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Van Swol EG, Gupta A, Nguyen SA, Wilson ME. Comparison of HOTV optotypes and Lea Symbols: a systematic review and meta-analysis. J AAPOS 2024; 28:103815. [PMID: 38237723 DOI: 10.1016/j.jaapos.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 10/18/2023] [Accepted: 11/08/2023] [Indexed: 01/30/2024]
Abstract
PURPOSE To report the findings of our systematic review and meta-analysis comparing the completion time and testing time of visual acuity testing using Lea Symbols or HOTV optotypes. METHODS A systematic search of PubMed, SCOPUS, and CINAHL was conducted according to the PRISMA guidelines. RESULTS The completion rate for HOTV optotypes and Lea Symbols visual acuity testing was reported for 7,948 patients (average age, 3.59 years; age range, 2-17; 49.96% females). The 3-year-olds' completion rate of HOTV was 74.09% (47.93%-93.29%), compared with a Lea Symbols completion rate of 77.80% (53.93%-94.57%). The 4-year-olds' completion rate was 88.20% (63.48%-99.73%) for HOTV and 90.118% (67.42%-99.90%) for Lea Symbols. In 3-year-olds, the mean testing time was 118.33 ± 6.54 seconds for HOTV and 120.33 ± 6.53 seconds for Lea Symbols (P < 0.0001). The difference in testing times in the 4-year-old age group was also statistically significant (86.98 ± 6.12 seconds for HOTV and 94.32 ± 6.57 seconds for Lea symbols) (P < 0.0001). CONCLUSIONS There was a statistically significant difference in the testing times between the HOTV optotypes and Lea Symbols in both the 3- and 4-year-old age groups; however, the difference of 2-7 seconds on average is unlikely to be clinically significant. Testing speed and completion rate improve with age for both tests.
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Affiliation(s)
| | - Annika Gupta
- College of Medicine, Medical University of South Carolina, Charleston
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - M Edward Wilson
- Department of Ophthalmology, Storm Eye Institute, Medical University of South Carolina, Charleston.
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Duan X, Zhou YN, Chen Y. Association between body stature and prevalence of reduced visual acuity in high school graduates in Hangzhou, China. Clin Exp Optom 2023:1-5. [PMID: 37918111 DOI: 10.1080/08164622.2023.2277292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 10/23/2023] [Indexed: 11/04/2023] Open
Abstract
CLINICAL RELEVANCE The association between myopia and body stature is of great significance for understanding prevention and control of myopia. It has been extensively studied in previous studies but without consistent conclusions. BACKGROUND The aim of this study is to investigate the association between body stature and prevalence of reduced visual acuity in high school graduates in Hangzhou, China. METHODS 50,620 high school graduates who finished the physical examination of the national college entrance examination in 2020 were included. Data were derived from the database of physical examination of the national college entrance examination. Height and weight were measured, and body mass index (BMI) was calculated according to the general formula. Visual acuity was measured by the standard logarithmic visual acuity chart. RESULTS The prevalence of reduced visual acuity was 90.38% in high school graduates. Girls had a higher prevalence of reduced visual acuity than boys (93.07% vs 87.60%, P < 0.001). Boys with normal visual acuity were significantly taller (P < 0.001) and heavier (P < 0.001) than those with reduced visual acuity. Girls with normal visual acuity were significantly taller than those with reduced visual acuity (P < 0.001). The prevalence of reduced visual acuity was significantly inversely associated with height in both boys (P < 0.001) and girls (P < 0.001). The risk of reduced visual acuity was the lowest in the fourth quartile of height. The prevalence of reduced visual acuity was significantly associated with BMI only in boys (P < 0.001). The risk of reduced visual acuity was the lowest in the third quartile of BMI. CONCLUSIONS The prevalence of reduced visual acuity was inversely associated with height in both boys and girls, and there was a U-shaped association with BMI only in boys.
