Clinical science

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Progression of myopia in teenagers and adults: a
nationwide longitudinal study of a prevalent cohort
Alexandre Ducloux,1 Simon Marillet,1,2 Pierre Ingrand,2 Mark A Bullimore,3
Rupert R A Bourne  ‍ ‍,4 Nicolas Leveziel  ‍ ‍1,4

1
Ophthalmology, CHU Poitiers, ABSTRACT estimated that myopia affects around half of young
Poitiers, France Background  The prevalence of myopia is increasing adults in the USA and Europe.10 Concurrently, the
2
Public Health Department,
University of Poitiers, Poitiers, worldwide. The purpose of this study was to evaluate the prevalence of high myopia is increasing globally,
Nouvelle-­Aquitaine, France progression of myopia in teenagers and adults in France. reaching up to 20% among Taiwanese students.11
3
Optometry, University of Methods  This nationwide prospective study followed In Europe, myopia prevalence has also increased
Houston College of Optometry, 630 487 myopic adults and teenagers (mean age in lesser proportion, and higher prevalence has
Houston, Texas, USA been reported for younger adults,12 13 with one
4 43.4 years±18.2, 59.8% of women) between January
Postgraduate Medical Institute,
Anglia Ruskin University Vision 2013 and January 2019. Myopia and high myopia population-­based study conducted in the UK even
and Eye Research Institute, were defined as a spherical equivalent less than or showing almost a doubling of myopia prevalence in
Cambridge, UK equal to –0.50 and –6.00 diopters (D), respectively. teenagers within a few decades, although the prev-
Demographic data were collected at first visit and alence in final year high school students was less
Correspondence to refractive characteristics were collected at each visit. than 20%.14
Dr Nicolas Leveziel, The myopia epidemic has significant socio-
Analysis of short-­term progression (first 12 to 26 months
Ophthalmology, CHU Poitiers,
Poitiers, France; postbaseline) was modelled using analysis of variance economic consequences, due not only to the cost
​nicolas.​leveziel@y​ ahoo.​fr (ANOVA). Progression of myopia was stratified according of optical corrections15 but also to the burden of
to age, gender and spherical equivalent at first visit. myopia complications, which can occur at a rela-
AD and SM contributed equally. Results  Higher proportions of progressors were tively early age with possible consequential loss of
Received 28 April 2021 observed in the youngest age groups: 14–15 (18.2 %) productivity.16 Indeed, myopic choroidal neovascu-
Accepted 12 November 2021 and 16–17 years old (13.9 %). In multivariate analysis, larisation frequently occurs at middle age17 while
after adjustment for over age, spherical equivalent and retinal detachment and glaucoma are more frequent
gender, the mean short-­term progression decreased from among high myopic patients compared with non-­
–0.36 D in the 14–15 years age group to –0.13 D in the myopes and frequently occur at a younger age.18 19
28–29 years age group. Young age and higher myopia at While myopia can also progress during early
baseline together were strongly associated with the risk adulthood, which is a concern for myopic patients
of developing high myopia, the 5-­year cumulative risk wishing to have refractive surgery, data on myopia
being 76% for youngest teenager with higher myopia progression in teenagers and young adults are
status at baseline. scarce in Europe.20 21 The purpose of this study was
Conclusion  In this large cohort of myopic teenagers to evaluate the progression of myopia in European
and adults, myopia progression was reported in 18.2% teenagers and in adulthood as a function of age,
and 13.9% of the 14–15 and 16–17 age groups, gender and degree of myopia at initial presentation.
respectively. The risk to develop high myopia was higher
for younger individuals with higher myopia at baseline
examination. MATERIALS AND METHODS
Study population
Data files were collected from 696 opticians located
in different regions of France. The full data set
INTRODUCTION included year of birth, gender, date of prescrip-
Myopia, defined as refractive error equal or infe- tion performed by the ophthalmologist, sphere and
rior to –0.50 diopters (D), is a major cause of cylinder measured by the ophtalmologist, type of
vision impairment and blindness due to uncor- prescription (spectacles or contact lenses) and type
rected refractive error or by complications related of correction (mainly near vision, distance vision
to myopia. Indeed, uncorrected refractive errors or progressive glasses) over a period from January
are the leading cause of moderate to severe visual 2013 to January 2019.
© Author(s) (or their impairment worldwide,1 including high-­ income Even in the case of correction renewal by the opti-
employer(s)) 2021. Re-­use countries and some other European countries.2 cian for various reasons, including broken glasses
permitted under CC BY-­NC. No Myopia is also a risk factor for various pathol- or desire to change glasses, the new correction was
commercial re-­use. See rights
and permissions. Published ogies such as glaucoma,3 cataract,4 retinal detach- available in the data set used for the analyses.
by BMJ. ment5 and myopic maculopathy.6 The latter has The analysis used data from the right eyes of
been reported to affect 0.5% of Germans aged myopic individuals aged 14 years and over. Files
To cite: Ducloux A,
35–74 years7 and 3.8% of older Singaporean adults with missing data for the right eye, gender or
Marillet S, Ingrand P, et al.
Br J Ophthalmol Epub ahead (mean age 57.2 years).8 age were, therefore, excluded from the analyses.
of print: [please include Day In East Asia, myopia affects 80% to 90% of Patients who were likely to have undergone intra-
Month Year]. doi:10.1136/ young adults.9 Western countries are not spared ocular surgery or refractive surgery, based on the
bjophthalmol-2021-319568 from the so-­called ‘myopia boom’ and studies have observation of major refractive changes observed
Ducloux A, et al. Br J Ophthalmol 2021;0:1–6. doi:10.1136/bjophthalmol-2021-319568 1
 Clinical science

