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Myopia management in clinical practice

Evidence-based guidance on the management of myopia in practice

optometristatwork

It is predicted that by 2050 approximately half of the world’s population will have myopia, with 10% projected to have high myopia.1

Risk factors for myopia include parental history, environmental factors, and being of East Asian ethnic origin.2 The presence of myopia increases the risk of several ocular pathologies, including myopic maculopathy, glaucoma, cataract and retinal detachment.3 While those with high levels of refractive error are at greatest risk, even low myopes have an increased likelihood of developing these conditions over their lifetime.4

In the UK, the prevalence of myopia in children has more than doubled in the last half a century and is manifesting at a younger age, leading to a greater proportion of children with high levels of refractive error. Earlier onset is associated with faster progression and a higher probability of developing high myopia, reinforcing the need for proactive identification and management during childhood.4,5

Strategies that delay onset and slow progression have the potential to reduce both the lifetime burden of refractive error and the associated risk of ocular disease. Additional benefits of retaining a lower level of myopia include improved unaided and best-corrected visual acuity, enhanced vision-related quality of life, reduced dependence on optical correction,6 improved eligibility and outcomes for refractive surgery,7 and a greater likelihood of meeting occupational vision standards.

A range of evidence-based interventions are available to support myopia management. These include optical interventions designed to slow axial elongation, pharmacological approaches such as low-dose atropine, as well as lifestyle modifications that can help to delay the onset, and potentially progression, of myopia.8

The uptake of myopia management interventions within mainstream clinical practice continues to increase. It is, therefore, essential that optometrists maintain up-to-date knowledge of available management options, including their evidence base, benefits, limitations, and suitability for different patient groups.

Decisions to recommend myopia management interventions should be made by the optometrist on a case-by-case basis, incorporating clinical findings, patient risk factors, patient and parent preferences, and practical considerations such as access and cost.

Members of the wider practice team involved in the patient journey should understand the rationale for myopia management and support consistent, evidence-based patient communication, directed by the optometrist on an individual basis.

If you, or the setting you are working in, do not offer myopia management interventions, then you should be able to establish which practitioners in the local area offer these services so you can direct patients if needed.

Lifestyle interventions

Delaying myopia onset is important: with each year of delay roughly equivalent to two to three years of treatment with current therapies.9

Time outdoors

Spending time outdoors can help to prevent and delay the onset of myopia development in children.10,11 The mechanism for this remains unclear but is likely to be multifactorial. If the onset of myopia can be delayed, this is likely to reduce the magnitude of the refractive error and reduce the risk of developing ocular comorbidity in later life.9 With this in mind, children at risk of myopia, for instance, those with a parental history of myopia or low hyperopia for their age, should be advised to spend regular time outdoors where possible. Current consensus supports a pragmatic target of approximately two hours per day outdoors where possible, while recognising that even incremental increases in outdoor time can be beneficial.10 Time outdoors may also slow the progression of refractive error in existing myopes but the evidence for this is less certain.12,13

Near activities and screen use

More time spent in education is a known risk factor for myopia, and although the mechanism remains unclear, this may be due to time spent on near tasks.11

While screen time and near work are commonly studied as risk factors for myopia, the evidence remains limited. Screen time alone is unlikely to be a primary causal factor; rather, it is often confounded with reduced outdoor time. The COVID-19 pandemic provided natural evidence that increased near work and screen use can accelerate myopia onset, especially in children,14-16 but outdoor activity remains the most supported modifiable protective factor.10,11 While further studies are needed to clarify the independent role of screen use, reducing non-essential time on near tasks, such as digital devices, by taking regular breaks, along with spending more time outdoors, offers a balanced approach that can be easily implemented.

Optical interventions

Single vision correction of myopia results in the eye being exposed to relative peripheral hyperopic defocus, which is thought to drive axial growth.17

It was once considered that undercorrection of myopia might slow its progression by reducing accommodative demand and lag during near tasks.18 The current evidence shows no benefit from undercorrection, with some studies demonstrating an increase in progression with this approach.19,20 With this in mind, regular sight tests to ensure that myopes are fully corrected are advised.

