The growing burden of myopia and its associated sight-threatening complications is now well documented,1,2 prompting a shift in clinical focus from refractive correction alone to strategies that slow ocular elongation and reduce long-term disease risk.3

Over the past decade, low-dose atropine, orthokeratology (OK), and optical defocus technologies, such as defocus incorporated multiple segments (DIMS) and highly aspherical lenslet target (HALT) spectacle lenses, have become established components of myopia management.4-7However, treatment responses vary considerably, and no single intervention is universally effective. Some children continue to demonstrate rapid axial elongation despite treatment, while others present with already elevated axial lengths that place them at increased risk of future pathological complications.

These challenges have driven interest in therapies that act through different biological pathways and may offer additional options for managing progressive myopia.

Repeated low-level red-light therapy (RLRL) has emerged as one such approach. Initially evaluated in China through a series of randomised controlled trials (RCTs), RLRL has demonstrated significant reductions in axial elongation and myopia progression compared with conventional correction.8 More recently, evidence has expanded to include international clinical trials, real-world cohort studies, combination therapy investigations, and longer-term follow-up data.9-13 At the same time, mechanistic studies have improved understanding of how RLRL may influence ocular growth, while accumulating safety data have provided further reassurance regarding its clinical use.14-16

This article reviews the evolving evidence for RLRL, examines current understanding of its mechanism of action and safety profile, and presents practical insights from clinicians who have integrated the therapy into routine myopia management.

EXPANDING CLINICAL EVIDENCE

Interest in RLRL was initially driven by a landmark multicentre RCT conducted in China. Children receiving RLRL demonstrated significantly less axial elongation and myopia progression than those wearing single-vision spectacles, with axial length used as the primary outcome measure.8 Subsequent studies confirmed these findings across multiple cohorts and clinical settings. A systematic review and meta-analysis, involving 13 studies and 1,857 participants, reported significant reductions in axial elongation and refractive progression, together with consistent increases in subfoveal choroidal thickness.9 These findings suggest that RLRL may influence biological pathways involved in ocular growth rather than simply modifying refractive outcomes.

One of the key questions for clinicians has been whether treatment effects can be sustained over the longer periods typically required for myopia management. Until recently, most published studies reported outcomes over one to two years. Encouragingly, emerging long-term data are beginning to address this question.

A multicentre real-world study recently published in the British Journal of Ophthalmology evaluated the efficacy and safety of RLRL over three years in 362 children and adolescents aged 7–18 years.12 Among the 91 participants who received treatment for at least three years, the satisfactory myopia control rate was 72.5%, defined as annual axial elongation of less than 0.10 mm, with a mean annual axial length change of just 0.06 mm. Satisfactory control rates exceeded 80% during earlier treatment periods, supporting the durability of treatment effects with continued therapy. These findings provide clinicians with increasing confidence that meaningful myopia control can be maintained over clinically relevant timeframes. Importantly, emerging studies from Australia and Europe suggest that these benefits may be generalisable across diverse populations and clinical settings.10-11

GROWING INTERNATIONAL EXPERIENCE

While the initial evidence for RLRL originated from China, more recent studies have demonstrated growing international adoption and evaluation.

An RCT conducted in Australia demonstrated significant slowing of axial elongation in a multi-ethnic cohort and reported no evidence of structural or functional retinal damage during follow-up.10 These findings are particularly relevant for Australian clinicians because they support the applicability of RLRL beyond East Asian populations.

Similarly, a randomised controlled study conducted in Spain evaluated RLRL in combination with OK among European children. The study reported significantly greater reductions in axial elongation compared with OK alone, with many participants demonstrating axial shortening. Importantly, no severe adverse events were observed during the study period.11

Collectively, these studies suggest that the benefits of RLRL may be generalisable across diverse patient populations and clinical settings. Preliminary data from Japan have reported substantial reductions in axial elongation over 12 months, with almost 70% of participants achieving satisfactory myopia control and many demonstrating axial shortening. While these findings await peer-reviewed publication, they further support the growing international experience with RLRL. Additional studies are currently underway in Australia, Japan, the Middle East, and the European Union, and are expected to further strengthen the global evidence base.

COMBINATION THERAPY: A NEW FRONTIER

As experience with RLRL grows, increasing attention is being directed towards its use alongside established myopia management interventions.

Recent studies have evaluated RLRL in combination with OK, DIMS spectacle lenses, and other optical therapies. Early findings suggest that combination approaches may provide additive benefits, particularly in children demonstrating continued progression despite monotherapy.11-13 A recent meta-analysis of adjunctive RLRL therapy reported greater reductions in axial elongation and refractive progression compared with control interventions, together with further increases in choroidal thickness.13

Although longer-term studies are still needed, these findings support the concept of personalised treatment strategies that combine complementary mechanisms of action to optimise myopia control.