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intervals between visits were aggregated into 6-­month intervals
to evaluate the mean myopia progression during the follow-­up.
Progression rates were expressed in diopters per year (D/y).
Analysis of progression values was stratified according to age at
first visit, gender and SE at first visit.
The p values displayed when comparing proportions of
progressors were computed using logistic regression to model
‘progressor status’ described above. Covariates were age group,
SE at baseline and gender.
We modelled progression during the first 12–24 months with
a univariate and multivariate analysis of variance (ANOVA).
Covariates included age group, SE at first prescription and
gender.
Average progression rates were computed using an ANCOVA
with age as covariate and continuous time between two prescrip-
tions as the main regressor. Progression rates were expressed in
D/y.
We estimated the cumulative probability of developing high
myopia using Kaplan-­Meier estimators stratified over age and SE
at baseline. We used a multivariate Cox model to compute the
multivariate HRs of the age and SE classes and gender as well.
All analyses were performed with SAS/STAT software, V.9.4 of
the SAS System for Windows. Copyright 2016 by SAS Institute.

RESULTS
Demographic and refractive data
The full data set included 630 487 myopes (59.8% of women)
with mean age of 43.4 years±18.2 and mean SE of –2.8±2.3 D.
Among them, 167 204 individuals belonged to the 14–29 year
age group (61.5% of women) with mean age 21.4 years±4.7 and
mean SE equal to –2.7±2.1 D.
Demographic and SE distributions of the cohort at baseline
and progression status are detailed in table 1.
Figure 1  Flowchart of study patients. SE, spherical equivalent. Median follow-­up was 3.1 years. Follow-­up duration was ≥2
years, ≥3 years, ≥4 years and  ≥5 years for 505 501 (80.2%),
335 309 (53.2%), 197 029 (31.3%) and 86 074 (13.7%) partic-
between two visits, were also excluded. The study flowchart ipants, respectively. For the 14–29  year age group, median
is presented in figure 1. Individuals with at least two optical follow-­up was 2.9 years. Follow-­up duration was  ≥2 years,
corrections separated by at least 1 year were selected. ≥3 years, ≥4 years and ≥5 years for 123 768 (74.0%), 78 805
(47.1%), 44  857 (26.8%) and 19  602 (11.7%) participants,
Definitions respectively.
Myopia was defined as a spherical equivalent (SE) less than or
equal to –0.50 D22 and high myopia by a SE ≤ –6.00 D. Progression of myopia as a function of age at baseline visit
Progressors were defined as individuals with a mean rate of The overall proportion of progressors was 7.8%. A higher propor-
progression of myopia exceeding –0.50 D per year in the period tion of progressors was observed in the younger (14–29 year)
between baseline and a second prescription within 12 and 26 age groups, with proportion of progressors values ranging
months after baseline. Individuals without prescription in this from 18.2% to 13.0% between the 14–15 and 18–19 year age
period were excluded from the corresponding analyses but were groups. Other groups with a high proportion of progressors
included for longitudinal analysis. This duration represents the were the 65–69, 70–74, 75–79, 80–84 and 85–100 age groups,
usual duration between prescriptions. We focus on this short with proportions of progressors being 11.1%, 12.7%, 12.6%,
period to define progressors and progression rates because 10.6% and 12.9%, respectively. The proportion of progres-
computing an average progression over the full 7 years implies sors also varied across SE groups (p<0.0001) and was highest
the assumption of a linear progression, which is not supported among individuals with SE ≤ –6.00 D in both age subgroups
by the literature. However, the mean myopia progression was (15.3% and 8.7% in the 14–29 and the 30–100 groups, respec-
also evaluated during the follow-­up of each individual, by the tively). Finally, although the proportion of progressors differed
difference of refractive error between the baseline examination significantly between genders in both age subgroups, myopia
and the final examination. progressed more among women in the 14–29 year age group.
These data results are detailed in table 2.
Statistical analysis The highest proportion of progressors was observed when
Age of myopia incidence was unknown in this cohort. The first combining younger age and higher myopia at baseline. Indeed,
prescription for myopia correction within the study window more than 20% of individuals aged 14–15 years with myopia ≤
was considered as the baseline for study purposes and subse- –4.00 D at baseline were progressors. These data are detailed in
quent visits were used to quantify progression over time. Time table 3.
2 Ducloux A, et al. Br J Ophthalmol 2021;0:1–6. doi:10.1136/bjophthalmol-2021-319568
 Clinical science

