Acta Ophthalmologica 2020

High prevalence of myopia in children and their

parents in Hong Kong Chinese Population: the
Hong Kong Children Eye Study
Jason C. Yam,1,2 Shu Min Tang,1,3 Ka Wai Kam,1,4 Li Jia Chen,1,4 Marco Yu,1,5
Antony K. Law,1 Benjamin H. Yip,6 Yu Meng Wang,1 Carol Y. L. Cheung,1 Danny S.C. Ng,1
Alvin L. Young,1,4 Clement C. Tham1 and Chi Pui Pang1
1
Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Kowloon, Hong Kong
2
Hong Kong Eye Hospital, Hong Kong, Hong Kong
3
Department of Ophthalmology, The First Affiliated Hospital of Fujian Medical University, Fujian, China
4
Department of Ophthalmology and Visual Sciences, Prince of Wales Hospital, Kowloon, Hong Kong,
5
Department of Mathematics and Statistics, Hang Seng Management College, Hong Kong, Hong Kong
6
Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore

ABSTRACT. half of the world’s population will have

Purpose: To determine the myopia prevalence in Hong Kong Chinese children become myopic by 2050, with as much
and their parents. as 10% being high myopia (Holden
Methods: It was a population-based cross-sectional study. A total of 4257 et al. 2016). Notably, high myopia is
children aged 6–8 years, and 5880 parents were recruited in the Hong Kong associated with the excessive growth of
Children Eye Study. Cycloplegic autorefraction was measured for children; and the eyeball and with the increasing risk
non-cycloplegic autorefraction for parents. Parental educational level, children’s of sight-threatening complications,
outdoor time, and near work were collected by validated questionnaires. including presenile cataract, glaucoma,
retinal detachment, choroidal neovas-
Results: In children aged 6–8 years, 25.0% were myopic, and among them,
cularization, myopic macular degener-
12.7% for the 6-year-olds, 24.4% for the 7-year-olds and 36.1% for the 8-year-
ation and macular haemorrhage (Lam
old. About 0.7% of children aged 8 years were high myopia. In all age groups, et al. 2005; Saw et al. 2005; Fujimoto
boys (their myopia rate: 13.9% at 6 years, 26.7% at 7 years, and 38.3% at et al. 2010; Takahashi et al. 2012;
8 years) were more myopic than girls (11.3% at 6 years, 22.0% at 7 years, Chang et al. 2013; Cho et al. 2016). It
33.4% at 8 years). Among parents, 72.2% were myopic (mother, 73.2%; father, is therefore a major public health
70.7%) and 13.5% high myopia (mother, 12.8%; father, 14.5%). It was concern, putting heavy health and eco-
observed that prevalence decreased with ages and increased with education level. nomic burden on the society. Of para-
Conclusion: There is a strikingly high prevalence of myopia in Hong Kong mount importance in this area are the
children aged 6–8, much higher than that of other regions of China. Of note, the identification of both environmental
prevalence of children was similar to that in 15 years ago. Furthermore, the and genetic risk factors of myopia
myopia prevalence of parents is high, and it had already increased in this cohort. development, as well as the measures
Prevention of childhood myopia is important, likewise for visual complications to prevent its onset progression. Hong
from high myopia in adults. Kong is a city located in southern
China and has one of the highest
prevalence rates of myopia throughout
Key words: adults – children – high myopia – myopia – prevalence – refractive errors
the world (Fan et al. 2004). Children
in Hong Kong experience intense aca-
Acta Ophthalmol. demic pressure under its competitive
ª 2020 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
education system (Hanushek 2006). In
doi: 10.1111/aos.14350 a school-based study conducted in
2004, the prevalence and incidence
prevalence over the past decades, espe- of myopia in Hong Kong were found
Introduction cially in the East Asian populations to be higher than that in Western
Myopia is the most common ocular (Lin et al. 2004; Dolgin 2015; Holden populations (Fan et al. 2004). With
disorder worldwide with increasing et al. 2016). It is predicted that nearly the recent increased popularity of

