Coronavirus disease 2019 outbreak and associated public health measures increase the progression of myopia among children and adolescents: Evidence synthesis

Evidence linking COVID-19 and the health/well-being of children and adolescents: an umbrella review

BACKGROUND

Experiences during childhood and adolescence have enduring impacts on physical and mental well-being, overall quality of life, and socioeconomic status throughout one's lifetime. This underscores the importance of prioritizing the health of children and adolescents to establish an impactful healthcare system that benefits both individuals and society. It is crucial for healthcare providers and policymakers to examine the relationship between COVID-19 and the health of children and adolescents, as this understanding will guide the creation of interventions and policies for the long-term management of the virus.

METHODS

In this umbrella review (PROSPERO ID: CRD42023401106), systematic reviews were identified from the Cochrane Database of Systematic Reviews; EMBASE (OvidSP); and MEDLINE (OvidSP) from December 2019 to February 2023. Pairwise and single-arm meta-analyses were extracted from the included systematic reviews. The methodological quality appraisal was completed using the AMSTAR-2 tool. Single-arm meta-analyses were re-presented under six domains associated with COVID-19 condition. Pairwise meta-analyses were classified into five domains according to the evidence classification criteria. Rosenberg's FSN was calculated for both binary and continuous measures.

RESULTS

We identified 1551 single-arm and 301 pairwise meta-analyses from 124 systematic reviews that met our predefined criteria for inclusion. The focus of the meta-analytical evidence was predominantly on the physical outcomes of COVID-19, encompassing both single-arm and pairwise study designs. However, the quality of evidence and methodological rigor were suboptimal. Based on the evidence gathered from single-arm meta-analyses, we constructed an illustrative representation of the disease severity, clinical manifestations, laboratory and radiological findings, treatments, and outcomes from 2020 to 2022. Additionally, we discovered 17 instances of strong or highly suggestive pairwise meta-analytical evidence concerning long-COVID, pediatric comorbidity, COVID-19 vaccines, mental health, and depression.

CONCLUSIONS

The findings of our study advocate for the implementation of surveillance systems to track health consequences associated with COVID-19 and the establishment of multidisciplinary collaborative rehabilitation programs for affected younger populations. In future research endeavors, it is important to prioritize the investigation of non-physical outcomes to bridge the gap between research findings and clinical application in this field.

Risk factors for myopia among children and adolescents: an umbrella review of published meta-analyses and systematic reviews

AIMS

To identify potential risk factors for myopia in children and adolescents and assess the credibility of each evidence, providing reference for the development of myopia prevention strategies.

METHODS

We searched PubMed, Web of Science and Embase databases from inception to April 2022 to find systematic reviews or meta-analyses investigating the relationship between potential risk factors and myopia, and conducted an umbrella review. We recalculated the pooled effect sizes and 95% CIs of each potential risk factor through random-effects model, and reported its 95% prediction interval and between-study heterogeneity. Small-study effect and excess of significance bias were assessed to reveal potential publication bias.

RESULTS

Twelve publications were included in this umbrella review, including eight meta-analyses and four qualitative systematic reviews. Twenty-two factors were identified, of which 16 were analysed quantitatively. Ten factors showed statistically significant association with myopia. Myopia in one or two parents and per additional hour of time spend outdoors per week were rated as highly suggestive evidence. Near work and gender were evaluated as suggestive evidence. The other five factors are weak evidence.

CONCLUSIONS

We found several risk factors for myopia with different levels of evidence, of which parental myopia presented the strongest association with myopia in children and adolescents. Our findings contribute to a better understanding of the association between potential risk factors and myopia among children and adolescents and are important for informing parenting, education, clinical practice guidelines and public health policy.

PROSPERO TRIAL REGISTRATION NUMBER

CRD42022333053.

Myopia in elementary school students in Eastern China during the COVID-19 pandemic

Background

Myopia is an increasingly serious public concern, particularly among primary school students. The prevalence of myopia and its influencing factors in primary school pupils in Eastern China during the COVID-19 pandemic had not been explored.

Methods

A randomly clustered sampling method was performed, and selected pupils from grade 1 to grade 3 in 15 primary schools in the Fenghua District of Zhejiang Province were included and given myopia screening and uniform questionnaire survey 1 year later.

