The influence of age, refractive error, visual demand and lighting conditions on accommodative ability in Malay children and adults

  • Ai-Hong ChenEmail author
  • Azmir Ahmad
  • Stephanie Kearney
  • Niall Strang



Near work, accommodative inaccuracy and ambient lighting conditions have all been implicated in the development of myopia. However, differences in accommodative responses with age and refractive error under different visual conditions remain unclear. This study explores differences in accommodative ability and refractive error with exposure to differing ambient illumination and visual demands in Malay schoolchildren and adults.


Sixty young adults (21–25 years) and 60 schoolchildren (8–12 years) were recruited. Accommodative lag and accommodative fluctuations at far (6 m) and near (25 cm) were measured using the Grand Seiko WAM-5500 open-field autorefractor. The effects of mesopic room illumination on accommodation were also investigated.


Repeated-measures ANOVA indicated that accommodative lag at far and near differed significantly between schoolchildren and young adults [F(1.219, 35.354) = 11.857, p < 0.05]. Post hoc tests using the Bonferroni correction showed that at near, there was a greater lag in schoolchildren (0.486 ± 0.181 D) than young adults (0.259 ± 0.209 D, p < 0.05). Repeated-measures ANOVA also revealed that accommodative lag at near demands differed statistically between the non-myopic and myopic groups in young adults and schoolchildren [F(3.107, 31.431) = 12.187, p < 0.05]. Post hoc tests with Bonferroni correction showed that accommodative lag at near was significantly greater in myopic schoolchildren (0.655 ± 0.198 D) than in non-myopic schoolchildren (0.202 ± 0.141 D, p < 0.05) and myopic young adults (0.316 ± 0.172 D, p < 0.05), but no significant difference was found between myopic young adults (0.316 ± 0.172 D) and non-myopic young adults (0.242 ± 0.126 D, p > 0.05). Accommodative lag and fluctuations were greater under mesopic room conditions for all ages [all p < 0.05].


Greater accommodative lag was found in myopes than in emmetropes, in schoolchildren than in adults, and under mesopic conditions than under photopic conditions. Accommodative fluctuations were greatest in myopes and in mesopic conditions. These results suggest that differences exist in the amount of blur experienced by myopes and non-myopes at different ages and under different lighting conditions.


Accommodation Myopia Lag of accommodation Illumination Children 



Special thanks to Prof. Edward Mallen (University of Bradford, UK) and Saiful Azlan Rosli (iROViS, UiTM) for their technical assistance with Grand Seiko and lighting setup.


This study was financially supported through an E-Science Fund grant (06-01-01-SF0452) under the Ministry of Science, Technology and Innovation of Malaysia.

Compliance with ethical standards

All procedures in this research adhered to the ethical standards of the institutional research committee in accordance with the 1964 Helsinki declaration.

Informed consent

Informed consent was obtained from all participants and the legal guardians in the study.

Conflict of interest

None of the authors has any proprietary interests or conflicts of interest related to this submission.


