Myopia Prevention and Outdoor Light Intensity in a School-Based Cluster Randomized Trial

Association Between Serum Vitamin D Levels and Myopia in the National Health and Nutrition Examination Survey (2001-2006)

PURPOSE

To assess the relationship between serum vitamin D levels and myopia in people aged 12-50 years using the National Health and Nutrition Examination Survey (NHANES) database.

METHODS

Demographics, vision, and serum vitamin D levels from NHANES (2001-2006) were analyzed. Multivariate analyses were performed to examine the relationship between serum vitamin D levels and myopia while controlling for sex, age, ethnicity, education level, serum vitamin A, and poverty status. The main outcome was presence or absence of myopia, defined as a spherical equivalent of -1 diopters or more.

RESULTS

Of the 11669 participants, 5,310 (45.5%) had myopia. The average serum vitamin D concentration was 61.6 ± 0.9 nmol/L for the myopic group and 63.1 ± 0.8 nmol/L for the non-myopic group (p = .01). After adjusting for all covariates, having higher serum vitamin D was associated with lower odds of having myopia (odds ratio 0.82 [0.74-0.92], p = .0007). In linear regression modeling that excluded hyperopes (spherical equivalent > +1 diopters), there was a positive relationship between spherical equivalent and serum vitamin D levels. Specifically, as serum vitamin D doubled, spherical equivalent increased by 0.17 (p = .02) indicating a positive dose-response relationship between vitamin D and myopia.

CONCLUSIONS

Participants with myopia, on average, had lower serum concentrations of vitamin D compared to those without myopia. While further studies are needed to determine the mechanism, this study suggests that higher vitamin D levels are associated with lower incidence of myopia.

Association Between Myopia and Pupil Diameter in Preschoolers: Evidence from a Machine Learning Approach Based on a Real-World Large-Scale Dataset

INTRODUCTION

Previous studies have explored the connections between various ocular biological parameters with myopia. Our previous study also found that pupil data can predict the myopic progression during the interventions for myopia. However, studies exploring the association between pupil diameter and myopia in preschoolers with myopia were lacking. Hence this study was aimed to investigate the association between pupil diameter and myopia in preschoolers with myopia based on a real-world, large-scale dataset.

METHODS

Data containing 650,671 preschoolers were collected from a total of 1943 kindergartens in Shenzhen, China. Refraction and pupil parameters were collected. After data filtering, the occurrence of myopia and its association with age, gender, pupil diameter, and other variables, were analyzed. Random forest (RF) and eXtreme gradient boosting (XGBoost) were selected from seven machine learning algorithms to build the model. The mean decrease accuracy (MDA), mean decrease Gini (MDG), and gain feature importance (GFI) techniques were employed to quantify the importance of pupil diameter and other features.

RESULTS

After the assessments, 51,325 valid records with complete pupil data were included, and 3468 (6.76%) were identified as myopia based on the calculated cycloplegic refraction. Preschoolers with myopia presented reduced pupil diameter and greater variation (5.00 ± 0.99 mm) compared to non-myopic preschoolers (6.22 ± 0.67 mm). A nonlinear relationship was found according to the scatterplots between pupil diameter and refraction (R2 = 0.14). Especially preschoolers with myopia had reduced pupil diameter compared to emmetropic preschoolers, but hyperope did not experience additional pupil enlargement. After adjusting for other covariates, this relationship is still consistent (P < 0.001). XGBoost and RF algorithms presented the highest performance and validated the importance of pupil diameter in myopia.

CONCLUSIONS

Based on a real-world large-scale dataset, the current study illuminated that preschoolers with myopia had a reduced pupil diameter compared to emmetropic preschoolers with a nonlinear pattern. Machine learning algorithms visualized and validated the pivotal role of pupil diameter in myopia.

TRIAL REGISTRATION

chictr.org Identifier: ChiCTR2200057391.

Myopia Control: Are We Ready for an Evidence Based Approach?

INTRODUCTION

Myopia and its vision-threatening complications present a significant public health problem. This review aims to provide an updated overview of the multitude of known and emerging interventions to control myopia, including their potential effect, safety, and costs.

METHODS

A systematic literature search of three databases was conducted. Interventions were grouped into four categories: environmental/behavioral (outdoor time, near work), pharmacological (e.g., atropine), optical interventions (spectacles and contact lenses), and novel approaches such as red-light (RLRL) therapies. Review articles and original articles on randomized controlled trials (RCT) were selected.

RESULTS

From the initial 3224 retrieved records, 18 reviews and 41 original articles reporting results from RCTs were included. While there is more evidence supporting the efficacy of low-dose atropine and certain myopia-controlling contact lenses in slowing myopia progression, the evidence about the efficacy of the newer interventions, such as spectacle lenses (e.g., defocus incorporated multiple segments and highly aspheric lenslets) is more limited. Behavioral interventions, i.e., increased outdoor time, seem effective for preventing the onset of myopia if implemented successfully in schools and homes. While environmental interventions and spectacles are regarded as generally safe, pharmacological interventions, contact lenses, and RLRL may be associated with adverse effects. All interventions, except for behavioral change, are tied to moderate to high expenditures.

CONCLUSION

Our review suggests that myopia control interventions are recommended and prescribed on the basis of accessibility and clinical practice patterns, which vary widely around the world. Clinical trials indicate short- to medium-term efficacy in reducing myopia progression for various interventions, but none have demonstrated long-term effectiveness in preventing high myopia and potential complications in adulthood. There is an unmet need for a unified consensus for strategies that balance risk and effectiveness for these methods for personalized myopia management.

Light exposure profiles differ between myopes and non-myopes outside school hours

PURPOSE

Considering the putative role of light in myopia, and variations in socioeconomic, lifestyle, educational and environmental factors across ethnicities, we objectively investigated light exposure patterns in Indian school children.

METHODS

The light exposure profile of 143 school children (9-15 years, 50 myopes) recorded using a validated wearable light tracker for six continuous days was analysed. Additional data for non-school days were available for 87 children (26 myopes). The illuminance exposure levels, time spent outdoors and epoch (number of times participant is exposed to a predefined range of lux level per day) were compared between myopes and non-myopes across different light conditions: ≥1000, ≥3000, ≥5000 and ≥10 000 lux. For school days, light exposure profiles during (1) before school, school and after school hours; and (2) class, break and transition (when a student travels to and from school) time were analysed.

RESULTS

The overall median (IQR) daily illuminance exposure level, time spent outdoors and epochs at outdoors (≥1000 lux) were 807 (507-1079) lux/day, 46 (30-64) min/day and 9 (6-12) times/day, respectively. The daily illuminance exposure on non-school days was significantly higher in non-myopes than myopes (6369 (4508-9112) vs 5623 (2616-6929) lux/day, p=0.04). During transition time (school days), non-myopes had significantly higher illuminance exposure (910 (388-1479) vs 550 (263-1098) lux/day, p=0.04), spent more time outdoors (25 (10-43) vs 14 (4-29) min/day, p=0.01) and had higher outdoor epochs (6 (4-11) vs 5 (2-8) times/day, p=0.01) than myopes.

CONCLUSIONS

A small but significant difference in illuminance exposure, time spent outdoors and epoch was noted between myopes and non-myopes during transition time, which may have implications in myopia control.

Impact of ophthalmic clinical service use in mitigating myopia onset and progression in preschool children: a retrospective cohort study

BACKGROUND

Although school screenings identify children with vision problems and issue referrals for medical treatment at an ophthalmic hospital, the effectiveness of this approach remains unverified.

OBJECTIVE

To investigate the impact of ophthalmic clinical services on the onset and progression of myopia in preschool children identified with vision impairment.

METHODS

Using data from the Shanghai Child and Adolescent Large-scale Eye Study (SCALE), this retrospective cohort study evaluated the visual development of children from three districts-Jing'an, Minhang, and Pudong-which are representative of geographic diversity and economic disparity in Shanghai's 17 districts. Initially, in 2015, the study encompassed 14,572 children aged 4-6 years, of whom 5,917 needed a referral. Our cohort consisted of 5,511 children who had two or more vision screenings and complete personal information over the follow-up period from January 2015 to December 2020. We divided these children into two groups based on their initial spherical equivalent (SE): a High-risk group (SE > -0.5 D) and a Myopia group (SE ≤ -0.5 D). Within each of these groups, we further categorized children into Never, Tardily, and Timely groups based on their referral compliance to compare the differences in the occurrence and progression of myopia. Cox proportional models were applied to estimate hazard ratios (HRs) for myopia incidence per person-years of follow-up in High-risk group. Generalized additive models(GAM) was used to calculating the progression for annual spherical equivalent changes in all children.

RESULTS

Of the 5,511 preschool children (mean age, 5.25 years; 52.24% male) who received a referral recommendation, 1,327 (24.08%) sought clinical services at an ophthalmic hospital. After six years of follow-up, 65.53% of children developed myopia. The six-year cumulative incidence of myopia in the Never, Tardily, and Timely groups was 64.76%, 69.31%, and 57.14%, respectively. These percentages corresponded to hazard ratios (HRs) of 1.31 (95% CI, 1.10-1.55) for the Tardily group and 0.55 (95% CI, 0.33-0.93) for the Timely group, compared with the Never group. The HRs were adjusted for age, sex, and SE at study entry. Interestingly, the Timely group showed significantly less SE progression than the other groups (P < 0.001), and SE progression was higher in the High-risk group (-0.33 ± 0.37D/year) than in children with myopia (-0.08 ± 0.55D/year).

CONCLUSION

Timely utilization of ophthalmic clinical services among children aged 4 to 6 years who fail school vision screenings can significantly reduce the incidence of myopia and slow SE progression.

