Ever since myopia research began, several decades of research have addressed genetic inheritance; however, the related population genes have not changed significantly. Meanwhile, the number of people with myopia has increased greatly as a result of changes in the physical living environment and lifestyle in recent years, and this indicates that environment may play a decisive role [33,40] (p. 8). Myopia is not only affected by genetic factors, but also by the biological hormone regulation of the internal physiological mechanism [62,63] (p. 13).

Furthermore, there is a close relationship between human behavior under the influence of the external environment and biological reaction. For instance, outdoor exposure could boost the secretion of dopamine in minor retinas, and this could regulate eye development and promote visual health [64]. Concurrently, the short-wavelength blue light of sunlight, namely the spectral component of 446–477 nm, is much more abundant in daylight than artificial lighting, and its substance is related to the secretion of melatonin, which can promote circadian rhythm, assist the development of the eyeball, and improve sleep [65]. Behaviors that are subject to different environmental influences will further affect the internal hormone regulation, and this clearly indicates that myopia is a disease caused by the interaction between genetic and environmental factors. Closer inspection shows it is more related to the surrounding environment of minors, after force majeure such as heredity are excluded. Similarly, key influencing factors, such as the minors getting out and enjoying outdoor activities, and the possession of a comfortable near work environment are closely connected to spatial environment characters. Hormones act as the inner core influencing mechanism, and the environment could be artificially designed externally and could influence visual behavior further. In being subject to the influence of the social environment and educational mode, near work behavior and outdoor exposure behavior are the main types of visual health behavior that are related to the spatial environment.

(1) Parents myopia

Myopia prevalence is significantly higher among children whose parents both have myopia. The greater the severity of parental myopia, the higher the risk of myopia [23,24,39,43,66,67] (p. 6,8,9). Minors’ eye AL (ocular axial length) values may also have been affected by parental genetics [62]. Parental myopia is also thought to be a symbol of genetic and shared family environmental exposure, and parents with myopia are more likely to create an environment that creates visual fatigue, including more intensive education or less time out-doors [34,63] (p. 8); however, gene-environment interactions are not well understood.

(2) Susceptibility gene

The minor’s gender affects the probability of myopia, which means it is more probable that girls will develop myopia during adolescence [23,24,68] (p. 6). Medical gene studies have found that at least 10 genes are associated with early-onset changes in refractive error [69]. Additionally, some gene mutations can lead to myopia or other refractive error phenotypes [70].

The risk of myopia developing varies in accordance with age—it progresses most rapidly between the ages of six and seven and slows down after the ages of 11 and 12 [23,33,48,71] (p. 6,8,9).

(3) Atropine

With regard to drug treatment related to Optometry, it has been found that antimuscarinic drugs, such as the most widely studied atropine, slow the progression of myopia; however, some minors do not respond to it, and there has been no large-scale popularization or application [72].

(1) peripheral refraction

The central refractive error is determined by the foveal region on the visual axis, although peripheral retinal and other regions also play an important role in eye growth [73]. The degree of peripheral hyperopia varies among different heritage groups [74,75], and minors with myopia have greater peripheral relative hyperopia [76]. Both emmetropic and hyperopic children had peripheral relative myopia at all eccentric points [77]. Peripheral hyperopia co-occurs with prolonged myopia and determines the myopia patients’ eyeball shape. In contrast, a longitudinal study found that baseline peripheral refraction did not predict nor influence the development of myopia [78].

(2) physiological hormone regulation

Recent medical studies found that outdoor exposure could promote the secretion of dopamine in minors’ retina and could regulate eye development and promote visual health [79]. Meanwhile, the short-wavelength blue light of sunlight, namely the spectral components of 446–477 nm, is much more abundant in daylight than artificial lighting. Additionally, this substance is related to the secretion of melatonin, which can promote the circadian rhythm and eye development, and improve sleep quality [65].

The difference in education level largely determines the difference in the probability and degree of myopia and intelligence test scores [80]. Education level was also positively correlated with AL length, which is an important judging factor for myopia [81,82]. Meanwhile, early intensive education is associated with higher prevalence of myopia than the other factors [83].Education level is usually measured by years of formal education or academic achievement, and is also highly correlated with near work time. Education level may therefore be a substitute factor for proximity work and number among the influencing factors of myopia [34,45,84] (p. 8,9). The relationship between education and myopia may also reflect the common inheritance of intelligence and refraction, which enrich the method of myopia researches.

When the traditional educational mode turns to multimedia teaching, the old instructional design criteria are no longer suitable. School type [32] (p. 8), desk lighting [40] (p. 8), sitting location in classroom, screening time [19,20,32,33] (p. 6,8) and multimedia teaching under daylight conditions [16] (p. 5), will also influence minors’ visual health through near work. Classroom unit spatial design should also be changed to adapt to the current education model, in order to provide more visual health environment.

The development of myopia is also related to geographical location, and urban dwellers have a higher risk of visual impairment and blindness than those in rural areas, including in China [42] (p. 9), [85], Ghana [86] and Australia [44], this may be caused by differences in lifestyle, urbanization, school type and demographic characteristics [22,32,33,34,47,51] (p. 6,8,9). Meantime, different geographical areas have various climacteric characteristics that are related to differences of daylight environment, this can be seen in Istanbul [87], Chongqing, Lasa [88], London, Chicago, Dubai and Bangkok and so on. London, Chicago, Dubai and Bangkok have different fenestration parameters in order to ensure the effective use of daylighting, due to local daylight performance [89]. Outdoor activities in China’s rural area have a weak protective effect on visual health, and this may be because minors in rural areas have a lower genetic susceptibility to myopia; in addition, environmental factors may be an important reason for visual impairment [90]. Additionally, the indoor environment, like plants, can also influence the relief of visual fatigue [27] (p. 7).

