"There is a professional obligation to provide evidence-based myopia management as standard of care for young patients. Yet, there are still important scientific questions that have substantial implications for enabling clinical practice," said Paul Gifford, PhD, FAAO, co-founder of Myopia Profile, in the lecture that he presented with Jeanne Saw, OD, at the 2026 meeting of the American Academy of Optometry. Drs. Gifford and Saw discussed the latest research on the "knowns" and "unknowns" for 4 unanswered questions in myopia management: ideal candidates, comparing efficacy, gauging success, and adult myopia. 

Candidates for Myopia Management

Myopia control treatment trials typically recruit young myopes with a particular range of age and refraction parameters, said Drs. Gifford and Saw. They presented data that highlight the limitations of randomized controlled trial (RCT) evidence¹:

Age at Study Entry/Age By Study End (Maximum Age)

• Myopia control spectacles: 8-13 years, 1 lens 6-10 years (max 19 years)

• Myopia control soft contact lenses: 8-12 years (max 19 years)

• Topical low-concentration atropine: 5-13 years (max 18-19 years)

• Orthokeratology: 7-16 years (max 20+ years)

Astigmatism

• Myopia control spectacles: up to 1.50 DC

• Myopia control soft contact lenses: up to 0.75 DC

• Topical low-concentration atropine: up to 2.50 DC

• Orthokeratology: 1 study up to 3.50 DC

Anisometropia

• Myopia control spectacles: up to 1.25 DS; one lens with evidence for unilateral myopic anisometropia showing less progression in the nonmyopic eye in comparison to orthokeratology.

• Myopia control soft contact lenses: up to 1.00 DS

• Topical low-concentration atropine: not specified in LAMP study

• Orthokeratology: multiple studies on unilateral myopia (fitting 1 eye) and bilateral anisomyopia (fitting both eyes) showing slower axial elongation in the more myopic eye.

Typical Candidates, Based on Median of All RCT Data

• 7-12 years of age at treatment commencement

• -0.75 to -4.50 D of myopia

• Up to 1.25 D astigmatism

• Up to 1.00 D anisometropia

The Knowns and Unknowns

The knowns are that atropine has evidence for younger children and higher myopia; orthokeratology has evidence for higher myopia, astigmatism, and anisometropia; and extended data (after RCTs) for dual-focus concentric soft CL and defocus incorporated multiple segment (DIMS) spectacle lenses to 18-19 years. The unknowns are what to expect for patients who don’t fit these criteria, as well as the influence of ethnicity.

Comparing Efficacy of Available Treatments

Few comparisons of the various interventions for myopia control exist in the literature, and conjecture remains as to whether myopia control efficacy can be described as an absolute or proportional effect, Drs. Gifford and Saw noted. They explained that myopia control treatment efficacy can be described and compared between treatments using millimeters, 1 D threshold, and percentages (See Below).   

The Knowns and Unknowns

The knowns are that most treatments appear similar in efficacy; atropine has a likely dose-response; and rebound effects are minimal with low-concentration atropine and optical treatments. The unknowns are describing efficacy using absolute or proportional effects; if there is a dose-response for optical treatments; and time-course and efficacy ceiling.

Gauging Long-Term Success of Treatments

“Determining the suitability and efficacy of myopia control treatments for the individual patients is a challenge, with suggestions in the literature including comparison to the mean and percentile growth charts,” said Dr. Saw. “The influence of age and expected emmetropic eye growth on myopia control expectations is also important.”

Methods of determining treatment outcomes include comparing over 1 year to account for seasonal variation in myopia progression; comparing refractive or axial-length progression to annual means of treatment groups in myopia-control RCTs; compare to age-matched untreated (single vision corrected) myopia progression, to observe the reduction; and use axial-length data—relative annual changes, percentile comparisons.

The Knowns and Unknowns

The knowns are that mean outcomes in myopia control studies provide simple treatment goals; comparing historical to current progression gives spuriously good results; and axial growth approaching emmetropic rate could indicate a full treatment effect. The unknowns are adjusting study means for younger/older children; comparing means when dealing with an individual; and goals for axial growth in myopia control—is emmetropic rate appropriate or should it be lower?

