Myopia management has undergone a fundamental shift in clinical optometry. Once regarded as a benign refractive inconvenience of childhood, myopia is now widely recognized as a progressive, lifelong disease that has measurable, dose-dependent associations with vision-threatening ocular pathology. Large epidemiologic studies demonstrate that increasing degrees of myopia are linked to higher lifetime risks of retinal detachment, myopic maculopathy, open-angle glaucoma, and earlier cataract development.1-3 Importantly, these risks rise incrementally with each additional diopter of myopia, reframing even “moderate” myopia as clinically consequential rather than optically trivial.
Work by Flitcroft1 and others has been instrumental in advancing this disease-based model. Population and modeling data suggest that each additional diopter of myopia confers a meaningful increase in the lifetime risk of irreversible visual impairment, particularly from myopic maculopathy and retinal detachment. From a public health perspective, relatively small reductions in the maximum level of myopia achieved in adulthood in a population (final myopia) can yield disproportionately large reductions in vision loss at the population level. This evidence supports a paradigm in which myopia progression is not merely tolerated but actively mitigated.
This reframing is now reflected in guidance from major professional and public health organizations. The World Health Organization has identified myopia as a leading cause of avoidable visual impairment worldwide and has called for strategies that delay onset and slow progression. The International Myopia Institute (IMI) has published a comprehensive series of white papers that define myopia, identify risk factors, and outline evidence-based management principles.4 Professional bodies including the American Academy of Ophthalmology, the American Optometric Association, the World Society of Paediatric Ophthalmology and Strabismus, and the World Council of Optometry have each emphasized that myopia management should be considered a component of contemporary standard eye care rather than an optional subspecialty service.
The Economic and Societal Burden of Myopia
Beyond its clinical consequences, myopia represents a substantial and growing economic burden at both the individual and societal levels. Economic modeling by Naidoo and colleagues has highlighted the magnitude of this impact by estimating productivity losses and lifetime costs associated with myopia and its complications.5 In their analysis, they estimated that global productivity losses attributable to uncorrected myopia exceeded hundreds of billions of US dollars annually, plus additional losses related to vision impairment from myopic macular degeneration.5
Importantly, the economic burden of myopia is not confined to individuals with high myopia. Because the risk of ocular pathology increases incrementally with each additional diopter, societal costs are distributed across the much larger population with low-to-moderate myopia. As prevalence rises globally, even small shifts in average refractive error have the potential to influence long-term health care utilization, productivity, and quality of life.
Naidoo5 and colleagues have also proposed frameworks for evaluating the lifetime economic impact of myopia management strategies. These models suggest that interventions that are capable of slowing myopia progression—even modestly—may reduce downstream costs by lowering the average maximum level of adult myopia and decreasing the likelihood of vision-threatening complications later in life. From this perspective, myopia management can be viewed not only as a clinical intervention, but also as a form of preventive investment with potential long-term societal value.
Pharmacologic Therapy With Low-Dose Atropine
Pharmacologic therapy, most commonly with low-dose atropine, represents one of the most versatile tools in the myopia control kit. Unlike optical interventions, atropine does not rely on modifying retinal image quality and therefore does not require changes to refractive correction. These characteristics make it uniquely useful early in the disease course and particularly well suited to patients who are not yet candidates for contact lens–based treatments.
Ideal candidates include younger children with early-onset myopia, children demonstrating rapid progression, and premyopic children as defined by the IMI—those with insufficient age-appropriate hyperopia to reasonably expect avoidance of myopia. In clinical practice, risk stratification can be strengthened further by incorporating family history, such as one or both parents with myopia or older siblings who are already affected. Increasingly, axial length measurements provide critical additional insight. Children whose axial elongation fails to slow with age or accelerates as they approach myopia may warrant intervention even before refractive thresholds are crossed.
