COVID-19, sweat, tears… and myopia?

The gap between parental knowledge and children practice of myopia control and challenge under COVID-19: a web-based survey in China

Objective

To evaluate parental knowledge of myopia control, investigate its association with children's practice and refractive status, and explore their change under the outbreak of COVID-19 pandemic.

Methods

In this web-based survey, a self-administered questionnaire was made online available during the COVID-19 outbreak between February 1th, 2022 and August 31th, 2022 in China. Participants were recruited via social media by convenience and snowball sampling. Parents of both sexes whose children aged between 3 and 18 were eligible. The overall questionnaire was composed of four categories: demographic information, parental knowledge of myopia, children's myopia-related behaviors and their change after the COVID-19 pandemic, and children's refractive status. SPSS version 18.0 was applied to perform the statistics analysis and p < 0.05 was considered to be statistically significant.

Results

A total of 423 eligible families were included in our online survey. The average age of children was 11.37 ± 2.83y (male 46.1%; female 53.9%), with a myopia incidence of 83.9% (355/423). Both children's age (OR = -0.6; 95%CI = -1.12 to -0.07; p = 0.026) and family income (OR = 2.60; 95%CI = 1.13 to 4.07; p = 0.001) had independently significant impacts on parental knowledge. Unexpectedly, parental knowledge was negatively correlated with children's onset age of myopia (p = 0.002, r = -0.165) and positively correlated with spectacles wearing (p = 0.014, r = 0.131), and no correlation was found between parental knowledge and the occurrence of children myopia, current diopter, annual myopia progression and the diopter of the first glasses (all p > 0.05). We found discordance phenomenon between parents' knowledge and children's behaviors, with parental knowledge being irrelevant to children's sleeping time (p = 0.159, r = 0.069), the frequency of lying reading (p = 0.462, r = -0.036) and keeping nutrition diet (p = 0.142, r = 0.072), and positively correlated with daily homework time (p = 0.012, r = 0.123). After the outbreak of COVID-19, 77.8% (329/423) of parents admitted that their children's daily routine had been changed, with children spending more time on sleeping (p < 0.001) and electronic products (p < 0.001), and taking less time to do outdoor activities (p < 0.001).

Conclusion

The ideal interaction mode that establishing positive impact between parental knowledge and children practice has not been reached in China, which might be the result of insufficient parents' cognition and discordance phenomenon between parental knowledge and children's behaviors. The pandemic of COVID-19 has obviously changed children's daily routine. More efforts should be made to narrow the gap between knowledge and behaviors of myopia control, and stay alert to the potential increased risk of myopia during COVID-19.

Analysis of Refractive Errors in a Large Italian Cohort of Pediatric Subjects Post the COVID-19 Pandemic

BACKGROUND

The prevalence of refractive errors has sharply risen over recent decades. Despite the established role of genetics in the onset and progression of such conditions, the environment was also shown to play a pivotal role. Indeed, the COVID-19 pandemic has majorly impacted people's lifestyles and healthy habits, especially among the youth, which might have led to a significant increase in this trend. Therefore, the aim of this study was to investigate the actual prevalence of refractive errors in a large cohort of pediatric patients.

METHODS

A large cohort of 496 participants was screened through anamnesis, a non-cycloplegic autorefractometry, a corrected and uncorrected visual acuity assessment, and a questionnaire and was retrospectively evaluated.

RESULTS

Overall, refractive errors were present in 25.1% of eyes, of which 14.6% were diagnosed with myopia/myopic astigmatism and 10.5% with hyperopia/hyperopic astigmatism. Among the patients enrolled, 298 (60%) had their eyes checked one year earlier or before and 122 (25%) had never had ophthalmological consultations; a total of 105 (21%) needed glasses and 34 (7%) required a change in their previous prescription. A substantial increase in daily electronic device screen exposure was declared by 426 patients (87.6%).

CONCLUSIONS

Pediatric patients appear to have a higher prevalence of refractive errors than before.

Myopia among children and adolescents: an epidemiological study in Fuzhou City

Objective

To provide a reference for the prevention and control of myopia by analyzing and discussing the findings of an epidemiological survey of the prevalence of myopia among children and adolescents in Fuzhou City from 2019 to 2021.

Methods

Participants for this cross-sectional study were drawn from Gulou District and Minqing County in Fuzhou City using cluster random sampling to account for differences in population density, economic development, and other environmental variables.

