Associations between Myopia and Dry Eye Disease in Children Subjects

Associations between Myopia and Dry Eye Disease in Children Subjects | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Associations between Myopia and Dry Eye Disease in Children Subjects Yili Chang, Fubao Zhang, Yanping Li, Haijian Hu, Shuifeng Wang, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9413350/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Introduction: The aim of this study was to investigate the correlation between myopia and dry eye disease (DED) in children. Method: A cross-sectional study involving 83 pediatric participants (166 eyes) aged 7–15 years was conducted. The participants were stratified into four groups on the basis of spherical equivalent (SE): the nonmyopia group (NMG, 38 eyes), the low-myopia group (LMG, 59 eyes), the moderate-myopia group (MMG, 52 eyes), and the high-myopia group (HMG, 17 eyes). Comprehensive ocular surface evaluation was performed using an ocular surface analyzer and noncontact partial coherence interferometry. The primary outcome measures included comparative analysis of tear film stability across groups, sex-based differences in ocular surface parameters, and correlation analysis between ocular surface metrics and myopia severity. Result: Significant differences in ocular surface parameters were observed among the study groups (P < 0.05). Compared with the NMG and LMG, the HMG markedly altered the tear film stability. Compared with their male counterparts, female participants in the HMG presented significantly shorter tear meniscus heights (TMHs), first noninvasive tear film break-up times (NIBUTs), and average tear film break-up times (P < 0.05). Correlations were identified between ocular surface parameters and myopia progression metrics. Conclusion: The study findings demonstrate a significant association between myopia severity and DED in pediatric populations. High myopia was associated with compromised tear film stability and reduced tear secretion, with female participants exhibiting more pronounced ocular surface changes. The results of this study provide evidence-based guidance to better protect young myopic eyes from associated DED; however, further research is warranted to form clinical recommendations. Dry eye disease Myopia Children Ocular surface Gender Figures Figure 1 Figure 2 1. Introduction Myopia is one of the most common eye diseases worldwide, and its incidence in young people in China is 90%-95%[ 1 , 2 ]. When the eye is elongated, the image of a distant object is focused in front of the retina through the refractive system, resulting in blurred distance vision[ 3 ]. The tear film, located on the foremost surface of the eye, plays an important role in maintaining clear vision and is an important component of the refractive system[ 4 – 6 ]. However, few studies have discussed the relationship between the degree of myopia and tear film stability in participants. Dry eye disease (DED), a multifactorial ocular surface disease characterized by the loss of tear film homeostasis, is accompanied by eye discomfort, visual impairment, and other ocular symptoms[ 7 – 10 ]. The incidence and severity of DED increase with age[ 11 , 12 ], and many doctors may neglect to check young participants for DED. However, in recent years, with the widespread use of visual display units and the increasing burden of schoolwork, the incidence of DED in children has increased annually[ 13 , 14 ]. DED may influence children's daily factivities and could have implications for their overall quality of life. Myopia is the most common eye disease among children. However, whether there is a correlation between myopia and DED remains unclear. The Keratograph 5 M ocular surface analyzer (OCULUS Optikgeräte GmbH, Wetzlar, Germany) is a noninvasive ocular surface examination instrument capable of providing accurate and objective imaging of the ocular surface, making it a suitable tool for evaluating ocular conditions in children. Most children demonstrate a high degree of cooperation with researchers during examinations, and all tests are conducted by the same operator, ensuring the reliability of the results[ 15 ]. Therefore, in this study, an ocular surface analyzer was utilized to assess the correlations between DED and myopia in children. To the best of our knowledge, this is the first study to systematically compare ocular surface parameters across varying degrees of myopia in pediatric populations. This finding may contribute to a better understanding of the potential interactions between myopia and DED in pediatric populations while also raising awareness among parents about the importance of children's ocular health. 2. Methods 2.1 Subjects The study was conducted from August 2021 to September 2023 at the Affiliated Eye Hospital of Nanchang University, and 83 participants (166 eyes) aged 7–15 years were recruited as research subjects. The research protocol was designed according to the Declaration of Helsinki and approved by the Ethics Committee of the Eye Hospital of Nanchang University. All participants and their legal guardians were thoroughly informed about the study objectives through oral and written explanations. Written informed consent was obtained from all legal guardians, and participant assent was acquired when appropriate. Experienced ophthalmologists conducted comprehensive eye examinations for all participants, including vision assessment, slit lamp anterior segment examination, and direct ophthalmoscopic fundus examination. All participants were examined after ciliary muscle paralysis to determine their refractive status. On the basis of spherical equivalent (SE), the participants were divided into a nonmyopia group (NMG, − 0.5D < SE ≤ + 0.5D), a low myopia group (LMG, − 3.0D < SE ≤ − 0.5D), a moderate myopia group (MMG, − 6.0D < SE ≤ − 3.0D), and a high myopia group (HMG, SE ≤ − 6.0D)[ 16 ]. Participants were required to meet the following inclusion criteria: aged between 7 and 15 years, stable fixation in both eyes, cooperative during examinations, binocular corrected visual acuity ≥ 1.0, normal intraocular pressure (10–21 mmHg), and transparent ocular media. The exclusion criteria were as follows: allergic conjunctivitis, a history of eye surgery or trauma, strabismus or abnormal eye movements, recent use (within the past month) of corneal contact lenses or topical eye drops, systemic diseases known to affect ocular health or keratoconjunctivitis affecting the tear film, acute eye infections, thermal burns or chemical injuries to the eye, and a diagnosis of dry eye syndrome requiring ongoing eye drops or physical therapy. These criteria ensured that the study population was free from confounding conditions, thereby maintaining the integrity and validity of the results. 2.2 Keratograph 5 M ocular surface analyzer examination Ocular surface evaluation included tear meniscus height (TMH), noninvasive tear film break-up time (NIBUT), and Meibomian Gland (MG) imaging (Fig. 1 ), all of which were performed via a noninvasive ocular surface analyzer. All examinations were performed by the same experienced and masked physician every morning, and the subject was confirmed not to be exposed to any electronic products or topical eye drops prior to the examination. 2.2.1 Tear meniscus height After adjusting the jaw and forehead positions, the subject focused on the front central point, and an image was obtained after blinking. The random software caliper tool was used to measure the TMH below the center of the cornea[ 17 ]. 2.2.2 Noninvasive tear film break-up time measurement The assessor adjusted the Keratograph 5 M to the NIBUT measurement mode. The assessment of Placido concentric rings during continuous eye-opening intervals included the first tear film break-up time (NIBUT-f) and the average time of all tear film break-up incidents (NIBUT-avg), and the tear film break-up time was classified from 1 to 4 according to severity[ 18 ]. 2.2.3 Imaging and scoring of the medial gland To obtain MG infrared images, the upper and lower eyelids were exposed, and a Keratograph 5 M was used for noncontact infrared imaging of the lower and upper eyelids. The degree of loss of MGs in each eyelid was scored as the meiboscore according to the following criteria: 0 (no loss of MGs); 1 (loss of MGs over less than 1/3 of the total area); 2 (loss of MGs over 1/3 to 2/3 of the total area); and 3 (loss of MGs over more than 2/3 of the total area). The upper and lower eyelid scores of each eye were summed, and the total score ranged from 0 to 6[ 19 , 20 ]. 2.3 Noncontact partial coherent laser interferometer The degree of myopia is closely related to the axial length (AL) and curvature of the eye. Before pupillary dilatation of all the participants, a noncontact partial coherent laser interferometer (IOL Master; Carl Zeiss Meditec, Oberkochen, Germany) was used to assess AL, flat keratometry (K1), and steep keratometry (K2)[ 21 ]. As recommended by Fan Q et al.[ 22 ], multiple valid measurements were obtained to improve data reliability, and their average values were used for statistical analysis. 