China Turns to School Reform to Control the Myopia Epidemic: A Narrative Review

Progression Patterns and Risk Factors of Axial Elongation in Young Adults With Nonpathologic High Myopia: Three-Year Large Longitudinal Cohort Follow-Up

PURPOSE

To investigate the progression patterns and risk factors of axial elongation in young adults with nonpathologic high myopia.

DESIGN

Prospective, clinical observational cohort study with 2- to 4-year follow-up.

METHODS

A total of 1043 eyes of 563 participants (3515 medical records) aged 18 to 50 years with nonpathologic high myopia (axial length [AL] ≥ 26 mm; myopic maculopathy < diffuse chorioretinal atrophy; without posterior staphyloma) were included from 1546 participants (6318 medical records). Annual axial elongation was calculated via linear mixed-effect models. The associated risk factors of axial elongation were determined by ordinal logistic regression analysis, with generalized estimate equations for eliminating an interocular correlation bias.

RESULTS

Based on 5359 times of AL measurements, the annual axial elongation of participants (mean [SD] age 31.39 [9.22] years) was 0.03 mm/year (95% confidence interval [CI], 0.03-0.04; P < .001) during a 30.23 (6.06) months' follow-up. Severe (>0.1 mm/year), moderate (0.05-0.09 mm/year), mild (0-0.049 mm/year), and nil (≤0 mm/year) elongation was observed in 122 (11.7%), 211 (20.2%), 417 (40.0%), and 293 (28.1%) eyes. The following risk factors were significantly associated with axial elongation: baseline AL ≥ 28 mm (odds ratio [OR], 4.23; 95% CI, 2.95-6.06; P < .001); age < 40 years (OR, 1.64; 95% CI, 1.18-2.28; P = .003); axial asymmetry (OR, 2.04; 95% CI, 1.26-3.29; P = .003), and women (OR, 1.52; 95% CI, 1.13-2.2.05; P = .006). Using antiglaucoma medications was a protective factor (OR, 0.46; 95% CI, 0.27-0.79; P = .005), which slowed 75% of axial elongation from 0.04 (0.06) to 0.01 (0.06) mm/y (P < .001).

CONCLUSIONS

Axial elongation continued in young adults with nonpathologic myopia. Risk factors included longer baseline AL and axial asymmetry, younger age, and woman. Topical use of antiglaucoma medications may be useful to reduce ongoing axial elongation.

Cultural roots of the myopia boom in Confucian Asia and their implications

Current evidence implicates educational pressures and reduced outdoor time as major causes of myopia. This paper examines the ongoing battle against the myopia epidemic in East Asia, including its cultural offshoots such as Singapore, where over 80% of young adults are myopic. East Asian societies share deeply rooted Confucian values that attach great importance to education and familial obligations, with heavy parental investment in education and the perception that academic excellence reflects filial piety. Coupled with a strong emphasis on standardised test results, East Asian children face intense educational pressures from a young age. Existing education-based myopia prevention strategies focus either on top-down school reforms to promote more outdoor time for students during school hours or on bottom-up awareness initiatives encouraging lifestyle changes. However, the entrenched Confucian worldview suggests that more extensive top-down reforms aimed at reducing competition in education, combined with widespread bottom-up awareness initiatives targeting the public-particularly parents, given their active involvement in children's education outside of school-may be required to truly turn the tide on myopia.

Lower indoor spatial frequency increases the risk of myopia in children

BACKGROUND/AIMS

Animal models have shown that the absence of high-frequency visual information can precipitate the onset of myopia, but this relationship remains unclear in humans. This study aims to explore the association between the spatial frequency content of the visual environment and myopia in children.

METHODS

Images from the rooms of children and their frequently visited outdoor areas were taken by their parents and collected by the researcher through questionnaires. The spatial frequency was quantified using Matlab. Cycloplegic refraction was used to measure the spherical equivalent (SE), and IOL Master was used to measure axial length (AL) and corneal radius (CR). AL/CR ratio was calculated.

RESULTS

The study included 566 children with an average age of (8.04±1.47) years, of which 270 were girls (47.7%), and the average SE was (0.70±1.21) D. Image analysis revealed that indoor spatial frequency slope was lower than that of the outdoor environment (-1.43±0.18 vs -1.11±0.23, p<0.001). There were 79 myopic individuals (14.0%). Images from indoor content of myopic children had a lower spatial frequency slope than non-myopic children (-1.47±0.16 vs 1.43±0.18, p=0.03) while there was no significant difference in outdoor spatial frequency slope. Regression analysis indicated that the indoor spatial frequency slope was positively associated with SE value (β=0.60, p=0.02) and inversely related to myopia (OR=0.24, p<0.05).

CONCLUSION

The spatial frequency of the outdoor environment is significantly higher than that of the indoor environment. Indoor spatial frequency is related to children's refractive status, with lower indoor spatial frequency being associated with a higher degree of myopia.

L. S, Jeong J, Saw SM, Sevdalis N, Najjar RP. Light Therapy for Myopia Prevention and Control: A Systematic Review on Effectiveness, Safety, and Implementation

Purpose

This systematic review focuses on the effectiveness, safety, and implementation outcomes of light therapy as an intervention to prevent or control myopia in children.

