Refractive Error, Visual Acuity and Causes of Vision Loss

in Children in Shandong, China. The Shandong Children

Eye Study
Jian Feng Wu1, Hong Sheng Bi2*, Shu Mei Wang3, Yuan Yuan Hu4, Hui Wu2, Wei Sun4, Tai Liang Lu4, Xing
Rong Wang2, Jost B. Jonas5*
1 Department of Ophthalmology, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China, 2 Eye Institute of Shandong University of Traditional
Chinese Medicine, Jinan, Shandong, China, 3 School of Public Health, Shandong University, Jinan, Shandong, China, 4 The Second Affiliated Hospital of Shandong
University of Traditional Chinese Medicine, Jinan, Shandong, China, 5 Department of Ophthalmology, Medical Faculty Mannheim of the Ruprecht-Karls-University,
Heidelberg, Germany

Abstract
Purpose: To examine the prevalence of refractive errors and prevalence and causes of vision loss among preschool and
school children in East China.

Methods: Using a random cluster sampling in a cross-sectional school-based study design, children with an age of 4–
18 years were selected from kindergartens, primary schools, and junior and senior high schools in the rural Guanxian
County and the city of Weihai. All children underwent a complete ocular examination including measurement of
uncorrected (UCVA) and best corrected visual acuity (BCVA) and auto-refractometry under cycloplegia. Myopia was defined
as refractive error of #20.5 diopters (D), high myopia as #26.0D, and amblyopia as BCVA #20/32 without any obvious
reason for vision reduction and with strabismus or refractive errors as potential reasons.

Results: Out of 6364 eligible children, 6026 (94.7%) children participated. Prevalence of myopia (overall: 36.960.6%;95%
confidence interval (CI):36.0,38.0) increased (P,0.001) from 1.761.2% (95%CI:0.0,4.0) in the 4-years olds to 84.663.2%
(95%CI:78.0,91.0) in 17-years olds. Myopia was associated with older age (OR:1.56;95%CI:1.52,1.60;P,0.001), female gender
(OR:1.22;95%CI:1.08,1.39;P = 0.002) and urban region (OR:2.88;95%CI:2.53,3.29;P,0.001). Prevalence of high myopia
(2.060.2%) increased from 0.760.3% (95%CI:0.1,1.3) in 10-years olds to 13.963.0 (95%CI:7.8,19.9) in 17-years olds. It was
associated with older age (OR:1.50;95%CI:1.41,1.60;P,0.001) and urban region (OR:3.11;95%CI:2.08,4.66);P,0.001).
Astigmatism ($0.75D) (36.360.6%;95%CI:35.0,38.0) was associated with older age (P,0.001;OR:1.06;95%CI:1.04,1.09), more
myopic refractive error (P,0.001;OR:0.94;95%CI:0.91,0.97) and urban region (P,0.001;OR:1.47;95%CI:1.31,1.64). BCVA was
#20/40 in the better eye in 19 (0.32%) children. UCVA #20/40 in at least one eye was found in 2046 (34.05%) children, with
undercorrected refractive error as cause in 1975 (32.9%) children. Amblyopia (BCVA #20/32) was detected in 44 (0.7%)
children (11 children with bilateral amblyopia).

Conclusions: In coastal East China, about 14% of the 17-years olds were highly myopic, and 80% were myopic. Prevalence of
myopia increased with older age, female gender and urban region. About 0.7% of pre-school children and school children
were amblyopic.

Citation: Wu JF, Bi HS, Wang SM, Hu YY, Wu H, et al. (2013) Refractive Error, Visual Acuity and Causes of Vision Loss in Children in Shandong, China. The
Shandong Children Eye Study. PLoS ONE 8(12): e82763. doi:10.1371/journal.pone.0082763
Editor: Steven Barnes, Dalhousie University, Canada
Received August 5, 2013; Accepted November 5, 2013; Published December 23, 2013
Copyright: ß 2013 Wu et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This study was supported by Shandong Science & Technology Department (2011GGB14097, 2011GGH21835, 2012YD18081), Shandong Health
Department (2011HD014), Jinan Science & Technology Bureau (201102061). The funders had no role in study design, data collection and analysis, decision to
publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: hongshengbi@126.com (HSB); jost.jonas@medma.ma.uni-heidelberg.de (JBJ)

Introduction previously examined the prevalence of myopia. These studies

were carried out either in countries others than mainland China
The prevalence of myopia has profoundly increased in East and [5–21], which due to its population size is one of the main target
Southeast Asia and myopia has become one of the most common countries in the research on myopia prevalence and its prevention,
causes for visual impairment in these regions [1,2]. Since myopia or the studies were performed ten or more years ago [22–25] or
can be associated with major ophthalmic diseases such as myopic were conducted 5 to 10 years ago in South China or West China
retinopathy and myopic glaucomatous optic neuropathy, the [26,27]. There were only three recent studies on the prevalence of
increased prevalence of myopia indicates an increased risk of myopia in children in China, one was performed without
myopia-induced visual impairment [3,4]. Numerous studies cycloplegia [28], and the two other ones were conducted in

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 Refractive Error in Shandong