2.4 Statistical analysis Statistical analysis was performed via SPSS version 24.0, and all variables are expressed as the means ± standard deviations (SDs). The Shapiro–Wilk test was used to test for a normal distribution. For the data that did not conform to a normal distribution, the Kruskal–Wallis test was used to compare each parameter between the groups. The Mann–Whitney U test was used to compare two groups. Spearman’s correlation coefficient analysis was also performed. P < 0.05 was considered to indicate statistical significance. 3. Results 3.1 Demographics and clinical characteristics of the study population Table 1 Demographics and clinical characteristics of the study population Parameter All subjects Age (years) 12.00 (10.00, 13.00) Eyes (male, female) 74, 92 SE (D) -2.25 (-4.00, -0.50) TMH (mm) 0.15 (0.12, 0.19) NIBUT-f (s) 9.98 (5.32 15.87) NIBUT-avg(s) 13.50 (8.00, 18.76) Classification 1 (0, 1) MG (score) 0 (0, 1) AL (mm) 24.57 (23.87, 25.14) K1 (D) 42.70 (41.82, 43.44) K2 (D) 44.00 (42.95, 45.11) A total of 83 participants (166 eyes), including 37 males and 46 females, participated in this study. Table 1 summarizes the demographic and clinical characteristics of the study population. SE= spherical equivalent, D= diopters, TMH= tear meniscus height, NIBUT-f = the first break-up time of the tear film, NIBUT-avg = the average time of all tear film break-up incidents, MG= meibomian gland, AL= axial length, K1 = flat keratometry, K2 = steep keratometry. 3.2 Comparison of clinical characteristics among participants with different degrees of myopia The participants were further divided into the NMG, which included 38 eyes (22.89%); the LMG, which included 59 eyes (35.54%); the MMG, which included 52 eyes (31.33%); and the HMG, which included 17 eyes (10.24%). Table 2 shows the clinical features of each group. There was no significant difference among the groups in terms of sex or age. For the ocular surface parameters (NIBUT-f, NIBUT-avg, and classification) of each group, the dynamic tear film stability gradually deteriorated with increasing degree of myopia. Compared with both the NMG and the LMG, the HMG exhibited significant differences. There was a significant difference in the amount of tear secretion (TMH) between the MMG and LMG; however, there was no statistically significant difference between the other groups. However, there were no significant differences in the MG among the groups. In addition, there were significant differences in the degrees of myopia and ALs among all groups ( P < 0.001), but there were no significant differences between the MMG and HMG. K1 and K2 in the HMG were significantly greater than those in the NMG, and K2 in the MMG significantly differed from those in the NMG and HMG. Table 2 Eye parameters of subjects with different degrees of myopia Parameter NMG LMG MMG HMG P value Age (years) 11.00 (9.00, 13.00) 11 (9.00, 13.00) 12.00 (10.00, 13.00) 13.00 (12.00, 13.50) 0.07 Eyes (male, female) 20,18 26, 33 22, 30 6, 11 0.64 SE (D) 0.00 (0.00, 0.00) -1.50 (-2.25, -0.75) -4.00 (-4.75, -3.50) -6.75 (-7.40, -6.25) < 0.001 a, b, c, d, e TMH (mm) 0.15 (0.12, 0.19) 0.16 (0.14, 0.19) 0.14 (0.11, 0.16) 0.15 (0.12, 0.20) < 0.05 d NIBUT-f (s) 14.34 (6.85, 20.31) 10.90 (7.14, 15.87) 7.68 (5.18, 13.35) 5.04 (4.15, 11.09) < 0.05 c, e NIBUT-avg(s) 15.69 (9.48, 21.98) 14.74 (11.24, 18.38) 11.01 (8.01, 16.97) 5.90 (4.96, 12.41) < 0.05 c, e Classification 0 (0, 1) 0 (0, 1) 1 (0, 1) 2 (1, 2) < 0.05 c, e MG (score) 0 (0, 1) 1 (0, 1) 0 (0, 1) 1 (0, 1) 0.348 AL (mm) 23.54 (23.10, 24.20) 24.44 (23.80 24.89) 25.12 (24.68, 25.80) 25.60 (24.89, 26.24) < 0.001 a, b, c, d, e K1 (D) 41.98 (41.30, 43.19) 42.45 (41.77, 43.49) 43.02 (42.06, 43.37) 43.66 (42.44, 44.94) < 0.05 c K2 (D) 43.30 (42.29, 44.70) 43.72 (42.83, 45.00) 44.21 (43.34, 45.21) 45.49 (44.00, 46.04) < 0.05 b, c, e P values were obtained from the Kruskal–Wallis test. P values for the comparison of ( a ) the NMG with the LMG, ( b ) the NMG with the MMG, ( c ) the NMG with the HMG, ( d ) the LMG with the MMG, ( d ) the LMG with the HMG and ( e ) the MMG with the HMG. A P value < 0.05 was considered to indicate statistical significance. NMG= nonmyopia group, LMG = low myopia group, MMG= moderate myopia group, HMG= high myopia group, SE= spherical equivalent, D= diopters, TMH= tear meniscus height, NIBUT-f= first break-up time of the tear film, NIBUT-avg= average time of all tear film break-up incidents, MG= meibomian gland, AL= axial length, K1 = flat keratometry, K2 = steep keratometry. 3.3 Comparison of ocular surface parameters between males and females in different myopia groups We further compared the ocular surface parameters of male and female children in different myopia groups. As shown in Table 3 , there were no significant differences among the ocular surface parameters in the NMG, LMG or MMG. However, in the HMG, the tear secretion amount and tear film stability in girls were significantly lower than those in boys, whereas there were no significant differences in the other parameters. Table 3 Parameters of the ocular surface in males and females in different myopia groups. Parameter SE (D) TMH (mm) NIBUT-f (s) NIBUT-avg(s) Classification MG (score) NMG male 0.00 (0.00, 0.00) 0.15 (0.15, 0.19) 16.64 (9.56, 20.98) 19.66 (14.66, 22.15) 0 (0, 1) 1 (0, 1) female 0.00 (0.00, 0.00) 0.16 (0.12, 0.19) 12.37 (4.98, 19.74) 13.89 (7.21, 21.20) 0 (0, 2) 0 (0, 1) P value 0.99 0.70 0.32 0.16 0.32 0.16 LMG male -1.38 (-1.88, -0.50) 0.16 (0.15, 0.19) 10.07 (5.30, 12.89) 12.50 (9.51, 18.41) 1 (0, 1) 1 (0, 1) female -1.50 (-2.50, -1.13) 0.15 (0.12, 0.19) 11.47 (9.37, 16.35) 14.97 (11.88, 18.45) 0 (0, 1) 0 (0, 1) P value 0.19 0.47 0.11 0.36 0.44 0.21 MMG male -3.75 (-4.75, -3.50) 0.15 (0.12, 0.17) 8.03 (5.30, 14.77) 9.98 (7.53, 19.98) 1 (0, 1) 1 (0, 1) female -4.00 (-4.81, -3.50) 0.14 (0.11, 0.16) 7.39 (5.02, 12.15) 11.24 (8.05, 15.37) 1 (0, 1) 0 (0, 1) P value 0.58 0.16 0.45 0.95 0.40 0.09 HMG male -6.38 (-6.81, -6.00) 0.20 (0.19, 0.20) 9.98 (5.17, 15.02) 9.98 (6.64, 19.25) 0.50 (0, 2) 1 (0, 1) female -7.00 (-7.75, -6.50) 0.14 (0.12, 0.16) 4.40 (3.31, 9.94) 5.32 (4.30, 10.90) 2 (1, 2) 1 (0, 1) P value 0.06 < 0.05 < 0.05 0.03 0.15 0.88 P values were obtained from the Mann–Whitney U test. A P value < 0.05 was considered to indicate statistical significance. NMG= nonmyopia group, LMG = low myopia group, MMG= moderate myopia group, HMG= high myopia group, SE= spherical equivalent, D= diopters, TMH= tear meniscus height, NIBUT-f = the first break-up time of the tear film, NIBUT-avg = the average time of all tear film break-up incidents, MG= meibomian gland. 3.4 Correlation analysis between ocular surface parameters and myopia parameters Spearman correlation analysis (Table 4 ) revealed that TMH, NIBUT-f, and NIBUT-avg were positively correlated with SE ( P < 0.05), and NIBUT-f and NIBUT-avg were negatively correlated with AL ( P < 0.05). Moreover, the classification was negatively and positively correlated with the SE and AL, respectively ( P < 0.05). Interestingly, the results also revealed a negative correlation between TMH and K2 ( P 0.05). Unary linear regression was further used to analyze the relationships between ocular surface parameters and myopia parameters, as shown in Fig. 2 . NIBUT-f and NIBUT-avg were positively correlated with SE ( P < 0.01), and NIBUT-f and NIBUT-avg were negatively correlated with AL ( P < 0.01). Table 4 Correlation analyses between ocular surface parameters and myopia parameters Parameter SE (D) AL (mm) K1 (D) K2 (D) r P r P r P r P TMH (mm) 0.20 0.01 -0.08 0.34 -0.13 0.09 -0.17 0.03 NIBUT-f (s) 0.30 < 0.01 -0.23 < 0.01 -0.08 0.32 -0.07 0.35 NIBUT-avg(s) 0.31 < 0.01 -0.21 < 0.01 -0.13 0.11 -0.13 0.11 Classification -0.33 < 0.01 0.24 < 0.01 0.10 0.20 0.11 0.18 MG (score) -0.00 0.98 0.04 0.661 -0.01 0.87 -0.00 0.98 R, Spearman's correlation analysis. P , Pearson's correlation analysis significance value. A P value < 0.05 was considered to indicate statistical significance. SE= spherical equivalent, D= diameter, AL= axial length, K1 = flat keratometry, K2 = steep keratometry, TMH= tear meniscus height, NIBUT-f = the first break-up time of the tear film, NIBUT-avg = the average time of all tear film break-up incidents, MG= meibomian gland. 