1
Acta Ophthalmologica 2020
electronic device usage, it has been
postulated that the prevalence of child-
hood myopia will surge to an even
higher level (Dirani et al. 2019). A high
prevalence of adult myopia in Hong
Kong has been reported in smaller
studies previously (Goh & Lam 1994;
Lam et al. 1994), but more recent data
have not been reported. These data are
highly relevant to public health because
the well-being of the working popula-
tion is likely to substantially affect the
social and economic development.
We therefore conducted the Hong
Kong Children Eye Study, a popula-
tion-based cohort that determines the
prevalence and incidence of myopia
and other children eye diseases in Hong
Kong, along with detailed ocular phe-
notyping and genotyping, and a longi-
tudinal follow-up. The study also
included ophthalmic investigations of
the parents. This article presents the
prevalence of myopia in both school
children and their parents.
Methods
Sample size consideration
According to previous studies, preva-
lence of major childhood eye diseases
was 1.3–7.7% in amblyopia (Robaei
et al. 2008; Pascual et al. 2014; Xiao
et al. 2015), 2.3–6% in strabismus
(Multi-ethnic Pediatric Eye Disease
Study Group 2008; Cheng et al. 2013)
and 5.7–78.4% in myopia (Fan et al.
2004; He et al. 2004; Rose et al. 2008a,
b). Prevalence of myopia in children
aged 5–15 was reported in He et al.
(2004) The mean 2-year accumulative
incidence of myopia in children aged 5–
9 was estimated to be 23.7%. Assuming
a design effect of 2.0, type 1 error of
0.05% and 20% lost to follow-up, 4355
children were minimal sample size and
sufficient power to detect a relative risk
of 1.25 for association between incident
myopia and a range of exposures in this
cohort. The power was also sufficient
to detect an odds ratio around 2
between prevalent eye disease and a
range of exposures for a prevalence
rate 1.3%. Therefore, we planned for a
total of 5000 children as the target
sample size for our study.
Sampling procedures
The sample selection was completed
based on a stratified and clustered
2
randomized sampling frame. We strat-
ified all Education Bureau registered
primary schools (n = 571) into the
seven cluster regions used by the
Hospital Authority Services in Hong
Kong: Hong Kong East Cluster, Hong
Kong West Cluster, Kowloon Central
Cluster, Kowloon West Cluster, Kow-
loon East Cluster, New Territories East
Cluster, and New Territories West
Cluster. This division into seven clus-
ters is determined by Hong Kong
Government according to even distri-
bution of population density in each
cluster. Therefore, 714 children should
be recruited from each cluster region.
The schools in each cluster region were
randomly assigned an invitation prior-
ity according to the ranking numbers
generated by computer. Invitations to
participate in the cohort were sent
according to the ranking numbers until
the required sample was achieved in
each cluster region.
The project conformed to the tenets
of the Declaration of Helsinki and has
obtained ethical approval from the
Institutional Review Board of the Chi-
nese University of Hong Kong.
Informed consent was obtained from
all participants. Detailed protocol of
the study is attached in the
Appendix S1. A total of 5000 children
were invited to join this study, of which
4305 children actually participated.
Forty-eight children who did not com-
plete cycloplegic refraction were
excluded. Finally, 4257 children have
completed cycloplegia refraction and
ocular biometry data (response rate
being 85.1%), including 2230 boys and
2027 girls aged 6–8 years, and 5880
parents, composed of 2512 men and
3368 women. The mean age of children
was 7.61  0.97 years; and the mean
age of adults 41.06  5.95 years
(range: 24–73 years).
Refraction and ocular examinations
Cycloplegic autorefraction was per-
formed for each child using an autore-
fractor (ARK-510A, Nidek,
Gamagori, Japan). The cycloplegic
regimen consisted of at least two
cycles of eye drops. At the first cycle,
two separate eye drops, cyclopentolate
1% (Cyclogyl, Alcon-Convreur, Rijk-
sweg, Belgium) and tropicamide 1%
(Santen, Osaka, Japan), were admin-
istered to both eyes at 5 min apart. A
second cycle of the same cycloplegic
drops was administered 10 min after
the first cycle. A third cycle of the
same cycloplegic eye drops was given
30 min after the second cycle if pupil-
lary light reflex was still present or if
the pupil size was <6.0 mm. Further
cycles of cycloplegic eye drops would
be administered if it was necessary to
ensure that the pupils are well dilated.
Five readings, all of which had to be
<0.25 D apart, were obtained and
averaged, at 30 min after the last drop
of cycloplegic agent. If cycloplegia
failed to reach these criteria, the chil-
dren were excluded from the analysis.
Those who could not complete the
cycloplegia as above were also
excluded from this study. Non-cyclo-
plegic refraction was measured for
each parent. Ocular biometry includ-
ing axial length (AL) and corneal
curvature was measured with noncon-
tact partial-coherence laser interferom-
etry (IOL Master; Carl Zeiss Meditec,
Oberkochen, Germany). Axial length
(AL) was measured as the distance
from the anterior corneal vertex to the
retinal pigment epithelium along fixa-
tion, automatically adjusted for retinal
thickness. Corneal radius of curvature
(CR), determined from the reflection
of a hexagonal array of lights on the
cornea, was measured along the flat-
test and steepest meridians. Axial
length (AL)/CR ratio was calculated
by dividing AL by mean CR.
All operators were well-trained and
assessed before conducting examina-
tions on subjects. All examinations
followed standard operating proce-
dures and were supervised by the prin-
cipal investigator (J.C.Y.).
Questionnaires on parental educational
level, children’s outdoor activities, and
near work
Validated questionnaires used in our
study were mainly derived from the
Chinese version of that used in the
Sydney Myopia Study (Ojaimi et al.
2005; Li et al. 2013) to facilitate com-
parison between the two studies. First,
adjustments for cultural differences and
local dialect were implemented by dis-
cussing with the representatives of local
teachers, parents and ophthalmologists
to make the questionnaires culturally
appropriate and linguistically accurate.
Second, a pilot study was performed
among 100 children’s parents to verify
the questionnaires’ reliability and

