Graefes Arch Clin Exp Ophthalmol
DOI 10.1007/s00417-015-3053-8
MISCELLANEOUS
Effect of undercorrection on myopia progression
in 12-year-old children
Si Yuan Li 1 & Shi-Ming Li 1 & Yue Hua Zhou 1 & Luo Ru Liu 2 & He Li 2 &
Meng Tian Kang 1 & Si Yan Zhan 3 & Ningli Wang 1 & Michel Millodot 4
Received: 10 September 2014 / Revised: 3 May 2015 / Accepted: 5 May 2015
# Springer-Verlag Berlin Heidelberg 2015
Abstract
Background To prospectively observe the effects of
undercorrection of myopia on myopia progression and axial
elongation in a population of 12-year-old Chinese children.
Methods A total of 2,267 children in the Anyang Childhood
Eye Study were examined at baseline, and 1,769 were follow-
ed for 1 year. Ocular examinations included cycloplegic
autorefraction, axial length, visual acuity, vertometry, and ac-
commodative lag. Questionnaires were completed by children
and parents. Undercorrection of myopia was determined at
baseline if presenting visual acuity could be improved by at
least 2 lines with subjective refraction.
Results Of 253 myopic children with spectacles and available
information, 120 (47.4 %) were undercorrected (−4.63D to
−0.50D) and 133 (52.6 %) were fully corrected. In a multivar-
iate model adjusting for age, gender, number of myopic par-
ents, time spent on near work and outdoor activities per day,
usage and time for wearing spectacles per day, children with
undercorrection had significantly more baseline myopia
(P<0.01) and longer axial length (P=0.03) than children with
* Shi-Ming Li
lishiming81@163.com
* Ningli Wang
wningli@vip.163.com
1
Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital
Medical University, Beijing Ophthalmology and Visual Sciences
Key Laboratory, Beijing 100730, China
2
Anyang Eye Hospital, Henan Province, China
3
Department of Epidemiology and Health Statistics, Peking
University School of Public Health, Beijing, China
4
School of Optometry and Vision Sciences, Cardiff University,
Cardiff, UK
full correction. However, there were no significant differences
in myopia progression (P=0.46) and axial elongation (P=
0.96) at 1 year between the two groups of children. The re-
gression analysis showed that myopia progression significant-
ly decreased with increasing amount of undercorrection (r2 =
0.02, P=0.02) in all children. Accommodative lag significant-
ly decreased with increasing amounts of undercorrection
(P<0.01).
Conclusions Based on this 1-year study in Chinese children,
undercorrection or full correction of myopia by wearing spec-
tacles did not show any differences in myopia progression or
axial elongation.
Keywords Myopia progression . Undercorrection .
Full correction . Children
Introduction
Myopia has become a major public health problem world-
wide, especially in Asia [1, 2]. Spectacles are the simplest
optical method to correct myopia to obtain better visual acuity.
However, inadequate correction of myopia by spectacles is
still very common [3, 4] and is the leading cause of visual
impairment among school-aged children in developing coun-
tries [5–10]. About 12.8 million children aged 5–15 years
have visual impairment due to lack of correction or
undercorrection of refractive error, with a global prevalence
of 0.96 %, of which the highest prevalence is in Chinese
children [11–13].
In China, 21.1 and 48.8 % of school-aged myopic children
wearing spectacles are undercorrected in urban [5] and rural
areas [6] respectively. Similar situations have been found in
other developing countries [8, 14]. In Nepal, only 57 % of
children with refractive errors wore spectacles at their first

