Predicting the onset of myopia in children: results from the CLEERE study

Research often attempts to identify risk factors associated with prevalent disease or that change the probability of developing disease. These factors may also help in predicting which individuals may go on to develop the condition of interest. However, risk factors may not always serve as the best predictive factors and not all predictive factors should be considered as risk factors. A child's current refractive error, parental history of myopia, and the amount of time children spend outdoors are excellent examples. Parental myopia and time outdoors are meaningful risk factors because they alter the probability of developing myopia and point to important hereditary and environmental influences. A child's current refractive error points to no particular mechanism and is therefore a poor risk factor. However, it serves as an excellent predictive factor for identifying children likely to develop future myopia. Risk factors may explain how a child reached a particular level of refractive error, but knowledge of that history may not be needed in order to make an accurate prediction about future refractive error. Current refractive error alone may be sufficient. This difference between risk factors and predictive factors is not always appreciated in the literature, including a recent publication in BMC Ophthalmology. This letter attempts to make that distinction and to explain why parental myopia and time outdoors are significant risk factors in the Collaborative Longitudinal Evaluation of Ethnicity and Refractive Error, yet are not significant for predicting future myopia in a multivariate model that contains current refractive error.