  1. 1.
    Hashim SE, Tan HK, Wan-Hazabbah WH, Ibrahim M (2008) Prevalence of refractive error in Malay primary school children in suburban area of Kota Bharu, Kelantan, Malaysia. Ann Acad Med Singap 37(11):940–946Google Scholar
  2. 2.
    Ramlee A, Pin GP (2012) Ocular biometric measurements in emmetropic and myopic Malaysian children - a population-based study. Med J Malaysia 67(5):497–502Google Scholar
  3. 3.
    Garner LF, Chung KM, Grosvenor TP, Mohidin M (1990) Ocular dimension and refractive power in Malay and Malanesian children. Ophthalmic Physiol Opt 10:234–238CrossRefGoogle Scholar
  4. 4.
    Goh PP, Abqariyah Y, Pokharel GP, Ellwein LB (2005) Refractive error and visual impairment in school-age children in Gombak District, Malaysia. Ophthalmology 112(4):678–685CrossRefGoogle Scholar
  5. 5.
    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(8):1279–1285CrossRefGoogle Scholar
  6. 6.
    Saw SM, Goh PP, Cheng A, Shankar A, Tan DT, Ellwein LB (2006) Ethnicity-specific prevalences of refractive errors vary in Asian children in neighbouring Malaysia and Singapore. Br J Ophthalmol 90(10):1230–1235CrossRefGoogle Scholar
  7. 7.
    Rose KA, Morgan IG, Smith W, Burlutsky G, Mitchell P, Saw S (2008) Myopia, lifestyle, and schooling in students of Chinese ethnicity in Singapore and Sydney. Arch Ophthalmol 126(4):527–530CrossRefGoogle Scholar
  8. 8.
    Lam CS, Goldschmidt E, Edwards MH (2004) Prevalence of myopia in local and international schools in Hong Kong. Optom Vis Sci 81(5):317–322CrossRefGoogle Scholar
  9. 9.
    Kleinstein RN, Jones LA, Hullett S, Kwon S, Lee RJ, Friedman NE, Manny RE, Mutti DO, Julie AY, Zadnik K (2003) Refractive error and ethnicity in children. Arch Ophthalmol 121(8):1141–1147CrossRefGoogle Scholar
  10. 10.
    Saw SM, Wu HM, Seet B, Wong TY, Yap E, Chia KS, Stone RA, Lee L (2001) Academic achievement, close up work parameters, and myopia in Singapore military conscripts. Br J Ophthalmol 85(7):855–860CrossRefGoogle Scholar
  11. 11.
    Zylbermann R, Landau D, Berson D (1993) The influence of study habits on myopia in Jewish teenagers. J Pediatr Ophthalmol Strabismus 30(5):319–322Google Scholar
  12. 12.
    Goldschmidt E, Jacobsen N (2014) Genetic and environmental effects on myopia development and progression. Eye. 28(2):126–133CrossRefGoogle Scholar
  13. 13.
    Chakraborty R, Ostrin LA, Nickla DL, Iuvone PM, Pardue MT, Stone RA (2018) Circadian rhythms, refractive development, and myopia. Ophthalmic Physiol Opt 38(3):217–245CrossRefGoogle Scholar
  14. 14.
    Saw SM, Chua WH, Hong CY (2002) Near-work in early-onset myopia. Invest Ophthalmol Vis Sci 43(2):332–339Google Scholar
  15. 15.
    Ip JM, Saw S, 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(7):2903–2910CrossRefGoogle Scholar
  16. 16.
    Kinge B, Midelfart A, Jacobsen G, Rystad J (2000) The influence of nearwork on development of myopia among university students. A three-year longitudinal study among engineering students in Norway. Acta Ophthalmol 78(1):26–29CrossRefGoogle Scholar
  17. 17.
    Lin Z, Vasudevan B, Mao GY, Ciuffreda KJ, Jhanji V, Li XX, Zhou HJ, Wang NL, Liang YB (2016) The influence of near work on myopic refractive change in urban students in Beijing: a three-year follow-up report. Graefes Arch Clin Exp Ophthalmol 254(11):2247–2255CrossRefGoogle Scholar
  18. 18.
    Hung GK, Ciuffreda KJ (2007) Incremental retinal-defocus theory of myopia development—schematic analysis and computer simulation. Comput Biol Med 37(7):930–946CrossRefGoogle Scholar
  19. 19.
    Flitcroft DI (1998) A model of the contribution of oculomotor and optical factors to emmetropization and myopia. Vis Res 38(19):2869–2879CrossRefGoogle Scholar
  20. 20.
    Norton T (1999) Animal models of myopia: learning how vision controls the size of the eye. ILAR J 40(2):59–77CrossRefGoogle Scholar
  21. 21.
    Day M, Seidel D, Gray LS, Strang NC (2009) The effect of modulating ocular depth of focus upon accommodation microfluctuations in myopic and emmetropic subjects. Vis Res 49(2):211–218CrossRefGoogle Scholar
  22. 22.