clinic visit [8]. In Africa, only 9.4 % of students with poor
vision wore spectacles for correction [14]. In Western coun-
tries, however, most children who need spectacles have been
corrected adequately based on visual acuity [3, 4]. For exam-
ple, the prevalence of undercorrected refractive error in 12-
year-old Australian children is only 8.3 % [3].
The effect of undercorrection of myopia on myopia pro-
gression in school-aged children is still controversial [15].
Some studies [16–20] have reported that undercorrection re-
tarded myopia progression compared to full correction, with
differences of −0.05 D/year to −0.40 D/year. On the other
hand, two recent randomized controlled trials (RCT) showed
that undercorrection produced more rapid myopia progression
than full correction, with differences of −0.23 D in 2 years
[21] and −0.17 D in 18 months [22].
Considering the higher prevalence of undercorrection of
myopia in children among developing countries, it is interest-
ing to explore whether undercorrection of myopia has contrib-
uted to faster myopia progression. In the present study, we
investigate the effects of undercorrection on myopia progres-
sion and axial elongation in a population of 12-year-old Chi-
nese children after 1 year of follow-up. The undercorrection of
myopia or not of children was suggested and determined by
the ophthalmologist or optometrist, and was agreed by the
parents and children. The children were selected from a cohort
that we have established.
Material and methods
The Anyang Childhood Eye Study (ACES) is a school-based
cohort study on children in the urban area of Anyang city,
central China. Design, methodology, and baseline data have
been reported previously [23]. In brief, 3,112 grade 1 students
and 2,363 grade 7 students were randomly selected using
stratified cluster sampling. Since few grade 1 children wore
spectacles, only grade 7 students were included for analysis.
They were firstly examined between September and Decem-
ber 2011 and followed up 1 year later. Written informed con-
sent from at least one parent was obtained. Ethics committee
approval was obtained from the institutional review board of
Beijing Tongren Hospital, Capital Medical University. The
ACES adhered to the tenets of the Declaration of Helsinki.
Distant LogMAR visual acuity with and without spectacles
(if worn) was tested using a Logarithmic Visual Acuity Chart
(Precision Vision, La Salle, IL, USA) at 4 m. The children
were examined monocularly (right eye followed by left eye),
and were asked not to squint their eyes. For the children with
distant visual acuity less than LogMAR 0.00, subjective re-
fraction was performed by a trained optometrist with an end-
point criterion of maximum plus to obtain their best-corrected
visual acuity.
Graefes Arch Clin Exp Ophthalmol
A vertometer (NIDEK, LM-990A) was used to measure the
dioptric power of the children’s current spectacles. An
autorefractor (HUVITZ, HRK-7000A, South Korea) was used
to measure cycloplegic refractive error. Each child was admin-
istered two drops of 1 % cyclopentolate (Alcon) followed by
one drop of Mydrin P (Santen, Japan) at a 5 min interval.
Cycloplegic refractive was performed 30 min to 1 h after the
last drop. A third drop of cyclopentolate was administered if
the pupillary light reflex was still present or the pupil size was
less than 6.0 mm.
IOL Master (Carl Zeiss, Meditec AG Jena, Germany) was
used to measure axial length. Accommodative response was
measured at 33 cm and distant refraction was measured at 5 m
using an open-field autorefractor (Shin-Nippon, Grand Seiko,
WAM-5500) [24]. Children were asked to wear spectacles to
view the targets, which was positioned equidistant from both
eyes. As for the near target, children were instructed to binoc-
ularly fixate on the smallest letters they could see clearly, and
were asked to read out the letters from right to left to ensure
that they were watching the targets.
An interviewer-administered questionnaire was completed
by the children and parents to collect information including
time spent on near work and outdoor activities, frequency of
wearing spectacles, usage of spectacle wear, age of myopia
onset, age of wearing first spectacles, frequency of changing
spectacles, and the number of myopic parents.
Only the right eye was included for analysis. Myopia was
defined as cycloplegic spherical equivalent (SE)≤−0.50 D.
Amount of myopia progression was defined as baseline SE
subtracted from SE 1 year later, and was adjusted by the base-
line SE. Undercorrection of myopia was determined at base-
line if presenting visual acuity could be improved by at least 2
lines on the chart with subjective refraction by increasing the
minus correction, and without changing spectacles within
1 year [4, 13]. The amount of undercorrected myopia was
defined as the difference in SE between diopters of current
spectacles and cycloplegic SE. Based on the amount of
undercorrected myopia (UCM), children with undercorrection
of myopia were further divided into four groups (0 D<UCM≤
0.5D, 0.5D < UCM ≤ 1.0D, 1.0D < UCM ≤ 1.5D and UCM
>1.5D). Accommodative lag was calculated using previous
equations [25, 26].
To keep the same correction method (spectacles) between
the two groups, myopic students not wearing spectacles were
excluded from this study. Statistical analysis was performed
using SAS9.1.3. Continuous variables were expressed as
mean±SD. Correlation coefficients were calculated to evalu-
ate a relationship between amount of undercorrection and my-
opia progression and axial elongation. Independent t test and
ANOVA were used to compare the characteristics of 2 or more
groups, respectively. Chi-square test was used to compare the
