Myopia Management’s Missing Conversation

WRITER Dee Makadia

While the conversations around myopia management have centred on daylight hours – outdoor time, near work, and the interventions that can slow myopia progression – Dee Makadia argues that we may be overlooking a critical part of the picture: the hours between dinner and bedtime.

A few months ago, I examined a teacher. After we spoke, her concern was not about what I’d told her about her eyes, instead, it was about one of her students. “He is bright,” she said, “but he is tired every morning. His concentration dips after midday and his reading has been getting worse.” She had assumed it was a learning issue. Nobody had asked about screens. Nobody had asked about sleep.

That conversation stood out. Not because it was unusual, but because it was the fifth time I’d heard a variation of it that day. In fact, I hear variations of it regularly, from teachers, from parents, and increasingly from young children themselves who lack the vocabulary to describe what they are experiencing but can tell you clearly that their eyes start losing focus or feel sore by the end of the day.

We have made significant progress in how we talk about myopia management. Outdoor time. Near work. Optical intervention. The evidence is strong and the conversation in practice has matured. But there is a part of this picture that I believe we are consistently undervaluing; the hours after the average school day ends.

What happens to a developing eye when its nightly biological reset is consistently disrupted?

That is the question I want to explore here.

THE EYE DOESN’T SWITCH OFF WHEN THE CHILD DOES

One of the things that genuinely surprised me when I began looking more closely at the circadian research was this: axial length is not always fixed across the day. It fluctuates. The eye follows a diurnal rhythm, in most individuals, elongating slightly during waking hours and shortening during sleep.1 Sleep is not passive recovery for the visual system. It is an active biological reset.

The retina, choroid, and sclera each carry their own molecular clocks, generating rhythmic oscillations in gene expression, neurotransmitter release, and tissue behaviour across the 24-hour cycle.2 When those clocks run well, the eye grows and resets in a predictable pattern. When they are disrupted, the research suggests something different begins to happen.

Animal model studies have been particularly revealing here. When the clock gene BMAL1 was selectively knocked out in the retina of mice, the result was relative myopia, with measurable elongation of both the overall axial length and the vitreous cavity compared to controls.3 That is a significant finding. To summarise: Disrupt the molecular clock in the retina, and the eye grows longer.

In human studies, the picture is consistent, though I want to be precise about what the evidence does and does not yet show. What research is pointing to: Myopic individuals demonstrate delayed circadian timing compared to non-myopes, higher morning melatonin concentrations, shorter sleep duration, and poorer sleep quality across multiple studies.4 A 2024 study published in Current Eye Research found associations between late bedtimes and reduced diurnal variations in axial length, with delays in bedtime correlating with axial length increases in young adults.5

It is worth noting Mendelian randomisation analyses have not confirmed that sleep disturbances directly drive axial elongation, and the relationship may be bidirectional. But a 2026 review in Frontiers in Physiology described circadian disruption as implicated in abnormal axial elongation through dopamine and melatonin signalling pathways, light-dependent retinal mechanisms, and diurnal fluctuations in intraocular pressure.2

For a clinician, it is a framework worth building into relevant conversations. The association is consistent enough to act on and the practical recommendations that follow from it are low risk, aligned, and useful.

EVENING SCREENS

Blue light in the 450 to 480 nanometre range is the primary driver of melatonin suppression through the melanopsin-containing photosensitive retinal ganglion cells. Evening exposure to screens in this wavelength range delays melatonin onset, pushes sleep later, and reduces total sleep duration.6

A child using a screen until 9pm is not simply losing sleep time. They are suppressing the melatonin signal that initiates the body’s shift into its overnight biological program. The eye’s diurnal reset, which depends on that program, is delayed or shortened. Night after night, across months and years of development, the cumulative effect on axial length regulation is a question the research community is actively working to answer.

I am not suggesting we overstate this to patients or families. But I do think it changes what we ask about in the consult. Sleep timing and evening screen habits are now clinically relevant data points. We should be collecting them.

WHY CHILDREN ARE THE PRIORITY

Children are not simply more exposed to screens than previous generations. They are more biologically vulnerable to the circadian consequences of that exposure. The crystalline lens in a child transmits significantly more short-wavelength light than an adult lens. Their circadian systems are more sensitive to evening light disruption. And their eyes are at the precise developmental stage where axial elongation is most responsive to environmental signals.

