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Role of lens in early refractive development: evidence from a large cohort of Chinese children
  1. Xiaotong Han1,
  2. Ruilin Xiong1,
  3. Ling Jin1,
  4. Shuai Chang1,
  5. Qianyun Chen1,
  6. Decai Wang1,
  7. Xiang Chen1,
  8. Yabin Qu2,
  9. Weijia Liu3,
  10. Mingguang He1,4,
  11. Ian Morgan5,
  12. Yangfa Zeng1,
  13. Yizhi Liu1
  1. 1State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, Guangdong, China
  2. 2Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
  3. 3School Health Unit, Guangzhou Center for Disease Control and Prevention, Guangzhou, Guangdong, China
  4. 4Experimental Ophthalmology, The Hong Kong Polytechnic University, Hong Kong, China
  5. 5Research School of Biology, Australian National University, Canberra, Australian Capital Territory, Australia
  1. Correspondence to Dr Yangfa Zeng, State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yan-sen University of Medical Sciences, Guangzhou, Guangdong, China; zengyangfa{at}


Aims To document longitudinal changes in spherical equivalent refraction (SER) and related biometric factors during early refractive development.

Methods This was a prospective cohort study of Chinese children, starting in 2018 with annual follow-ups. At each visit, children received cycloplegic autorefraction and ocular biometry measurements. Lens power (LP) was calculated using Bennett’s formula. Children were divided into eight groups based on baseline age: the 3-year-old (n=426, 49.77% girls), 4-year-old (n=834, 47.36% girls), 6-year-old (n=292, 46.58% girls), 7-year-old (n=964, 43.46% girls), 9-year-old (n=981, 46.18% girls), 10-year-old (n=1181, 46.32% girls), 12-year-old (n=504, 49.01%) and 13-year-old (n=644, 42.70%) age groups.

Results This study included right-eye data from 5826 children. The 3-year-old and 4-year-old age groups demonstrated an inflection point in longitudinal SER changes at a mild hyperopic baseline SER (+1 to +2 D), with children with more myopic SER showing hyperopic refractive shifts while those with more hyperopic SER showing myopic shifts. The hyperopic shift in SER was mainly attributed to rapid LP loss and was rarely seen in the older age groups. Axial elongation accelerated in the premyopia stage, accompanied by a partially counter-balancing acceleration of LP loss. For children aged 3–7 years, those with annual SER changes <0.25 D were all mildly hyperopic at baseline (mean: 1.23 D, 95% CI 1.20 to 1.27 D).

Conclusion Our findings suggest that during early refractive development, refractions cluster around or above +1.00 D. There is a pushback process in which increases in the rate of LP occur in parallel with increases in axial elongation.

  • Optics and Refraction
  • Epidemiology
  • Lens and zonules

Data availability statement

Data are available on reasonable request. Data will be shared on reasonable request to pursue additional studies or for replication.

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Data availability statement

Data are available on reasonable request. Data will be shared on reasonable request to pursue additional studies or for replication.

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  • Contributors Study concept and design: YZ and XH, acquisition, analyses or interpretation. Statistical analyses: LJ. Obtained funding: YZ and XH. Administrative, technical or material support: XC, YQ and WL. Study supervision: YZ. YZ is guarantor.

  • Funding Supported by the Construction Project of High-Level Hospitals in Guangdong Province (303020107; 303010303058) and National Natural Science Foundation of China (82101171).

  • Disclaimer The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

  • Competing interests None declared.

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

  • 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.