上海市少年儿童屈光发育现状及进展的纵向调查研究
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摘要
研究目的
了解目前上海地区中小学学生屈光状态及屈光参数的横向和纵向的流行病学特征,探讨正常屈光发育规律及近视发生发展的机制,为预防和控制近视提供依据。
研究对象和方法
分层随机抽样选取上海市徐汇和虹口两区12所学校小学和初中的6～15岁学生9086人,检测裸眼远视力、屈光度、眼轴长度、角膜曲率和身高、体重,问卷调查学生的年龄、性别、家族史等,完成两年随访的样本人数为小一到初一的6-13岁4651人。使用SPSS进行统计分析。
结果
1.屈光发育现状
上海徐汇、虹口两区6～15岁学生视力不良率为61.0%(以眼数记约54.5%),女性为63.5%,男性为58.8%。6～12岁学生视力不良率为54.5%,13～15岁学生为79.7%。
近视眼患病率为53.4%(以眼数记约47.7%),占视力不良学生的87.5%；女性为55.3%,男性为51.6%。6～12岁学生近视眼患病率率为45.2%,13～15岁学生为76.7%。
等效球镜度均值为-1.96±0.02D,眼轴均值为23.92±0.01mm,平均角膜曲率的均值为43.19±0.02D。
2.屈光发育进展情况
屈光状态在两年的随访中向近视方向漂移,近视眼患病率由31.5%升至55.7%,两年中平均年发病率为18.7%；高度近视眼患病率由2.1%增加到4.2%,年发病率为1.1%。
年发病率女性为19.9%,男性17.6%,；6～9岁33.5%,10～13岁47.8%。
两年内屈光参数的平均年增长值为：等效球镜度-0.282±0.008D,眼轴0.307±0.003mm,平均角膜曲率0.031±0.004D。
保持未近视者占样本人群的42.9%；新发近视占25.6%；持续近视者占31.5%。
3.近视发生发展的进程及相关因素
女性较男性易发生近视,但进展速率相似。10～13岁为近视的高发年龄,而发病较早(6-9岁)的儿童进展较快。父母近视人数的增多和近视程度的加深使子女易发生近视且发展较快。身高与眼轴的增长曲线相近,骨骼生长较快时近视的发病率及进展速率亦较高。
近视发生之前,眼轴增长较慢,其它屈光介质的平衡补偿作用较强,保持屈光度基本不变或平稳而缓慢地正视化。发病的过程中,眼轴增长速率明显加快,虽其它屈光介质尽力抵抗其近视化作用,但效果仍不足。此过程中遗传因素对屈光度近视化的驱动力增大,可能主要通过与骨骼生长与眼轴延长的共用基因作用。近视发生之后,环境因素对眼轴的作用增大,遗传因素对眼轴的驱动力减弱,对屈光度的驱动力却不变,可能亦开始促进其它屈光参数的异常近视化；作用减弱的并非眼轴与身高共用的基因。随着近视的加深,屈光参数增长减缓,可能与近视离焦加重有关。
结论
近视的发生发展是一个持续而稳定的过程,受性别、年龄、近视家族史、全身体格发育的影响。
由于遗传和环境因素的作用,在近视发生之前、之中、之后眼轴增长对屈光度近视化的促进作用逐渐增强,其它屈光介质的平衡补偿作用在发病时最强,突破临界点后反而促进近视进展。
本地区少年儿童的近视化趋势明显,近视眼的发病率和患病率在中国及全球均属于较高水平,且环境因素作用较强,故应重点监控,积极干预,加强近视防治。
Purpose
To investigate the refractive states and longitudinal changes in Shanghai students in grades1-9, approach the process of nomal ocular refractive development and the mechanisms of myopia development and progression, provide bases for moypic preventing and controlling.
Methods
9086students aged6to15in12schools were selected using stratified clustered random sampling, the distance visual acuity, refractive error, ocular axial length, corneal curvatures, height and weight were measured, questionnaires about their age, sex and family history were completed,4651students in grade1-7were followed up for2years. The data were analyzed using SPSS.