Methods

A systematic literature search was performed in PubMed, EMBASE, CINAHL, SCOPUS, and Web of Science up to January 27, 2024. Effectiveness outcomes included myopia incidence, and changes in axial length (AL), spherical equivalent refraction (SER), and choroidal thickness (CT). Safety outcomes relating to retinal health or damage and implementation outcomes including compliance rates and loss to follow-up were extracted. ROBINS-I, ROB 2, and ROB-2 CRT were used to assess risk of bias.

Results

Nineteen interventional studies were included. Increased outdoor time (n = 3), red-light therapy (n = 13), and increased classroom lighting (n = 1) had a significant effect on myopia incidence, and changes in AL, SER, and CT. Violet-light therapy (n = 2) was only effective in children aged 8 to 10 years and children without eyeglasses with less than 180 minutes of near-work time daily. Two studies using red-light therapy reported adverse effects. For all studies, only compliance rates and loss to follow-up were reported on implementation effectiveness.

Conclusions

Evidence is compelling for the effectiveness of red-light therapy and outdoors time; more data are needed to confirm safety. Robust data are still needed to prove the effectiveness of violet-light and increased classroom lighting. Clearer implementation strategies are needed for all light therapies.

Translational Relevance

Light therapy has emerged as effective for myopia prevention and control. This systematic review summarizes the state of knowledge and highlights gaps in safety and implementation for these strategies.

The association between screen time exposure and myopia in children and adolescents: a meta-analysis

OBJECTIVE

This study aimed to systematically review epidemiological evidence on associations between screen time exposure and myopia in children and adolescents, and to quantitatively evaluate summary effect estimates from existing literature.

METHOD

There were three online databases including PubMed, Embase, and Web of Science, for epidemiological studies on screen time exposure and myopia published before June 1, 2023. The risk of bias was assessed by the Newcastle Ottawa Scale (NOS) checklist. Summary odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to evaluate the correlation between screen time exposure and myopia using random or fixed-effect models by exposure type (categorical/continuous). We also performed subgroup analysis by screen device type, study quality, geographic region, and research period.

RESULTS

We searched 7,571 records from three databases and identified 19 eligible studies, including 14 high-quality studies and 5 moderate-quality studies. Meta-analyses suggested that there was a statistically significant correlation between screen time (high vs. low) and myopia. The pooled ORs with 95%CIs were respectively 2.24 (1.47-3.42) for cross-sectional studies, and 2.39 (2.07-2.76) for cohort studies. We also found a significant association between continuous exposure to screen time (per 1 h/d increase) and myopia in cohort studies. The pooled ORs with 95%CIs were 1.07 (1.01-1.13). In subgroup analysis stratified by screen device type in cross-sectional studies, screen time exposures from computers (categorical: OR = 8.19, 95%CI: 4.78-14.04; continuous: OR = 1.22, 95%CI: 1.10-1.35) and televisions (categorical: OR = 1.46, 95%CI: 1.02-2.10) were associated with myopia, while smartphones were not. Although publication bias was detected, the pooled results did not show significant changes after adjustment using the trim and fill method.

CONCLUSION

Our findings support that screen time exposure was significantly associated with myopia in children and adolescents. Notably, screen time exposure from computers may have the most significant impact on myopia.

Effect of intraocular pressure reduction on progressive high myopia (PHM study): study protocol of a randomised controlled trial

BACKGROUND

In adult patients with high myopia (HM), progressive axial elongation poses a significant risk for the development of subsequent ocular complications that may lead to visual impairment. Effective strategies to reduce or prevent further axial elongation in highly myopic adult patients have not been available so far. Recent studies suggested that medically lowering intraocular pressure (IOP) may reduce axial elongation.

OBJECTIVE

This clinical randomised controlled trial (RCT) aims to evaluate the efficacy of medical IOP reduction in adult patients with progressive HM (PHM).

TRIAL DESIGN

Single-centre, open-label, prospective RCT.

METHODS

This RCT will recruit 152 participants with PHM at the Zhongshan Ophthalmic Center (ZOC). Randomised in a ratio of 1:1, participants will receive IOP-lowering eyedrops (intervention group) or will be followed without treatment (control group) for 12 months. Follow-up visits will be conducted at 1, 6 and 12 months after baseline. Only one eye per eligible participant will be included for analysis. The primary outcome is the change in axial length (AL) within the study period of 12 months. Secondary outcomes include the incidence and progression of visual field (VF) defects, changes in optic disc morphology and incidence and progression of myopic maculopathy. Difference in AL changes between the two groups will be analysed using linear regression analysis. For the secondary outcomes, a multifactor Poisson regression within a generalised linear model will be used to estimate the relative risk of progression in VF defects and myopic maculopathy, and the rate of thinning in retinal nerve fibre layer and ganglion cell-inner plexiform will be assessed through Kaplan-Meier curves and log-rank tests.

ETHICS AND DISSEMINATION

Full ethics approval for this trial has been obtained from the Ethics Committee of ZOC, Sun Yat-sen University, China (ID: 2023KYPJ110). Results of this trial will be disseminated through peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

NCT05850936.

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.

Immediate versus delayed sequential bilateral ICL implantation: A retrospective comparison of vault height and visual outcomes

PURPOSE

To compare the visual outcomes and risks of suboptimal vault-related complications between immediate sequential bilateral ICL surgery (ISBICLS) and delayed sequential bilateral ICL surgery (DSBICLS).

DESIGN

A retrospective cohort study.

