PURPOSE. China is urbanizing rapidly, and the prevalence of myopia is high. This study was conducted to identify the reasons for observed differences in the prevalence of myopia among urban versus rural Chinese children. METHODS. All children with uncorrected acuity of 6/12 or worse and a 50% random sample of children with vision better than 6/12 at all secondary schools in mixed rural-urban Liangying Township, Guangdong, underwent cycloplegic refraction, and provided data on age, gender,

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... al education, weekly near work and time outdoors, and urban development level of respondents' neighborhoods (12-item questionnaire). Population density of 32 villages and urban zones in Liangying was calculated from census figures (mean population density, 217 persons/km 2 ; range, 94 -957; mean for Guangdong, 486). RESULTS. Among 5844 eligible children, 4612 (78.9%) had parental consent and completed examinations; 2957 were refracted per protocol, and 2480 (83.9%) of these had questionnaire data. Those with completed examinations were more likely to be girls (P Ͻ 0.001), and questionnaire respondents were more myopic (P ϭ 0.02), but otherwise did not differ significantly from nonrespondents. In multivariate models, older age (P Ͻ 0.001), more near work (P ϭ 0.02), and higher population density (P ϭ 0.003), but not development index, parental education, or time outdoors were significantly associated with more myopic refractive error. CONCLUSIONS. Higher population density appears to be associated with myopia risk, independent of academic activity, time spent outdoors, familial educational level, or economic development, factors that have been thought to explain higher myopia prevalence among urban children. Mechanisms for this apparent association should be sought. (Invest Ophthalmol Vis Sci.