Racket Sports Rank Highest for Pediatric Myopia Control
Key Takeaways
- Across 16 randomized controlled trials involving 9,084 children and adolescents, racket sports appeared to rank highest versus control for slowing axial elongation, with MD −0.30 mm and SUCRA 94.9%.
- Increased outdoor time ranked second for axial length, with MD −0.08 mm and SUCRA 55.7%; exploratory subgroup analyses suggested a more consistent axial-length signal in children aged 8.5 years or younger and in studies with follow-up longer than 24 weeks.
- Spherical-equivalent rankings differed from axial-length rankings: visual tracking exercise ranked highest at MD 0.38 D, followed by racket sports at MD 0.29 D, and the leading spherical-equivalent interval crossed the null.
Participants were generally school-aged children and adolescents, about 5 to 18 years old, who had myopia or were considered at risk of progression. The intervention network included increased outdoor time, structured outdoor exercise, racket sports, visual tracking exercise, general physical activity, and control groups that generally continued usual activities or had no regular physical exercise. AL and SE were analyzed as continuous outcomes using mean differences with 95% confidence intervals and ranked with SUCRA, with all 16 studies reporting SE and 11 also reporting AL. Across studies published from 2015 to 2025, durations ranged from about 8 to 156 weeks, intervention frequency ranged from 2 to 15 sessions per week, and the analysis used a consistency model that combined direct and indirect evidence.
Beyond the axial-length leaders, the pattern differed when refractive change was examined, with visual tracking exercise and racket sports ranking higher for spherical equivalent rather than increased outdoor time. The authors presented AL and SE as complementary rather than interchangeable outcomes, framing the discordant rankings as a signal that activity pathways may not map uniformly across structural and refractive measures. Exploratory subgroup analyses also suggested that increased outdoor time showed a steadier axial-length pattern in younger children and in longer-duration studies.
Network checks were broadly consistent with the main rankings: global inconsistency was not significant for either endpoint, at p=0.9928 for AL and p=0.6085 for SE, and heterogeneity was modest at τ 0.062 mm for AL and 0.21 D for SE. Node-splitting analyses found no significant direct-indirect differences for key comparisons, and sensitivity analyses excluding high-risk-of-bias studies did not materially change the overall pattern.
At the same time, few direct head-to-head comparisons meant some estimates were driven mainly by indirect evidence, overall RoB 2 assessments were mainly rated as some concerns, slight funnel-plot asymmetry suggested possible publication bias, cycloplegia was not used consistently for some SE measurements, and most trials did not objectively capture sunlight exposure, exercise intensity, or time spent in different settings. The age cutoff used in subgroup analyses was data-driven rather than a clinical threshold, and the ranking pattern held, although some estimates remained imprecise.
Clinician Questions
How did axial length and spherical equivalent rankings differ across outdoor and exercise interventions for pediatric myopia?
Axial length and spherical equivalent produced different intervention rankings in children and adolescents: racket sports ranked highest for slowing axial elongation, whereas visual tracking exercise ranked highest for spherical equivalent and racket sports ranked second for spherical equivalent. The leading spherical-equivalent estimate crossed the null, and the authors treated axial length and spherical equivalent as complementary rather than interchangeable outcomes.
What interventions were compared in the network meta-analysis of activity-based myopia control in children and adolescents?
The network meta-analysis compared increased outdoor time, structured outdoor exercise, racket sports, visual tracking exercise, general physical activity, and control. The randomized evidence base involved school-aged children and adolescents with myopia or at risk of progression, included 16 trials with 9,084 participants, and reported spherical equivalent in all studies and axial length in 11 studies.
Did younger age or longer follow-up change the signal for increased outdoor time in pediatric myopia?
Subgroup analyses suggested that increased outdoor time was more consistent for axial length in children aged 8.5 years or younger and in studies with follow-up longer than 24 weeks. Those subgroup findings were exploratory, and the 8.5-year cutoff was data-driven rather than a clinical definition.
How consistent were the network meta-analysis results for outdoor and exercise interventions in pediatric myopia?
For outdoor and exercise interventions in pediatric myopia, global inconsistency was not significant for axial length or spherical equivalent, node-splitting analyses found no significant direct-indirect differences for key comparisons, heterogeneity was τ 0.062 mm for axial length and 0.21 D for spherical equivalent, and sensitivity analyses excluding high-risk-of-bias studies did not materially change the overall pattern. Direct head-to-head evidence was limited, so some estimates relied mainly on indirect comparisons.
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