Time spent in outdoor activities in relation to myopia prevention and control: a meta-analysis and systematic review

Shuyu Xiong, Padmaja Sankaridurg, Thomas Naduvilath, Jiajie Zang, Haidong Zou, Jianfeng Zhu, Minzhi Lv, Xiangui He, Xun Xu, Shuyu Xiong, Padmaja Sankaridurg, Thomas Naduvilath, Jiajie Zang, Haidong Zou, Jianfeng Zhu, Minzhi Lv, Xiangui He, Xun Xu

Abstract

Outdoor time is considered to reduce the risk of developing myopia. The purpose is to evaluate the evidence for association between time outdoors and (1) risk of onset of myopia (incident/prevalent myopia); (2) risk of a myopic shift in refractive error and c) risk of progression in myopes only. A systematic review followed by a meta-analysis and a dose-response analysis of relevant evidence from literature was conducted. PubMed, EMBASE and the Cochrane Library were searched for relevant papers. Of the 51 articles with relevant data, 25 were included in the meta-analysis and dose-response analysis. Twenty-three of the 25 articles involved children. Risk ratio (RR) for binary variables and weighted mean difference (WMD) for continuous variables were conducted. Mantel-Haenszel random-effects model was used to pool the data for meta-analysis. Statistical heterogeneity was assessed using the I2 test with I2 ≥ 50% considered to indicate high heterogeneity. Additionally, subgroup analyses (based on participant's age, prevalence of myopia and study type) and sensitivity analyses were conducted. A significant protective effect of outdoor time was found for incident myopia (clinical trials: risk ratio (RR) = 0.536, 95% confidence interval (CI) = 0.338 to 0.850; longitudinal cohort studies: RR = 0.574, 95% CI = 0.395 to 0.834) and prevalent myopia (cross-sectional studies: OR = 0.964, 95% CI = 0.945 to 0.982). With dose-response analysis, an inverse nonlinear relationship was found with increased time outdoors reducing the risk of incident myopia. Also, pooled results from clinical trials indicated that when outdoor time was used as an intervention, there was a reduced myopic shift of -0.30 D (in both myopes and nonmyopes) compared with the control group (WMD = -0.30, 95% CI = -0.18 to -0.41) after 3 years of follow-up. However, when only myopes were considered, dose-response analysis did not find a relationship between time outdoors and myopic progression (R2 = 0.00064). Increased time outdoors is effective in preventing the onset of myopia as well as in slowing the myopic shift in refractive error. But paradoxically, outdoor time was not effective in slowing progression in eyes that were already myopic. Further studies evaluating effect of outdoor in various doses and objective measurements of time outdoors may help improve our understanding of the role played by outdoors in onset and management of myopia.

Keywords: dose-response analysis; meta-analysis; myopia; outdoor time.

© 2017 The Authors. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.

Figures

Figure 1
Figure 1
Flow diagram of the literature search and study selection.
Figure 2
Figure 2
Forest plot corresponding to main random‐effects meta‐analysis performed to quantify the relationship between the time spent on outdoor activities and the incidence or prevalence of myopia. All statistical tests were two‐sided. CI = confidence interval. [Colour figure can be viewed at wileyonlinelibrary.com].
Figure 3
Figure 3
Dose–response analysis of the time spent outdoors and the risk of myopia (y: risk ratio; and x: increased time spent outdoors). [Colour figure can be viewed at wileyonlinelibrary.com].
Figure 4
Figure 4
Subgroup analysis of the trials included to assess the relationship between outdoor activities and the myopia incidence or prevalence, CI = confidence interval, RR = relative risk, OR = odds ratio, RCT = randomized clinical trial, and CCT = controlled clinical trial. [Colour figure can be viewed at wileyonlinelibrary.com].
Figure 5
Figure 5
Forest plot corresponding to main random‐effects meta‐analysis performed to quantify the mean difference in myopic shift in refraction in the whole sample between the intervention group, with increased time spent outdoors, and the control group. All statistical tests were two‐sided. CI = confidence interval, and WMD = weighted mean difference. [Colour figure can be viewed at wileyonlinelibrary.com].
Figure 6
Figure 6
Dose–response analysis of the time spent outdoors and myopic progression rate (y: treatment effect or annual myopic progression, and x: increased time spent outdoors). [Colour figure can be viewed at wileyonlinelibrary.com].