    Day M, Strang N, Seidel D, Gray L, Mallen EA (2006) Refractive group differences in accommodation microfluctuations with changing accommodation stimulus. Ophthalmic Physiol Opt. 26:88–96CrossRefGoogle Scholar
  23. 23.
    Abbott ML, Schmid KL, Strang NC (1998) Differences in the accommodation stimulus response curves of adult myopes and emmetropes. Ophthalmic Physiol Opt. 18(1):13–20CrossRefGoogle Scholar
  24. 24.
    Berntsen DA, Sinnott LT, Mutti DO, Zadnik K (2011) Accommodative lag and juvenile-onset myopia progression in children wearing refractive correction. Vis Res 51(9):1039–1046CrossRefGoogle Scholar
  25. 25.
    Chen AH, Abidin AH (2002) Vergence and accommodation system in Malay primary school children. Malays J Med Sci 9(1):9–15Google Scholar
  26. 26.
    Mutti DO, Mitchell GL, Hayes JR, Jones LA, Moeschberger ML, Cotter SA, Kleinstein RN, Manny RE, Twelker JD, Zadnik K (2006) Accommodative lag before and after the onset of myopia. Invest Ophthalmol Vis Sci 47(3):837–846CrossRefGoogle Scholar
  27. 27.
    Yeo A, Kang K, Tang W (2006) Accommodative stimulus response curve of emmetropes and myopes. Ann Acad Med Singap 35(12):868–874Google Scholar
  28. 28.
    Tidbury LP, Czanner G, Newsham D (2016) Fiat lux: the effect of illuminance on acuity testing. Graefes Arch Clin Exp Ophthalmol 254(6):1091–1097CrossRefGoogle Scholar
  29. 29.
    Kaufman JE, Christensen JF (1972) IES lighting handbook: the standard lighting guide. Illuminating Engineering Society, New YorkGoogle Scholar
  30. 30.
    Borsting E, Tosha C, Chase C, Ridder WH III (2010) Measuring near induced transient myopia in college students with visual discomfort. Optom Vis Sci 87:760CrossRefGoogle Scholar
  31. 31.
    Day M, Strang NC, Seidel D, Gray LS (2008) Effect of contact lenses on measurement of the accommodation microfluctuations. Ophthalmic Physiol Opt. 28(1):91–95Google Scholar
  32. 32.
    Lin Z, Vasudevan B, Zhang YC, Qiao LY, Liang YB, Wang NL, Ciuffreda KJ (2012) Reproducibility of nearwork-induced transient myopia measurements using the WAM-5500 autorefractor in its dynamic mode. Graefes Arch Clin Exp Ophthalmol 250(10):1477–1483CrossRefGoogle Scholar
  33. 33.
    McBrien NA, Millodot M (1986) The effect of refractive error on the accommodative response gradient. Ophthalmic Physiol Opt. 6:145–149Google Scholar
  34. 34.
    Sreenivasan V, Irving EL, Bobier WR (2014) Can current models of accommodation and vergence predict accommodative behavior in myopic children? Vis Res 101:51–61CrossRefGoogle Scholar
  35. 35.
    Yeo AC, Atchison DA, Schmid KL (2013) Children’s accommodation during reading of Chinese and English texts. Optom Vis Sci 90(2):156–163CrossRefGoogle Scholar
  36. 36.
    Atchison DA, Varnas SR (2017) Accommodation stimulus and response determinations with autorefractors. Ophthalmic Physiol Opt. 37(1):96–104CrossRefGoogle Scholar
  37. 37.
    Monticone PP, Menozzi M (2011) A review on methods used to record and analyze microfluctuations of the accommodation in the human eye. J Eur Opt Soc 6:1103CrossRefGoogle Scholar
  38. 38.
    Dobson V, Quinn GE, Siatkowski RM, Baker JD, Hardy RJ, Reynolds JD, Trese MT, Tung B (1999) Agreement between grating acuity at age 1 year and Snellen acuity at age 5.5 years in the preterm child. Cryotherapy for retinopathy of prematurity cooperative group. Invest Ophthalmol Vis Sci 40(2):496–503Google Scholar
  39. 39.
    Corchuelo V, Pulgarín JD, Dolmetsch AM (2015) Ocular motility in children between ages 7 and 15. In: VI Latin American congress on biomedical engineering CLAIB 2014, Paraná, Argentina 29, 30 & 31 October 2014. Springer, Cham, pp 95–98Google Scholar
  40. 40.
    Chen AH, O’Leary DJ, Howell ER (2000) Near visual function in young children. Part I: near point of convergence. Part II: amplitude of accommodation. Part III: near heterophoria. Ophthalmic Physiol Opt. 20(3):185–198CrossRefGoogle Scholar
  41. 41.
    Benzoni JA, Rosenfield M (2012) Clinical amplitude of accommodation in children between 5 and 10 years of age. Optom Vis Dev 43(3):109–114Google Scholar
  42. 42.
