Impact of vision impairment and ocular morbidity and their treatment on depression and anxiety in children: a systematic review

Authors: Li D, Chan VF, Virgili G, Piyasena P, Negash H, Whitestone N, et al.

Geographical coverage: China, Israel, South Korea, Turkey, US and Iran

Sector: Burden of disease

Sub-sector: Epidemiology

Equity focus: Children

Study population: Children aged under 18 years

Review type: Other review

Quantitative synthesis method: Meta-analysis

Qualitative synthesis method: Qualitative synthesis

Background: Depression and anxiety are common disorders linked to vision impairment. While much research focuses on these conditions in older adults, the impact on children is less studied but potentially greater due to the duration of their effect. The findings on mental health in vision-impaired children are inconsistent. Additionally, chronic ocular conditions like strabismus can have adverse effects on children’s appearance, functionality, and psychology. Despite extensive research on strabismus’ impact on adults, its effect on children is not well-studied.

Objectives: To establish whether vision impairment and ocular morbidity and their treatment are associated with depression and anxiety in children.

Main findings:

This review found that, among children, vision impairment is associated with greater symptoms of depression and anxiety. Surgical treatment of strabismus improves these symptoms.

Of the 36 included studies, 21 observational studies concerned vision impairment, eight observational studies concerned strabismus, and the remaining seven studies were interventional. The 21 observational studies concerning vision impairment enrolled 7,255 participants and were published between 1986 and 2020. 14 of these studies were performed in LMICs, and seven studies were performed in high-income countries. These 21 studies were of cross-sectional design. Depression and anxiety were reported in 16 studies, and 17 studies, respectively. The eight observational studies concerning strabismus enrolled 668,463 participants and were published between 2008 and 2019. Three of these studies were carried out in LMICs, all in China. Five were carried out in high income countries: one in Israel and four in the United States. Of these, depression and anxiety were reported in six studies and eight studies, respectively. The seven studies concerning the intervention enrolled 20,455 participants and were published between 2005 and 2019. Five of these studies were carried out in LMICs: three in China, one in Iran, and one in Turkey. Two were carried out in high income countries, one each in the United States and Korea. Of the 29 observational studies, 17 studies scored low using the Joanna Briggs Institute quality appraisal checklist.

Vision impaired children demonstrated significantly higher scores of depression (standard mean difference [SMD], 0.57; 95% confidence interval [CI], 0.26e0.89; 11 studies) and anxiety (SMD, 0.62; 95% CI, 0.40e0.83; 14 studies) than normally sighted children. In particular, children with myopia demonstrated higher scores of depression (SMD, 0.58; 95% CI, 0.36e0.81; 6 studies) than normally sighted children. Strabismus surgery significantly improved symptoms of depression (SMD, 0.59; 95% CI, 0.12e1.06; three studies) and anxiety (SMD, 0.69; 95% CI, 0.25e1.14; four studies) in children.

Authors note that scaling up access to strabismus surgery could improve the mental health of affected children. However, further randomised controlled trials exploring the impact of public health measures for myopia correction on mental health in children are needed.


The review included studies that enrolled children or young adults with a mean age of less than 18 years, and studies focusing on mental health in adults with vision impairment. Vision impairment was defined according to the International Classification of Diseases, 11th Revision, with four levels of distance vision impairment. Both observational and interventional studies, including RCTs and before-and-after studies without a control group, were eligible. The intervention had to be ophthalmic, and studies with a comparison group were also eligible. Studies were included if they reported prevalence, scores, or both for depression and anxiety. The review permitted any study setting and only included original studies published in peer-reviewed journals.

Authors searched Medline, EMBASE, Web of Science, PsycInfo, Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials in the Cochrane Library, CINAHL, and Chinese databases Wanfang MED ONLINE and China National Knowledge Infrastructure from inception through 18 February 2021, without language restriction. The reference lists of relevant articles were checked for potentially relevant articles.

Two reviewers independently screened titles and abstracts for eligibility and extracted data into an Excel file. Additional coauthors cross-checked the data extraction forms for accuracy. Disagreements were resolved through team discussions. If data was missing from an article, the authors were contacted for the raw dataset.

The risk of bias and quality of studies were assessed using the Joanna Briggs Institute critical appraisal checklist for observational studies and RCTs and the relevant National Institutes of Health (United States) quality assessment tool for other study designs.

The meta-analysis was conducted using Stata software, separately for studies reporting depression and anxiety. A narrative synthesis was done for ineligible studies. Standardised mean differences (SMDs) were used due to the variety of measurement tools. Of the 15 studies on vision impairment, nine focused on myopia. Many studies didn’t specify visual acuity or causes of non-myopic impaired vision, preventing subgroup analysis by level or cause of vision impairment. Instead, stratification was done by myopia versus other causes. A random-effects model was used due to study heterogeneity. A leave-one-out sensitivity analysis was performed to assess the impact of individual studies on the meta-analytic outcomes.

Applicability/external validity: Authors note that included studies were highly heterogeneous, which may limit the applicability of the reported findings.

Geographic focus: Studies conducted in a wide range of countries were included, although the majority from LMICs were conducted in China. Authors did not consider how their findings might vary in different geographic settings.

Summary of quality assessment:

The approaches used to identify, include and critically appraise studies were generally robust, with a search that was inclusive in terms of language and time and with at least two authors undertaking all key tasks. However, there was no evidence of any attempts to consider unpublished material for inclusion in the review. Whilst the approaches to the analysis of the data were also generally robust, no separate analysis was undertaken based on the risk of bias of the included studies – although we appreciate this may have been challenging given the small number of studies involved and the fact that they had further been divided into subgroups. For these reasons, we have medium confidence in the findings of this review.

Publication Source:

Li D, Chan VF, Virgili G, Piyasena P, Negash H, Whitestone N, O’Connor S, Xiao B, Clarke M, Cherwek DH, Singh MK, She X, Wang H, Boswell M, Prakalapakorn SG, Patnaik JL, Congdon N. Impact of Vision Impairment and Ocular Morbidity and Their Treatment on Depression and Anxiety in Children: A Systematic Review. Ophthalmology. 2022 Oct;129(10):1152-1170. doi: 10.1016/j.ophtha.2022.05.020. Epub 2022 May 31. PMID: 35660416.