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Purpose: To compare the proportions of school children with myopia and impaired visual acuity in Greece and Bulgaria. Methods: A sample of 898 children, aged 10–15 years, was selected from two primary and two secondary schools in a Greek city (Heraklion), and one primary and secondary school in a Bulgarian city (Stara Zagora). Five hundred and eighty eight children were Greek (65.5%, mean age 12.5 ± 0.08 years) and 310 Bulgarian (34.5%, age 12.4 ± 0.07 years). VA was assessed with the habitual refractive correction. Refractive error was measured in the absence of cycloplegia using an auto-refractor. Results: The percentage of children, tested with their habitual refractive correction, with decimal VA <0.5 in at least one eye was 11.7% (95% CI 9.1–14.3%) for Greek and 5.2% (95% CI 2.7–7.6%) for Bulgarian pupils. The percentage of myopic children also differed between the two countries with the proportion with myopic refractive error ≤−0.75 D and decimal VA <0.8 at primary school level being 14.1% and 28.9% in Stara Zagora and Heraklion respectively and 13.0% and 46.9% (95% CI 18.2–29.2%, p < 0.0001) at secondary school level. Among the myopic pupils only 35.8% used corrective spectacles in Stara Zagora, compared to 70.7% of the children in Heraklion. Finally, myopia appeared more prevalent in female adolescents with the effect being statistically significant only for Greek children (55% vs 40% of males, p = 0.015). Conclusions: The increased proportion of myopic children in Heraklion, compared to Stara Zagora, may arise from a number of environmental and socio-economic factors, which need to be further investigated in order to understand the differences observed among European populations. [ABSTRACT FROM AUTHOR]