Gustavo Costa Santos1, Rafael Cunha de Almeida2, Willany Veloso Reinaldo1, Fernando Rocha Oliveira3, Shaun Schofield4, Roberto Conde Santos5, Glaucia Luciano da Veiga6, Fernando Luiz Affonso Fonseca6, Vagner Loduca Lima7, Renato Galão Cerquinho Leça7
doi: http://dx.doi.org/10.5195/ijms.2021.809
Volume 9, Number 2: 112-116
Received 28 10 2020: Rev-request 14 12 2020: Rev-request 26 01 2021: Rev-recd 18 12 2020: Rev-recd 26 01 2021: Accepted 06 04 2021
ABSTRACT
Background:Uncorrected refractive errors (Myopia, Hyperopia and Astigmatism) are one of the main causes of poor vision, attributing to 43% of vision deficiencies. Myopia is the most common visual disorder in the world and can progress up until the age of 20-25, when many people are in university. The etiological factors that cause myopia are still unclear and deserve to be studied. Our aim was to identify the prevalence of ametropias and self-perception of ophthalmic health in medical students at the Centro Universitário Saúde ABC/FMABC.
Methods:This is a cross-sectional study with data collected at Centro Universitário Saúde ABC/FMABC from medical students. A total of 232 students participated in the survey, from the 1st to the 4th year of study. Data was obtained through a questionnaire, which evaluates ophthalmologic health, ametropia, and self-perception.
Results:It was observed that 74.57% of the students had some type of ametropia, myopia being the most recurrent (59.05%). The study shows significant data of an increase in the grade of students from 1st to 4th grade throughout college. It was observed that the average daily study time of the students was 9.68 hours and abuse in the use of electronic devices.
Conclusion:This study presented a high prevalence of ametropias among medical students at the Centro Universitário ABC/FMABC, in addition to a high prevalence of multifactorial myopia and an increased need to update their diopters (degrees) during the course of university.
Keywords: Refractive errors; Medical students; Brazil. (Source: MeSH-NLM).
The promotion of eye health is a basic principle in increasing the quality of life because a better visual capacity allows the development of capabilities, improvement in school performance, and full participation in society.1 According to the World Health Organization (WHO),2 uncorrected refractive errors (Myopia, Hyperopia and Astigmatism) are one of the main causes of low vision, attributing 43% of vision deficiencies.3
Myopia is the visual disorder that deserves to be highlighted in this scenario. It is a pathology in which the image is focused before it reaches the retina, causing distant images to be visualized with low clarity. It is estimated that by 2020 the prevalence of myopia will be 23% in the world population, and by 2050 that prevalence will be about 50%.4 In Brazil, this prevalence varies from 11% to 36%, representing approximately a population between 22 and 72 million people.5
Despite the high prevalence in the population, the development of refractive errors is still an unclear issue, mainly regarding the possible etiological factors.6 As much as heredity is known as the main factor influencing the development of a refractive disorder, lifestyle appears to be a factor of great attention for ophthalmologic studies. The excessive utilization of vision for studies, which includes frequent and regular reading, in addition to studies with a continuous focus, apparently also constitute a risk factor.7, 8
Thus, studies describe a high prevalence of refractive errors in students from various fields.9 Among the most prevalent groups are medical students, who due to a lifestyle with intensive studies for several years, constitute a group at risk for myopia and worsening of vision after the beginning of the study.9, 10 Thus, the present work aims to identify the prevalence of ametropias (refractive error) and self-perception of ophthalmic health in medical students of the Centro Universitário Saúde ABC/FMABC, in the metropolitan region of São Paulo, Brazil.
This is a cross-sectional study of medical students at the Centro Universitário ABC/FMABC, carried out from July 2017 to July 2020. The study was approved by the Ethics Committee of Centro Universitário ABC/FMABC (protocol number 2.391.695) and is in line with Resolution 466/12 of the National Health Council.
The sample consists of 232 medical students from the first to the fourth year, without restrictions regarding gender or age. Data was obtained through a self-administered questionnaire structured by the researcher himself, consisting of twelve dissertation questions.11 Oral or written consent was obtained from study participants.
Administration of the questionnaire occurred during the class period. The students were identified by the following information: initials, age, sex, type of visual disorder (Myopia, Hyperopia and Astigmatism), methods of correction used, interest in refractive surgery, daily time devoted to studies, daily time spent using technology, and heredity. This study was carried out in accordance with the relevant guidelines and regulations/ethical principles of the Declaration of Helsinki.