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Table 1  Demographic and refractive characteristics of the cohort Table 2  Proportion (%) of progressors by age and SE at baseline
Age Gender Sphere and gender
Age N (mean±SD) (female, %) (mean±SD) Prescription between 12 and
All 630 487 43.4±18.2 59.8 −2.8±2.3 Total 26 months Progressors
14–19 64 600 16.4±1.7 57.9 −2.5±2.0 N N % N % p
20–24 49 902 22.0±1.4 64.0 −2.8±2.2 Age 14–29 167 204 87 631 52.4 10 190 11.6
25–29 52 702 27.0±1.4 63.4 −2.9±2.3 Age <0.0001
30–34 54 562 32.0±1.4 62.9 −3.0±2.4  14–15 23 463 16 124 68.7 2934 18.2
35–39 53 164 37.0±1.4 61.8 −2.9±2.4  16–17 21 093 13 880 65.8 1936 13.9
40–44 62 397 42.1±1.4 60.8 −2.8±2.4  18–19 20 044 11 299 56.4 1468 13.0
45–49 67 313 47.0±1.4 58.6 −2.8±2.5  20–21 19 994 9996 50.0 1020 10.2
50–54 56 184 51.9±1.4 56.8 −2.9±2.6  22–23 19 867 9325 46.9 898 9.6
55–59 44 617 56.9±1.4 55.9 −3.0±2.6  24–25 20 522 9094 44.3 726 8.0
60–64 35 988 61.9±1.4 55.5 −3.0±2.5  26–27 20 953 9052 43.2 643 7.1
65–69 29 937 66.9±1.4 56.2 −2.7±2.2  28–29 21 268 8861 41.7 565 6.4
70–74 19 810 71.9±1.4 55.8 −2.3±1.9 SE <0.0001
75–79 17 240 77.0±1.4 59.3 −2.0±1.7 ]−1 ; −0.5]
  32 387 17 059 52.7 1704 10.0
80–84 13 665 81.8±1.4 64.2 −1.9±1.5 ]−2 ; −1]
  47 008 24 339 51.8 2720 11.2
85–100 8406 87.6±2.5 69.3 −2.0±1.5 ]−3 ; −2]
  30 872 16 035 51.9 1794 11.2
30–100 463 283 51.4±14.3 59.2 −2.8±2.4 ]−4 ; −3]
  20 758 11 015 53.1 1313 11.9
With progression 178 886 51.2±14.6 61.7 −2.8±2.4 ]−5; −4]
  13 853 7327 52.9 943 12.9
status ]−6; −5]
  8862 4808 54.3 637 13.2
14–29 167 204 21.4±4.7 61.5 −2.7±2.1 ≤−6
  13 464 7048 52.3 1079 15.3
With progression 87 631 20.6±4.7 63.0 −2.7±2.2 Gender <0.0001
status
 F 102 794 55 178 53.7 6461 11.7
With mild or 153 740 21.3±4.7 61.6 −2.2±1.4
 M 64 410 32 453 50.4 3729 11.5
moderate myopia
Age 30–100 463 283 178 886 38.6 10 549 5.9
Progression status is defined for individuals with a prescription between 12 and 26
months after baseline. Mild or moderate myopia is defined as an SE > –6.00 D. Age <0.0001
SE, spherical equivalent.  30–34 54 562 21 646 39.7 1045 4.8
 35–39 53 164 20 574 38.7 813 4.0
 40–44 62 397 25 222 40.4 1058 4.2
When focusing on the 14–29 year age group, mean myopia  45–49 67 313 28 127 41.8 1147 4.1
progression during 12 to 26 months postbaseline decreased  50–54 56 184 20 671 36.8 765 3.7
progressively from –0.35 D in the 14–15 year age group to –0.13  55–59 44 617 15 449 34.6 686 4.4
