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Research Article | DOI: https://doi.org/DOI:10.31579/2690-4861/1043
Department of Ophthalmology, Faculty of Medicine, Ağrı İbrahim Çeçen University Ağrı, Türkiye.
*Corresponding Author: Yavuz Oruç, Department of Ophthalmology, Faculty of Medicine, Ağrı İbrahim Çeçen University Ağrı, Türkiye.
Citation: Yavuz Oruç, (2026), The Myopia Epidemic in Children: Environmental Factors and Current Evidence, International Journal of Clinical Case Reports and Reviews, 34(2); DOI:10.31579/2690-4861/1043
Copyright: © 2026, Yavuz Oruç. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 28 January 2026 | Accepted: 10 February 2026 | Published: 17 February 2026
Keywords: childhood myopia; myopia progression; outdoor activity; environmental factors; myopia epidemic; refractive errors
The progression of refractive errors during childhood, particularly the increasing prevalence and severity of myopia, has emerged as a major global public health concern. The phenomenon commonly referred to as the “myopia epidemic” has accelerated over recent decades, with especially high prevalence rates reported in East Asian populations. Childhood myopia progression is primarily driven by axial elongation of the eye and is influenced by a complex interaction between genetic predisposition and environmental factors. This narrative review summarizes current evidence on the key mechanisms underlying the increase in spectacle prescription in children. Major contributing factors include genetic susceptibility, reduced time spent outdoors, increased near work activities, seasonal variation, environmental pollution, reduced ocular blood flow, lifestyle-related factors such as physical activity and sleep patterns, and socioeconomic influences. Emerging evidence also suggests potential associations with vitamin D levels, nutritional status, and exposure to second hand smoke, although causal relationships remain incompletely understood. Overall, while genetic factors provide a fundamental basis for myopia development, modifiable environmental and behavioral factors play a decisive role in determining disease progression. Early identification, regular follow-up, and the implementation of evidence based environmental interventions, particularly increased outdoor exposure, remain central strategies for controlling childhood myopia progression.
The progression of refractive errors during childhood, particularly the increase in myopia, has emerged as a major public health concern worldwide [1,3]. In school-aged children, increasing spectacle prescription primarily reflects physiological ocular growth interacting with genetic susceptibility and environmental exposure [2,3]. This narrative review summarizes the main mechanisms underlying myopia progression in children and highlights current evidence from the literature. The phenomenon conceptualized as the “myopia epidemic” has become a significant ophthalmological and public health issue on a global scale over the past century [3]. The prevalence of myopia has accelerated markedly, reaching up to 80 to 90 percent among young adults in East Asian populations, while the prevalence of high myopia has risen to approximately 10–20%, raising concerns about future vision threatening complications. Although less pronounced, similar upward trends have also been reported in Europe and North America, underscoring the magnitude of this epidemiological problem [3]. This narrative review aims to summarize and critically evaluate current evidence on environmental and lifestyle factors associated with myopia progression in children. In addition, it seeks to identify gaps in the literature that warrant further investigation. The potential causes of the myopia epidemic are summarized below.
This narrative review was based on a comprehensive literature search of PubMed, Web of Science, and Scopus. Relevant articles published in English up to 2025 were identified using combinations of keywords related to childhood myopia, myopia progression, environmental factors, outdoor activity, near work, and lifestyle factors. Reference lists of selected articles were also screened to identify additional relevant studies. Original research articles, reviews, and meta-analyses focusing on children and adolescents were considered. Studies unrelated to myopia progression or not addressing environmental or lifestyle factors were excluded.
Pathophysiological Mechanisms
The fundamental biological basis of increasing childhood myopia is axial elongation of the eye. Infants are typically born hyperopic, and as the eye grows, this refractive state normally shifts toward emmetropia through the process of emmetropization. However, in myopic children, this process does not adequately halt. Longitudinal studies have shown that axial length increases more rapidly in myopic children than in emmetropic peers, with consistently greater annual axial elongation observed in children with progressive myopia. Numerous studies have demonstrated a direct relationship between myopia progression and increase in axial length [2,3].
Genetic Factors: Current Evidence
In recent years, advances in genomic technologies have profoundly transformed the understanding of the molecular mechanisms underlying myopia and refractive errors. Large-scale datasets generated by consortia such as the Consortium for Refractive Error and Myopia (CREAM) have produced the most comprehensive genome-wide association studies (GWAS) conducted to date in this field, establishing a new gold standard for genetic research on refractive errors [4]. Genetic predisposition plays a decisive role in both the age of onset and the rate of progression of childhood myopia. The influence of parental refractive status on children is commonly discussed within the framework of “myopic inheritance,” with evidence suggesting that epigenetic factors and environmental interactions further modulate the course of myopia [5].