Descriptive statistics were used to describe and summarize the data set, presenting distributions in measures of central tendency and variability, mean, and standard deviation. Age comparison was performed by Kruskal-Wallis test. To assess the sample normality, the Shapiro-Wilk test was performed, and the variables were considered normal for p-value > 0.05. For qualitative variables, the absolute and relative frequency were calculated. For qualitative variables, the Chi-Square test was used. To define the sample number the GPower software version 3.1 was used. The significance level adopted was 5%. The statistical program used was Stata® version 12.
Our sample consisted of 232 students, with the majority female at 157 (68%) students and the average age of the students at 22±2 years old. Among the self-declared changes were astigmatism, both hyperopia and astigmatism; myopia; and astigmatism.
The time that students spend in front of electronic devices daily deserves to be highlighted. Only 26% of students spend less than one hour in front of electronic media, with 47% between 1-5 hours, 22% between 6-11 hours, and 4% for more than eleven hours a day. (Table 1).
Table 1.Population Demographics.
| Variable | n (%) |
|---|---|
| Sample | 232 (100) |
| Age, mean (SD) | 21.8±2.5 |
| Sex | |
| Female | 157 (67.67) |
| Male | 75 (32.33) |
| Graduation Year | |
| 1st Year | 52 (22.41) |
| 2nd Year | 49 (21.12) |
| 3rd Year | 45 (19.40) |
| 4th Year | 86 (37.07) |
| Self-declared Ametropias Changes | |
| Astigmatism | 17 (7.33) |
| Hyperopia | 5 (2.16) |
| Hyperopia and Astigmatism | 14 (6.03) |
| Myopia | 62 (26.72) |
| Myopia and Astigmatism | 75 (32.33) |
| None | 59 (25.43) |
Among the sample, 173 (75%) students reported some type of ametropia and 59 (25%) reported no type of ametropia. In relation to ametropias, myopia presented a higher prevalence followed by astigmatism and hyperopia (Table 2). When analyzing the ametropias among the students according to the year of course, there was no statistically significant difference. In relation to age, a significant difference was observed between the years of the course, the fourth year with the highest mean age.
Table 2.Distribution of the Ametropias According to Year of the Course.
| Variable | 1st Year | 2nd Year | 3rd Year | 4th Year | Total | p-value |
|---|---|---|---|---|---|---|
| Age, mean (SD) | 19.8±2.1 | 21.1±2.0 | 22.2±2.2 | 23.1±2.4 | <0.001** | |
| Ametropia, n (%) | ||||||
| Yes | 33 (63.46) | 40 (81.63) | 33 (73.33) | 67 (77.91) | 173 (74.57) | 0.157 |
| No | 19 (36.54) | 9 (18.37) | 12 (26.67) | 19 (22.09) | 59 (25.43) | |
| Astigmatism, n (%) | ||||||
| Yes | 19 (36.54) | 26 (53.06) | 20 (44.44) | 41 (47.67) | 106 (45.69) | 0.393 |
| No | 33 (63.46) | 23 (46.94) | 25 (55.56) | 45 (52.33) | 126 (54.31) | |
| Hyperopia, n (%) | ||||||
| Yes | 6 (11.54) | 5 (10.20) | 1 (2.22) | 7 (8.14) | 19 (8.19) | 0.366 |
| No | 46 (88.46) | 44 (89.80) | 44 (97.78) | 79 (91.86) | 213 (91.81) | |
| Myopia, n (%) | ||||||
| Yes | 26 (50.00) | 31 (63.27) | 28 (62.22) | 52 (59.77) | 137 (59.05) | 0.497 |
| No | 26 (50.00) | 18 (36.73) | 17 (37.78) | 34 (39.53) | 95 (40.95) |
Table 3 shows the increase in the grade (diopters) of students throughout the medical course (p<0.001). There is a strong trend in the perception of worsening vision of the students during the course (p=0.06). Furthermore, the time spent in front of electronics daily was one of the factors that may have influenced the worsening of vision of the participants. Table 4 illustrates the ophthalmological characteristics of the students with ametropias, according to the year of the course. No statistically significant difference was observed between any variables studied.
