January 2025
Volume 66, Issue 1
Open Access
Clinical and Epidemiologic Research  |   January 2025
Ten-Year Change in Visual Function and Incidence of Visual Impairment in Highly Myopic Children and Adults
Author Affiliations & Notes
  • Yanping Chen
    State 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, China
  • Ruilin Xiong
    State 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, China
  • Jian Zhang
    State 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, China
  • Shaopeng Yang
    State 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, China
  • Huangdong Li
    State 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, China
  • Ziyu Zhu
    State 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, China
  • Peiyuan Wang
    State 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, China
  • Mingguang He
    School of Optometry, The Hong Kong Polytechnic University, Hong Kong
    Research Centre for SHARP Vision (RCSV), The Hong Kong Polytechnic University, Kowloon, Hong Kong
    Centre for Eye and Vision Research (CEVR), 17W Hong Kong Science Park, Hong Kong
  • Yingfeng Zheng
    State 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, China
    https://orcid.org/0000-0002-9952-6445
  • Wei Wang
    State 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, China
    https://orcid.org/0000-0002-5273-3332
  • Correspondence: Wei Wang, Zhongshan Ophthalmic Center, State Key Laboratory of Ophthalmology, Sun Yat-Sen University, Guangzhou 510060, China; [email protected]
  • Yingfeng Zheng, Zhongshan Ophthalmic Center, State Key Laboratory of Ophthalmology, Sun Yat-Sen University, Guangzhou 510060, China; [email protected]
  • Footnotes
     YC and RX contributed equally as co-first authors.
  • Footnotes
     YZ and WW contributed equally as corresponding authors.
Investigative Ophthalmology & Visual Science January 2025, Vol.66, 2. doi:https://doi.org/10.1167/iovs.66.1.2
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      Yanping Chen, Ruilin Xiong, Jian Zhang, Shaopeng Yang, Huangdong Li, Ziyu Zhu, Peiyuan Wang, Mingguang He, Yingfeng Zheng, Wei Wang; Ten-Year Change in Visual Function and Incidence of Visual Impairment in Highly Myopic Children and Adults. Invest. Ophthalmol. Vis. Sci. 2025;66(1):2. https://doi.org/10.1167/iovs.66.1.2.

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Abstract

Purpose: To investigate the 10-year changes in visual function and incidence of visual impairment (VI) in highly myopic eyes.

Methods: This longitudinal study enrolled highly myopic individuals who were followed up for 10 years. All participants underwent detailed ophthalmic examinations at baseline and follow-up visits. Best-corrected visual acuity (BCVA) was measured using Early Treatment of Diabetic Retinopathy Study protocol, and visual field (VF) was assessed with standard automatic perimetry.

Results: A total of 568 highly myopic eyes (284 participants) were included, with mean baseline age of 22.49 ± 13.07 years, spherical equivalent refraction (SER) of −9.72 ± 3.02 D, and axial length of 27.39 ± 1.53 mm. Over 10 years, the mean BCVA loss was −0.06 logMAR (95% confidence internal [CI], 0.05−0.07). The mean change rates in mean deviation (MD) and pattern standard deviation over time were −0.07 dB/y (95% CI, −0.08 to −0.06) and 0.036 dB/y (95% CI, 0.028 to 0.044), respectively. The 10-year incidence of monocular moderate and severe VI (MSVI), per World Health Organization (WHO) and US criteria, was 3.52% (95% CI, 2.16%–5.39%) and 6.35% (95% CI, 4.46%–8.72%). Higher MSVI incidence, defined by WHO and US criteria, was associated with more myopic SER and lower baseline MD. Additionally, higher US-defined MSVI incidence was correlated with worse baseline BCVA.

Conclusions: In a highly myopic population, both BCVA and VF deteriorated over time, with increasing MSVI incidence. Raising public awareness of vision risks linked to high myopia and implementing strategies to reduce the burden in high-risk individuals are essential.