Advances in myopia control strategies for children

Myopia has long been a global threat to public health. Timely interventions are likely to reduce the risk of vision-threatening complications. There are both established and rapidly evolving therapeutic approaches to slow myopia progression and/or delay its onset. The effective methods for slowing myopia progression include atropine eye-drops, defocus incorporated multiple segments (DIMS) spectacle lenses, spectacle lenses with highly aspherical lenslets target (HALT), diffusion optics technology (DOT) spectacle lenses, red light therapy (RLT), multifocal soft contact lenses and orthokeratology. Among these, 0.05% atropine, HALT lenses, RLT and +3.00 peripheral addition soft contact lenses yield over 60% reduction in myopia progression, whereas DIMS, DOT and MiSight contact lenses demonstrate at least 50% myopia control efficacy. 0.05% atropine demonstrates a more optimal balance of efficacy and safety than 0.01%. The efficacy of 0.01% atropine has not been consistent and requires further validation across diverse ethnicities. Combining atropine 0.01% with orthokeratology or DIMS spectacles yields better outcomes than using these interventions as monotherapies. Increased outdoor time is an effective public health strategy for myopia prevention while recent studies suggest that 0.05% low-concentration atropine and RLT therapy have promising potential as clinical myopia prevention interventions for high-risk groups. Myopia control spectacle lenses, being the least invasive, are safe for long-term use. However, when considering other approaches, it is essential to ensure proper instruction and regular follow-ups to maintain safety and monitor any potential complications. Ultimately, significant advances have been made in myopia control strategies, many of which have shown meaningful clinical outcomes. However, regular use and adequate safety monitoring over extended durations are imperative to foster confidence that can only come from extensive clinical experience.

The knowledge structure and research trends between light and myopia: A bibliometric analysis from 1981 to 2024

BACKGROUND

This bibliometric analysis explored the knowledge structure of and research trends in the relationship between light and myopia.

METHODS

Relevant literature published from 1981 to 2024 was collected from the Web of Science Core Collection database. Visual maps were generated using CiteSpace and VOSviewer. We analyzed the included studies in terms of the annual publication count, countries, institutional affiliations, prolific authors, source journals, top 10 most cited articles, keyword co-occurrence, and cocitations.

RESULTS

A total of 525 papers examining the relationship between light and myopia published between 1981 and 2024 were collected. The United States ranked first in terms of the number of publications and actively engaged in international cooperation with other countries. The New England College of Optometry, which is located in the United States, was the most active institution and ranked first in terms of the number of publications. Schaeffel Frank was the most prolific author. The most active journal in the field was Investigative Ophthalmology & Visual Science. The most frequently cited paper in the included studies was written by Saw, SM and was published in 2002. The most common keywords in basic research included "refractive error," "longitudinal chromatic aberration," and "compensation." The most common keywords in clinical research mainly included "light exposure," "school," and "outdoor activity." The current research hotspots in this field are "progression," "refractive development," and "light exposure." The cocitation analysis generated 17 clusters.

CONCLUSION

This study is the first to use bibliometric methods to analyze existing research on the relationship between light and myopia. In recent years, the intensity and wavelength of light have become research hotspots in the field. Further research on light of different intensities and wavelengths may provide new perspectives in the future for designing more effective treatments and interventions to reduce the incidence of myopia.

The Impact of Sunshine Duration on Myopia in Central China: Insights from Populational and Spatial Analysis in Hubei

Purpose

This study aimed to analyze myopia distribution in Hubei and the impact of regional Sunshine Duration on myopia in children and adolescents.

Patients and Methods

The Cross-sectional study included students (kindergarten to grade 12) through multistage cluster stratified sampling in 17 cities (103 areas) of Hubei, China, who underwent ophthalmic examinations from September 2021 to November 2021. The association of sunshine duration with the prevalence and distribution of myopia was analyzed. Using Moran's index to quantify the distribution relationship, a spatial analysis was constructed.

Results

A total of 435,996 students (53.33% male; mean age, 12.16±3.74 years) were included in the study. A negative association was identified between myopia prevalence and sunshine duration in the region, especially in population of primary students (r=-0.316, p<0.001). Each 1-unit increment in the sunshine duration was associated with a decreased risk of myopia prevalence (OR=0.996; 95% CI, 0.995-0.998; P <0.001). Regression showed a linear relationship between sunshine duration and myopia rates of primary school students [Prevalence%= (-0.1331*sunshine duration+47.73)%, p = 0.02]. Sunshine duration influenced the distribution of myopia rates among primary (Moran's I=-0.206, p<0.001) and junior high school (Moran's I=-0.183, p=0.002). Local spatial analysis showed that areas with low sunshine duration had high myopia prevalence concentration.

Conclusion

This study revealed sunshine duration associations with myopia prevalence at the regional and population levels. The results may emphasize the significance of promptly implementing myopia control in regions with poor sunshine. The effect of sunshine on myopia is pronounced in the early years of education, especially in primary students.

Myopia Is an Ischemic Eye Condition: A Review from the Perspective of Choroidal Blood Flow

Myopia is a common refractive error that affects a large proportion of the population. Recent studies have revealed that alterations in choroidal thickness (ChT) and choroidal blood flow (ChBF) play important roles in the progression of myopia. Reduced ChBF could affect scleral cellular matrix remodeling, which leads to axial elongation and further myopia progression. As ChT and ChBF could be used as potential biomarkers for the progression of myopia, several recent myopia treatments have targeted alterations in ChT and ChBF. Our review provides a comprehensive overview of the recent literature review on the relationship between ChBF and myopia. We also highlight the importance of ChT and ChBF in the progression of myopia and the potential of ChT as an important biomarker for myopia progression. This summary has significant implications for the development of novel strategies for preventing and treating myopia.

Longitudinal changes in crystalline lens thickness and power in children aged 6-12 years old

OBJECTIVES

To determine the three-year changes in crystalline lens power (LP) and thickness (LT) in children and their associated factors.

METHODS

Schoolchildren aged 6-12 years living in Shahroud, northeast Iran were examined in 2015 and 2018. The Bennett formula was used to calculate LP. Multiple generalized estimating equations (GEE) analysis was used for data analysis.

RESULTS

Among the 8089 examined eyes, the mean LP in Phase 1 and 2, and the three-year change were 21.61 ± 1.47D, 21.00 ± 1.42D, and -0.61 ± 0.52D, respectively. The GEE model showed that negative shifts in LP were less pronounced with increasing age (β = 0.176; p < 0.001), and were also less noticeable in hyperopes compared to emmetropes (β = 0.120; p < 0.001). The changes in LP decreased when outdoor activity increased among urban residents (β = 0.013; p = 0.039), while it increased in rural area (β = -0.020; p = 0.047). Mean three-year change in LT was 0.002 ± 0.13 mm. Female sex and aging by one year increased the LT by 0.022 mm (P < 0.001). However, LT decreased in 6-8-year-olds, while it increased in 10-12-year-old children, both in a linear fashion. The change in LT was less in myopes than in emmetropes (β = -0.018, P-value = 0.010).

CONCLUSION

LP decreases after three years in 6 to 12-year-old children. LT increases slightly after three years in 6 to 12-year-old children. The changes in LP and LT were associated with the refractive errors, place of residence, age and gender and outdoor activity time.

Effect of Resveratrol on MMP-2 Expression in Scleral Fibroblasts: An In Vitro Study

PURPOSE

To investigate the effects of resveratrol (Res) on human fetal scleral fibroblasts (HFSFs) and its potential mechanism.

METHODS

HFSFs were randomly divided into the Res-treated group and the control group. Following, HFSFs were treated with or without a concentration of 10 μM Res for 48 h. To detect the expression of related genes, reverse transcription quantitative PCR (RT-qPCR) and western blotting were used. The apoptosis rate of different groups was determined using flow cytometry.

RESULTS

The mRNA expression of matrix metalloproteinase 2 (MMP-2), Collagen, Type I, Alpha 1 (COL1A1), Janus Kinase 2 (JAK2), and Signal Transducer and Activator of Transcription 3 (STAT3)" was downregulated in the Res-treatment group compared to the control group, according to RT-qPCR. Western blotting revealed that Res therapy reduced the expression of MMP-2, JAK2, P-JAK2, STAT3, P-STAT3, and Bcl-2 associated protein X (Bax) while increasing the expression of COL1A1 and B-cell lymphoma-2 (Bcl-2). Flow cytometry showed that the cell apoptosis rate was significantly lower in HFSFs treated with Res.

CONCLUSIONS

In conclusion, these findings suggest that Res increases COL1A1 expression while inhibiting MMP-2 and cell apoptosis in HFSFs, possibly through modulation of the JAK2/STAT3 signaling pathway.

Development and validation of a smartwatch algorithm for differentiating physical activity intensity in health monitoring

To develop and validate a machine learning based algorithm to estimate physical activity (PA) intensity using the smartwatch with the capacity to record PA and determine outdoor state. Two groups of participants, including 24 adults (13 males) and 18 children (9 boys), completed a sequential activity trial. During each trial, participants wore a smartwatch, and energy expenditure was measured using indirect calorimetry as gold standard. The support vector machine algorithm and the least squares regression model were applied for the metabolic equivalent (MET) estimation using raw data derived from the smartwatch. Exercise intensity was categorized based on MET values into sedentary activity (SED), light activity (LPA), moderate activity (MPA), and vigorous activity (VPA). The classification accuracy was evaluated using area under the ROC curve (AUC). The METs estimation accuracy were assessed via the mean absolute error (MAE), the correlation coefficient, Bland-Altman plots, and intraclass correlation (ICC). A total of 24 adults aged 21-34 years and 18 children aged 9-13 years participated in the study, yielding 1790 and 1246 data points for adults and children respectively for model building and validation. For adults, the AUC for classifying SED, MVPA, and VPA were 0.96, 0.88, and 0.86, respectively. The MAE between true METs and estimated METs was 0.75 METs. The correlation coefficient and ICC were 0.87 (p < 0.001) and 0.89, respectively. For children, comparable levels of accuracy were demonstrated, with the AUC for SED, MVPA, and VPA being 0.98, 0.89, and 0.85, respectively. The MAE between true METs and estimated METs was 0.80 METs. The correlation coefficient and ICC were 0.79 (p < 0.001) and 0.84, respectively. The developed model successfully estimated PA intensity with high accuracy in both adults and children. The application of this model enables independent investigation of PA intensity, facilitating research in health monitoring and potentially in areas such as myopia prevention and control.