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Affiliation(s)
- Xu Duan
- Department of Cardiology, Hangzhou First People 's Hospital, Hangzhou, China
| | - Yi-Nan Zhou
- Department of Self-study Examination, Hangzhou Education Examination Authority, Hangzhou, China
| | - Yun Chen
- Department of National College Entrance Examination, Hangzhou Education Examination Authority, Hangzhou, China
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Wang P, Bianchet S, Carter M, Hopman W, Law C. Utilization and barriers to eye care following school-wide pediatric vision screening. CANADIAN JOURNAL OF OPHTHALMOLOGY 2023; 58:465-471. [PMID: 35525265 DOI: 10.1016/j.jcjo.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 02/27/2022] [Accepted: 04/10/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE In August 2018, Ontario introduced the Child Visual Health and Vision Screening Protocol outlining school-based senior kindergarten (aged 4-6 years) vision screening. We determine the prevalence of children at risk based on screening in an Ontario community and follow up to determine resource utilization after screening. METHODS Vision screening data (HOTV, Randot, Autorefractor) from 41 schools (1127 children) were collected for the 2018-2019 and 2019-2020 school years. Phone follow-up was conducted 1-1.5 years after screening to determine whether an optometry visit occurred, if glasses were prescribed, and potential barriers to accessing eye care. Independent t tests were used to compare time to follow-up between groups, and χ2 testing was used for associations between material and social deprivation. RESULTS Overall screening resulted in a 32.2% referral rate within our region. Of the referred children who responded, the rate of seeking out eye care was 69.9% (n = 64), and 65.2% of these visits were prompted specifically by vision screening, and 34.4% of referred children respondents were prescribed glasses. There was a significant relationship between receiving a referral and living in a more materially deprived (p = 0.001) and a more socially deprived area (p = 0.006). The most frequently reported barriers were related to insufficient insurance coverage for eye care or glasses, COVID-19-related difficulties, and scheduling conflicts. CONCLUSION Our vision screening program identified and referred more than one third of children screened for follow-up eye examinations, with children in more deprived neighbourhoods being more frequently referred. Around two thirds of referred children sought care, and one third were prescribed glasses in the follow-up sample.
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Affiliation(s)
- Patrick Wang
- Department of Ophthalmology, School of Medicine, Queen's University, Kingston, Ont
| | - Sonya Bianchet
- Department of Public Health Sciences, Kingston, Frontenac, Lennox, and Addington Public Health, Kingston, Ont
| | - Megan Carter
- Department of Public Health Sciences, Kingston, Frontenac, Lennox, and Addington Public Health, Kingston, Ont.; Department of Public Health Sciences, Queen's University, Kingston, Ont
| | - Wilma Hopman
- KGH Research Institute and Department of Public Health Sciences, Queen's University, Kingston, Ont
| | - Christine Law
- Department of Ophthalmology, Queen's University, Kingston, Ont..
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Abdul Rahman SNA, Naing NN, Othman AM, Mohamad Z, Ibrahim TMM, Hashim SE, Baig AA, Wong LS, Dewadas HD, Selvaraj S. Validity and Reliability of Vis-Screen Application: A Smartphone-Based Distance Vision Testing for Visual Impairment and Blindness Vision Screening. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050912. [PMID: 37241144 DOI: 10.3390/medicina59050912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/14/2023] [Accepted: 03/23/2023] [Indexed: 05/28/2023]
Abstract
Background and Objectives: The health-related mobile applications (app) might assist in promoting inclusive health and tele-treatment, especially for the less severe diseases. In this paper, a study had been done to determine the app's reliability in terms of raters and the app's agreement with the Snellen chart. Materials and Methods: A cross-sectional sectional study was conducted between November 2019 and September 2020. Participants were selected via purposive sampling from selected communities in Terengganu state. All participants underwent vision testing with the Vis-Screen app and Snellen chart for validity and reliability accordingly. Results: A total of 408 participants were involved, with a mean age of 29.3. The sensitivity of the presenting vision of the right eye (PVR) ranged from 55.6% to 88.4%, with specificity between 94.7% to 99.3%, while the positive and negative predictive values were between 57.9% and 81.7% and 96.8% and 99.0%, respectively. The positive likelihood ratios ranged between 16.73 and 73.89, whereas the negative likelihood ratios ranged from 0.12 to 0.45. The area under the receiver operating characteristic curve (AUC) for all cut-off points ranged between 0.93 and 0.97, and the optimum cut-off point was at 6/12. The kappa values for intra-rater and inter-rater were 0.85 and 0.75, respectively, while the app's reliability with the Snellen chart was 0.61. Conclusions: Vis-Screen was concluded to be valid and reliable for use as a screening tool for detecting individuals with visual impairment and blindness in the community. A valid and reliable portable vision screener like Vis-Screen will help expand the eye care feasibility while providing similar accuracy as the conventional charts in clinical practices.
