Progression in refractive error in children during COVID-19 pandemic due to virtual classes: A cohort study

Background: The pandemic resulted in increased screen hours in children due to virtual education. The rate of progression of myopia was noticed to be remarkable in the past 2 years. This study is an endeavor to study the effect of increased screen hours during COVID home confinement on the degree of progression of myopia in school children and to evaluate the difference in change of refractive errors with a variation in the screen size of the digital device used. Method(s): This was prospective observational study with a retrospective comparison arm, wherein 70 school children (140 eyes) aged 4-18 years were subjected to a cycloplegic refraction test. The difference in spherical equivalent refraction from the year 2018 to 19 was compared with that of the difference observed in the pandemic year 2019-2020. A statistical analysis was also made regarding the correlation of variation in refraction between the different genders, age groups, and screen sizes. Result(s): Of the 70 children, 29 (41.42%) were girls and 41 (58.58%) were boys. The gadgets being used vary from mobiles to laptops, and the range of screens and sizes varies from 100 cm2 to 500 cm 2. Similarly, the duration of device use varied from 4 to 8 h. For 2018, the mean value of the spherical equivalent was -1.69 +/- 1.42, for 2019 it was -1.92 +/- 1.50 and for 2020 the mean value was -2.61 +/- 1.47 for the right eye. The mean value of the spherical equivalent for the left eye in 2018 was -1.68 +/- 1.51, in 2019 the value was -1.87 +/- 1.58, and in 2020, the mean value was -2.73 +/- 1.78. Conclusion(s): Increased exposure to digital devices during the COVID-19 period has a role to play in the progression of myopia in school-aged children.Copyright © 2023 Authors. All rights reserved.

Myopia risk behaviour related to the COVID-19 lockdown in Europe: The generation R study.

PURPOSE: To battle the spreading of the COVID-19 virus, nationwide lockdowns were implemented during 2020 and 2021. Reports from China revealed that their strict home confinements led to an increase in myopia incidence. The Netherlands implemented a more lenient lockdown, which allowed children to go outside. We evaluated the association between COVID-19 restrictions, myopia risk behaviour and myopia progression in Dutch teenagers. METHOD: A total of 1101 participants (mean age 16.3 ± 3.65 yrs) completed questionnaires about their activities before, during and after lockdown (March-October 2020). We used a repeated-measures ANOVA to compare time use between these time periods. Ocular measurements were acquired before the COVID-19 pandemic when participants were 13 years old; only 242 participants had ocular measurements at 18 years of age at the time of this analysis. Linear regression analyses were used to evaluate the association between lifestyle factors and myopia progression. RESULTS: Children were on average 16.2 (1.03) years of age during lockdown. Total nearwork increased from 8.11 h/day to 11.79 h/day, and remained higher after lockdown at 9.46 h/day (p < 0.001). Non-educational nearwork increased by 2.22 h/day (+49%) during lockdown and was associated with faster axial length progression (B 0.002 mm/h/year; SE 0.001 p = 0.03). Before and during lockdown, the mean time spent outdoors was similar (1.78 h/day and 1.80 h/day, respectively). After lockdown, time spent outdoors decreased to 1.56 h/day (p < 0.001). CONCLUSION: The Dutch lockdown significantly increased digitised nearwork in adolescents but did not affect outdoor exposure. The changes in time spent performing nearwork remained after the lockdown measures had ended. We expect that the COVID-19 pandemic may lead to an increase in myopia prevalence and progression in European children.

Increased Screen Time as a Cause for Further Myopia BoomFollow up Study of School Health Survey

Background: Myopia is a major health issue around the world. The World Health Organization estimates that half of the population of the world may be myopic by 2050. In the present years, insufficient time spent in outdoor activities has been recognized as a major risk factor for myopia development. The duration and intensity of near work are also associated with myopia progression. Aim(s): To study the increase in myopic shift in school going children during covid 19 pandemic due to increased screen time. Material(s) and Method(s): A prospective cross sectional study was done as a follow up after 2 years (in March 2021) from a school health survey done in May 2019. 150 students, of ages 7-15 were included and spherical equivalent refraction was recorded for each child and progression of myopia was documented in dioptres. Children wearing contact lenses, with h/o any ocular surgery and children with pathological myopia were excluded from study. Result(s): Out of 145 children called for follow up, only 123 children reported in the OPD for follow up. The mean refractive error(spherical equivalent) had increased by +2D in children of ages 7-10 and by +1D in children from ages 11-13 and somewhat remained constant in older ages. The parents reported an increase in time spent on digital devices and prolonged near work and all this had a positive correlation with an increase in myopic shift. Conclusion(s): Shorter viewing distance, increased screen time and lesser outdoor activities is also associated with myopia progression, especially in younger children. Younger children's refractive status may be more sensitive to environmental changes than older children, as they are in a more important period for myopic development and progression. Copyright © 2022, Dr Yashwant Research Labs Pvt Ltd. All rights reserved.

