The incidence of myopia among children and adolescents in China shows a trend of high prevalence and younger age of onset, seriously affecting the physical and mental health of children and adolescents, and has become a focus of concern for the whole society. In order to actively implement General Secretary Xi Jinping's important instructions on the myopia problem of children and adolescents, further promote the implementation of the Comprehensive Plan for the Prevention and Control of Myopia in Children and Adolescents, guide scientific and standardized prevention and control work, and improve prevention and control technical capabilities, the Appropriate Technical Guidelines for the Prevention and Control of Myopia in Children and Adolescents (hereinafter referred to as the Guidelines) are hereby formulated.
I. Scope of Application
The Guidelines are applicable to the development of myopia prevention and control work for children and adolescents, and the target readers are myopia prevention and control technicians for children and adolescents at the provincial, municipal, and county levels.
II. Basic Knowledge of Myopia Prevention and Control
(I) Terminology.
1. Visual acuity: Also known as visual sharpness, refers to the ability of the eye to identify objects, divided into central visual acuity and peripheral visual acuity (i.e., visual field). The former refers to the visual sharpness of the fovea centralis in the macular area of the fundus, and the latter refers to visual acuity outside the fixation point of the macular area. Generally, visual acuity refers to central visual acuity. The ability to identify distant objects is called distance visual acuity, and the ability to identify near objects is called near visual acuity.
2. Uncorrected visual acuity: Also known as uncorrected vision, refers to visual acuity measured without any optical lens correction, including uncorrected distance visual acuity and uncorrected near visual acuity.
3. Corrected visual acuity: Refers to visual acuity measured after correction with optical lenses. It includes distance corrected visual acuity and near corrected visual acuity.
4. Visual impairment: Also known as low vision. Refers to distance visual acuity examined according to the Standard Logarithmic Visual Acuity Chart (GB11533—2011), where the uncorrected visual acuity of children and adolescents over 6 years old is below 5.0. Among these, visual acuity of 4.9 is mild visual impairment, 4.6≤visual acuity≤4.8 is moderate visual impairment, and visual acuity≤4.5 is severe visual impairment. The causes of visual impairment in children and adolescents are mostly refractive errors such as myopia, hyperopia, and astigmatism, as well as other eye diseases (such as amblyopia, strabismus, etc.).
5. Myopia: Refers to the pathological state in which, under relaxed accommodation, parallel light rays from beyond 5 meters are focused in front of the retina after passing through the refractive system of the eye, manifested as decreased distance visual acuity.
6. Screened myopia: The use of rapid and simple methods such as distance visual acuity examination, computer optometry under non-cycloplegic conditions (commonly known as computer optometry), or streak retinoscopy to screen out those among children and adolescents who may have myopia. When the uncorrected distance visual acuity of children and adolescents over 6 years old is <5.0, through computer optometry under non-cycloplegic conditions, spherical equivalent (SE) <﹣0.50D is determined as screened myopia; in areas without conditions to equip computer optometers, streak retinoscopy may be used, and when visual acuity decreases with a positive lens (convex lens) and improves with a negative lens (concave lens), it is determined as screened myopia.
7. Cycloplegic refraction examination: Cycloplegic refraction, commonly known as dilated pupil refraction, is the internationally recognized gold standard for diagnosing myopia. It is recommended that children under 12 years old, especially those undergoing refraction for the first time, or those with hyperopia, strabismus, amblyopia, and relatively large astigmatism, must undergo cycloplegic refraction, and children diagnosed with myopia who need glasses require regular follow-up refraction.
(II) Classification of myopia.
1. Determine the degree of myopia based on the spherical equivalent (SE) measured by a refractometer after cycloplegia. According to the SE, myopia can be classified into three levels: low, moderate, and high.
