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.