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      Prevalence of myopia and high myopia, and the association with education: Shanghai Child and Adolescent Large-scale Eye Study (SCALE): a cross-sectional study

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          Abstract

          Objectives

          To report on: (a) overall myopia and high myopia prevalence, and (b) the impact of education on the spherical equivalent refractive error in children across Shanghai.

          Design

          Cross-sectional study.

          Setting

          Across all 17 districts of Shanghai.

          Participants

          910 245 children aged 4–14 years from a school-based survey conducted between 2012 and 2013.

          Main outcome measures

          Data of children with non-cycloplegic autorefraction, visual acuity assessment and questionnaire were analysed (67%, n=6 06 476). Prevalence of myopia (≤−1.0 D) and high myopia (≤−5.0 D) was determined. We used a regression discontinuity design to determine the impact of school entry cut-off date (1 September) by comparing refractive errors at each age, for children born pre-September to post-1 September, and performed a multivariate analysis to explore risk factors associated with myopia. Data analysis was performed in 2017–2018.

          Results

          Prevalence rates of myopia and high myopia were 32.9% (95% CI: 32.8% to 33.1%) and 4.2% (95% CI: 4.1% to 4.2%), respectively. From 6 years of age onwards, children born pre-September were more myopic compared with those born post-1 September (ahead in school by 1 year, discontinuity at 6 years: −0.19 D (95% CI: −0.09 to −0.30 D); 14 years: −0.67 D (95% CI: −0.21 to −1.14 D)).

          Conclusions

          Our findings suggest that myopia is associated with education, that is primarily focused on near-based activities. Efforts to reduce the burden should be directed to public awareness, reform of education and health systems.

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          Most cited references27

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          Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050.

          Myopia is a common cause of vision loss, with uncorrected myopia the leading cause of distance vision impairment globally. Individual studies show variations in the prevalence of myopia and high myopia between regions and ethnic groups, and there continues to be uncertainty regarding increasing prevalence of myopia.
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            Myopia

            The Lancet, 379(9827), 1739-1748
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              The epidemics of myopia: Aetiology and prevention.

              There is an epidemic of myopia in East and Southeast Asia, with the prevalence of myopia in young adults around 80-90%, and an accompanying high prevalence of high myopia in young adults (10-20%). This may foreshadow an increase in low vision and blindness due to pathological myopia. These two epidemics are linked, since the increasingly early onset of myopia, combined with high progression rates, naturally generates an epidemic of high myopia, with high prevalences of "acquired" high myopia appearing around the age of 11-13. The major risk factors identified are intensive education, and limited time outdoors. The localization of the epidemic appears to be due to the high educational pressures and limited time outdoors in the region, rather than to genetically elevated sensitivity to these factors. Causality has been demonstrated in the case of time outdoors through randomized clinical trials in which increased time outdoors in schools has prevented the onset of myopia. In the case of educational pressures, evidence of causality comes from the high prevalence of myopia and high myopia in Jewish boys attending Orthodox schools in Israel compared to their sisters attending religious schools, and boys and girls attending secular schools. Combining increased time outdoors in schools, to slow the onset of myopia, with clinical methods for slowing myopic progression, should lead to the control of this epidemic, which would otherwise pose a major health challenge. Reforms to the organization of school systems to reduce intense early competition for accelerated learning pathways may also be important.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2021
                23 December 2021
                : 11
                : 12
                : e048450
                Affiliations
                [1 ]Shanghai Eye Disease Prevention and Treatment Center, Shanghai Eye Hospital; Shanghai Vision Health Center & Shanghai Children Myopia Institute , Shanghai, China
                [2 ]Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University; National Clinical Research Center for Eye Diseases;Center of Eye Shanghai Key Laboratory of ocular fundus diseases; Shanghai Engineering Center for Visual Science and Photomedicine , Shanghai, China
                [3 ]Brien Holden Vision Institute; School of Optometry and Vision Science, University of New South Wales , Sydney, New South Wales, Australia
                Author notes
                [Correspondence to ] Professor Xun Xu; drxuxun@ 123456sjtu.edu.cn ; Dr Haidong Zou; zouhaidong@ 123456hotmail.com ; Dr Jianfeng Zhu; jfzhu1974@ 123456hotmail.com

                XH and PS are joint first authors.

                Author information
                http://orcid.org/0000-0003-4250-0356
                http://orcid.org/0000-0002-5866-4446
                http://orcid.org/0000-0002-6831-7560
                http://orcid.org/0000-0002-4246-4343
                Article
                bmjopen-2020-048450
                10.1136/bmjopen-2020-048450
                8710858
                34949607
                dd80f3fd-6691-4927-a500-bdc589902eff
                © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

                History
                : 03 January 2021
                : 20 October 2021
                Funding
                Funded by: Three-year Action Program of Shanghai Municipality for Strengthening the Construction of the Public Health System (2011-2013);
                Award ID: 2011-15
                Funded by: High-end Research Team–Eye Health in Shanghai;
                Award ID: GWTD2015S08
                Funded by: Key Discipline of Public Health –Eye health in Shanghai;
                Award ID: 15GWZK0601
                Funded by: FundRef http://dx.doi.org/10.13039/100011779, Brien Holden Vision Institute;
                Funded by: Municipal Human Resources Development Program for Outstanding Young Talents in Medical and Health Sciences in Shanghai;
                Award ID: 2017YQ019
                Categories
                Ophthalmology
                1506
                1718
                Original research
                Custom metadata
                unlocked

                Medicine
                ophthalmology,public health,epidemiology
                Medicine
                ophthalmology, public health, epidemiology

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