Myopia is one of the leading causes of vision loss around the world[1]. In the United States, myopia affects approximately 25% of adult Americans[2]. Ethnic diversity appears to distinguish different groups with regard to prevalence. Caucasians have a higher prevalence than African Americans[3]. Asian populations have the highest prevalence rates with reports ranging from 50–90%[1, 4, 5]. Jewish Caucasians, one of the target populations of the present study, have consistently demonstrated a higher myopia prevalence than the general Caucasian population in both U.S. and European population surveys; Orthodox Jewish males in particular show increased susceptibility[6, 7].

Despite many decades of research, little is known about the precise molecular defects and abnormal biochemical pathways that result in myopia. Compelling data from familial aggregation and twin studies indicate that susceptibility to myopia is inherited. Several familial aggregation studies have reported a greater prevalence of myopia in children of myopic parents compared to children of nonmyopic parents [8–12]. Several twin studies have demonstrated a very high heritability (estimates ranging from 60 to 90%) for myopia [13–15]. Other recent genetic studies of families with -6.00 D or more of myopia (termed high or pathological myopia) have reported significant linkage to regions on chromosome 18p11.31, 12q21-23, 17q21-22 and 7q36 [16–19]. The 18p candidate region has been confirmed in an independent study of high myopia [20]. Mutti et al.[21] examined the hypothesis that families with milder, juvenile onset myopia might show linkage to these same candidate regions. They found no evidence to support such a role in this more common form of myopia but their study was not highly powered in the presence of heterogeneity. Evidence also exists that myopia may be under environmental influences. The rapid increase in the prevalence of myopia over the last several decades suggests that environmental factors are important [22, 23]. Furthermore, studies have shown a positive correlation of specific environmental factors, such as nearwork, with myopia [24, 25]. It has been postulated that myopia develops in a person who engages in significant periods of sustained nearwork as an adaptive response to achieve better focus for near images[26]. Interestingly, Cordain et al.[27] suggest a positive correlation for myopia with increased consumption of carbohydrates, hyperinsulinemia and type II diabetes. Finally, experimental findings from animal studies show that the refractive state of young chicks will adapt to compensate for refractive errors induced by spectacle lenses[28].

The combination of genetic and environmental influences on the development of myopia suggests that myopia is a complex disorder and should not be classified as a simple Mendelian trait. Further evidence is shown by studies that have reported correlation coefficients for myopia between offspring and parents and between pairs of siblings to lie between 0.07–0.36 [29–32]. Due to the possible complexity of myopia, population isolates offer many advantages for genome-wide mapping studies[33]. First, they have reduced genetic complexity. Second, the people in most isolates share a common environment and culture. Differences in diet, exercise, sanitary conditions, and exposure to infectious diseases are minimized. A common language and religion usually promote social cohesion. Therefore, some of the environmental noise surrounding complex diseases that are determined by a combination of nature and nurture may be avoided.

To avoid some of the complexity in mapping genes for myopia we have collected refractive measurements and DNA samples from Amish and orthodox Jewish families with myopia. The Old Order Amish are mostly rural farmers and craftsmen. They lead a culturally and technologically distinct lifestyle. They are a genetically well-defined founder population with large families and well-documented genealogies [34, 35]. Family history records of the Amish in Lancaster County, Pennsylvania, beginning from 1727 are highly preserved[36]. Other features of this population include a relatively high standard of living, low migratory tendencies, and no practice of birth control, which facilitate the recruitment of large and extended families.

The orthodox Jewish families in this study are all of Ashkenazi descent, a population with known founder effects in other common diseases[37]. This population also has somewhat larger family sizes than average in the US. In this initial report, we describe the design of our study and show that two regions (18p and 12q) previously reported to be linked to high myopia cannot explain the familial aggregation in these families with mostly moderate to milder forms of myopia. We had hypothesized that allelic heterogeneity might exist at these candidate loci such that in addition to highly penetrant alleles for extreme high myopia, there might also exist other susceptibility alleles of (possibly) lower penetrance that produce milder phenotypic forms of myopia. However, we found no strong evidence in support of this hypothesis.