(1) Low myopia: -3.00D ≤ SE < -0.50D (myopia between 50 and 300 degrees);
(2) Moderate myopia: -6.00D ≤ SE < -3.00D (myopia between 300 and 600 degrees);
(3) High myopia: SE < -6.00D (myopia above 600 degrees).
2. According to the progression and pathological changes of myopia, myopia can also be divided into simple myopia and pathological myopia.
(1) Simple myopia: mostly refers to myopia that develops during the growth period of the eyeball; when growth stops, the myopia also tends to stabilize, and the refractive error is generally within -6.00D. The vast majority of these patients have no pathological changes in the fundus, and vision can be corrected to normal with appropriate optical lenses.
(2) Pathological myopia: mostly refers to a type of myopia in which myopia continues to progress after growth stops and is accompanied by pathological changes in the fundus, also known as progressive myopia; the refractive error in most patients is above -6.00D. Common fundus changes include myopic crescent, lacquer cracks, choroidal neovascularization, macular choroidal atrophy, retinal detachment, posterior scleral staphyloma, etc.
(III) Symptoms and harms of myopia.
The typical symptom of myopia is decreased distance visual acuity. Its main manifestations include:
(1) Decreased distance visual acuity; in the early stage of myopia, distance visual acuity often fluctuates;
(2) Unconsciously squinting and tilting the head when looking at distant objects;
(3) Some people with uncorrected myopia may experience symptoms of visual fatigue;
(4) Those with higher degrees of myopia, in addition to poor distance visual acuity, often have symptoms such as poor night vision, floaters, drifting objects, and flashes of light, and may develop varying degrees of fundus changes. Especially in people with high myopia, the risk of retinal detachment, tears, holes, macular hemorrhage, neovascularization, and open-angle glaucoma is increased, and in severe cases it can lead to blindness.
III. Appropriate techniques for myopia prevention and control
(I) Screening for poor vision and myopia.
In accordance with the requirements of the Technical Specifications for Children's Eye and Vision Care and the National Basic Public Health Service Specifications (Third Edition), carry out eye care and vision examination for children aged 0-6, detect early eye diseases and high-risk factors affecting children's visual development, provide timely referral and early correction, and protect and promote the normal development of children's visual function.
Establish a regular vision screening system for primary and secondary school students, and carry out vision impairment examinations, including uncorrected visual acuity, corrected visual acuity (if glasses are worn), non-cycloplegic refraction examination, and assessment of visual health influencing factors. Areas with conditions are encouraged to add axial length and corneal curvature measurement. Distance vision screening shall adopt GB11533-2011 International Logarithmic Visual Acuity Chart. Screening frequency shall be no less than once per academic year; the automatic computer optometer used for computer optometry shall comply with the provisions of ISO10342-2010 Ophthalmic Instruments: Optometers.
Carry out vision screening for children and adolescents in kindergartens, primary and secondary schools, and provide professional technical services and guidance. Screening units shall, within 1 month after the screening is completed, feed back the screening results in accordance with the screening technical flowcharts (see Figure 1 and Figure 2), and propose targeted myopia prevention guidance or referral recommendations. Special attention shall be paid to information feedback and eye hygiene guidance for children and adolescents with myopia; for those suspected of insufficient hyperopia reserve (normal uncorrected visual acuity, refractive status not reaching the myopia standard but deviating from the physiological value range for the corresponding age group) and those with high-risk factors for myopia, high-risk warnings shall be given and key intervention shall be provided. At the same time, the examination results shall be fed back to the school within 1 month, including the examination time, number of examinees, and the occurrence of vision impairment and screening myopia rates by grade and class, and shall be compared with the examination results of the previous academic year.
Figure 1 Technical Flowchart for Vision and Refraction Screening of Preschool Children
Figure 2 Technical Flowchart for Vision and Refraction Screening of Primary and Secondary School Students
(2) Establish vision health records.