Results

A total of 4,213 students completed the myopia screening and questionnaire survey. Myopia was diagnosed in 1,356 pupils, with a myopia incidence of 32.19%. The spherical equivalent (SE) refraction of the included pupils decreased on average by 0.50 ± 2.15 D 1 year later. The myopia rate was positively correlated with the increase of grade, in which the myopia rate among grade 3 students was the highest at 39.69%. The myopia rate among female students was higher than that among male students. Students residing in urban areas had a higher myopia rate than in rural areas. Maintaining an near work distance ≥33 cm was a significant protective factor (OR = 0.84, 95% CI: 0.74-0.96). Students with two myopic parents had a higher risk of myopia (OR = 1.61, 95% CI: 1.34-1.92).

Conclusion

During the COVID-19 pandemic, the myopia rate among early primary school students in Eastern China was high. More attention and implementation of interventions from health and education departments, such as training the development of good eye behavior, should be considered to strengthen the intervention of myopia in primary school students.

Baseline metrics that may predict future myopia in young children

PURPOSE

We used baseline data from the PICNIC longitudinal study to investigate structural, functional, behavioural and heritable metrics that may predict future myopia in young children.

METHODS

Cycloplegic refractive error (M) and optical biometry were obtained in 97 young children with functional emmetropia. Children were classified as high risk (HR) or low risk (LR) for myopia based on parental myopia and M. Other metrics included axial length (AXL), axial length/corneal radius (AXL/CR) and refractive centile curves.

RESULTS

Based on the PICNIC criteria, 46 children (26 female) were classified as HR (M = +0.62 ± 0.44 D, AXL = 22.80 ± 0.64 mm) and 51 (27 female) as LR (M = +1.26 ± 0.44 D, AXL = 22.77 ± 0.77 mm). Based on centiles, 49 children were HR, with moderate agreement compared with the PICNIC classification (k = 0.65, p < 0.01). ANCOVA with age as a covariate showed a significant effect for AXL (p < 0.01), with longer AXL and deeper anterior chamber depth (ACD) (p = 0.01) in those at HR (differences AXL = 0.16 mm, ACD = 0.13 mm). Linear regression models showed that central corneal thickness (CCT), ACD, posterior vitreous depth (PVD) (=AXL - CCT - ACD-lens thickness (LT)), corneal radius (CR) and age significantly predicted M (R = 0.64, p < 0.01). Each 1.00 D decrease in hyperopia was associated with a 0.97 mm elongation in PVD and 0.43 mm increase in CR. The ratio AXL/CR significantly predicted M (R = -0.45, p < 0.01), as did AXL (R = -0.25, p = 0.01), although to a lesser extent.

CONCLUSIONS

Although M and AXL were highly correlated, the classification of pre-myopic children into HR or LR was significantly different when using each parameter, with AXL/CR being the most predictive metric. At the end of the longitudinal study, we will be able to assess the predictability of each metric.

Worsening vision at age 4-5 in England post-COVID: Evidence from a large database of vision screening data

PURPOSE

Myopia prevalence has increased in the UK at age 10-16y, but little is known about younger children. We hypothesise that if the 'myopia epidemic' is affecting young children, then there will be increasing rates of bilateral reduced unaided vision (V) at vision screenings of children 4-5 years of age.

METHODS

Retrospective anonymised data from computerised vision screening at age 4-5 years were analysed from serial cross-sectional data. Refractive error is not assessed in UK vision screening, so vision was investigated. Data were only included from schools that screened every year from 2015/16 to 2021/22. The criterion used was unaided monocular logMAR (automated letter-by-letter scoring) vision >0.20 in both the right and left eyes, so as to maximise the chances of detecting bilateral, moderate myopia rather than amblyopia.