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Affiliation(s)
- Siti Nor Aishah Abdul Rahman
- Faculty of Medicine, Medical Campus, Universiti Sultan Zainal Abidin, Jalan Sultan Mahmud, Kuala Terengganu 20400, Terengganu, Malaysia
| | - Nyi Nyi Naing
- Faculty of Medicine, Medical Campus, Universiti Sultan Zainal Abidin, Jalan Sultan Mahmud, Kuala Terengganu 20400, Terengganu, Malaysia
| | - Abdul Mutalib Othman
- Faculty of Medicine, Medical Campus, Universiti Sultan Zainal Abidin, Jalan Sultan Mahmud, Kuala Terengganu 20400, Terengganu, Malaysia
| | - Zarina Mohamad
- Faculty of Informatics and Computing, Besut Campus, Universiti Sultan Zainal Abidin, Besut 22200, Terengganu, Malaysia
| | - Tg Mohd Masrul Ibrahim
- Infostructure & Network Management Center, Gong Badak Campus, Universiti Sultan Zainal Abidin, Kuala Nerus 21300, Terengganu, Malaysia
| | - Syaratul Emma Hashim
- Faculty of Medicine, Medical Campus, Universiti Sultan Zainal Abidin, Jalan Sultan Mahmud, Kuala Terengganu 20400, Terengganu, Malaysia
| | - Atif Amin Baig
- University Institute of Public Health, Faculty of Allied Health Sciences, The University of Lahore, Lahore 54590, Pakistan
| | - Ling Shing Wong
- Faculty of Health and Life Sciences, INTI International University, Nilai 71800, Negeri Sembilan, Malaysia
| | - Hemaniswarri Dewi Dewadas
- Centre for Biomedical and Nutrition Research, Universiti Tunku Abdul Rahman, Jalan Universiti, Banda Barat, Kampar 31900, Perak, Malaysia
- Department of Business and Public Administration, Faculty of Business and Finance, Universiti Tunku Abdul Rahman, Jalan Universiti, Banda Barat, Kampar 31900, Perak, Malaysia
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Shah R, Edgar DF, Evans BJW. Worsening vision at age 4-5 in England post-COVID: Evidence from a large database of vision screening data. Ophthalmic Physiol Opt 2023; 43:454-465. [PMID: 36866712 DOI: 10.1111/opo.13112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 02/02/2023] [Accepted: 02/06/2023] [Indexed: 03/04/2023]
Abstract
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.
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Affiliation(s)
- Rakhee Shah
- Institute of Optometry, London, UK.,Centre for Applied Vision Research, City, University of London, London, UK
| | - David F Edgar
- Institute of Optometry, London, UK.,Centre for Applied Vision Research, City, University of London, London, UK
| | - Bruce J W Evans
- Institute of Optometry, London, UK.,Centre for Applied Vision Research, City, University of London, London, UK
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Comparison of Factors Associated with Myopia among Middle School Students in Urban and Rural Regions of Anhui, China. Optom Vis Sci 2022; 99:702-710. [PMID: 35914091 DOI: 10.1097/opx.0000000000001933] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SIGNIFICANCE The prevention and control of myopia have become a major public health task throughout the world. The analysis of the modifiable factors associated with myopia will help in planning concrete strategies that can be widely implemented by schools and families. PURPOSE This study assessed the modifiable factors associated with myopia and compared them between rural and urban regions. METHODS Data were collected from December 2020 to March 2021. A multi-stage stratified cluster sampling method was used to select 6154 middle school students. All children underwent an eye examination, including visual acuity and cycloplegic refraction. Data on near work, sleep and outdoor activities were collected in questionnaires. RESULTS The myopia prevalence values in urban and rural regions were 68.1% and 63.7%, respectively (χ2 = 15.57, P < .001). More than 3 hours homework per day(OR in urban and rural region: 1.36, 95% CI = 1.07-1.75 vs. 1.72, 95% CI = 1.43-2.07), 36-40 core subjects per week(1.30, 95% CI = 1.04-1.57 vs. 1.42, 95% CI = 1.24-1.64) and going to sleep before 10 o'clock (0.56, 95% CI = 0.32-0.93 vs. 0.50, 95% CI = 0.28-0.90) were significantly associated with myopia in both regions. In contrast, taking breaks during near work was a significant factor in the rural region (less than 1 hour: OR = 0.57, 95% CI = 0.42-0.76; 1-2 hours: OR = 0.63, 95% CI = 0.46-0.86), but not in the urban region. More time outdoors per day was associated with a reduced prevalence of myopia only for urban children (2-3 hours: OR = 0.55, 95% CI = 0.31-0.97; more than 3 hours: OR = 0.38, 95% CI = 0.19-0.75). CONCLUSIONS Homework loads and the time of going to sleep were associated with myopia for children in both urban and rural regions. However, time outdoors was only associated with myopia in urban regions and taking breaks during near work only associated with myopia in rural regions.