UNDERSTANDING AXIAL SHORTENING

One of the most intriguing observations reported in RLRL studies has been the occurrence of axial shortening in a proportion of treated children. While conventional myopia interventions typically aim to slow elongation, several RLRL studies have documented small reductions in measured axial length, with higher rates reported among children with more advanced myopia.11-13

The biological basis of this phenomenon remains under investigation. Current hypotheses suggest that improvements in choroidal perfusion and metabolic activity may reduce scleral hypoxia and influence scleral remodelling.14 These theories are supported by consistent observations of increased choroidal thickness and emerging mechanistic studies exploring retinal-choroidal signalling pathways.

Importantly, axial shortening should be interpreted cautiously. It is best viewed as a structural observation that may provide insight into treatment mechanisms rather than evidence of reversal of myopia itself. Nevertheless, these findings continue to generate considerable scientific interest and may contribute to a deeper understanding of ocular growth regulation.

MECHANISM OF ACTION

Although the clinical efficacy of RLRL is becoming increasingly well established, the precise mechanisms underlying its effects remain an active area of investigation. Unlike optical and pharmacological interventions that primarily influence retinal defocus or accommodative pathways, RLRL is thought to act through biological mechanisms involving the retina, choroid, and sclera.

One of the most consistent findings across clinical studies has been an increase in subfoveal choroidal thickness. Meta-analyses and individual trials have repeatedly demonstrated choroidal thickening during treatment, often within the first few months of therapy.9,11,13 Because the choroid is a highly vascular tissue responsible for supplying oxygen and nutrients to the outer retina, these observations have led to the hypothesis that RLRL may enhance choroidal perfusion and metabolic activity, thereby influencing scleral remodelling and ocular growth regulation.14

Another proposed mechanism involves photobiomodulation. Red-light within the wavelength range used by RLRL can be absorbed by mitochondrial chromophores, particularly cytochrome c oxidase, enhancing cellular energy metabolism without inducing thermal tissue damage. Experimental studies have demonstrated increased mitochondrial activity, reduced inflammatory signalling, preservation of choroidal thickness, and modulation of nitric oxide-related pathways following RLRL exposure.14

The phenomenon of axial shortening observed in some RLRL-treated children has generated particular scientific interest. While its biological basis remains incompletely understood, proposed mechanisms include choroidal expansion, improved tissue oxygenation, and changes in scleral remodelling.11-13 Emerging evidence from Japan has also identified structural changes, consistent with scleral reshaping in children demonstrating axial shortening, suggesting that multiple pathways may contribute to this response.

While no single mechanism has yet been definitively established, current evidence suggests that RLRL may influence ocular growth through complementary effects on choroidal physiology, cellular metabolism, and scleral remodelling. Together, these findings provide biological plausibility for the clinical outcomes observed in both randomised trials and real-world studies.

SAFETY: WHAT DOES THE EVIDENCE SHOW?

Safety remains a critical consideration whenever new technologies are introduced into clinical practice. Given that RLRL involves repeated exposure to visible red-light delivered directly to the eye, careful evaluation of retinal structure, retinal function, and long-term ocular health has accompanied its clinical development.

To date, evidence from RCTs, real-world cohort studies, and dedicated safety investigations has been reassuring. Across multiple studies, treatment has been associated with preserved visual acuity, stable retinal imaging findings, and no evidence of cumulative retinal injury during follow-up.8-12

One of the most comprehensive assessments comes from the recently published three-year multicentre real-world study involving 362 participants.12 While optical coherence tomography (OCT) identified retinal changes in a small number of eyes, best corrected visual acuity remained stable in all patients, and the observed findings were reversible following discontinuation of treatment. Full-field electroretinography demonstrated no treatment duration-dependent abnormalities, providing further evidence that retinal function remained preserved during prolonged treatment.

Additional reassurance comes from studies using advanced retinal imaging techniques, including adaptive optics scanning laser ophthalmoscopy. These investigations found no evidence of reduced cone photoreceptor density or clinically meaningful retinal microvascular changes in children receiving RLRL therapy.15 Together, structural and functional assessments support the retinal safety of RLRL when used according to current treatment protocols.