References

    1. Bar Dayan Y, Levin A, Morad Y et al. (2005): The changing prevalence of myopia in young adults: a 13‐year series of population‐based prevalence surveys. Invest Ophthalmol Vis Sci 46: 2760–2765.
    1. Berntsen DA, Sinnott LT, Mutti DO & Zadnik K (2012): A randomized trial using progressive addition lenses to evaluate theories of myopia progression in children with a high lag of accommodation. Invest Ophthalmol Vis Sci 53: 640–649.
    1. Chen C, Cheung SW & Cho P (2013): Myopia control using toric orthokeratology (TO‐SEE study). Invest Ophthalmol Vis Sci 54: 6510–6517.
    1. Cheng CY, Huang W, Su KC, Peng ML, Sun HY & Cheng HM (2013): Myopization factors affecting urban elementary school students in Taiwan. Optom Vis Sci 90: 400–406.
    1. Chia A, Chua WH, Cheung YB, Wong WL, Lingham A, Fong A & Tan D (2012): Atropine for the treatment of childhood myopia: safety and efficacy of 0.5%, 0.1%, and 0.01% doses (Atropine for the Treatment of Myopia 2). Ophthalmology 119: 347–354.
    1. Chia A, Lu QS & Tan D (2016): Five‐year clinical trial on atropine for the treatment of myopia 2: myopia control with Atropine 0.01% Eyedrops. Ophthalmology 123: 391–399.
    1. Chinn S (2000): A simple method for converting an odds ratio to effect size for use in meta‐analysis. Stat Med 19: 3127–3131.
    1. Cho P & Cheung SW (2012): Retardation of myopia in Orthokeratology (ROMIO) study: a 2‐year randomized clinical trial. Invest Ophthalmol Vis Sci 53: 7077–7085.
    1. Chua SY, Ikram MK, Tan CS et al. (2015): Relative contribution of risk factors for early‐onset myopia in young Asian children. Invest Ophthalmol Vis Sci 56: 8101–8107.
    1. Deng L, Gwiazda J & Thorn F (2010): Children's refractions and visual activities in the school year and summer. Optom Vis Sci 87: 406–413.
    1. Dharani R, Lee CF, Theng ZX et al. (2012): Comparison of measurements of time outdoors and light levels as risk factors for myopia in young Singapore children. Eye (Lond) 26: 911–918.
    1. Dirani M, Tong L, Gazzard G et al. (2009): Outdoor activity and myopia in Singapore teenage children. Br J Ophthalmol 93: 997–1000.
    1. Donovan L, Sankaridurg P, Ho A, Naduvilath T, Smith EL 3rd & Holden BA (2012): Myopia progression rates in urban children wearing single‐vision spectacles. Optom Vis Sci 89: 27–32.
    1. Downs SH & Black N (1998): The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non‐randomised studies of health care interventions. J Epidemiol Community Health 52: 377–384.
    1. Flitcroft DI (2012): The complex interactions of retinal, optical and environmental factors in myopia aetiology. Prog Retin Eye Res 31: 622–660.
    1. French AN, Ashby RS, Morgan IG & Rose KA (2013a): Time outdoors and the prevention of myopia. Exp Eye Res 114: 58–68.
    1. French AN, Morgan IG, Mitchell P & Rose KA (2013b): Patterns of myopigenic activities with age, gender and ethnicity in Sydney schoolchildren. Ophthalmic Physiol Opt 33: 318–328.
    1. French AN, Morgan IG, Mitchell P & Rose KA (2013c): Risk factors for incident myopia in Australian schoolchildren: The Sydney Adolescent Vascular and Eye Study. Ophthalmology 120: 2100–2108.
    1. Greenland S & Longnecker MP (1992): Methods for trend estimation from summarized dose‐response data, with applications to meta‐analysis. Am J Epidemiol 135: 1301–1309.
    1. Guggenheim JA, Northstone K, McMahon G, Ness AR, Deere K, Mattocks C, Pourcain BS & Williams C (2012): Time outdoors and physical activity as predictors of incident myopia in childhood: a prospective cohort study. Invest Ophthalmol Vis Sci 53: 2856–2865.
    1. Guggenheim JA, Williams C, Northstone K, Howe LD, Tilling K, St Pourcain B, McMahon G & Lawlor DA (2014): Does vitamin D mediate the protective effects of time outdoors on myopia? Findings from a prospective birth cohort. Invest Ophthalmol Vis Sci 55: 8550–8558.