Conduct regular vision examinations for children aged 0-6 and primary and secondary school students, refer to the Record Form for Myopia Screening Results of Children and Adolescents (see Table 1), standardize the recording of examination contents, and establish vision health records for children and adolescents. Areas with conditions may, according to circumstances, add contents such as eye appearance, eye position, eye movement, and refractive development.
Promptly analyze the vision health status of children and adolescents, early screen out myopia and other refractive errors, dynamically observe the development and changes of refractive status of children and adolescents at different periods, early detect the tendency or trend of myopia, formulate intervention measures, and strive to reduce the occurrence and development of myopia, especially high myopia. Primary schools shall receive the annual Record Forms for Vision Examination of Children and Adolescents and other vision health records transferred from medical and health institutions, ensure one file per person, transfer them in real time with changes in student status, and connect them with the vision examinations of primary and secondary school students.
Table 1 Record Form for Myopia Screening Results of Children and Adolescents
Province (Municipality/Autonomous Region): □□ City (Prefecture): □□
County (District): □□ Monitoring Point: □ (1 Urban; 2 Suburban)
School name (seal): □□
| 1.Personal basic informationName: Grade: □□ Code: □□□□ Gender: ① Male ② Female Age: (full years) Ethnicity: ID number: □□□□□□□□□□□□□□□□□□ Date of birth: □□□□ Year □□ Month □□ Day Examination time: □□□□ Year □□ Month □□ Day Class teacher signature: | |
| 2. 0-3 years old children eye appearance □ No abnormality □ Abnormal 0-3 years old children other examinations (optional): Light reflex □ No abnormality □ Abnormal Blink reflex □ No abnormality □ Abnormal Red ball test □ No abnormality □ Abnormal Eye position examination □ No abnormality □ Abnormal Eye movement □ No abnormality □ Abnormal Visual behavior observation □ No abnormality □ Abnormal Form filler/doctor signature: ____ | |
| 3. Vision examinationGlasses type: □ ① Framed glasses ② Contact lenses ③ Orthokeratology lenses, worn prescription (right) (left) ④ No glasses. Distance visual acuity test results: Eye Laterality Uncided visual acuity Glasses visual acuity Right eye Left eye (please record using the 5-point method) Form filler/doctor signature: Automatic computer optometry results: Eye Laterality Sphere (S) Cylinder (astigmatism C) Axis (astigmatism direction A) Right eye Left eye (sphere and cylinder please retain two decimal places) Other special circumstances requiring notation: Form filler/doctor signature: __________ | Computer optometry printout pasting area |
| Note: 1. Glasses visual acuity refers to the visual acuity level seen when wearing one's existing glasses. 2. In "computer optometry," "sphere" is the degree of myopia or hyperopia, negative values are myopia, positive values are hyperopia; "cylinder" is the astigmatism degree; axis is the direction of astigmatism, astigmatism axis only exists when there is astigmatism degree. 3. This computer optometry is non-cycloplegic refraction for myopia screening, and the results have no diagnostic significance. | |
(3) Cultivate healthy eye-use behavior.
Individuals, families, and schools should actively cultivate the awareness that "everyone is the first person responsible for their own health," and proactively learn and master eye health knowledge and skills; parents and guardians should understand scientific eye-use and eye-care knowledge, lead by example, strengthen outdoor activities and physical exercise, and reduce students' academic burden; cultivate and urge children and adolescents to develop good eye hygiene habits, so that they establish eye-loving and eye-protecting behavior.