Research published showed increased screen time is linked to more severe insomnia symptoms.7 The visual system consequences of that sleep disruption are now being mapped alongside the broader health picture, and what is emerging points in a consistent direction.

There is an insight here that I find genuinely underused in how we communicate with parents. The outdoor time recommendation, which remains the strongest evidence-based intervention we have for myopia risk reduction, does something else that we rarely mention. Bright natural light during the school day advances melatonin onset in the evening while supporting earlier and more consistent sleep timing.8 This one recommendation provides two protective mechanisms working simultaneously. The child who gets good outdoor time at school is not just protecting their eyes from axial elongation during the day. They are creating a better night’s sleep that evening.

That is a message parents can understand immediately. It is also a message that transforms outdoor time from a rough guideline into something with clear reasoning.

MY OWN CLINICAL OBSERVATION

Brendan Hunter* is a professional golfer. He came to me having already trialled two different pairs of blue light blocking glasses with no measurable benefit to either how he felt or how he performed. His professional grade wearable sleep monitor was showing consistently poor restorative sleep across six months of baseline data. Deep sleep and rapid eye movement (REM) sleep stages were both significantly below what his training and recovery demands required.

We reviewed his habits carefully. Nutrition timing in the evening. Fluid intake. Device type, and usage duration. Room lighting. The single intervention we introduced was a pair of blue light blocking lenses with a specific short-wavelength filter, worn consistently from 7pm each evening.

Over the following two months, tracked against his six-month baseline, Mr Hunter recorded a consistent improvement of more than 70% in restorative sleep. Deep sleep and REM both improved substantially. Nothing else in his routine changed.

Mr Hunter is one patient. This is not a controlled trial, and I am not presenting it as one. But two things from his case are directly relevant to the children we see in practice.

The first is that wavelength specificity matters. His previous two pairs of glasses had not filtered the relevant part of the spectrum with sufficient precision. Not all blue light lenses are clinically equivalent, and this is a conversation worth having with parents who have already tried something and found it did not help.

The second is that individual monitoring changes the conversation. When a patient or parent can see the outcome in their own data, the clinical recommendation shifts from advice to evidence. For families already using sleep tracking devices or applications, this is an accessible and engaging conversation to start. It also creates the kind of feedback loop that drives adherence in a way that a recommendation alone rarely does.

WHAT THIS MEANS IN PRACTICE

Given what the evidence now supports, I think the following strategies are worth building into how we communicate with pre-school and school-aged patients and their parents. None of these are new in isolation. What has changed is the rationale we can now offer, and the way that rationale connects daytime and evening habits into a single coherent picture.

Outdoor time, minimum 90 minutes daily under natural light. This remains the strongest intervention we have for myopia risk reduction, and it is also the most effective circadian anchor a school-age child has access to. I now explain both benefits together. The child who plays outside after school is protecting their eyes during the day and improving their sleep that night. Both mechanisms are real. Both are worth communicating.

The 10-10 rule as a classroom visual break. Every 10 minutes of near screen work, look far for 10 seconds. I prefer this to the 20-20-20 rule for a school setting because it is simpler, and frequent, and fits naturally into the rhythm of a lesson. It reduces the accommodative load that builds across a school day, and it is easy for a child to remember and self-monitor. Successful habit change requires smaller more regular intervention.

Device distance. Screens held closer than 30 cm place significantly greater demand on the accommodative system. Arm-length distance is practical and memorable for younger children, and it is something a teacher or parent can observe and correct without specialist training.

Evening screen limits framed as circadian protection. No screens within 90 minutes of sleep onset. The framing of this recommendation matters more than I used to appreciate. Parents who understand they are protecting their child’s biological clock, not simply following a screen time guideline, engage with it differently. I connect it explicitly to eye health and to the circadian research. That is a conversation we are positioned to have that most other health professionals are not.

Wavelength-specific blue light filtering on evening devices. Where evening screen use cannot be eliminated, lenses or screen filters that target the 450 to 480 nanometre range provide a practical layer of circadian protection. Not all products in this category filter the same wavelengths with the same precision.