categorical variables between groups. A multivariate linear
model was used to evaluate the associations between potential
Graefes Arch Clin Exp Ophthalmol
predictors and undercorrected myopia. A p value less than
0.05 was considered as significant.
Results
Of 2,363 eligible students, 2,267 (response rate, 95.9 %) par-
ticipated in the ACES at baseline. Of the latter, 1,067 were
myopic at baseline. Of those, 149 were excluded due to am-
blyopia, dominant strabismus, anisometropia over 1.5 D, and
astigmatism over 1.5 D. This left 918 myopic students who
were followed at baseline and at 1 year. Of these, 253 had
myopic spectacles and available information of other vari-
ables, including 120 (47.4 %) with undercorrection and 133
(52.6 %) with full correction of myopia. There were no sig-
nificant differences in basic characteristics between the two
groups of children (Table 1).
After adjusting for age, gender, number of myopic parents,
time spent on near work and outdoor activities per day, usage
and time for wearing spectacles per day, children with
undercorrection of myopia had significantly more baseline
myopia than children with full correction of myopia
(P<0.01). Mean myopia progression at 1 year follow-up
was −0.64 D/year and −0.68 D/year for the undercorrected
and fully corrected groups, which was not statistically signif-
icant (P=0.46, Table 2). Further, among undercorrected chil-
dren with different amounts of undercorrection, there were
also no significant differences in 1-year myopia progression
(P=0.22, Table 3). The regression analysis showed that myo-
pia progression significantly decreased with increasing
amount of undercorrection (r2 =0.02, P=0.02) among all chil-
dren (Fig. 1). Accommodative lag significantly decreased
with increasing amounts of undercorrection (P < 0.01,
Table 3).
As for axial length, multivariate analysis showed that chil-
dren with undercorrection had significantly longer axial length
compared to children with full correction at baseline (P=0.03,
Table 2). However, there were no significant differences in
axial elongation (P=0.96) between the two groups at 1 year,
and no significant correlation between axial elongation and
amount of myopia among all children (r2 =0.004, P=0.38,
Fig. 2).
Discussion
Although many animal studies have confirmed that optically
imposed myopic defocus slows myopia progression [27, 28],
there was a paucity of evidence from human studies that
undercorrecting myopic eyes with spectacles slowed myopia
progression. On the contrary, two recent trials reported that
undercorrection may accelerate myopia progression [21, 22].
The present study is the first one to investigate the effect of
undercorrection on myopia progression and axial elongation
in Chinese children coming from a cohort study with a large
sample size [23]. Furthermore, many confounding factors
such as age, gender, parental myopia, time spent on near work
and outdoors, usage and time for wearing spectacles per day
were taken into account and adjusted.
In this study, we found no significant differences in myopia
progression and axial elongation after a 1-year period between
children with undercorrection and full correction. Interesting-
ly, myopia progression decreased slightly with increasing
amount of undercorrection, although there was a lot of vari-
ability among the subjects. These findings indicate that
undercorrection may not cause faster myopia progression
compared to full correction in children. On the contrary, it
may reduce myopia progression, in agreement with the find-
ings of animal studies, although axial elongation didn’t signif-
icantly increase with increasing amount of undercorrection in
the present study, possibly because the increase was very
modest. Indeed, binocular undercorrection induces myopic
defocus at distance but clear retinal images at near. As a con-
sequence, the effect of the myopic defocus is temporary and
partial, and one could surmise that if it were continuous the
result of undercorrection would be a slower progression of
myopia than full correction, as has been shown in unilateral
undercorrection [19], and not a similar progression of both
groups as found in our study.
Previous studies showed that myopia progression was
faster for children with more severe myopia at baseline [29].
However, our children with more undercorrection had more
severe baseline myopia but slower myopia progression
(Table 2). This further suggests that undercorrection may com-
pensate for the effect of severe myopia at baseline, and then
finally retard rather than accelerate myopia progression in
children. We also found that accommodative lag significantly
decreased with increasing amounts of undercorrection
(Table 3), which might occur because children with
undercorrection had assistance when focusing at near, and
were more accurate at accommodating than those who have
no such assistance.
It is worth noting that for the definition of undercorrection
we adopted a presenting visual acuity, which could be im-
proved by at least 2 lines with subjective refraction. And the
myopia progression of full correction group (−0.68 D, Table 2)
was very close to that of children with undercorrection of 0D–
0.5D (−0.69 D, Table 3). Therefore, we assert that based on
the present 1-year study, our findings do not support the no-
tion that undercorrection of myopia causes faster myopia pro-
gression than full correction of myopia in Chinese children.
Although we cannot predict whether a longer period of
investigation would show such an effect of undercorrection
on myopia progression, we observed that in two previous
studies [21, 22], a contrary result was already noticeable at
1 year, which was not the case in our study. The discrepancy
 Graefes Arch Clin Exp Ophthalmol