validity. For outdoor activity, it was
found that the overall intraclass corre-
lation coefficient between two repeated
surveys (with an interval of 4 weeks)
was 0.72, and the Cronbach’s alpha
coefficient of each item was 0.68. The
near-work activities included home-
work and pleasure reading. Watching
television (TV), videos, digital video
discs and playing computer games were
classified as a midrange activities.
Diopter-hour was defined as: (hours
spent studying + hours spent reading
for pleasure)*3 + (hours spent playing
video games or working on the com-
puter at home)*2 + (hours spent
watching television) *1. Total outdoor
activities were divided into two cate-
gories, outdoor for leisure (including
walking, riding a bike, playing in park
and picnic) and sport activities. The
average number of outdoor activity
hours per day was calculated using
the formula: ((hours spent on weekday)
*5 + (hours spent on weekend day)
*2)/7. High parental education level
was defined as possessing a bachelor’s
degree or higher.
All data of questionnaires were dou-
ble entered to ensure the integrity and
precision at site. And for the missing
data in the questionnaires, the parents
would be further contacted for com-
pletion.
Definitions
Spherical equivalent refraction (SER)
was defined as spherical diopters (D)
plus one-half of cylindrical diopters. In
children aged 6–8 years, myopia was
defined as SER ≤ 0.50 D, emmetro-
pia as 0.50 D < SER < +0.50 D and
hyperopia as SER ≥ +0.50 D of right
eye. Mild myopia was defined as the
0.50 D ≤ SER < 3.00 D, moderate
myopia as 6.00 D < SER ≤ 3.00 D
and high myopia as SER ≤ 6.00 D of
right eye (Parssinen & Kauppinen
2019). In adults, myopia was defined
as SER ≤ 0.75 D of right eye. Other-
wise, the grading of myopia was similar
with children. Average corneal radius
of curvature (CR) was the average of
the steepest and flattest meridians.
Axial length (AL)/CR ratio was
defined as the ration of the AL to the
average CR of curvature. Only data
from the right eye were included in the
analysis in view of the high correlation
between both eyes (correlation effi-
cient = 0.96).
Statistical analysis
Prevalence and its 95% confidence
interval were calculated in different
refractive categories for both children
and parental cohorts. In both cohorts,
SER, AL and AL/CR ratio were com-
pared using t-tests. Trend analysis and
multiple regressions were performed to
detect any age differences of continu-
ous data. Linear regression analyses
were employed. A p-value of 0.05 or
less was considered statistically signif-
icant. All analyses were performed
using Stata Statistical Software
(version 14.0; StataCorp, College Sta-
tion, TX, USA).
Results
Prevalence of myopia in children aged 6–8
The mean SE of children was 0.14 
1.60 D and the mean AL 23.15 
0.95 mm. Prevalence of myopia was
46.3% according to the non-cycloplegic
refraction and decreased to 25% after
cycloplegia (Table 1). Age-specific myo-
pia rates were 12.7% at 6 years old,
24.4% at 7 and 36.1% at 8. Between the
age of 6 and 8, the mean refraction
changed among boys, from 0.48  1.3
to 0.39  1.93 D and among girls,
from 0.73  1.28 to 0.20  1.67 D;
the mean AL changed among boys, from
23.12  0.76 mm to 23.75  0.98 mm
and among girls, from 22.49  0.74 mm
to 23.19  0.87 mm; the mean AL/CR
changed among boys, from 2.95  0.09
to 3.04  0.11 and among girls, from
2.92  0.09 to 3.01  0.11 (Table 2).
Risk factors of myopia in the children’s
cohort: age, gender, outdoor time, near
work and parental education level
The prevalence of myopia increased
with age (Table 1). Children aged
8 years were at three times higher risk
of developing myopia than children
aged 6 years. Girls were less myopic
than boys and had a lower myopia
rate. A finding worthy of note is that
boys spent more time on outdoor
sports, but also on computers and
electronic devices (Table S1). Higher
parental education level and less out-
door time for leisure were risk factors
for myopia (Table 3). There was no
significant association of myopia with
diopter*hours of near work (Table 3).
Acta Ophthalmologica 2020
In a multivariate model (Table 3),
only parental education level and age
remained as significant risk factors
for myopia. Risk of myopia in boys
was similar to that in girls after
adjustment of near work, time out-
door and parental education level
(Table 3).
Prevalence of myopia in parents
The mean SE of parents was 2.71 
2.95 D (Mother, 2.69  2.89 D;
Father, 2.75  3.03 D) and the mean
AL 24.51  1.44 mm (Mother, 24.23 
1.38 mm; Father, 24.89  1.44 mm).
The overall prevalence of myopia was
72.2%, among which 34.4% was mild
myopia, 24.2% moderate myopia and
13.5% high myopia (Table 4). The mean
SE among their parents in different age
groups varied between 2.11 and
3.00 D, without significant gender dif-
ferences (Table 2). The prevalence
decreased with age in both women and
men (p < 0.001, Table 4). Notably,
77.5% of parents under 35-year-old were
myopic. The prevalence of mild myopia
was higher in younger parents (p < 0.001,
Table 4), but that of moderate myopia
was similar across the ages.
Risk factors of myopia in the parents’
cohort: age and education level effect of
myopia
A higher education level increased the
risk of myopia and high myopia in
parents. The SER was more myopic in
parents with higher education level
(Table S2). Among all groups, the 41-
to 45-year-olds had the highest preva-
lence of moderate and high myopia,
and the highest myopic refraction.
Education level of this age group was
also highest (Table S3).
Discussion
Data on myopia prevalence are
important for health policy planning.
We therefore reported the prevalence
in children (aged 6–8 years) to be
25.0%, and their parents 72.2%, in a
population-based sample in Hong
Kong. Boys were more myopic than
girls, but their risks were similar after
adjustment of near work, outdoor
time and parental education. In
adults, the prevalence decreased with
age but increased with education
level.
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Acta Ophthalmologica 2020

286 (19.1)

670 (44.8)

540 (36.1)
Highest prevalence of childhood myopia in

N = 1496

10 (0.7)
Hong Kong

Total
Our results revealed Hong Kong as
having the highest prevalence of child-

p-value

0.070

0.670

0.071
0.023
hood myopia as compared to other
parts of the world (Table 5) (Dong
et al. 2019). Among 6-year-old chil-

141 (17.4)

359 (44.3)

310 (38.3)
N = 810
dren, the myopia rates were 0.2% to
N (%)

9 (1.1)
Boys

7.4% in China (Zhao et al. 2000; Pi

et al. 2010; Lan et al. 2013; Wu et al.
145 (21.1)

311 (45.3)

230 (33.4)
2013; Li et al. 2014; Guo et al. 2016;
N = 686
8 years

N (%)

1 (0.1)
Qian et al. 2016; Guo et al. 2017a,b; Li
Girls

et al. 2017; Lyu et al. 2015; Chen et al.