The mainstay of optical interventions for myopia management is to impose myopic defocus or alter contrast with the aim of slowing down axial growth and subsequent myopic progression.8

Efficacy

The latest output from the International Myopia Institute (IMI) provides a useful summary of efficacy for different myopia control interventions used in clinical practice.8 Note that effect sizes vary substantially between individuals and across lens designs; the figures below represent average outcomes from randomised controlled trials (RCTs) rather than guaranteed results for any one patient: 

  • Soft contact lenses – efficacy across 14 RCTs report slowing of axial elongation up to 0.19mm after one year and 0.28mm after three years, which equates to ~0.50D and ~0.75D, respectively
  • Spectacle lenses – evidence from 10 RCTs indicates slowing of axial elongation of up to 0.35mm (~0.90D) over a two-year period 
  • Orthokeratology – across 10 RCTs, the median slowing of axial elongation is 0.17mm at one year and 0.30mm at two years, equating to ~0.50D and ~0.75D, respectively.

Evidence shows that these optical interventions deliver effective visual performance for patients.21-23

Safety of contact lens wear in children

The literature shows that contact lens wear for children, including orthokeratology, is considered safe, provided that appropriate advice is followed to reduce the risk of infection.24 Reassuringly, the incidence of corneal infiltrative events in children is no higher than in adults, and in the youngest age range of eight to 11 years, it may be markedly lower.25

Use of contact lenses for myopia management that fall outside the manufacturer’s recommended use

In cases where a patient’s refractive error falls outside of the available parameters for a specific myopia management product, a suitable alternative, for example, a multifocal contact lens,26 can be considered as long as an evidence-based approach is taken to justify its use. Given that myopia management options now cover an extensive range of refractive errors, these cases will be rare exceptions and should be justified accordingly.

Other interventions

Atropine

Atropine is used in various parts of the world for myopia management. Early work demonstrated that at 1% concentration, atropine is effective at slowing myopia progression,27 but has unacceptable side effects, including mydriasis, accommodative impairment and risk of allergic reaction, and is also associated with a significant rebound effect upon treatment cessation.8

Follow-up studies have focussed on much lower concentrations of atropine to try and strike a balance between achieving a meaningful clinical outcome while limiting side effects and the potential for rebound.8 Although low concentrations of atropine have been shown to be clinically useful, the optimum dose, frequency and duration of treatment, as well as the potential for long-term rebound, remains uncertain.8

Since 2019, 21 RCTs have been published on 0.01% atropine, demonstrating a median one-year efficacy of slowing axial elongation of 0.08mm and a median two-year efficacy of 0.12mm; this equates to ~0.25D and ~0.33D, respectively.8

In November 2025, the MHRA approved the first low-dose (0.01%) atropine formulation for treating myopia progression in children, with the product anticipated to be available in 2026.28 Key points:

  • Treatment may be initiated for children aged three to 14 years, with a progression rate of 0.50D or more per year, within a refractive range of -0.50D to -6.00D
  • It can be prescribed on a private basis by independent prescribing optometrists and ophthalmologists with appropriate competence in paediatric myopia management
  • General optometrists can refer to a suitably experienced IP optometrist or ophthalmologist or consider a co-management plan with a suitable prescriber, ensuring clear areas of clinical responsibility are set out 
  • Full details of the indications for use, contraindications and adverse effects are provided by the MHRA.28

Combination therapies

While combination or staged myopia management strategies may be considered in selected higher-risk or rapidly progressing cases, the current evidence base remains variable, with limited long-term outcome data.8 Accordingly, routine use of combination therapies is not currently expected in mainstream practice and may be more appropriately reserved for specialist or closely monitored settings. 

Repeated low-level red light therapy (RLRL)

RLRL is an emerging intervention for myopia management, where the patient is exposed to short durations of low-level red light (typically three minutes, twice per day, separated by at least four hours, five days per week) using a table-top device, intended for use at home. RLRL has been used to treat amblyopia in China for decades and anecdotal findings of increased choroidal thickness and stabilisation of axial elongation in those receiving this treatment have led to interest in using this approach for myopia management. At present, research outcomes come from studies of relatively short duration and mostly extend to cohorts in China.29-32 The safety of cumulative exposure to RLRL for myopia management over the longer-term is currently unknown. However, a 2023 case report highlighted retinal damage occurring in a child after five months of RLRL, with partial recovery upon cessation of treatment.33 Furthermore, a paper published in January 2024 highlighted that the output from some RLRL devices could put the retina at risk of photochemical and thermal damage, underlining the need for caution when using this therapy in clinical practice.34

A recent report has highlighted that the China National Medical Products Administration (NMPA) has implemented a major change to regulations affecting RLRL device manufacturing and sales.35 In short, RLRL devices have been reclassified from class II (intermediate-risk level) to class III (high-risk level) and can only be manufactured or sold in China if they meet these more stringent registration conditions. At present, no devices meet this new standard and none are expected to meet this new standard for at least five years.