High myopia is an escalating public health crisis, with the prevalence surging from 163 million affected individuals in 2000 to 938 million by 2050, signifying an imminent vision challenge.13 According to the World Health Organization (WHO), at least 2.2 billion people globally have vision impairment (VI) or blindness, as highlighted in the 2019 World Report on Vision.4 Critically, individuals with high myopia face a disproportionately higher risk of developing irreversible vision-threatening complications, leading to a significantly increased lifetime likelihood of VI or legal blindness,5,6 thereby imposing further financial and societal burdens.79 
Although population-based study has shed light on the cross-sectional prevalence and causes of VI in patients with high myopia,10 key gaps remain in the longitudinal progression of vision loss and incidence of VI over a long period, owing to the lack of long-term comprehensive data on both visual acuity (VA) and visual field (VF). Furthermore, highly myopic eyes are particularly at risk of functional blindness developing at a relatively young age.1113 However, the risk of VI in children and adolescents with high myopia is less well studied. Understanding the temporal trends of visual function and long-term risk of developing VI is important for the tailored prevention strategies and delivery of cost-effective service in the vulnerably visually impaired high myopia population. 
Given the limited number of high myopia cases in population-based studies, a high myopia registry study with extended follow-up is a more appropriate approach to address these knowledge gaps. Thus, the purposes of the present study are to report the progression of vision loss, along with the incidence of VI and related risk factors over a 10-year period in a cohort of highly myopic Chinese children and adults. 
Methods
Study Population
This longitudinal observational registry study (ISRCTN56368396) recruited highly myopic subjects aged 7 to 70 years with bilateral myopic sphere ≤−6.00 diopters (D) at the Zhongshan Ophthalmic Center (ZOC). The baseline examination was conducted from September 2011 to October 2012, with follow-up visits scheduled every 2 years. The 10-year follow-up was completed between May 2023 and October 2023. Participants were excluded if they had secondary myopia, retinal abnormalities other than myopic maculopathy (MM), cataract, glaucoma, IOP >21 mm Hg, or severe systemic diseases or had undergone intraocular surgery or myopia control interventions, including atropine therapy, orthokeratology, defocus incorporated multiple segment lens, repeated low-level red light, or corneal refractive surgery at baseline or 10-year visit. 
The study was approved by the Institutional Review Board of Sun Yat-sen University and the Ethics Committee of ZOC. All procedures adhered to the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants or their legal guardians for those under 18 years. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. 
Procedures
The baseline examination and 10-year follow-up protocol were the same.14,15 A standardized questionnaire covering ocular disease history, ocular surgical history, and any ocular treatments was administered in a face-to-face interview by trained personnel. Participants underwent comprehensive systemic and ophthalmic evaluations, including visual function assessments, biometry (Lenstar LS900 [Haag-Streit AG, Koeniz, Switzerland] or IOLMaster 500 [Carl Zeiss Meditec, Dublin, CA, USA]), cycloplegic automatic refraction (Topcon KR8800, Tokyo, Japan), IOP, slit-lamp examination (BQ-900; Haag-Streit AG), fundus photography (Canon CX-1, Tokyo, Japan), and optical coherence tomography (Topcon DRI OCT, Tokyo, Japan). MM was classified following the meta-analyses of the pathologic myopia (META-PM) study classification by two independent graders, which has been described in our previous reports.15,16 The classification system included five categories—no myopic lesions (C0), tessellated fundus (C1), diffuse atrophy (C2), patchy atrophy (C3), and macular atrophy (C4)—and three “plus” lesions. Posterior staphyloma (PS) was determined by fundus photographs based on Curtin's classification.17 The presence of PS was defined as an outpouching of the sclera at the posterior pole, with a curvature radius smaller than the surrounding curvature of the eye wall. 