Beyond refractive and demographic risk factors, biometric markers can further refine risk assessment. One such measure is the axial length–to–corneal radius ratio (AL/CR), which accounts for ocular elongation relative to corneal power.6 Longitudinal studies have demonstrated that baseline AL/CR predicts incident myopia over subsequent years and often performs better than axial length alone. In large school-based cohorts, AL/CR has been shown to predict 2-year to 4-year incident myopia with area-under-the-curve values in the mid-0.7 range, outperforming axial length as a single metric. Findings from the PICNIC study further support the clinical relevance of AL/CR in young children; it is an important biometric risk factor that is associated with subsequent myopia development when combined with age and refractive status. Together, these data support the use of AL/CR as an adjunctive marker in premyopic children—particularly those with borderline refractions—when deciding whether to initiate early intervention.7
Low-dose atropine offers several practical advantages. Once-daily dosing reduces dependence on daytime compliance, and lower concentrations are generally associated with minimal effects on accommodation and photophobia. Importantly, atropine is uniquely titratable among myopia control modalities. Clinicians can establish a default starting concentration and adjust dosing over time in response to refractive change and axial length trends. In selected cases, short monocular trials—such as administering 2 drops of the same concentration separated by 10 minutes in 1 eye—may help assess incremental efficacy and tolerance before committing to bilateral dose escalation. This monocular trial approach may also be used when deciding whether an older, seemingly stable patient is stable due to the treatment or regardless of the treatment. In these cases, reducing the dose in 1 eye for a short period of time will help assess the true stability of the patient’s myopia.
Another distinctive feature of atropine therapy is its adaptability to predictable seasonal variation. Multiple studies have demonstrated that myopia progression often accelerates during fall and winter months, coinciding with reduced outdoor time and increased academic demands.8 Atropine dosing can be adjusted seasonally to reflect these changes in risk, which reinforces the concept of myopia as a dynamic disease that benefits from ongoing, individualized management rather than a fixed prescription. Just remember: Change your clocks, change your smoke detector batteries, change your atropine.
Soft Contact Lens–Based Optical Treatments
Soft contact lens–based myopia control includes lenses that are designed to impose myopic defocus simultaneously with in-focus images, or lenses that were originally designed for presbyopia but can be used to manage myopia. These lenses are worn during waking hours and integrate naturally into many patients’ daily routines.
Ideal candidates include school-aged children and adolescents who demonstrate readiness for contact lens wear, participate in sports or other active pursuits, or prefer freedom from spectacles during the day. Families with prior experience using contact lenses or a strong commitment to hygiene and follow-up are particularly well suited to this category.
These lenses provide consistent optical treatment throughout the day and allow clinicians to reinforce adherence and wear time during routine visits. Because they are worn during periods of near work and distance viewing, they align well with the child’s natural visual environment. For many patients, soft contact lenses represent a balance between visual performance, lifestyle compatibility, and myopia management objectives. Many of the optical features of this category are also available in gas permeable or hybrid bifocals or multifocals, which may have certain advantages for some patients.
Orthokeratology
Orthokeratology occupies a distinctive place within the myopia control kit. By reshaping the cornea during overnight lens wear, orthokeratology provides functional unaided vision during the day while altering peripheral retinal defocus patterns.
Ideal candidates include motivated patients and families who are willing to commit to nightly wear, meticulous lens care, and regular follow-up. Orthokeratology is often attractive to children who are involved in sports or activities where daytime corrective devices are inconvenient or undesirable.
This category requires a higher level of practitioner expertise, specialized equipment such as corneal topographers, and patient education. Success depends on careful case selection, precise fitting, and ongoing monitoring. When appropriately prescribed and managed, orthokeratology offers a structured treatment framework that integrates well into long-term myopia management.
Spectacle Lens-Based Myopia Control
Spectacle-based myopia control lenses have expanded the ability to initiate treatment in younger children and in those who are not candidates for contact lens wear. These lenses incorporate optical designs that are intended to influence retinal defocus or contrast while preserving familiar spectacle use.
Ideal candidates include very young children, patients with contraindications to contact lens wear, and families who prioritize simplicity and safety. Spectacle lenses may also serve as an entry point to a staged approach that allows families to engage with myopia management before progressing to other interventions.
