using the right eye, myopia was defined as a spherical equivalent (SE) less than -0.5 or -1.0 diopters
(D) in subjects aged 19 years and older or as an SE less than -0.75 or -1.25 D in subjects aged 5 to 18 years
according to non-cycloplegic refraction. Other refractive errors were defined as follows: high myopia as an SE
less than -6.0 D; hyperopia as an SE larger than +0.5 D; and astigmatism as a cylindrical error less than -1.0 D.
The prevalence and risk factors of myopia were evaluated.
Results: Prevalence rates with a 95% confidence interval were determined for myopia (SE <-0.5 D, 51.9% [51.2
to 52.7]; SE <-1.0 D, 39.6% [38.8 to 40.3]), high myopia (5.0% [4.7 to 5.3]), hyperopia (13.4% [12.9 to 13.9]), and
astigmatism (31.2% [30.5 to 32.0]). The prevalence of myopia demonstrated a nonlinear distribution with the
highest peak between the ages of 19 and 29 years. The prevalence of hyperopia decreased with age in sub-
jects aged 39 years or younger and then increased with age in subjects aged 40 years or older. The preva-
lence of astigmatism gradually increased with age. Education was associated with all refractive errors; myopia
was more prevalent and hyperopia and astigmatism were less prevalent in the highly educated groups.
Conclusions: In young generations, the prevalence of myopia in Korea was much higher compared to the white
or black populations in Western countries and is consistent with the high prevalence found in most other Asian
countries. The overall prevalence of hyperopia was much lower compared to that of the white Western popu-
lation. Age and education level were significant predictive factors associated with all kinds of refractive errors.

Key Words: Astigmatism, Hyperopia, Myopia, Refractive errors

Received: April 4, 2015 Accepted: June 24, 2015

Corresponding Authors: Seung-Hee Baek, MD, PhD. Department of Ophthalmology, Kims Eye Hospital, Myung-Gok Eye Research Institute, Konyang
University College of Medicine, #136 Yeongshin-ro, Youngdeungpo-gu, Seoul 07301, Korea. Tel: 82-2-2639-7811, Fax: 82-2-2633-3976, E-mail: drs-
litlamp@kimeye.com
Hye Young Kim, MD. Department of Ophthalmology, National Health Insurance Service Ilsan Hospital, #100 Ilsan-ro, Ilsandong-gu, Goyang 10444, Ko-
rea. Tel: 82-31-900-0590, Fax: 82-31-900-0049, E-mail: khyeye@hanmail.net
*
These authors contributed equally to this work.

2016 The Korean Ophthalmological Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses
/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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 TH Rim, et al. Refractive Errors in Korea