Outdoor Activity: Evidence and Proposed Mechanisms
Both cross sectional and longitudinal studies have shown a consistent association between increased time spent outdoors and a lower risk of myopia in children. The protective effect of outdoor exposure cannot be explained only by reduced near work. Higher ambient light levels are believed to stimulate retinal dopamine release, which may slow axial elongation of the eye. This biological mechanism has been supported by experimental animal models and clinical human studies. In addition, outdoor environments provide wider visual fields, longer viewing distances, and more dynamic visual stimuli, all of which may help maintain ocular growth signals within physiological limits. Consequently, regular and sufficient outdoor activity is widely accepted as an important environmental intervention capable of slowing myopia development and progression, even in genetically predisposed children [6,7].
Ocular Blood Flow: Clinical and Experimental Findings
Reduced ocular blood flow has been proposed as a potential pathophysiological mechanism underlying choroidal and retinal thinning, as well as the associated axial elongation observed in myopia. Supporting this hypothesis, multiple studies have shown significantly lower ocular blood flow in myopic eyes compared with emmetropic eyes. These hemodynamic alterations are thought to impair tissue perfusion in the retina and choroid, contributing to structural weakening and reduced mechanical resistance of the ocular wall. Consequently, decreased ocular blood flow is increasingly regarded as an important biological marker involved in the development and progression of myopia [8].
Vitamin D: Observational Evidence
Lower serum vitamin D levels have been reported in individuals with myopia compared with non-myopic individuals. This finding is thought to reflect reduced outdoor exposure rather than a direct causal effect of vitamin D itself [9]. Nevertheless, given the potential biological effects of vitamin D on the retina and choroid, its role in myopia pathogenesis remains uncertain and warrants further investigation.
Near Work: Epidemiological Evidence and Visual Demand
The indoor visual environment differs markedly from outdoor settings and places greater optical demands on the visual system. The impact of this environment on ocular development can be explained through the concept of “dioptric variation.” Increased time spent indoors and prolonged near work activities, such as reading at close distances, have been associated with an elevated risk of myopia onset and progression in school-aged children. Near work performed under inadequate lighting conditions and at short viewing distances may induce sustained accommodative demand, thereby promoting axial elongation of the eye. These findings underscore the importance of visual habits as a key environmental determinant of myopia risk during childhood [7,10].
Air Pollution: Emerging Evidence
Air pollutants such as carbon monoxide, nitrogen oxides, and ozone are hypothesized to exert toxic effects on ocular tissues by reducing retinal dopamine release and inducing systemic inflammation, oxidative stress, and retinal ischemia. These pathophysiological processes may facilitate axial elongation and contribute to the development and progression of myopia. Accordingly, air pollution is increasingly recognized as a potential environmental risk factor for myopia, particularly among children living in urban areas [11].
Seasonal Variation
Research has demonstrated a direct association between seasonal cycles and both myopia progression and axial elongation rates. According to these findings, myopia progression tends to slow during the summer months and accelerate during the winter months [12].
Exposure to Tobacco Smoke
A recent large-scale cross-sectional study conducted among Hong Kong children aged 6–8 years revealed a significant association between exposure to second hand smoke and both the onset and progression of myopia. This finding suggests that environmental tobacco smoke may represent a modifiable environmental risk factor for childhood myopia [13].
Physical Activity
Given the protective effect of outdoor exposure on myopia progression, promoting sports and physical activity may be a beneficial strategy by encouraging children to spend more time outdoors. While not a direct treatment for myopia, such activities serve as supportive measures that help modify environmental risk factors associated with myopia development [7,14].
Sleep and Circadian Rhythms
Current evidence examining the relationship between sleep, circadian rhythms, and myopia remains limited and inconclusive. To strengthen the reliability of findings in this area and to better define causal relationships, well-designed longitudinal studies using universally accepted definitions of sleep quality and myopia are required [15].
Socioeconomic Status
Educational level is closely associated with socioeconomic status and may play an important role in childhood myopia development. In societies undergoing economic growth, increased educational expectations often result in earlier academic engagement, longer study hours, and higher near work demands. These changes are frequently accompanied by reduced outdoor activity. Together, these factors may indirectly contribute to a higher prevalence and faster progression of myopia in children [3,16].