Results

Myopia was more prevalent in 2020 than in 2019, but by 2021 it had dropped to about the same level as in 2019. Myopia was more prevalent among girls than boys during the course of the study period, with a three-year prevalence of 44.72% for boys and 52.16% for girls. Mild myopia accounted for 24.14% of all cases, followed by moderate myopia at 19.62%, and severe myopia at 4.58%. Students in urban regions had a prevalence of myopia equivalent to that of students in the suburbs, and this prevalence rose with age.

Conclusion

Myopia was quite prevalent among children and adolescents in Fuzhou City, and was shown to be steadily rising as students progressed through the school system. This suggests that all levels of government, educational institutions, medical facilities, and concerned parents in Fujian Province should focus on the issue of myopia and collaborate to reduce the risk factors for the development of myopia in school-aged participants.

The Cumulative Effect of Multilevel Factors on Myopia Prevalence, Incidence, and Progression Among Children and Adolescents in China During the COVID-19 Pandemic

Purpose

To estimate the effects of school closures and associated lifestyle changes on myopia in Chinese children and adolescents during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

Two cross-sectional surveys recruited 14,296 Chinese students aged 7 to 18 years in November 2019 and June 2020 from which an open cohort study (nested queue design) was derived and used to assess myopia prevalence, incidence, and progression rates (defined as students with progression in myopia severity at the second survey wave among those with myopia at baseline). The severity of myopia was determined by measurements of visual acuity (<5.0) and noncycloplegic refraction (spherical equivalent <-0.50 diopters). Twenty-three myopia-influencing factors were divided into three categories: eye-use habits, lifestyle, and family and subjective factors. Responses to each of these 23 factors were labeled as either positive or negative options and then combined to generate a comprehensive score.

Results

Boys and girls were equally represented (50%) and had the same average age (11.5 years) at each wave. The myopia prevalence increased from 48.2% to 60.0%, with 27.1% myopia incidence and 13.2% myopia progression rates for Chinese children and adolescents. Each of the 23 factors was associated with myopia prevalence but had no significant effect on myopia incidence or progression. However, these 23 factors had a cumulative effect on myopia risks; higher scores were associated with more positive factors and lower risk ratios of myopia and vice versa. Except for the progression rate, the myopia prevalence and incidence and risk ratios decreased with higher comprehensive scores.

Conclusions

School closures during the COVID-19 pandemic increased the risk of myopia in Chinese children and adolescents due to the accumulation of poor eyesight habits, unhealthy lifestyles, and excessive screen time.

Translational Relevance

Rather than focusing on single risk factors for myopia, future myopia prevention strategies should focus on integrating multiple comprehensive approaches across schools, families, and communities.

Effect of COVID-19 lockdown on refractive errors in Italian children aged 5-12 years: A multi-center retrospective study

PURPOSE

to explore the potential consequences of the COVID-19 lockdown on the prevalence of myopia among Italian children aged 5-12 years.

MATERIALS AND METHODS

retrospective multicenter study conducted in Italy. Population: children aged 5-12. Selection: random selection of children who received an eye exam between 2016 to 2021. Inclusion criteria: healthy children presenting for a routine eye exam. Exclusion criteria: presence of ocular comorbidities other than refractive error, such as blepharoptosis, media opacities, corneal or retinal dystrophies, strabismus, amblyopia, or concurrent therapy with atropine 0.01%. Outcome measure: age and spherical equivalent (SE) measured in diopters (D) in the right eye (RE) in cycloplegia. Statistical analysis: ANOVA test.

RESULTS

total of 803 children. In the years prior to COVID-19, the mean SE ± SD of healthy age-school children was: 0.54 ± 1.49 D in 2016; 0.43 ± 1.84 D in 2017; 0.34 ± 1.41 D in 2018; 0.35 ± 1.75 D in 2019 (ANOVA, p = .659). In 2021, the mean SE changed to -0.08 ± 1.44 D (ANOVA, p = .005). Mean age was comparable in all groups (ANOVA, p = .307). The prevalence of myopes (SE ≤-0.5D) and hyperopes (SE ≥ 2D) was respectively 24.10% and 9.64% among children aged 60-96 months, and 63.86% and 6.02% among children aged 97-144 months. These values represent a statistically-significant increase in the number of myopes (Chi-square, p = .016) and decrease in the number of hyperopes (Chi-square, p = .001), as compared to previous years (.06 and.48 respectively).

CONCLUSION

this retrospective study shows a statistically-significant decrease in the mean SE in children aged 5-12 in the year following the COVID-19 lockdown. The percentage of myopes has increased significantly, while the percentage of hyperopes has decreased. The lifestyle changes caused by the lockdown led children to spend more time on near-work activities and digital devices, and less time outdoors. These are known risk factors for the development and progression of myopia. Studies in different countries are encouraged.