Refractive error is one of the most common causes of vi- Study design and population
sual impairment worldwide and is the second leading A detailed description of the sampling, enumeration, vi-
cause of treatable blindness [1]. An increasing number of sual acuity, and ocular examination procedures was previ-
epidemiologic studies focusing on refractive errors have ously published [18]. All examinations and health inter-
been conducted, both in developing countries and in devel- views were conducted in mobile centers by trained team
oped countries [2-17]. However, there are few published members, including ophthalmology residents or ophthal-
studies that encompass all age groups and specifically re- mologists.
port changes in prevalence with age. There are a few stud-
ies [18,19] that have reported detailed data on the preva-
Examination methods and definition of refractive er-
lence of various refractive errors in the Korean population. rors
However, there is still little known about the prevalence of
various refractive errors across age groups. South Korea Refractive errors and visual acuity were examined in
has experienced rapid socioeconomic growth over the past subjects aged 5 years or older. Refractive error was mea-
several decades, and the estimated increase in the preva- sured three times using an autorefractor-keratometer
lence of refractive errors is a major public health and so- (KR8800; Topcon, Tokyo, Japan) under non-cycloplegic
cioeconomic concern. conditions. Average values of the three refraction measure-
The Korea National Health and Nutrition Examination ments were printed from the autorefractor and were re-
Survey (KNHANES, http://knhanes.cdc.go.kr) is an annu- corded using a negative cylinder notation. Participants
al nationally representative survey conducted by the Min- were excluded from analyses if any of the following was
istry of Health and Welfare in South Korea. The Korean present: (1) aged less than 5 years; (2) a history of cataract
Ophthalmological Society has participated in this survey surgery in the right eye; (3) a history of laser refractive
since July 2008 and has conducted ophthalmological inter- surgery in the right eye; or (4) missing autorefractor data
views and examinations with the purpose of elucidating of the right eye due to lack of time, inability to comply
the prevalence of common eye disorders, including refrac- with the protocol, or equipment malfunction. Prevalence
tive errors. On behalf of the Epidemiologic Survey Com- was calculated using the refractive error data of 33,355
mittee of the Korean Ophthalmological Society, we report participants for the right eye only. The refractive data was
the prevalence and risk factors of refractive errors in all converted to the spherical equivalent (SE), which was de-
age groups 5 years among the general South Korean pop- rived by adding the spherical component of the refraction
ulation derived from a nationwide epidemiological survey. to one-half the value of the cylindrical component. We de-
This study utilized all the data from ophthalmologic ex- fined myopia using two thresholds. For subjects aged 19
aminations conducted in the KNAHNES from 2008 to years or older, criteria were SE <-0.5 and <-1.0 diopters (D).
2012. Since non-cycloplegic autorefraction is likely to be overes-
timated in the young population, we used a more strict
definition of myopia for subjects aged 5 to 18 years: SE
Materials and Methods <-0.75 rather than SE <-0.5 D, and SE <-1.25 rather than
SE <-1.0 D. High myopia was defined and analyzed as an
Statement of ethics SE <-6.0 D. Hyperopia was defined as an SE >+0.5 D.
Astigmatism was defined as a cylindrical error (Cyl) -1.0
Ophthalmic examinations were conducted under the su- D, without reference to the axis. Astigmatism was defined
pervision of the Epidemiologic Survey Committee of the as with-the-rule if the axis was between 0 and 15 or 165
Korean Ophthalmological Society. This survey was re- and 180 degrees, as against-the-rule if the axis was be-
viewed and approved by the institutional review board of tween 75 and 105 degrees, and as oblique if the axis was
the Korea Centers for Disease Control and Prevention from 16 to 74 degrees or 106 to 164 degrees. Additionally,
(KCDC), and all participants provided written informed we provided the prevalence of refractive errors using the
consent. The study was conducted in accordance with the KCDC definition of the other eye in the supplementary
Declaration of Helsinki. material. Another study population was selected to assess

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Korean J Ophthalmol Vol.30, No.3, 2016