4. Discussion Myopia is the main cause of visual impairment worldwide, and it has increased significantly among school-aged children in China in recent years[ 23 , 24 ]. In addition, as electronic devices have become easier to use, children’s exposure to electronic screens has gradually increased, and the risk of developing myopia and DED has increased significantly[ 25 – 27 ]. Recent studies have shown that DED leads to a decrease in the stability of the tear film, which in turn affects visual clarity in children[ 6 ]. However, there is still a lack of research on whether there is a correlation between adolescent myopia and DED. Given the limitations of children's coordination and comprehension abilities, this study used ocular surface comprehensive analyzer to conduct an in-depth analysis of the correlation between DED and myopia in children. The adoption of this research method not only improves the accuracy and objectivity of data collection but also helps to comprehensively understand the potential connection between myopia and DED. This study is expected to provide more accurate guidance and suggestions for the protection of children's eye health. Since myopia and DED are affected by confounders such as screen time and visual behavior, participants unexposed to electronic devices every morning were selected for examination. Our results revealed that dynamic tear film stability gradually deteriorated with increasing degree of myopia in participants. The ocular surface parameters (NIBUT-f, NIBUT-avg and classification) in the HMG were significantly different from those in the NMG and LMG. The amount of tear secretion (TMH) significantly differed between the MMG and LMG. However, there were no significant differences in the MG scores among the groups. In addition, the K1 and K2 values in the HMG were significantly greater than those in the NMG, and the K2 values in the MMG significantly differed from those in the NMG and HMG. First, participants with DED may exhibit a shorter TBUT and more severe aberrations, which in turn lead to increased myopia[ 28 ]. Second, participants with moderate and high myopia may have further impacts on their ocular microenvironment and tear film stability due to their greater visual demands. Studies have shown that subjects with refractive errors are more likely to suffer from DED when glasses are used frequently[ 29 ], which is consistent with our research findings. Third, it may be related to changes in corneal curvature. Participants with high myopia may experience changes in the ocular microenvironment due to axial elongation and changes in eye shape, which can affect the stability of the tear film[ 30 ]. Fourth, adolescents with high myopia often exhibit poor tear film quality, which may be due to environmental factors. Specifically, they tend to spend less outdoor time, engage in closer work, and have longer exposure to artificial air conditioning, which can lead to more severe symptoms of dry eyes[ 31 ]. Myopia and dry eye may affect each other. However, this study did not establish a direct causal relationship between myopia and DED. Therefore, future research must adopt higher-quality research designs to further explore the relationships and mechanisms between myopia and DED. Moreover, participants with myopia and DED should also receive sufficient attention and timely treatment to improve their visual quality and quality of life. Studies have shown that DED affects women more frequently than men do, especially after menopause[ 32 – 34 ]. To further assess whether dry eye in participants with myopia is related to sex, comparative analyses of ocular surface parameters were performed between males and females in groups with different degrees of myopia. Our results revealed that the TMH, NIBUT-f and NIBUT-avg in girls were significantly lower than those in boys ( P < 0.05). Previous research has suggested that changes in sex hormones may be important factors leading to tear film disorders[ 35 , 36 ]. However, this study did not reveal significant differences in ocular surface parameters between females and males in the NMG, LMG, or MMG of adolescents. These findings suggest that the degree of myopia may be an important factor affecting the relationship between sex and DED. To our knowledge, this relationship has never been discussed in the literature before. Although this study provides some interesting findings, there are still many unknown areas that need further exploration. Notably, the sample size of high myopia participants in this study was relatively small, which may have had some impact on the universality and accuracy of the results. In summary, this study reveals the complex relationship between myopia and DED, providing new perspectives and ideas for future research. To further clarify whether there was an association between myopia and dry eye, Spearman's correlation and linear regression analyses were conducted. As shown in Table 4 and Fig. 2 , TMH, NIBUT-f and NIBUT-avg were positively correlated with SE ( P < 0.05), and NIBUT-f and NIBUT-avg were negatively correlated with AL ( P < 0.05). The DED grade was negatively correlated with SE and positively correlated with AL. Previous studies have also shown that there is a certain association between dry eye and myopia, but the specific mechanism is still unclear; this may be because when myopic eyeballs are elongated, changes in the front surface of the cornea may increase susceptibility to dryness[ 37 , 38 ]. DED may also cause reduced vision through various mechanisms, thereby increasing the degree of myopia in participants[ 39 ]. Interestingly, our results also revealed a negative correlation between TMH and K2 ( P < 0.05). Although the results are interesting, the reasons for this phenomenon are not yet clear, and more supporting data are needed. 5. Conclusion In summary, these findings indicate a significant correlation between the severity of myopia and DED in pediatric populations. High myopia was associated with impaired tear film stability and decreased tear secretion, with female participants demonstrating more significant ocular surface alterations than male participants. This research provides precise guidance and recommendations for the protection of children's eye health. However, further research is warranted to form clinical recommendations and explore the specific mechanisms of the interaction between myopia and DED in the future. Declarations Statement of Ethics This study was approved by the Ethics Committee of Eye Hospital Affiliated with Nanchang University, Jiangxi, China (Grant No. YLP202012013) and was conducted in accordance with the Declaration of Helsinki. In this study, all participants provided written informed consent. Conflict of interest statement The authors have no conflicting interests to declare. Funding This work was supported by grants from the Natural Science Foundation Youth Fund Project Of Jiangxi Province (20252BAC200497); National Natural Science Foundation incubation project of The Second Affiliated Hospital of Nanchang University (2023YNFY12003); and the Science and Technology Program of Jiangxi Provincial Health Commission. Author Contributions Y. C., and F. W. designed the study. H.Y. and H.H. recruited the participants and collected the data. F. Z., Y. L., H. H., S. W. and Y. S. analyzed the data; Y. C wrote the initial draft; and F. W. revised the manuscript. All authors read and approved the final version of the manuscript. Data availability statement The datasets generated and analyzed during the current study are not publicly available owing to ongoing research utilization but may be made available from the corresponding author upon reasonable request. References Saw SM, Matsumura S, Hoang QV. Prevention and management of myopia and myopic pathology. 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Impacts of gender and age on meibomian gland in aged people using artificial intelligence. Front Cell Dev Biol. 2023;11:1199440. https://doi.org/10.3389/fcell.2023.1199440 . Trindade M, Castro DVJ, Ayub G, Grupenmacher AT, Gomes HD, Viturino M, et al. Ocular manifestations and neuropathy in type 2 diabetes patients with charcot arthropathy. Front Endocrinol (Lausanne). 2021;12:585823. https://doi.org/10.3389/fendo.2021.585823 . Li DL, Yin ZJ, Li YZ, Zheng YJ, Qin Y, Liang G, et al. Identification of high-risk patterns of myopia in Chinese students based on four major behavioral risk factors: A latent class analysis. BMC Public Health. 2023;23(1):1378. https://doi.org/10.1186/s12889-023-15963-7 . Fan Q, Wang H, Jiang Z. Axial length and its relationship to refractive error in Chinese university students. Cont Lens Anterior Eye. 2022;45(2):101470. https://doi.org/10.1016/j.clae.2021.101470 . Tao L, Wang C, Peng Y, Xu M, Wan M, Lou J, et al. Correlation between increase of axial length and height growth in chinese School-Age children. Front Public Health. 2021;9:817882. https://doi.org/10.3389/fpubh.2021.817882 . Zhao J, Yu Y, Li Y, Li F, Zhang Z, Jian W, et al. Development and validation of predictive models for myopia onset and progression using extensive 15-year refractive data in children and adolescents. J Transl Med. 2024;22(1):289. https://doi.org/10.1186/s12967-024-05075-0 . Yang GY, Huang LH, Schmid KL, Li CG, Chen JY, He GH, et al. Associations between screen exposure in early life and myopia amongst chinese preschoolers. Int J Environ Res Public Health. 2020;17(3). https://doi.org/10.3390/ijerph17031056 . Wong CW, Tsai A, Jonas JB, Ohno-Matsui K, Chen J, Ang M, et al. Digital screen time during the COVID-19 pandemic: Risk for a further myopia boom? Am J Ophthalmol. 