Changes in Refractive Error Under COVID-19: A 3-Year Follow-up Study

UCI EyeMobile Exam Findings from School Children Following on-Site Screening

Purpose

Uncorrected refractive errors (REs) and amblyopia can lead to visual impairment with deleterious effects on quality of life and academic performance. Early detection and treatment by community vision care programs, such as the UCI EyeMobile for Children, can aid in addressing preventable vision loss.

Methods

A total of 5074 children between the ages of 3 and 10 years were screened at 153 locations, including preschools, head start programs, and elementary schools within Orange County (OC), California (CA). Subsequently, 1024 children presented for comprehensive eye examinations. A retrospective analysis of all examined children was conducted, determining the frequency and severity of REs and amblyopia and the spectacle prescription rate by age. Propensity score matching analysis evaluated the effect of median household income on RE and amblyopia frequency.

Results

Among those who failed initial screening and were subsequently examined, significant rates of REs and amblyopia were detected: myopia (24.4%), hyperopia (35.4%), astigmatism (71.8%), anisometropia (8.9%), amblyopia (7.0%), and amblyopia risk (14.4%). A majority (65.0%) of those examined received prescription spectacles from UCI EyeMobile, with around a third requiring a new or updated prescription. The frequency of REs and amblyopia and the spectacle prescription rate were uniform across OC congressional districts. Myopia and amblyopia risk was positively and negatively associated with household income, respectively.

Conclusion

The UCI EyeMobile for Children serves as a vital vision care program, providing free vision screening, comprehensive eye examinations, and spectacles. A significant number of children required examination, and a high frequency of REs and amblyopia were detected in examined children, with subsequent provision of prescription spectacles to most children.

Exploring Pediatric Vision Care: Insights from Five Years of Referral Cases in the UCI Eye Mobile and Implications of COVID-19

PURPOSE

To analyze referral rates, patient demographics, referral indications, and the impact of socioeconomic factors on ocular health from the University of California Irvine (UCI) Eye Mobile for Children, particularly during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

A retrospective chart review was performed on de-identified records of children examined on the UCI Eye Mobile. GraphPad Prism 10.0.0 and Python software were used for statistical analyses.

RESULTS

In the academic years from 2018 to 2022, 3,619 children received comprehensive eye examinations on the UCI Eye Mobile. Among them, 76 were referred to a pediatric ophthalmologist. The majority of these children were Hispanic (72.6%, 54 of 74), followed by Asian (10.9%, 8 of 74). A significant proportion (82.9%, 63 of 76) attended school districts with median incomes below that of Orange County. Statistically significant differences were found in age (P = .001; pre-COVID: 3.98 ± 1.08 years vs COVID: 5.75 ± 2.92 years) and gender (P = .023; pre-COVID female: 31 of 41 vs COVID female: 15 of 32) between the pre-COVID and COVID years. Additionally, there were significant differences in the proportion of children with hyperopia with astigmatism between the pre-COVID and COVID years (P = .044; pre-COVID: 23 of 40 vs COVID: 12 of 35). The most common indications for ophthalmologist referrals were for strabismus evaluation/treatment (28.9%, 22 of 76), followed by abnormal cup-to-disc ratio (21.1%, 16 of 76).

CONCLUSIONS

The study highlights the pivotal role of the UCI Eye Mobile for children in identifying ocular conditions needing referrals to subspecialty care. The majority of children needing these referrals attended schools in lower economic communities. Additionally, the COVID-19 pandemic appears to have influenced the demographic and clinical characteristics. [J Pediatr Ophthalmol Strabismus. 20XX:X(X):XXX-XXX.].