the KCDC definition of refractive errors of either eye. The Results

KCDC defined refractive error as follows: myopia as SE
-0.75 D, hyperopia as SE +1.0 D, astigmatism as Cyl Baseline characteristics of the study population
-0.75 D in either eye, and anisometropia as SE difference
2.0 D or as cylindrical difference 1.5 D between the A comparison of the demographic characteristics of the
eyes. 33,355 subjects included in this study with those excluded
from this study (n = 3,519) is provided in Table 1. Included
participants were more likely to be younger, male, in a
Independent variables
higher income group, and living in an urban area than
The analyzed sociodemographic variables were age, those who were excluded from this analysis. Another study
gender, household monthly income (lowest quintile/2nd to population for estimating prevalence of refractive errors
4th quintile/highest quintile), highest educational level using KCDC definition included 33,922 participants.
achieved (elementary school or lower/middle school/high
school/college graduate or higher), and residential area (ru-
Age- and gender-standardized prevalence
ral: town [eup], township [myeon], or neighborhood [dong]/
urban: city [si], county [gun], and district [gu]). Quintiles Table 2 provides the age- and gender-standardized prev-
of income were divided using the data from KNHANES alence of refractive errors in the right eyes. The prevalence
2008-2012 before the exclusion criteria were applied. with a 95% CI was determined for myopia (SE <-0.5 D,
51.9% [51.2 to 52.7]; SE <-1.0 D, 39.6% [38.8 to 40.3]), high
myopia (5.0% [4.7 to 5.3]), hyperopia (13.4% [12.9 to 13.9]),
Statistical analysis
and astigmatism (31.2% [30.5 to 32.0]) in all participants
Basic study population characteristics were reported. To 5 years of age. The prevalence of myopia had a nonlinear
determine the age- and gender-standardized prevalence of distribution with the highest peak between the ages of 19
refractive error, the prevalence was calculated according and 29 years, with a minor increase in subjects older than
to the guidelines of the KNHANES 2008-2012 data analy- 70 years for both thresholds of myopia of -0.5 D and -1.0 D.
sis using a poststratification adjustment. Poststratified High myopia showed a similar pattern to myopia, with the
weight was calculated based on the response and ex- highest prevalence of 10.2% in the age group of 19 to 29
traction rates in order to reflect the distribution of the 2010 years, but without the minor increase in subjects over 70
Korean population by age groups of 5-year intervals and years. The prevalence of hyperopia was lowest in subjects
by gender. Consequently, the sum of the weight according in their 30s (1.6%; CI, 1.2 to 2.1); it decreased with age in
to KNHANES 2008-2012 was representative of the Kore- subjects aged 39 years or younger and then increased with
an population as of 2010. Data was analyzed using the sur- age in subjects aged 40 years or older, with an abrupt in-
vey procedure of Stata SE ver. 13 (Stata Co., College Sta- crease in subjects aged 50 years or older. The prevalence of
tion, TX, USA) to account for the sample design and astigmatism gradually increased with age with a slight de-
sampling weight adjusted for oversampling and nonre- crease around 30 to 39 year ages. Table 3 provides the
sponders. Multivariate logistic regression analysis includ- prevalence of refractive errors using the KCDC definition.
ing age, gender, household monthly income, education, Fig. 1 shows 100% stacked column charts of the refrac-
and residential area was conducted to identify the sociode- tive error distribution in the right eye by age group. Myo-
mographic risk factors of refractive errors. Adjusted odds pia was more prevalent in children, adolescents, and young
ratios and 95% confidence intervals (CIs) were calculated. adults, whereas hyperopia was more prevalent among very
Only adults aged 19 years or older, assumed to be finished young children of 5 to 6 years of age, middle-age, and el-
growing, were included for evaluating risk factors of vari- derly subjects (Fig. 1A). Hyperopia showed a relatively
ous refractive errors. Results with p-values less than 0.05 lower prevalence of less than 5% from 12 to 49 years of
were considered statistically significant. age. The proportion of emmetropia between -0.5 and +0.5
D started at approximately 60% in children 5 to 6 years of
age, decreased in adolescents 12 to 18 years old, increased

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 TH Rim, et al. Refractive Errors in Korea

Table 1. Demographics of the study participants from the Korea National Health and Nutrition Examination Survey 2008-2012
Included (n = 33,355) Excluded (n = 3,519) p-value
Age (yr) <0.01
5-19 7,486 (22.4) 193 (5.5)
20-39 8,049 (24.1) 822 (23.4)
40-59 10,283 (30.8) 546 (15.5)
60-69 4,365 (13.1) 557 (15.8)
70 3,172 (9.5) 1,401 (39.8)
Sex <0.01
Male 15,165 (45.5) 1,301 (37.0)
Female 18,190 (54.5) 2218 (63.0)
Household income <0.01
Lowest quintile 5,841 (17.8) 1,205 (34.9)
2nd to 4th quintile 19,462 (59.2) 1,568 (45.4)
Highest quintile 7,602 (23.1) 682 (19.7)
Education level <0.01
Elementary school or lower 12,040 (36.7) 1,523 (46.6)
Middle school graduate 4,168 (12.7) 296 (9.1)
High school graduate 9,284 (28.3) 657 (20.1)
College graduate or higher 7,352 (22.4) 790 (24.2)
Residence <0.01
Urban 26,369 (79.1) 2,589 (73.6)
Rural 6,986 (20.9) 930 (26.4)
Values are presented as number (%); Chi-squares test was used to calculate the p-value.

to approximately 40% in subjects 50 to 59 years of age, whereas those with higher education levels were at signifi-
and then decreased with increasing age thereafter. The cantly lower risk of hyperopia. Female gender, higher
prevalence of astigmatism generally increased with age, household income, and higher education were significant
with a relatively low prevalence in the 30 to 39 year age protective factors against astigmatism.
group (Fig. 1B). Older adults were more likely to have
against-the-rule astigmatism than were younger people
(Fig. 1C). Discussion