Retinal characteristics in eyes with pathologic myopia among individuals self-identifying as Black

OBJECTIVE

Investigate retinal characteristics of pathologic myopia (PM) among patients self-identifying as Black.

DESIGN

Retrospective cohort single-institution retrospective medical record review.

METHODS

Adult patients between January 2005 and December 2014 with International Classification of Diseases (ICD) codes consistent with PM and given 5-year follow-up were evaluated. The Study Group consisted of patients self-identifying as Black, and the Comparison Group consisted of those not self-identifying as Black. Ocular features at study baseline and 5-year follow-up visit were evaluated.

RESULTS

Among 428 patients with PM, 60 (14%) self-identified as Black and 18 (30%) had baseline and 5-year follow-up visits. Of the remaining 368 patients, 63 were in the Comparison Group. For the study (n = 18) and Comparison Group (n = 29), median (25th percentile, 75th percentile) baseline visual acuity was 20/40 (20/25, 20/50) and 20/32 (20/25, 20/50) in the better-seeing eye and 20/70 (20/50, 20/1400) and 20/100 (20/50, 20/200), respectively, in the worse-seeing eye. In the eyes that did not have choroidal neovascularization (CNV) in the study and Comparison Group, median study baseline optical coherence tomography central subfield thickness was 196 μm (169, 306 μm) and 225 μm (191, 280 μm), respectively, in the better-seeing eye and 208 μm (181, 260 μm) and 194 μm (171, 248 μm), respectively, in the worse-seeing eye. Baseline prevalence of CNV was 1 Study Group eye (3%) and 20 Comparison Group eyes (34%). By the 5-year visit, zero (0%) and 4 (15%) additional eyes had CNV in the study and Comparison Group, respectively.

CONCLUSION

These findings suggest that the prevalence and incidence of CNV may be lower in patients with PM self-identifying as Black when compared with individuals of other races.

Predicting the onset of myopia in children by age, sex, and ethnicity: Results from the CLEERE Study

SIGNIFICANCE

Clinicians and researchers would benefit from being able to predict the onset of myopia for an individual child. This report provides a model for calculating the probability of myopia onset, year-by-year and cumulatively, based on results from the largest, most ethnically diverse study of myopia onset in the United States.

PURPOSE

This study aimed to model the probability of the onset of myopia in previously nonmyopic school-aged children.

METHODS

Children aged 6 years to less than 14 years of age at baseline participating in the Collaborative Longitudinal Evaluation of Ethnicity and Refractive Error (CLEERE) Study who were nonmyopic and less hyperopic than +3.00 D (spherical equivalent) were followed up for 1 to 7 years through eighth grade. Annual measurements included cycloplegic autorefraction, keratometry, ultrasound axial dimensions, and parental report of children's near work and time spent in outdoor and/or sports activities. The onset of myopia was defined as the first visit with at least -0.75 D of myopia in each principal meridian. The predictive model was built using discrete time survival analysis and evaluated with C statistics.

RESULTS

The model of the probability of the onset of myopia included cycloplegic spherical equivalent refractive error, the horizontal/vertical component of astigmatism (J0), age, sex, and race/ethnicity. Onset of myopia was more likely with lower amounts of hyperopia and less positive/more negative values of J0. Younger Asian American females had the highest eventual probability of onset, whereas older White males had the lowest. Model performance increased with older baseline age, with C statistics ranging from 0.83 at 6 years of age to 0.92 at 13 years.

CONCLUSIONS

The probability of the onset of myopia can be estimated for children in the major racial/ethnic groups within the United States on a year-by-year and cumulative basis up to age 14 years based on a simple set of refractive error and demographic variables.

The Current and Future Landscape of the Childhood Myopia Epidemic in China-A Review

Over the last two decades, the prevalence of myopia has gradually increased in China. Numerous epidemiological studies suggest that education and inadequate time spent outdoors are the major causes of the current myopia epidemic. China is one of the few countries that has begun to address the myopia epidemic with a national-level strategy, implementing nationwide education reform, cost-reduction measurements, and dissemination of information on myopia prevention and control. These "natural experiments" will provide insights into areas that may face similar or potential myopia problems.

Effects of online family health education on myopia prevention in children by parental myopia: a randomized clinical trial

CLINICAL RELEVANCE

Online family health education may be effective for myopia prevention in children, and the effects may be different between children with myopic and non-myopic parents.

BACKGROUND

Myopia is a common cause of vision loss. The aims of this study were to evaluate the effects of online family health education on preventing the development of myopia in children, and to estimate whether the effects vary according to parental myopia.

METHODS

A cluster randomised trial including grade 1 and grade 2 children from 12 primary schools was conducted in Guangzhou, China. Weekly online family health education messages were sent to parents in the intervention group. Data collection included eye examinations of children and questionnaires completed by parents.

RESULTS

Among the 3123 children included at baseline (1703 boys [54.5%]; mean [SD] age, 6.83 [0.73] years), 2376 completed the follow-up after 3 years. The differences in the incidence of myopia and myopic shift between the study groups were not significant in total. However, the 3-year cumulative incidence rate of myopia in the intervention group (125 of 445 [28.1%]) was significantly lower than that in the control group (225 of 603 [37.3%]; difference, 9.2% [95% CI, -14.9% to -3.5%]; P = 0.001) among children with non-myopic parents. In parallel, among children with non-myopic parents, the mean myopic change in SER was less for the intervention group than for the control group (-1.10 D vs. -1.24 D; difference, 0.13 D [95% CI, 0.03 to 0.23 D]; P = 0.01).

CONCLUSIONS

Compared with children with myopic parents, online family health education was more effective in children with non-myopic parents. The incidence of myopia and myopic shift in refraction have been reduced in children with non-myopic parents. Further studies are needed to assess these differences by parental myopia.

Comparison of three VST orthokeratology lenses in axial length growth and average corneal reshaping in myopia children: A retrospective self-controlled study

Purpose

To determine the differences in myopia control efficiency and corneal reshaping between three different brands of orthokeratology (OK) lenses (Lucid, Euclid, and Alpha).

Method

We retrospectively reviewed subjects who started simultaneously using different brands of OK lenses. For each participant, every 6 months in the 19 months of following, the changes in axial length (AL), horizontal and vertical maximum distances of the treatment zone (HMDTZ and VMDTZ), width of the high convex zone (WHCZ), distance of decentration, and horizontal and vertical components of the decentration vector were measured. The average values of the above data, the average value of the decentration vector (ADV), and the average value of decentration calculated algebraically (ADA) were calculated.

Results

All the three pairs (Lucid (n = 46) vs. Euclid (n = 46): groups Lucid-versus-Euclid-Lucid (LE-L) and LE-E), Lucid (n = 50) vs. Alpha (n = 50): groups LA-L and LA-A), and Euclid (n = 17) vs. Alpha (n = 17): groups EA-E and EA-A) showed good comparability. Regarding the change in AL during 19 months, none of the pairs showed significant differences (LE-L:0.27 ± 0.24 mm, LE-E:0.31 ± 0.24 mm (p = 0.68); LA-L:0.36 ± 0.26 mm, LA-A:0.36 ± 0.27 mm (p = 0.85); EA-E:0.34 ± 0.27 mm, EA-A:0.41 ± 0.28 mm (p = 0.63)). Regarding treatment zone, Lucid showed the largest HMDTZ and VMDTZ (both p < 0.05). Regarding the WHCZ, none of the pairs showed significant differences. For the ADV and ADA, Lucid had more ADV and ADA than Euclid (ADV: LE-L:0.73 ± 0.44 mm, LE-E:0.55 ± 0.45 mm, p < 0.05; ADA: LE-L:0.80 ± 0.41 mm, LE-E:0.63 ± 0.44 mm, p < 0.05), and the remaining pairs showed no significant difference. For the overall cohort with 113 eyes, the change in AL was weakly correlated with both ADV and ADA (both p < 0.05). Regarding the ADV/ADA, all pairs showed no significant differences, indicating equal lens position stability.

Conclusion

After OK, there were no significant differences between the different pairs of the three brands in AL growth, WHCZ, or lens position stability, although Lucid had a larger treatment zone than Euclid and Alpha, and Lucid had more decentration than Euclid. A larger lens decentration were weakly related to less AL growth.

Efficacy and Safety of Low-Dose Atropine on Myopia Prevention in Premyopic Children: Systematic Review and Meta-Analysis

Background: Early-onset myopia increases the risk of irreversible high myopia. Methods: This study systematically evaluated the efficacy and safety of low-dose atropine for myopia control in children with premyopia through meta-analysis using random-effects models. Effect sizes were calculated using risk ratios (RRs) with 95% confidence intervals (CIs). Comprehensive searches of PubMed, EMBASE, Cochrane CENTRAL, and ClinicalTrials.gov were conducted until 20 December 2023, without language restrictions. Results: Four studies involving 644 children with premyopia aged 4-12 years were identified, with atropine concentrations ranging from 0.01% to 0.05%. The analysis focused on myopia incidence and atropine-related adverse events. Lower myopia incidence (RR, 0.62; 95% CI, 0.40-0.97 D/y; p = 0.03) and reduction in rapid myopia shift (≥0.5 D/1y) (RR, 0.50; 95% CI, 0.26-0.96 D/y; p < 0.01) were observed in the 12-24-month period. Spherical equivalent and axial length exhibited attenuated progression in the atropine group. No major adverse events were detected in either group, whereas the incidence of photophobia and allergic conjunctivitis did not vary in the 12-24-month period. Conclusions: Our meta-analysis supports atropine's efficacy and safety for delaying myopia incidence and controlling progression in children with premyopia. However, further investigation is warranted due to limited studies.