INDEPENDENT SAFETY EVALUATION

In addition to clinical safety monitoring, the Eyerising Myopia Management Device (EMMD) has undergone independent evaluation by internationally recognised experts in ophthalmic laser safety. These include Dr Karl Schulmeister, an international laser safety scientist and project leader of the international laser safety standard IEC 60825-1, and Professor John Marshall, Emeritus Professor of Ophthalmology at University College London and a world-leading authority on retinal laser–tissue interactions.16

Using accredited laboratory measurements and established retinal safety models, the investigators independently assessed the optical output of the EMMD and its intended clinical use. Their analysis concluded that the device operates within recognised safety margins when used according to the prescribed treatment protocol.16

Importantly, these conclusions are consistent with findings from clinical studies reporting preserved visual acuity, stable retinal imaging, normal electrophysiological testing, and no evidence of cumulative retinal injury during follow-up. Together, the clinical and laboratory evidence provides reassuring support for the safety profile of RLRL therapy.

PRACTICAL MONITORING IN CLINICAL PRACTICE

As with other myopia management interventions, appropriate monitoring remains important. Baseline assessment typically includes cycloplegic refraction, axial length measurement, visual acuity assessment, and macular OCT imaging. An early review may be useful to assess treatment tolerance and adherence, while six-monthly follow-up facilitates monitoring of axial growth and treatment response.

Transient after-images remain the most commonly reported subjective effect and typically resolve spontaneously. Published studies have reported high levels of treatment acceptance and compliance, with many cohorts demonstrating adherence rates exceeding 85–90%. As clinical experience continues to expand internationally, ongoing surveillance and longer-term follow-up will further strengthen understanding of the therapy’s long-term safety profile.

CLINICAL PERSPECTIVES FROM EARLY ADOPTERS

While clinical trials provide the foundation for evidence-based practice, real-world clinical experience often shapes how new technologies are implemented in everyday care. As RLRL gains wider adoption, clinicians are developing practical approaches to patient selection, treatment monitoring, compliance support, and integration within broader myopia management strategies. The perspectives from Australian practitioners, on the following pages, illustrate how RLRL is being applied in routine clinical practice and the lessons learned along the way.

PRACTICAL CONSIDERATIONS FOR CLINICIANS

As clinical experience with RLRL continues to grow, several practical themes have emerged. Patients most likely to be considered for treatment include those with rapid axial elongation, early-onset myopia, high baseline axial length, strong family history, or ongoing progression despite established myopia control interventions. Increasingly, RLRL is also being incorporated into combination strategies for children requiring additional treatment beyond conventional optical or pharmacological approaches.

Objective monitoring remains central to treatment success. Baseline assessment typically includes cycloplegic refraction, axial length measurement, visual acuity assessment, and ocular health evaluation, with macular OCT imaging providing useful supplementary information. Following treatment initiation, an early review may help assess tolerance and adherence, while six-monthly follow-up incorporating axial length measurement allows clinicians to evaluate treatment response and guide ongoing management.

As a home-based therapy, patient engagement and compliance are critical. Clear communication, realistic expectation setting, and regular follow-up help support long-term adherence and optimise outcomes. As evidence continues to evolve, RLRL is becoming an increasingly valuable addition to the myopia management toolkit, offering clinicians a mechanistically distinct option for children at risk of progressive myopia.

WRITER Vivien Ta

One of the most challenging situations in myopia management is caring for children who continue to progress despite established treatments. While many patients respond well to optical interventions or atropine, a subset continue to demonstrate clinically significant axial elongation, placing them at increased risk of future pathological myopia.

One of my memorable experiences with RLRL involved a girl of Asian descent with a strong family history of myopia. Her mother was approximately -4.00D, while her father had high myopia exceeding -10.00D and glaucoma. She enjoyed reading and music and had significant academic demands, all of which contributed to concerns regarding her long-term risk of progressive myopia.

I first reviewed her in 2021 when she was

Figure 1. Axial length trajectory before and during RLRL therapy in a high-risk child with progressive myopia.

Figure 2. Serial OCT imaging demonstrating increased choroidal thickness during RLRL therapy.

essentially emmetropic. Over the following two years, she demonstrated progressive myopic change, despite lifestyle advice and the introduction of MiyoSmart spectacle lenses. By January 2024, her refractive error had increased to approximately -1.25D in both eyes, and a recent growth spurt raised further concerns. Additional myopia management options were discussed, although the family remained hesitant. Following further progression to -1.50D in both eyes, RLRL therapy was offered in April 2024 and commenced shortly thereafter, when the patient was 13 years old.