Results
1. States of Refractive development
The cross-sectional study showed a61.0%prevalence of poor eyesight among students aged6-15years of Xuhui and Hongkou districts. The rate was63.5%for female and58.8%for male;54.5%for students aged6to12,79.7%for13to15years old。
Myopic prevalence of age6to13was53.4%, female55.3%, male51.6%;45.2%for age6to12and76.7%for13to15.
The mean spherical equivalent refraction (SER), axial length (AL) and corneal curvature (CC) were-1.96±0.02D,23.92±0.01mm and43.19±0.02D.
2. Longitudinal changes of refraction
The refractive status had a myopic shift in the2-year follow-up, the prevalence of myopia increased from31.5%to55.7%, annual incidence was18.7%. The high myopia prevalence increased from2.1%to4.2%, annual incidence was1.1%。
The rate of incidence was19.9%for female and17.6%for male;33.5%for students6-9years old and47.8%for age10to13.
The annual changes of SER, AL and CC were-0.282±0.008D,0.307±0.003mm, and0.031±0.004D
The percentage of remained non-myopes was42.9%, newly developed and persistent myopes was25.6%and31.5%
3. The process and correlation factors of myopic onset and progression
Females were more likely to have myopia, while with the similar rate of progression. Students aged10to13had a higher risk of onset, but progressed less than6to9years old in myopes. The number of myopic parents and their degrees of myopia were positively associated with their chidren's risk of onset and the rate of progression. The growth curves of height and AL had the tendencies somewhat similar; the higher rates of myopic onset and progression were concomitants of the bone growth.
Before the onset of myopia, the elongation of AL was slow, the compensations by other refractive components, refraction had little change or emmetropized slowly. During the onset of myopia, the elongation of AL speeded up markedly, other refractive components tried their best to resist the myopic tendency but insufficiently. During the process, the driving force of genetic factors to refractive change increased, probably acted through the shared genetic mechanism between height and AL. After the onset of myopia, the effects of environmental factors on AL enhanced; genetic factors'influence weakened on AL, but with similar effects on SER, so they might begin to prompt the myopic tendencies of other refractive components; the effect-weakened genes weren't the shared genes between height and AL. The more myopic the SER in baseline, the less the myopic changes which occurred in refrective parameters, perhaps related to the increasing myopic defocus.
Conclusions
The onset and progression of myopia appear to be a consistent, gradual process; was associated with sex, age, myopic family history and height change rate.
Under the influence of genetic and environmental factors, the effects of AL elongation to myopic change of SER enhanced before, during, and after myopia's onset, the compensations and resistance of other refractive components peaked during the onset, then tended to promote the myopic progression after the onset.
The myopic tendency of the children and juveniles was obviously, the prevalence and incidence were high compared to other cities in China and the world, with greater effects of environmental factors than other cities. It's necessary to pay close attentions, give actively prevention, control the onset and progression of myopia.