Outdoor daylight exposure could protect visual health to a certain extent and delay the development of myopia, and this is because outdoor time is an important protective factor [15,17,21,23,24,46,52,55,92] (p. 5,6,9–11). Minors who spent less time outdoors and more time near work had a higher rate of myopia, and those who spent less time on near work had a lower rate [26,27,35,36,38,93,94,95] (p.7,8,16), which indicated increased outdoor time as a solution for myopia, and provided architecture design direction. Similarly, animal experiments have also found that a less bright environment can increase the probability of myopia [96].

However, the biological mechanism of the association between outdoor exposure and myopia remains unclear. It has been hypothesized that higher outdoor brightness increases field depth and reduces image blur, and that light stimulation induces dopamine production in the retina and adjusts eye growth [95]. It has also been hypothesized that the spectral component of daylight is an important visual health factor [97]. Studies have also identified the non-visual effects of light and Healthy Circadian Lighting, namely that light has an important impact on the human body’s circadian system. Non- visual photoreceptor cells (ipRGC) transmit light signals to the brain’s suprachiasmatic nucleus (SCN) and body clock and regulate the secretion of melatonin and cortisol (which are closely related to circadian rhythm) [98]. Both these explain how outdoor time could protect visual health.

• negative behaviors related to visual health

Near work is usually defined as long or close reading by minors. Children who read continuously within 30 cm for more than 30 min tend to develop myopia [99]. Meanwhile, children who read more than two hours per day and more than two books per week are more likely to be nearsighted [13,30,35,38,49,50,55,99] (p. 5,7–11). It has also been found that the light environment of near work will influence visual health [14] (p. 5). Meanwhile, outdoor activities can protect visual health [100].

Some studies have also found there is no association between close visual work and vision-related health risks [101,102]. Most myopia and near work are cross-sectional and cannot examine the temporal relationship. Those who have myopia may wear glasses and find it more difficult to participate in sports tasks, which results in lower levels of physical activity [103]. Parents also filled in most of the information about minors’ near work and outdoor time, which led to recall bias. In the future, more accurate and standard methods should be used to quantify the near work modifiable variables in near work, such as reading posture, rest during reading and appropriate lighting. These should be studied in order to promote health [104], and this could change e and adjust behavior in accordance with spatial environment design. The increased burden of school learning plays an important role in the high prevalence of myopia and visual impairment. This may be due to intensive near work, which increases the risk of myopia [33,105]. Bad eye habits and electronic devices are also risk factors [106,107]. Family eating habits and BMI risk factors [43] (p. 9), including changing from a Japanese to a Western diet, may increase the risk of myopia [18,19,108] (p. 5). Additionally, these factors could be improved in other ways, like social management policy and media guidance. This can help to produce positive behaviors related to visual health positive behaviors related to visual health.

• positive behaviors related to visual health

Resting behaviors (including night’s sleep and short rest) have been associated with the probability of minors’ myopia [25,50] (p. 7), that could protect visual health. The level of myopia is significantly associated with night sleep, and not with the duration of total noon and evening sleep [37,54,100] (p. 8,11). With regard to the biological mechanism, the circadian rhythm of human sleep mainly depends on the joint regulation of melatonin and dopamine, when melatonin combines with the corresponding eye receptors to jointly regulate the eye’s development [66] (p. 14). Short rests, meanwhile, have been found to reduce fatigue [103]. Some animal experiments have also demonstrated that the circadian rhythm disorder will increase the risk of myopia [109]. Change of minors’ daily waking and sleeping time is a simple measure that can be introduced to restrain myopia [110].

Eye exercises organized by schools have a certain protective effect on myopia [44,111] (p. 9). In addition appropriate myopia correction can also protect visual health, further reduce visual damage and slow myopia progression [112]. Parents’ awareness of refractive error also determines the proportion of minors‘ myopia correction, and this further affects visual health [53,113] (p. 11).

In referring to the loop diagram’s logical chain, it is both plausible and likely that the school spatial environment will impact on minors’ visual behavior. However, few review studies have discussed associations with minors’ visual health. In the causal loop diagrams of visual health, school layout is shown to be closely related to the indoor light environment through effects on near work behavior; in addition, spatial environment greatly influences minors’ outdoor times via hormone regulation and physiological processes in daylight. The natural elements could also relieve visual fatigue, and this applies both indoors and outdoors. These studies use direct and indirect routes to combine visual health promotion and school design.

Usually, visual health is always connected to near work behavior that is related to indoor light environment in school. Additionally, school layout, windows’ scale, buildings’ orientation and so on are the main influences. For the most part, visual health promotion has not only considered physical school environment variables but has provided general support to providing minors with adequate outdoor activities. For example, diverse playgrounds, convenient outdoor access, various types of activity equipment and varied travel experience all show how this can be achieved. While the specific relationship between school spatial environment and visual health has not been precisely defined, it has been demonstrated that the school environment promotes visual health opportunities. Minors’ outdoors activities at school have decreased dramatically over preceding decades, and this is why the importance of outdoors time as a way of improving visual health has been increasingly reiterated. Unfortunately, many schools and surrounding environments have not been conducive to outdoor activities. In addition, minors who lived in cities were more prone to myopia than rural counterparts, and in this regard it was significant that urban schoolchildren enjoyed substantially less school outdoor time.

The complex causal pathways between school spatial environmental factors and minors’ visual behaviors are still unclear. However, in acknowledging the ongoing need to improve visual health behaviors across numerous minor populations, schools have introduced and promoted design guidelines. They are summarized on the basis of the literature review and relevance analysis.