| Implementing entity | Technical measures |
| Individual | l Actively pay attention to signs of abnormal vision, such as being unable to see text on the blackboard clearly, eyes often dry, frequently rubbing eyes, and other symptoms, and promptly inform parents and teachers of vision changes. You can alternately close one eye for self-testing, so as to detect monocular vision impairment. l Do eye exercises carefully and standardly, concentrate when doing exercises, close the eyes, carefully and correctly press and knead acupoints, etc., to the extent of feeling soreness and distension. l Maintain correct reading and writing posture, "one fist, one foot, one inch"; do not read or use electronic products while walking, eating, lying in bed, in a shaking carriage, in dim light, or under direct sunlight. l Continuous eye use for reading and writing should not exceed 40 minutes, and after about every 40 minutes rest for 10 minutes, can look into the distance or do eye exercises, etc. l Control the time spent using electronic products. After using electronic products for study for 30-40 minutes in spare time, should rest and look into the distance to relax for 10 minutes. Use of electronic products for non-study purposes should not exceed 15 minutes each time. |
| Family | Urge children to maintain correct reading and writing posture, achieving "one fist, one foot, one inch"; do not read while lying down, and do not read or use electronic devices while walking or eating. Parents should minimize their own use of electronic devices when accompanying children. Parents should set clear rules and consciously control children's use of electronic devices, especially for preschool children, and actively choose alternative activities such as games, sports, and outdoor activities to reduce screen time. |
| Schools | Develop health education courses and activities related to myopia prevention and control to enhance the health literacy of teachers and students. Primary and secondary schools shall strictly organize all students to perform eye exercises once in the morning and once in the afternoon each day. Encourage students to go outside the classroom during breaks, with a 30-minute recess arranged in both the morning and afternoon. Teachers should teach and supervise students to maintain correct reading and writing posture. Guide students in the scientific and standardized use of electronic devices. Kindergarten teachers should proactively control the time spent using televisions, projectors, and other equipment during childcare and educational work. |
(4) Build a vision-friendly environment.
Families, schools, medical and health institutions, media, and other social organizations and all sectors of society should actively participate in building a vision-friendly environment. Families and schools shall, in accordance with relevant national policies and standards, reduce students' academic burden, improve lighting conditions, and provide desks and chairs suitable for the height of children and adolescents. Media and communities should intensify the promotion of relevant standards and knowledge to create a supportive social environment.
| Implementing entities | Technical measures |
| Families | Cooperate with schools to effectively reduce children's academic burden. Provide good indoor lighting and daylighting environment at home. Regularly adjust the height of desks and chairs to suit changes in children's height. Do not place televisions or other screen products in children's bedrooms. Ensure adequate sleep time for children. |
| Schools | Medical and health institutions |
| Reduce students' academic burden and organize teaching activities in accordance with national curriculum plans and curriculum standards. Conduct normal teaching based on the "zero starting point" approach, focus on improving classroom teaching efficiency, and shall not arbitrarily increase or decrease class hours, change difficulty levels, or adjust pace. Strengthen the coordinated management of homework quantity, time, and content by grade groups and subject groups. Teaching and homework assignments should not rely on electronic devices; the duration of using electronic devices for teaching shall in principle not exceed 30% of total teaching time, and paper-based homework should in principle be used. Purchase adjustable desks and chairs that meet standards. Provide a teaching environment that meets eye hygiene requirements. Accelerate the elimination of the "large class size" phenomenon. Strengthen vision health management and integrate myopia prevention and control knowledge into classroom teaching, campus culture, and students' daily behavior norms. Provide children with balanced and nutritious meals beneficial to vision health to promote vision protection. | Strengthen the capacity building of medical institutions and train pediatric eye health medical technicians. Provide personalized myopia prevention and control health education and tiered referrals based on the progression of children's and adolescents' vision. Organize experts to proactively enter schools, communities, and families to actively promote and disseminate health science knowledge for preventing myopia in children and adolescents. |
| Media and social organizations | Advocate healthy concepts and disseminate scientific health knowledge. Give full play to the role of radio and television, newspapers and periodicals, the internet, and new media, and use public service advertisements and other forms to promote myopia prevention and treatment knowledge from multiple levels and perspectives. |
(5) Increase daytime outdoor activities.