了解目前上海地区中小学学生屈光状态及屈光参数的横向和纵向的流行病学特征,探讨正常屈光发育规律及近视发生发展的机制,为预防和控制近视提供依据。
研究对象和方法
分层随机抽样选取上海市徐汇和虹口两区12所学校小学和初中的6～15岁学生9086人,检测裸眼远视力、屈光度、眼轴长度、角膜曲率和身高、体重,问卷调查学生的年龄、性别、家族史等,完成两年随访的样本人数为小一到初一的6-13岁4651人。使用SPSS进行统计分析。
结果
1.屈光发育现状
上海徐汇、虹口两区6～15岁学生视力不良率为61.0%(以眼数记约54.5%),女性为63.5%,男性为58.8%。6～12岁学生视力不良率为54.5%,13～15岁学生为79.7%。
近视眼患病率为53.4%(以眼数记约47.7%),占视力不良学生的87.5%；女性为55.3%,男性为51.6%。6～12岁学生近视眼患病率率为45.2%,13～15岁学生为76.7%。
等效球镜度均值为-1.96±0.02D,眼轴均值为23.92±0.01mm,平均角膜曲率的均值为43.19±0.02D。
2.屈光发育进展情况
屈光状态在两年的随访中向近视方向漂移,近视眼患病率由31.5%升至55.7%,两年中平均年发病率为18.7%；高度近视眼患病率由2.1%增加到4.2%,年发病率为1.1%。
年发病率女性为19.9%,男性17.6%,；6～9岁33.5%,10～13岁47.8%。
两年内屈光参数的平均年增长值为：等效球镜度-0.282±0.008D,眼轴0.307±0.003mm,平均角膜曲率0.031±0.004D。
保持未近视者占样本人群的42.9%；新发近视占25.6%；持续近视者占31.5%。
3.近视发生发展的进程及相关因素
女性较男性易发生近视,但进展速率相似。10～13岁为近视的高发年龄,而发病较早(6-9岁)的儿童进展较快。父母近视人数的增多和近视程度的加深使子女易发生近视且发展较快。身高与眼轴的增长曲线相近,骨骼生长较快时近视的发病率及进展速率亦较高。
近视发生之前,眼轴增长较慢,其它屈光介质的平衡补偿作用较强,保持屈光度基本不变或平稳而缓慢地正视化。发病的过程中,眼轴增长速率明显加快,虽其它屈光介质尽力抵抗其近视化作用,但效果仍不足。此过程中遗传因素对屈光度近视化的驱动力增大,可能主要通过与骨骼生长与眼轴延长的共用基因作用。近视发生之后,环境因素对眼轴的作用增大,遗传因素对眼轴的驱动力减弱,对屈光度的驱动力却不变,可能亦开始促进其它屈光参数的异常近视化；作用减弱的并非眼轴与身高共用的基因。随着近视的加深,屈光参数增长减缓,可能与近视离焦加重有关。
结论
近视的发生发展是一个持续而稳定的过程,受性别、年龄、近视家族史、全身体格发育的影响。
由于遗传和环境因素的作用,在近视发生之前、之中、之后眼轴增长对屈光度近视化的促进作用逐渐增强,其它屈光介质的平衡补偿作用在发病时最强,突破临界点后反而促进近视进展。
本地区少年儿童的近视化趋势明显,近视眼的发病率和患病率在中国及全球均属于较高水平,且环境因素作用较强,故应重点监控,积极干预,加强近视防治。
Purpose
To investigate the refractive states and longitudinal changes in Shanghai students in grades1-9, approach the process of nomal ocular refractive development and the mechanisms of myopia development and progression, provide bases for moypic preventing and controlling.
Methods
9086students aged6to15in12schools were selected using stratified clustered random sampling, the distance visual acuity, refractive error, ocular axial length, corneal curvatures, height and weight were measured, questionnaires about their age, sex and family history were completed,4651students in grade1-7were followed up for2years. The data were analyzed using SPSS.
Results
1. States of Refractive development
The cross-sectional study showed a61.0%prevalence of poor eyesight among students aged6-15years of Xuhui and Hongkou districts. The rate was63.5%for female and58.8%for male;54.5%for students aged6to12,79.7%for13to15years old。
Myopic prevalence of age6to13was53.4%, female55.3%, male51.6%;45.2%for age6to12and76.7%for13to15.
The mean spherical equivalent refraction (SER), axial length (AL) and corneal curvature (CC) were-1.96±0.02D,23.92±0.01mm and43.19±0.02D.
2. Longitudinal changes of refraction
The refractive status had a myopic shift in the2-year follow-up, the prevalence of myopia increased from31.5%to55.7%, annual incidence was18.7%. The high myopia prevalence increased from2.1%to4.2%, annual incidence was1.1%。
The rate of incidence was19.9%for female and17.6%for male;33.5%for students6-9years old and47.8%for age10to13.