Myopia Progression during the COVID-19 Era: A Systematic Review and Meta-analysis.

BACKGROUND: To evaluate myopia progression during the novel coronavirus disease 2019 (COVID-19) pandemic and its risk factors. METHODS: We searched PubMed, Scopus, and Web of Science to find literature until August 2022 related to COVID-19 pandemic and myopia progression. Outcomes of myopia progression included axial length (AL) and spherical equivalent (SE). Factors of screen time and outdoor activity time were analyzed. RESULTS: Thirty-three studies were included in this meta-analysis. Compared to the same period before the COVID-19 pandemic, myopia prevalence increased (OR = 1.11; 95% CI, 1.05-1.18). The outcomes of SE decreased -0.61 diopter (95% CI, -0.98 to -0.23), and AL increased 0.42 mm (95% CI, 0.13-0.7). Mean screen time was increased 6.25 hours/day (95% CI, 4.84-7.66), and outdoor activity time was decreased -1.52 hours/day (95% CI, -3.20 to -0.15). CONCLUSION: Establishing care policies is necessary to restrict behavioral changes and their consequences during the pandemic.

Trends of myopia development among primary and junior school students in the post-COVID-19 epidemic period.

Purpose: To investigate the trends of myopia among primary and junior school students in the post-COVID-19 epidemic period. Method: A prospective of cross-sectional study using spot photoscreenings in 123,538 children among primary and junior school students from 2019 to 2021 was conducted to evaluate the development of myopia in Xuzhou, China in the post-COVID-19 epidemic period. Equivalent refraction and the prevalence of myopia were recorded. Results: The spherical equivalent refraction of myopia decreased across all grades except grade 1 (0.23 ± 0.56 D in 2019, 0.24 ± 0.63 D in 2020) from 2019 to 2020. However, refraction exhibited a hyperopic shift in 2021 compared to 2020 for grades 1-5 (no significant decreased for grade 4). The prevalence of myopia in all grades increased in 2020 compared to 2019, and the most dramatic changes were observed from grades 2-5 and grades 7-8 (P < 0.05). The changes in myopia prevalence in grades 1-4 were mild, and the reduction in myopia for Grade 5 is significant from 2020 to 2021. Nevertheless, students in grades 6 and 9 exhibited the greatest growth in myopia prevalence (P < 0.01). All grades had higher myopia prevalence in 2021 compared with 2019, except grade 1 (P = 0.25). The prevalence of myopia in girls was higher compared with boys, and the urban myopia prevalence was higher than in rural areas over the 3 years except in 2019 (P = 0.18). Conclusions: The prevalence of myopia increased during the COVID-19 epidemic. However, the spherical equivalent refraction of lower grade children drifted to hyperopia and the trends of myopia development remained stable in the post-COVID-19 epidemic period. We should be more concerned about the prevalence of myopia in graduating for the primary or junior grades in the future.

A Cross-Sectional Prevalence Study of Myopia and High Myopia during COVID-19 Pandemic