Trends in Myopia and High Myopia from 1966 to 2019 in Olmsted County, Minnesota

PURPOSE

To investigate the prevalence of myopia and high myopia in Olmsted County, Minnesota, from 1966 to 2019.

DESIGN

Retrospective, cross-sectional, trend study.

METHODS

Manifest refractions or lens prescription were converted to spherical equivalent (SE) to estimate the prevalence of adult myopia and high myopia. Age, sex, race, and visual acuity were recorded. Subjects with an SE of -0.5 diopters (D) or less were considered to have myopia; those with an SE of -6.0 D or less were considered to have high myopia. Exclusion criteria included visually significant cataract, pseudophakia, prior refractive surgery, or age less than 18 years.

RESULTS

Among 81,706 sampled subjects, the myopia prevalence increased from 33.9% (95% CI, 31.1-36.8) in the 1960s to 57.1% (95% CI, 56.6-57.6) in the 2010s (P < .001). The high myopia prevalence increased from 2.8% (95% CI, 1.95-3.98) in the 1960s to 8.3% (95% CI, 8.08-8.62) in the 2010s (P < .001). Both male (32.0%-55.1%, P < .001) and female (40.6%-58.5%, P < .001) subjects experienced increasing myopia prevalence from the 1960s to the 2010s; both male (2.6%-7.4%, P < .001) and female (3.4%-9.1%, P < .001) subjects also had higher high myopia prevalence rates from the 1960s through the 2010s. Increasing myopia and high myopia prevalence was detected by decade in nearly all age groups (excluding 18- to 24-year-old high myopia subjects). White and Asian subjects had the highest myopia prevalence, whereas Black subjects had the lowest. From the 2000s to the 2010s, White (53.3%-57.0%, P < .001) and Black (41.0%-47.0%, P = .001) subjects had significant increases in myopia prevalence. The mean SE decreased from the 1960s (-0.42 D; 95% CI, -0.59 to +2.49) to the 2010s (-1.85 D; 95% CI, -1.88 to +2.96) (P < .001).

CONCLUSIONS

From 1966 to 2019 in Olmsted County, Minnesota, there was a 68% and 199% increase in myopia and high myopia prevalence, respectively.

The prevalence of myopia remains stable under tighter COVID-19 social restriction in preschoolers receiving a school-based eyecare program

PURPOSE

This study investigated the impact of different levels of COVID-19 social restrictions (social distancing in 2020, large-scale home confinement in 2021) on myopia prevalence and behaviours in a preschool population with school-based eyecare programme.

METHODS

Repeated cross-sectional surveys were conducted between August and December in 2019, 2020 and 2021. Children aged 5-6 years received ocular examinations, and questionnaires were answered by caregivers before the day of the examination. The main outcome measures were the changes in after-school time spent on homework, screen-based devices and outdoors. Secondary outcome was the change in myopia prevalence (spherical equivalent [SE] ≤ -0.5 D in either eye after cycloplegia).

RESULTS

A total of 9997 preschoolers were included in the analysis. Under tighter restrictions, more preschoolers spent ≥1 h/day on screen-based devices (42.8% in 2019, 45.2% in 2020, 48.9% in 2021, p < 0.001), and fewer preschoolers spent ≥30 min/day on after-school outdoor activities (49.5% in 2019, 46.0% in 2020, 41.0% in 2021, p < 0.001) on weekdays. A similar trend was found on weekends. While more preschoolers spent ≥2 h/day on screen-based devices (35.3% in 2019, 38.5% in 2020, 43.0% in 2021, p < 0.001), fewer preschoolers spent ≥2 h/day on outdoor activities (41.7% in 2019, 41.7% in 2020, 34.0% in 2021, p < 0.001). The mean SE and myopia prevalence were stable (9.1% in 2019, 10.3% in 2020, 9.4% in 2021, p = 0.707).

CONCLUSION

Our study showed dose-dependent effect of social restrictions on near-work and outdoor behaviours at home. The prevalence of myopia did not increase significantly with short-term cessation of school-based eyecare programmes.

A meta-analysis of randomized controlled trials evaluating the effectiveness and safety of the repeated low-level red light therapy in slowing the progression of myopia in children and adolescents

PURPOSE

The aim of this study was to evaluate the effectiveness and safety of repeated low-level red light (RLRL) therapy in controlling myopia progression in children through a meta-analysis.

METHODS

We searched several databases including PubMed, Embase, The Cochrane Library, Web of Science, CNKI, WANFANG, CBM, and VIP with languages restricted to both Chinese and English. The search was conducted from the establishment of the databases to March 23, 2023. We collected randomized controlled trials and controlled experiments to evaluate changes in axial length (AL) and spherical equivalent (SE) before and after RLRL intervention. Two researchers performed literature screening and data extraction, and RevMan software (Ver 5.3) and StataMP 17.0 were used for meta-analysis.

RESULTS

A total of 141 articles were retrieved, and finally, six randomized controlled trials met the inclusion and exclusion criteria, including 820 eyes (RLRL group: 411 eyes, control group: 409 eyes). The meta-analysis results showed that the RLRL group was significantly better than the control group in controlling AL, and the difference between the two groups was statistically significant (mean difference [MD] = -0.22, 95% confidence interval [CI] [ - 0.28, -0.16]; P < 0.001). The RLRL group was also better than the control group in terms of SE, and the difference between the two groups was statistically significant (MD = 0.46, 95% CI [0.32, 0.6]; P < 0.001). Five studies reported adverse reactions in the RLRL group, and two cases stopped treatment due to the feeling of too bright light, while the others had no significant side effects in the short term.

CONCLUSION

RLRL therapy is a safe and effective method for controlling myopia, which can inhibit the growth of AL and slow down the progression of myopia. However, further research and validation are needed to determine its treatment efficacy and course.

Urban greenspace and visual acuity in schoolchildren: a large prospective cohort study in China

BACKGROUND

Greenspace is known to have a positive impact on human health and well-being, but its potential effects on visual acuity have not been extensively studied.

OBJECTIVES

Our aim was to examine the relationship between long-term greenspace exposure and visual acuity in children, while also exploring the potential mechanisms in this association.

METHODS

We conducted this prospective cohort study based on the Children's growth environment, lifestyle, physical, and mental health development project (COHERENCE), which screened 286,801 schoolchildren in Guangzhou, China, starting in the 2016/17 academic year and followed them up for three academic years (2017/18-2019/20). Visual acuity was measured using a standardized logarithmic chart, and visual impairment was defined as visual acuity worse than 0.0 logarithm of the minimum angle of resolution (LogMAR) units in the better eye. We used the Normalized Difference Vegetation Index (NDVI), the Soil-Adjusted Vegetation Index (SAVI), and the Enhanced Vegetation Index (EVI) to assess the greenspace surrounding child's geocoded home and school at each visit.

RESULTS

Our analysis indicated that higher greenspace exposure was associated with greater visual acuity z-score at baseline and with slower decline in visual acuity z-score during the 3-year follow-up. An interquartile range increase in home-school-based NDVI 300m was associated with a 7% decrease [hazard ratios (HRs): 0.93, 95% confidence interval (CI): 0.92, 0.94] in the risk of visual impairment. We also found that air pollution, physical activity, outdoor time, and recreational screen time partially mediated the greenspace-visual acuity association.

CONCLUSION

Our findings suggest that increasing greenspace exposure could benefit children's visual acuity development and reduce the risk of visual impairment by reducing air pollution and recreational screen time while increasing physical activity and outdoor time. All results could have potential policy implications, given the individual and societal burdens associated with visual impairment.

The influence of the environment and lifestyle on myopia

BACKGROUND

Myopia, commonly known as near-sightedness, has emerged as a global epidemic, impacting almost one in three individuals across the world. The increasing prevalence of myopia during early childhood has heightened the risk of developing high myopia and related sight-threatening eye conditions in adulthood. This surge in myopia rates, occurring within a relatively stable genetic framework, underscores the profound influence of environmental and lifestyle factors on this condition. In this comprehensive narrative review, we shed light on both established and potential environmental and lifestyle contributors that affect the development and progression of myopia.

MAIN BODY

Epidemiological and interventional research has consistently revealed a compelling connection between increased outdoor time and a decreased risk of myopia in children. This protective effect may primarily be attributed to exposure to the characteristics of natural light (i.e., sunlight) and the release of retinal dopamine. Conversely, irrespective of outdoor time, excessive engagement in near work can further worsen the onset of myopia. While the exact mechanisms behind this exacerbation are not fully comprehended, it appears to involve shifts in relative peripheral refraction, the overstimulation of accommodation, or a complex interplay of these factors, leading to issues like retinal image defocus, blur, and chromatic aberration. Other potential factors like the spatial frequency of the visual environment, circadian rhythm, sleep, nutrition, smoking, socio-economic status, and education have debatable independent influences on myopia development.

CONCLUSION

The environment exerts a significant influence on the development and progression of myopia. Improving the modifiable key environmental predictors like time spent outdoors and engagement in near work can prevent or slow the progression of myopia. The intricate connections between lifestyle and environmental factors often obscure research findings, making it challenging to disentangle their individual effects. This complexity underscores the necessity for prospective studies that employ objective assessments, such as quantifying light exposure and near work, among others. These studies are crucial for gaining a more comprehensive understanding of how various environmental factors can be modified to prevent or slow the progression of myopia.