This study documented the prevalence of various refrac-

Sociodemographic factors associated with refractive
error in adults tive errors in the South Korean population 5 years of age
based on a nationwide health survey and outlined indepen-
Table 4 provides the sociodemographic factors associat- dent sociodemographic risk factors for each refractive er-
ed with refractive errors according to multivariate analysis ror.
of participants aged 19 years or older, reported with odds
ratio and 95% CI. Among participants 19 years of age,
Myopia and high myopia
risk of myopia and high myopia decreased and that of hy-
peropia and astigmatism increased with age. Female gen- The prevalence of myopia in children varies highly
der, higher education level, and urban residence were asso- across regions, and our relatively high prevalence (73.0%
ciated with a higher risk of both myopia and high myopia, in subjects between 12 and 18 years of age) was similar to

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Table 2. Age-standardized prevalence of refractive errors in the right eye (n = 33,355)

Myopia Myopia High myopia Hyperopia Astigmatism
Age (yr) (SE <-0.5 D) (SE <-1.0 D) (SE <-6.0 D) (SE >+0.5 D) (Cyl -1.0 D)
% 95% CI % 95% CI % 95% CI % 95% CI % 95% CI
Overall
5-6 13.2 10.8-16.1 8.0 6.1-10.5 0.1 0.0-0.5 16.4 13.8-19.5 14.1 11.7-16.8
7-11 48.2 45.9-50.6 37.3 35.1-39.7 2.1 1.6-2.9 5.3 4.3-6.5 17.1 15.5-18.8
12-18 73.0 71.0-74.8 62.6 60.4-64.7 9.3 8.1-10.6 2.6 2.0-3.4 34.0 31.7-36.3
19-29 76.4 74.6-78.1 62.8 60.8-64.8 10.2 9.1-11.5 2.2 1.6-2.9 30.8 28.9-32.8
30-39 68.0 66.4-69.5 52.4 50.7-54.2 5.8 5.1-6.6 1.6 1.2-2.1 23.6 22.2-25.1
40-49 55.3 53.7-56.9 38.3 36.6-39.9 4.5 3.9-5.3 3.6 3.1-4.3 25.5 24.1-27.0
50-59 29.6 28.1-31.1 18.0 16.7-19.3 1.5 1.1-2.0 23.3 21.9-24.6 31.8 30.2-33.4
60-69 14.2 13.0-15.5 8.9 7.9-10.1 1.2 0.9-1.6 52.1 50.4-53.9 48.6 46.8-50.5
70 16.6 15.0-18.3 11.6 10.3-13.2 1.1 0.8-1.6 58.0 55.9-60.1 63.6 61.6-65.5
Overall
5 51.9 51.2-52.7 39.6 38.8-40.3 5.0 4.7-5.3 13.4 12.9-13.9 31.2 30.5-32.0
20 49.9 49.0-50.8 36.9 36.1-37.8 4.6 4.2-4.9 15.7 15.1-16.3 32.3 31.5-33.1
40 35.3 34.4-36.3 23.5 22.6-24.4 2.6 2.3-2.9 24.9 24.1-25.7 36.1 35.2-37.1
Men
5 52.7 51.6-53.7 40.4 39.4-41.5 4.6 4.2-5.0 11.9 11.3-12.5 31.3 30.3-32.3
20 50.8 49.6-52.1 38.0 36.8-39.2 4.1 3.7-4.6 13.9 13.2-14.7 32.0 30.9-33.2
40 36.3 34.9-37.8 24.5 23.3-25.8 2.4 2.0-2.9 22.9 21.8-24.0 34.3 33.0-35.7
Women
5 51.2 50.2-52.2 38.6 37.7-39.6 5.4 4.9-5.9 15.0 14.4-15.7 31.1 30.2-32.1
20 48.9 47.9-50.0 35.8 34.8-36.9 5.0 4.6-5.6 17.4 16.7-18.2 32.6 31.6-33.6
40 34.4 33.2-35.6 22.6 21.5-23.7 2.7 2.3-3.2 26.8 25.8-27.8 37.9 36.7-39.0
Myopia was defined as SE <-0.75 D and SE <-1.25 D for subjects aged 5 to 18 years. Complex sample analysis was performed with refer-
ence to weight, stratification variance, and cluster variance, following the statistical guidelines of the Korea Centers for Disease Control
and Prevention. Age- and gender-standardized prevalence was provided based on post-stratified weight.
SE = spherical equivalent; D = diopters; CI = confidence interval; Cyl = cylindrical error.