D in the 28–29 year age group (table 4).  60–64 35 988 12 069 33.5 859 7.1
Decreasing rates of myopia progression with greater age  65–69 29 937 10 895 36.4 1214 11.1
were also observed over the full 6.5 years period (figure 2). In  70–74 19 810 7863 39.7 998 12.7
multivariate analysis, age appeared to be the major determinant  75–79 17 240 6926 40.2 876 12.6
of myopia progression. For the 14–15 year age group, mean  80–84 13 665 5616 41.1 596 10.6
myopia progression was –0.36 D. To a lesser degree, higher  85–100 8406 3828 45.5 492 12.9
myopia at baseline and female gender were other determinants SE <0.0001
of myopia progression. Although the highest myopes had the
]−1; −0.5]
  91 612 36 303 39.6 1984 5.5
greatest proportion of progressors, their mean progression rate
]−2; −1]
  129 631 49 526 38.2 2837 5.7
was no higher than in other groups (table 4).
]−3; −2]
  80 547 30 744 38.2 1652 5.4
]−4; −3]
  54 998 21 237 38.6 1172 5.5
Development of high myopia
]−5; −4]
  36 563 13 729 37.5 778 5.7
When combining a younger age at baseline and higher myopic
]−6; −5]
  25 029 9727 38.9 585 6.0
status, the 5-­year cumulative risk of development of high myopia
≤−6
  44 903 17 620 39.2 1541 8.7
reached 76%. For the age group 19–23 with higher myopic
status, the risk to develop high myopia was 58%. These data are Gender <0.0001
detailed in figure 3.  F 274 053 110 345 40.3 6260 5.7
 M 189 230 68 541 36.2 4289 6.3
DISCUSSION Progressors are individuals with a progression rate of more than −0.50 diopters per
This cohort study focused on myopia progression in a large data year in the first 12–26 months after baseline. Multivariate logistic regression type III
p-­values are displayed.
set of myopic individuals (n=6 30 487) followed over a 7-­year
SE, spherical equivalent.
period.
We reported a higher proportion of progressors in the younger
age groups with proportions ranging from 18.2% in the 14–15 of myopia (table 4). A higher proportion of progressors was also
age group to 6.4% in the 28–29 year age group (table 2). Further- observed after 65 years of age. This is likely to be explained by
more, the current study showed that the most important risk the occurrence of nuclear cataract, which tends to modify the
factor for myopia progression is younger age rather than degree refractive index of the lens towards myopia. The definition of
Ducloux A, et al. Br J Ophthalmol 2021;0:1–6. doi:10.1136/bjophthalmol-2021-319568 3
 Clinical science