    1. Guo Y, Liu LJ, Xu L, Lv YY, Tang P, Feng Y, Meng M & Jonas JB (2013a): Outdoor activity and myopia among primary students in rural and urban regions of Beijing. Ophthalmology 120: 277–283.
    1. Guo Y, Liu LJ, Xu L, Tang P, Lv YY, Feng Y, Meng M & Jonas JB (2013b): Myopic shift and outdoor activity among primary school children: one‐year follow‐up study in Beijing. PLoS ONE 8: e75260.
    1. Guo K, Yang DY, Wang Y et al. (2015): Prevalence of myopia in schoolchildren in Ejina: the Gobi Desert children eye study. Invest Ophthalmol Vis Sci 56: 1769–1774.
    1. Han X, Miao HL & Huang D (2014): Investigation of junior school student myopia in high‐altitude Tibetan areas in Qinghai Province. Int Eye Sci 14: 913–915.
    1. Hasebe S, Ohtsuki H, Nonaka T, Nakatsuka C, Miyata M, Hamasaki I & Kimura S (2008): Effect of progressive addition lenses on myopia progression in Japanese children: a prospective, randomized, double‐masked, crossover trial. Invest Ophthalmol Vis Sci 49: 2781–2789.
    1. He M, Xiang F, Zeng Y et al. (2015): Effect of time spent outdoors at school on the development of myopia among children in China: a randomized clinical trial. JAMA 314: 1142–1148.
    1. Holden BA, Fricke TR, Wilson DA et al. (2016): Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmology 123: 1036–1042.
    1. Hu YY, Wu JF, Lu TL, Wu H, Sun W, Wang XR, Bi HS & Jonas JB (2015): Effect of cycloplegia on the refractive status of children: the Shandong children eye study. PLoS ONE 10: e0117482.
    1. Huang J, Wen D, Wang Q et al. (2016): Efficacy comparison of 16 interventions for myopia control in children: a network meta‐analysis. Ophthalmology 123: 697–708.
    1. Ip JM, Saw SM, Rose KA, Morgan IG, Kifley A, Wang JJ & Mitchell P (2008): Role of near work in myopia: findings in a sample of Australian school children. Invest Ophthalmol Vis Sci 49: 2903–2910.
    1. Jin JX, Hua WJ, Jiang X et al. (2015): Effect of outdoor activity on myopia onset and progression in school‐aged children in northeast China: the Sujiatun Eye Care Study. BMC Ophthalmol 15: 73.
    1. Jones LA, Sinnott LT, Mutti DO, Mitchell GL, Moeschberger ML & Zadnik K (2007): Parental history of myopia, sports and outdoor activities, and future myopia. Invest Ophthalmol Vis Sci 48: 3524–3532.
    1. Jones‐Jordan LA, Mitchell GL, Cotter SA et al. (2011): Visual activity before and after the onset of juvenile myopia. Invest Ophthalmol Vis Sci 52: 1841–1850.
    1. Jones‐Jordan LA, Sinnott LT, Cotter SA, Kleinstein RN, Manny RE, Mutti DO, Twelker JD & Zadnik K (2012): Time outdoors, visual activity, and myopia progression in juvenile‐onset myopes. Invest Ophthalmol Vis Sci 53: 7169–7175.
    1. Lee YY, Lo CT, Sheu SJ & Yin LT (2015): Risk factors for and progression of myopia in young Taiwanese men. Ophthalmic Epidemiol 22: 66–73.
    1. Li SM, Li H, Li SY et al. (2015): Time outdoors and myopia progression over 2 years in chinese children: the Anyang childhood eye study. Invest Ophthalmol Vis Sci 56: 4734–4740.
    1. Lin LL, Shih YF, Hsiao CK & Chen CJ (2004): Prevalence of myopia in Taiwanese schoolchildren: 1983 to 2000. Ann Acad Med Singapore 33: 27–33.
    1. Lin Z, Vasudevan B, Jhanji V et al. (2014): Near work, outdoor activity, and their association with refractive error. Optom Vis Sci 91: 376–382.
    1. Low W, Dirani M, Gazzard G et al. (2010): Family history, near work, outdoor activity, and myopia in Singapore Chinese preschool children. Br J Ophthalmol 94: 1012–1016.
    1. Lu B, Congdon N, Liu X et al. (2009): Associations between near work, outdoor activity, and myopia among adolescent students in rural China: the Xichang Pediatric Refractive Error Study report no. 2. Arch Ophthalmol 127: 769–775.
    1. Ma MM, Zhang ZW, Song JG, Wang XC, Zhang YM & Bi‐Lian KE (2010): An epidemiological survey of refractive error and associated factors among middle school students in Deqing County of Zhejiang Province, China. Fudan Univ J Med Sci 37: 680–684.