Western China or Northern China far from the industrialized Shandong and the relatively highly developed city of Weihai in
coastal regions of China [29,30]. One of the characteristics of Eastern Shandong as study sites, since both differed markedly in
myopia in China is that its prevalence still appears to be their level of social and economic development.
increasing, and in particular, that the prevalence of high myopia A stratified cluster sampling method was applied. The sampling
is increasing even more markedly. It shows the importance of frame was based on the enumeration of grade-specific classes
having updated recent data on the actual prevalence of myopia in within the schools and kindergardens. Stratification of clusters by
the country. A recent study on university students in Shanghai/ grade and age ensured that all ages from 4 years to 18 years were
China and recent investigations on military conscripts in urban representatively included into the study samples. The sample size
Seoul/Korea as well as in rural Korean regions revealed that more was calculated by estimating an age-specific prevalence of
than 95% of the study populations were myopic, and that about refractive errors of 33.5% with a 20% error rate and a 95%
10–20% were highly myopic (myopia refractive error .26 confidence interval. Assuming a non-response rate of 10%, the
diopters) [31–33]. Also, there has been little information about cluster sample size was 210 for each age, so that 3150 children
regional differences in the prevalence of myopia in China. We with an age from 4 years to 18 years old of the two regions should
therefore conducted this study to examine the prevalence of be enrolled into the survey. Since there were about 50 students per
myopia in a school-based investigation in the East Chinese class, 127 classes were included. For each grade, the classes were
province of Shandong in a rural region and an urban area. Since drawn by a simple random sampling and all students in these
myopia is associated with visual impairment, we additionally classes were asked to participate in the study.
measured visual acuity and assessed the causes for visual Before the examinations were carried out, an interview was
impairment. Methods. performed using a standardized questionnaire to obtain informa-
tion of the children’s family history, time spent doing outdoor
Methods activities and indoor activities, study intensity, history of previous
eye examinations and treatments, lifestyle, etc. The questionnaire
Ethics Statement was similar to the questionnaire used previously in the RESC
The Ethics Board of the Eye Institute of the Shandong (Refractive Error Study in Children) studies [35,36]. The first step
University of Traditional Chinese Medicine and the local of the series of examinations consisted of the assessment of
Administration of the Education and School Board approved uncorrected visual acuity (UCVA), for which a tumbling ‘‘E’’ chart
the study and informed written consent was obtained from the (#600722, Good-Lite Co., Elgin, IL, USA) was used at a distance
parents or guardians of all children. of 3 m. The lowest line of the chart and the eyes of the tested
The Shandong Children Eye Study was a cross-sectional, children were approximately at the same height. The children
school-based study which was performed in the city of Weihai in were asked to start with the upper first line (visual acuity: 20/100)
the most Eastern part, and in the county of Guanxian in the most of the chart, and to continue with the next lines, if at maximum
Western part of the coastal province of Shandong in East China. one character of the line was incorrectly described. When the
According to the data from the census of 2010, the total children falsely described at least 2 characters in the line, visual
population of the city of Weihai was 2,804,800, and the total acuity was recorded as the value of the previous line. If the
population of the rural region of Guanxian was 764,900 [34]. In children could not read the 20/100 line at a distance of 3m, the
an attempt to cover the whole range of socioeconomic back- test was repeated at a distance of 1m. If at that distance no line
ground, we chose the rural county of Guanxian in Western could be read, visual acuity was tested as counting fingers, hand

Table 1. Enumerated and Examined Population Stratified by Age in the Shandong Children Eye Study.

Number (%) of Number (%) of Percentage of

Age (Years) Enumerated Population Examined Population Examined (%)

4 129 (2.0) 115 (1.9) 89.1

5 388 (6.1) 361 (6.0) 93.0
6 465 (7.3) 444 (7.4) 95.5
7 674 (10.6) 642 (10.7) 95.3
8 770 (12.1) 745 (12.4) 96.8
9 567 (8.9) 550 (9.1) 97.0
10 728 (11.4) 705 (11.7) 96.8
11 610 (9.6) 590 (9.8) 96.7
12 496 (7.8) 488 (8.1) 98.4
13 446 (7.0) 439 (7.3) 98.4
14 359 (5.6) 342 (5.7) 95.3
15 267 (4.2) 232 (3.9) 86.9
16 155 (2.4) 136 (2.3) 87.7
17 158 (2.5) 130 (2.2) 82.3
18 152 (2.4) 107 (1.8) 70.4
Total 6364 (100.0) 6026 (100.0) 94.7

doi:10.1371/journal.pone.0082763.t001

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 Refractive Error in Shandong

Figure 1. Distribution of the refractive error (spherical equivalent) of right eyes, stratified by age and gender in the Shandong
Children Eye Study.
doi:10.1371/journal.pone.0082763.g001

movement, light perception or no light perception. In a second ,20/20 underwent a repeated ophthalmoscopical examination in
step, auto-refractometry was performed (KR-8900, Topcon, medical mydriasis.
Itabashi, Tokyo, Japan). Each eye was measured at least 3 times. Refractive errors were defined as suggested by the Refractive
The difference between the maximum and minimum value of the Error Study in Children (RESC) surveys [35–36]. Myopia and
measurements of spherical refractive error and cylindrical hyperopia were calculated as spherical equivalent of the refractive
refractive error had to be less than 0.5 D, otherwise the error, defined as the sum of the spherical refractive error plus half
measurements had to be repeated. If UCVA was less than 20/ of the cylindrical refractive error (measured as minus values).
20, best corrected visual acuity (BCVA) was measured in a third Myopia was defined per subject as refractive error (spherical
step of the examination. For that purpose, the results of auto- equivalent) of #20.50D in one or both eyes. High myopia was
refractometry were used as basis. To assure the quality for the defined as refractive error #26.0D in one or both eyes. Mild
measurements of visual acuity and refractometry, the examiners hyperopia was defined as a refractive error of .+0.50D to
were repeatedly checked for the accuracy of their results. #+2.0D, and medium to marked hyperopia was defined as a
Intraocular pressure was measured by a non-contact tonometer refractive error of .+2.0 D, in one or both eyes if neither eye was
(CT-80A, Topcon, Co., Tokyo, Japan). An ophthalmologist myopic. Emmetropia was consequently considered to be a
examined the anterior and posterior ocular segments of all refractive error of .20.50D and #+0.50D in both eyes.
children. After ensuring that there was no risk for a medical Astigmatism was a cylindrical refractive error $0.75D in either
mydriasis, cycloplegia was performed. Cycloplegia was achieved eye. Anisometropia was defined as difference between right eye to
by using 1% cyclopentolate eye drops (Alcon, Ft. Worth, Texas, left eye in refractive error (spherical error) of $1.0D. All refractive
USA). After an initial topical anesthesia with one drop of 0.4% errors were measured under cycloplegia.
oxybuprocaine (Santen Co., Shiga, Japan) for each eye, three The reasons for a reduced UCVA were assessed by refractom-
drops of 1% cyclopentolate were instilled in intervals of 5 minutes. etry and by the ophthalmological examination. Amblyopia was
About 30 minutes after the last drop instillation, a repeated present if BCVA could not be improved to more than 20/32, if no
autorefractometry was performed. If a pupil diameter of at least other reason such as cataract could be detected as cause for the
6 mm was not achieved, another drop of cyclopentolate was given reduction in BCVA, and if factors such as strabismus, hyperopia,
and the examination was repeated 10 minutes later. Less than myopia or anisometropia could explain amblyopia. If these
10% of the children needed an additional drop of cyclopentolate conditions did not prevail, a reduced BCVA was considered to
due to an initially insufficient pupillary mydriasis and cycloplegia. be unexplained. The same definition of amblyopia was applied by
To assess the causes for visual impairment, children with a BCVA in the study by Negrel and colleagues [38].

