Do educational levels impact myopia prevalence?

Paper Title: Association between Global Myopia Prevalence and International Levels of Education

Authors: Monica Jong^1,2, Thomas Naduvilath^1,3, Jeanne Saw¹, Kunyoung Kim¹, Daniel Ian Flitcroft⁴

1. School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia
2. Johnson and Johnson Vision, Jacksonville, Florida
3. Brien Holden Vision Institute, Sydney, New South Wales, Australia
4. Department of Ophthalmology, Children's University Hospital, Dublin, Ireland

Date: October 2023

Reference: Jong M, Naduvilath T, Saw J, Kim K, Flitcroft DI. Association between Global Myopia Prevalence and International Levels of Education. Optom Vis Sci. 2023 Oct 1;100(10):702-707. 

[Link to paper]

This study investigated the relationship between myopia prevalence in teenagers (15-19 years old) and national educational performance.

Data from 35 regions were analysed, combining myopia prevalence information from meta-analysis by Holden et al¹ with triannual educational performance scores from the Programme for International Student Assessment (PISA) testing of maths, science and reading comprehension conducted between 2000 and 2018.¹ The statistical analysis used Generalized Estimating Equations (GEE) to examine the association between myopia prevalence and PISA scores.

The analysis revealed a significant positive correlation between higher PISA scores and increased myopia prevalence, even after accounting for chronological year effects. It emphasizes the potential impact of education policies on addressing the public health issue of myopia.

• The strongest correlation was found with PISA math scores, followed by science, and reading.
• The study proposes that countries achieving a balance between high PISA scores and lower myopia prevalence could serve as potential models for effective educational policies addressing myopia.

This study suggests two reasons why high educational outcomes may influence myopia prevalence: the amount of near work required to achieve such outcomes increases, as well as the potential contribution to less time spent outdoors. The age group of 15 to 19 year old's that were examined in this study likely experienced the onset of myopia at an earlier stage; the authors therefore suggest public health efforts targeting behavioral changes (including the reduction of near work intensity^2-4 and the promotion of increased outdoor time)⁵ should be directed towards parents and children right from the initiation of formal education. At an eye care practitioner level, this drives home the importance of emphasizing the importance of outdoor time and visual environment advice at this stage and thereafter.

Although the correlation between educational levels and myopia prevalence appears significant in the study, there are some limitations:

• Myopia prevalence for 15- to 19-year-olds is estimated from Holden et al.'s study but lacks direct assessment of students' vision status during OECD PISA testing.
• Holden et al.'s model, using urbanization as a predictive factor, may smooth out variability in different studies, impacting the interpretation of results.
• Irregular participation of countries in PISA testing, with about one-third abstaining in 2000, highlights the need for more data to draw solid conclusions.
• Scarcity of data for some countries in Holden et al.'s study necessitates extrapolation from similar countries, including Indonesia, Ireland, and Qatar, which lack primary prevalence data.

Future research should explore refractive data, time spent on near work and outdoors, and socioeconomic factors for a more comprehensive understanding of the link between educational achievement and myopia. Devices which offer real-time data on activities like near work and outdoor time, are expected to enhance our comprehension of the connection between near work and myopia.

Significance: The Global Myopia Prevalence and International Levels of Education study models national trends in educational performance with myopia prevalence in children; it examines the association of near work with myopia in the form of an ecologic analysis and also discusses how this may relate to educational frameworks.

Purpose: This study aimed to investigate the relationship between myopia prevalence and national educational performance.

Methods: The prevalence of myopia in the 15- to 19-year age group in 35 regions was obtained from a meta-analysis by Holden et al. (Ophthalmology 2016;123:1036–1042) and matched with educational performance quantified by the Organisation for Economic Cooperation and Development Programme for International Student Assessment (PISA) testing from 2000 to 2018. A generalized estimating equation was used to describe the relationship between PISA scores and myopia prevalence. Clustering effects of country and chronological year were accounted for in the analysis. Linear and nonlinear terms of PISA scores using lines of best fit were further explored.

Results: There is a significant positive relationship between Organisation for Economic Cooperation and Development PISA educational performance and myopia prevalence in teenagers with higher PISA scores correlating with higher myopia prevalence, even after accounting for chronological year (generalized estimating equation model: P = .001, .008, and .005 for math, science, and reading, respectively). Scatterplots with cubic and logistic fits indicated that PISA math showed the strongest relationship with myopia prevalence (r² = 0.64), followed by science (r² = 0.41) and reading (r² = 0.31).

Conclusions: These results strongly suggest that educational achievement at a national level is associated with higher myopia prevalence. Programme for International Student Assessment scores are a significant driver of many countries' education policies, and countries that have a balance between high PISA scores and lower myopia prevalence may be good models of educational policies to address the myopia public health issue.