VA was measured using the Early Treatment of Diabetic Retinopathy Study (ETDRS) chart, retroilluminated with automatic calibration to 85 cd/m2 (Precision Vision, Villa Park, IL, USA) at an initial testing distance of 4 m. All participants were refracted to determine refractive status and to obtain distance best-corrected visual acuity (BCVA) by experienced optometry. If the BCVA was worse than 20/20 Snellen equivalent in either eye, participants were retested with pinhole correction. If the pinhole-corrected VA in either eye was 20/63 or worse, VA was measured at a distance of 1 m. For those unable to read the chart letters at 1 m, additional tests for counting fingers, hand motion, or light perception were conducted. 
VF assessment was conducted by standard automatic perimetry (Zeiss Humphrey Visual Field 750i; Carl Zeiss Meditec), with the 24-2 Swedish Interactive Threshold Algorithm protocol in a single, distraction-free dark room (ambient light <5 lux).18,19 For this study, only VF results meeting the reliability criteria of a ≤33% false-positive rate, a ≤33% false-negative rate, and a ≤33% fixation loss rate were included in the analysis. The VF examination was available at baseline and the 8-year follow-up visit. 
Statistical Analyses
Both eyes of each participant were included in the analysis. Quantitative variables were presented as mean (standard deviation [SD]), while categorical variables were reported as number (percentage). The t-test or χ2 test was employed to compare mean values or percentage variables, as appropriate. The rate of spherical equivalent refraction (SER; sphere + half of cylinder) progression and axial length (AL) elongation was calculated by the difference between the corresponding values at baseline and the 10-year visit, divided by the follow-up duration. 
Change in VA was determined by comparing the difference in line numbers and logMAR on the ETDRS chart between the baseline and the 10-year follow-up visits. Each line on the chart was assigned a numeric value from 1 to 18, with a BCVA of 20/800, 20/640, and 20/500 corresponding to line numbers 1, 2, and 3, respectively. A BCVA of 20/20 was represented by line number 17, while line 18 corresponded to a BCVA of 20/16. The progression of vision loss was calculated by subtracting the baseline line number from the line number at the 10-year follow-up. Multivariate linear mixed-effects models were employed to identify factors associated with changes in the BCVA line over the 10-year period, with age, sex, baseline SER, BCVA, MM category, PS, and mean deviation (MD) as the fixed effects, while a random intercept was included at the subject and eye levels. Similarly, the longitudinal change rates of VF metrics were assessed in the multivariate linear mixed-effects models. 
According to the WHO criteria, monocular incidence of moderate and severe visual impairment (MSVI) was defined as a BCVA of <20/60 and ≥20/400, while the incidence of blindness was defined as a BCVA of <20/400 among eyes that did not have the condition or had a less severe condition at baseline. MSVI and blindness were also classified based on US criteria, with cutoffs of <20/40 and ≥20/200 for MSVI and <20/200 for blindness. The 10-year incidence of MSVI was shown stratified by age (≥7–18, 19–40, 41–70 years), sex (male and female), SER (≤−6 to −8, −8 to −10, ≤−10 D), AL (≤28, 28–30, >30 mm), BCVA (≥20/25, ≥20/32-20/40, ≤20/50), PS (yes and no), and MD (highest, second, lowest tertiles). To eliminate the influence of established pathologic myopia at baseline on visual impairment, sensitivity analysis among nonpathologic myopic eyes was performed. Risk factors for MSVI incidence were evaluated using logistic regression models with generalized estimating equations (GEEs). Odds ratios (ORs) and 95% confidence intervals (CIs) were reported. 
Statistical analyses were performed using Stata (version 17; StataCorp, College Station, TX, USA) and R (version 4.2.1; R Foundation for Statistical Computing, Vienna, Austria). A two-sided P value <0.05 was considered as statistically significant. 
Results
Population Characteristics
A total of 1556 highly myopic eyes (778 participants) were eligible at baseline, after excluding those with other retinopathies than MM, glaucoma, or IOP >21 mm Hg or had undergone myopia treatment. Among them, 592 eyes (296 participants) attended the 10-year follow-up visit. We have further excluded 10 eyes diagnosed with cataract, 4 with glaucoma, 2 with other retinopathies than MM, 2 with nystagmus, and 6 that had ever undergone intraocular surgery over 10 years; 568 highly myopic eyes (284 participants) were eventually included in the analysis (Fig. 1). 
Figure 1.
 