Impact of the coronavirus disease 2019 pandemic on the progression, prevalence, and incidence of myopia: A systematic review

We systematically reviewed the literature on the effects of the coronavirus disease 2019 (COVID-19) pandemic on the progression, prevalence, and incidence of myopia. A comprehensive literature search was performed on PubMed, Cochrane Central Register of Controlled Trials, and Scopus databases. Studies included in the review assessed myopia progression, prevalence, and/or incidence as the primary outcome. Of 523 articles yielded in the initial search, 23 studies (6 cross-sectional and 17 cohort) were eligible for inclusion. Sixteen of these were conducted in China and one each in Hong Kong, Turkey, Spain, Israel, India, Korea, and Tibet. Quality appraisals were conducted with the Joanna Briggs Institute Critical Appraisal Checklists. Of the included studies, a large majority reported a greater myopic shift and increase in myopia prevalence during the COVID-19 pandemic compared to the pre-COVID-19 years. All three studies on myopia incidence showed increased incidence during the COVID-19 pandemic. Myopia progression accelerated during the COVID-19 pandemic, even in individuals using low-concentration atropine eye drops in two studies but not in those using orthokeratology treatment in one study. Overall, the studies found that the COVID-19 pandemic and its associated home confinement measures generally increased myopia progression, prevalence, and incidence, even in individuals using low-concentration atropine eye drops.

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.

Epidemiology and trends in the uptake of refractive error services in Harare, Zimbabwe: a hospital-based retrospective study

Aim

The study aimed to determine the epidemiology and evaluate the trends in the uptake of refractive error services in Harare.

Methods

A clinic-based retrospective study at the Greenwood Park Eye Centre and its three subsidiaries was conducted from January 1, 2015 to December 31, 2020.

Results

12,216 patients' records were retrieved, out of which 1074 (8.79%) had refractive error cases. The prevalence of visual impairment at presentation was 5.80% [95% CI: 5.39 - 6.23]. Among those with refractive error, the sample prevalence of visual impairment before correction was 41.30% [CI: 38.3 - 44.3, 95%], and 2.20% [95% CI: 1.4 - 3.3] after correction. There was inconsistency in the percentage utilization of refractive error services, with the highest being 42.60% in 2015. Refractive error types were related to age, employment position, and type of visual impairment prior to refractive error treatment.

Conclusion

There was a low percentage of refractive error services uptake in urban Zimbabwe.

Evaluating the impact of COVID-19 pandemic-related home confinement on the refractive error of school-aged children in Germany: a cross-sectional study based on data from 414 eye care professional centres

OBJECTIVE

This study aimed at evaluating refractive changes in German school-aged children before and after the COVID-19 pandemic.

DESIGN

Cross-sectional study.

SETTING

414 eye care professional centres from Germany.

PARTICIPANTS

Refractive data from 59 926 German children aged 6-15 years were examined over a 7-year period (2015-2021).

PRIMARY AND SECONDARY OUTCOME MEASURES

Spherical equivalent refraction was assessed as a function of year, age and gender. The refractive values concerning 2020 and 2021 were compared with those assigned to prior years (2015-2019).

RESULTS

The refractive data associated with 2020 and 2021 showed a myopic refractive shift of approximately -0.20D compared with the 2015-2019 range. The refractive change was statistically considerable in the 6 to 11-year range (p<0.05), while from 12 to 15 years was negligible (p≥0.10). Percentage of myopes was also impacted in 2021 (p=0.002), but not in 2020 (p=0.25). From 6 to 11 years, the percentage of myopes in 2021 increased significantly by 6.02% compared with the 2015-2019 range (p≤0.04). The highest percentage increase occurred at 8 and 10 years of age, showing a rise of 7.42% (p=0.002) and 6.62% (p=0.005), respectively. From 12 to 15 years, there was no significant increase in the percentage of myopes in 2021 (p≥0.09). Percentage of myopes in 2020 was not influenced at any age (p≥0.06).

CONCLUSION

Disruption of normal lifestyle due to pandemic-related home confinement appears to lead to a myopic refractive shift in children aged 6-11 years in Germany. The greater effect observed at younger ages seems to emphasise the importance of refractive development in this age group.

Refractive Error Changes Due to COVID-19 Pandemic Confinement in Children from Puerto Rico: A Retrospective Study

SIGNIFICANCE

The progression of myopia increased in children after the pandemic confinement. A myopic shift in the refractive error of the Hispanic population was found regardless of the refractive status of the school-aged children studied.