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 Refractive Error in Shandong

Figure 2. Distribution of the refractive error (spherical equivalent) of right eyes, stratified by age and region of habitation, in the
Shandong Children Eye Study.
doi:10.1371/journal.pone.0082763.g002

Statistical analysis was performed using a commercially (3186 (52.9%) boys) with a mean age of 9.763.3 years (range 4 to
available statistical software package (SPSS for Windows, version 18 years) (Table 1). Out of the 6026 children, 3112 children lived
21.0, IBM-SPSS, Chicago, IL). In a first step, we examined the in the rural Guanxian County (51.6%) and 2914 children came
mean values (presented as mean 6 standard deviation). Frequen- from the city of Weihai (48.4%). Except for a boy with phthisis
cies were presented as mean 6 standard error. In a second step, bulbi in his left eye, all children underwent bilateral cycloplegic
we performed a univariate binary regression analysis with the refractive error measurements.
presence of myopia (or of hyperopia) as dependent parameter and The mean spherical equivalent of the right eyes was
one of the ocular parameters or one of the general parameters as 20.2262.06 D (median: 0.38 D; range: 211.75D to +10.5D)
independent parameter. In a third step, we carried out a and of the left eyes 20.1362.05 D (median: 0.50 D; range:
multivariate binary regression analysis, with the presence of 211.75D to +11.25D). The mean spherical equivalent of the
myopia (or of hyperopia) as the dependent variable and all those worse eye was 20.1862.11 D (median: 0.50 D; range: 211.75D
parameters as independent parameters which were significantly to +11.25D).
associated with the dependent variable in the univariate analysis. Prevalence of myopia was overall 36.960.6% (95%CI: 36.0,
For continuous variables such as refractive error, we first 38.0). The prevalence of myopia increased from 1.761.2%
performed a univariate analysis to search for associations. We (95%CI: 0.0, 4.0) in the 4 years old children to 84.663.2%
then carried out a multivariate linear regression analysis including (95%CI: 78.0, 91.0) in 17-year olds (Fig. 1, 2, 3). In univariate
those variables which were significantly associated with the analysis, prevalence of myopia was significantly associated with
continuous variable in the univariate analysis. Odds ratios (OR) female gender (P,0.001) and urban region of habitation
and 95% confidence intervals (95%CI) were calculated. All P- (P,0.001) (Fig. 1, 2). We then performed a multivariate analysis
values were 2-sided and were considered statistically significant (binary regression analysis) with presence of myopia as dependent
when the values were less than 0.05. variable and age, gender and region of habitation as independent
parameters. It revealed that the presence of myopia was
Results significantly associated with older age (OR: 1.56 (95%CI: 1.52,
1.60); P,0.001), female gender (OR: 1.22 (95%CI: 1.08, 1.39);
Out of the 6364 children who were primarily eligible for the P = 0.002) and region of habitation OR: 2.88 (95%CI: 2.53,
study, 328 refused the examination and 10 children who had an 3.29); P,0.001).
intraocular pressure of more than 25 mmHg in one or both eyes The prevalence of high myopia was 2.060.2%. It increased
were excluded from the survey to avoid any risk associated with significantly from 0% in the 4-years old, to 0.760.3% (95%CI:
cycloplegia. The study eventually included 6026 (94.7%) children 0.1, 1.3) in the 10-years olds, to 5.961.3% (95%CI: 3.4, 8.4) in the

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 Refractive Error in Shandong

Figure 3. Prevalence of Medium to Marked Hyperopia (.+2.0 Diopter (D)), Mild Hyperopia (.+0.50D to #+2.0D), Emmetropia, Mild
Myopia (#20.50D) and High Myopia (#26.0D) Stratified by Age in the Shandong Children Eye Study.
doi:10.1371/journal.pone.0082763.g003

14-years olds, and to 13.963.0 (95%CI: 7.8, 19.9) in the 17-years lence of high myopia remained significantly associated with older
olds (Tables 2, 3, 4) (Fig. 4). Prevalence of high myopia was age (OR: 1.50 (95%CI: 1.41, 1.60); P,0.001) and region of
additionally associated with female gender (P,0.001) and urban habitation (OR: 3.11 (95%CI: 2.08, 4.66); P,0.001), while gender
region of habitation (P,0.001). In multivariate analysis, preva- was no longer significantly (P = 0.25) associated.

Figure 4. Prevalence of High Myopia (Defined as Refractive Error #26.0 Diopters) Stratified by Age and Region of Habitation in the
Shandong Children Eye Study.
doi:10.1371/journal.pone.0082763.g004

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 Table 2. Prevalence (%) (95% confidence interval) of high myopia, myopia, hyperopia, astigmatism, and anisometropia as measured under cycloplegia among children with an
age of 4 to 18 years, stratified by age, gender and region of habitation (n: Number of children).

Age Total Mild Hyperopia Medium to Marked

(years) Number High Myopia Myopia .+0.5D, #+2.0D Hyperopia .+2.0D Astigmatism Anisometropia

Prevalence Prevalence Prevalence Prevalence Prevalence

n (%) n Prevalence (%) n (%) n (%) n (%) n (%)

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4 115 0 2 2 1.7 (0.3–5.3) 89 77.4(69.2–84.4) 17 14.8(9.1–22.0) 40 34.8 (26.5–43.8) 4 3.5 (1.1–7.9)
5 361 0 2 3 0.8 (0.2–2.1) 290 80.3(76.0–84.2) 46 12.7(9.6–16.4) 107 29.6 (25.1–34.5) 7 1.9 (0.8–3.7)
6 444 2 0.5 (0.1–1.4) 18 4.1 (2.5–6.2) 314 70.7(66.4–74.8) 77 17.3(14.0–21.0) 139 31.3 (27.1–35.7) 11 2.5 (1.3–4.2)
7 642 0 2 50 7.8 (5.9–10.0) 440 68.5(64.9–72.0) 65 10.1(8.0–12.6) 206 32.1 (28.6–35.8) 18 2.8 (1.7–4.3)
8 745 4 0.5 (0.2–1.2) 151 20.3 (17.5–23.3) 405 54.4(50.8–57.9) 43 5.8(4.2–7.6) 237 31.8 (28.5–35.2) 25 3.4 (2.2–4.8)
9 550 2 0.4 (0.1–1.1) 169 30.7 (27.0–34.7) 257 46.7(42.6–50.9) 27 4.9(3.3–6.9) 187 34.0 (30.1–38.0) 33 6.0 (4.2–8.2)
10 705 5 0.7 (0.3–1.5) 274 38.9 (35.3–42.5) 276 39.1(35.6–42.8) 28 4.0(2.7–5.6) 232 32.9 (29.5–36.4) 46 6.5 (4.9–8.5)
11 590 5 0.8 (0.3–1.8) 292 49.5 (45.5–53.5) 183 31.0(27.4–34.8) 18 3.1(1.9–4.6) 198 33.6 (29.8–37.4) 41 6.9 (5.1–9.2)
12 488 9 1.8 (0.9–3.3) 266 54.5 (50.1–58.9) 129 26.4(22.7–30.5) 7 1.4(0.6–2.8) 186 38.1 (33.9–42.5) 38 7.8 (5.6–10.4)
13 438 15 3.4 (2.0–5.4) 281 64.2 (59.6–68.6) 84 19.2(15.7–23.0) 8 1.8(0.8–3.4) 179 40.9 (36.3–45.5) 49 11.2 (8.2–14.4)
14 342 20 5.8 (3.7–8.7) 236 69.0 (64.0–73.8) 52 15.2(11.7–19.3) 5 1.5(0.5–3.1) 155 45.3 (40.1–50.6) 51 14.9 (11.4–18.9)
15 232 17 7.3 169 72.8 (66.9–78.3) 32 13.8(9.8–18.6) 4 1.7(0.5–4.0) 124 53.4 (47.0–59.8) 34 14.7 (10.5–19.6)
(4.4–11.2)