Study flowchart on the inclusion of study participants and eyes. MMD, myopia macular degeneration.
Figure 1.
 
Study flowchart on the inclusion of study participants and eyes. MMD, myopia macular degeneration.
The baseline and 10-year characteristics of included participants are depicted in Table 1. No significant differences were observed between participants and nonparticipants in terms of age, sex, IOP, MD, pattern standard deviation (PSD), MM category, and PS, while those not in follow-up had worse BCVA, longer AL, and more myopic SER at baseline (Supplementary Table S1). Among the included participants, the mean baseline age was 22.49 ± 13.07 years, with 52.46% female. The mean baseline SER and AL were −9.72 ± 3.02 D and 27.39 ± 1.53 mm, respectively. 
Table 1.
 
Characteristics of Study Participants Over 10 Years
Table 1.
 
Characteristics of Study Participants Over 10 Years
Change in VA
Table 2 and Figure 2 presents the change in distance BCVA between baseline and 10-year follow-up visit. BCVA decreased in nearly half of the highly myopic eyes, while 40.56% of eyes remained unchanged and 10.58% showed improvement, with a mean change of −0.64 lines (95% CI, −0.76 to −0.53) and 0.06 logMAR (95% CI, 0.05 to 0.07). In the multivariate linear mixed-effects model, progression of BCVA loss over the 10-year interval was associated with a more severe MM category, a lower MD tertile, and baseline BCVA ≥20/25. 
Table 2.
 
Change of Distance BCVA Line in Highly Myopic Eyes Over 10 Years and Its Associated Factors
Table 2.
 
Change of Distance BCVA Line in Highly Myopic Eyes Over 10 Years and Its Associated Factors
Figure 2.
 
Change of BCVA in highly myopic eyes over 10 years stratified by age and sex. Data are presented as mean ± SE in the plot.
Figure 2.
 
Change of BCVA in highly myopic eyes over 10 years stratified by age and sex. Data are presented as mean ± SE in the plot.
Change in VF
Figure 3 presents the longitudinal changes of MD and PSD by age group and sex. In highly myopic eyes, mean MD and PSD loss over time were −0.07 dB/y (95% CI, −0.08 to −0.06) and 0.036 dB/y (95% CI, 0.028 to 0.044), respectively. The adjusted mean change rates of MD were −0.05 dB/y (95% CI, −0.07 to −0.03), −0.05 dB/y (95% CI, −0.08 to −0.02), and −0.11 dB/y (95% CI, −0.15 to −0.07) in female high myopes aged ≥7 to 18, 19 to 40, and 41 to 70 years, respectively. MD declined more in males across all age groups compared to females, with values of −0.08 dB/y (95% CI, −0.10 to −0.05), −0.08 dB/y (95% CI, −0.11 to −0.05), and −0.14 dB/y (95% CI, −0.18 to −0.10) among individuals aged ≥7 to 18, 19 to 40, and 41 to 70 years. For PSD, the longitudinal change rates were 0.04 dB/y (95% CI, 0.03 to 0.05), 0.02 dB/y (95% CI, 0.005 to 0.04), and 0.03 dB/y (95% CI, 0.008 to 0.06) in those aged ≥7 to 18, 19 to 40, and 41 to 70 years, respectively. 
Figure 3.
 
Longitudinal change rate of visual field in highly myopic eyes stratified by age and sex. Change rates of MD (A) and PSD (B) were assessed using linear mixed-effects models, where baseline age, sex, SER, BCVA, MM category, and PS were included as fixed factors in the models, and subjects and eyes were included as random factors.
Figure 3.
 
Longitudinal change rate of visual field in highly myopic eyes stratified by age and sex. Change rates of MD (A) and PSD (B) were assessed using linear mixed-effects models, where baseline age, sex, SER, BCVA, MM category, and PS were included as fixed factors in the models, and subjects and eyes were included as random factors.
Incidence of MSVI and Blindness
Table 3 presents the cumulative 10-year incidence of MSVI by two definitions among Chinese highly myopic eyes. Over the 10-year period, the incidence of monocular MSVI was 20 of 568 at-risk eyes (3.52%; 95% CI, 2.16%–5.39%) according to WHO criteria and 35 of 551 at-risk eyes (6.35%; 95% CI, 4.46%–8.72%) according to US criteria. Eyes from males with a more myopic SER, longer AL, more severe MM category, PS, and lower MD tertile exhibited a higher incidence of MSVI. Blindness developed in 2 highly myopic eyes of 566 at risk over 10 years under both WHO and US definitions (0.35%; 95% CI, 0.04%–1.27%). Table 4 shows the incidence of MSVI in high myopia individuals at each biennial follow-up year over 10 years, with the cumulative incidence gradually increasing over time. In the sensitivity analysis, the MSVI incidence was relatively lower at 0.89% (95% CI, 0.24%–2.27%) and 2.26% (95% CI, 1.09%–4.12%) by WHO and US criteria, respectively (Supplementary Table S2). 
Table 3.
 
Ten-Year Incidence of Moderate and Severe Visual Impairment in WHO and US Definitions by Baseline Factors in High Myopia Eyes
Table 3.
 
