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Combining visual acuity with refraction reduces overestimation of myopia prevalence in school screenings: an
Ningfeng Li1,2, Yu Jiang1,2, Xu Zhang1,2
1Department of Ophthalmology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China.
Background:
School myopia screening commonly employs non-cycloplegic spherical equivalent refraction (SER ≤ -0. 50 D) for its practicality. However, this SER-only approach likely overestimates the prevalence of visually significant myopia, as it cannot distinguish true myopia from accommodative pseudomyopia, especially in younger children. We quantified the disparity between this SER-only criterion and a combined criterion integrating uncorrected visual acuity (UCVA), the SER + UCVA criterion, and examined its variation across age groups.
Methods:
This serial cross-sectional study (2018-2021) included 20,750 students aged 5-18 years from Southern China. Myopia was defined using two criteria based on non-cycloplegic measurements in at least one eye: (1) SER-only: SER ≤ -0.50 D; and (2) SER + UCVA: SER ≤ -0.50 D plus age-impaired UCVA (>0.20 logMAR at age 5; >0.00 logMAR at ages ≥6) in the same eye. Age-stratified prevalence estimates were compared.
Results:
The SER + UCVA criterion yielded consistently lower prevalence estimates than the SER-only criterion (e.g., 48.89% vs. 59.48% in 2021), corresponding to a 15-21% annual relative overestimation. Crucially, this overestimation demonstrated a strong age gradient. It was most severe in young children, with the SER-only myopia prevalence nearly double the SER + UCVA myopia prevalence at ages 5-6 years (relative difference >50%), and progressively narrowed to approximately 10-15% in adolescents (14-18 years). Notably, a significant acceleration in SER + UCVA myopia prevalence was observed in children aged 7-10 years between 2019 and 2020. Furthermore, from age 10 onwards, SER + UCVA myopia prevalence was significantly higher in females than males (all P < 0.001).
Conclusion:
Sole reliance on non-cycloplegic SER substantially overestimates the burden of visually significant myopia, especially in younger children. Incorporating UCVA provides a more accurate and functionally relevant metric for public health screening. We advocate for adopting age-specific SER + UCVA criteria in school-based screenings to optimize referral efficiency, with the greatest benefit expected for younger populations where specificity gains are maximal.