2018; Pan et al. 2018), 6.6% in Singa-
378 (25.6)

737 (50.0)

360 (24.4)
N = 1475

3 (0.2) pore (Dirani et al. 2010) and 5.9% in

Total

India (Murthy et al. 2002). It was

31.6% for aged 8 in Taiwan, and
p-value

<2% for ages 6–8 in Nepal. In the

0.013

0.750

0.030
0.093

West, for 6 year-old children, it was

1.4% in Australia (Robaei et al. 2005)
174 (22.9)

383 (50.4)

203 (26.7)

and 2.7% in the Netherlands (Tideman

N = 760
N (%)

3 (0.4)

et al. 2017). Of special note is that the

Boys

prevalence was zero among 4.5–7 years

old in Denmark (Sandfeld et al. 2018).
204 (28.5)

354 (49.5)

157 (22.0)
N = 715

The high prevalence in Hong Kong

7 years

N (%)
Girls

0 (0)

children was also supported by their

longer age-specific ALs and higher age-
specific AL/CR ratios (Table 2). Of
468 (36.4)

655 (50.9)

163 (12.7)
N = 1286

note, comparing with our report, the

3 (0.2)
Total

Berkeley Infant Biometry Study has

reported a higher SE (1.11  1.01 D)
p-value

and shorter AL (22.39  0.71 mm) in

0.076

0.459

0.137
0.091

Chi-squared test was used to assess the difference of refractive errors between boys and girls.

196 Caucasian children aged 6.5 years

old in United States (Mutti et al. 2018).
225 (34.1)

343 (52.0)

92 (13.9)

N = number of cases, SER = spherical equivalent refraction, % = percentage of cases.

A recent study in Beijing reported that

N = 660
N (%)

3 (0.5)

the AL of children aged 5–8 years was

Boys

22.73  0.73 mm, with AL/CR ratio

at 2.91  0.17 (Wang et al. 2018).
243 (38.8)

312 (49.8)

71 (11.3)
N = 626

Similarly, studies from other regions

6 years

N (%)
Girls

0 (0)

in China have also reported a shorter

AL and lower AL/CR ratio among the
1132 (26.6)

2062 (48.4)

1063 (25.0)

same age group, when compared to

N = 4257

16 (0.4)

Hong Kong (Table 5). Quality of

Total

cycloplegia is always an issue when

Table 1. The prevalence of refractive errors in children.

comparing data of this kind. However,

p-value

both AL and CR can be measured

<0.001

0.806

0.001
0.001

accurately without cycloplegia. The

fact that the higher AL/CR ratios and
1085 (48.7)

higher prevalences of myopia appear in

540 (24.2)

605 (27.1)
N = 2230

15 (0.7)

parallel suggests that cycloplegia is not

N (%)
Boys

a major problem.
All age groups

592 (29.2)

977 (48.2)

458 (22.5)
N = 2027

Comparison between Hong Kong and

1 (0.05)
N (%)
Girls

other regions of China

Interestingly, a kindergarten study in
SER < +1.0 D)

Shenzhen of China—a city located

Hypermetropia

Myopia (SER
High myopia
≤ 0.50 D)

≤ 6.00 D)
Emmetropia

geographically adjacent to Hong

Sample size

( 0.5 D <
≥ +1.0 D)

Kong, revealed a myopia prevalence

(SER

(SER

of only 3.7% of children aged 6 years

(Guo et al. 2017a,b), which was one-

4
 Acta Ophthalmologica 2020

p-value*
third lower than our report. Consis-

<0.001
0.442

0.004

<0.001
0.068

<0.001

0.005
<0.001

<0.001
tently, their SE were higher and AL/
CR ratio lower than the 6-years-olds in
Hong Kong (Shenzhen’s 6-year-old

2.44  3.08
2.11  3.43

2.15  3.39

24.23  1.29
24.76  1.66

24.69  1.62
children: SE: 1.23 D, AL/CR 2.91 ver-

3.13  0.17
3.18  0.2

3.17  0.2
sus Hong Kong’s 6-year-old children:
SE 0.6 D, AL/CR 2.94) (Guo et al.

0.094

0.033

0.153
>50

2017a,b). This notable difference in

prevalence between Shenzhen cohort
2.60  3.32
2.93  3.11

2.81  3.30 and our study could be attributed to

24.23  1.49
24.89  1.46

3.13  0.18
3.18  0.18

3.16  0.18
24.63  1.5
the intensity in academic works of the

<0.001

<0.001
respective schooling systems. In the
46–50

0.139

Shenzhen cohort, children aged 6 years

were in kindergartens, while in our
Hong Kong study 6-year-old children
3.00  3.20
2.95  3.02

2.98  3.12

24.43  1.52
24.98  1.46

24.67  1.51

3.14  0.18
3.17  0.18

3.15  0.18
were in grade one, which demands
more near-work activities (Guo et al.
<0.001

<0.001
41–45

0.694

2017a,b). However, in many cities of

China, children also entered primary
school at that age, similar to Hong
2.53  2.65
2.74  2.64

2.60  2.65

24.16  1.27

24.41  1.33
24.9  1.31

3.11  0.16
3.15  0.16

3.12  0.16

Kong, but still their myopia prevalence

was lower (Table 5) (Zhao et al. 2000;
<0.001

<0.001
36–40

0.128
Age of parents (years)

Fan et al. 2004; He et al. 2004; Pi et al.