those of other Asian countries, which have been shown to ferent myopia-driving socioenvironmental factors in dif-
have some of the highest prevalence rates of myopia in the ferent regions, such as urbanization with an increase of
world [20]. A recent study of Sydney schoolchildren formal education.
showed ethnic differences in myopia prevalence; children Among the young adults aged 20 to 39 years, the preva-
of East Asian ethnicity had a higher incidence of myopia lence of myopia and high myopia were higher compared to
than European Caucasian children [21]. The trend of in- those of the white population in the United States [13], and
creasing prevalence of myopia with increasing age in chil- this high prevalence was similar to other countries in Asia
dren and adolescents was explicitly evident in this study, [22,23]. Myopia and high myopia seem to be more preva-
which is also consistent with studies of children from Chi- lent in Asia compared to all races in the United States, es-
na [6,10,17], Taiwan [9], Chile [7], and Germany [14]. On pecially in the younger generations [13]. Unlike the large
the other hand, the prevalence of myopia in Nepal was differences in prevalence across regions among young
lower than that of other countries, without clear increasing adults aged 20 to 39 years, the prevalence of myopia in the
or decreasing trends [8]. These different tendencies in my- 40 years or older age group seemed to be similar across re-
opia prevalence by age in children might be caused by dif- gions; even when differences were noted by region, the

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 TH Rim, et al. Refractive Errors in Korea

Table 3. Age-standardized prevalence of refractive errors in either eye according to the Korea Centers for Disease Control and
Prevention definition (n = 33,922)
Myopia (SE -0.75 D) Hyperopia (SE +1.00 D) Astigmatism (Cyl -0.75 D) Anisometropia
Age (yr)
% 95% CI % 95% CI % 95% CI % 95% CI
Overall
5-6 20.4 17.5-23.6 8.7 6.8-11.0 33.7 30.0-37.5 2.8 1.7-4.4
7-11 58.4 56.0-60.7 4.4 3.5-5.5 41.2 39.0-43.4 4.0 3.2-4.9
12-18 80.2 78.4-81.9 2.8 2.2-3.7 61.9 59.7-64.1 6.7 5.7-7.9
19-29 76.9 75.1-78.5 2.1 1.6-2.8 57.6 55.6-59.6 6.2 5.2-7.3
30-39 68.5 66.9-70.1 1.2 0.9-1.6 50.3 48.5-52.0 5.0 4.4-5.8
40-49 54.9 53.2-56.6 2.5 2.1-3.1 54.0 52.4-55.6 5.4 4.7-6.2
50-59 30.0 28.5-31.5 16.2 15.0-17.4 64.7 63.1-66.3 4.1 3.5-4.7
60-69 15.0 13.7-16.3 43.2 41.5-44.9 79.5 78.0-80.9 7.4 6.5-8.4
70 18.0 16.4-19.7 50.3 48.2-52.3 89.4 88.1-90.6 17.0 15.2-18.8
Overall
5 53.5 52.7-54.3 11.0 10.5-11.4 59.5 58.8-60.3 6.0 5.7-6.4
20 49.9 49.0-50.8 12.8 12.3-13.3 61.2 60.3-62.0 6.2 5.8-6.6
40 35.3 34.4-36.3 20.1 19.4-20.8 66.4 65.5-67.3 6.6 6.2-7.1
Men
5 54.2 53.2-55.3 9.5 9.0-10.0 58.6 57.6-59.7 5.8 5.4-6.3
20 50.8 49.5-52.0 11.1 10.4-11.7 60.1 58.9-61.3 5.9 5.4-6.5
40 36.0 34.7-37.4 18.0 17.1-19.0 63.9 62.6-65.2 6.0 5.3-6.7
Women
5 52.8 51.8-53.8 12.5 11.9-13.1 60.4 59.5-61.4 6.2 5.8-6.7
20 49.1 48.0-50.1 14.6 13.9-15.2 62.2 61.2-63.2 6.4 5.9-6.9
40 34.7 33.5-35.9 22.1 21.2-23.0 68.7 67.6-69.9 7.2 6.6-7.9
Anisometropia was defined as an SE difference 2.0 D or a cylindrical difference 1.5 D in either eye. Complex sample analysis was
performed with reference to weight, stratification variance, and cluster variance, following the statistical guidelines of the Korea Centers
for Disease Control and Prevention. Age- and gender-standardized prevalence and age-standardized prevalence was provided based on
post-stratified weight.
SE = spherical equivalent; D = diopters; CI = confidence interval; Cyl = cylindrical error.