Given the significant regulatory change regarding the use of RLRL in China, the AOP has taken the decision to pause insurance cover for the use of this therapy until the position around potential safety issues becomes clearer. Members who have already been providing RLRL therapy to patients should contact the clinical and regulatory team for further guidance.

Case scenarios

The young, progressing myope

Seven years of age. Sits close to TV. Eyes recorded as ‘normal’ at previous sight test 12 months ago. Father myopic.

Refraction: 

R -1.00DS 
L -1.00DS 

Given the age of onset and change in refractive error over the past 12 months, this child is at high risk of myopia progression. An evidence-based discussion about myopia management interventions would be appropriate here, covering the following points:

  • Outline in broad terms why it is necessary to try and slow down myopia progression due to potential ocular health implications. The basis of this discussion should be balanced and in the context of absolute risk of ocular comorbidity that may arise in later life 
  • Advise on lifestyle modifications including time outdoors and limiting non-essential near tasks where possible 
  • Discuss the types of interventions that are currently available and their relative merits and limitations 
  • Indicate how long the intervention might be needed for, which could be well into the teenage years when risk of progression is lower 
  • Stress that individual outcomes cannot be predicted, and that the expectation is to slow down, rather than stop or reverse myopia progression. 

The nature of the discussion may take place across several visits and delivered in line with the patient’s and parents’ level of understanding.

Due to the age of myopia onset and refractive change over one year, a six-month review would be appropriate in this case.

The older, stable myope 

15 years old. No family history of myopia. First Rx prescribed two years ago: 

R -1.25DS 
L -1.00DS 

Refraction today: 

R -1.50DS 
L -1.25DS 

This patient has a relatively late onset, low magnitude of myopia which is progressing slowly. The following approach could be taken in this case:

  • Advise a two-year recall unless the patient develops symptoms in the meantime 
  • Although the refractive error is stable, advice on lifestyle modifications would still be appropriate 
  • A single vision intervention would be suitable here and can be justified accordingly on the records, along with clear instructions from the optometrist to guide the dispensing process. 

The child at risk of myopia 

Six years of age. Attending for his first routine sight test. Both parents myopic. Cycloplegic refraction: 

R +0.50DS 
L +0.50DS 

This child has a high risk of developing myopia by the age of 10 years due to a low level of hyperopia for his age and a strong parental history of myopia.11,36

In terms of advice to the family:

  • A one-year recall would be appropriate, unless the patient develops symptoms in the meantime
  • Spending time outdoors and limiting time on non-essential near tasks could help to delay the onset of myopia.

Measuring success

Recent IMI White Papers highlight the value of risk-based approaches to myopia management and the use of axial length measurement to support monitoring where available;37 however, access to axial length instrumentation is not yet universal in UK primary care. As such, axial length monitoring may be considered best practice where feasible, but its absence should not preclude the delivery of evidence-based myopia management using refractive and clinical progression data alone.

Cycloplegic subjective refraction remains the reference standard for the assessment of refractive error. Where this cannot be undertaken, cycloplegic retinoscopy or cycloplegic autorefraction provide the most reliable alternatives. Without cycloplegia, open-field autorefractors provide results that most closely align with cycloplegic retinoscopy.37

As changes in myopia can be seasonal, with slower progression more likely during summer, this should be considered when evaluating the success of interventions. Assessing the clinical picture across a 12-month period can help to account for any seasonal variability in progression.38 

Record keeping and consent

When offering myopia management interventions, it is important that informed consent is undertaken, with appropriate details noted on the records, in accordance with GOC Standards of Practice 3 and 8, respectively.39 

The AOP has produced an information leaflet, approved by the Plain English Campaign, which includes a detachable consent form to be completed by the patient’s parent or legal guardian.40 

The leaflet is designed to be used by a practitioner to reinforce advice given to the patient and their parent or legal guardian during the examination. If you are recommending myopia management interventions for a child or young person you should explain what myopia and myopia management is before providing them with this leaflet.