2010; Lam et al. 2012; Lan et al. 2013;
Li et al. 2013; Wu et al. 2013; Li et al.
2.48  2.41
2.44  2.27

24.02  1.21
24.68  1.21

24.14  1.24

2014; You et al. 2014; Guo et al. 2015;

2.47  2.38

3.09  0.14
3.12  0.14

3.10  0.14

He et al. 2015a,b; Lyu et al. 2015; Guo

<0.001

et al. 2016; Qian et al. 2016; Guo et al.

0.841

0.055
≤35

2017a,b; Wang et al. 2017; Pan et al.

2018). In Guangzhou, its myopia
Mothers + fathers

Mothers + fathers

Mothers + fathers

prevalence of 6- and 7-year-olds were

0.2% and 13.3% respectively, which
was much lower than the rates in Hong
Kong (Guo et al. 2016). In Shanghai,
p-value†

p-value†

p-value†
Mother

Mother

Mother
Father

Father

Father

the prevalence was 5.2% in children

Table 2. Ocular parameters of children and parents in different age groups and genders.

aged 6 years (Ma et al. 2016). Another

Shanghai cohort, the Baoshan Eye
Study, also reported a prevalence lower
p-value*

than our study, with a 19.4% myopia

<0.001
<0.001

<0.001

<0.001
<0.001

<0.001

<0.001
<0.001

<0.001

rate at 8 years-old. Of note, SE and

AL/CR ratio of our 6-year-old children
* Trend analysis to analyse the difference across different age groups.

were comparable to their 8-year-old

0.20  1.67
0.39  1.93

0.30  1.82

23.19  0.87
23.75  0.98

23.49  0.97

3.01  0.11
3.04  0.11

3.03  0.11

Shanghai children, and our 8-year-olds

comparable to their 10-year-olds (He
<0.001

<0.001

t-test to analyse the difference between male and female.

0.043

et al. 2015a,b). Furthermore, the base-

line data of GOAL’s study in Guangz-
8

hou showed that only 1.81–1.89% 6-

22.76  0.86
23.39  0.88

23.08  0.92
0.29  1.38
0.08  1.55

0.18  1.47

2.97  0.09

year-old children were myopic. This

3.00  0.1

2.98  0.1

randomized clinical trial showed that

<0.001

<0.001
Age of children (years)

0.006

the addition of 40 min of outdoor

Spherical equivalent refraction (diopter)

activity at school compared with usual

7

activity resulted in a reduced incidence

Axial length/corneal radius ratio
22.49  0.74
23.12  0.76

22.81  0.81
0.73  1.28

0.60  1.29

2.92  0.09
2.95  0.09

2.94  0.09

rate of myopia over the next 3 years

0.48  1.3

(He et al. 2015a,b). A striking differ-

<0.001

<0.001

<0.001

ence could be the crowded living envi-

ronment in Hong Kong, which may
6

Axial length (mm)

promote lots of near-work activities,

Girls + boys

Girls + boys

Girls + boys

and less outdoor time, compared with

Characteristic

mainland China (Ng et al. 2018). Pre-

p-value†

p-value†

p-value†

vious study has also reported a signif-

Girls

Girls

Girls
Boys

Boys

Boys

icantly lower myopia prevalence of

Chinese children in Australia (3.3%)
†

5
Acta Ophthalmologica 2020

Table 3. Association of age, gender, outdoor time, near work and parental education level with the prevalence due to the schooling
myopia in children. effects could potentially be lowered in
future (教育部等八部门 2018).
Crude OR p-value Adjusted OR p-value