Treatment of Rapid Progression of Myopia: Topical Atropine 0.05% and MF60 Contact Lenses

This retrospective study evaluates the effectiveness of combining 0.05% atropine with MF60 contact lenses in managing rapid myopia progression in children over one year. The study involved three groups: the treatment group (TG) with 15 children (53% male, average age 12.9 ± 1.04), the MF group (MF) with 12 children (50% male, average age 12.8 ± 0.8) using only MF60 lenses, and the control group (CG) with 14 children (43% male, average age 12.1 ± 0.76). Baseline myopia and axial length (AL) were similar across groups, with the TG, MF, and CG showing -4.02 ± 0.70 D, -4.18 ± 0.89 D, -3.86 ± 0.99 D, and 24.72 ± 0.73 mm, 24.98 ± 0.70 mm, 24.59 ± 1.02 mm, respectively. Prior to the study, all groups exhibited significant myopia and AL progression, with no previous myopia control management. The treatment involved daily 0.05% atropine instillation, the use of MF60 lenses and increased outdoor activity. Biannual cycloplegic refraction and slit lamp evaluations confirmed no adverse reactions. After one year, the TG showed a significant reduction in myopia and AL progression (-0.43 ± 0.46 D, p < 0.01; 0.22 ± 0.23 mm, p < 0.01), whereas the CG showed minimal change (-1.30 ± 0.43 D, p = 0.36; 0.65 ± 0.35 mm, p = 0.533). The MF group also exhibited a notable decrease (-0.74 ± 0.45 D, p < 0.01; 0.36 ± 0.23 mm). Increased outdoor activity during the treatment year did not significantly impact myopia control, suggesting its limited additional effect in this cohort. The study concludes that the combination of 0.05% atropine and peripheral defocus soft contact lenses effectively controls myopia progression in children.

The association between pupillary responses and axial length in children differs as a function of season

The association between pupillary responses to repeated stimuli and adult refractive error has been previously demonstrated. This study evaluated whether this association exists in children and if it varies by season. Fifty children aged 8-17 years (average: 11.55 ± 2.75 years, 31 females) with refractive error between + 1.51 and - 5.69 diopters (non-cycloplegic) participated (n = 27 in summer, and n = 23 in winter). The RAPDx pupilometer measured pupil sizes while stimuli oscillated between colored light and dark at 0.1 Hz in three sequences: (1) alternating red and blue, (2) red-only, and (3) blue-only. The primary outcome was the difference in pupillary responses between the blue-only and red-only sequences. Pupillary constriction was greater in response to blue light than to red for those with shorter eyes in summer (β = - 9.42, P = 0.034) but not in winter (β = 3.42, P = 0.54). Greater constriction comprised faster pupillary escape following red light onset and slower redilation following stimulus offset of both colors (P = 0.017, 0.036, 0.035 respectively). The association between axial length and children's pupillary responses in summer, but not winter may be explained by greater light-associated release of retinal dopamine in summer. Shorter eyes' more robust responses are consistent with greater light exposure inhibiting axial elongation and reducing myopia risk.

Myopia progression in children during home confinement in the COVID-19 pandemic: A systematic review and meta-analysis

PURPOSE

Myopia is a growing pandemic, especially in children, who risk low vision later in life. Home confinement during the COVID-19 pandemic may have increased myopia progression through increased screentime, decreased time outdoors and increased near work activities. The aim of this study is to compare progression of myopia in children during home confinement period in the COVID-19 pandemic with pre-COVID-19 progression.

METHODS

On January 2023 PubMed, EMBASE and Cochrane were searched for relevant studies. Studies meeting the following criteria were eligible for inclusion: children (under 18 years), home confinement due to COVID-19, spherical equivalent refractive (SER) and axial length (AL) measurements and a follow-up period to measure progression. Quality appraisal was performed by two reviewers independently using the Joanna Briggs Institute tool for cohort studies. Outcomes for myopia were assessed through meta-analysis, analyzing SER (random effects) and AL (fixed effects).

RESULTS

Hundred and two articles were identified in the search, of which five studies were included in the analysis. Risk of bias is moderate with a few critical flaws in the studies. Myopia progressed more rapidly during the COVID-19 pandemic compared to the pre-COVID-19 period, both in terms of SER (-0.83D [95 %CI, -1.22, -0.43] and AL (0.36 mm [95 %CI, 0.13, 0.39]).

CONCLUSION

Progression of myopia during the COVID-19 pandemic accelerated more rapidly compared to the pre-COVID-19 period. Impact of home confinement on myopia may be considered when future lockdown measures are being contemplated.

Increase of Intraocular Pressure after Application of 0.125% Atropine Eye Drops in Children Using Ortho-K Contact Lenses

Introduction

This report describes a case of elevated intraocular pressure following the use of 0.125% atropine eye drops in a child wearing orthokeratology lenses.

Case Presentation

A 9-year-old boy presented to our clinic with myopia, and he had been wearing orthokeratology lenses overnight for 23 months. He was treated previously with a once-daily administration of topical 0.125% atropine eye drops to reduce myopic progression. Three days after treatment, his intraocular pressure was 36 mm Hg in the right eye and 32 mm Hg in the left eye. Two days after the discontinuation of atropine eye drops and overnight orthokeratology lenses, the intraocular pressure was 18/20 mm Hg in both eyes.

Conclusion

Low-dose atropine eye drops can cause intraocular pressure elevation in patients wearing overnight orthokeratology lenses. Although it may resolve promptly, short-term follow-up with intraocular pressure checks may be necessary for the early diagnosis and treatment of this complication.

Light exposure therapy for myopia control: a systematic review and Bayesian network meta-analysis

AIMS

To compare and rank the myopia control effects of different light wavelengths in children using a systematic review and Bayesian network meta-analysis (Bayesian NMA).

METHODS

The review protocol was registered with PROSPERO. We searched PubMed, EMBASE and MEDLINE for relevant clinical and animal studies published as of 2 February 2023. We included studies comparing red, violet or full-spectrum light with controls. Data extracted included descriptive statistics and study outcomes (axial length (AL) elongation and progression of spherical equivalent (SE) refraction). After quality assessment, estimates of treatment effect outcomes (mean differences (MDs) and 95% CIs) were first pooled for the animal and clinical studies in a traditional meta-analysis. To compare and rank the different light wavelengths, the Bayesian NMA was then conducted for all the included clinical studies (12 studies) and separately for only randomised controlled trials (8 studies). MDs, 95% credible intervals (CrIs) and ranks of the various light wavelengths were estimated in the Bayesian NMA.

RESULTS

When all clinical studies were included in the Bayesian NMA (12 studies), only red-light significantly slowed AL elongation, MD (95% CrI), -0.38 mm (-0.59 mm to -0.16 mm)/year and SE refraction progression, 0.72D (0.35D to 1.10D)/year compared with controls. It remained the only significant intervention when effect sizes from only RCTs (eight studies) were separately combined, (-0.28 mm (-0.40 mm to -0.15 mm)/year and 0.57D (0.22D to 0.92D)/year, for AL and SE refraction, respectively).

CONCLUSION

Myopia control efficacy varied among different wavelengths of light, with red light ranked as the most effective.

PROSPERO REGISTRATION NUMBER

Clinical studies: CRD42022368998; animal studies: CRD42022368671.

Understanding Posterior Staphyloma in Pathologic Myopia: Current Overview, New Input, and Perspectives

Posterior staphyloma (PS) is considered the hallmark of pathologic myopia and is defined as an outpouching of a circumscribed portion of the eyeball with a radius of curvature smaller than that of the adjacent zone. Although more common in eyes with high myopia, it can affect those without it. The presence of PS is associated with a structurally and functionally worse course of high myopia that can lead to visual disability. Unfortunately, the pathogenesis of PS is unclear so far. Thus, due to the increasing prevalence of myopia which has been further exacerbated by the advent of COVID-19 lockdown, researchers are eager to elucidate the pathogenesis of pathologic myopia and that of its complications, especially PS, which will allow the development of preventive strategies. The aim of this work was to review the morphological characteristics of PS with emphasis on similarities with peripapillary staphyloma and to discuss the pathogenesis of PS considering recent suggestions about that of peripapillary staphyloma.

Myopia management algorithm. Annexe to the article titled Update and guidance on management of myopia. European Society of Ophthalmology in cooperation with International Myopia Institute

Myopia is becoming increasingly common in young generations all over the world, and it is predicted to become the most common cause of blindness and visual impairment in later life in the near future. Because myopia can cause serious complications and vision loss, it is critical to create and prescribe effective myopia treatment solutions that can help prevent or delay the onset and progression of myopia. The scientific understanding of myopia's causes, genetic background, environmental conditions, and various management techniques, including therapies to prevent or postpone its development and slow its progression, is rapidly expanding. However, some significant information gaps exist on this subject, making it difficult to develop an effective intervention plan. As with the creation of this present algorithm, a compromise is to work on best practices and reach consensus among a wide number of specialists. The quick rise in information regarding myopia management may be difficult for the busy eye care provider, but it necessitates a continuing need to evaluate new research and implement it into daily practice. To assist eye care providers in developing these strategies, an algorithm has been proposed that covers all aspects of myopia mitigation and management. The algorithm aims to provide practical assistance in choosing and developing an effective myopia management strategy tailored to the individual child. It incorporates the latest research findings and covers a wide range of modalities, from primary, secondary, and tertiary myopia prevention to interventions that reduce the progression of myopia.

An empirical study on the effect of outdoor illumination and exercise intervention on Children's vision

Objective

To explore the relationship between outdoor lighting and sports and the development of myopia, and to analyze the effects of outdoor lighting and exercise on the diopter of children with normal vision and myopia, so as to provide guidance for the prevention and treatment of myopia in children and adolescents in the future.

