Development and validation of a novel nomogram for predicting the occurrence of myopia in schoolchildren: A prospective cohort study

Abstract

•Myopia onset was closely related to ocular indicators.•Single spherical equivalent refraction performed poorly in predicting myopia among Chinese schoolchildren.•An online myopia risk calculator was developed to predict incident myopia in schoolchildren. PurposeMyopia is a major public health issue and occurs at young ages. Apart from its high prevalence, myopia results in high costs and irreversible blinding diseases. Accurate prediction of the risk of myopia onset is crucial for its precise prevention. We aimed to develop and validate an effective nomogram for predicting myopia onset in schoolchildren.DesignSchool-based prospective cohort study.MethodsA total of 1073 schoolchildren were enrolled from November 2014 to May 2019 in China, and were divided into the training and validation cohorts. Myopia was defined as a spherical equivalent refraction (SER) ≤−0.5 diopters. Predictors of myopia were determined through the least absolute shrinkage and selection operator regression and multivariable Cox proportional hazard model based on the training cohort. The predictive performance of the nomogram was validated internally through time-dependent receiver operating characteristic (ROC) curves, calibration plot, decision curve analysis, and Kaplan-Meier curves.ResultsIndependent predictors at baseline including gender, SER, axial length, corneal refractive power, and positive relative accommodation were included in the nomogram prediction model. This nomogram demonstrated excellent calibration, clinical net benefit, and discrimination, with all the area under the ROC curves (AUCs) between 0.74 and 0.86 in the training and validation cohorts. The Kaplan-Meier curves showed that 3 distinct risk groups stratified through X-tile analysis were well discriminated and robust among subgroups. The Harrell's C-index and net reclassification improvement demonstrated that the nomogram substantially improved compared with previous models. An online myopia risk calculator was generated for better individual prediction.ConclutionsThe nomogram provides accurate and individual prediction of myopia onset in schoolchildren. External validation is needed to verify the generalizability of this nomogram. Myopia is a major public health issue and occurs at young ages. Apart from its high prevalence, myopia results in high costs and irreversible blinding diseases. Accurate prediction of the risk of myopia onset is crucial for its precise prevention. We aimed to develop and validate an effective nomogram for predicting myopia onset in schoolchildren. School-based prospective cohort study. A total of 1073 schoolchildren were enrolled from November 2014 to May 2019 in China, and were divided into the training and validation cohorts. Myopia was defined as a spherical equivalent refraction (SER) ≤−0.5 diopters. Predictors of myopia were determined through the least absolute shrinkage and selection operator regression and multivariable Cox proportional hazard model based on the training cohort. The predictive performance of the nomogram was validated internally through time-dependent receiver operating characteristic (ROC) curves, calibration plot, decision curve analysis, and Kaplan-Meier curves. Independent predictors at baseline including gender, SER, axial length, corneal refractive power, and positive relative accommodation were included in the nomogram prediction model. This nomogram demonstrated excellent calibration, clinical net benefit, and discrimination, with all the area under the ROC curves (AUCs) between 0.74 and 0.86 in the training and validation cohorts. The Kaplan-Meier curves showed that 3 distinct risk groups stratified through X-tile analysis were well discriminated and robust among subgroups. The Harrell's C-index and net reclassification improvement demonstrated that the nomogram substantially improved compared with previous models. An online myopia risk calculator was generated for better individual prediction. The nomogram provides accurate and individual prediction of myopia onset in schoolchildren. External validation is needed to verify the generalizability of this nomogram. Myopia, the most common reason for distance vision impairment,1Repka M. Prevention of myopia in children.JAMA. 2015; 314: 1137-1139Crossref PubMed Scopus (14) Google Scholar,2Holden BA Fricke TR Wilson DA et al.Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050.Ophthalmology. 2016; 123: 1036-1042Abstract Full Text Full Text PDF PubMed Scopus (2263) Google Scholar has become a major public health problem worldwide.3Dolgin E. The myopia boom.Nature. 2015; 519: 276-278Crossref PubMed Scopus (549) Google Scholar The global prevalence of myopia was approximately 22.9% in 2000 and is projected to reach 49.8% by 2050,2Holden BA Fricke TR Wilson DA et al.Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050.Ophthalmology. 2016; 123: 1036-1042Abstract Full Text Full Text PDF PubMed Scopus (2263) Google Scholar and the economic burden of myopia is $202 billion per year.4Smith TS Frick KD Holden BA et al.Potential lost productivity resulting from the global burden of uncorrected refractive error.Bull World Health Organ. 2009; 87: 431-437Crossref PubMed Scopus (235) Google Scholar In East Asia, the “myopia boom” is especially severe.3Dolgin E. The myopia boom.Nature. 