Once the patient’s parent or legal guardian has read the leaflet and are confident that they understand the risks of myopia, and potential benefits and limitations of current myopia management interventions, they should be asked to complete the consent form at the end of the leaflet. A copy of the consent form should be kept with the patient's records. 

What we don’t know 

Although the myopia management evidence base continues to evolve at pace, uncertainty remains in some areas:8

  • At this moment, it is not possible to predict an individual’s response to a given intervention 
  • The mechanism of action for many interventions remains unclear 
  • A greater understanding of long-term outcomes, including the potential for rebound effects, across a range of diverse populations, and utilising different interventions, is required 
  • Although a central aim of myopia management is to reduce the lifetime risk of ocular comorbidity, the impact of slowing axial elongation upon long-term clinical outcomes is unknown at present. 

Key points

  • All optometrists should keep up to date with the current evidence base so they can advise patients appropriately
  • The decision to recommend a myopia management intervention should be guided by the optometrist on a case-by-case basis
  • Conversations with the patient and their parents should outline the risks of myopia and likely expectations from intervention, being careful to avoid scaremongering or overpromising.

References

  1. Holden BA, Fricke TR, Wilson DA, Jong M, Naidoo KS, Sankaridurg P, et al. Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050. Ophthalmology. 2016;123(5):1036-42 
  2. Morgan IG, Wu PC, Ostrin LA, Tideman JWL, Yam JC, Lan W, et al. IMI Risk Factors for Myopia. Invest Ophthalmol Vis Sci. 2021;62(5):3 
  3. Haarman AEG, Enthoven CA, Tideman JWL, Tedja MS, Verhoeven VJM, Klaver CCW. The Complications of Myopia: A Review and Meta-Analysis. Invest Ophthalmol Vis Sci. 2020;61(4):49 
  4. McCullough S, Adamson G, Breslin KMM, McClelland JF, Doyle L, Saunders KJ. Axial growth and refractive change in white European children and young adults: predictive factors for myopia. Sci Rep. 2020;10(1):15189 
  5. McCullough SJ, O'Donoghue L, Saunders KJ. Six Year Refractive Change among White Children and Young Adults: Evidence for Significant Increase in Myopia among White UK Children. PLoS One. 2016;11(1):e0146332 
  6. Bullimore MA, Brennan NA. Myopia Control: Why Each Diopter Matters. Optom Vis Sci. 2019;96(6):463-5 
  7. Gomel N, Negari S, Frucht-Pery J, Wajnsztajn D, Strassman E, Solomon A. Predictive factors for efficacy and safety in refractive surgery for myopia. PLoS One. 2018;13(12):e0208608 
  8. Bullimore MA, Saunders KJ, Baraas RC, Berntsen DA, Chen Z, Chia AWL, et al. IMI-Interventions for Controlling Myopia Onset and Progression 2025. Invest Ophthalmol Vis Sci. 2025;66(12):39 
  9. Bullimore MA, Brennan NA. Myopia: An ounce of prevention is worth a pound of cure. Ophthalmic Physiol Opt. 2023;43(1):116-21 
  10. Ashby R, Harb EN, Ostrin LA, Flitcroft DI, Schaeffel F, Karouta C, et al. IMI: The Role of Light in Refractive Development and Myopia: Evidence from Animal and Human Studies. Invest Ophthalmol Vis Sci. 2025;66(15):5 
  11. Tahhan N, Bullimore MA, He X, Ostrin LA, Gawne TJ, Gifford KL, et al. IMI-2025 Digest. Invest Ophthalmol Vis Sci. 2025;66(12):27 
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  16. Wang W, Zhu L, Zheng S, Ji Y, Xiang Y, Lv B, et al. Survey on the Progression of Myopia in Children and Adolescents in Chongqing During COVID-19 Pandemic. Front Public Health. 2021;9:646770 
  17. Jonas JB, Ang M, Cho P, Guggenheim JA, He MG, Jong M, et al. IMI Prevention of Myopia and Its Progression. Invest Ophthalmol Vis Sci. 2021;62(5):6 