The primary strengths of this category are accessibility and ease of use. Although effectiveness depends on consistent wear, spectacle lenses allow clinicians to intervene early when progression is more rapid, and to establish expectations for on-going monitoring and care.
Environmental and Behavioral Interventions
Environmental and behavioral strategies such as outdoor time, managing near-work duration, encouraging regular visual breaks, and addressing ergonomics and viewing distance are essential adjuncts within the myopia control kit.
All children who are at risk for myopia progression are candidates for these interventions, regardless of their primary treatment modality. While not intended as standalone therapies, environmental strategies reinforce overall management goals and promote healthy visual habits.
Building and Adjusting the Kit Over Time
The strength of a myopia control kit lies in its flexibility. As children age, mature, and demonstrate changes in progression patterns, management strategies may evolve. Components can be added, modified, or titrated based on refractive outcomes, axial length trends, and patient readiness.
Rather than viewing treatment categories as competitors, successful myopia management treats them as complementary tools. Regular monitoring allows clinicians to intervene proactively while maintaining continuity of care and reinforcing the concept of myopia as a chronic, manageable disease.
Conclusion
A myopia toolkit can be viewed much like a home toolkit. Every homeowner owns basic tools—a hammer, screwdriver, and level—to handle routine upkeep and prevent small problems from becoming larger ones. In optometry, a comparable toolkit is risk assessment, monitoring, patient education, and entry-level myopia interventions that should be part of everyday care. These foundational tools alone can meaningfully reduce risk when applied consistently and early.
More complex problems require more specialized tools and training. Just as plumbing, electrical work, or structural repairs demand expertise, advanced myopia treatments such as specialty contact lenses or orthokeratology require experience, instrumentation, and close follow-up. At the highest level, complex or rapidly progressing myopia may benefit from specialty-focused care that integrates multiple modalities and actively adjusts treatment over time.
Seen through this lens, the myopia control toolkit is not about doing everything, but about doing something and doing it well. When all optometrists apply the tools for which they have training and are comfortable using, and collaborate or refer when appropriate, far more children stand to benefit from timely, effective myopia management.OM
References
- Flitcroft DI. The complex interactions of retinal, optical and environmental factors in myopia aetiology. Prog Retin Eye Res. Nov 2012;31(6):622-60. doi:10.1016/j.preteyeres.2012.06.004
- Tideman JW, Snabel MC, Tedja MS, et al. Association of axial length with risk of uncorrectable visual impairment for Europeans with myopia. JAMA Ophthalmol. 2016;134(12):1355-1363. doi:10.1001/jamaophthalmol.2016.4009
- Holden BA, Fricke TR, Wilson DA, et al. Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmology. 2016;123(5):1036-1042. doi:10.1016/j.ophtha.2016.01.006
- Flitcroft DI, He M, Jonas JB, et al. IMI - Defining and classifying myopia: a proposed set of standards for clinical and epidemiologic studies. Invest Ophthalmol Vis Sci. 2019;60(3):M20-M30. doi:10.1167/iovs.18-25957
- Naidoo KS, Fricke TR, Frick KD, et al. Potential lost productivity resulting from the global burden of myopia: systematic review, meta-analysis, and modeling. Ophthalmology. 2019;126(3):338-346. doi:10.1016/j.ophtha.2018.10.029
- Tang T, Zhao H, Liu D, et al. Axial length to corneal radius of curvature ratio and refractive error in Chinese preschoolers aged 4-6 years: a retrospective cross-sectional study. BMJ Open. 2023;13(12):e075115. doi:10.1136/bmjopen-2023-075115
- Vera-Diaz FA, Jnawali A, Panorgias A, Bex PJ, Kerber KL. Baseline metrics that may predict future myopia in young children. Ophthalmic Physiol Opt. 2023;43(3):466-481. doi:10.1111/opo.13113
- Gwiazda J, Deng L, Manny R, Norton TT, Group CS. 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. doi:10.1167/iovs.13-13029