2015; 519: 276-278Crossref PubMed Scopus (549) Google Scholar Approximately 80% to 90% of teenagers graduating from high school are myopic in urban areas of East and Southeast Asian countries, and 10% to 20% present high myopia.5Tsai TH Liu YL Ma IH et al.Evolution of the prevalence of myopia among Taiwanese schoolchildren: a review of survey data from 1983 through 2017.Ophthalmology. 2021; 128: 290-301Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar,6Morgan IG Ohno-Matsui K Saw SM. Myopia.Lancet. 2012; 379: 1739-1748Abstract Full Text Full Text PDF PubMed Scopus (1199) Google Scholar In China, a representative country of East Asia, only 10% to 20% of the population was myopic 60 years ago; however, close to 90% of Chinese young adults suffer from myopia today.3Dolgin E. The myopia boom.Nature. 2015; 519: 276-278Crossref PubMed Scopus (549) Google Scholar Myopia is most likely to occur during adolescence, with its incidence peaking during primary school.7Mutti DO Zadnik K Fusaro RE et al.Optical and structural development of the crystalline lens in childhood.Invest Ophthalmol Vis Sci. 1998; 39: 120-133PubMed Google Scholar Meanwhile, the prevalence of myopia tends to occur at a younger age than that in the past, which provides more time for progression toward high myopia until refraction stabilizes in the mid-20s.8Baird PN Saw SM Lanca C et al.Myopia.Nat Rev Dis Primers. 2020; 6: 99Crossref PubMed Scopus (190) Google Scholar McCullough and associates9McCullough S Adamson G Breslin KMM et al.Axial growth and refractive change in white European children and young adults: predictive factors for myopia.Sci Rep. 2020; 10: 15189Crossref PubMed Scopus (30) Google Scholar observed that a young age of myopia onset is related to faster progression. Furthermore, current evidence suggests that a substantial proportion of people with high myopia will finally develop pathologic myopia,10Choudhury F Meuer SM Klein R et al.Prevalence and characteristics of myopic degeneration in an adult Chinese American population: the Chinese American Eye Study.Am J Ophthalmol. 2018; 187: 34-42Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar in which case there is a considerable risk of ocular complications, such as glaucoma, macular atrophy, or retinal detachment.8Baird PN Saw SM Lanca C et al.Myopia.Nat Rev Dis Primers. 2020; 6: 99Crossref PubMed Scopus (190) Google Scholar It is widely believed that myopia is a multifactorial disease, mainly caused by a large number of micro-effect genes and major environmental factors.3Dolgin E. The myopia boom.Nature. 2015; 519: 276-278Crossref PubMed Scopus (549) Google Scholar,6Morgan IG Ohno-Matsui K Saw SM. Myopia.Lancet. 2012; 379: 1739-1748Abstract Full Text Full Text PDF PubMed Scopus (1199) Google Scholar A randomized clinical trial has proved that additional outdoor time is effective in reducing the risk of myopia onset.11He M Xiang F Zeng Y et al.Effect of time spent outdoors at school on the development of myopia among children in China: a randomized clinical trial.JAMA. 2015; 314: 1142-1148Crossref PubMed Scopus (583) Google Scholar With the development of valid preventative measures, it is crucial to identify schoolchildren with a high risk of myopia in the early stage to provide a precise intervention plan. Several studies have reported that ocular variables are closely related to the onset of myopia. Gwiazda and associates reported the potential predictive power of the refractive error in childhood myopia onset.12Gwiazda J Thorn F Bauer J et al.Emmetropization and the progression of manifest refraction in children followed from infancy to puberty.Clin Vis Sci. 1993; 8: 337-344Google Scholar Afterward, the refractive error was proved to be a remarkable ocular indicator for myopia onset prediction, and the first prediction model of incident myopia was established with the spherical equivalent refraction (SER), axial length (AL), and corneal refractive power (CR) using the Orinda Longitudinal Study of Myopia (OLSM) database (OLSM-1999).13Zadnik K Mutti D Friedman N et al.Ocular predictors of the onset of juvenile myopia.Invest Ophthalmol Vis Sci. 1999; 40: 1936-1943PubMed Google Scholar Jones and associates14Jones LA Sinnott LT Mutti DO et al.Parental history of myopia, sports and outdoor activities, and future myopia.Invest Ophthalmol Vis Sci. 2007; 48: 3524-3532Crossref PubMed Scopus (535) Google Scholar further added the outdoor activity hours, number of myopic parents, and their interaction term to obtain a better myopia prediction model (OLSM-2007) with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.90. In addition, Zadnik and associates16Zadnik K Sinnott LT Cotter SA et al.Prediction of juvenile-onset myopia.JAMA Ophthalmol. 2015; 133: 683-689Crossref PubMed Scopus (154) Google Scholar demonstrated SER as a single best predictor for incident myopia and structured a prediction model that included SER, gender, and race, based on data from the Collaborative Longitudinal Evaluation of Ethnicity and Refractive Error (CLEERE) with a C from to the of the to be myopia prediction are well and M G et the of a model to predict the onset of myopia in Ophthalmol Vis Sci. PubMed Scopus Google Scholar demonstrated the predictive of their model with an validation cohort. the of the model is of the of a M G et the of a model to predict the onset of myopia in Ophthalmol Vis Sci. 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