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Table 3  Proportion (%) of progressors in younger age subgroup
(14–29 N=87 631) by age and SE at baseline
Age 14–15 16–17 18–19 20–21 22–23 24–25 26–27 28–29 Total
SE
]−1 ; −0.5] 14.9 11.7 11.0 7.1 7.7 6.7 5.7 5.3 10.0
]−2 ; −1] 17.0 13.7 13.7 9.4 8.6 7.6 6.2 5.3 11.2
]−3 ; −2] 19.1 13.4 12.0 9.3 9.2 7.3 6.2 6.2 11.2
]−4 ; −3] 19.1 15.0 12.6 12.0 9.8 8.0 7.4 6.2 11.9
]−5; −4] 20.4 15.6 15.2 13.0 10.3 10.4 7.9 6.0 12.9
]−6; −5] 22.9 16.0 14.1 14.1 13.4 7.8 7.9 8.4 13.3
≤ −6 27.4 18.9 16.0 13.6 13.8 10.5 11.7 10.1 15.3
Total 18.2 14.0 13.0 10.2 9.6 8.0 7.1 6.4 11.6
Progressors are individuals with a progression rate of more than –0.5 diopters per year in
the first 12–26 months after baseline.
SE, spherical equivalent.

progressors adopted in the current study (mean rate of progres-

sion exceeding –0.50 D/y) was consistent with the definition Figure 2  Average progression of myopia (in diopters) according to
provided in the report of the joint WHO—Brien Holden Vision age in the younger subgroup (14–29, N=167 204). Values between
Institute Global Scientific Meeting on myopia published in 2015. parentheses indicate the average progression rate over the 6.5 years
This study completes data from a recent study focusing on period in diopters per year.
the progression of myopia among myopic children.23 Large data
sets on progression of myopia in European teenagers and young
therefore, that most reported an annual progression ranging
adults are scarce, but there are a number of small university-­
from –0.18 to –0.71 D/y, which is higher than in the present
based studies worthy of mention. The study design, sample size,
study. On the contrary, the annual myopia progression observed
mean follow-­up and mean annual myopia progression of these
in our study is very similar to that reported by Polling et al,21
studies are summarised in table 5.
probably because of similar sample selection. In a less selective
Most of these studies were mainly conducted on university
group, Pärssinen et al reported 20-­year follow-­up data from a
students, a selected group, while the profile of young individuals
longitudinal study that began in 240 myopic children aged 8–12
included in the current study was likely to be closer to that of the
years.20 Adult progression data were available from 147 subjects.
general population for the same age group. It is not surprising,
Mean myopic progression over 8 years of persons with ages
exceeding 20–24 years was –0.45±0.71 D with 45% of subjects
progressing at least –0.50 D.
Table 4  Progression of myopia (in diopters) between 12 and 26
Few studies have followed progression in myopic children
months according to age, spherical equivalent at baseline and gender:
into their college years, the exception being the Correction of
univariate and multivariate analysis in the 14–29 age subgroup
Myopia Evaluation Trial.24 Data from 440 of the original 469
(N=87 631)
participants with at least 6 years of follow-­up and at least seven
Univariate Multivariate refraction measurements after the age of 11 years were anal-
Progression Progression p ysed. Among these, age and refractive error at myopia stabilisa-
Age     <0.0001 tion could be established in 426 participants. The mean age at
 14–15 −0.35 (−0.36; −0.34) −0.36 (−0.37; −0.36) myopia stabilisation (defined as the age at which the estimated