Ten-Year Incidence of Moderate and Severe Visual Impairment in WHO and US Definitions by Baseline Factors in High Myopia Eyes
Table 4.
 
Incidence of Moderate and Severe Visual Impairment in WHO and US Criteria in Highly Myopic Eyes at Each Biennial Follow-up Over 10 Years
Table 4.
 
Incidence of Moderate and Severe Visual Impairment in WHO and US Criteria in Highly Myopic Eyes at Each Biennial Follow-up Over 10 Years
Incidence of MSVI in Children and Adolescents
In highly myopic children and teenagers, MSVI developed in 8 out of 336 at-risk eyes (2.38%; 95% CI, 1.03%–4.64%) based on WHO criteria and 13 out of 328 at-risk eyes (3.96%; 95% CI, 2.13%–6.68%) based on US criteria (Table 5). Similarly, eyes from males, with a more myopic SER, longer AL, worse BCVA, and more severe MM, showed a higher incidence of MSVI. 
Table 5.
 
Ten-year incidence of moderate and severe visual impairment in World Health Organization and United States criteria by baseline factors in high myopia eyes of children and teenagers (aged 7–18 years).
Table 5.
 
Ten-year incidence of moderate and severe visual impairment in World Health Organization and United States criteria by baseline factors in high myopia eyes of children and teenagers (aged 7–18 years).
Risk Factors for MSVI
According to WHO criteria, every 1 D more myopic in baseline SER and every 1-dB decrease in baseline MD were associated with a 20% (OR = 1.20; 95% CI, 1.02–1.41; P = 0.032) and an 86% (OR = 1.86; 95% CI, 1.35–2.55; P < 0.001) increase in 10-year MSVI incidence, respectively (Table 6). For US criteria, every 1 D more myopic in baseline SER and every 1-dB decrease in baseline MD were associated with a 21% (OR = 1.21; 95% CI, 1.08–1.35; P = 0.001) and a 54% (OR = 1.54; 95% CI, 1.17–2.03; P = 0.002) increase, respectively, in the 10-year incidence of MSVI. Furthermore, the MSVI incidence by US criteria was correlated to decreased BCVA lines (OR = 3.44; 95% CI, 2.21–5.37; P < 0.001). Univariate significant associations were found between AL and the incidence of MSVI as well as between MM category and the incidence of MSVI (all univariate P < 0.05), while no significant associations were observed in the multivariate models. 
Table 6.
 
Generalized Estimating Equation Analysis of Associated Factors With 10-Year Incidence of MSVI in Highly Myopic Eyes
Table 6.
 