METHODS

Patients who underwent bilateral ICL implantation between November 2014 and December 2021 at the Eye and ENT Hospital of Fudan University (Shanghai, China) were included and divided into two groups: (1) ISBICLS: both eye surgeries performed on the same day, and (2) DSBICLS: second eye surgery performed < 7 days following the first one. Propensity score matching (PSM) was performed to compare the visual outcomes. Multivariable logistic regression models were used to estimate the odds ratios (ORs) of the suboptimal vaults.

RESULTS

Finally, 10,985 eyes were included. After PSM, 204 first surgery eyes and 162 s surgery eyes with complete postoperative data were matched. The safety and efficacy indices did not statistically differ between groups (all > 1.00), except that ISBICLS first surgery eyes achieved better efficacy index than DSBICLS group (1.03 ± 0.26 vs. 1.08 ± 0.23, P = 0.034). Excessive vault was observed in eight (4.06 %) ISBICLS first eyes, one (0.50 %) DSBICLS first eye, and none in the second surgery eye in either group. An insufficient vault was observed in one second eye and one DSBICLS second eye. We found no evidence of differences in the rate of excessive vault (OR = 0.831, 95 % CI: 0.426-1.622, P = 0.588) or insufficient vault (OR = 0.609, 95 % CI:0.062-5.850, P = 0.668).

CONCLUSION

ISBICLS provided safety, efficacy, and refraction predictability comparable to DSBICLS without increasing the risk of suboptimal vault-related complications.

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 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.

Eye exercises for myopia prevention and control: a comprehensive systematic review and meta-analysis of controlled trials

OBJECTIVES

To evaluate the efficacy of eye exercises in preventing and controlling myopia.

METHODS

We searched studies on eye exercises from nine Chinese and English databases from their inception to December 15, 2022. Using random-effect models and sensitivity/subgroup analyses, we estimated the effects of eye exercises compared to control on changes in three measures: visual acuity, refractive error (both quantified using standardized mean differences, SMDs), and protective/mitigating effects (assessed through risk ratios, RRs).

RESULTS

Eleven studies were included in the meta-analysis, with 921 participants. Nine studies had some concerns of bias in at least two domains, and two studies had a high risk of bias in two domains. Seven studies used visual acuity to measure myopia; visual acuity declined after eye-exercise interventions (SMD = -0.67, 95% CI -1.28 to -0.07, Z = 2.17, P = 0.03) and the effect was not better than control (SMD = -0.50, 95% CI -1.16 to 0.16, Z = 1.49, P = 0.14). Two studies used refractive error to measure myopia; the effect of eye-exercise interventions did not differ from control (SMD = -1.74, 95% CI -6.27 to 2.79, Z = 0.75, P = 0.45). Seven studies reported on protective/mitigating effects; eye exercises exhibited a greater protective/mitigating effect than control (RR = 0.40, 95% CI 0.23-0.71, Z = 3.13, P < 0.01).

CONCLUSIONS

Overall, the results suggest that eye exercises have limited to no efficacy in preventing or controlling myopia progression. Until robust evidence supports their efficacy, available evidence suggests retiring the eye-exercise policy.

Development of a risk score for myopia: A cohort study conducted among school-aged children in China

PURPOSE

To evaluate the myopia risk in school-aged children one year after lifting a pandemic-related lockdown and develop a tool to identify high-risk groups.

METHODS

In total, 38,079 children without myopia from 38 schools were included. The outcomes were myopia incidence and progression in 1 year after the COVID-19 lockdown was lifted, both obtained by the spherical equivalent refraction (SER). We separated the population into an exploratory (75%) and a validation sample (25%) to construct the risk score model.

RESULTS

In total, 9811 (29.57%) students became myopic, and the overall myopia progression was 0.22 ± 0.62 D. Even less myopia progression was noted in the pre-myopia group at baseline (All: P = 0.045, Boy: P = 0.005). The risk score model included seven predictors: gender, grade, SER at baseline, residence, parental myopia, eye discomfort symptoms, and online courses. The model had a score range of 0-46 and an optimal cutoff of 34. The area under the receiver operating curve of the model was 0.726 (0.719-0.732) for the exploratory sample and 0.731 (0.720-0.742) for the validation sample.

CONCLUSIONS

The risk score can serve as a practical tool for classifying the risk of myopia in school-aged children.

High Myopia Normative Database of Peripapillary Retinal Nerve Fiber Layer Thickness to Detect Myopic Glaucoma in a Chinese Population

PURPOSE

To develop and validate the performance of a high myopia (HM)-specific normative database of peripapillary retinal nerve fiber layer (pRNFL) thickness in differentiating HM from highly myopic glaucoma (HMG).

DESIGN

Cross-sectional multicenter study.

PARTICIPANTS

A total of 1367 Chinese participants (2325 eyes) with nonpathologic HM or HMG were included from 4 centers. After quality control, 1108 eyes from 694 participants with HM were included in the normative database; 459 eyes from 408 participants (323 eyes with HM and 136 eyes with HMG) and 322 eyes from 197 participants (131 eyes with HM and 191 eyes with HMG) were included in the internal and external validation sets, respectively. Only HMG eyes with an intraocular pressure > 21 mmHg were included.

METHODS

The pRNFL thickness was measured with swept-source (SS) OCT. Four strategies of pRNFL-specified values were examined, including global and quadrantic pRNFL thickness below the lowest fifth or the lowest first percentile of the normative database.

MAIN OUTCOMES MEASURES

The accuracy, sensitivity, and specificity of the HM-specific normative database for detecting HMG.