 16–17 −0.29 (−0.30; −0.29) −0.31 (−0.31; −0.30) spherical refractive error was within 0.50 D of the asymp-
 18–19 −0.27 (−0.28; −0.26) −0.28 (−0.29; −0.27) tote) was 15.6±4.2 years, and the mean amount of myopia at
 20–21 −0.24 (−0.25; −0.23) −0.24 (−0.25; −0.23)
 22–23 −0.22 (−0.23; −0.21) −0.23 (−0.24; −0.22)
 24–25 −0.18 (−0.19; −0.17) −0.19 (−0.20; −0.18)
 26–27 −0.16 (−0.17; −0.15) −0.17 (−0.18; −0.16)
 28–29 −0.13 (−0.14; −0.12) −0.13 (−0.14; −0.12)
SE     <0.0001
 −1 to −0.5 −0.21 (−0.22; −0.20) −0.18 (−0.19; −0.17)
 −2 to −1 −0.24 (−0.25; −0.24) −0.22 (−0.23; −0.22)
 −3 to −2 −0.25 (−0.25; −0.24) −0.23 (−0.24; −0.22)
 −4 to −3 −0.26 (−0.27; −0.25) −0.24 (−0.25; −0.23)
 −5 to −4 −0.27 (−0.28; −0.26) −0.26 (−0.27; −0.25)
 −6 to −5 −0.26 (−0.28; −0.25) −0.26 (−0.27; −0.25)
 ≤ −6 −0.28 (−0.29; −0.27) −0.27 (−0.29; −0.26)
Sex     <0.0001
 F −0.25 (−0.25; −0.24) −0.25 (−0.25; −0.24)
 M −0.24 (−0.25; −0.24) −0.23 (−0.24; −0.23) Figure 3  Kaplan-­Meier estimations of the 5 year cumulative
Multivariate ANOVA type III p-­values are displayed. probability to develop high myopia stratified by age and SE at baseline
ANOVA, analysis of variance. in the younger subgroup (14–29, N=153 740). SE, spherical equivalent.
4 Ducloux A, et al. Br J Ophthalmol 2021;0:1–6. doi:10.1136/bjophthalmol-2021-319568
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stabilisation was –4.87±2.01 D. While progression rates were
not specified, a companion paper presented a graph of mean
refractive error as a function of age.25 Digitisation of these data

–0.50 D/y (children≤10 y)

–0.19 D/y (for 13–15 y)
–0.09 D/y (for 16–18 y)
–0.08 D/y (for 19–21 y)

–0.16 D/y (for 14–15 y)

–0.13 D/y (for 16–17 y)
–0.10 D/y (for 18–19 y)
–0.08 D/y (for 20–21 y)
reveals a mean progression rate of –0.16, –0.08 and –0.03 D/y
Mean annual myopia

in 14–15, 16–17 and 18–19 year olds, respectively. While the

progression rate at the youngest age was similar to that in the

–0.31 D/year*

–0.71 D/year†
present study, the rates in the two older age groups were slower.
Duration follow-­up (years) progression

–0.63 D/year
Many studies have been conducted in Asian countries, usually
–0.23 D/y
–0.22 D/y
–0.20 D/y
–0.18 D/y
► in children, because myopia progresses more rapidly in paedi-
►
►
►

►
►
►
►
atric populations and because the burden of myopia currently
represents a major public health concern.26–28 A number of
reasons help to explain the apparent discrepancy of myopia
1–22 years (mean 5.8)

progression between Asian and Caucasian populations. Indeed,

7 years (mean 2.9)

major differences in terms of environmental pressure could
explain some degrees of divergence. In other terms, a larger
number of progressors in East Asian populations, for example,
5 years

environmental exposure, could contextualise the so-­ called

2.5

‘myopia boom’ observed in that part of the world and the

*
3
†
†

higher prevalence of myopia compared with that reported in

Children and young adults up to 21

Teenagers and young adults (21.4)

European populations.
If environmental,29 optical30 and pharmacologic31 approaches
may help to reduce the progression of myopia in young people,
particularly in the 7–12 year age group, which is more prone to
progress, these strategies are minimally effective in adults and are
12 and 17 years

likely to have little or no impact on the final degree of myopia.