Table 3.Student Characteristics in Relation to Health Habits and Perception According to Year of Course.
| Variable | 1st year | 2nd year | 3rd year | 4th year | Total | p-value |
|---|---|---|---|---|---|---|
| Average hours of study, mean±SD | 9.9±1.8 | 9.4±1.8 | 9.8±1.7 | 9.5±1.8 | 9.7±1.8 | 0.330 |
| Frequency of ophthalmology visits, n (%) | ||||||
| At least one consultation a year | 25 (48.08) | 28 (57.14) | 28 (62.22) | 57 (66.28) | 138 (59.48) | 0.383 |
| Every two or more years | 9 (17.31) | 9 (18.37) | 4 (8.89) | 9 (10.47) | 31 (13.36) | |
| When you believe it is necessary | 18 (34.62) | 12 (24.49) | 13 (28.89) | 20 (23.26) | 6 (27.16) | |
| There's been an increase in your grade (diopters) since you went to college, n (%) | ||||||
| Yes | 3 (9.09) | 18 (45.00) | 18 (54.55) | 37 (55.22) | 76 (43.93) | <0.001* |
| No | 21 (63.64) | 15 (37.50) | 13 (39.39) | 26 (38.81) | 75 (43.35) | |
| Does not know | 9 (27.27) | 7(17.50) | 2 (6.06) | 4 (5.97) | 22 (12.72) | |
| Do you believe your vision has gotten worse since you went to college, n (%) | ||||||
| Yes | 22 (42.31) | 17 (34.69) | 9 (20.00) | 37 (43.02) | 85 (36.64) | 0.066 |
| No | 29 (55.77) | 32 (65.31) | 36 (80.00) | 46 (53.49) | 143(61.64) | |
| Does not know | 1 (1.92) | 0 (0.00) | 0 (0.00) | 3 (1.92) | 4 (1.72) | |
| Do you believe your eye prescription needs updating, n (%) | ||||||
| Yes | 9 (17.31) | 9 (18.37) | 6 (13.64) | 22 (26.51) | 46 (20.18) | 0.246 |
| No | 40 (76.92) | 37 (75.51) | 36 (81.82) | 61 (73.49) | 174 (76.32) | |
| Does not know | 3 (5.77) | 3 (6.12) | 2 (4.55) | 0 (0.00) | 8 (3.51) | |
| Time spent in front of the electronic media daily, n (%) | ||||||
| Less than 1 hour | 15 (28.85) | 12 (24.49) | 9 (20.00) | 25 (29.07) | 61 (26.29) | 0.053 |
| 1h-5h | 27(51.92) | 19 (38.78) | 19 (42.22) | 45 (52.33) | 110 (47.41) | |
| 6h-10h | 9 (17.31) | 12 (24.49) | 15 (33.33) | 15 (17.44) | 51 (21.98) | |
| 11h-15h | 1 (1.92) | 6 (12.24) | 2 (4.44) | 1 (1.16) | 10 (4.31) | |
| Daily study time, n (%) | ||||||
| 6h-10h | 38 (73.08) | 34 (69.39) | 27 (60.00) | 62 (72.09) | 161 (69.40) | 0.596 |
| 11h-15h | 13 (25.00) | 15 (30.61) | 18 (40.00) | 23 (26.74) | 69 (29.74) | |
| Greater than or equal to 16 | 1 (1.92) | 0 (0.00) | 0 (0.00) | 1 (1.16) | 2 (0.86) | |
Ophthalmological Characteristics of Students with Ametropias, According to the Year of the Course.
| Variable | 1st year | 2nd year | 3rd year | 4th year | Total | p-value |
|---|---|---|---|---|---|---|
| Age the ametropia was diagnosed, n (%) | ||||||
| 1–5 years | 4 (9.52) | 0 (0.00) | 1 (3.33) | 3 (4.62) | 8 (4.65) | 0.261 |
| 6–10 years | 6 (14.29) | 9 (25.71) | 4 (13.33) | 8 (12.31) | 27 (15.70) | |
| 11–15 years | 12 (28.57) | 12 (34.29) | 11 (36.67) | 28 (43.08) | 63 (36.63) | |
| 16–20 years | 16 (38.10) | 11 (31.43) | 11 (36.67) | 24 (36.92) | 62 (36.05) | |
| 21–25 years | 1 (2.38) | 1 (2.86) | 3 (10.00) | 2 (3.08) | 7 (4.07) | |
| Does not know | 3 (7.14) | 2 (5.71) | 0 (0.00) | 0 (0.00) | 5 (2.91) | |
| Uses glasses, yes [n (%)] | 38 (92.68) | 34 (94.44) | 24 (85.71) | 61 (91.04) | 157 (91.28) | 0.648 |
| No | 3 (7.32) | 2 (5.56) | 4 (14.29) | 6 (8.96) | 15 (8.72) | |
| Uses lenses, yes [n (%)] | 18 (43.90) | 16 (44.44) | 15 (53.57) | 26 (38.81) | 75 (43.60) | 0.621 |
| No | 23 (56.10) | 20 (55.56) | 13 (46.43) | 41 (61.19) | 97 (56.40) | |
| Eye surgery, yes [n (%)] | 1 (2.44) | 1 (2.78) | 0 (0.00) | 1 (1.49) | 3 (1.74) | 0.835 |
| No | 40 (97.56) | 35 (97.22) | 28 (100.00) | 66 (98.51) | 169 (98.26) | |
| Does your father have ametropia, yes [n (%)] | 39 (75.00) | 39 (79.59) | 36 (80.00) | 71 (82.56) | 185 (79.74) | 0.899 |
| No | 9 (17.31) | 8 (16.33) | 6 (13.33) | 9 (10.47) | 32 (13.79) | |
| Does not know | 4 (7.69) | 2 (4.08) | 3 (6.67) | 6 (6.98) | 15 (6.47) | |
| Does your mother have ametropia, yes [n (%)] | 37 (71.15) | 40 (81.63) | 38 (84.44) | 61 (70.93) | 176 (75.86) | 0.458 |
| No | 11 (21.15) | 7 (14.29) | 4 (8.89) | 20 (23.26) | 42 (18.10) | |
| Does not know | 4 (7.69) | 2 (7.69) | 3 (6.67) | 5 (5.81) | 14 (6.03) | |
| Does your brother/sister have ametropia, yes [n (%)] | 25 (48.08) | 26 (53.06) | 26 (57.78) | 38 (57.78) | 115 (49.57) | 0.774 |
| No | 23 (44.23) | 21 (42.86) | 16 (35.56) | 43 (50.00) | 103 (44.40) | |
| Does not know | 4 (7.69) | 2 (4.08) | 3 (6.67) | 5 (5.81) | 14 (6.03) | |
This study found a high prevalence of ametropias among students. The results of the study show significant differences in relation to the grade increase reported by students since entering the course.