6
16 136 18 13.2 114 83.8 (77.0–89.4) 9 6.6(3.2–11.6) 2 1.5(0.2–4.5) 73 53.7 (45.3–61.9) 21 15.4 (10.0–22.1)
(8.2–19.6)
17 130 18 13.8 110 84.6 (77.8–90.1) 9 6.9(3.4–12.1) 0 2 64 49.2 (40.7–57.8) 24 18.5 (12.4–25.7)
(8.6–20.5)
18 107 3 2.8 (0.7–7.1) 86 80.4 (72.2–87.1) 8 7.5(3.5–13.5) 3 2.8(0.7–7.1) 60 56.1(46.6–65.3) 18 16.8 (10.6–24.7)

doi:10.1371/journal.pone.0082763.t002
Refractive Error in Shandong

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 Refractive Error in Shandong

Table 3. Prevalence (95% confidence intervals) of high myopia, myopia, hyperopia, astigmatism, and anisometropia as measured under cycloplegia among children with an age
The prevalence of mild hyperopia was 42.8% (95%CI: 41.5,
44.0). In univariate analysis, it decreased significantly with older

Prevalence

6.5 (5.6–7.4)
7.5 (6.6–8.5)

6.1 (5.3–7.0)
7.9 (7.0–8.9)
7.0 (6.4–7.7)
age (P,0.001), urban region of habitation (P,0.001) and female
gender (P,0.001). In binary regression analysis, prevalence of

Anisometropia
mild hyperopia remained significantly associated with younger age

(%)
(OR: 0.72 (95%CI: 0.70, 0.73); P,0.001), rural region of
habitation (OR: 0.58 (95%CI: 0.52, 0.64); P,0.001) and male

206
214

189
231
420
gender (OR: 0.83 (95%CI: 0.75, 0.92); P,0.001).

n
The prevalence of medium to marked hyperopia was 5.8%
(95%CI: 5.2, 6.4). In univariate analysis, it decreased significantly
Prevalence (%)

35.4 (33.8–37.1)
37.3 (35.5–39.1)

32.1 (30.5–33.8)
40.7 (39.0–42.5)
36.3 (35.1–37.5)
with older age (P,0.001) and urban region of habitation
(P = 0.04). It did not differ significantly (P = 0.91) between boys
and girls. In binary regression analysis, prevalence of medium to
Astigmatism

marked hyperopia remained significantly associated with younger

age (OR: 0.76 (95%CI: 0.72, 0.79); P,0.001) and rural region of
habitation (OR: 0.80 (95%CI: 0.64, 0.99); P = 0.04).
1129
1058

1000
1187
2187
Astigmatism was found in 36.360.6% (95%CI: 35.0, 38.0). Its
n

mean value was 0.4360.51 diopters (median: 0.25 diopters; range:

Prevalence (%)

0.00 to 6.50 diopters). In multivariate analysis, the amount of

Marked6Hyperopia

astigmatism was associated with older age (P,0.001; standardized

6.4 (5.6–7.3)
5.2 (4.4–6.0)
5.8 (5.2–6.4)
5.8(5.0–6.6)
5.8(5.0–6.8)

coefficient beta: 0.07; regression coefficient B: 0.01; 95%CI: 0.01,

0.02) and more myopic refractive error (P = 0.008; beta: 20.04; B:
Medium to

20.01; 95%CI: 20.02, 20.01), while it was not associated with

.+2.0D

urban region of habitation (P = 0.14) nor gender (P = 0.08). In

184
166

199
151
350

binary regression analysis, the prevalence of astigmatism remained

n

significantly associated with older age (P,0.001; regression

coefficient B: 0.06; OR: 1.06 (95%CI: 1.04, 1.09), more myopic
refractive error (P,0.001; B: 20.07; OR: 0.94 (95%CI: 0.91,
Prevalence (%)

44.9(43.2–46.7)
40.3(38.5–42.1)

49.2(47.5–51.0)
35.9(34.2–37.6)
42.8(41.5–44.0)

0.97), and urban region of habitation (P,0.001; B: 0.38; OR: 1.47

(95%CI: 1.31, 1.64).
.+0.5D, #+2.0D
Mild Hyperopia
of 4 to 18 years, stratified by age, gender and region of habitation (n: Number of children).

Prevalence of anisometropia was 7.060.3% (95%CI: 6.0, 8.0).

It was associated with older age (P,0.001), myopic refractive error
(P,0.001), and urban region of habitation (P = 0.005) while it was
not associated with gender (P = 0.10). In binary regression analysis,
1432
1145

1531
1046
2577

prevalence of anisometropia remained significantly associated with

n

older age (OR: 1.22 (95%CI: 1.19, 1.26); P,0.001) and urban
region (OR: 1.55 (95%CI: 1.26, 1.90); P,0.001), while it was no
Prevalence (%)

longer significantly associated with refractive error (P = 0.37).

