The NICER Study
The Northern Ireland Childhood Errors of Refraction (NICER) study is the largest study in the UK and Ireland to examine how children's vision, in particular their refractive error (i.e. how long- or short-sighted they are) changes through childhood and adolescence.
The study began in 2006 when over a thousand 6-7 and 12-13 year old local school children were recruited and had their first vision assessment.
Our research team visited primary and post-primary schools in the North and West of Northern Ireland where we measured how well each child could see, how long- or short-sighted they were, the size of their eyes, their height and weight and also asked them and their parents about their child's lifestyle, diet and the family's history of spectacle wear.
Three, six and nine years after the initial assessment, each participant was invited to have these measures repeated.
These data, spanning nine years, provide us with a unique insight into the visual development of children in Northern Ireland and the factors influencing their vision and visual status.
This is the first study to present typical growth patterns of the eye from childhood to early adulthood in a UK-based population. Using this knowledge regarding normal eye development we can identify children who are at greater risk of developing eye conditions such as short-sight (myopia) and can use this information to adjust the advice we give to children and their parents and manage their eye-sight more effectively.
Resources for Eye Care Practitioners
We have used the results from the NICER study to develop a range of resources for eye care practitioners which can be accessed by clicking on the links. These include the PreMO Risk Indicator which uses a child’s refractive error, axial length and family history of myopia to stratify their risk of future myopia by likely age of onset. It can also be used to determine appropriate management options once the child has become myopic.
We’ve also created Axial Length Growth Charts, which look similar to those used to monitor a child’s development of height and weight. These can be used to monitor eye growth and determine when axial length changes are not following the normal pattern highlighting incipient myopia.
For practitioners who currently do not have access to ocular biometry and precise axial length measurement, we have also created a table to Estimate Axial Length from average corneal curvature and spherical equivalent refraction measures.
The study has been funded throughout by the College of Optometrists.
Key findings from The NICER Study
Key findings from The NICER Study to date:
- Nearly 1 in 5 teenagers in Northern Ireland are short-sighted (myopic)
- Teenagers in Northern Ireland are three times more likely to be short-sighted than comparable Australian teenagers, but not as likely to be short-sighted as Asian teenagers. The interplay between environment and genetics is likely to be important in determining how many children become short-sighted and how short-sighted they become. Our current research is exploring how environmental factors influence childhood myopia development in more detail.
- The number of children who are short sighted in the UK has doubled over the last 50 years. Children in the UK are becoming short-sighted at a younger age than we previously thought; the development of short-sight is most likely to occur in the primary school years when the greatest amount of eye growth also occurs. Children’s eyes continue to grow into adulthood, although this growth rapidly slows in the teenage years.
- Children with parents who are short-sighted (myopic) are at an increased risk of developing short-sight themselves and are more likely to develop it at a younger age.
- Long-sight (hyperopia), astigmatism (sometimes referred to as ‘rugby ball’ shaped eyes) and a difference in refractive error between the two eyes (anisometropia) are more common in Northern Ireland than in other populations
- Few children in Northern Ireland have significant visual impairment. However, 25% of children needing glasses, don't routinely bring them to school and their vision is poorer because of this
With these findings in mind, we are starting a new study to find out whether the situation is getting worse and what is causing it. Like before, we are hoping local school children will help us to complete our new research study.
The new NICER Study
What is this new study about?
Short-sight (myopia) is becoming more common across the world and is starting in children at younger ages than ever before. This means that many children need glasses or contact lenses to see far away objects and will continue to need glasses through their adult life to see clearly for driving, watching TV etc. Short-sight is not just a problem because it means wearing glasses for clear vision; it is also linked to some serious eye problems in later life.
So, the fact that more children are becoming short-sighted is worrying for their long-term eye health and vision.
Short-sight tends to ‘run’ in families but research has shown that children’s lifestyles are encouraging short-sightedness to develop, even when their parents don’t wear glasses. Research from other countries suggests that modern children spend less time outdoors, more time studying and more time using smart phones and tablets.
Do these features of modern life encourage short-sight?
We want to find out more about this by investigating;
- How many children in Northern Ireland are short-sighted now and compare this with our previous figures from 2006 (before smart-phones and tablets became commonly used) and,
- How much time children spend studying, playing outside and using smart-phones and tablets.
