Long-term Impact of COVID-19-Related Behavioral Changes on Myopia Progression in Children: A Four-Year Cohort Study.

PURPOSE: To evaluate the effect of behavioral changes during the COVID-19 pandemic on myopia progression in children and to determine whether these changes modified the efficacy of low-concentration atropine.

METHODS

This retrospective longitudinal study included children aged 7 to 15 years who underwent annual examinations from 2019 to 2023. A subset of participants completed a behavioral questionnaire in 2021. Annual spherical equivalent measurements from pre-COVID-19 (2019), during the COVID-19 (2020), and post-COVID-19 (2021-2023) periods were analyzed using linear mixed-effects models. Changes in mobile device use and outdoor activity were assessed with repeated measures ANOVA. Subgroup analyses were performed based on the degree of increase in device use and the duration of remote education.

RESULTS

Seventy-seven children (140 eyes) were included in the refractive analysis, of whom 37 (69 eyes) completed the behavioral questionnaire and were included in behavioral analyses. Myopia progression during COVID-19 increased compared with the pre-COVID-19 period. A greater increase in mobile device use was significantly associated with faster progression between 2021 and 2022 (p = 0.005). Longer duration of remote education showed a similar association (p = 0.035). Changes in outdoor activity were not clearly associated with refractive outcomes. Low-dose atropine did not show a meaningful treatment effect in this cohort.

CONCLUSIONS

Myopia progression accelerated during the pandemic and was strongly associated with increased screen time and prolonged remote education. These behavioral factors had a greater influence on progression than low-dose atropine, underscoring the importance of addressing visual habits in pediatric myopia management.