RESULTS

Setting the fifth percentile of the global pRNFL thickness as the threshold, using the HM-specific normative database, we achieved an accuracy of 0.93 (95% confidence interval [CI], 0.90-0.95) and 0.85 (95% CI, 0.81-0.89), and, using the first percentile as the threshold, we acheived an accuracy of 0.85 (95% CI, 0.81-0.88) and 0.70 (95% CI, 0.65-0.75) in detecting HMG in the internal and external validation sets, respectively. The fifth percentile of the global pRNFL thickness achieved high sensitivities of 0.75 (95% CI, 0.67-0.82) and 0.75 (95% CI, 0.68-0.81) and specificities of 1.00 (95% CI, 0.99-1.00) and 1.00 (95% CI, 0.97-1.00) in the internal and external validation datasets, respectively. Compared with the built-in database of the OCT device, the HM-specific normative database showed a higher sensitivity and specificity than the corresponding pRNFL thickness below the fifth or first percentile (P < 0.001 for all).

CONCLUSIONS

The HM-specific normative database is more capable of detecting HMG eyes than the SS OCT built-in database, which may be an effective tool for differential diagnosis between HMG and HM.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

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.

Study on the relationship between scoliosis and vision problems: A narrative review

Adolescent scoliosis is one of the most common surgical disorders of the pediatric spine. With timely detection and early treatment, most scoliotic children can avoid major and expensive surgery. Vision problems are also frequently found at an early age and can take a toll on individuals quality of life. However, scoliosis, a severe health hazard to adolescents, is often accompanied by vision problems clinically, including myopia, astigmatism, strabismus, amblyopia, horizontal paralysis, and blindness. And people with genetic defects have a higher probability of suffering both spinal problems and vision problems than those with nongenetic defects. However, many individuals viewed scoliosis and vision problems as 2 irrelevant diseases. This review searched PubMed, China National Knowledge Infrastructure, and Web of Science for studies on adolescent, scoliosis, eye diseases, myopia, strabismus, spinal disorders, and vision problems for almost 3 decades, and thus confirmed the potential relationship between adolescent scoliosis and vision problems.

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).

Optic Nerve Head Abnormalities in Nonpathologic High Myopia and the Relationship With Visual Field

PURPOSE

To describe the optic nerve head (ONH) abnormalities in nonpathologic highly myopic eyes based on swept-source optical coherence tomography (OCT) and the relationship with visual field (VF).

DESIGN

Secondary analysis from a longitudinal cohort study.

METHODS

Highly myopic patients without myopic maculopathy of category 2 or higher were enrolled. All participants underwent a swept-source OCT examination focused on ONH. We differentiated between 3 major types (optic disc morphologic abnormality, papillary/peripapillary tissue defect, and papillary/peripapillary schisis) and 12 subtypes of ONH abnormalities. The prevalence and characteristics of ONH abnormalities and the relationship with VF were analyzed.

RESULTS

A total of 857 participants (1389 eyes) were included. Among the 1389 eyes, 91.86%, 68.61%, and 34.92% of them had at least 1, 2, or 3 ONH abnormalities, respectively, which corresponded to 29.55%, 31.79%, and 35.67% of VF defects, respectively. Among the 12 subtypes of the 3 major types, peripapillary hyperreflective ovoid mass-like structure, visible retrobulbar subarachnoid space, and prelaminar schisis were the most common, respectively. Perimetric defects corresponding to OCT abnormalities were more commonly found in eyes with peripapillary retinal detachment, peripapillary retinoschisis, and peripapillary hyperreflective ovoid mass-like structure. Glaucoma-like VF defects were more common in eyes with deep optic cups (28.17%) and with optic disc pit/pit-like change (18.92%).

CONCLUSIONS

We observed and clarified the ONH structural abnormalities in eyes with nonpathologic high myopia. These descriptions may be helpful to differentiate changes in pathologic high myopia or glaucoma.

Longitudinal Changes in Choroidal Structure Following Repeated Low-Level Red-Light Therapy for Myopia Control: Secondary Analysis of a Randomized Controlled Trial

PURPOSE

Repeated low-level red-light (RLRL) therapy has been confirmed as a novel intervention for myopia control in children. This study aims to investigate longitudinal changes in choroidal structure in myopic children following 12-month RLRL treatment.

MATERIALS AND METHODS

The current study is a secondary analysis from a multicenter, randomized controlled trial (NCT04073238). Choroidal parameters were derived from baseline and follow-up swept-source optical coherence tomography scans taken at 1, 3, 6, and 12 months. These parameters included the luminal area (LA), stromal area (SA), total choroidal area (TCA; a combination of LA and SA), and choroidal vascularity index (CVI; ratio of LA to TCA), which were automatically measured by a validated custom choroidal structure assessment tool.

RESULTS

A total of 143 children (88.3% of all participants) with sufficient image quality were included in the analysis (n=67 in the RLRL and n=76 in the control groups). At the 12-month visit, all choroidal parameters increased in the RLRL group, with changes from baseline of 11.70×10 3  μm 2 (95% CI: 4.14-19.26×10 3  μm 2 ), 3.92×10 3  μm 2 (95% CI: 0.56-7.27×10 3  μm 2 ), 15.61×10 3  μm 2 (95% CI: 5.02-26.20×10 3  μm 2 ), and 0.21% (95% CI: -0.09% to 0.51%) for LA, SA, TCA, and CVI, respectively, whereas these parameters reduced in the control group.