Age 1.75 (1.63–1.88) <0.001 1.86 (1.66–2.09) <0.001

Slightly lower prevalence compared with
Sex
15 years ago
Male Reference Reference
Female 0.78 (0.68–0.90) 0.001 0.82 (0.66–1.01) 0.064 Another important finding of our study
Time of outdoor 0.92 (0.82–1.04) 0.174 N.A. is that the myopia prevalence of our
Outdoor for sports 0.99 (0.83–1.20) 0.961 N.A.
current report was slightly lower than
Outdoor for leisure 0.79 (0.65–0.95) 0.014 0.86 (0.65–1.14) 0.282
Diopter*hour 1.02 (0.99–1.05) 0.115 N.A. that of our previous study conducted
Maternal education level 15 years ago (Fan et al. 2004)
≤High school Reference Reference (Table 5). While the mean SE was
≥Undergraduate 1.14 (1.10–1.19) <0.001 1.12 (1.06–1.18) <0.001 slightly higher, the myopia rates were
Paternal education level also higher in aged 6–8 in the previous
≤High school Reference Reference study (Fan et al. 2004; 17% at age 6, to
≥Undergraduate 1.10 (1.05–1.15) <0.001 1.10 (1.05–1.15) <0.001 28% at age 7 and 37.5% at age 8). This
Adjusted OR: age, gender, outdoor for leisure, parental education and parental myopia status is in contrast to the recent speculation,
were in the logistic model. as there have been many postulations
N.A. = not available. that the recent prevalence of myopia
will surge due to the burgeoning use of
computers and electronic devices. It
Table 4. Prevalence of myopia in parents.
has also been suggested that digital
Mild myopia Moderate screen time is the major modifiable risk
Myopia 3D myopia 6.0 D factor for myopia (Dirani et al. 2019).
SER ≤ < SER ≤ < SER ≤ High myopia However, it should be noted that Fan
No. of 0.75 D 0.75 D 3.0 D SER ≤ 6.0 D et al.’s study was conducted in 1998–
subjects N (%) N (%) N (%) N (%) 2000, when smart phone and electronic
devices like tablets had not appeared
Overall 5880 4243 (72.2) 2024 (34.4) 1424 (24.2) 795 (13.5)
≤35 years 849 658 (77.5) 387 (45.6) 187 (22.0) 84 (9.9) yet, and yet the myopia prevalence was
36–40 years 1696 1264 (74.5) 655 (38.6) 419 (24.7) 190 (11.2) as high as nowadays. Therefore, we
41–45 years 2030 1494 (73.6) 644 (31.7) 512 (25.2) 338 (16.7) need to be cautious about regarding
46–50 years 892 594 (66.6) 236 (26.5) 225 (25.2) 133 (14.9) electronic devices as a major myopi-
>50 years 413 233 (56.4) 102 (24.7) 81 (19.6) 50 (12.1) genic risk factor in children. On the
Female 3368 2467 (73.2) 1252 (37.2) 783 (23.2) 432 (12.8) other hand, this may suggest that the
≤35 years 690 533 (77.2) 315 (45.7) 153 (22.1) 65 (9.4) schooling system and the intense aca-
36–40 years 1127 838 (74.4) 460 (40.8) 257 (22.8) 121 (10.7)
demic environment, basically
41–45 years 1148 847 (73.8) 371 (32.3) 291 (25.3) 185 (16.1)
46–50 years 353 218 (61.8) 91 (25.8) 72 (20.4) 55 (15.6) unchanged over the past 15 years, have
>50 years 50 31 (62.0) 15 (30.0) 10 (20.0) 6 (12.0) all along remained the major driving
Males 2512 1776 (70.7) 772 (30.7) 641 (25.5) 363 (14.5) force. Here our observations suggested
≤35 years 159 125 (78.6) 72 (45.3) 34 (21.4) 19 (11.9) that only measures restricted to lower-
36–40 years 569 426 (74.9) 195 (34.3) 162 (28.5) 69 (12.1) ing the use of electronic and computer
41–45 years 882 647 (73.4) 273 (31.0) 221 (25.1) 153 (17.3) devices would not be strong enough to
46–50 years 539 376 (69.8) 145 (26.9) 153 (28.4) 78 (14.5) alleviate the epidemic of myopia. Inter-
>50 years 363 202 (55.6) 87 (24.0) 71 (19.6) 44 (12.1)
ventions based on changing school
N = number of cases, SER = spherical equivalent refraction, % = percentage of cases. systems should be advocated.

Gender effect on myopia

than those in Singapore (29.1%), sug-
gesting the influence of different edu-
cation system on myopia rate (Rose
et al. 2008a,b). Thus, in all, the short of
outdoor activities was one potential
reason of the high prevalence of
myopia in Hong Kong. Another possi-
ble explanation for the higher preva-
lence in Hong Kong could be the
greater intensity of its preschool edu-
cation compared with that of other
Chinese cities, as children in Hong
Kong tend to start preschool as early
as age 2, with significant academic
focus. Whereas in mainland, the pre-
school system varies among cities; and
although some children in major cities
also attend 2–3 years of preschool, the
academic stress is relatively less. As
early as 2000, the Chinese government
was trying to lower the academic bur-
den of primary school students (中共中
央、国务院 1999; 教育部 2000; 教育部
等九部门 2018). Of note, the govern-
ment has recently adopted policies to
control the myopia onset and progres-
sion of children and adolescents
throughout the country, and therefore
In our report, boys were more myopic
than girls, which is consistent with the
study by Lam et al. (2012), but in
contrast with others (Fan et al. 2004;
Wu et al. 2013; Li et al. 2014; Li et al.
2017; Qian et al. 2016). Fan et al. found
that OR of myopia was 1.06 higher in
girls than in boys. Wu et al. (2013)
reported that in general, myopia preva-
lence increased in female (OR = 1.22),
but found that boys are more myopic
among younger children. Li et al. shows
a higher OR (1.7, 95% CI, 1.1–2.7) of

6
 Table 5. Comparison of myopia prevalence, spherical equivalent refraction (SER), axial length (AL) and AL/corneal radius (CR) in China.

Myopia prevalence AL (mm) Spherical equivalence (Diopter) AL/CR

Cycloplegic Study Sample Myopia Age
Authors Year refraction location size definition (years) 6 years 7 years 8 years 6 years 7 years 8 years 6 years 7 years 8 years 6 years 7 years 8 years

