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      We appreciate Dr Bruce's interest in our paper and share her intrigue on the nature of the interaction between gender and myopia.
      • Holden B.A.
      • Fricke T.R.
      • Wilson D.A.
      • et al.
      Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050.
      Some papers included in our systematic review and meta-analysis provide age- and sex-specific data as Dr Bruce notes, but many do not. In addition to data availability, our analysis suggested that age, urbanization, location, and ethnicity had stronger effects than sex or gender on myopia prevalence, so we prioritized maintaining disaggregation and statistical strength accordingly.
      We also think the primary data may hint toward a broader gender effect involving factors such as lifestyle and educational opportunity rather than a simpler sex-linked difference. A specific sex-linked difference in myopia development would be expected to remain stable across time and place, whereas a more diffuse gender difference would not. As Dr Bruce notes, recent evidence in the most heavily researched Global Burden of Disease regions of North America High Income, East Asia, Asia Pacific High Income, and Western Europe seems to support a specific sex-linked pattern. However, other regions (North Africa and Middle East most definitively, but also South Asia and East Africa)
      • Bastawrous A.
      • Mathenge W.
      • Foster A.
      • Kuper H.
      Prevalence and predictors of refractive error and spectacle coverage in Nakuru, Kenya: a cross-sectional, population-based study.
      • Murthy G.V.
      • Gupta S.K.
      • Ellwein L.B.
      • et al.
      Refractive error in children in an urban population in New Delhi.
      • Hashemi H.
      • Rezvan F.
      • Beiranvand A.
      • et al.
      Prevalence of refractive errors among high school students in Western Iran.
      • Anera R.G.
      • Soler M.
      • De La Cruz Cardona J.
      • et al.
      Prevalence of refractive errors in school-age children in Morocco.
      trend to the contrary, providing a global view more consistent with myopia dependence on broader gender role. Evidence suggests more hyperopia in females in these contrary regions, and includes such distinctly contrasting findings as Hashemi et al.
      • Hashemi H.
      • Rezvan F.
      • Beiranvand A.
      • et al.
      Prevalence of refractive errors among high school students in Western Iran.
      who report myopia prevalence of 19% in female and 40% in male high school children in Iran. Therefore, we agree with Dr Bruce that it is a worthwhile goal to study the interaction between gender and myopia, but one that we believe requires further systematic review and analysis.

      References

        • Holden B.A.
        • Fricke T.R.
        • Wilson D.A.
        • et al.
        Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050.
        Ophthalmology. 2016; 123: 1036-1042
        • Bastawrous A.
        • Mathenge W.
        • Foster A.
        • Kuper H.
        Prevalence and predictors of refractive error and spectacle coverage in Nakuru, Kenya: a cross-sectional, population-based study.
        Int Ophthalmology. 2013; 33: 541-548
        • Murthy G.V.
        • Gupta S.K.
        • Ellwein L.B.
        • et al.
        Refractive error in children in an urban population in New Delhi.
        Invest Ophthalmol Vis Sci. 2002; 43: 623-631
        • Hashemi H.
        • Rezvan F.
        • Beiranvand A.
        • et al.
        Prevalence of refractive errors among high school students in Western Iran.
        J Ophthalmic Vis Res. 2014; 9: 232-239
        • Anera R.G.
        • Soler M.
        • De La Cruz Cardona J.
        • et al.
        Prevalence of refractive errors in school-age children in Morocco.
        Clin Exp Ophthalmol. 2009; 37: 191-196

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