It was observed that 75% of the students of the Medicine course at Centro Universitário ABC/FMABC (FMABC) from the first to the fourth academic year had some ametropia, with myopia being the most recurrent in 59% of the cases. This prevalence is higher than the average of the world population, which estimates that 22% of the world population has myopia.4
It is believed that the highest prevalence of myopia is observed in adults in Southeast Asia.12 A study carried out with populations of average age similar to the current one, with a sample of 15 to 25 years old, observed a prevalence of myopia of 48% in Singapore, 35% in China, and 24% in Peninsular Malaysia.13 However, North American studies,14 in which they obtained a database of individuals aged 18-24 years, with twelve or more years of study in their lives, found a prevalence of 43%. In a study carried out by the Department of Ophthalmology, Faculty of Medicine of Botucatu (UNESP),15 in a population examined in the cities of the west-central region of the state of São Paulo, the prevalence of myopia was higher between the second and third decade of life (43% for men and 42% for women). The difference of prevalence seen in these studies may be associated with the evaluation method, as well as genetic factors and lifestyle habits, however all of them present lower values than those found in FMABC students.
Although the prevalence of ametropias between school years is similar and all of them are high, the current study shows significant data regarding an increase in the grade (diopters) of students from the first to the fourth year of college. To find out the reasons for this increase in diopters in medical students at FMABC, the average time in which students studied and/or read throughout the day was analyzed.
An average study time of 10 hours was obtained, and of this, 7 hours (maximum time of their classes throughout the day) represented the period spent in the classroom. There was an association between the time dedicated to daily studies / readings and a high prevalence of myopia (in addition to the increase in the degree of myopia throughout college).
In a systematic review done in Australia,16 young people with low time of outdoor activities and high time of use of vision for activities of approximate reading were more likely to be nearsighted. Moreover, it was found that individuals who participate in outdoor activities are more likely to have myopia. In Saudi Arabia,17 a study regarding the presence of myopia included 504 medical students aged between 18 and 27 years (mean of 21 years), and a high prevalence of myopia was also observed among medical students.
Studies show that myopic young people tend to spend more time on computers, whether reading or writing, during periods outside the work or school environment, than non-myopic young people.18 The use of computers and electronic averages (at 4hr/day) may be associated with a longer axial ocular length,19 suggesting that each activity has a unique effect and different mechanism to affect myopia. An association between a higher level of education and the use of electronics (since education involves several types of close work, such as reading and using the computer) could be a factor in the development of myopia.20,21
With regard to heredity, the prevalence of ametropias in parents of the students in the current study was observed, with 80% of fathers having some ametropia and 76% of mothers. However, it is worth mentioning that presbyopia appears as a highlight in this absolute value, and it is not possible to analyze only the prevalence value of myopia in the parents of the participants, since the majority of students did not know what type of ametropia their parents had. Heredity is considered as the main influencing factor for the appearance of a refractive disorder.6–8 In a study carried out in young people with one or two myopic parents, their risks were two to eight times higher of developing myopia compared to those without myopic parents.22
The study, by means of a self-reported questionnaire, may underestimate the prevalence of ametropias. Thus, it is possible to say that the prevalence of myopia and the increase in the diopters of medical students at FMABC could be even higher, since 20% of respondents with ametropia(s) stated that they believe that their grade needed updating. In addition, 13% of students usually go to the ophthalmologist every two or more years and 27% when they believe it is necessary.