Nutritional Status
Although the relationship between dietary habits and myopia development remains controversial, recent studies have provided important insights into the effects of systemic health on ocular structure. In particular, components of Western-style diets have been proposed to influence ocular biomechanics and axial growth [17].
Optical Correction
Under correction of myopia, defined as deliberately prescribing spectacles with lower power than required, has long been debated in ophthalmology. Although previously believed to reduce progression by preventing “ocular dependency,” current scientific evidence indicates the opposite effect [18].
While genetic predisposition constitutes an undeniable foundation for myopia development, environmental visual and non-visual factors play a critical role in determining disease progression. Among these, “time spent outdoors” and “near work activities” are widely regarded as the two strongest and most independent variables influencing myopia, exerting opposing effects: outdoor activity acts as a protective factor, whereas intensive near work aggravates progression.Despite growing interest in environmental and lifestyle influences on childhood myopia, the strength and consistency of evidence vary across specific factors. In particular, findings related to vitamin D status, sleep patterns, and dietary habits remain inconsistent across studies. These discrepancies likely reflect differences in study design, exposure assessment, and residual confounding, especially by time spent outdoors. As a result, causal relationships for several proposed risk factors remain uncertain. However, the complex interactions between the physical properties of light, spatial visual environments, and myopia pathophysiology remain incompletely understood and require further investigation. Similarly, the roles of lifestyle factors such as sleep patterns and dietary habits continue to be debated within the academic community. Current literature emphasizes the importance of early diagnosis, regular follow-up, and environmental modifications in slowing myopia progression. From the authors’ perspective, the available evidence indicates that not all proposed environmental factors contribute equally to childhood myopia progression. While several associations have been reported, interventions targeting outdoor exposure and near work behavior remain the most consistent, practical, and immediately applicable strategies. This focused interpretation represents the authors’ critical synthesis of current evidence. In conclusion, although the need for more advanced predictive models persists, the primary focus in addressing the ongoing “myopia epidemic” should be the widespread implementation of evidence-based strategies (such as increasing time spent outdoors), the establishment of early detection mechanisms, and the timely optimization of treatment for affected individuals.
Conflict of Interest
The author declares no conflict of interest related to this manuscript.
Financial Support
No financial support was received for this study.
Ethical Approval
As this study is a review article, approval from an ethics committee was not required.
Author Contributions
All sections of the manuscript were prepared by the author.
Informed Consent
Informed consent was not required, as this study did not involve human or animal participants.
Data sharing is not applicable to this article as no new data were generated or analyzed in this narrative revie
During the preparation of this work, ChatGPT 5 was employed solely to enhance grammar and readability. All text generated was carefully reviewed and edited by the authors, who take full responsibility for the accuracy, integrity, and final content of the published article.
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Dear Agrippa Hilda, Editorial Coordinator, Journal of Neuroscience and Neurological Surgery. The entire process including article submission, review, revision, and publication was extremely easy. The journal editor was prompt and helpful, and the reviewers contributed to the quality of the paper. Thank you so much! Eric Nussbaum, MD
Dr Hala Al Shaikh This is to acknowledge that the peer review process for the article ’ A Novel Gnrh1 Gene Mutation in Four Omani Male Siblings, Presentation and Management ’ sent to the International Journal of Clinical Case Reports and Reviews was quick and smooth. The editorial office was prompt with easy communication.