Managing Young Adult Myopia Progression

“The onset and progression of myopia in young adults is a common clinical observation, but the research evidence on frequency, magnitude, and management is scant,” said Dr. Gifford. The presenters added that 15% of adults have onset of myopia in their 20s; 20% of myopes progress by at least 1 D in their 20s; 40% of myopes progress by at least 0.50 D in their 20s; and axial growth can continue in adult myopia progression—not just refractive.

Adult-onset myopia is common, representing a third or more of all myopia in Western populations, but less in East Asia. Also, stabilization data may underestimate the rates of continuing myopia progression due to early onset—specifically, 50% stabilize by age 15 (refraction) or 16 (axial length), 75% stabilize by age 18, and 90% by age 21, they said.^2-6

Drs. Gifford and Saw also explained that management is challenging as there are no RCT data in this age group. They presented the following extended data (continuation of RCTs after control group switched to treatment): covering patients up to age 18-19 for DIMS⁷ and HAL⁸ spectacle lenses, and dual-focus concentric SCLs⁹; and long-term clinical data for patients wearing orthokeratology for 10 years, up to 26 years of age.¹⁰ They also stressed that retinal health monitoring is vital for adult myopes, and tessellated fundus can predict future onset of myopic macular degeneration in adulthood.

The Knowns and Unknowns

The knowns are that progression is common and not just refractive, and risk factors are less modifiable than in children. The unknowns are whether treatments supported by RCT data will work in young adults and if young adults will experience similar vision outcomes and acceptance to children. OM

References

1. Gifford K, Maher C, Gifford P. The limits of evidence-based myopia control. Invest Ophthalmol Vis Sci. 2023;64(8):824. Accessed September 15, 2026. https://iovs.arvojournals.org/article.aspx?articleid=2786126

2. Bullimore MA, Lee SS, Schmid KL, et al. IMI-onset and progression of myopia in young adults. Invest Ophthalmol Vis Sci. 2023;64(6):2. doi:10.1167/iovs.64.6.2

3. COMET Group. Myopia stabilization and associated factors among participants in the Correction of Myopia Evaluation Trial (COMET). Invest Ophthalmol Vis Sci. 2013;54(13):7871-7884. Published 2013 Dec 3. doi:10.1167/iovs.13-12403

4. Bullimore MA, Jones LA, Moeschberger ML, Zadnik K, Payor RE. A retrospective study of myopia progression in adult contact lens wearers. Invest Ophthalmol Vis Sci. 2002;43(7):2110-2113.

5. Pärssinen O, Kauppinen M, Viljanen A. The progression of myopia from its onset at age 8-12 to adulthood and the influence of heredity and external factors on myopic progression. A 23-year follow-up study. Acta Ophthalmol. 2014;92(8):730-739. doi:10.1111/aos.12387

6. Lee SS, Lingham G, Sanfilippo PG, et al. Incidence and progression of myopia in early adulthood. JAMA Ophthalmol. 2022;140(2):162-169. doi:10.1001/jamaophthalmol.2021.5067 

7. Lam CSY, Tang WC, Zhang HY, et al. Long-term myopia control effect and safety in children wearing DIMS spectacle lenses for 6 years. Sci Rep. 2023;13(1):5475. Published 2023 Apr 4. doi:10.1038/s41598-023-32700-7

8. Li X, Huang Y, Liu C, et al. Myopia control efficacy of spectacle lenses with highly aspherical lenslets: results of a 5-year follow-up study. Eye Vis (Lond). 2025;12(1):10. Published 2025 Mar 5. doi:10.1186/s40662-025-00427-3

9. Chamberlain P, Hammond DS, Bradley A, et al. Eye growth and myopia progression following cessation of myopia control therapy with a dual-focus soft contact lens. Optom Vis Sci. 2025;102(5):353-358. doi:10.1097/OPX.0000000000002244

10. Hiraoka T, Sekine Y, Okamoto F, Mihashi T, Oshika T. Safety and efficacy following 10-years of overnight orthokeratology for myopia control. Ophthalmic Physiol Opt. 2018;38(3):281-289. doi:10.1111/opo.12460