33.9 (32.2–35.5)
40.2 (38.4–42.0)

30.7 (29.1–32.3)
43.5 (41.7–45.3)
36.9(35.6–38.1)

Out of the 6026 children who underwent cycloplegic refrac-

tometry, 18 children (age: 4 and 5 years) did not sufficiently
cooperate for a reliable visual acuity test, so that data of visual
acuity measurements were eventually available for 6008 children
Myopia

(Table 5). Out of these 6008 children, 1628 (27.1%) children had
1079
1142

1267
2221
954

an uncorrected visual acuity (UCVA) of 20/40 or worse in the

n

better eye, and 156 (2.6%) children had an UCVA of 20/200 or

less in the better eye (Table 5). UCVA was significantly associated
with female gender (OR: 1.36 (95%CI: 1.22–1.53; P,0.001) and
Prevalence

1.6 (1.2–2.0)
2.4 (1.8–3.0)

1.3 (0.9–1.7)
2.7 (2.1–3.3)
2.0 (1.6–2.3)

rural region (P,0.001; OR: 1.75 (95%CI: 1.56–1.96). Using the

same categorization as the one used by Xiang and colleagues, a
High Myopia

(%)

normal vision (UCVA in the better eye $6/6) was achieved by

60.2% children, a mildly reduced visual acuity (6/9,UCVA,6/
6) by 7.8% of the children, a moderately reduced visual acuity (6/
118
51
67

40
78
n

18,UCVA #6/9) by 12.2% of the children, and a severely

doi:10.1371/journal.pone.0082763.t003

reduced visual acuity (UCVA #6/18) by 19.7% of the children

Number

[39]. UCVA strongly decreased with older age (P,0.001;

3186
2839

3111
2914
6025

regression coefficient B: 20.05; standardized regression coefficient

r: 20.48).
Out of the 6008 children with visual acuity measurements, 2046
(34.05%) children had an UCVA of #20/40 in at least one eye
(Table 6). Out of these 2046 children, 1975 (96.6%) children
achieved a visual acuity of $20/32 by providing adequate
Gender

Region
Female

correction of refractive error. Using BCVA, 19 (0.32%) children

Urban
Total
Rural
Male

had a BCVA of #20/40 in the better eye, and there was no child
with a BCVA #20/200 in the better eye. BCVA was significantly

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 Refractive Error in Shandong

Table 4. Mean refractive error (mean 6 standard deviation) in the Shandong Children Eye Study stratified by age, gender and
region of habitation (n: Number of children).

Refractive Error (Diopters) Mean ±

Age (Years) Gender Region of Habitation n Standard Deviation

4 Boys Rural 25 1.3760.47

Urban 38 1.5061.64
Girls Rural 17 1.5760.73
Urban 35 1.1361.13
5 Boys Rural 105 1.4360.82
Urban 103 1.3060.93
Girls Rural 69 1.5560.68
Urban 84 1.3761.22
6 Boys Rural 136 1.5661.08
Urban 128 1.2161.02
Girls Rural 81 1.2961.29
Urban 98 1.1960.88
7 Boys Rural 181 1.1760.79
Urban 182 0.5761.07
Girls Rural 118 1.2760.79
Urban 161 1.0760.97
8 Boys Rural 207 0.8661.28
Urban 178 0.3561.46
Girls Rural 174 0.5461.81
Urban 186 0.2261.59
9 Boys Rural 172 0.4461.31
Urban 120 20.3461.50
Girls Rural 111 0.3061.41
Urban 147 0.0761.85
10 Boys Rural 181 0.1961.36
Urban 178 20.7161.68
Girls Rural 155 0.4461.52
Urban 190 20.5261.88
11 Boys Rural 164 20.2361.70
Urban 145 20.8561.81
Girls Rural 157 20.3461.93
Urban 124 1.2461.96
12 Boys Rural 130 20.47621.57
Urban 133 21.1962.01
Girls Rural 121 20.4961.70
Urban 104 21.7662.13
13 Boys Rural 120 20.7362.15
Urban 107 21.6062.43
Girls Rural 128 210.0161.84
Urban 84 21.8862.07
14 Boys Rural 94 20.9462.07
Urban 65 22.5962.22
Girls Rural 107 1.4062.24
Urban 75 22.9162.22
15 Boys Rural 58 20.6462.15
Urban 64 23.0562.81
Girls Rural 55 21.6162.19
Urban 55 22.9762.10

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 Refractive Error in Shandong

Table 4. Cont.

Refractive Error (Diopters) Mean ±

Age (Years) Gender Region of Habitation n Standard Deviation

16 Boys Rural 36 21.2962.60

Urban 23 23.3962.43
Girls Rural 37 22.2762.61
Urban 40 23.8662.33
17 Boys Rural 37 22.0261.97
Urban 15 24.6362.14
Girls Rural 34 21.6862.13
Urban 44 23.8962.27
18 Boys Rural 55 21.9061.94
Urban 4 23.8162.39
Girls Rural 45 22.4261.98
Urban 3 24.6761.01

doi:10.1371/journal.pone.0082763.t004

higher in the urban region of habitation (P,0.001) and did not Greater Beijing giving another example for the increased
differ significantly (P = 0.49) between boys and girls. Amblyopia prevalence of myopia across the generations [42]. Correspond-
(defined as BCVA #20/32, explained by factors such as ingly, a recent study from Beijing showed that the refractive error
strabismus or refractive errors, and no morphological reason for of children at the age of 11 years was similar to that of their
BCVA reduction) was the reason for reduced visual acuity in 44 parents, while children at the age of 18 years were up to 2.0 D
children (2.15% of the 2046 or 0.73% of the total study more myopic than their parents [43].
population), with 11 children having bilateral amblyopia. Nine The prevalence of high myopia of 13.9% in the 17-year-old
of these children had bilateral hyperopia and two children were children of our study was higher than in most previous children
highly myopic in both eyes with a myopic refractive error of studies, and it was markedly higher than in the Beijing Eye Study
#27.38 D and #211.00 D in both eyes, respectively. In 33 on adults (2.6%; 95%CI: 2.2, 3.1). Interestingly, the prevalence of
children, amblyopia was unilateral with hyperopia being the cause high myopia showed a particular pattern, with the prevalence of
in 10 children and anisometropia in 23 children. Other causes of high myopia starting to increase around the age of 10–12 years
reduced vision were congenital cataract, corneal opacity due to (Fig. 3). This pattern has also been previously reported from
keratitis, lens injury, bilateral optic nerve atrophy and unilateral Taiwan and from Guangzhou, and Xiang and colleagues have
phthisis bulbi. Visual impairment in 28 eyes of 22 children suggested that it should be called ‘‘acquired high myopia’’, because
remained unexplained. the age of onset roughly corresponded to the time it would take for
early onset myopia to progress to high myopia [23,44,45].
Discussion Since the prevalence of high myopia increased with older age,
one can assume that that the prevalence of high myopia in the
Our school-based study was performed in a rural region and in
school children of our study will further increase when the children
a city in the East Chinese province of Shandong. The overall
prevalence of myopia was 36.960.6% and increased from get older. It agrees with the high prevalence of high myopia of
1.761.2% in the 4 years olds to 84.663.2% in 17-year olds. 20% found in recent studies on university students in Shanghai
Prevalence of myopia was associated with female gender, urban and on military conscripts in urban and rural Korea [31–33].
region of habitation and increasing age. The prevalence of high Since high myopia can lead to vision threatening ocular disorders,
myopia was 2.060.2% and increased from 0.760.3% in 10-years the impact of myopia on Public Health in China will therefore
olds to 13.963.0 in the 17-years olds. As myopia in general, high markedly increase. In the adult population in China, degenerative
myopia was associated with urban region but not with gender. myopia is responsible for one third of the causes of visual
Astigmatism was found in 36.360.6% of the children, and it was impairment and is second only to cataract [1].
associated with older age, urban region and more myopic Out of 6008 children, 2046 (34.05%) children had an UCVA of
refractive error. Anisometropia was detected in 7.060.3% of the #20/40 in at least one eye, with refractive error being the cause in
study population in association with older age and urban region. 1975 (32.9%) children. This prevalence of 32.9% of refractive
These results agree with previous population-based and school- error as cause for UCVA was comparable to the figures found in
based investigations in China documenting a marked increased the recent Global Burden of Disease Study, in which refractive
prevalence of myopia in the younger generation [22–27]. It is in error was the most common cause for UCVA [46]. Among the
contrast to other countries such as Laos, Iran, South Africa, causes for a reduced BCVA, amblyopia was the most common one
Morocco, Brazil and Poland and Scandinavian countries, in which in our study population, although the prevalence of amblyopia was
either no increased prevalence of myopia or a considerably less relatively low (0.73%). The prevalence of amblyopia of 0.73% in
marked increase in the prevalence of myopia has been reported our study population was in agreement with the prevalence of
[5,8,11–18,21,40,41]. The prevalence of low to medium myopia 0.8% found in the Singaporean Preschoolers Study [47].
was markedly higher in the present Shandong Children Eye Study UCVA strongly decreased with older age in our study
than in the previous study on adults in the neighboring region of population. It confirms the recent study by Xiang and colleagues