The limitation of this study included the lack of discrimination between the Medical School years studied, given the possibility that there is a difference in exposure to reading and/or electronic equipment use between the different medical school years. Finally, we could be still apply an analysis of the optical correction method of students with ametropia, remembering that many have both contact lenses and glasses to wear on different occasions; only 2% of respondents have already had refractive surgery, which is understandable, since the minimum average age for indication of refractive surgery is twenty years (according to the First Brazilian Census on Refractive Surgery).23
The current study shows us a high prevalence of ametropias among medical students at FMABC, especially myopia, when compared to studies in the literature with a similar target population. There is significant data regarding an increase in the grade (diopters) of students from the first to the fourth year throughout college, in addition to a need to update their grade during the course. In the present study, it is worth mentioning the time used for daily study and reading and the abusive use of high-tech electronic devices.
The Authors have no funding, financial relationships or conflicts of interest to disclose.
Formal analysis, data curation, writing the main manuscript, preparation of the figures, review and editing: GCS and RCA. Data curation, writing, review and editing: GCS, WVR. Data curation, formal analysis, preparation of the figures, review and editing: WVR, SS, and RCS. Data curation. and Data curation and editing: GL, FLAF, VLL and RGCL. All authors reviewed the manuscript.
None
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Gustavo Costa Santos, 1 MD, Disciplina de Oftalmologia, Centro Universitário ABC, Santo André, Brasil
Rafael Cunha de Almeida, 2 MD, MSc, Disciplina de Oftalmologia, Centro Universitário ABC, Santo André, Brasil
Willany Veloso Reinaldo, 1 MD, Disciplina de Oftalmologia, Centro Universitário ABC, Santo André, Brasil
Fernando Rocha Oliveira, 3 MD, Laboratório de Delineamento de Estudos e escrita científica Centro Universitário ABC, Santo André, Brasil
Shaun Schofield, 4 MD, Utah Valley University, Orem, United State of America, United States
Roberto Conde Santos, 5 MD, Universidade Federal de Alfenas, Alfenas, Brasil
Glaucia Luciano da Veiga, 6 MSc, PhD, Laboratório de Análises Clínicas, Centro Universitário ABC, Santo André, Brasil
Fernando Luiz Affonso Fonseca, 6 MSc, PhD, Laboratório de Análises Clínicas, Centro Universitário ABC, Santo André, Brasil
Vagner Loduca Lima, 7 MD, PhD, Disciplina de Oftalmologia, Centro Universitário ABC, Santo André, Brasil
Renato Galão Cerquinho Leça, 7 MD, PhD, Disciplina de Oftalmologia, Centro Universitário ABC, Santo André, Brasil
About the Author: Gustavo Costa Santos is an MD up to 1 year after graduation in Centro Universitário ABC/FMABC, Santo André, Brazil. He is now an MD in the Brazilian military service.
Correspondence: Glaucia Luciano da Veiga, Address: Av. Lauro Gomes, 2000 - Vila Sacadura Cabral, Santo André, Brazil. Email: grlveiga@gmail.com
Editor: Paul Morgan Student Editors: Adnan Mujanovic Student Editors: Anup Chalise Copyeditor: Ciara Egan Proofreader: Madeleine Jemima Cox Layout Editor: Francisco J. Bonilla-Escobar
Cite as: Santos GC, Almeida RCd, Reinaldo WV, Rocha Oliveira F, Schofield S, Santos RC, et al. Prevalence and Progression of Ametropias in Medical Students. Int J Med Students. 2021 May-Jun;9(2):112-6.
Copyright © 2021 Gustavo Costa Santos, Rafael Cunha de Almeida, Willany Veloso Reinaldo, Fernando Rocha Oliveira, Shaun Schofield, Roberto Conde Santos, Glaucia Luciano da Veiga, Fernando Luiz Affonso Fonseca, Vagner Loduca Lima, Renato Galão Cerquinho Leça
This work is licensed under a Creative Commons Attribution 4.0 International License.
International Journal of Medical Students, VOLUME 9, NUMBER 2, May-June 2021