Cost-Effectiveness Analysis of Myopia Progression Interventions in Children

**Background:** Myopia (nearsightedness) is a major cause of visual impairment worldwide, with prevalence projected to increase from 2.6 billion in 2020 to 4.8 billion by 2050. The high and rising prevalence has become a global health concern due to potential long-term complications such as cataracts, myopic macular degeneration, glaucoma, and retinal detachments. The health costs associated with myopia are substantial, including direct costs of correction and indirect costs from productivity loss. While various interventions (pharmacological, spectacles, contact lenses) have been evaluated for efficacy in slowing myopia progression, comprehensive cost-effectiveness analyses comparing a broad spectrum of interventions are lacking. This study aimed to determine the cost-effectiveness of 13 myopia progression interventions in 10-year-old children over a 5-year period.

**Methods:** A model-based economic evaluation was conducted using a Markov model with three health states: low myopia (−0.50 to −2.99 D), moderate myopia (−3.00 to −5.99 D), and high myopia (≥−6.0 D). The target population was a hypothetical cohort of 10-year-old children with myopia. Model inputs were obtained from published literature, including randomized clinical trials. The interventions compared were: atropine 0.05%, atropine 0.01%, defocus incorporated multiple segments spectacles (DIMS), outdoor activity, daily disposable soft contact lenses (MiSight), multifocal soft contact lenses (MSCLs), rigid gas-permeable contact lenses (RGPCLs), progressive addition lenses (PALs), bifocal spectacle lenses (BSLs), orthokeratology, highly aspherical lenslets (HALs), and red light therapy. Single-vision lenses (SVLs) served as the comparator. The analysis was performed from a societal perspective, including direct costs (consultations, follow-up visits, optometric services, spectacles, contact lens solutions, medications) and indirect costs (adverse events, caretakers' loss of productivity). Costs were based on 2022 Hong Kong dollars and converted to US dollars (HK $7.85 per US $1), discounted at 3% annually. Effectiveness outcomes were change in spherical equivalent refraction (SER) and axial length (AL) over 1 year, derived from published meta-analyses. The main outcome was the incremental cost-effectiveness ratio (ICER). Deterministic and probabilistic sensitivity analyses were performed.

**Key Results:** Over a 5-year time horizon, the projected total cost was lowest for outdoor activity (HK $34,108 [US $4,345]) and highest for orthokeratology (HK $120,474 [US $15,347]). Compared with SVLs, outdoor activity resulted in an incremental cost saving of HK $204 (US $26). For SER reduction, outdoor activity yielded a cost savings of HK $39 (US $5)/SER reduction. Atropine 0.05% had an ICER of HK $1,727 (US $220)/SER reduction, and red light therapy had an ICER of HK $6,641 (US $846)/SER reduction. For AL reduction, outdoor activity yielded a cost savings of HK $63 (US $8)/AL reduction, atropine 0.05% had an ICER of HK $3,360 (US $428)/AL reduction, and orthokeratology had an ICER of HK $18,652 (US $2,376)/AL reduction. ICERs for spectacle options ranged from HK $2,763 (US $352)/SER reduction to HK $5,770 (US $735)/SER reduction, and for contact lenses from HK $6,186 (US $788)/SER reduction to HK $9,318 (US $1,187)/SER reduction. Probabilistic sensitivity analysis showed that at higher willingness-to-pay (WTP) thresholds (≥HK $19,625 [US $2,500]/SER reduction), atropine 0.05% was the most likely cost-effective strategy (40% at HK $19,625/SER reduction), followed by HALs (25%) and red light therapy (8%). At lower WTP thresholds, outdoor activity was the most likely cost-effective strategy (100% at WTP of HK $0/SER reduction).

**Clinical Implications:** This study provides the first comprehensive cost-effectiveness analysis of multiple myopia progression interventions in children. The findings suggest that atropine 0.05% and outdoor activity are the most cost-effective strategies, with outdoor activity even yielding cost savings. These results are important for health policy planning, especially in resource-limited settings. While more expensive interventions like red light therapy, HALs, and orthokeratology may also be cost-effective at higher WTP thresholds, atropine 0.05% and outdoor activity offer the best economic value. The study also highlights the additional health benefits of outdoor activity beyond myopia control, such as reducing childhood obesity and increasing vitamin D levels. Limitations include potential underestimation of costs, lack of generalizability to other regions, and absence of quality-of-life assessment. Nonetheless, this analysis provides pivotal data to guide clinicians and policymakers in selecting cost-effective interventions to address the growing myopia epidemic.