Dear Erin Aust, Editorial Coordinator, Journal of General Medicine and Clinical Practice. We are pleased to share our experience with the “Journal of General Medicine and Clinical Practice”, following the successful publication of our article. The peer review process was thorough and constructive, helping to improve the clarity and quality of the manuscript. We are especially thankful to Ms. Erin Aust, the Editorial Coordinator, for her prompt communication and continuous support throughout the process. Her professionalism ensured a smooth and efficient publication experience. The journal upholds high editorial standards, and we highly recommend it to fellow researchers seeking a credible platform for their work. Best wishes By, Dr. Rakhi Mishra.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. The peer review process of the journal of Clinical Cardiology and Cardiovascular Interventions was excellent and fast, as was the support of the editorial office and the quality of the journal. Kind regards Walter F. Riesen Prof. Dr. Dr. h.c. Walter F. Riesen.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. Thank you for publishing our article, Exploring Clozapine's Efficacy in Managing Aggression: A Multiple Single-Case Study in Forensic Psychiatry in the international journal of clinical case reports and reviews. We found the peer review process very professional and efficient. The comments were constructive, and the whole process was efficient. On behalf of the co-authors, I would like to thank you for publishing this article. With regards, Dr. Jelle R. Lettinga.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, I would like to express my deep admiration for the exceptional professionalism demonstrated by your journal. I am thoroughly impressed by the speed of the editorial process, the substantive and insightful reviews, and the meticulous preparation of the manuscript for publication. Additionally, I greatly appreciate the courteous and immediate responses from your editorial office to all my inquiries. Best Regards, Dariusz Ziora
Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation, Auctores Publishing LLC, We would like to thank the editorial team for the smooth and high-quality communication leading up to the publication of our article in the Journal of Neurodegeneration and Neurorehabilitation. The reviewers have extensive knowledge in the field, and their relevant questions helped to add value to our publication. Kind regards, Dr. Ravi Shrivastava.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, Auctores Publishing LLC, USA Office: +1-(302)-520-2644. I would like to express my sincere appreciation for the efficient and professional handling of my case report by the ‘Journal of Clinical Case Reports and Studies’. The peer review process was not only fast but also highly constructive—the reviewers’ comments were clear, relevant, and greatly helped me improve the quality and clarity of my manuscript. I also received excellent support from the editorial office throughout the process. Communication was smooth and timely, and I felt well guided at every stage, from submission to publication. The overall quality and rigor of the journal are truly commendable. I am pleased to have published my work with Journal of Clinical Case Reports and Studies, and I look forward to future opportunities for collaboration. Sincerely, Aline Tollet, UCLouvain.
Dear Ms. Mayra Duenas, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. “The International Journal of Clinical Case Reports and Reviews represented the “ideal house” to share with the research community a first experience with the use of the Simeox device for speech rehabilitation. High scientific reputation and attractive website communication were first determinants for the selection of this Journal, and the following submission process exceeded expectations: fast but highly professional peer review, great support by the editorial office, elegant graphic layout. Exactly what a dynamic research team - also composed by allied professionals - needs!" From, Chiara Beccaluva, PT - Italy.
Dear Maria Emerson, Editorial Coordinator, we have deeply appreciated the professionalism demonstrated by the International Journal of Clinical Case Reports and Reviews. The reviewers have extensive knowledge of our field and have been very efficient and fast in supporting the process. I am really looking forward to further collaboration. Thanks. Best regards, Dr. Claudio Ligresti
Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation. “The peer review process was efficient and constructive, and the editorial office provided excellent communication and support throughout. The journal ensures scientific rigor and high editorial standards, while also offering a smooth and timely publication process. We sincerely appreciate the work of the editorial team in facilitating the dissemination of innovative approaches such as the Bonori Method.” Best regards, Dr. Matteo Bonori.
I recommend without hesitation submitting relevant papers on medical decision making to the International Journal of Clinical Case Reports and Reviews. I am very grateful to the editorial staff. Maria Emerson was a pleasure to communicate with. The time from submission to publication was an extremely short 3 weeks. The editorial staff submitted the paper to three reviewers. Two of the reviewers commented positively on the value of publishing the paper. The editorial staff quickly recognized the third reviewer’s comments as an unjust attempt to reject the paper. I revised the paper as recommended by the first two reviewers.
Dear Maria Emerson, Editorial Coordinator, Journal of Clinical Research and Reports. Thank you for publishing our case report: "Clinical Case of Effective Fetal Stem Cells Treatment in a Patient with Autism Spectrum Disorder" within the "Journal of Clinical Research and Reports" being submitted by the team of EmCell doctors from Kyiv, Ukraine. We much appreciate a professional and transparent peer-review process from Auctores. All research Doctors are so grateful to your Editorial Office and Auctores Publishing support! I amiably wish our article publication maintained a top quality of your International Scientific Journal. My best wishes for a prosperity of the Journal of Clinical Research and Reports. Hope our scientific relationship and cooperation will remain long lasting. Thank you very much indeed. Kind regards, Dr. Andriy Sinelnyk Cell Therapy Center EmCell
Dear Editorial Team, Clinical Cardiology and Cardiovascular Interventions. It was truly a rewarding experience to work with the journal “Clinical Cardiology and Cardiovascular Interventions”. The peer review process was insightful and encouraging, helping us refine our work to a higher standard. The editorial office offered exceptional support with prompt and thoughtful communication. I highly value the journal’s role in promoting scientific advancement and am honored to be part of it. Best regards, Meng-Jou Lee, MD, Department of Anesthesiology, National Taiwan University Hospital.