CONCLUSIONS

Following RLRL therapy, the choroidal thickening was found to be accompanied by increases in both the vessel LA and SA, with the increase in LA being greater than that of SA. In the control group, with myopia progression, both the LA and SA decreased over time.

Differences in visual stimulation between reading and walking and implications for myopia development

Visual input plays an important role in the development of myopia (nearsightedness), a visual disorder that blurs vision at far distances. The risk of myopia progression increases with the time spent reading and decreases with outdoor activity for reasons that remain poorly understood. To investigate the stimulus parameters driving this disorder, we compared the visual input to the retina of humans performing two tasks associated with different risks of myopia progression, reading and walking. Human subjects performed the two tasks while wearing glasses with cameras and sensors that recorded visual scenes and visuomotor activity. When compared with walking, reading black text in white background reduced spatiotemporal contrast in central vision and increased it in peripheral vision, leading to a pronounced reduction in the ratio of central/peripheral strength of visual stimulation. It also made the luminance distribution heavily skewed toward negative dark contrast in central vision and positive light contrast in peripheral vision, decreasing the central/peripheral stimulation ratio of ON visual pathways. It also decreased fixation distance, blink rate, pupil size, and head-eye coordination reflexes dominated by ON pathways. Taken together with previous work, these results support the hypothesis that reading drives myopia progression by understimulating ON visual pathways.

The Causal Effect of Education on Myopia: Evidence That More Exposure to Schooling, Rather Than Increased Age, Causes the Onset of Myopia

Purpose

To distinguish the effects of age and grade on the development of myopia.

Methods

Grade 1 (n = 1465, mean age 6.71 ± 0.29 years; 53.5% male) and Grade 2 students (n = 1381, mean age 7.76 ± 0.30 years; 52.5% male) were examined in 2018, with a follow-up examination in 2019. Cycloplegic spherical equivalent (SE) in diopter (D) was measured. Regression discontinuity (RD) analysis was used to assess the causal effects on refraction at each visit.

Results

The sample in a grade was divided into three 4-month age blocks according to their birth month, the youngest, middle, and the oldest. At the 2018 visit, within each grade, there were no significant differences in SE among age blocks (all P > 0.05), despite an age range of 12 months. However, comparing the youngest block in Grade 2 to the oldest block in Grade 1, an average age difference of four months, a significant difference in SE was found (0.82 ± 0.69 D vs. 1.05 ± 0.55 D, t-test P < 0.01). Formal RD analysis found a significant casual effect of grade increase on myopic refraction shift (β = -0.32 D; 95% CI, -0.73 to -0.01; P = 0.042). Consistent results were found using the 2019 data.

Conclusions

Increased grade, rather than increasing age, is the major cause of myopic shifts in refraction. A causal link implies that interventions aimed at reducing the myopigenic exposures experienced during a school year have the potential to markedly reduce the myopic shifts in refraction associated with a grade of schooling.

Peripheral Defocus and Myopia Management: A Mini-Review

Myopia is the most common refractive error in the world, and its' prevalence continually increases. The potential pathological and visual complications of progressive myopia have inspired researchers to study the sources of myopia, axial elongation, and explore modalities to arrest progression. Considerable attention has been given over the past few years to the myopia risk factor known as hyperopic peripheral blur, the focus of this review. The primary theories currently believed to be the cause of myopia, the parameters considered to contribute and influence the effect of peripheral blur, such as the surface retinal area or depth of blur will be discussed. The currently available optical devices designed to provide peripheral myopic defocus will be discussed, including bifocal and progressive addition ophthalmic lenses, peripheral defocus single vision ophthalmic lenses, orthokeratology lenses, and bifocal or multifocal center distance soft lenses, as well as their effectivity as mentioned in the literature to date.

The impact of parental migration on left-behind children's vision health in rural China

BACKGROUND

Parental migration is an important factor affecting left-behind children's health. However, few studies have addressed the effect of parental migration on children's vision health in China. To fill the gap, this study aimed to assess the impact of parental migration on left-behind children's vision health and to explore the possible mechanisms of the effect.

METHODS

Data were obtained from the baseline survey of the China Education Panel Survey (CEPS), which included over 10,000 junior high school students. This study used myopia, the most common vision problem among junior high school students, and tried to analyze whether myopia was corrected with eyeglasses as indicator variables of vision health. The impact of parental migration on vision health was assessed using an instrumental variables approach.

RESULTS

The results show that parental migration reduced the likelihood of myopia in left-behind children and decreased the possibility of myopic left-behind children being corrected. This result passed a series of robustness tests. The mechanism analysis indicated that compared to non-left-behind children, left-behind children spent more time on outdoor activities and less time on after-school classes, reducing their risk of being myopic. Further, because left-behind children live apart from their parents, their myopia problem is more difficult for parents to notice, and left-behind children are less likely to inform their parents of their myopia than non-left-behind children actively. This helps to explain why left-behind children have a lower correction rate with eyeglasses.

CONCLUSIONS

Our findings suggest that parental migration, while not increasing the prevalence of myopia in left-behind children, has led to inequity in myopic left-behind children's correction. Given the severe consequences of uncorrected myopia, action is required to enhance the correction rate of myopic left-behind children.

The impact of the first peak of the COVID-19 pandemic on childhood myopia control practice patterns among ophthalmologists-an international pediatric ophthalmology and strabismus council global perspective

BACKGROUND

The prevalence of myopia keeps increasing during the COVID-19 pandemic. We aimed to map the worldwide treatment preferences of ophthalmologists managing myopia control during the first wave of the pandemic.