2021;223:333–7. https://doi.org/10.1016/j.ajo.2020.07.034 . Elhusseiny AM, Eleiwa TK, Yacoub MS, George J, Elsheikh RH, Haseeb A, et al. Relationship between screen time and dry eye symptoms in pediatric population during the COVID-19 pandemic. Ocul Surf. 2021;22:117–9. https://doi.org/10.1016/j.jtos.2021.08.002 . Hazra D, Yotsukura E, Torii H, Mori K, Maruyama T, Ogawa M, et al. Relation between dry eye and myopia based on tear film breakup time, higher order aberration, choroidal thickness, and axial length. Sci Rep. 2022;12(1):10891. https://doi.org/10.1038/s41598-022-15023-x . Nichols JJ, Ziegler C, Mitchell GL, Nichols KK. Self-reported dry eye disease across refractive modalities. Invest Ophthalmol Vis Sci. 2005;46(6):1911–4. https://doi.org/10.1167/iovs.04-1294 . Hiraoka T, Asano H, Ogami T, Nakano S, Okamoto Y, Yamada Y, et al. Influence of Dry Eye Disease on the Measurement Repeatability of Corneal Curvature Radius and Axial Length in Patients with Cataract. J Clin Med. 2022;11(3):710. https://doi.org/10.3390/jcm11030710 . Zou X, Nagino K, Yee A, Midorikawa-Inomata A, Eguchi A, Nakao S, et al. Relationship between dry eye disease and myopia: A systematic review and meta-analysis. Heliyon. 2024;10(19):e38674. https://doi.org/10.1016/j.heliyon.2024.e38674 . Clayton JA. Dry eye. N Engl J Med. 2018;378(23):2212–23. https://doi.org/10.1056/NEJMra1407936 . Vehof J, Sillevis SN, Nibourg SA, Hammond CJ. Sex differences in clinical characteristics of dry eye disease. Ocul Surf. 2018;16(2):242–8. https://doi.org/10.1016/j.jtos.2018.01.001 . Li W, Lin MC. Sex disparity in how pain sensitivity influences dry eye symptoms. Cornea. 2019;38(10):1291–8. https://doi.org/10.1097/ICO.0000000000002050 . Craig JP, Wang M, Ambler A, Cheyne K, Wilson GA. Characterising the ocular surface and tear film in a population-based birth cohort of 45-year old New Zealand men and women. Ocul Surf. 2020;18(4):808–13. https://doi.org/10.1016/j.jtos.2020.08.005 . Boga A, Stapleton F, Chapman M, Golebiowski B. Effects of elevated serum estrogen on dry eye in women undergoing in vitro fertilisation. Ocul Surf. 2023;29:511–20. https://doi.org/10.1016/j.jtos.2023.06.015 . Ilhan N, Ilhan O, Ayhan TE, Daglioglu MC, Coskun M, Parlakfikirer N et al. Is there a relationship between pathologic myopia and dry eye syndrome? Cornea. 2014;33(2):169 – 71. https://doi.org/10.1097/ICO.0000000000000033 Xu L, Wang YX, Guo Y, You QS, Jonas JB. Prevalence and associations of steep cornea/keratoconus in Greater Beijing. The Beijing Eye Study. PLoS ONE. 2012;7(7):e39313. https://doi.org/10.1371/journal.pone.0039313 . Morthen MK, Magno MS, Utheim TP, Snieder H, Jansonius N, Hammond CJ, et al. The vision-related burden of dry eye. Ocul Surf. 2022;23:207–15. https://doi.org/10.1016/j.jtos.2021.10.007 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 09 May, 2026 Reviews received at journal 03 May, 2026 Reviewers agreed at journal 22 Apr, 2026 Reviewers invited by journal 20 Apr, 2026 Editor invited by journal 16 Apr, 2026 Editor assigned by journal 15 Apr, 2026 Submission checks completed at journal 15 Apr, 2026 First submitted to journal 14 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9413350","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":630084322,"identity":"f05e3e22-ce41-41c6-b90e-65ba6232f707","order_by":0,"name":"Yili Chang","email":"","orcid":"","institution":"Affiliated Eye Hospital of Nanchang University, Nanchang University School of Ophthalmology \u0026 Optometry","correspondingAuthor":false,"prefix":"","firstName":"Yili","middleName":"","lastName":"Chang","suffix":""},{"id":630084323,"identity":"cbc71eea-7460-4417-a500-43392e63c989","order_by":1,"name":"Fubao Zhang","email":"","orcid":"","institution":"The First Hospital of Nanchang","correspondingAuthor":false,"prefix":"","firstName":"Fubao","middleName":"","lastName":"Zhang","suffix":""},{"id":630084324,"identity":"3a1071e6-a5f6-42e4-b81c-c4618d512912","order_by":2,"name":"Yanping Li","email":"","orcid":"","institution":"Affiliated Eye Hospital of Nanchang University, Nanchang University School of Ophthalmology \u0026 Optometry","correspondingAuthor":false,"prefix":"","firstName":"Yanping","middleName":"","lastName":"Li","suffix":""},{"id":630084326,"identity":"36a86c9f-6075-45cc-a5f3-d90fece311df","order_by":3,"name":"Haijian Hu","email":"","orcid":"","institution":"The Second Affiliated Hospital of Nanchang University","correspondingAuthor":false,"prefix":"","firstName":"Haijian","middleName":"","lastName":"Hu","suffix":""},{"id":630084327,"identity":"332972f4-e8c2-4859-8180-cb49351bfa6e","order_by":4,"name":"Shuifeng Wang","email":"","orcid":"","institution":"Affiliated Eye Hospital of Nanchang University, Nanchang University School of Ophthalmology \u0026 Optometry","correspondingAuthor":false,"prefix":"","firstName":"Shuifeng","middleName":"","lastName":"Wang","suffix":""},{"id":630084330,"identity":"2c23ddda-ee56-4661-ba78-bd1fdd7f7a5c","order_by":5,"name":"Hai He","email":"","orcid":"","institution":"Affiliated Eye Hospital of Nanchang University, Nanchang University School of Ophthalmology \u0026 Optometry","correspondingAuthor":false,"prefix":"","firstName":"Hai","middleName":"","lastName":"He","suffix":""},{"id":630084331,"identity":"06023f4f-2bd1-4418-87e1-59088361fe0e","order_by":6,"name":"Yuning Song","email":"","orcid":"","institution":"Affiliated Eye Hospital of Nanchang University, Nanchang University School of Ophthalmology \u0026 Optometry","correspondingAuthor":false,"prefix":"","firstName":"Yuning","middleName":"","lastName":"Song","suffix":""},{"id":630084332,"identity":"f9528c5f-c441-44fd-a985-619a1e309e7c","order_by":7,"name":"Han Yan","email":"","orcid":"","institution":"Affiliated Eye Hospital of Nanchang University, Nanchang University School of Ophthalmology \u0026 Optometry","correspondingAuthor":false,"prefix":"","firstName":"Han","middleName":"","lastName":"Yan","suffix":""},{"id":630084334,"identity":"6559a4ec-5ce1-4f66-88db-2b566fe8da3c","order_by":8,"name":"Feifei Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAsklEQVRIiWNgGAWjYBAC9uYDDAc+GNjIsbG3HyBOC8+xBMaHMyrSjPl4ziQQrYXZmOfM4cR5Eg4GRGph4zGTnNmWlt4mwZDA8KNiG3FaJD622eS2STceYOw5c5uwFnv53m0gW3LbZA4kMDO2EaGFh413mzRv2+F0NokEA6K1bAZ5P4EULfwfQYFs2AYM5INE+YWHjS0BFJXy8u3tBx/8qCBCCwo4QKL6UTAKRsEoGAW4AABSUjwDi1qNyAAAAABJRU5ErkJggg==","orcid":"","institution":"The Second Affiliated Hospital of Nanchang University","correspondingAuthor":true,"prefix":"","firstName":"Feifei","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2026-04-14 09:25:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9413350/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9413350/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108027825,"identity":"0490e2c9-e766-415d-be6c-d4b8469dc652","added_by":"auto","created_at":"2026-04-28 15:26:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":523264,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOcular surface analyzer examination.\u003c/strong\u003e (A) Tear meniscus height, (B) meibomian gland imaging, (C) noninvasive tear film break-up time.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9413350/v1/367bd72fa3b256624a9fce76.png"},{"id":108027826,"identity":"9993248b-4100-45fc-a296-3854244e5696","added_by":"auto","created_at":"2026-04-28 15:26:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":236134,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eScatter diagram showing the linear relationships between SE and AL with the NIBUT.\u003c/strong\u003e (A) NIBUT-f versus SE. (B) NIBUT-avg versus SE. (C) NIBUT-f versus AL. (D) NIBUT-avg versus AL. A \u003cem\u003eP\u003c/em\u003e value \u0026lt;0.05 was considered to indicate statistical significance.\u003c/p\u003e\n\u003cp\u003eSE= spherical equivalent, D= dioptre, AL= axial length, NIBUT-f= the first break-up time of the tear film, NIBUT-avg = the average time of all tear film break-up incidents.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9413350/v1/a37188c1508392d9f3309050.png"},{"id":108182043,"identity":"6ae044e4-83f9-45d9-9cce-5c7671cfbf73","added_by":"auto","created_at":"2026-04-30 08:59:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1218944,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9413350/v1/046a07f6-7cbf-4601-a80e-8cb19cc2aadd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Associations between Myopia and Dry Eye Disease in Children Subjects","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eMyopia is one of the most common eye diseases worldwide, and its incidence in young people in China is 90%-95%[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. When the eye is elongated, the image of a distant object is focused in front of the retina through the refractive system, resulting in blurred distance vision[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The tear film, located on the foremost surface of the eye, plays an important role in maintaining clear vision and is an important component of the refractive system[\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, few studies have discussed the relationship between the degree of myopia and tear film stability in participants.\u003c/p\u003e \u003cp\u003eDry eye disease (DED), a multifactorial ocular surface disease characterized by the loss of tear film homeostasis, is accompanied by eye discomfort, visual impairment, and other ocular symptoms[\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The incidence and severity of DED increase with age[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and many doctors may neglect to check young participants for DED. However, in recent years, with the widespread use of visual display units and the increasing burden of schoolwork, the incidence of DED in children has increased annually[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. DED may influence children's daily factivities and could have implications for their overall quality of life.