Dear Editorial Team, Journal-Clinical Cardiology and Cardiovascular Interventions, “Publishing my article with Clinical Cardiology and Cardiovascular Interventions has been a highly positive experience. The peer-review process was rigorous yet supportive, offering valuable feedback that strengthened my work. The editorial team demonstrated exceptional professionalism, prompt communication, and a genuine commitment to maintaining the highest scientific standards. I am very pleased with the publication quality and proud to be associated with such a reputable journal.” Warm regards, Dr. Mahmoud Kamal Moustafa Ahmed
Dear Maria Emerson, Editorial Coordinator of ‘International Journal of Clinical Case Reports and Reviews’, I appreciate the opportunity to publish my article with your journal. The editorial office provided clear communication during the submission and review process, and I found the overall experience professional and constructive. Best regards, Elena Salvatore.
Dear Mayra Duenas, Editorial Coordinator of ‘International Journal of Clinical Case Reports and Reviews Herewith I confirm an optimal peer review process and a great support of the editorial office of the present journal
Dear Editorial Team, Clinical Cardiology and Cardiovascular Interventions. I am really grateful for the peers review; their feedback gave me the opportunity to reflect on the message and impact of my work and to ameliorate the article. The editors did a great job in addition by encouraging me to continue with the process of publishing.
Dear Cecilia Lilly, Editorial Coordinator, Endocrinology and Disorders, Thank you so much for your quick response regarding reviewing and all process till publishing our manuscript entitled: Prevalence of Pre-Diabetes and its Associated Risk Factors Among Nile College Students, Sudan. Best regards, Dr Mamoun Magzoub.
International Journal of Clinical Case Reports and Reviews is a high quality journal that has a clear and concise submission process. The peer review process was comprehensive and constructive. Support from the editorial office was excellent, since the administrative staff were responsive. The journal provides a fast and timely publication timeline.
Dear Maria Emerson, Editorial Coordinator of International Journal of Clinical Case Reports and Reviews, What distinguishes International Journal of Clinical Case Report and Review is not only the scientific rigor of its publications, but the intellectual climate in which research is evaluated. The submission process is refreshingly free of unnecessary formal barriers and bureaucratic rituals that often complicate academic publishing without adding real value. The peer-review system is demanding yet constructive, guided by genuine scientific dialogue rather than hierarchical or authoritarian attitudes. Reviewers act as collaborators in improving the manuscript, not as gatekeepers imposing arbitrary standards. This journal offers a rare balance: high methodological standards combined with a respectful, transparent, and supportive editorial approach. In an era where publishing can feel more burdensome than research itself, this platform restores the original purpose of peer review — to refine ideas, not to obstruct them Prof. Perlat Kapisyzi, FCCP PULMONOLOGIST AND THORACIC IMAGING.
Dear Grace Pierce, International Journal of Clinical Case Reports and Reviews I appreciate the opportunity to review for Auctore Journal, as the overall editorial process was smooth, transparent and professionally managed. This journal maintains high scientific standards and ensures timely communications with authors, which is truly commendable. I would like to express my special thanks to editor Grace Pierce for his constant guidance, promt responses, and supportive coordination throughout the review process. I am also greatful to Eleanor Bailey from the finance department for her clear communication and efficient handling of all administrative matters. Overall, my experience with Auctore Journal has been highly positive and rewarding. Best regards, Sabita sinha
Dear Mayra Duenas, Editorial Coordinator of the journal IJCCR, I write here a little on my experience as an author submitting to the International Journal of Clinical Case Reports and Reviews (IJCCR). This was my first submission to IJCCR and my manuscript was inherently an outsider’s effort. It attempted to broadly identify and then make some sense of life’s under-appreciated mysteries. I initially had responded to a request for possible submissions. I then contacted IJCCR with a tentative topic for a manuscript. They quickly got back with an approval for the submission, but with a particular requirement that it be medically relevant. I then put together a manuscript and submitted it. After the usual back-and-forth over forms and formality, the manuscript was sent off for reviews. Within 2 weeks I got back 4 reviews which were both helpful and also surprising. Surprising in that the topic was somewhat foreign to medical literature. My subsequent updates in response to the reviewer comments went smoothly and in short order I had a series of proofs to evaluate. All in all, the whole publication process seemed outstanding. It was both helpful in terms of the paper’s content and also in terms of its efficient and friendly communications. Thank you all very much. Sincerely, Ted Christopher, Rochester, NY.
