Effect of undercorrection on myopia progression in 12 year-old children

Abstract
Background To prospectively observe the effects of undercorrection of myopia on
myopia progression and axial elongation in a population of 12-year-old Chinese children.
Methods A total of 2,267 children in the Anyang Childhood Eye Study were examined at
baseline, and 1,769 were followed for 1 year. Ocular examinations included cycloplegic
autorefraction, axial length, visual acuity, vertometry, and accommodative lag.
Questionnaires were completed by children and parents. Undercorrection of myopia was
determined at baseline if presenting visual acuity could be improved by at least 2 lines
with subjective refraction. Results Of 253 myopic children with spectacles and available
information, 120 (47.4 %) were undercorrected (−4.63D to −0.50D) and 133 (52.6 %)
were fully corrected. In a multivariate model adjusting for age, gender, number of myopic
parents, time spent on near work and outdoor activities per day, usage and time for
wearing spectacles per day, children with undercorrection had significantly more baseline
myopia (P<0.01) and longer axial length (P=0.03) than children with full correction.
However, there were no significant differences in myopia progression (P=0.46) and axial
elongation (P= 0.96) at 1 year between the two groups of children. The regression
analysis showed that myopia progression significantly decreased with increasing amount
of undercorrection (r2= 0.02, P=0.02) in all children. Accommodative lag significantly
decreased with increasing amounts of undercorrection (P<0.01). Conclusions Based on
this 1-year study in Chinese children, undercorrection or full correction of myopia by
wearing spectacles did not show any differences in myopia progression or axial
elongation.

Introduction
Myopia has become a major public health problem worldwide, especially in Asia.
Spectacles are the simplest optical method to correct myopia to obtain better visual
acuity. However, inadequate correction of myopia by spectacles is still very common and
is the leading cause of visual impairment among school-aged children in developing
countries. About 12.8 million children aged 5–15 years have visual impairment due to
lack of correction or undercorrection of refractive error, with a global prevalence of 0.96
%, of which the highest prevalence is in Chinese children.
In China, 21.1 and 48.8 % of school-aged myopic children wearing spectacles are
undercorrected in urban and rural areas respectively. Similar situations have been found
in other developing countries . In Nepal, only 57 % of children with refractive errors wore
spectacles at their first clinic visit. In Africa, only 9.4 % of students with poor vision wore
spectacles for correction. In Western countries, however, most children who need
spectacles have been corrected adequately based on visual acuity. For example, the
prevalence of undercorrected refractive error in 12- year-old Australian children is only
8.3 %.

The effect of undercorrection of myopia on myopia progression in school-aged children is

still controversial. Some studies have reported that undercorrection retarded myopia
progression compared to full correction, with differences of −0.05 D/year to −0.40
D/year. On the other hand, two recent randomized controlled trials (RCT) showed that
undercorrection produced more rapid myopia progression than full correction, with
differences of −0.23 D in 2 years and −0.17 D in 18 months.

Considering the higher prevalence of undercorrection of myopia in children among

developing countries, it is interesting to explore whether undercorrection of myopia has
contributed to faster myopia progression. In the present study, we investigate the effects
of undercorrection on myopia progression and axial elongation in a population of 12 year
old Chinese children after 1 year of follow-up. The undercorrection of myopia or not of
children was suggested and determined by the ophthalmologist or optometrist, and was
agreed by the parents and children. The children were selected from a cohort that we have
established.

Material and methods

The Anyang Childhood Eye Study (ACES) is a school-based cohort study on children in
the urban area of Anyang city, central China. Design, methodology, and baseline data
have been reported previously. In brief, 3,112 grade 1 students and 2,363 grade 7 students
were randomly selected using stratified cluster sampling. Since few grade 1 children wore
spectacles, only grade 7 students were included for analysis. They were firstly examined
between September and December 2011 and followed up 1 year later. Written informed
consent from at least one parent was obtained. Ethics committee approval was obtained
from the institutional review board of Beijing Tongren Hospital, Capital Medical
University. The ACES adhered to the tenets of the Declaration of Helsinki.
Distant LogMAR visual acuity with and without spectacles (if worn) was tested using a
Logarithmic Visual Acuity Chart (Precision Vision, La Salle, IL, USA) at 4 m. The
children were examined monocularly (right eye followed by left eye), and were asked not
to squint their eyes. For the children with distant visual acuity less than LogMAR 0.00,
subjective refraction was performed by a trained optometrist with an endpoint criterion of
maximum plus to obtain their best-corrected visual acuity.

