Childhood-onset myopia is an increasingly prevalent public health issue. It is estimated that by 2050, half of the world’s population will be affected, and cases above –5.00 D are associated with a significantly higher risk of severe ocular conditions. The goal of myopia management is not to cure the condition but to delay its onset and slow its progression, thereby reducing final axial length and the risk of associated complications.

Background and objectives

Over the past decades, the prevalence of myopia among children aged 10–16 has doubled. Children with myopic parents or those who develop myopia between the ages of 6 and 13 tend to reach higher levels of refractive error compared to those with a later onset. Recent studies have shown that even moderate myopia can affect long-term ocular health, increasing the risk of myopic maculopathy, glaucoma, and retinal detachment. The main goal of treatment is to slow progression through optical, pharmacological, and lifestyle interventions.

Environmental optimization and prevention

Strong evidence suggests that spending more time outdoors has a protective effect against the development of myopia, although the exact mechanism remains unclear. Near work activities — such as intensive reading, prolonged screen use, and extended studying — are associated with faster progression.
Children should spend at least two hours outdoors each day and take regular breaks during near visual tasks.

Available treatment options

Several validated approaches are currently available for myopia control in children. These target either the modification of peripheral retinal defocus or biological processes influencing axial elongation.

Contact lenses for myopia management

Multifocal and orthokeratology lens designs have proven effective in reducing myopia progression by 40–60% during the first 1–3 years of treatment compared with standard correction. The effect is most pronounced during the first year of wear, and discontinuing treatment may cause a temporary acceleration of progression (the so-called “rebound effect”).
Studies show that the risk of corneal events in children is similar to or even lower than in adults, provided that hygiene and handling instructions are strictly followed.

Spectacle lenses for myopia management

Spectacle lenses designed for myopia management, based on the principle of peripheral myopic defocus, reduce progression by approximately 50% and axial elongation by 60%. They represent a safe and comfortable alternative without additional risks compared to conventional spectacles.

Low-dose atropine therapy

Low-concentration atropine (0.01–0.05%) has the ability to slow myopia progression by strengthening the sclera and improving choroidal circulation, thereby reducing the tendency toward axial elongation. Although not yet authorized in all European countries, recent studies indicate promising results and good tolerability in children.

How long should treatment continue?

Determining the optimal duration of treatment remains one of the main current uncertainties. Research indicates that premature discontinuation — especially in children who are still growing — may result in rapid resumption of progression.
According to the International Myopia Institute (IMI):

• continuation should be reassessed annually
• a minimum monitoring period of twelve months is recommended after discontinuation
• treatment should not be stopped until stabilization of refraction and axial length is documented

According to the World Council of Optometry, wearing myopia management spectacles remains advisable until late adolescence, or shortly thereafter — around the age of 18–20 — when myopia progression typically stabilizes physiologically.

Risk–benefit balance

Although the absolute risk of severe complications is low, each additional diopter of myopia increases the relative risk of retinal pathology by about 40%. Limiting myopia progression offers further benefits, including better unaided visual acuity, thinner and lighter lenses, improved outcomes in refractive surgery, and greater visual comfort in daily activities.

Areas of uncertainty and research directions

Despite significant scientific progress, several questions remain open:

• there are no clear criteria for determining when treatment can be safely discontinued without rebound
• most studies have been conducted in Asian populations, and validation in European cohorts is ongoing
• economic analyses on cost-effectiveness are lacking
• combinations of optical and pharmacological therapies require further investigation

Conclusions

Reducing axial elongation is associated with a lower risk of severe ocular complications, such as myopic maculopathy and retinal detachment. Continuing treatment until complete stabilization of myopia and close follow-up after discontinuation are essential to maintain the achieved benefits.
As new longitudinal studies become available, treatment duration will increasingly be tailored to age, individual response, and risk profile — ensuring an evidence-based and patient-specific approach.

Source: College of Optometrists, “Childhood-onset Myopia Management: Evidence Review”, 2022.