difference was not large [5,13,15,24]. The overall pattern of tion. A myopic shift due to cataract might explain the mi-
prevalence of myopia being higher in younger adults and nor increase of myopia in the participants 70 years of age.
lower in the elderly in this study was consistent with that This pattern has been shown consistently in several studies
of urbanized populations ofSingapore [5,12], southern In- of different ethnic groups, including Japanese subjects [24],
dia [25], and the white United States population [2]. Urban- all three ethnic groups in Singapore [5,12,16], Latinos in
ization and economic development including increasing Los Angeles (United States) [26], and residents of Barba-
level of education combined with genetic susceptibility dos [4].
might contribute to increasing trends of myopia in younger A previous study comparing the prevalence of myopia in
generations compared to older generations in these areas. the United States between 1970 and 2000 revealed that the
The prevalence changes across age groups in this report increase in the prevalence of myopia was more prominent
were similar to those of other developing countries in Asia, in black participants than in white participants, and the re-
which might reflect the age-related prevalence pattern of searchers explained this by the increase of formal educa-
myopia in Asian countries with similar levels of urbaniza- tion, associated with associated with near work demands,

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Korean J Ophthalmol Vol.30, No.3, 2016

A B
100 100

80 80
SE distribution
60 +3.0< SE 60
Percent

Percent
+1.0< SE +3.0 Cyl distribution
+0.5< SE +1.0 Cyl = 0.0
40 -0.5 SE +0.5 40 -1.0 Cyl <0.0
-1.0 SE <-0.5 -2.0 Cyl <-1.0
20 -5.0 SE <-1 20 -4.0 Cyl <-2.0
-6.0 SE <-5.0 -6.0 Cyl <-4.0
SE <-6.0 Cyl <-6.0
0 0
5-6 7-11 12-18 19-29 30-39 40-49 50-59 60-69 70 5-6 7-11 12-18 19-29 30-39 40-49 50-59 60-69 70
Age Age

C
100

80

60
Percent

40
Axis distribution
Oblique
Fig. 1. Age-specific proportions of refractive errors in the right
20
Against-the-rule eye by (A) spherical equivalent (SE), (B) cylindrical error (Cyl),
With-the-rule and (C) axis distribution of astigmatism (n = 33,355).
0
5-6 7-11 12-18 19-29 30-39 40-49 50-59 60-69 70
Age

in the black population [27]. The increased prevalence pia in Korean adults and can also be considered a result of
from around 20% in adults to over 70% in younger gener- a myopic shift in younger generations. The prevalence of
ations in this study can be explained using a cohort effect hyperopia can be represented as a U-shaped curve, de-
associated with urbanization and economic development creasing with age until the fourth decade, then abruptly
combined with genetic susceptibility, rather than a direct increasing from the sixth decade onward (Table 2 and Fig.
effect of aging alone. 1A). In children, the tendency of decreasing hyperopia
with age was consistent with studies conducted in various
other areas [6,10,17]. In adults, the trend of increasing hy-
Hyperopia
peropia prevalence with age was shown in the NHANES
In Asia, the prevalence of hyperopia has been reported [13], both the Chinese and Malay populations of Singapore
to be around 20% to 35% among adults [5,12,28], which is [5,12], Sumatra [28], Germany [14], and the Baltimore Eye
similar to our data (24.9% in subjects, 40 years of age). Study [29], although the specific ages for the beginning
When hyperopia was defined as SE +0.5 D, the preva- and end of the shifts varied across studies. Other epide-
lence of hyperopia in the 40 years age group was about miologic studies have reported that, after the age of 60
20% greater than that of whites in Wisconsin, as reported years, the prevalence of hyperopia is no longer associated
by the Beaver Dam Eye Study (BDES) (49.0% in BDES; with age [2-4,29,30]. In Korea, the cataract surgery rate
28.0% in this KNHANES population, unpresented data) among the population in their 80s is almost 50% [31].
[2]. The prevalence of hyperopia, defined as SE >+0.5 D, Therefore, the hyperopia prevalence might have been over-
was also higher in Australia (Blue Mountains Eye Study, estimated in our elderly subjects because severe cataracts
BMES) [3] compared to Korea based on a similar age that drive a myopic shift were more likely to have been re-
group of 44 years or older (55.6% in BMES; 36.5% in this moved by cataract surgery, and therefore, excluded from
KNHANES population, unpresented data). The low hyper- this study.
opia prevalence in the 40 to 49 year age group (3.6%)
might have contributed to this lower prevalence of hypero-