Avertometer (NIDEK,LM-990A) was used tomeasure the dioptric power of the children’s
current spectacles. An autorefractor (HUVITZ, HRK-7000A, South Korea) was used to
measure cycloplegic refractive error. Each child was administered two drops of 1 %
cyclopentolate (Alcon) followed by one drop of Mydrin P (Santen, Japan) at a 5 min
interval. Cycloplegic refractive was performed 30 min to 1 h after the last drop. A third
drop of cyclopentolate was administered if the pupillary light reflex was still present or
the pupil size was less than 6.0 mm.

IOL Master (Carl Zeiss, Meditec AG Jena, Germany) was used to measure axial length.
Accommodative response was measured at 33 cm and distant refraction was measured at
5 m using an open-field autorefractor (Shin-Nippon, Grand Seiko, WAM-5500). Children
were asked to wear spectacles to view the targets, which was positioned equidistant from
both eyes. As for the near target, children were instructed to binocularly fixate on the
smallest letters they could see clearly, and were asked to read out the letters from right to
left to ensure that they were watching the targets.

An interviewer-administered questionnaire was completed by the children and parents to

collect information including time spent on near work and outdoor activities, frequency of
wearing spectacles, usage of spectacle wear, age of myopia onset, age of wearing first
spectacles, frequency of changing spectacles, and the number of myopic parents.

Only the right eye was included for analysis. Myopia was defined as cycloplegic
spherical equivalent (SE)≤−0.50 D. Amount of myopia progression was defined as
baseline SE subtracted from SE 1 year later, and was adjusted by the baseline SE.
Undercorrection of myopia was determined at baseline if presenting visual acuity could
be improved by at least 2 lines on the chart with subjective refraction by increasing the
minus correction, and without changing spectacles within 1 year. The amount of
undercorrected myopia was defined as the difference in SE between diopters of current
spectacles and cycloplegic SE. Based on the amount of undercorrected myopia (UCM),
children with undercorrection of myopia were further divided into four groups (0
D<UCM≤ 0.5D, 0.5D<UCM≤1.0D, 1.0D<UCM≤1.5D and UCM >1.5D).
Accommodative lag was calculated using previous equations.

To keep the same correction method (spectacles) between the two groups, myopic
students not wearing spectacles were excluded from this study. Statistical analysis was
performed using SAS9.1.3. Continuous variables were expressed as mean±SD.
Correlation coefficients were calculated to evaluate a relationship between amount of
undercorrection and myopia progression and axial elongation. Independent t test and
ANOVAwere used to compare the characteristics of 2 ormore groups, respectively. Chi
square test was used to compare the categorical variables between groups. A multivariate
linear model was used to evaluate the associations between potential predictors and
undercorrected myopia. A p value less than 0.05 was considered as significant.

Results
Of 2,363 eligible students, 2,267 (response rate, 95.9 %) participated in the ACES at
baseline. Of the latter, 1,067 were myopic at baseline. Of those, 149 were excluded due to
amblyopia, dominant strabismus, anisometropia over 1.5 D, and astigmatism over 1.5 D.
This left 918 myopic students who were followed at baseline and at 1 year. Of these, 253
had myopic spectacles and available information of other variables, including 120 (47.4
%) with undercorrection and 133 (52.6 %) with full correction of myopia. There were no
significant differences in basic characteristics between the two groups of children (Table
1).

After adjusting for age, gender, number of myopic parents, time spent on near work and
outdoor activities per day, usage and time for wearing spectacles per day, children with
undercorrection of myopia had significantly more baseline myopia than children with full
correction of myopia (P<0.01). Mean myopia progression at 1 year follow-up was −0.64
D/year and −0.68 D/year for the undercorrected and fully corrected groups, which was
not statistically significant (P=0.46, Table 2). Further, among undercorrected children
with different amounts of undercorrection, there were also no significant differences in 1
year myopia progression (P=0.22, Table 3). The regression analysis showed that myopia
progression significantly decreased with increasing amount of undercorrection (r2=0.02,
P=0.02) among all children (Fig. 1). Accommodative lag significantly decreased with
increasing amounts of undercorrection (P<0.01, Table 3).

As for axial length, multivariate analysis showed that children with undercorrection had
significantly longer axial length compared to children with full correction at baseline
(P=0.03, Table 2). However, there were no significant differences in axial elongation
(P=0.96) between the two groups at 1 year, and no significant correlation between axial
elongation and amount of myopia among all children (r2=0.004, P=0.38, Fig. 2).