The annual changes of SER, AL and CC were-0.282±0.008D,0.307±0.003mm, and0.031±0.004D
The percentage of remained non-myopes was42.9%, newly developed and persistent myopes was25.6%and31.5%
3. The process and correlation factors of myopic onset and progression
Females were more likely to have myopia, while with the similar rate of progression. Students aged10to13had a higher risk of onset, but progressed less than6to9years old in myopes. The number of myopic parents and their degrees of myopia were positively associated with their chidren's risk of onset and the rate of progression. The growth curves of height and AL had the tendencies somewhat similar; the higher rates of myopic onset and progression were concomitants of the bone growth.
Before the onset of myopia, the elongation of AL was slow, the compensations by other refractive components, refraction had little change or emmetropized slowly. During the onset of myopia, the elongation of AL speeded up markedly, other refractive components tried their best to resist the myopic tendency but insufficiently. During the process, the driving force of genetic factors to refractive change increased, probably acted through the shared genetic mechanism between height and AL. After the onset of myopia, the effects of environmental factors on AL enhanced; genetic factors'influence weakened on AL, but with similar effects on SER, so they might begin to prompt the myopic tendencies of other refractive components; the effect-weakened genes weren't the shared genes between height and AL. The more myopic the SER in baseline, the less the myopic changes which occurred in refrective parameters, perhaps related to the increasing myopic defocus.
Conclusions
The onset and progression of myopia appear to be a consistent, gradual process; was associated with sex, age, myopic family history and height change rate.
Under the influence of genetic and environmental factors, the effects of AL elongation to myopic change of SER enhanced before, during, and after myopia's onset, the compensations and resistance of other refractive components peaked during the onset, then tended to promote the myopic progression after the onset.
The myopic tendency of the children and juveniles was obviously, the prevalence and incidence were high compared to other cities in China and the world, with greater effects of environmental factors than other cities. It's necessary to pay close attentions, give actively prevention, control the onset and progression of myopia.
引文
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[48]Pointer J.S, A 6-year longitudinal optometric study ofthe refractive trend in school-aged children [J]. Ophthalmic Physiol Opt,2001,21:361-7.
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[52]Fan DS, Lam DS, Lam RF, et ak. Prevalence, incidence, and progression of myopia of school children in Hong Kong [J]. Invest Ophthalmol Vis Sci.2004 Apr; 45(4):1071-5.
[53]Lam DS, Edwards M, Millodot M, et al. A 2-year longitudinal study of myopia progression and optical component changes among Hong Kong schoolchildren [J]. Optom Vis Sci.1999 Jun; 76(6):370-80.
[54]Ren YL, Lin Y, Hnang YM, et al. Prevalence anf incidence of myopia of school clIildren in Zhongshan city [J].Int J Ophthalmo.2010; 10(11):2150-2152.
[55]Saw SM, Nieto FJ, Katz J, et al. Factors related to the progression of myopia in Singaporean children [J]. Optom Vis Sci.2000 Oct; 77(10):549-54.
[56]Weizhong L, Zhikuan Y, Wen L, et al. A longitudinal study on the relationship between myopia development and near accommodation lags in myopic children [J]. Ophthal Physiol Opt 2008; 28:57-61.
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[1]Jones LA, Sinnott LT, Mutti DO, et al. Parental history of myopia, sports and outdoor activities, and future myopia[J]. Invest Ophthalmol Vis Sci.2007 Aug; 48(8):3524-32.
[2]Sorsby A, Benjamin B, Sheridan M. Refraction and Its Components:During the Growth of the Eye from the Age of Three [A]. In Medical Research Council memorandum[C]. London:H.M.S.O.1961;301 (Special):1-67.
[3]Wong HB, Machin D, et al. Ocular component growth curves among Singaporean children with different refractive error status [J]. Invest Ophthalmol Vis Sci.2010 Mar; 51(3):1341-7.