Generalized Estimating Equation Analysis of Associated Factors With 10-Year Incidence of MSVI in Highly Myopic Eyes
Discussion
Due to a paucity of reports in this area, little is known about the longitudinal trajectory of visual function decline and the incidence of VI in highly myopic eyes. This study revealed a progressive deterioration in both VA and VF in highly myopic children and adults over time. Over the course of 10 years, 3.52% of high myopes developed MSVI according to WHO criteria and 6.35% by US standards, and 0.35% progressed to blindness. 
Nearly half of the highly myopic eyes underwent deterioration in distance BCVA over a 10-year interval. Our findings align with a previous hospital-based retrospective study, which reported that 28.26% high myopes aged ≥40 years had BCVA loss of more than two lines for 10 years.20 Eyes with more severe MM were significantly more likely to experience greater vision loss, particularly those with patchy or macular atrophy, where the mean BCVA declined by 2.53 lines. A better baseline BCVA was associated with a higher likelihood of vision line deterioration, likely due to the ceiling effect, as poorer BCVA values may have less room to further decrease.21 The association between lower MD tertile and BCVA loss may be related to underlying optic neuropathy in highly myopic eyes.22,23 
VF is recognized as a key aspect of visual function, and different VF defect patterns have been documented in high myopia, including normal type, glaucoma-like type defects, high myopia-related type defects, and combined defects.24 In our previous study, 49.4% of nonpathologic highly myopic eyes developed VF defects over an 8-year period, with an enlarged blind spot and nonspecific defects being the most common types.18 However, the longitudinal, quantifiable changes in VF metrics in highly myopic eyes have remained poorly understood. This study, for the first time, provides long-term evidence of VF loss in terms of MD and PSD in a highly myopic population. 
This longitudinal report addresses the evidence gap concerning the long-term incidence of VI in a vulnerable population with high myopia. High myopia–related degeneration has been ranked as the leading or second most common cause of blindness and VI in the Shihpai Eye Study, Tajimi Study, Beijing Eye Study, Handan Eye Study, and Taizhou Eye Study.2529 In a subgroup of 212 highly myopic adults from the Beijing Eye Study, the prevalence of WHO-defined MSVI and blindness was 18.9% and 4.7%, respectively.10 In our cross-sectional analysis of the high myopia cohort, the rates of MSVI and blindness were 4.1%/5.9% and 0.2%/0.6%, respectively, using the WHO and US definitions.5 The longitudinal incidence of MSVI or any VI was reported to be 3.6% over 4 years, according to WHO criteria, and between 1.8% and 12.3% over 4 to 15 years, according to US criteria, among adults aged over 40 years in the general population.3033 In the present study, WHO-defined MSVI developed in 5.71% and US-defined MSVI developed in 12.12% of >40-year-old adult participants with high myopia over 10 years. 
Early-onset myopia has increased the prevalence of high myopia in the next generation of children and adolescents. Although the WHO VISION 2020 global initiative against blindness prioritized childhood visual disability, progress has been hindered by a lack of epidemiologic data on childhood VI, particularly in those with high myopia.34 In this relatively young cohort, we found that a considerable number of children and adolescents (2.38% and 3.96% by WHO and US criteria) with high myopia progressed to MSVI incidence over a decade, highlighting the importance of regular monitoring of visual function and targeted prevention strategies at this young age group. The association between age and MSVI risk in this study should be interpreted with caution, as age refers to age at enrollment rather than age at high myopia onset. Future studies that account for the precise onset age of high myopia may offer a more accurate assessment of age-related MSVI risk. 
Identifying risk factors provides valuable insights into the potential causes of VI incidence and offers guidance for public health resource allocation. A 1 D more myopic in baseline SER was correlated with a 1.20-fold and 1.21-fold risk of MSVI incidence in the WHO and US criteria, respectively. MM and optic neuropathy were identified as the two main causes of VI in a population-based recruited high myopia study, with a higher prevalence of MM and optic neuropathy observed in more advanced high myopia groups (<−15.0 D).10 After adjusting for MM category and other covariates, the significant association between baseline MD and MSVI incidence suggests that optic neuropathy may play a more critical role in the long-term development of VI in highly myopic eyes.23 This finding also emphasized the early prevention of high-risk high myopes with more severe SER and lower MD. However, in our cohort, no significant multivariate association was found between MM category and MSVI, potentially due to the small number of cases in the more severe C3/C4 MM group. Future studies with larger sample sizes and more severe MM cases are needed to validate this finding. 
Strengths and Limitations
Strengths of this study lie in its registry cohort design, featuring a large sample size of representative highly myopic individuals and a decade-long follow-up period. Additional strengths include the use of standardized and extensive examination methodologies at both baseline and follow-up visits, the coverage of high myopia children and adults, and utilization of two accepted VI definitions, along with comprehensive assessments of VA and VF. Nevertheless, several limitations should be acknowledged. First, our study was conducted based on a registry cohort in the hospital rather than a population-based study, making it unclear whether our results can be applied directly to a high myopia group in the general population. Thus, future large-scale population-based research is necessary to validate these findings. Second, selection bias should be considered when interpreting our results. Only participants attending the baseline and 10-year follow-up visits were included in the present analysis. While the baseline characteristics were largely balanced between participants and nonparticipants, those who did not attend follow-ups had worse BCVA, longer AL, and more myopic SER at baseline, and the extent of this bias's influence remains uncertain. Third, the inclusion of individuals with pathologic myopia might lead to an overestimation of MSVI risk in overall highly myopic eyes; hence, caution is warranted in the interpretation of our results. Fourth, the impact of vision deterioration on quality of life was not addressed in this study and warrants further investigation. Fifth, the inability to identify the specific causes of VI incidence was another limitation. However, we made an effort to explore the risk factors of VI with respect to ocular structures, visual function, and fundus lesions, which provide valuable insights into the potential causes. Lastly, it is important to validate our results in populations beyond the Chinese ethnicity to enhance the generalizability. 
Conclusions
In conclusion, for a highly myopic population aged 7 to 70 years, VA and VF deteriorated over time with increasing incidence of VI. Over the 10-year period, 3.52% of individuals with high myopia developed MSVI based on WHO criteria and 6.35% by US standards, and 0.35% progressed to blindness. More myopic SER and lower MD were associated with an increased risk of MSVI incidence. Highly myopic children and teenagers also experience VI at a young age, emphasizing the need for targeted eye care services for this group. It is imperative to increase public awareness of the vision health risks associated with high myopia and implement effective strategies to alleviate the burden on this population. 
Acknowledgments
The authors thank the participants who were involved in this study, without whom the trial would not have been possible. 
Supported by the National Natural Science Foundation of China (No. 82401298 & 82371086) and the Chinese Postdoctoral Science Foundation (No. 2024M763790). The funder 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. 
Author Contributions: Wang had full access to all of the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: YP Chen, RL Xiong, W Wang. Data collection: YP Chen, RL Xiong. Analysis and interpretation of data: YP Chen, RL Xiong, W Wang. Drafting of the manuscript: YP Chen, RL Xiong, W Wang. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: YP Chen, J Zhang. Obtained funding: W Wang. Administrative, technical, or material support: W Wang. Overall supervision: W Wang. 
Disclosure: Y. Chen, None; R. Xiong, None; J. Zhang, None; S. Yang, None; H. Li, None; Z. Zhu, None; P. Wang, None; M. He, None; Y. Zheng, None; W. Wang, None 
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Figure 1.
 