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Hashemi H, Khabazkhoob M, Nabovati P, Emamian MH, Fotouhi A. A longitudinal study of local stereoacuity and associated factors in schoolchildren: The Shahroud Schoolchildren Eye Cohort Study. Clin Exp Optom 2022; 106:415-421. [PMID: 35263552 DOI: 10.1080/08164622.2022.2048998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
CLINICAL RELEVANCE Impaired stereoacuity is seen in some children without amblyopia, strabismus, and clinically significant refractive errors. Therefore, there are probably other factors affecting stereoacuity. BACKGROUND The aim of this work was to investigate the longitudinal changes of local stereoacuity and associated factors in schoolchildren. METHODS The present report is a part of the Shahroud Schoolchildren Eye Cohort Study. The target population was children aged 6 to 12 years in Shahroud, Iran. The second phase of the study was conducted in 2018 by re-inviting all participants in the first phase (2015). After an initial interview, study participants underwent optometric examination and ocular biometry. Stereoacuity was evaluated using Stereo Fly Test. Exclusion criteria were functional amblyopia, strabismus, significant refractive errors, probable ocular pathology/organic amblyopia in either of the two study phases, a history of intraocular surgery or ocular trauma, and incomplete data. RESULTS The data of 4666 children were analysed for this report, of which 53.7% were male. The mean age of the studied participants in the second phase was 12.37 ± 1.71 years. The mean stereoacuity was 42.31 (95% CI: 42.05 - 42.57) seconds of arc in the first phase, which reduced to 51.72 (95% CI: 50.79-52.65) seconds of arc in the second phase (P < 0.001). The prevalence of poor stereoacuity was 0.17% (95% CI: 0.06-0.29) in the first phase, which increased to 3.94% (95% CI: 3.34-4.54) in the second phase (P < 0.001). According to the multiple linear regression, older age in the first study phase (β = 0.011, P < 0.001), urban residence (β = -0.019, P = 0.006), increased spherical anisometropia (0.038, P = 0.013), and increased axial length (β = 0.062, P = 0.003) were significantly associated with reduction of stereoacuity (in log scale) after three years. CONCLUSION In addition to the known risk factors of amblyopia, strabismus, and significant refractive errors, other factors are also associated with stereoacuity changes in children.
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Affiliation(s)
- Hassan Hashemi
- Noor Research Center for Ophthalmic Epidemiology, Noor Eye Hospital, Tehran, Iran
| | - Mehdi Khabazkhoob
- Department of Medical Surgical Nursing, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Payam Nabovati
- Rehabilitation Research Center, Department of Optometry, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Hassan Emamian
- Ophthalmic Epidemiology Research Center, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Akbar Fotouhi
- Department of Epidemiology and Biostatistics, Tehran University of Medical Sciences, Tehran, Iran
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Gogate P, Kalamkar S, Kaur H, Phadke S, Shinde A. Prevalence of ocular morbidity in preschool children in Pune, Maharashtra. JOURNAL OF CLINICAL OPHTHALMOLOGY AND RESEARCH 2022. [DOI: 10.4103/jcor.jcor_128_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Pinhole does not increase screening accuracy of detecting decreased best corrected visual acuity in schoolchildren. BMC Ophthalmol 2021; 21:416. [PMID: 34856946 PMCID: PMC8638540 DOI: 10.1186/s12886-021-02150-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 10/20/2021] [Indexed: 11/30/2022] Open
Abstract
Background Decreased best corrected visual acuity among children should be treated early in life, and vision screening in schoolchildren is an efficient and feasible selection for developing countries. Thus, the screening accuracy of different visual acuity tests is the key point for making vision screening strategies. The present study aims to explore the screening accuracy of uncorrected visual acuity (UCVA) and pin-hole corrected visual acuity (PCVA) using different vision chart in the detection of decreased best-corrected visual acuity (BCVA) among schoolchildren. Methods Grade one primary schoolchildren in urban Lhasa with data of UCVA using tumbling E chart (UCVAE), PCVA using tumbling E