[4]Saw SM, Chua WH, Gazzard G, et al. Eye growth changes in myopic children in Singapore [J]. Br J Ophthalmol.2005 Nov;89(11):1489-94.
[5]Lam DS, Fan DS, Lam RF, et al. The effect of parental history of myopia on children's eye size and growth:results of a longitudinal study [J]. Invest Ophthalmol Vis Sci.2008 Mar;49(3):873-6.
[6]Gwiazda J, Hyman L, Hussein M, et al. A randomized clinical trial of progressive addition lenses versus single vision lenses on the progression of myopia in children [J]. Invest Ophthalmol Vis Sci.2003 Apr; 44(4):1492-500.
[7]Lam DS, Edwards M, Millodot M, et al. A 2-year longitudinal study of myopia progression and optical component changes among Hong Kong schoolchildren [J]. Optom Vis Sci.1999 Jun; 76(6):370-80.
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[9]Fan DS, Lam DS, Lam RF, et ak. Prevalence, incidence, and progression of myopia of school children in Hong Kong [J]. Invest Ophthalmol Vis Sci.2004 Apr;45(4):1071-5.
[10]Matsumura H, Hirai H. Prevalence of myopia and refractive changes in students from 3 to 17 years of age [J]. Surv Ophthalmol.1999 Oct; 44 Suppl 1:S109-115.
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[12]Jones LA, Mitchell GL, Mutti DO, et al. Comparison of ocular component growth curves among refractive error groups in children [J]. Invest Ophthalmol Vis Sci.2005 Jul;46(7):2317-27.
[13]Braun CI, Freidlin V, Sperduto RD, et al. The progression of myopia in school age children:data from the Columbia Medical Plan [J]. Ophthalmic Epidemiol.1996 Mar;3(1):13-21.
[14]Saw SM, Nieto FJ, Katz J. et al. Factors related to the progression of myopia in Singaporean children [J]. Optom Vis Sci.2000 Oct; 77(10):549-54.
[15]Hyman L, Gwiazda J, Hussein M, et al. Relationship of age, sex, and ethnicity with myopia progression and axial elongation in the correction of myopia evaluation trial [J]. Arch Ophthalmol.2005 Jul; 123(7):977-87.
[16]Saw SM, Tong L, Chua WH, Incidence and progression of myopia in Singaporean school children [J]. Invest Ophthalmol Vis Sci.2005 Jan; 46(1):51-7.
[17]Saw SM, Nieto FJ, Katz J, et al. Familial clustering and myopia progression in Singapore school children [J]. Ophthalmic Epidemiol.2001 Sep;8(4):227-36.
[18]Saw SM, Chua WH, Hong CY, et al. Height and its relationship to relation and biometry parameters in Singapore Chinese children[J]. IOVS,2002 May; 43(5):1408-13.
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[1]Jones LA, Sinnott LT, Mutti DO, et al. Parental history of myopia, sports and outdoor activities, and future myopia[J]. Invest Ophthalmol Vis Sci.2007 Aug; 48(8):3524-32.
[2]Sorsby A, Benjamin B, Sheridan M. Refraction and Its Components:During the Growth of the Eye from the Age of Three [A]. In Medical Research Council memorandum[C]. London:H.M.S.O.1961;301 (Special):1-67.
[3]Wong HB, Machin D, et al. Ocular component growth curves among Singaporean children with different refractive error status [J]. Invest Ophthalmol Vis Sci.2010 Mar; 51(3):1341-7.
[4]Saw SM, Chua WH, Gazzard G, et al. Eye growth changes in myopic children in Singapore [J]. Br J Ophthalmol.2005 Nov;89(11):1489-94.
[5]Lam DS, Fan DS, Lam RF, et al. The effect of parental history of myopia on children's eye size and growth:results of a longitudinal study [J]. Invest Ophthalmol Vis Sci.2008 Mar;49(3):873-6.