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 TH Rim, et al. Refractive Errors in Korea

Table 4. Sociodemographic risk factors of refractive errors in the Korean population 19 years of age-multivariate logistic analysis
(n = 26,174)
Myopia (SE <-0.5 D) High myopia (SE <-6 D) Hyperopia (SE >+0.5 D) Astigmatism (Cyl -1.0 D)
aOR 95% CI p-value aOR 95% CI p-value aOR 95% CI p-value aOR 95% CI p-value
Age (yr)
19-29 1.0 (Ref) 1.0 (Ref) 1.0 (Ref) 1.0 (Ref)
30-39 0.61 0.54-0.68 <0.01 0.44 0.37-0.52 <0.01 0.89 0.62-1.27 0.51 0.72 0.65-0.80 <0.01
40-49 0.40 0.36-0.44 <0.01 0.36 0.30-0.43 <0.01 1.38 1.01-1.91 0.05 0.74 0.67-0.82 <0.01
50-59 0.17 0.15-0.19 <0.01 0.16 0.12-0.21 <0.01 12.53 9.46-16.59 <0.01 0.95 0.86-1.06 0.38
60-69 0.07 0.06-0.08 <0.01 0.15 0.11-0.21 <0.01 44.74 33.74-59.31 <0.01 1.75 1.56-1.96 <0.01
70 0.09 0.07-0.10 <0.01 0.15 0.10-0.23 <0.01 60.63 45.50-80.80 <0.01 3.29 2.91-3.73 <0.01
Sex
Male 1.0 (Ref) 1.0 (Ref) 1.0 (Ref) 1.0 (Ref)
Female 1.12 1.05-1.18 <0.01 1.35 1.18-1.54 <0.01 1.04 0.96-1.12 0.36 0.93 0.88-0.99 0.02
Monthly house
income
Lowest 1.0 (Ref) 1.0 (Ref) 1.0 (Ref) 1.0 (Ref)
quintile
2nd to 4th 0.93 0.85-1.01 0.09 0.91 0.73-1.13 0.40 1.03 0.94-1.12 0.56 0.90 0.83-0.97 <0.01
quintile
Highest 0.97 0.87-1.07 0.52 1.03 0.81-1.31 0.80 0.92 0.82-1.04 0.20 0.81 0.74-0.89 <0.01
quintile
Education
Elementary 1.0 (Ref) 1.0 (Ref) 1.0 (Ref) 1.0 (Ref)
school
Middle 1.00 0.89-1.13 0.95 0.92 0.60-1.40 0.69 1.05 0.94-1.17 0.39 0.91 0.82-1.00 0.06
school
High school 1.55 1.40-1.71 <0.01 1.70 1.22-2.37 <0.01 0.81 0.73-0.90 <0.01 0.89 0.82-0.98 0.01
University or 2.38 2.13-2.66 <0.01 2.49 1.78-3.49 <0.01 0.65 0.56-0.74 <0.01 0.84 0.76-0.93 <0.01
higher
Residential area
Urban 1.0 (Ref) 1.0 (Ref) 1.0 (Ref) 1.0 (Ref)
Rural 0.88 0.82-0.95 <0.01 0.79 0.65-0.96 0.02 0.94 0.87-1.02 0.15 0.98 0.92-1.05 0.65
SE = spherical equivalent; D = diopters; aOR = adjusted odds ratio; CI = confidence interval; Cyl = cylindrical error.