Complex Interplay Between COVID-19 Lockdown and Myopic Progression

Purpose

To compare the myopic progression before and during strict home confinement when coronavirus disease 2019 (COVID-19) outbreak and explore the potential influencing factors.

Methods

A cross-sectional study. One hundred and fifteen myopic children (115 right eyes) who replace their frame-glasses from December 2019 to January 2020 and with complete refractive records in our hospital since myopia were involved in the study. At the beginning of the strict home confinement and after a 3-month strict home confinement during the COVID-19 pandemic, they were invited to our hospital to examine the axial length and refractive errors. And visual functions, convergence insufficiency symptom survey (CISS) scale and questionnaires were also performed. Besides, the axial length and refractive errors before the COVID-19 were got from outpatient case files. The effect of strict home confinement on myopia was assessed by comparing monthly axial elongation before COVID-19 and during strict home confinement. Spearman correlation analysis was performed to explore the correlation between potential influencing factors and myopia progression.

Results

Axial length's monthly elongation during strict home confinement was 35% higher than normal periods (0.046 vs. 0.033 mm/month, P = 0.003). The proportion of severe asthenopia doubled (P = 0.020). For myopia progression, heredity, close indoor work time and electronic products were risk factors. Besides, the protective factors were age, rest time after continuous eye usage, sleep time and distance from eye to computer screen.

Conclusions

During COVID-19, the decline in outdoor activities and increase of exposure time to digital screens accelerated the progression of myopia by 1/3.

Screen-based behaviour in children is more than meets the eye

Increased screen time (ST) in children is quickly becoming a public health concern as children are now reliant on technology for social interaction and educational development. The eye-health community has paid considerable attention to this in the recent literature, documenting it as digital eye strain. Continual close eye work and a lack of outdoor play contribute to digital eye strain and today’s myopia epidemic. This is a cause for concern for public health stakeholders insofar as it leads to sedentary, screen-based behaviour (SSB) in children. This results in a lack of physical activity and impacts both their bodies and their mental health. The potentially harmful effects of prolonged screen exposure on developing brains and bodies are likely to be unique and significant as physiological growth changes intersect with exponentially expanding e-platforms. While embracing the benefits of a highly digitalised world, we need to simultaneously mitigate the potential risks they pose to the health of growing children.

Impact of online classes and home confinement on myopia progression in children during COVID-19 pandemic: Digital eye strain among kids (DESK) study 4

Purpose

This study was performed to compare the rate of progression of myopia before and during the COVID-19 pandemic and to assess the risk factors of hastened progression.

Methods

All children with myopia of spherical equivalence ≤ -0.5 D with at least two prior documented refractions 6 months and 1 year before were included. The annual progression rate before COVID-19 and during COVID-19 was calculated. Annual myopia progression was categorized as no progression (0), slow progression (<1 D), and fast progression (≥1 D).

Results

A total of 133 children (266 eyes) aged 6-18 years were included in the study. Mean annual myopia progression was found to be statistically significant during COVID-19 as compared with pre-COVID-19 (0.90 vs 0.25 D, P < 0.00001). A total of 45.9% of children showed an annual progression of ≥1 D during the pandemic as compared with 10.5% before the COVID-19 (p < 0.00001). In multivariate analysis, history of rapid progression in pre-COVID-19 era (P = 0.002) and sun exposure <1 h/day (P < 0.00001) were found to be independent risk factors for rapid myopia progression.

Conclusion

Parents should consider risk of rapid myopia progression in children during current pandemic and children should be provided with socially distant outdoor activities to increase their sun exposure and diminish the rate of myopia progression.

Dietary ω-3 polyunsaturated fatty acids are protective for myopia

Myopia is a leading cause of visual impairment and blindness worldwide. However, a safe and accessible approach for myopia control and prevention is currently unavailable. Here, we investigated the therapeutic effect of dietary supplements of omega-3 polyunsaturated fatty acids (ω-3 PUFAs) on myopia progression in animal models and on decreases in choroidal blood perfusion (ChBP) caused by near work, a risk factor for myopia in young adults. We demonstrated that daily gavage of ω-3 PUFAs (300 mg docosahexaenoic acid [DHA] plus 60 mg eicosapentaenoic acid [EPA]) significantly attenuated the development of form deprivation myopia in guinea pigs and mice, as well as of lens-induced myopia in guinea pigs. Peribulbar injections of DHA also inhibited myopia progression in form-deprived guinea pigs. The suppression of myopia in guinea pigs was accompanied by inhibition of the "ChBP reduction-scleral hypoxia cascade." Additionally, treatment with DHA or EPA antagonized hypoxia-induced myofibroblast transdifferentiation in cultured human scleral fibroblasts. In human subjects, oral administration of ω-3 PUFAs partially alleviated the near-work-induced decreases in ChBP. Therefore, evidence from these animal and human studies suggests ω-3 PUFAs are potential and readily available candidates for myopia control.

