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Environmental Risk Factors Can Reduce Axial Length Elongation and Myopia Incidence in 6- to 9-Year-Old Children


Tideman JWL, Polling JR, Jaddoe VWV, Vingerling JR, Klaver CCW








  • The purpose of this study is to identify risk factors for axial length (AL) elongation and incident school myopia.

  • The design is a Population-based prospective birth-cohort study.

  • Participants included four thousand seven hundred thirty-four (4,734) children examined at 6 and 9 years of age from the Generation R Study in Rotterdam, The Netherlands.

  • Axial length and corneal radius (CR) were measured with an IOLMaster 500 and daily life activities and demographic characteristics were obtained by questionnaire. 

  • Three thousand three hundred sixty-two children (71%) were eligible for cycloplegic refractive error measurements. 

  • Linear regression models on AL elongation were used to create a risk score based on the regression coefficients resulting from environmental and ocular factors. 

  • The predictive value of the prediction score for myopia (≤-0.5 diopter) was estimated using receiver operating characteristic curves. To test if regression coefficients differed for baseline AL-to-CR ratio, interaction terms were calculated with baseline AL-to-CR ratio and environmental factors.

  • From 6 to 9 years of age, average AL elongation was 0.21±0.009 mm/year and myopia developed in 223 of 2136 children (10.4%), leading to a myopia prevalence at 9 years of age of 12.0%. Seven parameters were associated independently (P < 0.05) with faster AL elongation: parental myopia, 1 or more books read per week, time spent reading, no participation in sports, non-European ethnicity, less time spent outdoors, and baseline AL-to-CR ratio. 

  • The discriminative accuracy for incident myopia based on these risk factors was 0.78. Axial length-to-CR ratio at baseline showed statistically significant interaction with number of books read per week (P < 0.01) and parental myopia (P < 0.01). Almost all predictors showed the highest association with AL elongation in the highest quartile of AL-to-CR ratio; incidental myopia in this group was 24% (124/513).

  • Determination of a risk score can help to identify school children at high risk of myopia. Our results suggest that behavioral changes can offer protection particularly in these children.