THE AFTER-SCHOOL CONVERSATION

The teacher I examined did not know she was describing a sleep and circadian problem. She just knew her student was struggling. As it turned out, he had adopted a later bedtime and was on his phone until well past 10pm most evenings.

We are not yet able to draw a definitive line between disrupted sleep and accelerated axial elongation in children. The research is moving in that direction, and the biological evidence is strong. But we do not need to wait for that line to be drawn before we start asking the question.

The myopia conversation has been well-served by its focus on what happens during the school day. What is less developed is the conversation about what happens after the bell. For most children, the hours between dinner and sleep are now filled with continued near work and screen exposure under artificial light. The biological system that governs eye growth does not switch off when the homework is done.

The question we must ask parents of our paediatric patients then, is, “when did your child last go to bed before 9pm without screens 90mins before?”.

KEY TAKEAWAYS

• The eye follows a diurnal rhythm, with axial length fluctuating across the 24-hour cycle. Sleep is an active biological reset for the visual system, not passive recovery.

• Myopic individuals consistently show delayed circadian timing, higher morning melatonin, and poorer sleep quality compared to non-myopes. The association is consistent but causation in humans is not yet confirmed.

• Evening blue light in (and not limited to) the 450 to 480 nanometre range suppresses melatonin onset and disrupts the circadian program that the eye’s nightly reset depends on.

• Outdoor time does double duty: it reduces axial elongation risk and anchors the circadian clock for better sleep that evening. Both benefits should be communicated together.

• The 10-10 rule (every 10 minutes of near work, look far for 10 seconds) is a simple, classroom-applicable visual break that reduces accommodative load across the school day.

• Evening screen protection and limits framed as circadian protection, rather than screen time guidelines, increase parental engagement and adherence.

• Sleep timing and evening screen habits are now clinically relevant data points in a myopia consult. Adding one question to the history can open a significantly more useful conversation.

Dee Makadia is an optometrist and founder of Eyehouse (eyehouse.com.au). With over 20 years’ of clinical experience across Australia and the United Kingdom, he has a particular interest in eye longevity, digital eye health, and the intersection of lifestyle habits and visual outcomes. He regularly delivers education sessions in school and community settings across Australia.

Disclosure: Eyehouse is an Australian eye health platform that distributes blue light filtering and eye care products. This article represents Mr Makadia’s independent clinical perspective and was written without commercial influence.

References
1. Stone RA, Quinn GE, Schmid G, et al. Diurnal axial length fluctuations in human eyes. Invest Ophthalmol Vis Sci. 2004;45(1):63-70. doi: 10.1167/iovs.03-0294.
2. Zhang N, Han G, Hao R. The role of circadian rhythms in the pathogenesis of myopia. Front Physiol. 2026 Apr 1;17:1797489. doi: 10.3389/fphys.2026.1797489.
3. Stone RA, McGlinn AM, Pardue MT, et al. Altered ocular parameters from circadian clock gene disruptions. PLOS ONE. 2019. doi: 10.1371/journal.pone.0217111.
4. Chakraborty R, Micic G, Lack LC, et al. Myopia, or near-sightedness, is associated with delayed melatonin circadian timing and lower melatonin output in young adult humans.
Sleep. 2021;44(3). doi: 10.1093/sleep/zsaa208.
5. Liu XN, Yap SEL, Sankaridurg PR, et al. Late bedtime and altered diurnal axial length rhythms of the eye. Curr Eye Res. 2024;49(1):101-109. doi: 10.1080/02713683.2024.2396383.
6. Chang AM, Aeschbach D, Duffy JF, Czeisler CA. Evening use of light-emitting eReaders negatively affects sleep, circadian timing, and next-morning alertness. Proc Natl Acad Sci. 2015;112(4):1232-1237. doi: 10.1073/pnas.1418490112.
7. He X, Pan B, Ma N, Li D, Kong W, Liu Q, et al. The association of screen time and the risk of sleep outcomes: a systematic review and meta-analysis. Front Psychiatry. 2025;16:1640263. doi: 10.3389/fpsyt.2025.1640263.
8. He M, Xiang F, Morgan G, et al. Effect of time spent outdoors at school on the development of myopia among children in China: A randomized clinical trial. JAMA. 2015;314(11):1142-1148. doi: 10.1001/jama.2015.10803.