    Mutti DO, Jones LA, Moeschberger ML, Zadnik K (2000) AC/a ratio, age, and refractive error in children. Invest Ophthalmol Vis Sci 41:2469–2478Google Scholar
  43. 43.
    Seidel D, Gray LS, Heron G (2003) Retinotopic accommodation responses in myopia. Invest Ophthalmol Vis Sci 44(3):1035–1041CrossRefGoogle Scholar
  44. 44.
    Bailey MD, Sinnott LT, Mutti DO (2008) Ciliary body thickness and refractive error in children. Invest Ophthalmol Vis Sci 49(10):4353–4360CrossRefGoogle Scholar
  45. 45.
    Rabbetts RB (1998) Ocular aberrations. In: Butterworth-Heinemann (ed) Clinical visual optics, 3rd edn. Butterworth Heinemann, Oxford, pp 288–289Google Scholar
  46. 46.
    Rosenfield M, Hong SE, George S (2004) Blur adaptation in myopes. Optom Vis Sci 81(9):657–662CrossRefGoogle Scholar
  47. 47.
    Cufflin M, Mankowska A, Mallen E (2007) Effect of blur adaptation on blur sensitivity and discrimination in emmetropes and myopes. Invest Ophthalmol Vis Sci 48(6):2932–2939CrossRefGoogle Scholar
  48. 48.
    Aggarwala KR, Kruger ES, Mathews S, Kruger PB (1995) Spectral bandwidth and ocular accommodation. J Opt Soc Am 12(3):450–455CrossRefGoogle Scholar
  49. 49.
    Zloto O, Wygnanski-Jaffe T, Farzavandi SK, Gomez-de-Liaño R, Sprunger DT, Mezer E (2018) Current trends among pediatric ophthalmologists to decrease myopia progression-an international perspective. Graefes Arch Clin Exp Ophthalmol 256(12):2457–2466CrossRefGoogle Scholar
  50. 50.
    Walline JJ (2016) Myopia control: A review. Eye Contact Lens 42(1):3–8CrossRefGoogle Scholar
  51. 51.
    Gong CR, Troilo D, Richdale K (2017) Accommodation and phoria in children wearing multifocal contact lenses. Optom Vis Sci 94(3):353–360CrossRefGoogle Scholar
  52. 52.
    Charman WN, Radhakrishnan H (2009) Accommodation, pupil diameter and myopia. Ophthalmic Physiol Opt 29(1):72–79CrossRefGoogle Scholar
  53. 53.
    Buehren T, Collins MJ (2006) Accommodation stimulus–response function and retinal image quality. Vis Res 46(10):1633–1645CrossRefGoogle Scholar
  54. 54.
    Bernal-Molina P, Montés-Micó R, Legras R, López-Gil N (2014) Depth-of-field of the accommodating eye. Optom Vis Sci 91(10):1208–1214CrossRefGoogle Scholar
  55. 55.
    Maqsood F (2017) Effects of varying light conditions and refractive error on pupil size. Cogent Med 4(1):1338824CrossRefGoogle Scholar
  56. 56.
    Chen Z, Niu L, Xue F, Qu X, Zhou Z, Zhou X, Chu R (2012) Impact of pupil diameter on axial growth in orthokeratology. Optom Vis Sci 89(11):1636–1640CrossRefGoogle Scholar
  57. 57.
    Guillon M, Dumbleton K, Theodoratos P, Gobbe M, Wooley CB, Moody K (2016) The effects of age, refractive status, and luminance on pupil size. Optom Vis Sci 93(9):1093CrossRefGoogle Scholar
  58. 58.
    Kasthurirangan S, Glasser A (2006) Age related changes in the characteristics of the near pupil response. Vis Res 46(8-9):1393–1403CrossRefGoogle Scholar
  59. 59.
    He JC, Sun P, Held R, Thorn F, Sun X, Gwiazda JE (2002) Wavefront aberrations in eyes of emmetropic and moderately myopic school children and young adults. Vis Res 42(8):1063–1070CrossRefGoogle Scholar
  60. 60.
    Hazel CA, Cox MJ, Strang NC (2003) Wavefront aberration and its relationship to the accommodative stimulus-response function in myopic subjects. Optom Vis Sci 80(2):151–158CrossRefGoogle Scholar
  61. 61.
    Lopez-Gil N, Martin J, Liu T, Bradley A, Díaz-Muñoz D, Thibos LN (2013) Retinal image quality during accommodation. Ophthalmic Physiol Opt. 33(4):497–507CrossRefGoogle Scholar
  62. 62.
    Gwiazda J, Thorn F, Bauer J, Held R (1993) Myopic children show insufficient accommodative response to blur. Invest Ophthalmol Vis Sci 34(3):690–694Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Ai-Hong Chen
    • 1
    Email author
  • Azmir Ahmad
    • 1
  • Stephanie Kearney
    • 2
  • Niall Strang
    • 2
  1. 1.Optometry, Faculty of Health SciencesUniversiti Teknologi MARABandar Puncak AlamMalaysia
  2. 2.Vision Sciences, School of Health and Life SciencesGlasgow Caledonian University (GCU)GlasgowUK

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