  18. Nakatsuka C, Hasebe S, Nonaka F, Ohtsuki H. Accommodative lag under habitual seeing conditions: comparison between myopic and emmetropic children. Jpn J Ophthalmol. 2005;49(3):189-94 
  19. García García M, Breher K, Ohlendorf A, Wahl S. To Correct or Not Correct? Actual Evidence, Controversy and the Questions That Remain Open. J Clin Med. 2020;9(6) 
  20. Logan NS, Wolffsohn JS. Role of un-correction, under-correction and over-correction of myopia as a strategy for slowing myopic progression. Clin Exp Optom. 2020;103(2):133-7 
  21. Chamberlain P, Peixoto-de-Matos SC, Logan NS, Ngo C, Jones D, Young G. A 3-year Randomized Clinical Trial of MiSight Lenses for Myopia Control. Optom Vis Sci. 2019;96(8):556-67 
  22. Lam CSY, Tang WC, Tse DY, Lee RPK, Chun RKM, Hasegawa K, et al. Defocus Incorporated Multiple Segments (DIMS) spectacle lenses slow myopia progression: a 2-year randomised clinical trial. Br J Ophthalmol. 2020;104(3):363-8 
  23. Santodomingo-Rubido J, Villa-Collar C, Gilmartin B, Gutiérrez-Ortega R. Myopia control with orthokeratology contact lenses in Spain: a comparison of vision-related quality-of-life measures between orthokeratology contact lenses and single-vision spectacles. Eye Contact Lens. 2013;39(2):153-7 
  24. Prousali E, Haidich AB, Fontalis A, Ziakas N, Brazitikos P, Mataftsi A. Efficacy and safety of interventions to control myopia progression in children: an overview of systematic reviews and meta-analyses. BMC Ophthalmol. 2019;19(1):106 
  25. Bullimore MA. The Safety of Soft Contact Lenses in Children. Optom Vis Sci. 2017;94(6):638-46 
  26. Walline JJ, Walker MK, Mutti DO, Jones-Jordan LA, Sinnott LT, Giannoni AG, et al. Effect of High Add Power, Medium Add Power, or Single-Vision Contact Lenses on Myopia Progression in Children: The BLINK Randomized Clinical Trial. Jama. 2020;324(6):571-80 
  27. Chua WH, Balakrishnan V, Chan YH, Tong L, Ling Y, Quah BL, et al. Atropine for the treatment of childhood myopia. Ophthalmology. 2006;113(12):2285-91. 
  28. https://mhraproducts4853.blob.core.windows.net/docs/9d282d4760f69a95fe878304724d4039cfcced33 [Accessed 25/03/2026] 
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  30. Dong J, Zhu Z, Xu H, He M. Myopia Control Effect of Repeated Low-Level Red-Light Therapy in Chinese Children: A Randomized, Double-Blind, Controlled Clinical Trial. Ophthalmology. 2023;130(2):198-204 
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  32. Xiong R, Zhu Z, Jiang Y, Wang W, Zhang J, Chen Y, et al. Longitudinal Changes and Predictive Value of Choroidal Thickness for Myopia Control after Repeated Low-Level Red-Light Therapy. Ophthalmology. 2023;130(3):286-96 
  33. Liu H, Yang Y, Guo J, Peng J, Zhao P. Retinal Damage After Repeated Low-level Red-Light Laser Exposure. JAMA Ophthalmol. 2023;141(7):693-5 
  34. Ostrin LA, Schill AW. Red light instruments for myopia exceed safety limits. Ophthalmic Physiol Opt. 2024;44(2):241-8 
  35. Wang YX, Wang N, Wong TY. Red Light Therapy for Myopia-Current Regulatory Changes in China. JAMA Ophthalmol. 2025;143(3):197-8 
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  37. Jones D, Chow A, Fadel D, Gonzalez Meijome JM, Grzybowski A, Kollbaum P, et al. IMI-Instrumentation for Myopia Management. Invest Ophthalmol Vis Sci. 2025;66(9):7 
  38. Gwiazda J, Deng L, Manny R, Norton TT. Seasonal variations in the progression of myopia in children enrolled in the correction of myopia evaluation trial. Invest Ophthalmol Vis Sci. 2014;55(2):752-8 
  39. www.optical.org/standards-and-guidance/standards/standards-of-practice-for-optometrists-and-dispens.html [Accessed 25/03/2026] 
  40. www.aop.org.uk/advice-and-support/business/resources-for-your-practice/myopia-management-consent-for-treating-a-child [Accessed 25/03/2026]. 

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