Prevalence of clinically significant refractive error in children in Europe: Systematic review and meta-analysis

Purpose: This meta-analysis estimated clinically significant refractive error prevalence in European children and examined variations based on cycloplegic versus non-cycloplegic refraction, age and sex. Methods: A systematic review (PubMed, Cochrane Library, EMBASE, PROSPERO ID: CRD42022322608) identified studies (January 2000 – June 2024) reporting myopia (≤−0.50D), hyperopia (≥+2.00D) and astigmatism (≥1.00 DC) prevalence in children aged 4–17 years in Europe. Twenty-six studies from 14 countries (n = 37,282) were included. Pooled prevalence estimates (EPP) were calculated using a random-effects model with Freeman-Tukey double-arcsine transformation. Results: Estimated pooled prevalences were refractive error: 17.90% (95% CI: 13.67–22.56), myopia: 14.31% (95% CI: 8.89–20.74; 24 studies), hyperopia: 10.20% (95% CI: 6.51–14.59; 11 studies), and astigmatism: 10.26% (95% CI: 5.83–15.74, eight studies). Cycloplegic and non-cycloplegic prevalence did not differ significantly (myopia: χ2 = 0.08, p = 0.78; hyperopia: χ2 = 0.29, p = 0.59). Myopia prevalence increased with age (6.17% at 4–9 years, 16.66% at 14 + years), while hyperopia declined (14.27% at 4–9 years, 7.04% at 10–13 years). Astigmatism remained stable; however, studies did not report its co-occurrence with myopia or hyperopia, limiting insights into its combined burden. No significant sex differences were observed. Data from 27 European countries were unavailable, limiting regional comparisons. Conclusions: Approximately 18% of European children have clinically significant refractive error, with myopia increasing with age and hyperopia decreasing. Myopia prevalence was highest in Russia, hyperopia in Denmark, and astigmatism in Northern Ireland. Further studies reporting cycloplegic prevalences with improved geographical representation and more granular reporting – particularly of astigmatism and its co-occurrence with other refractive errors are needed for better comparability and management of refractive errors in European children.