    1. Marcus MW, de Vries MM, Junoy Montolio FG & Jansonius NM (2011): Myopia as a risk factor for open‐angle glaucoma: a systematic review and meta‐analysis. Ophthalmology 118: 1989–1994. e1982.
    1. Morgan I & Rose K (2005): How genetic is school myopia? Prog Retin Eye Res 24: 1–38.
    1. Morgan IG, Ohno‐Matsui K & Saw SM (2012): Myopia. Lancet 379: 1739–1748.
    1. Morgan IG, Iribarren R, Fotouhi A & Grzybowski A (2015): Cycloplegic refraction is the gold standard for epidemiological studies. Acta Ophthalmol 93: 581–585.
    1. Mutti DO, Mitchell GL, Moeschberger ML, Jones LA & Zadnik K (2002): Parental myopia, near work, school achievement, and children's refractive error. Invest Ophthalmol Vis Sci 43: 3633–3640.
    1. Onal S, Toker E, Akingol Z, Arslan G, Ertan S, Turan C & Kaplan O (2007): Refractive errors of medical students in Turkey: one year follow‐up of refraction and biometry. Optom Vis Sci 84: 175–180.
    1. Oner V, Bulut A, Oruc Y & Ozgur G (2015): Influence of indoor and outdoor activities on progression of myopia during puberty. Int Ophthalmol 36: 121–125.
    1. Orsini N, Bellocco R & Greenland S (2006): Generalized least squares for trend estimation of summarized dose–response data. STATA J 6: 40–57.
    1. Pan CW, Chen Q, Sheng X et al. (2015): Ethnic variations in myopia and ocular biometry among adults in a rural community in China: the yunnan minority eye studies. Invest Ophthalmol Vis Sci 56: 3235–3241.
    1. Parssinen O & Lyyra AL (1993): Myopia and myopic progression among schoolchildren: a three‐year follow‐up study. Invest Ophthalmol Vis Sci 34: 2794–2802.
    1. Parssinen O, Kauppinen M & Viljanen A (2014): The progression of myopia from its onset at age 8‐12 to adulthood and the influence of heredity and external factors on myopic progression. A 23‐year follow‐up study. Acta Ophthalmol 92: 730–739.
    1. Pascolini D & Mariotti SP (2011): Global estimates of visual impairment: 2010. Br J Ophthalmol 96: 614–618.
    1. Peckham CS, Gardiner PA & Goldstein H (1977): Acquired myopia in 11‐year‐old children. Br Med J 1: 542–545.
    1. Ramessur R, Williams KM & Hammond CJ (2015): Risk factors for myopia in a discordant monozygotic twin study. Ophthalmic Physiol Opt 35: 643–651.
    1. Read SA, Collins MJ & Vincent SJ (2014): Light exposure and physical activity in myopic and emmetropic children. Optom Vis Sci 91: 330–341.
    1. Read SA, Collins MJ & Vincent SJ (2015): Light exposure and eye growth in childhood. Invest Ophthalmol Vis Sci 56: 6779–6787.
    1. Resnikoff S, Pascolini D, Mariotti SP & Pokharel GP (2008): Global magnitude of visual impairment caused by uncorrected refractive errors in 2004. Bull World Health Organ 86: 63–70.
    1. Rose KA, Morgan IG, Ip J, Kifley A, Huynh S, Smith W & Mitchell P (2008a): Outdoor activity reduces the prevalence of myopia in children. Ophthalmology 115: 1279–1285.
    1. Rose KA, Morgan IG, Smith W, Burlutsky G, Mitchell P & Saw SM (2008b): Myopia, lifestyle, and schooling in students of Chinese ethnicity in Singapore and Sydney. Arch Ophthalmol 126: 527–530.
    1. Sankaridurg P, Holden B, Smith E 3rd et al. (2011): Decrease in rate of myopia progression with a contact lens designed to reduce relative peripheral hyperopia: one‐year results. Invest Ophthalmol Vis Sci 52: 9362–9367.
    1. Saw SM, Nieto FJ, Katz J, Schein OD, Levy B & Chew SJ (2000): Factors related to the progression of myopia in Singaporean children. Optom Vis Sci 77: 549–554.
    1. Saw SM, Hong RZ, Zhang MZ, Fu ZF, Ye M, Tan D & Chew SJ (2001): Near‐work activity and myopia in rural and urban schoolchildren in China. J Pediatr Ophthalmol Strabismus 38: 149–155.
    1. Saw SM, Zhang MZ, Hong RZ, Fu ZF, Pang MH & Tan DT (2002): Near‐work activity, night‐lights, and myopia in the Singapore‐China study. Arch Ophthalmol 120: 620–627.