METHODS

An online questionnaire inquiring about pharmacological and optical treatment patterns during the first half of 2020 was sent to pediatric ophthalmology as well as general ophthalmology memberships worldwide. The results among pediatric ophthalmologists were compared to a previous study we performed before the pandemic.

RESULTS

A total of 2269 respondents from 94 countries were included. Most respondents were pediatric ophthalmologists (64.6%), followed by ophthalmologists from other subspecialties (32.3%). The preferred modality for all geographical regions was a combination therapy of pharmacological and optical treatments. When evaluated independently, the pharmacological treatment was more popular than the optical treatment in most regions other than East Asia (P < 0.001). Compared to a pre-pandemic questionnaire, the participation of pediatric ophthalmologists affiliated with non-university hospitals increased. Additionally, the prevalence of respondents utilizing either any type of pharmacological treatment and those that using only evidence-based treatments increased globally. Although a decline in the use of optical treatment was evident worldwide, the use of evidence-based optical treatments increased.

CONCLUSION

Ophthalmologists around the world preferred a combination therapy of pharmacological and optical treatments. More pediatric ophthalmologists treated myopia progression and preferred a better evidence-based approach to control myopia. These trends reflect a positive response and more awareness of the rising prevalence of myopia due to the increased burden of myopia imposed by the COVID-19 pandemic.

Prevalence and Risk Factors of Refractive Errors and Effective Spectacle Coverage in Emiratis and Non-Emiratis Aged 40 Years or Older: the Dubai Eye Health Survey

PURPOSE

The aim was to investigate the prevalence and risk factors of refractive errors (REs) and the effective spectacle coverage in Emiratis and non-Emiratis in Dubai.

DESIGN

The Dubai Eye Health Survey was a population-based cross-sectional study of participants aged 40 years or older.

METHODS

Distance and near visual acuity (VA), and noncycloplegic automated refraction were tested according to a standardized protocol. Distance VA was tested using the Early Treatment Diabetic Retinopathy Study (ETDRS) logMAR chart at 3 m and near VA was measured using the near vision logMAR chart at 40 cm under ambient lighting. Myopia was defined as spherical equivalent of refraction of less than -0.50 diopters (D), and hypermetropia as spherical equivalent of more than +0.50 D. Astigmatism was defined as cylinder power of 0.5 D or greater. Effective spectacle coverage for distance vision was computed as met need/(met need+unmet need+under-met need)×100%. Multivariable logistic regression models were used to examine associations between sociodemographic factors and RE.

RESULTS

The authors included 892 participants (446 Emiratis and 446 non-Emiratis) in the analysis. The prevalence of hypermetropia was 20.4% [95% confidence interval (CI): 16.8%-24.4%] in Emiratis and 20.6% (95% CI: 20.0%-24.7%) in non-Emiratis. The prevalence of myopia and high myopia was 27.4% (95% CI: 23.3%-31.7%) and 1.8% (95% CI: 0.8%-3.5%) in Emiratis, and 19.5% (95% CI: 15.9%-23.5%) and 0.9% (95% CI: 0.2%-2.3%) in non-Emiratis, respectively. High education (P=0.02) and not currently working (P=0.002) were risk factors of myopia in non-Emiratis only. The prevalence of astigmatism was 7.4% (95% CI: 5.1%-10.2%) in Emiratis and 1.6% (95% CI: 0.6%-3.2%) in non-Emiratis. This prevalence was higher in individuals aged over 60 years (P<0.001) and men (P=0.014) among Emiratis. The prevalence of anisometropia and uncorrected presbyopia was 11.4% (95% CI: 8.6%-14.8%) and 0.7% (95% CI: 0.1%-2.0%) in Emiratis, and 9.2% (95% CI: 6.7%-12.3%) and 0.4% (95% CI: 0.05%-1.6%) in non-Emiratis, respectively. The effective spectacle coverage was 62.3% (95% CI: 54.0%-70.6%) and 69% (95% CI: 60.5%-77.5%) in Emiratis and non-Emiratis, respectively.

CONCLUSIONS

A high proportion of Emiratis and non-Emiratis was affected by RE without optimal effective spectacle coverage, highlighting the imperativeness of intervention to alleviate the burden. The findings may help facilitate evidence-based policymaking concerning the delivery of eye care services and allocation of medical resources in Dubai.

Development and Validation of a Model to Predict Who Will Develop Myopia in the Following Year as a Criterion to Define Premyopia

PURPOSE

To develop and validate models to predict who will develop myopia in the following year based on cycloplegic refraction or ocular biometry and to identify thresholds of premyopia.

METHODS

Prospective longitudinal data of nonmyopic children at baseline from the Guangzhou Twins Eye Study and the Guangzhou Outdoor Activity Longitudinal Study were used as the training set, and the Singapore Cohort Study of the Risk factors for Myopia study formed the external validation set. Age, sex, cycloplegic refraction, ocular biometry, uncorrected visual acuity, and parental myopia were integrated into 3 logistic regression models to predict the onset of myopia in the following year. Premyopia cutoffs and an integer risk score system were derived based on the identified risk.