\u003c/p\u003e \u003cp\u003eMyopia is the most common eye disease among children. However, whether there is a correlation between myopia and DED remains unclear. The Keratograph 5 M ocular surface analyzer (OCULUS Optikger\u0026auml;te GmbH, Wetzlar, Germany) is a noninvasive ocular surface examination instrument capable of providing accurate and objective imaging of the ocular surface, making it a suitable tool for evaluating ocular conditions in children. Most children demonstrate a high degree of cooperation with researchers during examinations, and all tests are conducted by the same operator, ensuring the reliability of the results[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Therefore, in this study, an ocular surface analyzer was utilized to assess the correlations between DED and myopia in children. To the best of our knowledge, this is the first study to systematically compare ocular surface parameters across varying degrees of myopia in pediatric populations. This finding may contribute to a better understanding of the potential interactions between myopia and DED in pediatric populations while also raising awareness among parents about the importance of children's ocular health.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Subjects\u003c/h2\u003e \u003cp\u003eThe study was conducted from August 2021 to September 2023 at the Affiliated Eye Hospital of Nanchang University, and 83 participants (166 eyes) aged 7\u0026ndash;15 years were recruited as research subjects. The research protocol was designed according to the Declaration of Helsinki and approved by the Ethics Committee of the Eye Hospital of Nanchang University. All participants and their legal guardians were thoroughly informed about the study objectives through oral and written explanations. Written informed consent was obtained from all legal guardians, and participant assent was acquired when appropriate. Experienced ophthalmologists conducted comprehensive eye examinations for all participants, including vision assessment, slit lamp anterior segment examination, and direct ophthalmoscopic fundus examination.\u003c/p\u003e \u003cp\u003eAll participants were examined after ciliary muscle paralysis to determine their refractive status. On the basis of spherical equivalent (SE), the participants were divided into a nonmyopia group (NMG, \u0026minus;\u0026thinsp;0.5D\u0026thinsp;\u0026lt;\u0026thinsp;SE\u0026thinsp;\u0026le;\u0026thinsp;+\u0026thinsp;0.5D), a low myopia group (LMG, \u0026minus;\u0026thinsp;3.0D\u0026thinsp;\u0026lt;\u0026thinsp;SE\u0026thinsp;\u0026le;\u0026thinsp;\u0026minus;\u0026thinsp;0.5D), a moderate myopia group (MMG, \u0026minus;\u0026thinsp;6.0D\u0026thinsp;\u0026lt;\u0026thinsp;SE\u0026thinsp;\u0026le;\u0026thinsp;\u0026minus;\u0026thinsp;3.0D), and a high myopia group (HMG, SE\u0026thinsp;\u0026le;\u0026thinsp;\u0026minus;\u0026thinsp;6.0D)[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Participants were required to meet the following inclusion criteria: aged between 7 and 15 years, stable fixation in both eyes, cooperative during examinations, binocular corrected visual acuity\u0026thinsp;\u0026ge;\u0026thinsp;1.0, normal intraocular pressure (10\u0026ndash;21 mmHg), and transparent ocular media. The exclusion criteria were as follows: allergic conjunctivitis, a history of eye surgery or trauma, strabismus or abnormal eye movements, recent use (within the past month) of corneal contact lenses or topical eye drops, systemic diseases known to affect ocular health or keratoconjunctivitis affecting the tear film, acute eye infections, thermal burns or chemical injuries to the eye, and a diagnosis of dry eye syndrome requiring ongoing eye drops or physical therapy. These criteria ensured that the study population was free from confounding conditions, thereby maintaining the integrity and validity of the results.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Keratograph 5 M ocular surface analyzer examination\u003c/h2\u003e \u003cp\u003eOcular surface evaluation included tear meniscus height (TMH), noninvasive tear film break-up time (NIBUT), and Meibomian Gland (MG) imaging (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), all of which were performed via a noninvasive ocular surface analyzer. All examinations were performed by the same experienced and masked physician every morning, and the subject was confirmed not to be exposed to any electronic products or topical eye drops prior to the examination.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.2.1 Tear meniscus height\u003c/h2\u003e \u003cp\u003eAfter adjusting the jaw and forehead positions, the subject focused on the front central point, and an image was obtained after blinking. The random software caliper tool was used to measure the TMH below the center of the cornea[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.2.2 Noninvasive tear film break-up time measurement\u003c/h2\u003e \u003cp\u003eThe assessor adjusted the Keratograph 5 M to the NIBUT measurement mode. The assessment of Placido concentric rings during continuous eye-opening intervals included the first tear film break-up time (NIBUT-f) and the average time of all tear film break-up incidents (NIBUT-avg), and the tear film break-up time was classified from 1 to 4 according to severity[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.2.3 Imaging and scoring of the medial gland\u003c/h2\u003e \u003cp\u003eTo obtain MG infrared images, the upper and lower eyelids were exposed, and a Keratograph 5 M was used for noncontact infrared imaging of the lower and upper eyelids. The degree of loss of MGs in each eyelid was scored as the meiboscore according to the following criteria: 0 (no loss of MGs); 1 (loss of MGs over less than 1/3 of the total area); 2 (loss of MGs over 1/3 to 2/3 of the total area); and 3 (loss of MGs over more than 2/3 of the total area). The upper and lower eyelid scores of each eye were summed, and the total score ranged from 0 to 6[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Noncontact partial coherent laser interferometer\u003c/h2\u003e \u003cp\u003eThe degree of myopia is closely related to the axial length (AL) and curvature of the eye. Before pupillary dilatation of all the participants, a noncontact partial coherent laser interferometer (IOL Master; Carl Zeiss Meditec, Oberkochen, Germany) was used to assess AL, flat keratometry (K1), and steep keratometry (K2)[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. As recommended by Fan Q et al.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], multiple valid measurements were obtained to improve data reliability, and their average values were used for statistical analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Statistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed via SPSS version 24.0, and all variables are expressed as the means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations (SDs). The Shapiro\u0026ndash;Wilk test was used to test for a normal distribution. For the data that did not conform to a normal distribution, the Kruskal\u0026ndash;Wallis test was used to compare each parameter between the groups. The Mann\u0026ndash;Whitney U test was used to compare two groups. Spearman\u0026rsquo;s correlation coefficient analysis was also performed. \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to indicate statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Demographics and clinical characteristics of the study population\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics and clinical characteristics of the study population\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll subjects\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.00 (10.00, 13.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEyes (male, female)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74, 92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSE (D)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-2.25 (-4.00, -0.50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTMH (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.15 (0.12, 0.19)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNIBUT-f (s)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.98 (5.32 15.87)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNIBUT-avg(s)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.50 (8.00, 18.76)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClassification\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMG (score)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAL (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.57 (23.87, 25.14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eK1 (D)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.70 (41.82, 43.44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eK2 (D)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.00 (42.95, 45.11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA total of 83 participants (166 eyes), including 37 males and 46 females, participated in this study. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the demographic and clinical characteristics of the study population.\u003c/p\u003e \u003cp\u003eSE= spherical equivalent, D= diopters, TMH= tear meniscus height, NIBUT-f\u0026thinsp;=\u0026thinsp;the first break-up time of the tear\u003c/p\u003e \u003cp\u003efilm, NIBUT-avg\u0026thinsp;=\u0026thinsp;the average time of all tear film break-up incidents, MG= meibomian gland, AL= axial length, K1\u0026thinsp;=\u0026thinsp;flat keratometry, K2\u0026thinsp;=\u0026thinsp;steep keratometry.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Comparison of clinical characteristics among participants with different degrees of myopia\u003c/h2\u003e \u003cp\u003eThe participants were further divided into the NMG, which included 38 eyes (22.89%); the LMG, which included 59 eyes (35.54%); the MMG, which included 52 eyes (31.33%); and the HMG, which included 17 eyes (10.24%). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the clinical features of each group. There was no significant difference among the groups in terms of sex or age. For the ocular surface parameters (NIBUT-f, NIBUT-avg, and classification) of each group, the dynamic tear film stability gradually deteriorated with increasing degree of myopia. Compared with both the NMG and the LMG, the HMG exhibited significant differences. There was a significant difference in the amount of tear secretion (TMH) between the MMG and LMG; however, there was no statistically significant difference between the other groups. However, there were no significant differences in the MG among the groups. In addition, there were significant differences in the degrees of myopia and ALs among all groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), but there were no significant differences between the MMG and HMG. K1 and K2 in the HMG were significantly greater than those in the NMG, and K2 in the MMG significantly differed from those in the NMG and HMG.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEye parameters of subjects with different degrees of myopia\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNMG\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLMG\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMMG\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHMG\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.00 (9.00, 13.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (9.00, 13.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.00 (10.00, 13.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.00 (12.00, 13.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEyes (male, female)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20,18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26, 33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22, 30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6, 11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSE (D)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.00 (0.00, 0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.50 (-2.25, -0.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-4.00 (-4.75, -3.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-6.75 (-7.40, -6.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e \u003csup\u003e\u003cb\u003ea, b, c, d, e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTMH (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.15 (0.12, 0.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.16 (0.14, 0.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.14 (0.11, 0.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.15 (0.12, 0.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.05\u003c/b\u003e \u003csup\u003e\u003cb\u003ed\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNIBUT-f (s)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.34 (6.85, 20.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.90 (7.14, 15.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.68 (5.18, 13.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.04 (4.15, 11.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.05\u003c/b\u003e \u003csup\u003e\u003cb\u003ec, e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNIBUT-avg(s)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.69 (9.48, 21.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.74 (11.24, 18.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.01 (8.01, 16.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.90 (4.96, 12.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.05\u003c/b\u003e \u003csup\u003e\u003cb\u003ec, e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClassification\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (1, 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.05\u003c/b\u003e \u003csup\u003e\u003cb\u003ec, e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMG (score)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.348\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAL (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.54 (23.10, 24.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.44 (23.80 24.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.12 (24.68, 25.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25.60 (24.89, 26.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e \u003csup\u003e\u003cb\u003ea, b, c, d, e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eK1 (D)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.98 (41.30, 43.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.45 (41.77, 43.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43.02 (42.06, 43.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43.66 (42.44, 44.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.05\u003c/b\u003e \u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eK2 (D)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43.30 (42.29, 44.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.72 (42.83, 45.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44.21 (43.34, 45.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45.49 (44.00, 46.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.05\u003c/b\u003e \u003csup\u003e\u003cb\u003eb, c, e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eP\u003c/em\u003e values were obtained from the Kruskal\u0026ndash;Wallis test. \u003cem\u003eP\u003c/em\u003e values for the comparison of (\u003csup\u003ea\u003c/sup\u003e) the NMG with the LMG, (\u003csup\u003eb\u003c/sup\u003e) the NMG with the MMG, (\u003csup\u003ec\u003c/sup\u003e) the NMG with the HMG, (\u003csup\u003ed\u003c/sup\u003e) the LMG with the MMG, (\u003csup\u003ed\u003c/sup\u003e) the LMG with the HMG and (\u003csup\u003ee\u003c/sup\u003e) the MMG with the HMG. A \u003cem\u003eP\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to indicate statistical significance.\u003c/p\u003e \u003cp\u003eNMG= nonmyopia group, LMG\u0026thinsp;=\u0026thinsp;low myopia group, MMG= moderate myopia group, HMG= high myopia group, SE= spherical equivalent, D= diopters, TMH= tear meniscus height, NIBUT-f= first break-up time of the tear film, NIBUT-avg= average time of all tear film break-up incidents, MG= meibomian gland, AL= axial length, K1\u0026thinsp;=\u0026thinsp;flat keratometry, K2\u0026thinsp;=\u0026thinsp;steep keratometry.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Comparison of ocular surface parameters between males and females in different myopia groups\u003c/h2\u003e \u003cp\u003eWe further compared the ocular surface parameters of male and female children in different myopia groups. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, there were no significant differences among the ocular surface parameters in the NMG, LMG or MMG. However, in the HMG, the tear secretion amount and tear film stability in girls were significantly lower than those in boys, whereas there were no significant differences in the other parameters.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParameters of the ocular surface in males and females in different myopia groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE (D)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTMH (mm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNIBUT-f (s)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNIBUT-avg(s)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eClassification\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMG (score)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eNMG\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.00 (0.00, 0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.15 (0.15, 0.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.64 (9.56, 20.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e19.66 (14.66, 22.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.00 (0.00, 0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.16 (0.12, 0.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.37 (4.98, 19.