Current 2019 Yes Hong 4275 SER ≤ 0.50 D 6–8 12.7% 24.4% 36.1% 22.81  0.81 23.08  0.92 23.49  0.97 0.60  1.29 0.18  1.47 0.30  1.82 2.94  0.09 2.98  0.10 3.03  0.11
study Kong
Pan 2018 Yes South- 4778 SER < 0.50 D Grade 1 14.5% 22.64  0.69 0.87  0.68
western (7.7
years)
Wang 2018 No Beijing 2970 N.A. 5–8 5–8 years: 22.73  0.73 5–8 years: 2.91  0.17
Guo 2017 No Beijing 35 745 SER ≤ 0.50 D 6–18 0.20  0.86 0.03  0.98 0.31  1.12
Guo 2017 Yes Shenzhen 1133 SER ≤ 0.50 D 3–6 3.7% 22.63  0.63 1.23  0.85 2.84  0.06
Guo 2016 Yes Guangzhou 3055 SER ≤ 0.50 D 3–10 0.2% 13.3% 38.8%
Qian 2016 Yes Yunnan 7681 SER < 0.50 D 5–16 21.7%
Ma 2016 Yes Shanghai 5532 SER ≤ 0.50 D 3–10 5.2% 14.3% 30.8%
He 2016 Yes Guangzhou Intervention: SER ≤ 0.50 D Grade 1 Intervention: 1.84% Intervention: 22.60  0.71 Intervention: 1.30  0.97
919 (6.60 Control: 1.89% Control: 22.66  0.70 Control: 1.26  0.81
Control: years)
929
Lyu 2015 Yes Beijing 4249 SER ≤ 0.50 D 5–14 7.4% 18.0% 28.5% 0.81  1.00 0.16  1.52 0.97  1.69
He 2015 Yes Shanghai 4686 SER ≤ 0.50 D 6–11 6–7 years: 11.1% 19.4% 6–7 years: 22.88  0.74 23.11  0.80 6–7 years: 0.58  0.97 0.34  1.09 6–7 years: 2.91  0.08 2.94  0.11
Li 2014 Yes Rural 1675 SER ≤ 0.50 D 5–18 0.9%
Northern
Gao 2014 Yes Handan 878 SER ≤ 0.50 D 6–18 6–11 years: 14.4% 6–11 years: 22.97  0.77 6–11 years: 0.27  1.27
You 2014 No Beijing 15 066 SER ≤ 1.00 D 7–18 5.3% 7.8% 0.00  0.93 0.10  1.09
Lan 2013 Yes Guangzhou 2478 SER ≤ 0.50 D 3–6 1.6% 1.33  0.70
Wu 2013 Yes Shandong 6026 SER ≤ 0.50 D 4–18 4.1% 7.8% 20.3%
Li 2013 Yes Anyang 2893 SER ≤ 0.50 D Grade 1 3.9% 22.72  0.76 1.44  1.05
(7.1
years)
Lam 2012 No Hong 2651 SER < 0.50 D 6 and 18.3% 23.06  0.69 23.30  0.76 23.67  0.90 0.06  1.03
Kong 12 years (Boys) (Boys) (Boys)
22.56  0.93 22.81  0.79 23.10  0.84
(Girls) (Girls) (Girls)
Pi 2010 Yes Chongqing 3070 SER ≤ 0.50 D 6–15 0.4% 1.9% 5.0% 1.36  0.58 1.22  0.77 0.94  0.95
He 2004 Yes Urban 4364 SER ≤ 0.50 D 5–15 5.9% 7.7% 14.0%
Southern
Fan 2004 Yes Hong 7560 SER ≤ 0.50 D 5–16 17.0% 28.9% 37.5% 0.67 0.44 0.00
Kong
Zhao 2000 Yes Shunyi 5884 SER ≤ 0.50 D 5–15 5–7
years:
2.6%
Acta Ophthalmologica 2020