Understanding risks of refractive error among Chinese children amidst pandemic disruptions: results from a rapid survey

BACKGROUND

Despite effectiveness in delaying the spread of the pandemic, frequent and extended disruption to children's livelihoods have fomented new norms in which learning routines encounter immense change. In particular, increased sedentary e-learning engagement with electronic screens and exposure to stressful circumstances are likely to pose adverse risks for children's vision development.

METHODS

This present study examines the link between near-sighted refractive error, and sedentary exposure to electronic screens, psychosocial stress level, and outdoor activities. A Rapid Survey Methodology (RSM) design was utilized to collect information on subject's vision condition, sedentary electronic screen use, and level of psychosocial stress, in addition to detailed socio-demographic background characteristics.

RESULTS

This study involves 2234 subjects enrolled in 1st to 6th grade in primary schools. Every 1 diopter hour increase in electronic screen use per day is associated with 1.036 OR (95% CI =1.024-1.047, p-value< 0.050), while every 1 h • W m^- 2 sr^- 1 of illuminance-weighted electronic screen use per day is associated with 2.285 OR (95% CI =1.829-2.855, p-value< 0.050) increased likelihood of near-sighted refractive error. Higher level of psychosocial stress is associated with 2.441 OR (95% CI =1.870-3.187, p-value< 0.050) and 2.403 OR (95% CI =1.839-3.141, p-value< 0.050) increased likelihood of near-sighted refractive error. Frequency of outdoor activity is not significantly associated with increased likelihood of near-sighted refractive error (p-value> 0.050).

CONCLUSIONS

Findings in this study show that many factors, including grade level and prior vision condition, contribute to increased risks of near-sighted refractive error during the COVID-19 pandemic. More strikingly, pandemic-related behavioral modifications such as lengthy sedentary electronic screen use and elevated levels of psychosocial stress are two critical channels affecting children's eye health.

Transnational and Transdisciplinary Lessons from the COVID-19 Pandemic

On 7 January 2020, China identified a virus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [...]

Rates of Myopia Development in Young Chinese Schoolchildren During the Outbreak of COVID-19

Importance

During the outbreak of COVID-19, outdoor activities were limited and digital learning increased. Concerns have arisen regarding the impact of these environmental changes on the development of myopia.

Objective

To investigate changes in the development of myopia in young Chinese schoolchildren during the outbreak of COVID-19.

Design, Setting, and Participants

In this observational study, 2 groups of students from 12 primary schools in Guangzhou, China, were prospectively enrolled and monitored from grade 2 to grade 3. Comparisons between the exposure and nonexposure groups were made to evaluate any association between environmental changes during the COVID-19 outbreak period and development of myopia. The exposure group received complete eye examinations in November and December 2019 and November and December 2020. The nonexposure group received examinations in November and December 2018 and November and December 2019.

Main Outcomes and Measures

Changes in cycloplegic spherical equivalent refraction (SER), axial length (AL) elongation, and myopia incidence from grade 2 to grade 3.

Results

Among the 2679 eligible students in grade 2 (mean [SD] age, 7.76 [0.32] years; 1422 [53.1%] male), 2114 (1060 in the nonexposure group and 1054 in the exposure group) were reexamined in grade 3. Compared with the period from November and December 2018 to November and December 2019, the shift of SER, AL elongation, and myopia incidence from grade 2 to grade 3 from November and December 2019 to November and December 2020 was 0.36 D greater (95% CI, 0.32-0.41; P < .001), 0.08 mm faster (95% CI, 0.06-0.10; P < .001), and 7.9% higher (95% CI, 5.1%-10.6%; P < .001), respectively. In grade 3 students, the prevalence of myopia increased from 13.3% (141 of 1060 students) in November and December 2019 to 20.8% (219 of 1054 students) in November and December 2020 (difference [95% CI], 7.5% [4.3-10.7]; P < .001); the proportion of children without myopia and with SER greater than -0.50 D and less than or equal to +0.50 D increased from 31.1% (286 of 919 students) to 49.0% (409 of 835 students) (difference [95% CI], 17.9% [13.3-22.4]; P < .001).