PURPOSE

This study aimed to evaluate the refractive error in Puerto Rican children before and after the COVID-19 pandemic. We were interested in whether there was a significant change in refractive error attributed to online learning during the pandemic lockdown.

METHODS

A retrospective record review of children aged 7 to 18 years who underwent a comprehensive visual evaluation between 2018 and 2021 at the Inter American Eye Institute in Puerto Rico was performed. The spherical equivalent pre- and post-lockdown was compared. The study excluded the best-corrected visual acuities worse than 20/40, any corneal or retinal disease, and amblyopia.

RESULTS

In total, 801 records were included in this study. The mean age was 12.7 ± 3.2 years, with 50.3% male and 49.7% female children. The mean spherical equivalent for the right and left eyes was similar ( r = 0.93, P ≤ .001). A significant difference in the mean spherical equivalent was found pre- and post- lockdown (0.22 ± 0.59 D, t800 = 10.44, P ≤ .001). A myopic shift post-lockdown was significant for all ages except those in the 7- (0.13 ± 0.79 D, t28 = 0.84, P = .40) and 8-year-old range (0.12 ± 0.65 D, t40 = 1.22, P = .23), respectively. No significant change was found between sexes before (0.16 ± 0.12 D; t799 = 1.38, P = .16) and after (0.15 ± 0.13 D; t799 = 1.19, P = .23) confinement.

CONCLUSIONS

The current study revealed a significant myopic shift in Hispanic school-aged children as a result of the pandemic confinement.

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 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.

Myopic axial elongation in school children and the COVID-19 lockdown in Russia: The Ural Children Myopia Study

BACKGROUND

To explore an influence of the COVID-19-related lockdown on ocular axial elongation in school children in Russia.

METHODS

The participants of the school-based Ufa Children Myopia Study in Ufa/Russia underwent, at baseline in 2019/2020 before the COVID-19 outbreak and after a COVID-19-related lockdown, a detailed interview and ophthalmological examination including laser interferometric biometry for axial length measurement.

RESULTS

The study included 461 children (age:10.7±2.1 years;range:6.8-16.9 years). The mean follow-up was 1.41±0.33 years. Mean axial length at baseline was 23.96±0.95mm and 23.94±0.95mm in the right and left eyes, respectively. During the study period, annual axial elongation (right/left eyes) was 0.19±0.17mm/0.19±0.22mm. Before the COVID-19 lockdown, the age-dependent coefficient for axial length (ADCAL) for the right/left eyes was 0.21mm (95%CI:0.17,0.25)/0.20mm (95%CI:0.16,0.24). In children younger than 9.6 years (n = 157), annual axial elongation (right eyes) during the study period was larger than the ADCAL before the COVID-19 outbreak (0.29 mm (95%:0.00,0.66) versus 0.21 mm (95%CI:0.02,0.41)). In the groups aged 9.6 to 11.4 years (n = 148) and aged >11.4 years (n = 156), annual axial elongation during the study period was comparable to the ADCAL before the COVID-19 outbreak (0.18mm (95%CI:-0.07,0.46) versus 0.22mm (95%CI:-0.05,0.48), and (0.09mm (95%CI:-0.15,0.34) versus 0.14mm (95%CI:0.00,0.28), respectively). In children aged ≤9 years at study end, axial length at study end was 0.20 mm larger than axial length at baseline in the participants aged ≤9 years at baseline. Larger axial elongation during the study period was associated (multivariable analysis) with younger age (beta:-0.62;P<0.001), female sex (beta:0.21;P<0.001), longer study period (beta:0.22;P<0.001), and longer axial length at baseline (beta:0.28;P<0.001), and marginally, with less time spent outdoors (beta:-0.07;P = 0.06).

CONCLUSIONS

The COVID-19-related lockdown in the Russian city of Ufa was associated with a relatively minor increase in axial elongation, detected only in children aged <9.6 years.