Methods

A total of 201 children were divided into two groups according to myopia or not. Each group was randomly divided into 4 groups: outdoor exercise group, outdoor control group, indoor exercise group and indoor control group. Among them, the outdoor exercise group and indoor exercise group received moderate and high intensity aerobic exercise 3 times a week for 60 min each time for 12 months, while the outdoor control group and indoor control group had normal study and life during the corresponding period of time. No additional exercise intervention. At the end of the experiment, the diopter of each group was compared.

Results

The diopter of all groups with normal vision and myopia decreased significantly after the experiment (p < 0.01). There were significant differences in diopter between outdoor exercise group and indoor control group (p < 0.01), between outdoor exercise group and indoor control group (p < 0.05), and between indoor exercise group and indoor control group (p < 0.01). There were significant differences in diopter between indoor exercise group and indoor control group (p < 0.01). The differences among myopic children after the experiment showed that there was significant difference in diopter between outdoor exercise group and indoor exercise group (p < 0.05), between outdoor exercise group and indoor control group (p < 0.01), and between outdoor control group and indoor control group (p < 0.05). There were significant differences in the changes of diopter between the outdoor control group and the indoor exercise group with normal vision and myopia before and after the experiment (p < 0.05).

Conclusion

Outdoor light and exercise intervention can have a beneficial effect on children's vision, but because of whether children are myopic or not, the effect is different, outdoor light and exercise have a better effect on reducing the diopter of children with normal vision.

Seasonal and Annual Change in Physiological Ocular Growth of 7- to 11-Year-Old Norwegian Children

Purpose

To investigate seasonal and annual change in physiological eye growth in Norwegian school children.

Methods

Measurements of ocular biometry, non-cycloplegic spherical equivalent autorefraction (SER), and choroidal thickness (ChT) were obtained for 92 children (44 females) aged 7 to 11 years at four time points over a year (November 2019-November 2020). Seasons (3- and 5-month intervals) were classified as winter (November-January), winter-spring (January-June), and summer-autumn (June-November). Cycloplegic SER was obtained in January and used to group children. The seasonal and annual changes were tested with a linear mixed-effects model (P values were adjusted for multiple comparisons).

Results

All the children experienced annual ocular growth, irrespective of SER, but less so during the summer-autumn. The baseline SER was lower (P < 0.001), axial length (AL) was longer (P < 0.038), and choroids were thicker in 10- to 11-year-old than 7- to 8-year-old mild hyperopes (P = 0.002). Assuming mild hyperopes (n = 65) experience only physiological eye growth, modeling revealed seasonal and annual increases in AL across sex and age (P < 0.018), with less change during the summer-autumn than winter-spring. The 7- to 8-year-olds had a larger decrease annually and over winter-spring in SER (P ≤ 0.036) and in ChT over winter-spring than the 10- to 11-year-olds (P = 0.006).

Conclusions

There were significant seasonal and annual changes in AL in children who had physiological eye growth irrespective of age within this cohort. Annual changes in SER and seasonal choroidal thinning were only observed in 7- to 8-year-old children. This indicates continued emmetropization in 7- to 8-year-olds and a transition to maintaining emmetropia in 10- to 11-year-olds.

Significant myopic shift over time: Sixteen-year trends in overall refraction and age of myopia onset among Chinese children, with a focus on ages 4-6 years

Background

Myopia or near-sightedness is a major cause of blindness in China and typically develops between the ages of 6-12 years. We aimed to investigate the change in refractive error and the age of myopia onset in Chinese children from 2005 to 2021.

Methods

We first conducted a series of cross-sectional studies to determine the refractive states and the age of myopia onset over time, after which we analysed longitudinal data to investigate the dose-response relationship between hyperopic reserve and future risk of myopia. The analysis was based on the refraction data of children aged 4-18 years who visited the Fudan University Eye and Ear, Nose, and Throat (FUEENT) Hospital, a large tertiary hospital in Shanghai, China, for eye examinations between 2005 and 2021. We examined the prevalence of hyperopia (spherical equivalent refractive error (SERE) >0.75D), pre-myopia (-0.50D < SERE ≤ 0.75D), and myopia (SERE ≤-0.50D), the average SERE for each age group at the initial visit, the average age of myopia onset, and the safety threshold of hyperopic reserve against myopia onset.

Results

We included 870 372 eligible patients aged 4-18 years who attended examination between 2005 and 2021, 567 893 (65.2%) of whom were myopic at their initial visit to FUEENT. The mean SERE decreased in most (n/N = 14/15) of the age groups over the 16 calendar years, with a mean SERE for the whole cohort decreasing from -1.01D (standard deviation (SD) = 3.46D) in 2005 to -1.30D (SD = 3.11D) in 2021. The prevalence of pre-myopia increased over the 16 years (P < 0.001), while those of myopia and hyperopia remained largely stable (both P > 0.05). We observed a significant decrease in the prevalence of hyperopia (2005: 65.4% vs 2021: 51.1%; P < 0.001) and a significant increase in the prevalence of pre-myopia (2005: 19.0% vs 2021: 26.5%; P < 0.001) and myopia (2005: 15.6% vs 2021: 22.4%; P < 0.001) in children aged 4-6 years. We found an earlier myopia onset over time, with the mean age of onset decreasing from 10.6 years in 2005 to 7.6 years in 2021 (P < 0.001). Children with a hyperopic reserve of less than 1.50D were at increased risk of developing myopia during a median follow-up of 1.3 years.

Conclusions

We found an overall myopic shift in SERE in Chinese children aged 4-18 years over the past 16 years, particularly in those aged 4-6 years. The mean age of myopia onset decreased by three years over the same period. The "safety threshold" of hyperopic reserve we identified may help target the high-risk population for early prevention.

Predicting the child who will become myopic - can we prevent onset?

Myopia has become a global epidemic with significant public health impacts. Identifying the child at risk of developing myopia, i.e. the pre-myopic child and implementing strategies to prevent the onset of myopia, could significantly reduce the burden of myopia on an individual and society. This paper is a review of publications that have identified ocular characteristics of children at risk of future myopia development including a lower than age normal amount of hyperopia and accelerated axial length elongation. Risk factors associated with increased risk of myopia development such as education exposure and reduced outdoor time, and strategies that could be implemented to prevent myopia onset in children are also explored. The strong causal role of education and outdoor time on myopia development suggests that lifestyle modifications could be implemented as preventative measures to at-risk children and may significantly impact the myopia epidemic by preventing or delaying myopia onset and its associated ocular health consequences.

Assessing the utility of ChatGPT as an artificial intelligence-based large language model for information to answer questions on myopia

PURPOSE

ChatGPT is an artificial intelligence language model, which uses natural language processing to simulate human conversation. It has seen a wide range of applications including healthcare education, research and clinical practice. This study evaluated the accuracy of ChatGPT in providing accurate and quality information to answer questions on myopia.

METHODS

A series of 11 questions (nine categories of general summary, cause, symptom, onset, prevention, complication, natural history, treatment and prognosis) were generated for this cross-sectional study. Each question was entered five times into fresh ChatGPT sessions (free from influence of prior questions). The responses were evaluated by a five-member team of optometry teaching and research staff. The evaluators individually rated the accuracy and quality of responses on a Likert scale, where a higher score indicated greater quality of information (1: very poor; 2: poor; 3: acceptable; 4: good; 5: very good). Median scores for each question were estimated and compared between evaluators. Agreement between the five evaluators and the reliability statistics of the questions were estimated.

RESULTS

Of the 11 questions on myopia, ChatGPT provided good quality information (median scores: 4.0) for 10 questions and acceptable responses (median scores: 3.0) for one question. Out of 275 responses in total, 66 (24%) were rated very good, 134 (49%) were rated good, whereas 60 (22%) were rated acceptable, 10 (3.6%) were rated poor and 5 (1.8%) were rated very poor. Cronbach's α of 0.807 indicated good level of agreement between test items. Evaluators' ratings demonstrated 'slight agreement' (Fleiss's κ, 0.005) with a significant difference in scoring among the evaluators (Kruskal-Wallis test, p < 0.001).

CONCLUSION

Overall, ChatGPT generated good quality information to answer questions on myopia. Although ChatGPT shows great potential in rapidly providing information on myopia, the presence of inaccurate responses demonstrates that further evaluation and awareness concerning its limitations are crucial to avoid potential misinterpretation.

Cost-Effectiveness Analysis of Myopia Progression Interventions in Children

Importance

Several interventions exist for treating myopia progression in children. While these interventions' efficacy has been studied, their cost-effectiveness remains unknown and has not been compared.

Objective

To determine cost-effective options for controlling myopia progression in children.

Design, Setting, and Participants

In this cost-effectiveness analysis, a Markov model was designed to compare the cost-effectiveness of interventions for controlling myopia progression over 5 years from a societal perspective in a simulated hypothetical cohort of patients aged 10 years with myopia. Myopia interventions considered included atropine eye drops, 0.05% and 0.01%, defocus incorporated multiple segment spectacles, outdoor activity, soft contact lenses (daily disposable and multifocal), rigid gas-permeable contact lenses, progressive addition lenses, bifocal spectacle lenses, orthokeratology, highly aspherical lenslets (HALs), and red light therapy; all interventions were compared with single-vision lenses. Deterministic and probabilistic sensitivity analysis determined the association of model uncertainties with the cost-effectiveness. Costs were obtained from the charges of the Hospital Authority of Hong Kong and The Chinese University of Hong Kong Eye Center.

Main Outcome and Measures

The mean costs (in US dollars) per child included the cost of hospital visits, medications, and optical lenses. The outcomes of effectiveness were the annual spherical equivalent refraction (SER) and axial length (AL) reductions. Incremental cost-effectiveness ratios (ICERs) were calculated for each strategy relative to single-vision lenses over a time horizon of 5 years.

Results

Outdoor activity, atropine (0.05%), red light therapy, HALs, and orthokeratology were cost-effective. The ICER of atropine, 0.05%, was US $220/SER reduction; red light therapy, US $846/SER reduction; and HALs, US $448/SER reduction. Outdoor activity yielded a savings of US $5/SER reduction and US $8/AL reduction. Orthokeratology resulted in an ICER of US $2376/AL reduction.