RESULTS

In total, 2896 subjects with at least 2 visits were included. Cycloplegic refraction at baseline is a better predictor to identify the children with myopia onset [C-statistic=0.91, 95% confidence interval (CI), 0.87-0.94; C-statistic=0.92, 95% CI, 0.92-0.92 for internal and external validation, respectively], comparing to axial length, corneal curvature radius (CR) and anterior chamber depth (C-statistic=0.81, 95% CI, 0.73-0.88; C-statistic=0.80, 95% CI, 0.79-0.80, respectively), and axial length/CR (C-statistic=0.78, 95% CI, 0.71-0.85; C-statistic=0.76, 95% CI, 0.75-0.76). With a risk of >70%, the definitions of premyopia indicating approaching myopia onset were 0.00 D for 6-8 years and -0.25 D for ≥9 years in children with 2 myopic parents.

CONCLUSIONS

Either cycloplegic refraction or ocular biometry can predict 1-year risk of myopia. Premyopia can be successfully defined through risk assessments based on children's age and predict who would require more aggressive myopia prophylaxis.

Low-Concentration Atropine Monotherapy vs. Combined with MiSight 1 Day Contact Lenses for Myopia Management

Objectives: To assess the decrease in myopia progression and rebound effect using topical low-dose atropine compared to a combined treatment with contact lenses for myopic control. Methods: This retrospective review study included 85 children aged 10.34 ± 2.27 (range 6 to 15.5) who were followed over three years. All had a minimum myopia increase of 1.00 D the year prior to treatment. The children were divided into two treatment groups and a control group. One treatment group included 29 children with an average prescription of 4.81 ± 2.12 D (sphere equivalent (SE) range of 1.25−10.87 D), treated with 0.01% atropine for two years (A0.01%). The second group included 26 children with an average prescription of 4.14 ± 1.35 D (SE range of 1.625−6.00 D), treated with MiSight 1 day dual focus contact lenses (DFCL) and 0.01% atropine (A0.01% + DFCL) for two years. The control group included 30 children wearing single-vision spectacles (SV), averaging −5.06 ± 1.77 D (SE) range 2.37−8.87 D). Results: There was an increase in the SE myopia progression in the SV group of 1.19 ± 0.43 D, 1.25 ± 0.52 D, and 1.13 ± 0.36 D in the first, second, and third years, respectively. Myopia progression in the A0.01% group was 0.44 ± 0.21 D (p < 0.01) and 0.51 ± 0.39 D (p < 0.01) in the first and second years, respectively. In the A0.01% + DFCL group, myopia progression was 0.35 ± 0.26 D and 0.44 ± 0.40 D in the first and second years, respectively (p < 0.01). Half a year after the cessation of the atropine treatment, myopia progression (rebound effect) was measured at −0.241 ± 0.35 D and −0.178 ± 0.34 D in the A0.01% and A0.01% + DFCL groups, respectively. Conclusions: Monotherapy low-dose atropine, combined with peripheral blur contact lenses, was clinically effective in decreasing myopia progression. A low rebound effect was found after the therapy cessation. In this retrospective study, combination therapy did not present an advantage over monotherapy.

Role of tutorial classes and full day schooling on self-reported age of myopia onset: findings in a sample of Argentinian adults

PURPOSE

To investigate the effect of tutorial classes and schooling schedule in childhood on age of myopia onset.

METHODS

Refractive data for subjects ≥18 years of age were collected from 8 dispensing opticians or refractive ophthalmologists' offices in Argentina. Age of myopia onset, spherical equivalent (SE), and risk factors were determined using questionnaires. Multiple linear regression models were applied to assess possible factors associated with age of myopia onset or final adult SE.

RESULTS

A total of 274 adults (61.3% females) with myopia between -0.50 and -6.00 D were included. Mean age was 36.9 ± 14.5 years. The mean adult SE was -2.95 ± 1.45 D, and the mean age of myopia onset was 14.2 ± 5.4 years. Subjects that attended after-school tutorial classes (β = -2.23; P = 0.005) or a full day schedule in primary school (β = -1.07; P = 0.035) or that spent more time on near work (β = -0.70; P = 0.010) in childhood, had younger age of myopia onset.

CONCLUSIONS

In our study cohort, adults that had attended tutorial classes and/or full-day schooling during childhood had younger age of myopia onset.

Systematic Review and Meta-Analysis on the Impact of COVID-19 Pandemic-Related Lifestyle on Myopia

PURPOSE

To conduct a systematic review and meta-analysis to assess the effects of coronavirus disease 2019 (COVID-19) pandemic-related lifestyle on myopia outcomes in children to young adults.

METHODS

A systematic search was conducted on PubMed, Embase, and the Cochrane Central Register of Controlled Trials databases (with manual searching of reference lists of reviews). Studies included assessed changes in myopia-related outcomes (cycloplegic refraction) during COVID and pre-COVID. Of 367 articles identified, 7 (6 prospective cohorts; 1 repeated cross-sectional study) comprising 6327 participants aged 6 to 17 were included. Quality appraisals were performed with Joanna Briggs Institute Critical Appraisal Checklists. Pooled differences in annualized myopic shifts or mean spherical equivalent (SE) during COVID and pre-COVID were obtained from random-effects models.