Astigmatism gapore Malays (27.8%) and lower than that of the Singa-
pore Chinese population (44.2%) [28]. The prevalence of
Astigmatism (Cyl, -1.0 D) was found in 14.1% of the astigmatism demonstrated an increasing trend with age,
Korean population aged 5 to 6 years. Among children aged which is consistent with previous studies [11,12,29].
less than 6 years, ethnic differences in the prevalence of In our population, with-the-rule astigmatism was
astigmatism seem to exist, as Caucasians were less likely dominant in children and young adults, and the proportion
to have astigmatism compared to other ethnicities [32]. of against-the-rule astigmatism increased with age after
Astigmatism (Cyl, -1.0 D) was found in 36.1% of this Ko- young adulthood. This trend was also reported in southern
rean population aged 40 years or older, which was similar India [25]. It is not possible to make a direct conclusion
to the prevalence found in adults in Sumatra (35.8%) [28] about lifetime changes in astigmatism from this cross-sec-
and the whole adult population of the NHANES in 1999 to tional study; however, our results indicate that against-
2004 (31.0%) [13] and slightly higher than that of the Sin- the-rule astigmatism is caused by changes related to aging.

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Sociodemographic factors and refractive error lence of myopia could have been overestimated and that of
This study confirmed the associations between age, hyperopia could have been underestimated in these young
household monthly income, education, and residential area children [34]. However, the difference in refractive error
and various refractive errors. Age and education were as- caused by accommodation is likely not very large; a previ-
sociated with all types of refractive errors. Women, those ous large epidemiologic study on Beijing children reported
with a higher education level, and those living in an urban that the mean difference in autorefractometry with or
area were more likely to be myopic. It is difficult to form a without cycloplegia was only 0.29 0.40 D in myopic eyes
firm conclusion regarding the association between gender (SE <-0.5 D) [35]. Nonetheless, we used a higher SE value
and myopia prevalence considering the inconsistent results to define myopia, i.e., SE -1.0 rather than -0.75 D, in
reported in previous studies [2,5,11-13]. Higher education children and adolescents (aged 5 to 18) in order to mini-
[5,12,13,29,30] and urban residence [11] were generally con- mize overestimation of myopia prevalence due to non-cy-
sidered risk factors for myopia, and our results support this cloplegic autorefraction. Second, the characteristics of par-
association. Some studies, including the NHANES [13], ticipants were different from those of nonparticipants;
the Tanjong Pagar Survey [5], and the Sumatra Eye Study KNHANES 2009-2012 participants who were included in
[28], found that higher income is associated with an in- this study were more likely to be young, male, in a higher
creasing prevalence of myopia; however, the present study income group, and living in an urban area than were those
did not show a significant association. Respondents with a who were excluded from this study. However, we present-
higher level of education were less likely to have hyperopia ed our results based on our inclusion criteria, and analyses
in this study. Hyperopia was also reported to have a lower of the subjects who had undergone ophthalmologic surgery
prevalence in respondents with a higher educational level that would affect refractive errors such as cataract surgery
in the Singapore Malay Eye Survey [12] and the Sumatra or laser refractive surgeries were excluded from our inves-
Eye Study [28]; however, the Meiktila Eye Study per- tigation, as has been done in other epidemiological studies.
formed in rural Myanmar [33] reported a higher preva- In conclusion, we provide the prevalence of refractive
lence of hyperopia in subjects with higher education. In errors in all age groups 5 years using a national represen-
terms of astigmatism, higher educational level was associ- tative sample. Our findings demonstrated that the preva-
ated with lower prevalence of astigmatism in our results. lence of myopia was higher and that the prevalence of hy-
The Sumatra Eye study found no significant relationship peropia was lower than those previously reported in
between education level and astigmatism [28], whereas the Western countries. The prevalence of myopia was much
Beijing Eye Study showed that astigmatism was associated higher in adolescents and young adults compared to the
with a low educational background [11]. other age groups, which is consistent with that of other
The major strength of this study is that it used a large- East Asian countries.
scale, population-based sample that represents the entire
general South Korean population across all ages. We report
the prevalence of refractive errors, on behalf of the Epide- Conflict of Interest
miologic Survey Committee of the Korean Ophthalmolog-
ical Society, using data from 33,355 participants including No potential conflict of interest relevant to this article
all age groups 5 years, including the entire ophthalmic was reported.
data of the KNHANES series. Our study has several lim-
itations. As previously stated, the prevalence of myopia in
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