Study flowchart on the inclusion of study participants and eyes. MMD, myopia macular degeneration.
Figure 1.
 
Study flowchart on the inclusion of study participants and eyes. MMD, myopia macular degeneration.
Figure 2.
 
Change of BCVA in highly myopic eyes over 10 years stratified by age and sex. Data are presented as mean ± SE in the plot.
Figure 2.
 
Change of BCVA in highly myopic eyes over 10 years stratified by age and sex. Data are presented as mean ± SE in the plot.
Figure 3.
 
Longitudinal change rate of visual field in highly myopic eyes stratified by age and sex. Change rates of MD (A) and PSD (B) were assessed using linear mixed-effects models, where baseline age, sex, SER, BCVA, MM category, and PS were included as fixed factors in the models, and subjects and eyes were included as random factors.
Figure 3.
 
Longitudinal change rate of visual field in highly myopic eyes stratified by age and sex. Change rates of MD (A) and PSD (B) were assessed using linear mixed-effects models, where baseline age, sex, SER, BCVA, MM category, and PS were included as fixed factors in the models, and subjects and eyes were included as random factors.
Table 1.
 
Characteristics of Study Participants Over 10 Years
Table 1.
 
Characteristics of Study Participants Over 10 Years
Table 2.
 
Change of Distance BCVA Line in Highly Myopic Eyes Over 10 Years and Its Associated Factors
Table 2.
 
Change of Distance BCVA Line in Highly Myopic Eyes Over 10 Years and Its Associated Factors
Table 3.
 
Ten-Year Incidence of Moderate and Severe Visual Impairment in WHO and US Definitions by Baseline Factors in High Myopia Eyes
Table 3.
 
Ten-Year Incidence of Moderate and Severe Visual Impairment in WHO and US Definitions by Baseline Factors in High Myopia Eyes
Table 4.
 
Incidence of Moderate and Severe Visual Impairment in WHO and US Criteria in Highly Myopic Eyes at Each Biennial Follow-up Over 10 Years
Table 4.
 
Incidence of Moderate and Severe Visual Impairment in WHO and US Criteria in Highly Myopic Eyes at Each Biennial Follow-up Over 10 Years
Table 5.
 
Ten-year incidence of moderate and severe visual impairment in World Health Organization and United States criteria by baseline factors in high myopia eyes of children and teenagers (aged 7–18 years).
Table 5.
 
Ten-year incidence of moderate and severe visual impairment in World Health Organization and United States criteria by baseline factors in high myopia eyes of children and teenagers (aged 7–18 years).
Table 6.
 
Generalized Estimating Equation Analysis of Associated Factors With 10-Year Incidence of MSVI in Highly Myopic Eyes
Table 6.
 
Generalized Estimating Equation Analysis of Associated Factors With 10-Year Incidence of MSVI in Highly Myopic Eyes
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