RESULTS

Anonymised raw data were obtained for 359,634 screening episodes from 2075 schools. Once schools were excluded where data were not available for every year and data were cleaned, the final database comprised 110,076 episodes. The proportion (percentage and 95% CI) failing the criterion from 2015/16 to 2021/22 were 7.6 (7.2-8.0), 8.5 (8.1-8.9), 7.5 (7.1-7.9), 7.8 (7.4-8.2), 8.7 (8.1-9.2), 8.5 (7.9-9.0) and 9.3 (8.8-9.7), respectively. The slope of the regression line showed a trend for increasing rates of reduced bilateral unaided vision, consistent with increasing frequency of myopia (p = 0.06). A decreasing linear trendline was noted for children 'Under Professional Care'.

CONCLUSIONS

For children 4-5 years of age, there were signs of reduced vision over the last 7 years in England. Consideration of the most likely causes support the hypothesis of increasing myopia. The increase in screening failures highlights the importance of eye care in this young population.

Myopia risk behaviour related to the COVID-19 lockdown in Europe: The generation R study

PURPOSE

To battle the spreading of the COVID-19 virus, nationwide lockdowns were implemented during 2020 and 2021. Reports from China revealed that their strict home confinements led to an increase in myopia incidence. The Netherlands implemented a more lenient lockdown, which allowed children to go outside. We evaluated the association between COVID-19 restrictions, myopia risk behaviour and myopia progression in Dutch teenagers.

METHOD

A total of 1101 participants (mean age 16.3 ± 3.65 yrs) completed questionnaires about their activities before, during and after lockdown (March-October 2020). We used a repeated-measures ANOVA to compare time use between these time periods. Ocular measurements were acquired before the COVID-19 pandemic when participants were 13 years old; only 242 participants had ocular measurements at 18 years of age at the time of this analysis. Linear regression analyses were used to evaluate the association between lifestyle factors and myopia progression.

RESULTS

Children were on average 16.2 (1.03) years of age during lockdown. Total nearwork increased from 8.11 h/day to 11.79 h/day, and remained higher after lockdown at 9.46 h/day (p < 0.001). Non-educational nearwork increased by 2.22 h/day (+49%) during lockdown and was associated with faster axial length progression (B 0.002 mm/h/year; SE 0.001 p = 0.03). Before and during lockdown, the mean time spent outdoors was similar (1.78 h/day and 1.80 h/day, respectively). After lockdown, time spent outdoors decreased to 1.56 h/day (p < 0.001).

CONCLUSION

The Dutch lockdown significantly increased digitised nearwork in adolescents but did not affect outdoor exposure. The changes in time spent performing nearwork remained after the lockdown measures had ended. We expect that the COVID-19 pandemic may lead to an increase in myopia prevalence and progression in European children.

Myopia Progression during the COVID-19 Era: A Systematic Review and Meta-analysis

BACKGROUND

To evaluate myopia progression during the novel coronavirus disease 2019 (COVID-19) pandemic and its risk factors.

METHODS

We searched PubMed, Scopus, and Web of Science to find literature until August 2022 related to COVID-19 pandemic and myopia progression. Outcomes of myopia progression included axial length (AL) and spherical equivalent (SE). Factors of screen time and outdoor activity time were analyzed.

RESULTS

Thirty-three studies were included in this meta-analysis. Compared to the same period before the COVID-19 pandemic, myopia prevalence increased (OR = 1.11; 95% CI, 1.05-1.18). The outcomes of SE decreased -0.61 diopter (95% CI, -0.98 to -0.23), and AL increased 0.42 mm (95% CI, 0.13-0.7). Mean screen time was increased 6.25 hours/day (95% CI, 4.84-7.66), and outdoor activity time was decreased -1.52 hours/day (95% CI, -3.20 to -0.15).

CONCLUSION

Establishing care policies is necessary to restrict behavioral changes and their consequences during the pandemic.

Paediatric myopia shift during the COVID-19 pandemic home quarantine: a systematic review and meta-analysis

BACKGROUND

Outdoor activities were restricted during the COVID-19 outbreak, although digital learning grew. Concerns have been raised about the impact of these environmental changes on myopia status. This research aimed to examine myopia shift during the COVID-19 pandemic and offer the community evidence-based data.

METHODS

The literature search was undertaken in PubMed, SCOPUS, Science Direct, Web of Science and Google Scholar databases on published papers before 17 May 2022. The main outcome was mean spherical equivalent refraction (SER) before, at the onset and at the end of follow-up during the COVID-19 pandemic.