Purpose : The COVID-19 pandemic has caused societal, behavioral changes that have resulted in increased near work and less outdoor time. These changes may influence myopia progression. We performed a retrospective, cross-sectional prevalence study on the population base in Olmsted County, Minnesota to determine if there are short-term changes in myopia. Methods : Individuals living in Olmsted County who received ophthalmic care at Mayo Clinic Rochester from 2018 to 2021 were analyzed. Exclusion criteria included 1) visually significant cataract, 2) pseudophakia, 3) prior refractive surgery and 4) Age < 6 years. Manifest refractions were converted to spherical equivalent (SE). Patients with a SE ≤ -0.5 D were classified as myopic while SE ≤ -6.0 D were classified with high myopia. Individual age, sex, visual acuity, and lens prescription data were recorded. An algorithm was designed to estimate prevalence for patients without a manifest refraction utilizing their visual acuity, as was used in the NHANES study . Results : We sampled 11,783 invidiual records (8,413 adults;3,370 children). In adults from 2018 to 2021, the prevalence of myopia was similar at 61% vs 59% (p=0.3887) and high myopia was also similar at 10% vs 9.9% (p=0.5447). In children from 2018 to 2021, the prevalence of both myopia was similar at 21% vs 17% (p=0.2) and high myopia was also similar at 2.6% and 3.8% (p=.37). Conclusions : From 2018 to 2021, we did not find any trends in myopia development over a relatively brief, 4-year window in either pediatric or adult patients living in Olmsted County, Minnesota.

Effect of COVID-19 lockdown on refractive errors in children aged 5-12 years: a retrospective study

Purpose : To explore whether the COVID-19 lockdown increased the incidence of myopia among age-school children. Methods : Retrospective study recruiting children aged 5-12. Selection: random. Inclusion criteria: healthy children presenting for an eye exam since 2016. Exclusion criteria: presence of ocular comorbidities other than refractive error, spherical equivalent (SE) less than -4D or greater than +4D, BCVA less than 20/20, blepharoptosis, media opacities, corneal or retinal dystrophies, strabismus, amblyopia, nystagmus, or concurrent therapy with atropine 0.01%. Outcome measure: age measured in months, SE of the right eye (RE) measured in diopters (D) under cycloplegia (cyclopentolate 1%). Statistical analysis: ANOVA, Chi-square, Tukey's test. Significance: p < .05. Results : A total of 803 children. In the years prior to COVID-19, the mean SE ± SD diopters in the RE: 0.54 ± 1.49 D in 2016 (n = 160), 0.43 ± 1.84 D in 2017 (n = 145), 0.34 ± 1.41 D in 2018 (n = 152), 0.35 ± 1.75 D in 2019 (n = 166) (ANOVA, p = .659) (Fig. 1). In 2021 (n = 180), the mean SE was -0.08 ± 1.44 D (ANOVA, p = .005). Using the Tukey's test, the mean SE of 2021 changed by -0.619 D 95% CI [-1.091, -0.147] and -0.501 D 95% CI [-0.986, -0.016] as compared to the SE of 2016 and 2017, respectively (Fig. 2). Mean age was comparable in all groups (ANOVA, p = .307). The decrease of the mean SE of the 2021 group corresponds to an increase in the percentage of myopes (≤-0.5D) and a decrease in the percentage of hyperopes (≥ 2D). Myopes represent the 24.10% of children aged 60-96 months, and 63.86% of children aged 97-144 months. Hyperopes represent 9.64% of children aged 60-96 months, and 6.02% of children aged 97-144 months. This represents 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 the previous years (2016- 2019). Conclusions : 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 (2021). The percentage of myopes has increased significantly, while the percentage of hyperopes has decreased. Children aged 8-12 years showed the greatest refractive change. The lifestyle changes imposed by the lockdown were likely responsible for the increased prevalence of myopia observed in 2021.

The effect of home confinements on myopic risk profile in European adolescents: The Generation R Study

Purpose : To battle the spreading of the COVID-19 virus, all over the world measures like home confinement and nation-wide lockdowns have been implemented at regular intervals. These measures have shown an increase in myopic incidence particularly in China, which applied a very strict lockdown and home confinement. The Netherlands used a so called “intelligent lockdown” which allowed children to go outside. We evaluated the association between COVID restrictions and myopia risk factors in an European cohort of adolescents. Methods : A total of 1101 participants (mean age 16.3 ± 3.65 yrs) of the population-based prospective birth-cohort study Generation R filled in a questionnaire about their behavior before, during, and after lockdown in the Netherlands. These participants had undergone cycloplegic refractive error measurement at 13 years of age. We evaluated time spent outdoors, time spent online (handheld or other devices), time spent on near work (education and non-educational) from March-October 2020 in myopic (spherical equivalent <-0.5D) and non-myopic children. We used a repeated measures ANOVA to compare differences between these time periods, and logistic regression corrected for age, gender, and ethnicity to evaluate differences between myopic and non myopic children. Results : During and after lockdown the children spent signicantly more time online (+113 and +59min/day) on both hand held (+64 and +10 min/day) and other devices (+49 and +7 min/day), and on educational nearwork (+73 and +63min/day). Non-educational near work increased only significantly during lockdown (+176 min/day). Time spent outside did not change significantly and was ±2 hours/day. Children of non-European descent spent more time online (235min/day vs 260 min/day, P= 0.004) and on non-educational near work (452 min/day vs 559 min/day, p=0.0002). We found no significant difference in behavior between myopic and non-myopic children. Conclusions : The Dutch lockdown for COVID increased digitized near work in adolescents, but did not affect outdoor exposure. Children without myopia did not do better than those already myopic. Based on these results, we expect that the COVID pandemic will also lead to an increase in myopia prevalence and progression in European children, but to a lesser extent than in Asia.