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 Refractive Error in Shandong

Table 5. Distribution of uncorrected and best corrected visual acuity in each visual acuity category, given in number, percentage
and 95% confidence interval (CI).

Visual Acuity Category Uncorrected Visual Acuity Best Corrected Visual Acuity

Number Percentage (95%CI) Number Percentage (95%CI)

$20/32 in both eyes 3962 65.8 (64.6–67.0) 5938 98.8(98.5–99.1)

$20/32 in one eye 418 7.0 (6.3–7.6) 51 0.8 (0.6–1.1)
20/40 to 20/63 in better eye 684 11.4 (10.6– 12.2) 17 0.3 (0.2–0.4)
20/80 to 20/160 in better eye 788 13.1 (12.2–13.9) 2 0.03(0.01–0.1)
#20/200 in better eye 156 2.6 (2.2–3.0) 2 2
Total 6008 100 6008 100

doi:10.1371/journal.pone.0082763.t005

who estimated the prevalence of myopia based on reduced prevalence of astigmatism in our study population was relatively
unaided visual acuity in Chinese school children in Guangzhou high, with higher rates reported only in studies from Singapore
over the past 20 years [39]. They found that in 1988, over 80% and Guangzhou [10,23]. Potential limitations of our study should
of children in grade 1 (age 6 years) and about 30% in Grade 12 be mentioned. Firstly, Shandong providence in coastal East China
(age 17 years) had normal UCVA. By 2007, these figures is not representative of China as a whole, although our study
dropped to only 60% in grade 1 and about 10% in Grade 12. In included an urban part and a rural region. Shandong is
the period from 2003 to 2007, the figures remained unchanged economically less developed than the metropolitan regions of
at both the grade 1 and grade 12 levels. The authors concluded Beijing, Shanghai and Guangzhou, and it is better developed than
that the prevalence of reduced UCVA increased markedly in the provinces of Inner Mongolia or Western China. Secondly, our
children from Guangzhou over the last 20 years, but stabilized in investigation was a cross-sectional study which did not allow
the past few years. drawing conclusions on a longitudinal course and causal
The overall prevalence of mild hyperopia and medium to relationship between parameters. Any statement about an increase
marked hyperopia in our study was 42.8% and 5.8% respectively, in the prevalence of myopia in our study was therefore meant only
and as a corollary to the prevalence of myopia, it decreased with in a cross sectional manner when comparing younger children
older age (Fig. 3). Again as a corollary to the prevalence of myopia, with older children. Thirdly, in a similar manner, the comparison
the prevalence of hyperopia overall was associated with younger in the prevalence of myopia in children from Shandong with the
age and rural region of habitation. The decrease in the prevalence prevalence of myopia in adults from Beijing is not quite correct in
of hyperopia overall and the increase in the prevalence of myopia view of the different locations. The comparison of the data from
with increasing age of the children as found in our study the children from Shandong with the data from the adults from
population from Shandong was similar to changes as described Beijing however is however in agreement with the comparison
by Morgan and colleagues in the Guangzhou ‘‘Refractive Error from children and adults in Beijing and from children and adults
Study in Children’’ study [37]. Interestingly and in contrast to in Guangzhou [23,26,48,49], although also in the latter compar-
myopia, hyperopia overall was not significantly correlated with isons, issues about longitudinal changes remained resolved.
gender in our study. Fourthly, although the response rate in our study to participate
Astigmatism was detected in 36.3% of the children in our in the cycloplegic examination was relatively high with 94.7%, the
survey. Its mean amount was 0.4360.51 diopters. It was group of 18-years old teenagers had a relatively low response rate
associated with older age and more myopic refractive error. The of 70.4% (Table 1). It may have been the reason why the

Table 6. Causes of Uncorrected Visual Acuity (#20/40) in the Shandong Children Eye Study.