Table 1 Baseline characteristics

of 12-year-old myopic children Characteristic Undercorrection: n (%) Full correction: n (%) P
with spectacles
All 120 (47.4) 133 (52.6)
Gender 0.39
Male 74 (61.7) 75 (56.4)
Female 46 (38.3) 58 (43.6)
Age (years) 12.66±0.44 12.65±0.46 0.88
Number of myopic parents 0.31
None 51 (48.1) 67 (58.3)
One 39 (36.8) 33 (28.7)
Two 16 (15.1) 15 (13.0)
Time spent in near work (hours/day) 3.67±1.90 3.52±1.46 0.51
Time spent in outdoor activities (hours/day) 1.87±1.11 1.88±1.21 0.96
Time wearing spectacles per day 0.39
>12 h 28 (23.9) 28 (23.1)
8–12 h 45 (38.5) 37 (30.6)
4–8 h 23 (19.7) 28 (23.1)
1–4 h 14 (12.0) 13 (10.7)
<1 h 7 (6.0) 15 (12.4)
Usage of spectacle wear per day
Both distant and near 52 (44.4) 52 (43.0) 0.99
Distant and near occasionally 23 (19.7) 26 (21.5)
Distant only 22 (18.8) 22 (18.2)
Distant occasionally 11 (9.4) 12 (9.9)
Near only 9 (7.7) 9 (7.4)
Frequancy of chaning spectacles 0.80
Less than once a year 36 45
Once a year 45 43
Twice a year 23 29
More than twice a year 13 14
Cycloplegic SE (D) −3.75±1.23 −3.12±1.29 <0.01
Axial length (mm) 25.04±0.77 24.81±0.81 0.03
Accommodative lag (D) 0.83±0.55 0.88±0.58 0.57

between the results of these studies and our own is not clear. two studies [21, 22] and the population was of different ethnic
However, we enrolled a much larger sample size than in those origin. Moreover, we evaluated the amount of time spent

Table 2 Myopia progression, axial elongation and other ocular parameters between children with undercorrection and full correction

Variables (mean±SD)a Total (n=253) Undercorrection (n=120) Full correction (n=133) P

Myopia progression (D/year) −0.66±0.37 −0.64±0.44 −0.68±0.46 0.46

Axial elongation (mm/year) 0.31±0.14 0.31±0.11 0.31±0.12 0.96
Cycloplegic SE after 1 year (D) −4.10±0.48 −4.39±0.45 −3.80±0.43 <0.01
Axial length after 1 year (mm) 25.23+0.88 25.35±0.80 25.12±0.85 0.04
Uncorrected visual acuityb 0.71±0.19 0.76±0.22 0.68±0.23 <0.01
Presenting visual acuityb 0.19±0.14 0.30±0.11 0.08±0.12 <0.01
Accommodative lag (D) 0.86±0.56 0.83±0.55 0.88±0.58 0.57

SE spherical equivalent
a
All data were adjusted for baseline refraction, age, gender, number of myopic parents, time spent in near work and outdoors, time wearing spectacles per
day, and usage of spectacles per day
b
LogMAR unit
Graefes Arch Clin Exp Ophthalmol

Table 3 Myopia progression, axial elongation and other ocular parameters of undercorrected children based on amounts of undercorrection of myopia
(UCM)