The overall results of these preliminary studies do not indicate any strong evidence for linkage of myopia in these families to the candidate regions on chromosomes 12 or 18. Although some families show marginal evidence of linkage to one of these regions, the results could be due to chance. Our negative results for these candidate regions have several possible explanations. First, the diagnostic criteria used in the previous studies [9, 10] that implicated these candidate regions were based on limiting the affection status to the sphere component of a plus cylinder refraction. An individual was considered affected with high myopia if the sphere was equal to or greater than -6D regardless of the astigmatic error. Our study required an individual to have -1D in each meridian to be considered affected. Therefore, the criterion for being affected was quite different between the two studies. Second, the study population in our study included moderate and low myopes in addition to a small number of high myopes. None of our families showed strong aggregation of high myopia. Therefore, there were no families in our study recruited exclusively for high myopia and no families that would have been highly powerful for the detection of linkage to a high myopia trait. We utilized this study design to search for allelic heterogeneity with regard to the 18p and 12q loci thinking that one or both loci may predispose to moderate/mild forms of myopia. Thus, the current linkage analysis was done to test the hypothesis that other alleles at the candidate high myopia loci on chromosomes 18 and 12 might contribute to the etiology of moderate/mild myopia. The mild evidence of linkage in a few families indicates that this hypothesis cannot be fully ruled out for a very small proportion of families with mild forms of myopia. However, there is no strong evidence in favor of this hypothesis and strong negative evidence against linkage in most of the families in this study.

Previous studies attempting to confirm the high myopia loci on chromosomes 18 and 12 have yielded inconsistent results. Naiglin et al.[19]collected 23 French families with high myopia (spherical equivalent ≥ -6D) and performed a genome scan with 400 markers. Significant linkage was not found on 18p and 12q. Lam et al.[20] mapped 15 families with high myopia, ≥ -6.0D, using only 18p markers. Statistically significant (LOD > 3) linkage was not demonstrated although a multipoint LOD over 2.0 was observed, thus giving evidence of confirmation of the 18p candidate region. Mutti et al.[21] collected 53 families with varying degrees of myopia (affected ≥ -0.75D in each meridian) and genotyped the family members with 18p and 12q loci markers implicated in high myopia. No evidence of linkage to milder forms of myopia was found to the chromosome 18p and 12q loci previously associated with high myopia. Our study, although consistent with the results of Mutti et al.[21] was significantly different in design. First, Mutti et al. used a heterogeneous population that could decrease the chances of obtaining significant linkage for a minor gene effect from 18p or 12q if substantial ethnic heterogeneity exists. Both the Amish and Ashkenazi populations used in our study are more homogeneous and each sample was analyzed using marker allele frequencies estimated from the sample. Second, their study utilized 221 samples while we genotyped 613 individuals. Our power simulations predicted higher power in the presence of heterogeneity in our Ashkenazi families than was predicted for the Mutti et al. study. Our Amish families were of similar size and structure and so should have similar predicted power as the Ashkenazi families, and our combined analyses of the two data sets should provide much more power than that predicted by the simulations of the Ashkenazi families alone. The combination of the Mutti et al. study with the results presented here strongly suggest that these two candidate regions do not play a large role in the causation of moderate/mild myopia in several populations examined.

These studies suggest that myopia is complex and probably caused by the interaction of multiple genes with the environment. Therefore, to understand myopia it is necessary to apply the equation: Genes + Environment=Outcome. The difficulty here is the uncertainty surrounding both terms in the equation; ideally, one set of genetic factors will interact with one set of environmental influences to produce identical outcomes, but it is unknown whether this is always going to be the case. Therefore, to lessen the problem of multiple gene interaction as well as gene-environment interaction confounding the results, strategies to limit this problem should be utilized in the genetic mapping of myopia. The use of isolated populations is one approach to limiting the heterogeneity across populations and is the approach we are using for a genome wide scan in these families. Furthermore, the definition of myopia needs to be standardized so comparisons across studies can be made accurately. Previous studies have utilized different requirements with regard to affection status making cross comparisons difficult. In conclusion, we find little evidence implicating previously described susceptibility loci for high myopia on chromosomes 12 and 18 as being important in the etiology of common, moderate/mild myopia in our two population samples.