Cause of Uncorrected Percentage of Children with Uncorrected

Visual Acuity Number of Visual Acuity #20/40 in the
of #20/40 Right Eyes* Left Eyes* Children* Total Study Population

Undercorrected Refractive 1810 (97.6%) 1774 (97.5%) 1975 (96.6%) 32.87%

Error
Amblyopia 29 (1.56%) 26 (1.43%) 44 (2.15%) 0.73%
Corneal Opacity 0 (0%) 1 (0.05%) 1 (0.05%) 0.02%
Lens Disease 1 (0.05%) 2 (0.11%) 2 (0.10%) 0.03%
Fundus Disorder 1 (0.05%) 1 (0.05%) 1 (0.05%) 0.02%
Other Disease 0 (0%) 1 (0.05%) 1 (0.05%) 0.02%
Unexplained 14 (0.75%) 14 (0.77%) 22 (1.08%) 0.37%
Total 1855 (100%) 1819 (100%) 2046 (100%) 34.05%

*: % refers to the total group of children with uncorrected visual acuity of #20/40 (n = 2046 children).
doi:10.1371/journal.pone.0082763.t006

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 Refractive Error in Shandong

prevalence of high myopia was considerably lower in the 18-years In conclusion, in coastal East China, about 14% of the 17-years
old group than in the 17-years old group (13.8% (95%CI: 8.6, olds were highly myopic, and 80% were myopic. Prevalence of
20.5) versus 2.8% (0.7, 7.1), so that we mainly reported on the myopia increased with older age, female gender and urban region.
prevalence of high myopia in the 17-years old children. Fifthly, our About 0.7% of pre-school children and school children were
study protocol was not completely consistent with the one applied amblyopic. The marked increase in the prevalence of myopia, in
by the Refractive Error Study in Children (RESC). We used a particular of high myopia, in the young generation of China as
tumbling E chart, while the RESC used an ETDRS (Early compared to elderly population groups will be of importance for
Treatment of Diabetic Retinopathy Study) Eye Chart. Sixthly, future public health politics and warrants measures to prevent the
while school participation is, for all practical purposes, universal in development of myopia.
China, this is not true at the kindergarten level. There may
therefore have been a sampling bias in the 4 and 5 year-olds. Author Contributions
Seventhly, we defined astigmatism as a cylindrical refractive error
Conceived and designed the experiments: JFW HSB SMW YYH HW WS
$0.75D in either eye. Since other studies used a cut-off value of TLL XRW JBJ. Performed the experiments: JFW HSB SMW YYH HW
1.00 diopters [6,26], differences in the prevalence of astigmatism WS TLL XRW. Analyzed the data: JFW HSB SMW YYH HW WS TLL
between our study and other investigations may also be due to the XRW JBJ. Contributed reagents/materials/analysis tools: HSB. Wrote the
difference in the definition of astigmatism. paper: JFW HSB SMW YYH HW WS TLL XRW JBJ.

References
1. Xu L, Wang Y, Li Y, Wang Y, Cui T, et al. (2006) Causes of blindness and visual 21. French AN, Morgan IG, Burlutsky G, Mitchell P, Rose KA (2013) Prevalence
impairment in an urban and rural area in Beijing: the Beijing Eye Study. and 5- to 6-year incidence and progression of myopia and hyperopia in
Ophthalmology 113: 1134.e1–11. Australian schoolchildren. Ophthalmology 120: 1482–1491.
2. Morgan IG, Ohno-Matsui K, Saw SM (2012) Myopia. Lancet 379: 1739–1748. 22. Zhao J, Pan X, Sui R, Munoz SR, Sperduto RD, et al. (2000) Refractive Error
3. Xu L, Wang Y, Wang S, Wang Y, Jonas JB (2007) High myopia and glaucoma Study in Children: results from Shunyi District, China. Am J Ophthalmol 129:
susceptibility. The Beijing Eye Study. Ophthalmology 114: 216–220. 427–435.
4. Liu HH, Xu L, Wang YX, Wang S, You QS, et al. (2010) Prevalence and 23. He M, Zeng J, Liu Y, Xu J, Pokharel GP, et al. (2004) Refractive error and
progression of myopic retinopathy in Chinese adults: The Beijing Eye Study. visual impairment in urban children in southern China. Invest Ophthalmol Vis
Ophthalmology 117: 1763–1768. Sci 45: 793–799.
5. Villarreal MG, Ohlsson J, Abrahamsson M, Sjöstrom A, Sjöstrand J (2000) 24. Tong L, Saw SM, Chia KS, Tan D (2004) Anisometropia in Singapore school
Myopisation: the refractive tendency in teenagers. Prevalence of myopia among children. Am J Opthalmol 137: 474–479.
young teenagers in Sweden. Acta Ophthalmol Scand 78: 177–181. 25. Fan DS, Lam DS, Lam RF, Lau JT, Chong KS, et al. (2004) Prevalence,
6. Murthy GV, Gupta SK, Ellwein LB, Muñoz SR, Pokharel GP, et al. (2002) incidence, and progression of myopia of school children in Hong Kong. Invest
Refractive error in children in an urban population in New Delhi. Invest Ophthalmol Vis Sci 45: 1071–1075.
Ophthalmol Vis Sci 43: 623–631. 26. He M, Huang W, Zheng Y, Huang L, Ellwein LB (2007) Refractive error and
7. Naidoo KS, Raghunandan A, Mashige KP, Govender P, Holden BA, et al. visual impairment in school children in rural southern China. Ophthalmology
(2003) Refractive error and visual impairment in African children in South 114: 374–382.
Africa. Invest Ophthalmol Vis Sci 44: 3764–3770. 27. Congdon N, Wang Y, Song Y, Choi K, Zhang M, et al. (2008) Visual disability,
8. Villarreal GM, Ohlsson J, Cavazos H, Abrahamsson M, Mohamed JH (2003) visual function, and myopia among rural chinese secondary school children: the
Prevalence of myopia among 12- to 13-Year- old schoolchildren in Northern Xichang Pediatric Refractive Error Study (X-PRES)–report 1. Invest Ophthal-
Mexico. Optom Vis Sci 80: 369–373. mol Vis Sci 49: 2888–2894.
9. Goh PP, Abqariyah Y, Pokharel GP, Ellwein LB (2005) Refractive error and 28. You QS, Wu LJ, Duan JL, Luo YX, Liu LJ, et al. (2012) Factors associated with
visual impairment in school-age children in Gombak District, Malaysia. myopia in school children in China: The Beijing Childhood Eye Study. PLoS
Ophthalmology 112: 678–685. One 7: 1–10.
10. Saw SM, Goh PP, Cheng A, Shankar A, Tan DT, et al. (2006) Ethnicity-specific 29. Pi LH, Chen L, Liu Q, Ke N, Fang J, et al. (2012) Prevalence of eye diseases and
prevalences of refractive errors vary in Asian children in neighbouring Malaysia causes of visual impairment in school-aged children in western China.
and Singapore. Br J Ophthalmol 90: 1230–1235. J Epidemiol 22: 37–44.
11. Fotouhi A, Hashemi H, Khabazkhoob M, Mohammad K (2007) The prevalence 30. Li Z, Xu K, Wu S, Lv J, Jin D, et al. (2013) Population-based survey of refractive
of refractive errors among school-children in Dezful, Iran. Br J Ophthalmol 91: error among school-aged children in rural northern china: the heilongjiang eye
study. Clin Experiment Ophthalmol. 2013 Aug 16. doi: 10.1111/ceo.12198.
287–292.
[Epub ahead of print].
12. Czepita D, Zejmo M, Mojsa A (2007) Prevalence of myopia and hyperopia in a
31. Sun J, Zhou J, Zhao P, Lian J, Zhu H, et al. (2012) High prevalence of myopia
population of Polish schoolchildren. Ophthalmic Physiol Opt 27: 60–65.
and high myopia in 5060 Chinese university students in Shanghai. Invest
13. Salomao SR, Cinoto RW, Berezovsky A, Mendieta L, Nakanami CR, et al.
Ophthalmol Vis Sci 53: 7504–7509.
(2008) Prevalence and causes of visual impairment in low-middle income school
32. Jung SK, Lee JH, Kakizaki H, Jee D (2012) Prevalence of myopia and its
children in Sao Paulo, Brazil. Invest Ophthalmol Vis Sci 49: 4308–4313.
association with body stature and educational level in 19-year-old male
14. Ip JM, Huynh SC, Robaei D, Rose KA, Morgan IG, et al. (2008) Ethnic conscripts in Seoul, South Korea. Invest Ophthalmol Vis Sci 53: 5579–5583.
differences in refraction and ocular biometry in a population-based sample of
33. Lee SJ, Urm SH, Yu BC, Sohn HS, Hong YS, et al. (2011) [The prevalence of
11-15-year-old Australian children. Eye 22: 649–656.
high myopia in 19 year-old men in Busan, Ulsan and Gyeongsangnam-do]. J
15. Anera RG, Soler M, de la Cruz Cardona J, Salas C, Ortiz C (2009) Prevalence Prev Med Public Health.;44: 56–64.
of refractive errors in school-age children in Morocco. Clin Experiment 34. http://www.stats.gov.cn/english/statisticaldata/censusdata/rkpc2010/indexch.
Ophthalmol 37: 191–196. htm; Assessed: May 27th, 2013.
16. Jamali P, Fotouhi A, Hashemi H, Younesian M, Jafari A (2009) Refractive errors 35. McKean-Cowdin R, Cotter SA, Tarczy-Hornoch K, Wen G, Kim J, et al.
and amblyopia in children entering school: Shahrood, Iran. Optom Vis Sci 86: (2013) Prevalence of amblyopia or strabismus in Asian and Non-Hispanic white
364–369. preschool children: Multi-Ethnic Pediatric Eye Disease Study. Ophthalmology
17. Yekta A, Fotouhi A, Hashemi H, Dehghani C, Ostadimoghaddam H, et al. 120: 2117–2124.
(2010) Prevalence of refractive errors among schoolchildren in Shiraz, Iran. Clin 36. Tarczy-Hornoch K, Cotter SA, Borchert M, McKean-Cowdin R, Lin J, et al.
Experiment Ophthalmol 38: 242–248. (2013) Prevalence and causes of visual impairment in Asian and Non-Hispanic
18. Ostadimoghaddam H, Fotouhi A, Hashemi H, Yekta A, Heravian J, et al. (2011) white preschool children: Multi-Ethnic Pediatric Eye Disease Study. Ophthal-
Prevalence of the refractive errors by age and gender: the Mashhad eye study of mology 120: 1220–1226.
Iran. Clin Experiment Ophthalmol 39: 743–751. 37. Morgan IG, Rose KA, Ellwein LB; Refractive Error Study in Children Survey
19. Casson RJ, Kahawita S, Kong A, Muecke J, Sisaleumsak S, et al. (2012) Group (2010) Is emmetropia the natural endpoint for human refractive
Exceptionally low prevalence of refractive error and visual impairment in development? An analysis of population-based data from the refractive error
schoolchildren from Lao People’s Democratic Republic. Ophthalmology 119: study in children (RESC). Acta Ophthalmol 88: 877–884.
2021–2027. 38. Negrel AD, Maul E, Pokharel GP, Zhao J, Ellwein LB. Refractive error study in
20. O’Donoghue L, McClelland JF, Logan NS, Rudnicka AR, Owen CG, et al. children: sampling and measurement methods for a multi-country survey.
(2013) Profile of anisometropia and aniso-astigmatism in children: prevalence Am J Ophthalmol 2000;129: 421–426.
and association with age, ocular biometric measures, and refractive status. Invest 39. Xiang F, He M, Zeng Y, Mai J, Rose KA, et al. (2013) Increases in the
Ophthalmol Vis Sci 54: 602–608. prevalence of reduced visual acuity and myopia in Chinese children in