[6]Gwiazda J, Hyman L, Hussein M, et al. A randomized clinical trial of progressive addition lenses versus single vision lenses on the progression of myopia in children [J]. Invest Ophthalmol Vis Sci.2003 Apr; 44(4):1492-500.
[7]Lam DS, Edwards M, Millodot M, et al. A 2-year longitudinal study of myopia progression and optical component changes among Hong Kong schoolchildren [J]. Optom Vis Sci.1999 Jun; 76(6):370-80.
[8]Zhao J, Mao J, Luo R, et al. The progression of refractive error in school-age children:Shunyi district, China [J]. Am J Ophthalmol.2002 Nov; 134(5):735-43.
[9]Fan DS, Lam DS, Lam RF, et ak. Prevalence, incidence, and progression of myopia of school children in Hong Kong [J]. Invest Ophthalmol Vis Sci.2004 Apr;45(4):1071-5.
[10]Matsumura H, Hirai H. Prevalence of myopia and refractive changes in students from 3 to 17 years of age [J]. Surv Ophthalmol.1999 Oct; 44 Suppl 1:S109-115.
[11]Mutti DO, Hayes JR, Mitchell GL, et al. Refractive error, axial length, and relative peripheral refractive error before and after the onset of myopia [J]. Invest Ophthalmol Vis Sci.2007 Jun; 48(6):2510-9.
[12]Jones LA, Mitchell GL, Mutti DO, et al. Comparison of ocular component growth curves among refractive error groups in children [J]. Invest Ophthalmol Vis Sci.2005 Jul;46(7):2317-27.
[13]Braun CI, Freidlin V, Sperduto RD, et al. The progression of myopia in school age children:data from the Columbia Medical Plan [J]. Ophthalmic Epidemiol.1996 Mar;3(1):13-21.
[14]Saw SM, Nieto FJ, Katz J. et al. Factors related to the progression of myopia in Singaporean children [J]. Optom Vis Sci.2000 Oct; 77(10):549-54.
[15]Hyman L, Gwiazda J, Hussein M, et al. Relationship of age, sex, and ethnicity with myopia progression and axial elongation in the correction of myopia evaluation trial [J]. Arch Ophthalmol.2005 Jul; 123(7):977-87.
[16]Saw SM, Tong L, Chua WH, Incidence and progression of myopia in Singaporean school children [J]. Invest Ophthalmol Vis Sci.2005 Jan; 46(1):51-7.
[17]Saw SM, Nieto FJ, Katz J, et al. Familial clustering and myopia progression in Singapore school children [J]. Ophthalmic Epidemiol.2001 Sep;8(4):227-36.
[18]Saw SM, Chua WH, Hong CY, et al. Height and its relationship to relation and biometry parameters in Singapore Chinese children[J]. IOVS,2002 May; 43(5):1408-13.
[19]Maikari JM. Myopia and stature[J]. Acta Ophthalmol,1987 Dec; 65(6):673-6.
[20]Wang D, Ding X, Liu B, et al. Longitudinal changes of axial length and height are associated and concomitant in children [J]. Invest Ophthalmol Vis Sci.2011 Oct 10; 52(11):7949-53.
[21]Goss DA, Cox VD, Herrin-Lawson GA, et al. Refractive error, axial length, and height as a function of age in young myopes [J]. Optom Vis Sci.1990 May; 67(5):332-8.
[22]Yang Z, Lan W, Liu W, et al. Association of ocular dominance and myopia development:a 2-year longitudinal study[J]. Invest Ophthalmol Vis Sci.2008 Nov; 49(11):4779-83.
[23]Parssinen O, Lyyra AL. Myopia and myopic progression among schoolchildren:a three-year follow-up study[J]. Invest Ophthalmol Vis Sci.1993 Aug; 34(9):2794-802.
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[25]褚仁远,瞿小妹.建立儿童屈光发育档案是预防近视的基础步骤[J].中华眼科杂志,2009,45(7)：577-579.
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