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Prevalence, incidence and risk factors of strabismus in a Chinese population-based cohort of preschool children: the Nanjing Eye Study
  1. Danni Chen1,
  2. Rui Li1,
  3. Xiaoxiao Li1,
  4. Dan Huang2,
  5. Yue Wang1,
  6. Xiaoyan Zhao1,
  7. Xiaohan Zhang3,
  8. Qigang Sun4,
  9. Qingfeng Hao1,
  10. Haohai Tong1,
  11. Xinyuan Yao5,
  12. Weixiao Fan5,
  13. Weijing Lu5,
  14. Jingsong Dang5,
  15. Hui Zhu1,
  16. Hu Liu1
  1. 1 Ophthalmology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
  2. 2 Child Healthcare, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
  3. 3 Ophthalmology, Wuxi Children’s Hospital, Wuxi, China
  4. 4 Maternal and Child Healthcare Hospital of Yuhuatai District Nanjing China, Nanjing, China
  5. 5 The Fourth School of Clinical Medicine of Nanjing Medical University, Nanjing, China
  1. Correspondence to Hu Liu and Hui Zhu, Department of Ophthalmology, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, China; liuhu{at}; zhny1125{at}


Aims To evaluate the prevalence, incidence and their related risk factors of strabismus among preschool children in China.

Methods Children born between September 2011 and August 2012 in Yuhuatai District of Nanjing were invited to participate in the Nanjing Eye Study for a comprehensive eye examination annually since 2015. The data presented in this paper were obtained from 2015 to 2017, when these children grew from the age of 3 to 5 years. Eye examinations included visual acuity, anterior segment, posterior segment, refraction, and ocular alignment and motility. Risk factors were evaluated using univariable and multivariable logistic regression models for prevalent and incident strabismus.

Results In 2015, a total of 2018 children (87.7% response rate) of 2300 eligible preschoolers completed the baseline eye examination when they were 3 years old. Among the 2018 participants, 50 had strabismus (prevalence rate, 2.48%). In multivariable analysis, prevalent strabismus was independently associated with parental strabismus history (OR=11.60, p<0.001), hyperopia (OR=6.22, p<0.001), prematurity (OR=3.07, p=0.01) and astigmatism (OR=2.15, p=0.04). Among 1766 children followed up for 2 years, 63 developed strabismus (annual incidence rate, 1.78%), of whom 57 had exotropia and 6 had esotropia. In multivariable analysis, incident strabismus was significantly associated with parental strabismus history (OR=5.55, p=0.04) and prematurity (OR=3.77, p<0.001).

Conclusions In this population-based cohort study, we found a higher incidence of strabismus and a higher exotropia:esotropia ratio than previous studies in preschool children. Parental strabismus history and prematurity were associated with a higher risk for both prevalent and incident strabismus.

  • Epidemiology

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  • DC, RL and XL contributed equally to the study and they should be regarded as joint first authors.

  • Contributors HL and HZ designed the study. DC, RL and HZ wrote the main manuscript text. DC, LX and HD prepared tables. DC, RL, XL, DH, XY, WF, WL and JD performed data interpretation and analysis. RL, YW, XZ, XZ, QS, QH and HT performed the ocular examinations.

  • Funding This work was supported by the National Natural Science Foundation of China (Grant No. 81673198; No. 81803258). The funding organisations had no role in the design or conduct of this research.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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