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13.89 (7.21, 21.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0 (0, 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e \u003cb\u003evalue\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eLMG\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-1.38 (-1.88, -0.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.16 (0.15, 0.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10.07 (5.30, 12.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12.50 (9.51, 18.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-1.50 (-2.50, -1.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.15 (0.12, 0.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11.47 (9.37, 16.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14.97 (11.88, 18.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e \u003cb\u003evalue\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eMMG\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-3.75 (-4.75, -3.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.15 (0.12, 0.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8.03 (5.30, 14.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9.98 (7.53, 19.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-4.00 (-4.81, -3.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.14 (0.11, 0.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.39 (5.02, 12.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11.24 (8.05, 15.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e \u003cb\u003evalue\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eHMG\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-6.38 (-6.81, -6.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.20 (0.19, 0.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9.98 (5.17, 15.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9.98 (6.64, 19.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.50 (0, 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-7.00 (-7.75, -6.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.14 (0.12, 0.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.40 (3.31, 9.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.32 (4.30, 10.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (1, 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (0, 1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e \u003cb\u003evalue\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eP\u003c/em\u003e values were obtained from the Mann\u0026ndash;Whitney U test. A \u003cem\u003eP\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to indicate statistical significance.\u003c/p\u003e \u003cp\u003eNMG= nonmyopia group, LMG\u0026thinsp;=\u0026thinsp;low myopia group, MMG= moderate myopia group, HMG= high myopia group, SE= spherical equivalent, D= diopters, TMH= tear meniscus height, NIBUT-f\u0026thinsp;=\u0026thinsp;the first break-up time of the tear film, NIBUT-avg\u0026thinsp;=\u0026thinsp;the average time of all tear film break-up incidents, MG= meibomian gland.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Correlation analysis between ocular surface parameters and myopia parameters\u003c/h2\u003e \u003cp\u003eSpearman correlation analysis (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) revealed that TMH, NIBUT-f, and NIBUT-avg were positively correlated with SE (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and NIBUT-f and NIBUT-avg were negatively correlated with AL (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Moreover, the classification was negatively and positively correlated with the SE and AL, respectively (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Interestingly, the results also revealed a negative correlation between TMH and K2 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, no significant differences were detected among the other parameters (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Unary linear regression was further used to analyze the relationships between ocular surface parameters and myopia parameters, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. NIBUT-f and NIBUT-avg were positively correlated with SE (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and NIBUT-f and NIBUT-avg were negatively correlated with AL (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation analyses between ocular surface parameters and myopia parameters\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSE (D)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eAL (mm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eK1 (D)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eK2 (D)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTMH (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNIBUT-f (s)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNIBUT-avg(s)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClassification\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMG (score)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.661\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eR, Spearman's correlation analysis. \u003cem\u003eP\u003c/em\u003e, Pearson's correlation analysis significance value. A \u003cem\u003eP\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to indicate statistical significance.\u003c/p\u003e \u003cp\u003eSE= spherical equivalent, D= diameter, AL= axial length, K1\u0026thinsp;=\u0026thinsp;flat keratometry, K2\u0026thinsp;=\u0026thinsp;steep keratometry, TMH= tear meniscus height, NIBUT-f\u0026thinsp;=\u0026thinsp;the first break-up time of the tear film, NIBUT-avg\u0026thinsp;=\u0026thinsp;the average time of all tear film break-up incidents, MG= meibomian gland.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eMyopia is the main cause of visual impairment worldwide, and it has increased significantly among school-aged children in China in recent years[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In addition, as electronic devices have become easier to use, children\u0026rsquo;s exposure to electronic screens has gradually increased, and the risk of developing myopia and DED has increased significantly[\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Recent studies have shown that DED leads to a decrease in the stability of the tear film, which in turn affects visual clarity in children[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, there is still a lack of research on whether there is a correlation between adolescent myopia and DED. Given the limitations of children's coordination and comprehension abilities, this study used ocular surface comprehensive analyzer to conduct an in-depth analysis of the correlation between DED and myopia in children. The adoption of this research method not only improves the accuracy and objectivity of data collection but also helps to comprehensively understand the potential connection between myopia and DED. This study is expected to provide more accurate guidance and suggestions for the protection of children's eye health.\u003c/p\u003e \u003cp\u003eSince myopia and DED are affected by confounders such as screen time and visual behavior, participants unexposed to electronic devices every morning were selected for examination. Our results revealed that dynamic tear film stability gradually deteriorated with increasing degree of myopia in participants. The ocular surface parameters (NIBUT-f, NIBUT-avg and classification) in the HMG were significantly different from those in the NMG and LMG. The amount of tear secretion (TMH) significantly differed between the MMG and LMG. However, there were no significant differences in the MG scores among the groups. In addition, the K1 and K2 values in the HMG were significantly greater than those in the NMG, and the K2 values in the MMG significantly differed from those in the NMG and HMG. First, participants with DED may exhibit a shorter TBUT and more severe aberrations, which in turn lead to increased myopia[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Second, participants with moderate and high myopia may have further impacts on their ocular microenvironment and tear film stability due to their greater visual demands. Studies have shown that subjects with refractive errors are more likely to suffer from DED when glasses are used frequently[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], which is consistent with our research findings. Third, it may be related to changes in corneal curvature. Participants with high myopia may experience changes in the ocular microenvironment due to axial elongation and changes in eye shape, which can affect the stability of the tear film[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Fourth, adolescents with high myopia often exhibit poor tear film quality, which may be due to environmental factors. Specifically, they tend to spend less outdoor time, engage in closer work, and have longer exposure to artificial air conditioning, which can lead to more severe symptoms of dry eyes[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Myopia and dry eye may affect each other. However, this study did not establish a direct causal relationship between myopia and DED. Therefore, future research must adopt higher-quality research designs to further explore the relationships and mechanisms between myopia and DED. Moreover, participants with myopia and DED should also receive sufficient attention and timely treatment to improve their visual quality and quality of life.