Conclusions and Relevance

These findings suggest that atropine eye drops, 0.05%, and outdoor activity are cost-effective for controlling myopia progression in children. Though more expensive, red light therapy, HALs, and orthokeratology may also be cost-effective. The use of these interventions may help to control myopia in a cost-effective way.

Myopia prevention and control in children: a systematic review and network meta-analysis

OBJECTIVES

To analyse and compare the efficacy of different interventions for myopia prevention and control in children.

METHODS

We searched CNKI, VIP, Wan-Fang, CBM, Chinese Clinical Registry, PubMed, The Cochrane Library, Web of Science, Embase and ClinicalTrials.gov from inception to July 2022. We selected randomized controlled trials (RCTs) that included interventions to slow myopia progression in children. The main outcomes included mean annual change in axial length (AL) (millimetres/year) and in refraction (R) (dioptres/year).

RESULTS

A total of 80 RCTs (27103 eyes) were included. In comparison with control, orthokeratology (AL, -0.36 [-0.53, -0.20], P < 0.05; R, 0.56 [0.34, 0.77], P < 0.05), 1%Atropine (AL, -0.39 [-0.65, -0.13], P < 0.05; R, 0.54 [0.31, 0.77], P < 0.05), 0.01%Atropine + orthokeratology (AL, -0.47 [-0.80, -0.14], P < 0.05; R, 0.81 [0.43, 1.20], P < 0.05) could significantly slow the progression of myopia; in addition, progressive multi-focal spectacle lenses (PMSL) (0.42, [0.06, 0.79], P < 0.05), bifocal soft contact lenses (0.40, [0.03, 0.77], P < 0.05), 0.5%Atropine (0.67 [0.25, 1.10], P < 0.05), 0.1%Atropine (0.42 [0.15, 0.71], P < 0.05), 0.05%Atropine (0.57 [0.28, 0.86], P < 0.05), 0.01%Atropine (0.33 [0.15, 0.52], P < 0.05), 1%Atropine + bifocal spectacle lenses (BSL) (1.30 [0.54, 2.00], P < 0.05), 1%Atropine + PMSL (0.66 [0.23, 1.10], P < 0.05), 0.01%Atropine + single vision spectacle lenses (SVSL) (0.70 [0.23, 1.10], P < 0.05), 0.01%Atropine + orthokeratology (0.81 [0.43, 1.20], P < 0.05), BSL + Massage (0.85 [0.22, 1.50], P < 0.05), SVSL + Red light (0.59 [0.06, 0.79], P < 0.05) showed significant slowing effect on the increase in R.

CONCLUSIONS

This network meta-analysis suggests that the combined measures were most effective in AL and R, followed by Atropine.

Time Spent Outdoors Partly Accounts for the Effect of Education on Myopia

Purpose

The purpose of this study was to investigate if education contributes to the risk of myopia because educational activities typically occur indoors or because of other factors, such as prolonged near viewing.

Methods

This was a two-sample Mendelian randomization study. Participants were from the UK Biobank, Avon Longitudinal Study of Parents and Children, and Generation R. Genetic variants associated with years spent in education or time spent outdoors were used as instrumental variables. The main outcome measures were: (1) spherical equivalent refractive error attained by adulthood, and (2) risk of an early age-of-onset of spectacle wear (EAOSW), defined as an age-of-onset of 15 years or below.

Results

Time spent outdoors was found to have a small genetic component (heritability 9.8%) that tracked from childhood to adulthood. A polygenic score for time outdoors was associated with children's time outdoors; a polygenic score for years spent in education was inversely associated with children's time outdoors. Accounting for the relationship between time spent outdoors and myopia in a multivariable Mendelian randomization analysis reduced the size of the causal effect of more years in education on myopia to -0.17 diopters (D) per additional year of formal education (95% confidence interval [CI] = -0.32 to -0.01) compared with the estimate from a univariable Mendelian randomization analysis of -0.27 D per year (95% CI = -0.41 to -0.13). Comparable results were obtained for the outcome EAOSW.

Conclusions

Accounting for the effects of time outdoors reduced the estimated causal effect of education on myopia by 40%. These results suggest about half of the relationship between education and myopia may be mediated by children not being outdoors during schooling.

Effect of Extracurricular After-School Physical Activities on Academic Performance of Schoolchildren: A Cluster Randomized Clinical Trial

Importance

The beneficial effects of increasing outdoor physical activity time on children's myopia onset and physical well-being are widely acknowledged. However, in countries with competitive educational systems, such as China, parents and school administrators may be relatively reluctant to increase the extracurricular physical activity time for children due to concerns that this action will compromise children's academic performance.

Objective

To investigate whether additional extracurricular physical activity time after school compromises the academic performance of schoolchildren.

Design, Setting, and Participants

This cluster randomized clinical trial was conducted from October 2020 to June 2021 in Yudu, Jiangxi, China. Eligible children in grades 3 and 4 from 24 elementary schools were randomized to the intervention or control group. Primary analysis was conducted in the full sample using the intention-to-treat principle.

Interventions

The intervention group received 2 hours of after-school physical activity time outdoors on school days. The control group was free to arrange their after-school activity.

Main Outcomes and Measures

The primary outcome was the between-group mean difference in mathematics test scores at the end of 1 academic year, with a noninferiority margin of -3.3 points. Standardized mathematics tests, physical fitness assessments (in reference to the 2018 National Physical Fitness Survey Monitoring Programme in China), and cycloplegic autorefraction were performed at baseline and the end of 1 academic year. Myopia was defined as a cycloplegic spherical equivalent refraction of -0.5 diopters or less in either eye.

Results

A total of 2032 children (mean [SD] age, 9.22 [0.62] years; 1040 girls [51.2%]) from 24 schools were randomized to the intervention group (12 schools; 1012 children) or control group (12 schools; 1020 children). The mean (SD) mathematics score at the end of 1 academic year was 78.01 (17.56) points in the intervention group and 77.70 (17.29) points in the control group. The adjusted between-group mean difference was 0.65 points (95% CI, -2.85 to 4.15). The adjusted between-group mean difference in physical fitness score was 4.95 points (95% CI, 3.56-6.34; P < .001) and -1.90% (95% CI, -18.72% to 14.91%; P > .99) in myopia incidence.

Conclusions and Relevance

Results of this trial indicate that, compared with the control practice of free play after school, adding 2 hours of extracurricular physical activity outdoors after school was noninferior in academic performance and had superior efficacy in improving physical fitness.

Trial Registration

ClinicalTrials.gov Identifier: NCT04587765.

Indoor and outdoor human behavior and myopia: an objective and dynamic study

Significance

Myopia holds significant public health concern given its social, ocular disease and economic burdens. Although environmental factors are primarily to blame for the rapid rise in prevalence, key risk factors remain unresolved.

Purpose

The aim of this study was to objectively characterize, using a wearable technology, the temporal indoor and outdoor behavioral patterns and associated environmental lighting characteristics of young myopic and nonmyopic University students.

Methods

Participants were recruited to continuously wear an Actiwatch for 3 weeks, during either or both academic and non-academic periods. The device allows continuous recording of activity and incident light. Recorded illuminance levels were used as a proxy for outdoors (>1,000 lux), with the dynamics (interval frequency and duration) of indoor and outdoor activities, as well as lighting characteristics derived. In addition, participant input regarding near work was obtained daily. Participants were classified by both myopia and axial length status (based on collected refractive error and biometry data) for the purpose of data analysis.

Result

A total of 55 students, aged 18 to 25 years of age, participated. Overall, the dosing of indoor and outdoor activities was similar across participants, regardless of myopia status, during the academic period. Nonetheless, an apparent difference in the timing of outdoor activities was noted with myopes going outdoors later in the day, particularly during the weekend (p = 0.03). While a trend was observed between increased lighting levels experienced outdoors and shorter axial lengths, there was no significant relationship with myopia status. Noteworthy, participants generally significantly overestimated time spent outdoors, compared to Actiwatch-derived estimates of the same.

Conclusion

While the findings from this cohort of young adult students did not reveal substantial myopia-related differences in behavior, the power of a more objective and dynamic approach to quantifying behavior cannot be understated, providing argument for general adoption of wearable technologies in future clinical myopia studies.

Safety and efficacy of 0.01% and 0.1% low-dose atropine eye drop regimens for reduction of myopia progression in Danish children: a randomized clinical trial examining one-year effect and safety

BACKGROUND

To investigate the efficacy and safety of 0.1% and 0.01% low-dose atropine eye drops in reducing myopia progression in Danish children.

METHODS

Investigator-initiated, placebo-controlled, double-masked, randomized clinical trial. Ninety-seven six- to twelve-year old myopic participants were randomized to 0.1% loading dose for six months followed by 0.01% for six months (loading dose group, Number (N) = 33), 0.01% for twelve months (0.01% group, N = 32) or vehicle for twelve months (placebo, N = 32). Primary outcomes were axial length and spherical equivalent refraction. Secondary outcomes included adverse events and reactions, choroidal thickness and ocular biometry. Outcomes were measured at baseline and three-month intervals. Data was analyzed with linear-mixed model analysis according to intention-to-treat.

RESULTS

Mean axial elongation was 0.10 mm less (95% confidence interval (CI): 0.17; 0.02, adjusted-p = 0.06) in the 0.1% loading dose and 0.07 mm less (95% CI: 0.15; 0.00, adjusted-p = 0.16) in the 0.01% group at twelve months compared to placebo. Mean spherical equivalent refraction progression was 0.24 D (95% CI: 0.05; 0.42) less in the loading dose and 0.19 D (95% CI: 0.00; 0.38) less in the 0.01% groups at twelve months, compared to placebo (adjusted-p = 0.06 and 0.14, respectively). A total of 108 adverse events were reported during the initial six-month loading dose period, primarily in the loading dose group, and 14 were reported in the six months following dose switching, all deemed mild except two serious adverse events, unrelated to the intervention.