PLOS ONE | www.plosone.org 11 December 2013 | Volume 8 | Issue 12 | e82763

 Refractive Error in Shandong

Guangzhou over the past 20 years. Eye (Lond) 2013 Sep 6. doi: 10.1038/ 45. Xiang F, He M, Morgan IG (2012) The impact of severity of parental myopia on
eye.2013.194. [Epub ahead of print]. myopia in Chinese children. Optom Vis Sci 89: 884–891.
40. Fledelius HC (2000) Myopia profile in Copenhagen medical students 1996–98. 46. Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, et al. (2012) Disability-
Refractive stability over a century is suggested. Acta Ophthalmol Scand 78: 501– adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–
505. 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet
41. Midelfart A, Kinge B, Midelfart S, Lydersen S (2002) Prevalence of refractive 380: 2197–223.
errors in young and middle-aged adults in Norway. Acta Ophthalmol Scand 80: 47. Chia A, Lin X, Dirani M, Gazzard G, Ramamurthy D, et al. (2013) Risk factors
501–505. for strabismus and amblyopia in young Singapore Chinese children. Ophthalmic
42. Xu L, Li J, Cui T, Hu A, Fan G, et al. (2005) Refractive error in urban and rural Epidemiol 20: 138–147.
adult Chinese in Beijing. Ophthalmology 112: 1676–1683. 48. He M, Huang W, Li Y, Zheng Y, Yin Q, et al. (2009) Refractive error and
43. Liang YB, Lin Z, Vasudevan B, Jhanji V, Young A, et al. (2013) Generational biometry in older Chinese adults: the Liwan eye study. Invest Ophthalmol Vis
difference of refractive error in the baseline study of the Beijing Myopia Sci 50: 5130–5136.
Progression Study. Br J Ophthalmol 97: 765–769. 49. Liang YB, Lin Z, Vasudevan B, Jhanji V, Young A, et al. (2013) Generational
44. Xiang F, He M, Morgan IG (2012) The impact of parental myopia on myopia in difference of refractive error in the baseline study of the Beijing Myopia
Chinese children: population-based evidence. Optom Vis Sci 89: 1487–1496. Progression Study. Br J Ophthalmol 97: 765–769.

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