\u003c/p\u003e \u003cp\u003eStudies have shown that DED affects women more frequently than men do, especially after menopause[\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. To further assess whether dry eye in participants with myopia is related to sex, comparative analyses of ocular surface parameters were performed between males and females in groups with different degrees of myopia. Our results revealed that the TMH, NIBUT-f and NIBUT-avg in girls were significantly lower than those in boys (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Previous research has suggested that changes in sex hormones may be important factors leading to tear film disorders[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. However, this study did not reveal significant differences in ocular surface parameters between females and males in the NMG, LMG, or MMG of adolescents. These findings suggest that the degree of myopia may be an important factor affecting the relationship between sex and DED. To our knowledge, this relationship has never been discussed in the literature before. Although this study provides some interesting findings, there are still many unknown areas that need further exploration. Notably, the sample size of high myopia participants in this study was relatively small, which may have had some impact on the universality and accuracy of the results. In summary, this study reveals the complex relationship between myopia and DED, providing new perspectives and ideas for future research.\u003c/p\u003e \u003cp\u003eTo further clarify whether there was an association between myopia and dry eye, Spearman's correlation and linear regression analyses were conducted. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, TMH, NIBUT-f and NIBUT-avg were positively correlated with SE (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and NIBUT-f and NIBUT-avg were negatively correlated with AL (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The DED grade was negatively correlated with SE and positively correlated with AL. Previous studies have also shown that there is a certain association between dry eye and myopia, but the specific mechanism is still unclear; this may be because when myopic eyeballs are elongated, changes in the front surface of the cornea may increase susceptibility to dryness[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. DED may also cause reduced vision through various mechanisms, thereby increasing the degree of myopia in participants[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Interestingly, our results also revealed a negative correlation between TMH and K2 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Although the results are interesting, the reasons for this phenomenon are not yet clear, and more supporting data are needed.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eIn summary, these findings indicate a significant correlation between the severity of myopia and DED in pediatric populations. High myopia was associated with impaired tear film stability and decreased tear secretion, with female participants demonstrating more significant ocular surface alterations than male participants. This research provides precise guidance and recommendations for the protection of children's eye health. However, further research is warranted to form clinical recommendations and explore the specific mechanisms of the interaction between myopia and DED in the future.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eStatement of Ethics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Eye Hospital Affiliated with Nanchang University, Jiangxi, China (Grant No. YLP202012013) and was conducted in accordance with the Declaration of Helsinki. In this study, all participants provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicting interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by grants from the Natural Science Foundation Youth Fund Project Of Jiangxi Province (20252BAC200497); National Natural Science Foundation incubation project of The Second Affiliated Hospital of Nanchang University (2023YNFY12003); and the Science and Technology Program of Jiangxi Provincial Health Commission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eY. C., and F. W. designed the study. H.Y. and H.H. recruited the participants and collected the data. F. Z., Y. L., H. H., S. W. and Y. S. analyzed the data; Y. C wrote the initial draft; and F. W. revised the manuscript. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available owing to ongoing research utilization but may be made available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSaw SM, Matsumura S, Hoang QV. Prevention and management of myopia and myopic pathology. 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Ocul Surf. 2022;23:207\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jtos.2021.10.007\u003c/span\u003e\u003cspan address=\"10.1016/j.jtos.2021.10.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Dry eye disease, Myopia, Children, Ocular surface, Gender","lastPublishedDoi":"10.21203/rs.3.rs-9413350/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9413350/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eThe aim of this study was to investigate the correlation between myopia and dry eye disease (DED) in children.\u003c/p\u003e\u003ch2\u003eMethod:\u003c/h2\u003e \u003cp\u003eA cross-sectional study involving 83 pediatric participants (166 eyes) aged 7\u0026ndash;15 years was conducted. The participants were stratified into four groups on the basis of spherical equivalent (SE): the nonmyopia group (NMG, 38 eyes), the low-myopia group (LMG, 59 eyes), the moderate-myopia group (MMG, 52 eyes), and the high-myopia group (HMG, 17 eyes). Comprehensive ocular surface evaluation was performed using an ocular surface analyzer and noncontact partial coherence interferometry. The primary outcome measures included comparative analysis of tear film stability across groups, sex-based differences in ocular surface parameters, and correlation analysis between ocular surface metrics and myopia severity.\u003c/p\u003e\u003ch2\u003eResult:\u003c/h2\u003e \u003cp\u003eSignificant differences in ocular surface parameters were observed among the study groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Compared with the NMG and LMG, the HMG markedly altered the tear film stability. Compared with their male counterparts, female participants in the HMG presented significantly shorter tear meniscus heights (TMHs), first noninvasive tear film break-up times (NIBUTs), and average tear film break-up times (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Correlations were identified between ocular surface parameters and myopia progression metrics.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eThe study findings demonstrate a significant association between myopia severity and DED in pediatric populations. High myopia was associated with compromised tear film stability and reduced tear secretion, with female participants exhibiting more pronounced ocular surface changes. The results of this study provide evidence-based guidance to better protect young myopic eyes from associated DED; however, further research is warranted to form clinical recommendations.\u003c/p\u003e","manuscriptTitle":"Associations between Myopia and Dry Eye Disease in Children Subjects","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-28 15:26:42","doi":"10.21203/rs.3.rs-9413350/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"145003833517594175397827936328760990204","date":"2026-05-09T19:56:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-03T07:12:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"297620803544653741679516117857034409017","date":"2026-04-22T04:36:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-20T04:18:14+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-16T11:30:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-15T08:42:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-15T08:42:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Ophthalmology","date":"2026-04-14T09:19:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"40700212-b70e-4d88-b6cd-f4366d939401","owner":[],"postedDate":"April 28th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"145003833517594175397827936328760990204","date":"2026-05-09T19:56:47+00:00","index":32,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-03T07:12:15+00:00","index":30,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-28T15:26:42+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-28 15:26:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9413350","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9413350","identity":"rs-9413350","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}