The patient demonstrated very good engagement with treatment. Over the first 12 months of therapy, axial length shortened by 0.18 mm in the right eye and 0.19 mm in the left eye, with most of the shortening occurring during the first six months of treatment (Figure 1). This was accompanied by a modest hyperopic shift in spherical equivalent refraction (SER), while best-corrected visual acuity remained excellent throughout follow-up (6/4.8 in the right eye and 6/4.8− in the left eye). At the 24-month review, myopia progression remained stable, with the axial shortening maintained. OCT imaging demonstrated considerable choroidal thickening, with no adverse structural or functional retinal changes observed during follow-up (Figure 2).

For me, this case highlights the potential of RLRL therapy to favourably influence axial growth trajectories, even in children with significant hereditary risk factors for progressive myopia.

WRITER Griffin Ngo

In our practice, RLRL is incorporated within a comprehensive myopia management framework rather than being used as a standalone intervention. Treatment decisions are guided by axial length progression, individual risk factors, family history, and previous response to therapy.

One patient who highlighted the potential role of RLRL was a 16-year-old male with very high myopia. His refractive error measured approximately -10.75/-2.00×35 in the right eye and -14.50/-3.00×155 in the left eye. Due to the magnitude of his refractive error, orthokeratology was not considered suitable, while commercially available soft contact lens designs offered limited myopia control potential. As a semi-professional soccer player who travelled frequently for competition, he also required a management strategy that could accommodate a demanding schedule.

To address both refractive correction and myopia control, multifocal scleral lenses were prescribed as his primary visual correction, while RLRL was selected as the principal myopia control intervention. The patient adapted well and remained highly motivated throughout follow-up. Despite frequent travel commitments, including overseas soccer tournaments, he consistently maintained treatment, even taking the RLRL device with him while travelling. to demonstrate gradual axial elongation. Following initiation of therapy in November 2024, axial length initially decreased before stabilising. At 12 months, the right eye remained shorter than at the start of therapy, while the left eye demonstrated only 0.13 mm of axial elongation over the same period (Figure 3). These outcomes represented a substantial improvement compared with the previous trend of progressive axial growth.

For me, this case highlights the potential role of RLRL in highly myopic adolescents for whom conventional myopia control options may be limited. It also demonstrates that successful outcomes can be achieved when treatment adherence is maintained, even in patients with demanding lifestyles.

Figure 3. Axial length changes following initiation of RLRL therapy in an adolescent with high myopia.

WRITER Philip Cheng

In my practice, the children most likely to be considered for RLRL are not necessarily newly diagnosed myopes. More commonly, they are patients who continue to progress despite using established myopia control treatments, demonstrate faster-than-expected axial elongation for their age, have strong hereditary risk factors, or present with early-onset myopia, placing them at high risk of developing high myopia later in life.

Through my years of experience in managing myopia, one of the key lessons I have learned is that successful implementation depends as much on communication as it does on clinical efficacy. For children who are still progressing in their myopia despite treatment, their parents are generally concerned and are interested in potentially more effective options for their child. Rather than focusing on the technology itself, I begin by discussing the child’s current progression and explaining why additional intervention may be warranted. This helps parents understand the rationale for treatment escalation before introducing RLRL as a potential solution.

To support decision making, we offer potential RLRL candidates and their family a hands-on demonstration of the device and provide them with written information addressing common questions. Our clinic’s front-of-house team plays an important role in this process. Each team member is trained in talking to patients and parents about myopia management options and the processes involved with each treatment, including RLRL. In my experience, seeing the device and allowing both the child and parents to experience the treatment significantly reduces uncertainty and improves acceptance. Most parents become comfortable with the treatment after this introductory process with our team, with only a small proportion requiring further clinical discussion with our optometrists.

Compliance is key to effective myopia management and maintaining long-term adherence is important with any prescribed treatment. RLRL is the only myopia treatment where the practitioner can monitor compliance remotely. Every patient is reviewed one month after commencement and receives ongoing compliance monitoring via the Eyerising portal. Monthly follow-up messages are used to reinforce good adherence, identify barriers to treatment, and intervene early when compliance begins to decline. For patients with persistent compliance issues, review appointments are brought forward so that concerns can be addressed before treatment outcomes are affected.

Figure 4. A structured workflow for integrating RLRL therapy into routine clinical practice.

This structured approach (Figure 4) has allowed RLRL to be incorporated efficiently into our busy clinical practice without disrupting routine workflows. More importantly, it has helped build a growing cohort of engaged patients and families who remain committed to long-term myopia management. In my experience, careful patient selection, clear communication, and proactive follow-up are just as important as the treatment itself in achieving successful outcomes.

This article was sponsored by Eyerising International.

References available at mieducation.com.