Conclusions and Relevance

In this study, development of myopia increased during the COVID-19 outbreak period in young schoolchildren in China. Consequently, myopia prevalence and the proportion of children without myopia who were at risk of developing myopia increased. Future studies are needed to investigate long-term changes in myopia development after the COVID-19 pandemic.

Examining risk factors related to digital learning and social isolation: Youth visual acuity in COVID-19 pandemic

Background

Around the globe, various self-quarantine, social distancing, and school-closure policies were implemented during the coronavirus disease-19 (COVID-19) outbreak to reduce disease transmission. Many economies/territories were compelled to consider digital learning modalities. In particular, increased digital learning engagement with digital devices and mounting psychosocial stress due to social isolation are likely to pose adverse risks for youth visual health globally. This study examines the association between increased digital device use, psychosocial stress, and myopia symptoms among Chinese youth during the COVID-19 pandemic.

Methods

This is a retrospective observational population study consisting of 3918 participants enrolled in primary, secondary, and university in China. Participants are recruited through an online survey, which included self-reported information on daily digital device use, psychosocial stress level, condition of visual acuity, and demographic information. We utilize statistical tools including χ² test, paired sample t test, and multiple multivariate logistic regression.

Results

Each hour increase in digital device use is associated with 1.25 odds ratio OR (95% confidence interval (CI) = 1.21-1.30; P < 0.001) increased risk of developing myopic symptoms, each additional hour of digital device use weighted by near-view and blue-light exposure is associated with OR = 1.04 OR (95% CI = 1.03-1.05; P < 0.001) and OR = 2.25 (95% CI = 1.94-2.60; P < 0.001) increased risk respectively. Subjects reporting under stressful conditions are between OR = 1.98 (95% CI = 1.67-2.36; P < 0.001) and OR = 2.03 (95% CI = 1.71-2.42; P < 0.001) more likely to develop myopic symptoms, relative to those citing less stress.

Conclusions

The COVID-19 pandemic led to favorable conditions for myopigenic behavioral changes characterized by extended sedentary engagement with digital devices, which are significantly associated with higher risks of myopia incidence. Relatedly, psychosocial stress accompanying prolonged social isolation during the pandemic is a less noticeable, albeit significant risk factor for myopia development.

Student Health Implications of School Closures during the COVID-19 Pandemic: New Evidence on the Association of e-Learning, Outdoor Exercise, and Myopia

The coronavirus disease 2019 (COVID-19) pandemic forced many education systems to consider alternative remote e-learning modalities, which have consequential behavioral and health implications for youth. In particular, increased e-learning engagement with digital screens and reduction in outdoor activities are two likely channels posing adverse risks for myopia development. This study investigated the association between e-learning screen use, outdoor activity, lighting condition, and myopia development among school-age children in China, during the first wave of the COVID-19 pandemic. Data were collected from 3405 school-age children attending primary, lower-secondary, and upper-secondary schools in China. Univariate parametric and nonparametric tests, and multivariate logistic regression analysis were used. Findings show that each diopter hour increase in daily e-learning screen use is significantly associated with progression of myopia symptoms (OR: 1.074, 95% CI: 1.058–1.089; p < 0.001), whereas engaging in outdoor exercise four to six times per week (OR: 0.745, 95% CI: 0.568–0.977; p = 0.034) and one to three times per week (OR: 0.829, 95% CI: 0.686–0.991; p = 0.048) is associated with a lower likelihood of myopia progression than none at all. In addition, we found that indoor lighting that is either “too dim” (OR: 1.686, 95% CI: 1.226–2.319; p = 0.001) or “too bright” (OR: 1.529, 95% CI: 1.007–2.366; p = 0.036) is significantly associated higher likelihood of myopic symptoms. Findings in this study uncover the less observable vision consequences of the COVID-19 pandemic on youths through digital online learning and highlight the importance of considering appropriate mitigation strategies to deal with this emerging public health challenge.

Acute Acquired Concomitant Esotropia From Excessive Application of Near Vision During the COVID-19 Lockdown

The public health measures imposed in many countries to slow the spread of the novel coronavirus (COVID-19) outbreak could have negative effects on children's physical and mental health. The authors describe four cases of acquired concomitant acute esotropia likely caused from excessive application of near vision during the COVID-19 lockdown. [J Pediatr Ophthalmol Strabismus. 2020;57:e88-e91.].