Discussion
Although many animal studies have confirmed that optically imposed myopic defocus
slows myopia progression, there was a paucity of evidence from human studies that
undercorrecting myopic eyes with spectacles slowed myopia progression. On the
contrary, two recent trials reported that undercorrection may accelerate myopia
progression. The present study is the first one to investigate the effect of undercorrection
on myopia progression and axial elongation in Chinese children coming from a cohort
study with a large sample size. Furthermore, many confounding factors such as age,
gender, parental myopia, time spent on near work and outdoors, usage and time for
wearing spectacles per day were taken into account and adjusted.

In this study, we found no significant differences inmyopia progression and axial

elongation after a 1-year period between children with undercorrection and full
correction. Interestingly, myopia progression decreased slightly with increasing amount
of undercorrection, although there was a lot of variability among the subjects. These
findings indicate that undercorrection may not cause faster myopia progression compared
to full correction in children. On the contrary, it may reduce myopia progression, in
agreement with the findings of animal studies, although axial elongation didn’t
significantly increase with increasing amount of undercorrection in the present study,
possibly because the increase was very modest. Indeed, binocular undercorrection
induces myopic defocus at distance but clear retinal images at near. As a consequence,
the effect of the myopic defocus is temporary and partial, and one could surmise that if it
were continuous the result of undercorrection would be a slower progression of myopia
than full correction, as has been shown in unilateral undercorrection, and not a similar
progression of both groups as found in our study.
Previous studies showed that myopia progression was faster for children with more
severe myopia at baseline. However, our children with more undercorrection had more
severe baseline myopia but slower myopia progression (Table 2). This further suggests
that undercorrection may compensate for the effect of severe myopia at baseline, and the
finally retard rather than accelerate myopia progression in children. We also found that
accommodative lag significantly decreased with increasing amounts of undercorrection
(Table 3), which might occur because children with undercorrection had assistance when
focusing at near, and were more accurate at accommodating than those who have no such
assistance.

It is worth noting that for the definition of undercorrection we adopted a presenting visual
acuity, which could be improved by at least 2 lines with subjective refraction. And the
myopia progression of full correction group (−0.68 D, Table 2) was very close to that of
children with undercorrection of 0D– 0.5D (−0.69 D, Table 3). Therefore, we assert that
based on the present 1-year study, our findings do not support the notion that
undercorrection of myopia causes faster myopia progression than full correction of
myopia in Chinese children.

Although we cannot predict whether a longer period of investigation would show such an
effect of undercorrection on myopia progression, we observed that in two previous
studies, a contrary result was already noticeable at 1 year, which was not the case in our
study. The discrepancy between the results of these studies and our own is not clear.
However, we enrolled a much larger sample size than in those two studies and the
population was of different ethnic origin. Moreover, we evaluated the amount of time
spent outdoors, which was not done in the studies above, and time outdoors is known to
be a protective factor for myopia onset; the more time spent outdoors, the less likely to
become myopic. As suggested by Smith, the undercorrected children in these two studies
may have spent more time viewing near objects and less time outdoors to avoid blurred
vision, whereas the children in our cohort spent the same amount of time outdoors (1.88
and 1.87 h/day) whether undercorrected or fully corrected (Table 1).

In this study, we found that 47.4%of myopic children with spectacles were
undercorrected. This proportion was similar to those of previous studies in urban and
rural areas of southern China (21.1 %–48.8 %) and was much higher than that of Beijing
(7.99 %) and Australia (8.3 %). Our study demonstrated that children with older age of
myopia onset, more myopia, and younger age of wearing first spectacles were more likely
to be undercorrected. With increasing amount of undercorrection, the presenting visual
acuity was significantly worse . These findings were consistent with previous studies on
junior school children in Guangdong and primary school children in Beijing. It indicated
that younger children with initial spectacles, older myopic children, and children with
more myopia should be carefully prescribed with more accurate correction of myopia to
obtain better presenting visual acuity.

Some limitations remain in the present study. First, it is a case–control study with
longitudinal observations, not a randomized controlled trial. Although many confounding
factors have been adjusted, selection bias might have existed and misled the results.
Second, undercorrection of myopia was defined as improved presenting visual acuity for
at least 2 lines with subjective refraction. Using this criterion of undercorrection of
myopia may not have detected all undercorrected children becausemyopesmay possess
reduced blur sensitivity. Third, this was a study with only a 1-year period, which was not
long enough to draw a robust conclusion. However, the children might change their
spectacles every year with an increase in myopia. The spectacles might switch between
undercorrection and full correction which would make it hard for classification.

In summary, we found that children with undercorrection of myopia showed no

significant difference in myopia progression compared to children with full correction in
this 1- year study. Undercorrection might not accelerate myopia progression in a
population of 12-year-old Chinese children.