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.