What is involved if you and your child consent to take part in this new study?
Your child (and their classmates) will have their eyes tested at school by an Optometrist; the test should take about 1 hour. We will measure how well your child sees (without/with glasses if they wear them). We will ask them to look into a piece of equipment so we can measure the size and shape of their eyes and how long- or short-sighted they are.
Nothing touches their eyes and these measurements are taken very quickly whilst they look at a small target, usually a light.
We will measure each child’s height, waist circumference and weight and help them fill in a questionnaire to find out how much time they think they spend on activities like playing outside, reading, watching television, using a smartphone or tablet. After the eye test we will check the results carefully.
If we find your child needs glasses or needs to update his/her glasses we will write to you advising that your child should visit your local Optometrist to have a full eye test.
Watch our animation for more information
Watch our animation for more information on what to expect if you are asked to participate in our study.
NICER 2.0: The Story So far
So far over 150 children have taken part in NICER 2.0 across 7 different school.
Can anything be done to stop Myopia getting worse?
Traditionally, when someone has myopia, they are given glasses or contact lenses to allow them to see clearly. Some people have surgery on their eyes to provide clear vision without glasses or contact lenses (refractive surgery). However, none of these options stop myopia getting worse.
Our researchers are working with other researchers across the world, and in the UK and Ireland to find out if an eye drop can help slow down the progression of myopia, so that children don’t continue to need stronger glasses as they get older.
This will ultimately help to keep their eyes as healthy as possible throughout their lives.
Ulster University were the first UK site to enrol children into this research in April 2019.
Children who are already short-sighted are being enrolled and will use eye drops every night for up to four years.
The drops will either contain the active treatment (low dose atropine) or will be a ‘placebo’ eye drop. More children will receive the treatment than be on the placebo drop, and all children will be offered the treatment at some point during the trial. For more information on this research please visit The CHAMP Study webpages.
Invited research and professional presentations related to the NICER study research
- McCullough, SJ, ‘Discussion workshop- Myopia’, Northern Ireland Clinical Research Network, Belfast, February 2019
- McCullough, SJ, ‘Exploring Myths and Misconception in Myopia Management-Is Binocular Vision a Critical Component of Myopia Management?’, British Contact Lens Association Conference, Manchester, May 2019
- Saunders KJ, ‘Are disrupted circadian rhythms responsible for the myopia epidemic?’, Association for Optometry and Vision Science, Vancouver, April 2019.
- Saunders KJ, ‘Myopia and the Modern Child: Findings from the NICER study’, International Aeir Optometry Development Conference, Changsha, China, 19-21 November 2018
- Saunders KJ, ‘Is Modern Life Bad for Children’s Eyes?’, Congresso Internacional de Optometria e Ciencias da Visao (CIOCV2018), Braga, Portugal, 28-29 April 2018
- Saunders KJ, ‘Childhood Myopia in the 21st Century: Results of the NICER Study’, Specsavers Nordic Conference Series, Sweden, Denmark, Norway, Finland, 10-13 Oct 2016
- Saunders KJ, Childhood ‘Myopia in the 21st Century: Results of the NICER Study’, Optometry Tomorrow, Birmingham, March 2016
- Saunders KJ, ‘Childhood Myopia in the 21st Century: Results of the NICER Study’, Optrafair, Birmingham, April 2016
- McCullough, SJ, ‘Is Binocular Vision a Critical Component of Myopia Management and Control?’Optometry Today, October 2020.
- McCullough SJ. ‘Your eyes and the outdoors’. Vista Magazine, Eye Health Week 2018.
- McCullough, S.J., Saunders, K.J. ‘The Northern Ireland Childhood Errors of Refraction (NICER) Study: Childhood Myopia in the 21st Century’, Optometry Today, June 2016
- Saunders KJ, Breslin K, McClelland J, McCullough S and O’Donoghue L. ‘Myopia: a growing problem’. Expert Statement: Royal Irish Academy Life and Medical Sciences Committee, Oct 2015
- Saunders KJ ‘Testing visual acuity of young children: an evidenced-based guide for optometrists’. Profile (Specsavers global journal for all professional staff and students), June 2015.
- O’Donoghue L and Saunders KJ (2011). Uncorrected childhood refractive error in the UK. Points de Vue International Review of Ophthalmic Optics.
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