Indications and Outcomes of Surgery for High Myopia: STAAR Intraocular Collamer Lens (ICL) vs. LASIK

Purpose : Although the ICL is more invasive than laser-assisted in situ keratomileusis (LASIK), it is indicated for patients with very high myopia, commonly over -7D. ICL is associated with certain risks including cataract and glaucoma which may develop years after surgery requiring additional procedures. In this study, we examined the outcome and safety profile of ICL vs. LASIK at 1 week, 1 month, and 1 year postoperatively. Methods : In this retrospective study, we examined records from a single surgeon (KK) as well as 2 patients with post ICL complications requiring ICL removal. An important aim of this study was to use the 1 year follow up data since this is one of the standard ICL follow up visits. We hypothesized that the FDA approved ICL (2005) would have a comparable target refractive outcome and safety profile when compared to LASIK. Results : There were a total of 45 ICL eyes and 65 LASIK eyes. Preoperatively, ICL patients had a significantly higher manifest refraction spherical equivalent (MRSE) and cycloplegic refraction spherical equivalent (CRSE) than LASIK patients (p<0.05). For patients who received the ICL implants, the average MRSE at 1-week, 1-month, 1-year post-op was -0.37D±(0.13), -0.29D±(0.09), -0.53D±(0.15);and -1.60D±(0.16), -0.36D±(0.15), -0.36D±(0.07) for patients who received LASIK. The differences in post-op MRSE between ICL and LASIK were not statistically significant (p>0.05). The only significant differences were 1 month LogMAR best corrected visual acuity and 1 year LogMAR distance uncorrected visual acuity (p<0.05), in which LASIK had better visual acuity. Common postoperative findings in both groups were refractive target deviations and punctate keratitis. Reoperation rates in the ICL and LASIK groups were 21.4% and 10.8% respectively, which was not statistically significant (p>0.05). 42.6% of ICL patients underwent the procedure during the COVID-19 pandemic compared to 26.2% of LASIK. Conclusions : Our results demonstrate that ICL is safe and effective for patients with high myopia. Although ICL patients had a significantly higher preoperative MRSE compared to the LASIK group, the ICL patients were able to achieve similar refractive targets. There were no cases of glaucoma or cataract at 1 year in the ICL group. In conclusion, ICL surgery is as safe and effective as LASIK surgery in correcting patients with high myopia, regardless of pre-operative refractive error.

Myopia Progression Among School-Aged Children in the Coronavirus (COVID-19) Distance Learning Era

Purpose : To investigate the effect of online learning and other environmental factors on myopia progression during the COVID-19 pandemic. Methods : A retrospective, cohort study on children aged from 6 to 14 years with myopia. Data were gathered from 3 visits;pre-COVID 19, at the beginning of the pandemic, and during the pandemic. Patients' demographics (number of hours spent on screens for educational and recreational purposes, type of screen used, and number of hours spent outdoors), best corrected visual acuity (BCVA), uncorrected visual acuity (UCVA), and cycloplegic refraction to quantify spherical equivalent (SE) were measured for all participants. Progression of myopia was calculated based on difference between the three visits. Results : One hundred and fifty patients met our inclusion criteria. Mean age was 11±2.4 years. There were 70 males (47%). They mainly used mobile phones (62%) and had insufficient outdoor play (88%). Out of 300 eyes, 221 (74%) had progression in myopia. A significant difference was found in SE between pre-COVID-19 (-0.29 ±0.23) and post-COVID-19 (-0.40 ±0.11) with a p-value of 0.023. Additionally, UCVA showed difference between the initial Vs. 1st follow-up visit (0.57±0.37 vs 0.64±0.36, p-value =0.001), and first follow-up visit Vs. 2nd follow-up visit (0.64±0.36 vs 0.70±0.36, p-value =0.001). Survival analysis showed significant hazard ratio on change in SE for high age group (>9 years), (HR [95% CI], 0.71 [0.51-0.84]), recreational screen usage (HR [95% CI], 1.26 [1.15-1.66]) and insufficient outdoor time (HR [95% CI], 1.45 [1.35-1.67]). Conclusions : Myopia progression was accelerated compared to pre-COVID-19 times in terms of spherical equivalent. Younger age group, prolonged screen users and insufficient outdoor time contributed to the further increase in myopia. However, the type of device had no effect statistically on the progression of myopia.