Mean age

5–16 (9.3)
(years)
17–21

6–15
20.6
23.1
18.3

Strengths and limitations of this study

The strength of this study consists in large sample size and longi-
(for 14–29 years)

tudinal design, providing original data on progression of myopia

Sample size

in teenagers and adults in different age groups, by level of

167 204

myopia at baseline and by gender. We also observed that myopia

2053
2555

2760
7560
3070
497
224
143

progression towards high myopia represented 45% of the more

myopic individuals aged 24–29 at baseline (figure 3), a result
Retrospective

Retrospective

showing that if myopia progresses more among children, young

Prospective
Prospective
Prospective

Prospective
Prospective
Prospective
Prospective

adults are also, although in a lesser manner, affected by progres-

Design

sion of myopia. To our knowledge, this is the largest longitudinal

study on the progression of myopia in Europe. With its focus on
Children (prescription from opticians) (Netherlands)

teenagers and young adults, it provides new information that

may contribute to better understanding and anticipation of the
magnitude of this public health problem, because higher myopia
First year medical students (Danemark)

prevalence means higher prevalence of myopia-­related ocular

Table 5  Studies on myopia progression in teenagers and young adults

complications.32
Engineering Norwegian students

We acknowledge several limitations in this study. When speaking

Teenagers and adults (France)
Population-­based (Australia)

of progression of myopia, we only included individuals presenting

School-­based (Hong Kong)
Population-­based (China)
Medical students (China)

for new prescriptions; persons with no correction and those who did
not renew their correction during the study period were excluded
US Air Force cadets

*In the population of children aged 12 years at first examination.

from the analysis. Furthermore, people with stable corrections would

Population

be less likely to renew them, potentially leading to overestimation of

progression rates. There were also missing data due to change of
optician. In this context, a nation wide database would be very useful
to avoid loss of data for that reason. In addition, the study design
prevented us from estimating the frequency of adult-­onset myopia.
Indeed, a low myope presenting during the study period may have
been either a new myope or an existing myope. While the means
Jacobsen, Jensen and Goldschmidt35

of determination of refractive status—with or without cycloplegia—

Polling, Klaver and Tideman21

†For myopic eyes at baseline.

was not provided in the data set, in accordance with national recom-
mendations cycloplegia is usually used in children and not among
Kinge and Midelfart34
O’Neal and Connon33

adults. However, the assumption that refractive errors will be similar

Lv and Zhang36 2013

at all measures for a same individual is not likely to markedly affect

Current study

estimates of progression. Finally, the computing of progression rates

French et al37

Zhou et al39
Fan et al38

(and progressor status) over the first 12–26 months after baseline
Authors

leads to overestimates as individuals with faster progression rates are

more likely to frequently renew their equipment.
Ducloux A, et al. Br J Ophthalmol 2021;0:1–6. doi:10.1136/bjophthalmol-2021-319568 5
 Clinical science

Br J Ophthalmol: first published as 10.1136/bjophthalmol-2021-319568 on 22 December 2021. Downloaded from http://bjo.bmj.com/ on January 29, 2022 by guest. Protected by copyright.
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Open access  This is an open access article distributed in accordance with the school children in Hong Kong. Invest Ophthalmol Vis Sci 2004;45:1071–5.
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properly cited, appropriate credit is given, any changes made indicated, and the use incidence of myopia in school-­aged children in Western China. J Epidemiol
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