7
Acta Ophthalmologica 2020
myopia in the female genders and pre-
sented a significant relationship between
myopia and gender. Li et al. (2017) also
indicated that myopia prevalence of
girls was higher than boys. Qian et al.
(2016) also reported the myopia risk as
being 0.33 higher (OR = 1.33) in girls
than in boys. The majority of these
studies attributed the higher myopic
prevalence in girls to more reading and
writing works and less sports. Never-
theless, environmental factors and
height were not adjusted in these studies.
By contrast, another study showed that
boys were 6.4% more myopic than girls
in Hong Kong children (Lam et al.
2012). Also, Wang et al. (2018) showed
that the AL/CR ratio of boys
(2.92  0.14) were much larger than
that of girls (2.89  0.21) in Beijing.
Our findings could be potentially attrib-
uted by the confounders. First, boys
were taller than girls in our study
(Table S1). Second, such factors as
outdoor time, near work and parental
education levels may play a role (Parssi-
nen & Lyyra 1993; Rose et al. 2008a,b).
In our report, boys spent more time not
only on outdoor sports, but also on
computers and electronic devices
(Table S1). Nevertheless, after adjust-
ment of confounding factors, the risk of
myopia in boys and girls became similar
(p = 0.064), possibly suggesting the
absence of independent gender effect
for myopia. However, with the impre-
cise measurements of these risk factors
by questionnaires in our study, the
significance of the association could be
reduced or disappeared even though
there is in fact independent gender effect.
High prevalence of myopia in adults in
Hong Kong
We have observed a strikingly high
prevalence of myopia at 72.2% and
high myopia at 13.5% in parents aged
around 25–50 years in Hong Kong.
This is among one of the highest
reported prevalences in adult epidemi-
ological studies (Cheng et al. 2003; Xu
et al. 2005; Liang et al. 2013). Previous
literatures reported high prevalence
only in selected and highly educated
population (Sun et al. 2012; Wang
et al. 2017; Wei et al. 2018). Therefore,
our current prevalence of myopia in the
general adult population is extremely
high as regards public health. In the
inner city of Baltimore in the USA, a
report in 1997 showed a myopia
8
prevalence of 28.1% in White people
and 19.4% in Black people, and with
the age growth, the risk of myopia
decreased in adults older than 40 years
(Katz et al. 1997). In Singapore, the
myopia rate was 38.7% among 1232
Chinese adults aged 40–79 years (Wong
et al. 2000). The Liwan Eye Study in
southern China reported myopia preva-
lence of adults aged above 50 years as
32.3% (He et al. 2009); while in the
recent Shanghai Eye Study, prevalence
was found to be 22.82% (He et al.
2015a,b).
However, comparison of the present
study with others needs to be cautious
due to the age and cohort effects. First,
the age reported in our cohort was
younger than that of other reports,
hence the higher myopia prevalence.
Here, one of the limitations of our
study is non-cycloplegic refraction for
parents, which may tend to overesti-
mate the prevalence of myopia in
younger people. Morgan et al. (2015)
suggested that cycloplegic refraction
should be required in adults up to age
50. Although the majority of adult
myopia studies also include non-cyclo-
plegic refraction, their reported age
range tends to be older, around 40–
70, as compared to our younger adults
aged 25–50. A previous report has
determined a difference of 0.29 D more
hyperopic after cycloplegia in adults, in
which the effect was more prominent in
hyperopia subjects than in myopes
(Krantz et al. 2010). In this study, we
therefore employed a more stringent
criterion of myopia: <0.75 D instead of
<0.50 D. Second, cohort effects should
be considered in our reported preva-
lence of adult myopia. For example,
Tanjong Pagar study was published
20 years ago (Wong et al. 2000). Since
then there may have been an increase in
the prevalence of myopia in the
younger cohorts. Therefore, an
updated prevalence of adults of com-
parable age with our study would be
needed to compare the prevalence
between Hong Kong and other places.
Likewise, a pilot study in Hong Kong
conducted more than 20 years ago on
355 Chinese adults older than 40 years
old reported a myopia prevalence of
40% (Van Newkirk 1997), but now we
found a 73% prevalence for the same
age group. Furthermore, their ALs
(Female, 23.43  1.10 mm, Male
23.94  1.15 mm) were much shorter
than our cohort’s (Mother, 24.23 
1.38 mm; Father, 24.89  1.44 mm).
In 1994, Goh and Lam reported that
among 105 19- to 40-year-old adults
(Goh & Lam 1994), 71% were myopic;
however, its definition of myopia was
SER < 0.50 D. If we had used the
same definition, the myopia rate of
adults in our study would have been
80%. Such an increase could be well
attributed to the cohort effect. The
majority of the parents in our study
were born after 1970s, when in 1978 the
Hong Kong Government implemented
the 9-year compulsory primary and
secondary school education system.
Therefore, the parent participants in
our cohort were exposed to a well-
resourced and competitive education
system. This is consistent with our
finding that myopia prevalence was
significant correlated with a higher
educational level (Parssinen 1987;
Parssinen 2012), which was also con-
sistent with the finding of previous
studies (Williams et al. 2015; Morgan
et al. 2018). Of note, among all age
groups, the 41- to 45-years-olds were
most myopic, which was also corre-
lated with their relatively higher level
of education (Table S3). The strikingly
high prevalence of myopia among
adults in Hong Kong, suggesting that
the myopic boom happened in this
working age group. This confers clin-
ical significance, owing to the antici-
pated surge of myopia-associated
ocular complications and the potential
burden on Hong Kong society.
Limitations
The refractive error of children was
determined by cycloplegic refraction,
but that of parents by non-cycloplegic
refraction. Furthermore, the adult sam-
ple was parents on a population-based
children cohort, and therefore those
adults without children in the general
population have not been included.
This exclusion might introduce bias,
because childless adults may tend to be
better educated. Lastly, the response
rate of parents was relatively low,
especially for the father, which might
also introduce bias into the study.
Conclusions
There is a strikingly high prevalence of
myopia in Hong Kong children aged
6–8, much higher than that of other
regions of China. Nevertheless, the

prevalence is still slightly lower than
that of 15 years ago in Hong Kong, in
contrast to the postulate that a surge of
myopia due to the advent of electronic
devices. Furthermore, the prevalence of
myopia in Hong Kong parents is high,
and that a shift in myopia incidence has
arrived in the working age group in this
generation. Thus, the prevention of
childhood myopia, as well as control
and treatment of visual complications
from high myopia in adults, is crucial
in public health.
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Received on November 1st, 2018.
Accepted on December 20th, 2019.
Correspondence:
Jason C. Yam, FRCSEd
Department of Ophthalmology and Visual
Sciences
The Chinese University of Hong Kong, Hong
Kong Eye Hospital
147K Argyle Street, Kowloon
Hong Kong
Tel: +(852) 3943-5813
Fax: +(852) 2768-9568
Email: yamcheuksing@cuhk.edu.hk
JCY & SMT contributed equally.
We thank all the participants in the study. This
study was supported in part by CUHK Jockey Club
Children Eye Care Programme, the General
Research Fund (GRF), Research Grants Council,
Hong Kong (14111515 (JCSY)); in part by the
Direct Grants of the Chinese University of Hong
Kong (4054197 (CPP), 4054193 (LJC) and 4054121
& 4054199 (JCSY)); and partly by the UBS Opti-
mus Foundation Grant 8984 (JCSY).
Supporting Information
Additional Supporting Information
may be found in the online version of
this article:
Table S1. The difference of environ-
mental factors between boys and girls.
Table S2. Prevalence of myopia and
refraction of parents stratified by level
of education.
Table S3. The education level of adults
among different age groups.
Appendix S1. Protocol of the Hong
Kong Children Eye Study.