    1. Saw SM, Shankar A, Tan SB, Taylor H, Tan DT, Stone RA & Wong TY (2006): A cohort study of incident myopia in Singaporean children. Invest Ophthalmol Vis Sci 47: 1839–1844.
    1. Saxena R, Vashist P, Tandon R, Pandey RM, Bhardawaj A, Menon V & Mani K (2015): Prevalence of myopia and its risk factors in urban school children in Delhi: the North India Myopia Study (NIM Study). PLoS ONE 10: e0117349.
    1. Scheiman M, Zhang Q, Gwiazda J, Hyman L, Harb E, Weissberg E, Weise KK & Dias L (2014): Visual activity and its association with myopia stabilisation. Ophthalmic Physiol Opt 34: 353–361.
    1. Sherwin JC, Hewitt AW, Coroneo MT, Kearns LS, Griffiths LR & Mackey DA (2012a): The association between time spent outdoors and myopia using a novel biomarker of outdoor light exposure. Invest Ophthalmol Vis Sci 53: 4363–4370.
    1. Sherwin JC, McKnight CM, Hewitt AW, Griffiths LR, Coroneo MT & Mackey DA (2012b): Reliability and validity of conjunctival ultraviolet autofluorescence measurement. Br J Ophthalmol 96: 801–805.
    1. Sherwin JC, Reacher MH, Keogh RH, Khawaja AP, MacKey DA & Foster PJ (2012c): The association between time spent outdoors and myopia in children and adolescents: A systematic review and meta‐analysis. Ophthalmology 119: 2141–2151.
    1. Tan GJ, Ng YP, Lim YC, Ong PY, Snodgrass A & Saw SM (2000): Cross‐sectional study of near‐work and myopia in kindergarten children in Singapore. Ann Acad Med Singapore 29: 740–744.
    1. Tandon PS, Saelens BE, Zhou C, Kerr J & Christakis DA (2013): Indoor versus outdoor time in preschoolers at child care. Am J Prev Med 44: 85–88.
    1. Tideman JW, Polling JR, Voortman T et al. (2016): Low serum vitamin D is associated with axial length and risk of myopia in young children. Eur J Epidemiol 31: 491–499.
    1. Vitale S, Sperduto RD & Ferris FL 3rd (2009): Increased prevalence of myopia in the United States between 1971–1972 and 1999–2004. Arch Ophthalmol 127: 1632–1639.
    1. Walline JJ, Greiner KL, McVey ME & Jones‐Jordan LA (2013): Multifocal contact lens myopia control. Optom Vis Sci 90: 1207–1214.
    1. Wen XF, Zhang J & Zhao Y (2015): Analysis of poor vision conditions and risk factors of myopia in primary school He'xi district of Sanya. Int Eye Sci 15: 684–686.
    1. Wu PC, Tsai CL, Hu CH & Yang YH (2010): Effects of outdoor activities on myopia among rural school children in Taiwan. Ophthalmic Epidemiol 17: 338–342.
    1. Wu PC, Tsai CL, Wu HL, Yang YH & Kuo HK (2013): Outdoor activity during class recess reduces myopia onset and progression in school children. Ophthalmology 120: 1080–1085.
    1. Wu LJ, Wang YX, You QS et al. (2015): Risk factors of myopic shift among primary school children in Beijing, China: a prospective study. Int J Med Sci 12: 633–638.
    1. Xie HL, Xie ZK, Zhou F & Hu L (2013): [Myopia prevalence and influencing factor analysis of primary and middle school students in our country]. Zhonghua yi xue za zhi 93: 999–1002.
    1. Yi JH & Li RR (2011): [Influence of near‐work and outdoor activities on myopia progression in school children]. Zhongguo Dang Dai Er Ke Za Zhi 13: 32–35.
    1. Zadnik K, Sinnott LT, Cotter SA et al. (2015): Prediction of juvenile‐onset myopia. JAMA Ophthalmol 133: 683–689.
    1. Zhang J & Yu KF (1998): What's the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA 280: 1690–1691.
    1. Zhang M, Li L, Chen L et al. (2010): Population density and refractive error among Chinese children. Invest Ophthalmol Vis Sci 51: 4969–4976.
    1. Zhou R, Zhang WF, Yang Y, Li YT, Zhang J & Wang WP (2014): Analysis of myopia prevalence and influencing factors among primary school students in the urban area of Lanzhou city. Int Eye Sci 14: 903–907.
    1. Zhou Z, Morgan IG, Chen Q, Jin L, He M & Congdon N (2015): Disordered sleep and myopia risk among Chinese children. PLoS ONE 10: e0121796.

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi