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Article(id=1325532634377633885, tenantId=1146029695717560320, journalId=1256213402557890569, issueId=1325531848021140417, articleNumber=null, orderNo=null, doi=10.16835/j.cnki.1000-9817.2025345, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1754841600000, receivedDateStr=2025-08-11, revisedDate=1758556800000, revisedDateStr=2025-09-23, acceptedDate=null, acceptedDateStr=null, onlineDate=1793961207240, onlineDateStr=2026-11-06, pubDate=1764000000000, pubDateStr=2025-11-25, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1793961207240, onlineIssueDateStr=2026-11-06, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1793961207240, creator=13701087609, updateTime=1793961207240, updator=13701087609, issue=Issue{id=1325531848021140417, tenantId=1146029695717560320, journalId=1256213402557890569, year='2025', volume='46', issue='11', pageStart='1521', pageEnd='1672', issueExtLink='null', onlineDate='null', pubDate='1764000000000', pubDateStr='2025-11-25', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1793961019759, creator='13701087609', updateTime=1793961019759, updator='13701087609', preIssue=null, nextIssue=null, articleTotal=null, ext=null, issueFiles=null, downloadFileDto=null}, startPage=1645, endPage=1649, ext={EN=ArticleExt(id=1325532640794919006, articleId=1325532634377633885, tenantId=1146029695717560320, journalId=1256213402557890569, language=EN, title=Association of axial length-to-corneal radius ratio on myopia progression among primary school students in Jing'an District, Shanghai 2019-2023, columnId=1325500884406379444, journalTitle=Chinese Journal of School Health, columnName=Disease Control, runingTitle=null, highlight=null, articleAbstract=
Objective

To investigate the current prevalence of myopia and the progression of the axial length/corneal radius ratio(AL/CR) among primary school students in Jing'an District, Shanghai, and to analyze the value of dynamic AL/CR monitoring and elucidate its longitudinal association with myopia progression, so as to provide evidences for supporting myopia prevention and control interventions.

Methods

From 2019 to 2023, by using a stratified cluster random sampling method, 17 624 students from two primary schools in Jing'an District, Shanghai were selected for annual vision screenings in five consecutive years. Additionally, a retrospective cohort of 480 eligible first-grade students identified in 2019 was followed up until 2023. The analysis focused on the myopia prevalence and the trend in the AL/CR. Differences in screening myopia rates across different student groups from 2019 to 2023 were compared using the Chi-square test. The trends in myopia rates were analyzed using the Chi-square trend test. The Kruskal-Wallis H test was employed to compare AL/CR and its annual increment across groups. A linear mixed-effects model was used to identify factors influencing AL/CR, and a time-dependent Cox regression model was developed to predict the risk of myopia onset.

Results

From 2019 to 2023, the screening myopia rates were 36.65%, 38.31%, 40.47%, 39.56%, and 39.76% for each respective year. Cohort analyses revealed Grade 5 girls had significantly greater AL/CR increments than boys (Z=-2.05, P < 0.05). Linear mixed models identified baseline AL/CR (β=1.051, 95%CI=1.012-1.091), grade level (β=0.040, 95%CI=0.038-0.042), and first-year AL/CR increment (β=0.788, 95%CI=0.733-0.843) as primary determinants (all P < 0.01). Boys showed slower AL/CR progression than girls (β=-0.003, 95%CI=-0.005 to-0.001, P < 0.01). The time-dependent Cox model demonstrated that both baseline AL/CR (Z=3.40) and its time-varying effect (Z=10.41) significantly predicted myopia risk(both P < 0.01). The effect of AL/CR on myopia risk significantly increased with follow-up time, and the growth rate exceeded a linear progression pattern.

Conclusions

AL/CR progression is primarily driven by baseline values and grade advancement, with slower progression in boys. Dynamic AL/CR monitoring outperforms baseline measurements in predicting myopia progression. Students with rapid AL/CR increments require early intervention.

, authors=Wenyan XU1, Limeng WANG1, Yongfu YU2, authorsList=Wenyan XU, Limeng WANG, Yongfu YU, authorCompany=null, correspAuthors=null, authorNote=null, correspAuthorsNote=null, copyrightStatement=Copyright ©2025 Chinese Journal of School Health. All rights reserved., copyrightOwner=null, extLink=null, articleAbsUrl=null, sourceXml=null, magXml=null, pdfUrl=null, pdf=null, pdfFileSize=null, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=null, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=null, mapNumber=null, fund=null), CN=ArticleExt(id=1325532655525314656, articleId=1325532634377633885, tenantId=1146029695717560320, journalId=1256213402557890569, language=CN, title=上海市静安区2019—2023年小学生轴率比与近视发展的关联, columnId=1325500884628677558, journalTitle=中国学校卫生, columnName=疾病控制, runingTitle=null, highlight=null, articleAbstract=
目的

了解上海市静安区小学生近视现况，探讨小学生轴率比(AL/CR)进展情况，分析AL/CR的动态监测价值及其与近视进展的纵向关联机制，为开展小学生近视防控工作提供依据。

方法

2019—2023年采用分层整群随机抽样方法，抽取上海市静安区2所小学17 624名小学生开展连续5年视力筛查，并将2019年符合条件的一年级小学生480人，按回顾式队列的方法随访至2023年。分析近视率及AL/CR的变化趋势，运用χ2检验对不同组别小学生2019—2023年筛查近视率进行比较分析，采用χ2趋势检验对筛查近视率的趋势进行分析；采用Kruskal-Wallis H检验比较不同组别小学生AL/CR和AL/CR增量，应用线性混合效应模型分析AL/CR的影响因素，并构建含时依变量的近视发生风险预测Cox回归模型。

结果

2019—2023年小学生筛查性近视检出率分别为36.65%，38.31%，40.47%，39.56%，39.76%。队列研究结果显示，五年级女生的AL/CR增长量高于男生，差异有统计学意义(Z=-2.05，P＜0.05)。线性混合效应模型结果显示，小学生AL/CR的影响因素有基线AL/CR(β=1.051，95%CI=1.012~1.091)、年级(β=0.040，95%CI=0.038~0.042)、首年增长量(β=0.788，95%CI=0.733~0.843)，且男生随年级增长AL/CR发展速度较女生缓慢(β=-0.003，95%CI=-0.005~-0.001)(P值均＜0.01)。时依Cox回归模型结果显示，基线AL/CR和AL/CR时变效应均有统计学意义(Z值分别为3.40，10.41，P值均＜0.01)，AL/CR对筛查性近视风险的影响随随访时间增强，且增长速度快于线性增长。

结论

小学生的AL/CR主要由基线值和年级增长驱动，男生随年级增长的AL/CR发展速度较女生缓慢。AL/CR的动态监测比基线值更能预测近视进展，对于AL/CR高增长的学生应该及早干预。

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徐文燕(1983-)，女，江西吉安人，硕士，主管医师，主要从事学校卫生与眼病防治工作

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徐文燕(1983-)，女，江西吉安人，硕士，主管医师，主要从事学校卫生与眼病防治工作

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(in Chinese), articleTitle=null, refAbstract=null)], funds=[Fund(id=1325532707060727943, tenantId=1146029695717560320, journalId=1256213402557890569, articleId=1325532634377633885, awardId=null, language=CN, fundingSource=上海市眼病防治中心—“沪眼星光”儿童青少年近视防控人员培养计划项目(HYXG-QJ06), fundOrder=null, country=null)], companyList=[AuthorCompany(id=1325532665147048034, tenantId=1146029695717560320, journalId=1256213402557890569, articleId=1325532634377633885, xref=1, ext=[AuthorCompanyExt(id=1325532665532924003, tenantId=1146029695717560320, journalId=1256213402557890569, articleId=1325532634377633885, companyId=1325532665147048034, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1Department of School Health and Eye Disease Prevention, Center for Disease Control and Prevention of Jing'an District, Shanghai 200072, China), AuthorCompanyExt(id=1325532666388562020, tenantId=1146029695717560320, journalId=1256213402557890569, articleId=1325532634377633885, companyId=1325532665147048034, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1上海市静安区疾病预防控制中心学校卫生与眼病防治科，200072)]), AuthorCompany(id=1325532668435382373, tenantId=1146029695717560320, journalId=1256213402557890569, articleId=1325532634377633885, xref=2, ext=[AuthorCompanyExt(id=1325532668498296934, tenantId=1146029695717560320, journalId=1256213402557890569, articleId=1325532634377633885, companyId=1325532668435382373, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2复旦大学公共卫生学院)])], figs=[ArticleFig(id=1325532696084234369, tenantId=1146029695717560320, journalId=1256213402557890569, articleId=1325532634377633885, language=EN, label=Tab.1, caption=

Comparison of detection rates of screening myopia among primary school students from 2019 to 2023 in different groups

, figureFileSmall=null, figureFileBig=null, tableContent=
组别选项统计值2019年2020年2021年2022年2023年
人数检出人数人数检出人数人数检出人数人数检出人数人数检出人数
性别男1 841671(36.45)1 907741(38.86)1 718687(39.99)1 845713(38.64)1 927752(39.02)
女1 671616(36.86)1 779671(37.72)1 583649(41.00)1 633663(40.60)1720698(40.58)
χ2值0.050.460.311.300.86
P值0.830.490.580.250.35
年级一786104(13.23)837129(15.41)745130(17.45)768114(14.84)800117(14.62)
二731180(24.62)773209(27.04)716221(30.87)755241(31.92)775238(30.71)
三695275(39.57)720315(43.75)654286(43.73)709305(43.02)729337(46.23)
四661338(51.13)691356(51.52)609344(56.49)651331(50.84)698365(52.29)
五639390(61.03)665403(60.60)577355(61.53)595385(64.71)645393(60.93)
χ趋势2值455.22419.81358.43403.64401.62
P值＜0.01＜0.01＜0.01＜0.01＜0.01
合计3 5121 287(36.65)3 6861 412(38.31)3 3011 336(40.47)3 4781 376(39.56)3 6471 450(39.76)
), ArticleFig(id=1325532696637882498, tenantId=1146029695717560320, journalId=1256213402557890569, articleId=1325532634377633885, language=CN, label=表1, caption=

不同组别小学生2019—2023年筛查近视检出率比较

, figureFileSmall=null, figureFileBig=null, tableContent=
组别选项统计值2019年2020年2021年2022年2023年
人数检出人数人数检出人数人数检出人数人数检出人数人数检出人数
性别男1 841671(36.45)1 907741(38.86)1 718687(39.99)1 845713(38.64)1 927752(39.02)
女1 671616(36.86)1 779671(37.72)1 583649(41.00)1 633663(40.60)1720698(40.58)
χ2值0.050.460.311.300.86
P值0.830.490.580.250.35
年级一786104(13.23)837129(15.41)745130(17.45)768114(14.84)800117(14.62)
二731180(24.62)773209(27.04)716221(30.87)755241(31.92)775238(30.71)
三695275(39.57)720315(43.75)654286(43.73)709305(43.02)729337(46.23)
四661338(51.13)691356(51.52)609344(56.49)651331(50.84)698365(52.29)
五639390(61.03)665403(60.60)577355(61.53)595385(64.71)645393(60.93)
χ趋势2值455.22419.81358.43403.64401.62
P值＜0.01＜0.01＜0.01＜0.01＜0.01
合计3 5121 287(36.65)3 6861 412(38.31)3 3011 336(40.47)3 4781 376(39.56)3 6471 450(39.76)
), ArticleFig(id=1325532697040535683, tenantId=1146029695717560320, journalId=1256213402557890569, articleId=1325532634377633885, language=EN, label=Tab.2, caption=

Comparison of AL/CR and increase of AL/CR among primary school students' gender and myopia status in different grades [M(P25, P75), n=480]

, figureFileSmall=null, figureFileBig=null, tableContent=
AL/CR及增长量年级统计值性别近视状况总体
男生女生近视不近视
AL/CR一2.91(2.86, 2.95)2.88(2.85, 2.92)a2.89(2.85, 2.94)2.89(2.85, 2.94)
二2.95(2.90, 3.00)2.92(2.88, 2.96)a3.00(2.96, 3.05)2.93(2.88, 2.97)b2.94(2.89, 2.98)
三2.99(2.93, 3.04)2.96(2.91, 3.01)a3.04(3.00, 3.08)2.94(2.90, 2.98)b2.98(2.92, 3.03)
四3.02(2.96, 3.08)3.01(2.94, 3.07)3.07(3.03, 3.13)2.96(2.92, 3.01)b3.01(2.95, 3.08)
五3.05(2.98, 3.12)3.04(2.97, 3.11)3.09(3.05, 3.16)2.97(2.93, 3.02)b3.05(2.98, 3.12)
H值350.88361.30133.37225.47703.32
P值＜0.01＜0.01＜0.01＜0.01＜0.01
AL/CR增长量二0.04(0.02, 0.06)0.04(0.02, 0.06)0.06(0.03, 0.09)0.03(0.02, 0.06)b0.04(0.02, 0.06)
三0.04(0.02, 0.06)0.04(0.02, 0.06)0.06(0.04, 0.09)0.03(0.01, 0.04)b0.04(0.02, 0.06)
四0.03(0.02, 0.05)0.04(0.02, 0.06)0.05(0.03, 0.07)0.03(0.01, 0.04)b0.04(0.02, 0.06)
五0.03(0.02, 0.05)0.04(0.02, 0.06)a0.04(0.03, 0.06)0.03(0.01, 0.04)b0.04(0.02, 0.06)
H值8.281.8834.4432.545.97
P值0.040.59＜0.01＜0.010.11
), ArticleFig(id=1325532699909439620, tenantId=1146029695717560320, journalId=1256213402557890569, articleId=1325532634377633885, language=CN, label=表2, caption=

不同年级小学生分性别和近视状况下轴率比及增长量比较[M(P25, P75)，n=480]

, figureFileSmall=null, figureFileBig=null, tableContent=
AL/CR及增长量年级统计值性别近视状况总体
男生女生近视不近视
AL/CR一2.91(2.86, 2.95)2.88(2.85, 2.92)a2.89(2.85, 2.94)2.89(2.85, 2.94)
二2.95(2.90, 3.00)2.92(2.88, 2.96)a3.00(2.96, 3.05)2.93(2.88, 2.97)b2.94(2.89, 2.98)
三2.99(2.93, 3.04)2.96(2.91, 3.01)a3.04(3.00, 3.08)2.94(2.90, 2.98)b2.98(2.92, 3.03)
四3.02(2.96, 3.08)3.01(2.94, 3.07)3.07(3.03, 3.13)2.96(2.92, 3.01)b3.01(2.95, 3.08)
五3.05(2.98, 3.12)3.04(2.97, 3.11)3.09(3.05, 3.16)2.97(2.93, 3.02)b3.05(2.98, 3.12)
H值350.88361.30133.37225.47703.32
P值＜0.01＜0.01＜0.01＜0.01＜0.01
AL/CR增长量二0.04(0.02, 0.06)0.04(0.02, 0.06)0.06(0.03, 0.09)0.03(0.02, 0.06)b0.04(0.02, 0.06)
三0.04(0.02, 0.06)0.04(0.02, 0.06)0.06(0.04, 0.09)0.03(0.01, 0.04)b0.04(0.02, 0.06)
四0.03(0.02, 0.05)0.04(0.02, 0.06)0.05(0.03, 0.07)0.03(0.01, 0.04)b0.04(0.02, 0.06)
五0.03(0.02, 0.05)0.04(0.02, 0.06)a0.04(0.03, 0.06)0.03(0.01, 0.04)b0.04(0.02, 0.06)
H值8.281.8834.4432.545.97
P值0.040.59＜0.01＜0.010.11
), ArticleFig(id=1325532701088039045, tenantId=1146029695717560320, journalId=1256213402557890569, articleId=1325532634377633885, language=EN, label=Tab.3, caption=

Mixed effect analysis of the influencing factors of the AL/CR of the primary school cohort(n=480)

, figureFileSmall=null, figureFileBig=null, tableContent=
自变量β值(95%CI)标准误t值P值
截距2.830(2.816~2.833)0.004650.61＜0.01
性别
  男0.002(-0.006~0.010)0.0040.460.64
年级0.040(0.038~0.042)0.00147.87＜0.01
性别×年级
  男×年级-0.003(-0.005~-0.001)0.001-2.760.01
BMI
  超重0.001(-0.004~0.006)0.0030.330.74
  肥胖0.001(-0.005~0.006)0.0030.110.92
  消瘦0.003(-0.006~0.012)0.0050.580.56
基线AL/CR1.051(1.012~1.091)0.01952.99＜0.01
基线SE-0.008(-0.013~-0.003)0.003-3.00＜0.01
首年AL/CR增长量0.788(0.733~0.843)0.02828.10＜0.01
学校类型
  重点0.001(-0.005~0.007)0.0030.400.69
籍贯
  非上海0.006(-0.005~0.016)0.0051.050.30
), ArticleFig(id=1325532703231328390, tenantId=1146029695717560320, journalId=1256213402557890569, articleId=1325532634377633885, language=CN, label=表3, caption=

小学生近视队列AL/CR影响因素的线性混合效应分析(n=480)

, figureFileSmall=null, figureFileBig=null, tableContent=
自变量β值(95%CI)标准误t值P值
截距2.830(2.816~2.833)0.004650.61＜0.01
性别
  男0.002(-0.006~0.010)0.0040.460.64
年级0.040(0.038~0.042)0.00147.87＜0.01
性别×年级
  男×年级-0.003(-0.005~-0.001)0.001-2.760.01
BMI
  超重0.001(-0.004~0.006)0.0030.330.74
  肥胖0.001(-0.005~0.006)0.0030.110.92
  消瘦0.003(-0.006~0.012)0.0050.580.56
基线AL/CR1.051(1.012~1.091)0.01952.99＜0.01
基线SE-0.008(-0.013~-0.003)0.003-3.00＜0.01
首年AL/CR增长量0.788(0.733~0.843)0.02828.10＜0.01
学校类型
  重点0.001(-0.005~0.007)0.0030.400.69
籍贯
  非上海0.006(-0.005~0.016)0.0051.050.30
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上海市静安区2019—2023年小学生轴率比与近视发展的关联
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徐文燕 1 , 王丽蒙 1 , 余勇夫 2
中国学校卫生 | 疾病控制 2025,46(11): 1645-1649
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中国学校卫生 |疾病控制 2025 , 46 (11) : 1645 -1649
上海市静安区2019—2023年小学生轴率比与近视发展的关联
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徐文燕(1983-)，女，江西吉安人，硕士，主管医师，主要从事学校卫生与眼病防治工作

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徐文燕(1983-)，女，江西吉安人，硕士，主管医师，主要从事学校卫生与眼病防治工作

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徐文燕1, 王丽蒙1, 余勇夫2
作者信息
  • 1上海市静安区疾病预防控制中心学校卫生与眼病防治科，200072
  • 2复旦大学公共卫生学院
作者简介:

徐文燕(1983-)，女，江西吉安人，硕士，主管医师，主要从事学校卫生与眼病防治工作

Association of axial length-to-corneal radius ratio on myopia progression among primary school students in Jing'an District, Shanghai 2019-2023
Wenyan XU1, Limeng WANG1, Yongfu YU2
Affiliations
  • 1Department of School Health and Eye Disease Prevention, Center for Disease Control and Prevention of Jing'an District, Shanghai 200072, China
出版时间: 2025-11-25 doi: 10.16835/j.cnki.1000-9817.2025345
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摘要
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目的

了解上海市静安区小学生近视现况，探讨小学生轴率比(AL/CR)进展情况，分析AL/CR的动态监测价值及其与近视进展的纵向关联机制，为开展小学生近视防控工作提供依据。

方法

2019—2023年采用分层整群随机抽样方法，抽取上海市静安区2所小学17 624名小学生开展连续5年视力筛查，并将2019年符合条件的一年级小学生480人，按回顾式队列的方法随访至2023年。分析近视率及AL/CR的变化趋势，运用χ2检验对不同组别小学生2019—2023年筛查近视率进行比较分析，采用χ2趋势检验对筛查近视率的趋势进行分析；采用Kruskal-Wallis H检验比较不同组别小学生AL/CR和AL/CR增量，应用线性混合效应模型分析AL/CR的影响因素，并构建含时依变量的近视发生风险预测Cox回归模型。

结果

2019—2023年小学生筛查性近视检出率分别为36.65%，38.31%，40.47%，39.56%，39.76%。队列研究结果显示，五年级女生的AL/CR增长量高于男生，差异有统计学意义(Z=-2.05，P＜0.05)。线性混合效应模型结果显示，小学生AL/CR的影响因素有基线AL/CR(β=1.051，95%CI=1.012~1.091)、年级(β=0.040，95%CI=0.038~0.042)、首年增长量(β=0.788，95%CI=0.733~0.843)，且男生随年级增长AL/CR发展速度较女生缓慢(β=-0.003，95%CI=-0.005~-0.001)(P值均＜0.01)。时依Cox回归模型结果显示，基线AL/CR和AL/CR时变效应均有统计学意义(Z值分别为3.40，10.41，P值均＜0.01)，AL/CR对筛查性近视风险的影响随随访时间增强，且增长速度快于线性增长。

结论

小学生的AL/CR主要由基线值和年级增长驱动，男生随年级增长的AL/CR发展速度较女生缓慢。AL/CR的动态监测比基线值更能预测近视进展，对于AL/CR高增长的学生应该及早干预。

近视  /  眼轴长度  /  角膜曲率半径  /  回归分析  /  学生
Objective

To investigate the current prevalence of myopia and the progression of the axial length/corneal radius ratio(AL/CR) among primary school students in Jing'an District, Shanghai, and to analyze the value of dynamic AL/CR monitoring and elucidate its longitudinal association with myopia progression, so as to provide evidences for supporting myopia prevention and control interventions.

Methods

From 2019 to 2023, by using a stratified cluster random sampling method, 17 624 students from two primary schools in Jing'an District, Shanghai were selected for annual vision screenings in five consecutive years. Additionally, a retrospective cohort of 480 eligible first-grade students identified in 2019 was followed up until 2023. The analysis focused on the myopia prevalence and the trend in the AL/CR. Differences in screening myopia rates across different student groups from 2019 to 2023 were compared using the Chi-square test. The trends in myopia rates were analyzed using the Chi-square trend test. The Kruskal-Wallis H test was employed to compare AL/CR and its annual increment across groups. A linear mixed-effects model was used to identify factors influencing AL/CR, and a time-dependent Cox regression model was developed to predict the risk of myopia onset.

Results

From 2019 to 2023, the screening myopia rates were 36.65%, 38.31%, 40.47%, 39.56%, and 39.76% for each respective year. Cohort analyses revealed Grade 5 girls had significantly greater AL/CR increments than boys (Z=-2.05, P < 0.05). Linear mixed models identified baseline AL/CR (β=1.051, 95%CI=1.012-1.091), grade level (β=0.040, 95%CI=0.038-0.042), and first-year AL/CR increment (β=0.788, 95%CI=0.733-0.843) as primary determinants (all P < 0.01). Boys showed slower AL/CR progression than girls (β=-0.003, 95%CI=-0.005 to-0.001, P < 0.01). The time-dependent Cox model demonstrated that both baseline AL/CR (Z=3.40) and its time-varying effect (Z=10.41) significantly predicted myopia risk(both P < 0.01). The effect of AL/CR on myopia risk significantly increased with follow-up time, and the growth rate exceeded a linear progression pattern.

Conclusions

AL/CR progression is primarily driven by baseline values and grade advancement, with slower progression in boys. Dynamic AL/CR monitoring outperforms baseline measurements in predicting myopia progression. Students with rapid AL/CR increments require early intervention.

Myopia  /  Axial length  /  Corneal curvature radius  /  Regression analysis  /  Students
徐文燕, 王丽蒙, 余勇夫. 上海市静安区2019—2023年小学生轴率比与近视发展的关联. 中国学校卫生, 2025 , 46 (11) : 1645 -1649 . DOI: 10.16835/j.cnki.1000-9817.2025345
Wenyan XU, Limeng WANG, Yongfu YU. Association of axial length-to-corneal radius ratio on myopia progression among primary school students in Jing'an District, Shanghai 2019-2023[J]. Chinese Journal of School Health, 2025 , 46 (11) : 1645 -1649 . DOI: 10.16835/j.cnki.1000-9817.2025345
正文
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2018年全国近视调查数据显示，我国儿童青少年总体近视率为53.6%，其中小学生为36.0%[1]。近视一旦发生则不可逆转，如不及时干预和控制会迅速发展，一旦进展成高度近视，将增加眼底并发症的发生风险，严重者还可能致盲，给生活带来不便和沉重负担[2-3]。本研究于2019—2023年针对上海市静安区小学生开展近视筛查，系统了解辖区内小学生近视率水平和眼轴长度(axial length, AL)与角膜曲率半径(corneal curvature radius, CR)比值，即轴率比(AL/CR)的进展情况；通过构建连续5年的回顾式队列，对比不同组别小学生AL/CR及AL/CR增长量，为辖区内小学生近视发生的预测预警和及早科学干预提供依据。
1　对象与方法
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1.1　对象
2019—2023年每年9—10月，采用分层整群随机抽样方法，在上海市静安区50所小学中依据教学水平(普通/重点)进行分层，采用抽签法随机抽取2所小学作为监测学校，将抽中学校的所有在校生全部纳入调查，并连续监测5年。所有参与监测项目的学生家长均签署书面知情同意书。2019—2023年的筛查数据经清洗整理合并，共纳入17 624名一至五年级的小学生，年龄为6~11岁；每年筛查人数分别为3 512，3 686，3 301，3 478，3 647名。从2019年的筛查对象中，选择全部的一年级小学生，排除其中已经近视、不同意参与、配戴角膜塑形镜、患有眼部疾病及核心数据缺失者，按照回顾式队列的方法随访至2023年，最终选择连续5年有随访数据的480人作为研究对象，其中男生262名(54.58%)，女生218名(45.42%)。本研究为《上海市儿童近视综合防控：建立儿童屈光发育档案》项目的一部分，沿用上海市第一人民医院伦理委员会审批(批号：2015KY149)。
1.2　方法
1.2.1　视力检查
视力检查的指标有球镜、柱镜、轴位散光方向、角膜曲率、AL、裸眼视力和戴镜视力。按照《中小学生屈光不正筛查规范》(WS/T 663—2020)[4]要求，采用国际标准对数视力表进行裸眼及戴镜视力检查；采用TOPCON KR800台式电脑验光仪进行非睫状肌麻痹下电脑验光。采用蔡司IOL-Master 500非接触测量双眼AL、角膜曲率[角膜平坦轴曲率(flat meridian keratometry，K1)和角膜陡峭轴曲率(steep meridian keratometry，K2)]，角膜曲率均值K=(K1+K2)/2，CR=337.5/K[5]。按以往研究[6]采用右眼数据进行统计分析。
1.2.2　体格发育评价
采用机械式身高计测量身高、电子体重计测量体重, 并计算体质量指数(body mass index, BMI)=体重(kg)/[身高(m)]2。根据《学龄儿童青少年超重与肥胖筛查》 (WS/T 586—2018)[7], 依照年龄和性别所对应的界值判定学生超重、肥胖情况；根据《学龄儿童青少年营养不良筛查》(WS/T 456—2014)[8]判定学生消瘦情况。
1.2.3　判定标准
裸眼视力＜5.0且非睫状肌麻痹下电脑验光等效球镜度数(spherical equivalent, SE)＜-0.50 D则判定该眼为筛查性近视[9]，其中SE=球镜度数+柱镜度数/2。
1.3　质量控制
近视筛查均由经过培训且获得资质的专业技术人员严格按照操作规范和标准要求进行，并抽取5%进行质控复测，误差率在5%以内。若复测误差率>5%，及时召开会议研究，对超过允许误差范围的指标进行复测、复检、改正。所有数据由质控人员进行全程监督，采用抽签法抽取学生进行重测。每次筛查结束后，现场负责人对采集的数据进行核对，检查是否存在遗漏或逻辑错误。
1.4　统计学分析
从上海市居民眼健康信息系统导出屈光监测数据并进行清洗与整理，使用R 4.3.1软件进行数据整理和统计分析。采用Kolmogorov-Smirnov方法检验数据的正态性，符合正态分布的连续变量采用(x ±s)描述，不符合正态分布的采用M(P25, P75)描述；组间比较采用Wilcoxon秩和检验或Kruskal-Wallis H检验。分类变量采用频数和构成比表示；采用χ2检验比较不同组间小学生筛查性近视检出率，采用趋势χ2检验分析不同年份和年级间筛查性近视检出率的变化趋势。采用nlme包基于回顾性队列数据建立线性混合效应模型，探究小学生AL/CR的影响因素，采用survival包建立含时依变量的近视发生风险的Cox回归模型；考虑到基线个体差异和近视进展程度，模型纳入了性别、基线AL/CR及其时变效应、基线BMI及其时变效应等关键预测因子。时变效应通过时间函数x×log(t+1) 进行建模[10]，并使用个体脱敏后的个人识别号作为聚类变量以调整个体相关性。模型拟合优度通过Concordance指数评估，整体显著性采用似然比检验验证。时依变量每年更新1次，并通过尺度Schoenfeld残差法验证非时变固定效应的比例风险假设。双侧检验水准α=0.05。
2　结果
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2.1　小学生2019—2023年筛查性近视检出率
2019—2023年小学生筛查性近视检出率分别为36.65%，38.31%，40.47%，39.56%，39.76%。随着年级的升高，小学生筛查性近视率呈上升趋势(P值均＜0.01)。不同性别间筛查性近视检出率差异均无统计学意义(P值均＞0.05)。见表1。
2.2　小学生AL/CR及增长情况
2.2.1　不同年级小学生AL/CR进展情况
一至五年级，女生的AL/CR均低于男生，但只有一至三年级性别差异有统计学意义(Z值分别为-3.45，-3.72，-2.11，P值均＜0.01)；近视学生的AL/CR均高于不近视的学生(Z值分别为-8.33，-12.74，-13.68，-14.94，P值均＜0.01)。纵向来看，一至五年级，无论性别和近视状况，AL/CR差异均有统计学意义(P值均＜0.01)。见表2。
二至五年级学生AL/CR的增长量差异无统计学意义(P=0.11)；其中男生增长量随年级增高而下降，且年级差异有统计学意义(P=0.04)，女生增长量的年级差异无统计学意义(P=0.59)。近视和不近视的学生AL/CR增长量差异均有统计学意义(P值均＜0.01)；五年级女生的AL/CR增长量高于男生，差异有统计学意义(Z=-2.05，P=0.04)；二到五年级近视学生的AL/CR增长量均高于不近视学生，差异均有统计学意义(Z值分别为-5.66，-10.38，-9.01，-8.19，P值均＜0.01)。见表2。
2.2.2　小学生AL/CR的影响因素分析
采用线性混合效应模型分析小学生AL/CR的影响因素。模型的固定效应包括性别(以女生为参照组)、年级(连续变量)、BMI类型(以正常为参照组)、基线AL/CR、基线SE、首年AL/CR增长量、学校类型(以普通为参照组)及籍贯(以上海为参照组)。在固定效应中，年级每升高一级，AL/CR增加0.040，基线AL/CR对当前AL/CR的预测效应最强(β=1.051)；首年AL/CR增长量正向预测当前AL/CR(β=0.788)(P值均＜0.01)。性别主效应、BMI类型、学校类型、籍贯对AL/CR影响均无统计学意义(P值均>0.05)。见表3。
2.2.3　含时依变量的近视发生风险预测模型
采用含时依变量(即AL/CR和BMI)的Cox回归模型，预测小学生将来近视发生的风险。模型Concordance指数为0.813(SE=0.015)，整体显著(χ2=283.52，P＜0.01)。通过尺度Schoenfeld残差法验证非时变固定效应的基本符合比例风险假设。
结果显示，不同性别小学生近视风险差异无统计学意义(P=0.55)；基线AL/CR和AL/CR时变效应均有统计学意义(P值均＜0.01)，基线AL/CR每增加1个单位，近视风险增加134%(HR=2.34，95%CI=1.43~3.83)；AL/CR对近视风险的影响随随访时间增强，且增长速度快于线性增长。基线BMI有统计学意义，基线BMI每增加1单位，风险增加16%(HR=1.16，95%CI=1.08~1.25，P＜0.01)，而BMI随时间变化呈现出增加近视风险的趋势，但未达到统计学意义(HR=1.40，95%CI=0.98~1.99，P=0.07)。
3　讨论
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本研究发现基线AL/CR及首年增量对当前AL/CR的预测效力最强，与国际共识一致[11]。AL/CR作为眼球屈光要素的综合指标，比单一眼轴长度更能反映近视病理进展[12]。值得注意的是，动态监测AL/CR的预测价值高于基线值：AL/CR对近视风险的影响随随访时间增强，且增长速度快于线性增长。验证了Hou等[13]在新加坡儿童中的发现——年度屈光变化比基线值更能预测远期进展。建议将AL/CR纳入学校近视筛查常规项目，对高增长个体启动早期干预[14]。
五年级女生呈现更快的AL/CR增速，且线性混合模型证实男生随年级的增速缓于女生。这一现象可能与性激素调节巩膜重塑相关。动物实验表明雌激素受体信号通路可抑制巩膜成纤维细胞增殖，延缓眼轴伸长[15]。而女生青春期启动早于男生，可能通过雌激素水平上升介导巩膜刚度增加[16-17]，部分解释本研究中高年级女生AL/CR增速更快的现象。国内体质健康报告显示小学高年级女生户外活动时间比男生少15%~20%[18]，这种现象可能加速近视发展。值得注意的是，本研究中低年级小学生AL/CR增速性别差异无统计学意义，提示青春期可能是关键时间窗，需及早针对性设计女生近视防控方案。
线性混合效应模型和时依Cox回归模型中BMI的效应存在不一致，但时依Cox回归模型中基线BMI每增加1个单位，近视风险上升16%，与多项研究结果一致[6, 19]。高BMI可能通过3条路径影响近视：(1) 胰岛素样生长因子-1水平升高，激活视网膜胰岛素样生长因子-1受体，促进眼轴增长[20]；(2) 体内慢性炎症因子(如白细胞介素6)干扰巩膜细胞外基质代谢[21]；(3) 维生素D缺乏(肥胖儿童血清水平降低32%)削弱多巴胺介导的巩膜保护作用[22]。尽管时变BMI效应仅有边缘统计学意义，但基于其稳定的基线风险效应，建议将BMI纳入筛查体系，对超重学生实施“运动处方+营养教育”联合干预。
本研究的时依Cox回归模型证实AL/CR动态监测可实现近视发生风险分层预警。尝试提出小学生近视的三级防控路径：(1)一级预防：建立AL/CR电子档案，对基线AL/CR＞2.90或首年增幅＞0.05者强化户外活动(每日≥120 min)[23]；(2)二级干预：将BMI纳入筛查指标，将高BMI学生列为重点人群，由校医进行体重干预和管理；(3)三级预警：采用本研究开发的时依Cox回归模型对学生进行风险分层。
本研究存在一定局限性：样本仅来自静安区2所学校，外推性受限；未采集父母遗传、近距离用眼时长、户外运动时间等行为数据；电脑验光在非睫状肌麻痹条件下进行，没有进行散瞳处理，可能会高估近视率。未来需开展多中心研究，整合遗传、环境、用眼行为和户外活动等多维度数据[24]构建更为全面稳健的风险预测模型。
基金
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  • 上海市眼病防治中心—“沪眼星光”儿童青少年近视防控人员培养计划项目(HYXG-QJ06)
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2025年第46卷第11期
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doi: 10.16835/j.cnki.1000-9817.2025345
  • 接收时间：2025-08-11
  • 首发时间：2026-11-06
  • 出版时间：2025-11-25
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  • 收稿日期：2025-08-11
  • 修回日期：2025-09-23
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上海市眼病防治中心—“沪眼星光”儿童青少年近视防控人员培养计划项目(HYXG-QJ06)
作者信息
    1上海市静安区疾病预防控制中心学校卫生与眼病防治科，200072
    2复旦大学公共卫生学院
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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
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