Progression of Vision in Chinese School-Aged Children Before and After COVID-19.

Objectives: To investigate the changes of vision, including the prevalence of myopia, hyperopia, poor vision, and the spherical equivalent refraction (SER), in school-aged children before and after the pandemic of Coronavirus Disease 2019 (COVID-19). Methods: A school-based vision screening study was performed on children in 133 primary schools in Wuhan. This study was conducted in 4 consecutive years (2018-2021). Results: A total of 468,094 children (936,188 eyes) were recruited, 255,863 (54.7%) were boys. The SER decreased in 2020 compared to other years after the age of 10. A positive myopia shift was found in younger children aged 6 (0.1 D), 7 (0.05D), and 8 (0.03 D) in 2020 compared to 2019. The progression of vision has improved slightly in 2021. Among the students included in the study, 33.7% were myopia. Conclusion: The vision of older children decreased significantly during the COVID-19. After the pandemic, there is still a high risk for them. In the future, the focus on vision prevention and control should move forward to preschool children.

Trends in Myopia Development Among Primary and Secondary School Students During the COVID-19 Pandemic: A Large-Scale Cross-Sectional Study.

Objectives: To evaluate myopia development among primary and secondary school students during the coronavirus 2019 (COVID-19) pandemic. Methods: A cross-sectional study was conducted to evaluate the development of myopia among students in Shenzhen, China during the COVID-19 outbreak. Results: The study included 1,472,957 and 1,573,824 students in 2019 and 2020, respectively. The prevalence of myopia was 46.9 and 50.5% in 2019 and 2020, respectively. The prevalence of myopia among students in the former Shenzhen Special Economic Zone (SEZ) was higher than that in areas outside the former Shenzhen SEZ (2019: 47.0 vs. 43.7%; 2020: 50.5 vs. 47.3%). The prevalence of myopia among girls was higher than that among boys (2019: 50.4 vs. 44.0%; 2020: 54.0 vs. 47.6%). The 50th percentile (P50) of spherical equivalent refraction (SER) in the right eye among girls was lower than that in boys. The prevalence of myopia continued to increase as the grade increased, with the greatest annual increase observed in Grades 2-5 (3.4-3.9%). The P50 of SER in the right eye of students decreased as the grade increased. Conclusions: The prevalence of myopia among students increased during the COVID-19 pandemic, especially in primary school Grades 2-5.

Progression of myopia in a natural cohort of Chinese children during COVID-19 pandemic.

PURPOSE: To determine myopia progression in children during the COVID-19 and the related factors associated with myopia. METHODS: All subjects underwent three-timepoint ocular examinations that were measured in July 2019, January, and August 2020. We compared the changes in uncorrected visual acuity (UCVA), mydriatic spherical equivalent (SE), and axial length (AL) between two periods (before and during COVID-19). A questionnaire was performed to investigate risk factors for myopia. RESULTS: Compared with before the COVID-19, the mean (S.D.) myopia progression during the COVID-19 was significantly higher in right eyes (- 0.93 (0.65) vs. - 0.33 (0.47) D; p < 0.001). However, the differences in UCVA changes and the axial elongation between two periods were clinically insignificant. Through logistic regressive analysis, we found the difference of the SE changes was associated with the baseline AL (P = 0.028; 95% confidence interval [CI], 1.058, 2.632), online education (P = 0.02; 95% CI, 1.587, 8.665), and time of digital screen (p < 0.005; 95% CI, 1.587, 4.450). CONCLUSIONS: Children were at higher risk of myopia progression during COVID-19, which was associated with the baseline AL, the longtime online learning, and digital screen reading.