RESULTS

Among 518 articles, 10 studies were included in the meta-analysis. The mean SER differences during the COVID-19 pandemic follow-up (mean follow-up time was 10 months) compared with before the pandemic was 0.15 dioptre (D) (95% CI -0.39 to 0.69, p=0.58). After age adjustment using meta-regression, the mean SER differences during the COVID-19 follow-up compared with before the pandemic was - 0.46 D (95% CI -0.59 to -0.34, p<0.001). Over the mean follow-up time during the COVID-19 pandemic, the SER mean difference was -0.55 D (95% CI -0.78 to -0.32, p<0.001), showing that the mean SER had decreased significantly during the COVID-19 pandemic. The mean SER differences in myopic patients before COVID-19 compared with during the pandemic follow-up was -0.49 D (95% CI -0.53 to -0.45, p=0.00). So the prior pandemic myopic patients became more myopic during the pandemic follow-up time.

CONCLUSION

During home quarantine, the mean SRE shifting in paediatrics accelerated. This phenomenon should be given more attention by policymakers, eyecare experts, educators and parents.

The Impact of the COVID-19 Pandemic on Myopia Progression in Children: A Systematic Review

Myopia is the most common refractive error among children. The coronavirus disease 2019 (COVID-19) pandemic has affected children's health in many ways. Policy changes due to the COVID-19 pandemic, such as home quarantine and online schooling, have been proposed as causes for the increased risk of myopia progression. During strict home quarantine, children spend less time outdoors and more time using electronic devices which are important risk factors associated with myopia. Our systematic review aims to assess the relationship between myopia progression and these risk factors in children.

We did the literature search from PubMed, Google Scholar, and ScienceDirect. A total of 10 research papers were selected for final review using the Preferred Reporting Item for Systematic Review and Meta-Analyses (PRISMA) guidelines. The research articles used had a quality of more than 70%. The quality of these articles was determined using the Joanna Briggs Institute (JBI) tool. Our review included eight cross-sectional and two cohort studies. Most of these studies used questionnaires to assess the risk factors of myopia. Standardized ocular examinations were done in most studies to measure visual acuity, spherical equivalent, and axial lengths. Our study found that the progression of myopia was affected by the reduced time spent outdoors and increased screen time during the pandemic. We also found that children's increased use of electronic devices, such as mobile phones and tablets, has significantly affected myopia progression during the pandemic.

Outbreak of COVID-19-Related Myopia Progression in Adults: A Preliminary Study

PURPOSE

The COVID-19 pandemic has necessitated specific public health measures, resulting in the alteration of lifestyles, such as increased digital screen time and fewer outdoor activities. Such conditions have increased the progression of myopia in children. However, no investigation of myopia progression in early adulthood has been conducted during this period. Consequently, this study aimed to evaluate the outbreak of COVID-19-related myopia progression among adults at an optometry clinic during the COVID-19 pandemic.

MATERIALS AND METHODS

This was a retrospective cohort study in which participants aged 18-25 years who first visited (baseline) the optometry clinic between June 2019 and March 2020 were recruited for follow-up from November 2021 to March 2022. Spherical equivalent refraction (SER), uncorrected distance visual acuity (UCDVA), and binocular cross cylinder (BCC) were recorded at baseline and a follow-up visit. Using questionnaires, a survey was conducted to assess the lifestyle changes that transpired during the COVID-19 pandemic.

RESULTS

In total, 37 participants with a mean age of 22.5±1.4 years were enrolled, of which 89.2% were female. Following the outbreak of the COVID-19 pandemic, most participants self-reported increased daily use of digital devices (89.2%), online education (86.5%), and spending more time at home (94.6%), which increased by approximately 7.6±3.2 hours, 5.9±1.7 hours, and 13.2±7.5 hours, respectively. There were statistically significant differences between SER and BCC at baseline and after approximately 2 years of the COVID-19 pandemic (p < 0.05). The mean two-year myopia progression was -0.59±0.67 D (Maximum = 0.00 D, Minimum = -3.38 D).

CONCLUSION

This study revealed that myopia could progress during adulthood among those who have lived under public health measures intended to address the COVID-19 pandemic.