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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Multifocal versus single vision lenses intervention to slow progression of myopia in school-age children: a meta-analysis

SM Li, YZ Ji, SS Wu, SY Zhan, B Wang, LR Liu, SY Li, NL Wang, and JJ Wang.

Review published: 2011.

Link to full article: [Journal publisher]

CRD summary

The review concluded that multifocal lenses in school-aged children slowed myopia progression compared to single vision lenses, but the effect was of limited clinical significance. The conclusions of this generally well-conducted review reflected the evidence and are likely to be reliable.

Authors' objectives

To compare the effectiveness of multifocal and single vision lenses to slow progression of myopia in school-aged children.


MEDLINE, EMBASE and The Cochrane Library were searched up to October 2010. References of studies identified by these searches were consulted. Science Citation Index, clinical trials registries were also searched. No language restrictions were applied. Search terms were reported.

Study selection

Randomised controlled trials (RCTs) including school-aged children (between six and 15 years old) with myopia were eligible for inclusion. Bifocal or progressive lenses had to be used in a treatment arm and single vision lenses in a control group. Studies had to report on change in refractive errors (spherical equivalent) from baseline to the end of the intervention.

Two thirds of the studies used progressive addition lenses and a third used bifocal lenses as the intervention. Two thirds of the studies were conducted in Asia. Children were between six and thirteen years old and all had myopia. The power of near addition lenses ranged from +1.50D to +2.00, and most trials used +1.50D.

Two reviewers independently screened titles and abstracts for inclusion.

Assessment of study quality

Study quality was assessed with the Jadad scale, which covered randomisation, blinding, withdrawals and drop-outs. Information on allocation concealment and intention-to-treat was also addressed.

Two reviewers independently conducted the quality assessment. Disagreements were resolved via discussion or with the help of a third reviewer.

Data extraction

Changes in refraction, and axial length data were extracted to calculate mean differences and 95% confidence intervals (CIs). Authors were contacted to obtain missing data.

Two reviewers independently extracted the data.

Methods of synthesis

Meta-analyses were performed to calculate pooled weighted mean differences (WMDs). A fixed-effect model was used unless there was significant heterogeneity, in which case a random-effects model was adopted. Heterogeneity was calculated using Χ² and Ι².

Sensitivity analyses were used to test the robustness of the pooled effects. Analyses of predefined subgroups were used to compare effects in children with different baseline refraction levels, ethnic groups and treatment duration.

Results of the review

Nine RCTs (1,464 children) were included in the review. Study quality was considered generally high; Jadad scores ranged from 3 to 5 out of 5. All studies reported appropriate methods of randomisation; most used allocation concealment and blinding. Only four trials used an intention-to-treat method of analysis, but follow-up and compliance rates were generally high. Follow-up ranged from six to 36 months (mean 20.1 months).

Compared to single vision lenses, multifocal lenses had a positive effect on refraction levels which was statistically significant (WMD 0.25D, 95% CI 0.13 to 0.38; nine trials). There was evidence of heterogeneity (Ι²=66%).

A statistically significant reduction in axial length was observed, favouring multifocal lenses (WMD -0.12mm, 95% CI -0.18 to -0.05; six trials). Evidence of heterogeneity was found (Ι²=65%).

Subgroup analyses showed that the positive effect of multifocal lenses on refraction was statistically significant in Asian children (six trials, p<0.00001) but not in Caucasian children (three trials). There was a significant reduction in refraction for children with low (under -3.0D) myopia (p=0.0007) and moderate (over -3.0D) myopia (p<0.00001), but those with moderate myopia had greater benefits. Results remained statistically significant at up to 24 months, but not beyond 30 months.

Authors' conclusions

Compared to single vision lenses, multifocal lenses in school-aged children slowed myopia progression, but the effect was of limited clinical significance. The effect on refraction appeared greater in patients with moderate myopia compared to those with low myopia, and Asian children benefited more from the intervention than Caucasian children.

CRD commentary

The review question and selection criteria were clear. The authors searched several relevant sources without language restrictions and attempted to identify unpublished trials. Review processes were performed in duplicate, which minimised the risk of reviewer errors or bias.

Trial quality was assessed with appropriate criteria, and the results of the quality assessment were reported. The methods of synthesis were generally appropriate. Appropriate attempts were made to identify potential sources of heterogeneity. The fact that two thirds of the included trials were conducted in Asia should be considered when interpreting the applicability of the review findings.

The authors commented on the clinical significance of the findings, which appeared appropriate. The conclusions generally reflected the evidence and are likely to be reliable.

Implications of the review for practice and research

Practice: The authors stated that application of multiple lenses only to children subgroups such as Asian children with moderate or high levels of myopia might be appropriate.

Research: Future RCTs should investigate the optimal treatment period, how long the effect of multiple lenses could last after the end of the intervention, and whether customised near addition lenses were more effective.


Chinese Ministry of Science and Technology; China Postdoctoral Science Foundation.

Bibliographic details

Li SM, Ji YZ, Wu SS, Zhan SY, Wang B, Liu LR, Li SY, Wang NL, Wang JJ. Multifocal versus single vision lenses intervention to slow progression of myopia in school-age children: a meta-analysis. Survey of Ophthalmology 2011; 56(5): 451-460. [PubMed: 21813146]

Indexing Status

Subject indexing assigned by NLM


Adolescent; Child; Disease Progression; Eyeglasses; Humans; Myopia /physiopathology /therapy; Prosthesis Design; Randomized Controlled Trials as Topic; Vision Disorders /prevention & control



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 21813146


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