chart (PCVAE), UCVA using Lea Symbols chart (UCVAL), PCVA using Lea Symbols chart (PCVAL) and BCVA using Lea Symbols chart were reviewed. Decreased BCVA was defined as BCVA≤20/32(≥0.2 logMAR). Difference, reliability, and diagnostic parameters in the detection of decreased BCVA of different visual acuity results were analyzed. Results Overall, 1672 children aged 6.58 ± 0.44 years fulfilling the criteria. The prevalence of decreased BCVA was 6.8%. Although no significant differences were found between UCVAE vs UCVAL (p = .84, paired t-test) as well as PCVAE vs PCVAL (p = .24), the ICC between them was low (0.68 and 0.57, respectively). The average difference between BCVA and UCVAE, UCVAL, PCVAE, PCVAL was logMAR -0.08 (− 0.37, 0.21), − 0.08 (− 0.29, 0.17), − 0.05 (− 0.30, 0.19), − 0.06 (− 0.23, 0.12) using Bland–Altman method. The area under the receiver operating characteristic curve of UCVAE, PCVAE, UCVAL, PCVAL for the detection of decreased BCVA was 0.78 (0.73, 0.84), 0.76 (0.71, 0.82), 0.95 (0.94, 0.96), 0.93 (0.91, 0.95), respectively. Conclusion Pinhole does not increase the screening accuracy of detecting decreased BCVA in grade one primary schoolchildren. Visual acuity test using Lea Symbols is more efficient than Tumbling E in the screening of that age. Trial registration Data were maily from the Lhasa Childhood Eye Study which has finished the clinical registration on (ChiCTR1900026693).
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Xiang S, Zhao S, Li X, Li L, Xie L, Kang R, Zhong Y. The prevalence of reduced visual acuity in children from an urban district in China from 2002 to 2018. Eye (Lond) 2020; 35:2550-2555. [PMID: 33188291 DOI: 10.1038/s41433-020-01269-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 10/23/2020] [Accepted: 10/28/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND To investigate trends in the prevalence of reduced visual acuity (VA), a proxy measure for myopia, in an urban district in China. METHODS Data were extracted from the dataset of the 2002 and 2018 Annual Survey on Students' Constitution and Health from Yuhua District, Changsha City, China. Children aged 6-15 years were included in the study. VA was measured using a LogMAR tumbling E chart. The prevalence of reduced VA was calculated by age and gender. The chi-square test was used to compare the differences between groups. RESULTS The final VA analysis included 26217 children in 2002 and 45510 children in 2018. The overall prevalence of reduced VA increased from 28.3% in 2002 to 46.5% in 2018 (P < 0.001). The prevalence of reduced VA started to increase markedly from the age of 14 years in 2002, while in 2018 it started to increase markedly from the age of 9 years. The prevalence of severely reduced VA increased in all age groups from 2002 to 2018 and increased with age (all P < 0.001). In 2002, over 50% of children in all age groups had normal VA. By 2018, the prevalence of normal VA decreased from 61.4% in those aged 6 years to 31.9% in those aged 15 years. CONCLUSIONS The prevalence of reduced VA among children aged 6-15 years in Yuhua District has become more common with age, and there has been a marked increase in the prevalence of reduced VA from 2002 to 2018. The remarkable epidemic of reduced VA started 5 years earlier in 2018 than in 2002. Evidence from the present study suggests that interventions should be launched before the age of 9 years.
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Affiliation(s)
- Shiting Xiang
- Hunan Children's Research Institute (HCRI), Hunan Children's Hospital, 86 Ziyuan Road, Changsha, 410007, China
| | - Sha Zhao
- Department of Child health service, Hunan Children's Hospital, 86 Ziyuan Road, Changsha, 410007, China
| | - Xun Li
- Hunan Children's Research Institute (HCRI), Hunan Children's Hospital, 86 Ziyuan Road, Changsha, 410007, China
| | - Liping Li
- Hunan Children's Research Institute (HCRI), Hunan Children's Hospital, 86 Ziyuan Road, Changsha, 410007, China
| | - Lihua Xie
- Department of outpatient service, Hunan Children's Hospital, 86 Ziyuan Road, Changsha, 410007, China
| | - Rutong Kang
- Department of Child health service, Hunan Children's Hospital, 86 Ziyuan Road, Changsha, 410007, China
| | - Yan Zhong
- Department of Child health service, Hunan Children's Hospital, 86 Ziyuan Road, Changsha, 410007, China.
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