CONCLUSIONS

Low-dose atropine eye drops are safe over twelve months in otherwise healthy children. There may be a modest but clinically relevant reduction in myopia progression in Danish children after twelve months treatment, but the effect was statistically non-significant after multiple comparisons adjustment. After dose-switching at six months the loading dose group approached the 0.01% group, potentially indicating an early "rebound-effect".

TRIAL REGISTRATION

this study was registered in the European Clinical Trials Database (EudraCT, number: 2018-001286-16) 05/11/2018 and first posted at www.

CLINICALTRIALS

gov (NCT03911271) 11/04/2019, prior to initiation.

The association between sleep duration and risk of myopia in Chinese school-aged children: a cross-sectional study

BACKGROUND

Myopia is one of the most commonly diagnosed refractive disorders worldwide. Identifying risk factors for myopia at an early age may help to characterize children who would benefit most from individualized lifestyle advice and early interventions. The influence of sleep duration on myopia risk remains controversial and thus needs to be evaluated.

METHODS

A population-based cross-sectional study of Chinese school-aged children was conducted. Information on sleep duration was derived. The association between sleep duration and myopia risk was investigated by logistic regression analysis.

RESULTS

Myopia prevalence among 9530 Chinese school-aged children was 75.4% and decreased from 84.9%, 76.5%, 65.8%, to 61.3% along with the extension of sleep duration. Univariate logistic regression found longer sleep duration of 8-9 h (OR = 0.58, 95% CI: 0.51-0.66), 9-10 h (OR = 0.34, 95% CI: 0.30-0.39), and ≥ 10 h (OR = 0.28, 95% CI: 0.24-0.33) were protective factors for myopia in all participants (P for trend < 0.001). In the multivariate analyses, sleep duration was inversely associated with the risk of myopia, and a dose-effect relationship was observed when the analysis was split by age category.

CONCLUSIONS

Long sleep duration was associated with decreased risk of myopia in Chinese school-aged children.

Effects of school myopia management measures on myopia onset and progression among Chinese primary school students

BACKGROUND

Schools play an organizational role in managing myopia-related behavioral habits among students. We evaluated the effects of school myopia management measures on myopia onset and progression in a school-based prospective 1-year observational study.

METHODS

In total, 8319 children from 26 elementary schools were included. Online questionnaire completed by a parent, in which school myopia management experience including outdoor activities in recess or physical education class, teachers' supervision, and teaching facilities. Variables were defined as implemented well or poorly, according to the Comprehensive Plan to Prevent Myopia among Children and Teenagers. Children underwent ophthalmic examinations, and the incidence and progression of myopia from 2019 to 2020 were estimated. Multilevel logistic regression models were constructed to analyze the association between school management measures and myopia development in 8,9 years and 10,11 years students.

RESULTS

From 2019 to 2020, the incidence of myopia among primary school students was 36.49%; the mean difference of spherical equivalent in myopic children was - 0.29 ± 1.22 diopters. The risk of incident myopia was reduced by 20% in 8,9 years participants with well-implemented class recess compared with those with poorly implemented class recess (adjusted odds ratio [aOR]: 0.80, p = 0.032). PE outdoor time was significantly associated with myopia incidence in 10,11 years students (aOR: 0.76, p = 0.043). Compared with poorly implemented reading and writing posture, desk and chair height, 10,11 participants with well-implemented desk and chair height were less likely to have rapid myopic progression (p = 0.029, p = 0.022).

CONCLUSION

In Shanghai, children's myopia is associated with better implementation of school myopia management measures. The present findings suggest that outdoor activities during class recess or PE class, providing suitable desks and chairs, and adequate instruction in reading and writing postures might protect against pathological eye growth. An age-specific myopia prevention and control programs in school is of primary importance.

Risk Factors for Myopia: A Review

Due to the myopia prevalence increase worldwide, this study aims to establish the most relevant risk factors associated with its development and progression. A review search was carried out using PubMed, Web of Science, and Scopus databases to identify the main myopia risk factors. The inclusion criteria for the articles were those related to the topic, carried out in subjects from 5 to 30 years, published between January 2000 and May 2023, in English, and with the full text available. Myopia etiology has proven to be associated with both genetic and environmental factors as well as with gene-environment interaction. The risk of developing myopia increases in children with myopic parents (one parent ×2 times, two parents ×5 times). Regarding environmental factors, education is the main risk factor correlated with myopia prevalence increase. Further, several studies found that shorter distance (<30 cm) and longer time spent (>30 min) for near work increase the risk of myopia. Meanwhile, increased outdoor activity (>40 min/day) has been shown to be a key factor in reducing myopia incidence. In conclusion, the interventional strategy suggested so far to reduce myopia incidence is an increase in time outdoors and a reduction in the time spent performing near-work tasks.

Using Light Meters to Investigate the Light-Myopia Association - A Literature Review of Devices and Research Methods

With the increasing prevalence of myopia, evaluating its relationship with objective light exposure as a potential adjustable environmental factor in myopia development has been an emerging research field in recent years. From a thorough literature search, we identify ten wearable light meters from human studies on light exposure and myopia and present an overview of their parameters, thereby demonstrating the wide between-device variability and discussing its implications. We further identify 20 publications, including two reanalyses, reporting investigations of light-myopia associations with data from human subjects wearing light meters. We thoroughly review the publications with respect to general characteristics, aspects of data collection, participant population, as well as data analysis and interpretation, and also assess potential patterns regarding the absence or presence of light-myopia associations in their results. In doing so, we highlight areas in which more research is needed as well as several aspects that warrant consideration in the study of light exposure and myopia.

Implementing a digital comprehensive myopia prevention and control strategy for children and adolescents in China: a cost-effectiveness analysis

Background

Children and adolescents' myopia is a major public problem. Although the clinical effect of various interventions has been extensively studied, there is a lack of national-level and integral assessments to simultaneously quantify the economics and effectiveness of comprehensive myopia prevention and control programs. We aimed to compare the cost-effectiveness between traditional myopia prevention and control strategy, digital comprehensive myopia prevention and control strategy and school-based myopia screening program in China.

Methods

A Markov model was used to compare the cost-utility and cost-effectiveness among school-based myopia screening, traditional myopia prevention and control strategy, and digital comprehensive myopia prevention and control strategy among 6 to 18-year-old rural and urban schoolchildren. Parameters were collected from published sources. The primary outcomes were quality-adjusted life-year, disability-adjusted life-year, incremental cost-utility ratio, and incremental cost-effectiveness ratio. Extensive sensitivity analyses were performed to test the robustness and sensitivity of base-case analysis.

Findings

Compared with school-based myopia screening strategy, after implementing digital comprehensive myopia prevention and control strategy, the prevalence of myopia among 18-year-old students in rural and urban areas was reduced by 3.79% and 3.48%, respectively. The incremental cost-utility ratio per quality-adjusted life-year gained with the digital myopia management plan ($11,301 for rural setting, and $10,707 for urban setting) was less than 3 times the per capita gross domestic product in rural settings ($30,501) and less than 1 time the per capita gross domestic product in urban settings ($13,856). In cost-effectiveness analysis, the incremental cost-effectiveness ratio produced by digital comprehensive myopia management strategy ($37,446 and $41,814 per disability-adjusted life-year averted in rural and urban settings) slightly exceeded the cost-effectiveness threshold. When assuming perfect compliance, full coverage of outdoor activities and spectacles satisfied the cost-effectiveness threshold, and full coverage of outdoor activities produced the lowest cost ($321 for rural settings and $808 for urban settings).

Interpretations

Health economic evidence confirmed the cost-effectiveness of promoting digital comprehensive myopia prevention and control strategies for schoolchildren at the national level. Sufficient evidence provides an economic and public health reference for further action by governments, policy-makers and other myopia-endemic countries.

Funding

National Natural Science Foundation of China, NSFC (82171051), Beijing Natural Science Foundation (JQ20029), Capital Health Research and Development of Special (2020-2-1081), National Natural Science Foundation of China, NSFC (82071000), National Natural Science Foundation of China, NSFC (8197030562).

Parental awareness of the implications of myopia and strategies to control its progression: A survey-based study

PURPOSE

Myopia has emerged as a significant public health concern. Effective methods have now been developed to delay its onset and progression. However, this information may not be reaching parents, and they are key players in terms of implementing the necessary preventive measures. This study investigated parental awareness of myopia, its implications and the strategies available for controlling it.

METHODS

A self-administered online survey was distributed to parents of children 6-16 years of age. To be eligible to respond, their child had to be myopic or at risk of developing myopia due to family history.

RESULTS

A total of 330 parents completed the survey, of which 321 were included for analysis. Sixty-seven percent of respondents had at least one myopic son/daughter, and most were between -1.00 and -1.75 D. Among parents of myopic children, 20.9% thought that their child's myopia progressed moderately. Sixty-seven percent of parents had a significant level of concern about the progression of the myopia and felt that it was caused mainly by the use of electronic devices and genetics. A generalised linear model showed that parental concern was significantly predicted by the perception of evolution (p < 0.001) and the number of known health-related consequences (p < 0.001). Almost 40% of parents were unaware of the existence of myopia control strategies. Relatives and eye care practitioners are the main sources of information. The most well-known myopia control strategy was myopia control soft contact lenses (29.2%), although the option that most parents would opt for was spectacles with peripheral defocus lenses (47.1%). The selection of a contact-lens-based myopia control method correlated significantly with the age of the children (p < 0.001).

CONCLUSIONS

Society in general and parents in particular need more information about myopia, its consequences and the options available for its control. Eye care practitioners play an important role in this issue.