Schools, families, and communities should work together to reduce prolonged continuous near-vision work among children and adolescents, take multiple measures to provide relevant conditions for children and adolescents, and urge children and adolescents to engage in outdoor activities.
| Implementing body | Technical measures |
| Individuals | Develop health awareness and eye-use habits, adopt healthy behaviors, and engage in at least 2 hours of daytime outdoor activities every day. Ensure sufficient sleep time: 10 hours per day for primary school students, 9 hours for junior high school students, and 8 hours for senior high school students. |
| Families | By accompanying children walking to school, engaging in parent-child outdoor activities after school and on holidays, and other means, actively guide, support, and urge children to engage in daytime outdoor activities. Ensure that children are exposed to outdoor natural light for more than 60 minutes per day when at home. For children who already have myopia, outdoor activity time should be further increased to delay the progression of myopia. Encourage and support children to participate in various forms of sports activities, urge children to conscientiously complete winter and summer vacation sports homework, master 1 to 2 sports skills, and guide children to develop a lifelong exercise habit. |
| Schools | Strengthen outdoor physical exercise and ensure that primary and secondary school students have more than 1 hour of physical activity time per day while at school. Emphasize the cultivation of good eye-use habits. Implement the national physical education and health curriculum standards. Ensure 4 class hours per week for grades 1 and 2 of primary school, 3 class hours per week for grades 3 to 6 and junior high school, and 2 class hours per week for senior high school. Primary and secondary schools should arrange 30 minutes of large recess sports activities every day. Kindergartens should ensure that children engage in more than 2 hours of outdoor activities every day, and boarding kindergartens should not have less than 3 hours, of which physical activity time should not be less than 1 hour, with reasonable adjustments made according to regional, seasonal, and age-stage characteristics. Fully implement the system of students' physical education family homework during winter and summer vacations, and supervise and inspect students' completion. Avoid "primary school-style" teaching in kindergartens and value the role of life and play in the growth of children aged 3 to 6. |
(6) Standardize vision health monitoring and assessment.
Vision health monitoring and assessment can promptly understand the distribution characteristics and changing trends of poor vision and myopia among student groups, identify high-risk populations and high-risk factors, and provide a data basis for formulating and evaluating myopia prevention and control measures.
Formulate a local implementation plan for monitoring common diseases and health influencing factors among students, organize relevant training, and carry out on-site investigation and monitoring, data entry, result analysis and reporting. The myopia monitoring flowchart is shown in Figure 3.
Write local myopia monitoring and evaluation reports level by level, promptly report the monitoring and evaluation reports to the government and notify the education administrative department, and in light of local actual conditions, formulate or adjust myopia intervention measures and activities, and release key information to the public through the media.
Figure 3 Flowchart of myopia monitoring for children and adolescents
(7) Scientific diagnosis, treatment and correction.
Through myopia screening and monitoring, children and adolescents should be managed by classification and scientifically corrected.
1. For students with normal vision but high-risk factors for myopia, advise them to change high-risk behaviors and improve the visual environment.
2. For those with insufficient hyperopia reserve or decreased uncorrected visual acuity, whose visual function may be abnormal, advise them to receive refractive examinations such as medical optometry at a medical institution, confirm the diagnosis and take timely measures for correction.
3. Wearing frame glasses is the preferred method for correcting refractive errors. Parents are advised to go to a medical institution and, in accordance with the requirements of doctors or optometrists, choose glasses of appropriate diopters for their children and wear them according to medical advice. For those with normal vision while wearing glasses, preschool children should go to a medical institution every 3 months or every 6 months, and primary and secondary school students every 6 to 12 months, to have their uncorrected visual acuity and corrected visual acuity checked. If vision while wearing glasses decreases, it is necessary to determine under a doctor's guidance whether the glasses need to be replaced.
4. For children and adolescents with myopia, when using low-concentration atropine or wearing orthokeratology lenses (OK lenses) to slow the progression of myopia, it is recommended to go to a qualified medical institution and follow medical advice under a doctor's guidance.