Variables (mean±SD)a 0D<UCM≤0.5D: 0.5D<UCM ≤1.0D: 1.0D<UCM ≤1.5D: 1.5D<UCM: P

n=25 n=35 n=29 n=14

Myopia progression (D/year) −0.69±0.10 −0.62±0.08 −0.58±0.08 −0.42±0.12 0.22

Axial elongation (mm/year) 0.34±0.15 0.29±0.12 0.28±0.11 0.26±0.15 0.38
Cycloplegic SE (D) −3.32±1.18 −3.67±1.22 −3.95±1.13 −4.93±1.24 <0.01
Axial length (mm) 25.19±0.80 24.96±0.83 25.21±0.75 25.02±0.86 0.54
Uncorrected visual acuityb 0.86±0.20 0.78±0.18 0.78±0.16 0.67±0.22 0.07
Presenting visual acuityb 0.25±0.10 0.26±0.12 0.35±0.11 0.44±0.11 <0.01
Accommodative lag (D) 1.19±0.50 0.91±0.53 0.70±0.48 0.68±0.56 <0.01
a
All data were adjusted for baseline refraction, age, gender, number of myopic parents, time spent in near work and outdoors, time wearing spectacles per
day and usage of spectacles per day
b
LogMAR unit

outdoors, which was not done in the studies above, and time
outdoors is known to be a protective factor for myopia onset
[30–32]; the more time spent outdoors, the less likely to be-
come myopic. As suggested by Smith [15], the undercorrected
children in these two studies may have spent more time view-
ing near objects and less time outdoors to avoid blurred vision,
whereas the children in our cohort spent the same amount of
time outdoors (1.88 and 1.87 h/day) whether undercorrected
or fully corrected (Table 1).
In this study, we found that 47.4 % of myopic children with
spectacles were undercorrected. This proportion was similar
to those of previous studies in urban and rural areas of south-
ern China (21.1 %–48.8 %) [5, 6] and was much higher than
that of Beijing (7.99 %) [7] and Australia (8.3 %) [4]. Our
study demonstrated that children with older age of myopia
onset, more myopia, and younger age of wearing first specta-
cles were more likely to be undercorrected. With increasing
amount of undercorrection, the presenting visual acuity was
significantly worse . These findings were consistent with
previous studies on junior school children in Guangdong [6]
and primary school children in Beijing [7]. It indicated that
younger children with initial spectacles, older myopic chil-
dren, and children with more myopia should be carefully pre-
scribed with more accurate correction of myopia to obtain
better presenting visual acuity.
Some limitations remain in the present study. First, it is a
case–control study with longitudinal observations, not a ran-
domized controlled trial. Although many confounding factors
have been adjusted, selection bias might have existed and
misled the results. Second, undercorrection of myopia was
defined as improved presenting visual acuity for at least 2
lines with subjective refraction. Using this criterion of
undercorrection of myopia may not have detected all
undercorrected children because myopes may possess reduced
blur sensitivity. Third, this was a study with only a 1-year
period, which was not long enough to draw a robust conclu-
sion. However, the children might change their spectacles ev-
ery year with an increase in myopia. The spectacles might

Fig. 1 Scatter plot and regression line of myopia progression as a

function of the amount of undercorrection in all children (r2 =0.02, p= Fig. 2 Scatter plot and regression line of axial elongation as a function of
0.02) the amount of undercorrection in all children (r2 =0.004, p=0.38)

switch between undercorrection and full correction which
would make it hard for classification.
In summary, we found that children with undercorrection
of myopia showed no significant difference in myopia pro-
gression compared to children with full correction in this 1-
year study. Undercorrection might not accelerate myopia pro-
gression in a population of 12-year-old Chinese children.
Acknowledgments The ACES was supported by Beijing Nova Pro-
gram (Z121107002512055), the Major State Basic Research Develop-
ment Program of China (B973^ Program, 2011CB504601) of the Minis-
try of Science and Technology, the Major International (Regional) Joint
Research Project of the National Natural Science Foundation of China
(81120108007), the National Natural Science Foundation of China
(81300797), and Research Foundation of Beijing Tongren Hospital Af-
filiated to Capital Medical University (2012-YJJ-019).
All authors certify that they have NO affiliations with or involvement
in any organization or entity with any financial interest (such as honoraria;
educational grants; participation in speakers’ bureaus; membership, em-
ployment, consultancies, stock ownership, or other equity interest; and
expert testimony or patent-licensing arrangements), or non-financial in-
terest (such as personal or professional relationships, affiliations, knowl-
edge or beliefs) in the subject matter or materials discussed in this
manuscript.
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