RESULTS

In all 7 studies, SE moved toward a myopic direction during COVID (vs pre-COVID), where 5 reported significantly faster myopic shifts [difference in means of changes: -1.20 to -0.35 diopters per year, [D/y]; pooled estimate: -0.73 D/y; 95% confidence interval (CI): -0.96, -0.50; P<0.001], and 2 reported significantly more myopic SE (difference in means: -0.72 to -0.44 D/y; pooled estimate: -0.54 D/y; 95% CI: -0.80, -0.28; P<0.001). Three studies reported higher myopia (SE ≤-0.50 D) incidence (2.0- to 2.6-fold increase) during COVID versus pre-COVID. Of studies assessing lifestyle changes, all 4 reported lower time outdoors (pre-COVID vs during COVID: 1.1-1.8 vs 0.4-1.0 hours per day, [h/d]), and 3 reported higher screen time (pre-COVID vs during COVID: 0.7-2.8 vs 2.4-6.9 h/d).

CONCLUSIONS

This review suggests more myopic SE shifts during COVID (vs pre-COVID) in participants aged 6 to 17. COVID-19 restrictions may have worsened SE shifts, and lifting of restrictions may lessen this effect. Evaluations of the long-term effects of the pandemic lifestyle on myopia onset and progression in large studies are warranted to confirm these findings.

Temporal and spatial characterization of myopia in China

Purpose

The aim of this study was to characterize the temporal and spatial distribution of myopia among students aged 7-18 years, by analyzing the aggregation area and providing the basis for the prevention and control of myopia in China.

Methods

A database for the spatial analysis of myopia in China during 1995-2014 was established using ArcGIS10.0 software as a platform for data management and presentation. A spatial autocorrelation analysis of myopia was undertaken, and a temporal and spatial scan analysis was performed using SaTScan9.5 software.

Results

Our data demonstrated that the prevalence of myopia in China in 1995, 2000, 2005, 2010, and 2014 was 35.9, 41.5, 48.7, 57.3, and 57.1%, respectively, thus indicating a gradual upward trend. The prevalence of myopia was analyzed in various provinces (municipalities and autonomous regions), and the highest was found in Jiangsu Province, with an average Moran's I index of 0.244295 in China (P ≤ 0.05). According to the local Moran's I autocorrelation analysis, there was a spatial aggregation of myopia prevalence among students in the entire country, with Shandong, Jiangsu, Anhui, and Shanghai being classified as high-high aggregation areas, while Hainan and Guangxi were classified as low-low aggregation areas. In addition, the Getis-Ord General G results of the global hotspot analysis showed a countrywide myopia prevalence index of 0.035020 and a Z score of 1.7959 (P = 0.07251). Because the myopia prevalence correlation difference was not statistically significant, there were no "positive hotspots" or "negative hotspots." The local hotspot analysis shows that Shandong and Jiangsu belong to high-value aggregation areas, while Hainan and Guizhou belong to low-value aggregation areas. Further analysis using time-space scanning showed 15 aggregation regions in five stages, with four aggregation regions having statistically significant differences (P ≤ 0.05). However, the aggregation range has changed over time. Overall, from 1995 to 2014, the aggregation areas for the myopia prevalence in Chinese students have shifted from the northwest, north, and northeast regions to the southeast regions.

Conclusion

Our data demonstrate that, from 1995 to 2014, the prevalence of myopia increased in students aged 7-18 years in China. In addition, the prevalence of myopia is randomly distributed in various provinces (municipalities and autonomous regions) and exhibits spatial aggregation. Also, the gathering area is gradually shifting to the southeast, with the existence of high-risk areas. It is, therefore, necessary to focus on this area and undertake targeted prevention and control measures.

Associations of Children's Close Reading Distance and Time Spent Indoors with Myopia, Based on Parental Questionnaire

Purpose: To study the association of parents’ reports about their children’s near work and outdoor habits with myopia in their children. Methods: Data from a questionnaire study conducted in 1983 among Finnish schoolchildren were reanalyzed. Vision screening had been performed for all the schoolchildren (n = 4961) in the 1st, 5th, and 8th grades (7-, 11-, and 15-year-olds) in an area of Central Finland. The questionnaire, including information about myopia, was returned by 4305 (86.7%) participants. Items concerned parents’ estimates of their child’s habitual reading distance, time spent indoors as compared with age peers, daily near work, outdoors time, and parents’ myopia. The associations of myopia with these factors were studied. Results: Myopia prevalence in those with a habitual close reading distance vs. others was 14.3% vs. 2.1%, 28.7% vs. 13.1% and 45.8% vs. 24.7% for the 7-, 11- and 15-year-olds (p < 0.001 in all age-groups). Myopia prevalence in children reported by their parents as spending more time indoors than age peers was 10.9% vs. 2.8% (p < 0.001), 25.0% vs. 14.7% (p = 0.004) and 41.9% vs. 25.7% (p < 0.001) in the three age groups. Myopia prevalence among those reported as spending both more time indoors and reading at a close distance vs. others was 44.2% vs. 11.9% (Fisher’s exact t-test, p < 0.001). In the multiple logistic regression models, parental myopia almost doubled the risk of myopia in the 11- and 15-year-olds. ORs (95% CI) for myopia adjusted for parental myopia and sex were for close reading distance 7.381 (4.054−13.440), 2.382 (1.666−3.406), 2.237 (1.498−3.057), (p < 0.001), and for more time spent indoors, 3.692 (1.714−7.954), p = 0.001, 1.861 (1.157−2.992), p = 0.010), 1.700 (1.105−2.615), p = 0.016, in the three age groups. Conclusion: Children, especially 7-year-olds, reported by their parents as having a close reading distance and spending a lot of time indoors were associated with a higher risk for myopia.