Myopia is more than just a refractive error – it is a progressive and potentially sight-threatening condition. A treatment cascade – a systematic approach that escalates care based on risk, progression, and patient profile – is essential for modern myopia management. This article outlines a practical treatment cascade model to help optometrists make evidencebased decisions at every stage of care and understand when to refer and co-manage with ophthalmologists.

WRITER Emmy Cui

The prevalence of myopia is rapidly rising worldwide and is now recognised as a significant public health concern. By 2050, it is projected nearly half the world’s population will be myopic, with up to 10% having high myopia.¹ In Australia, similar trends are emerging, particularly among school-aged children.

As optometrists, we are at the forefront of identifying, managing, and reducing the risks associated with myopia.

MAPPING THE RISK PROFILE

Early onset of myopia is strongly associated with faster progression and a higher risk of developing high myopia.2 The pathological consequences of high myopia include retinal detachment, myopic maculopathy, choroidal neovascularisation, and glaucoma. These complications arise primarily due to excessive axial elongation.

The first stage in any treatment cascade is to identify which patients are at risk.

Risk factors include:

• Family history of parental myopia,

• East and South Asian ethnicity,

• Early onset of myopia (<9 years),

• Limited outdoor time,

• Excessive near work,

• Rapid axial length elongation,

• Refractive status – low hyperopic reserve for age, and

• Binocular vision function abnormalities.

THE TREATMENT CASCADE: WHAT ARE THE OPTIONS?

Managing myopia involves a range of interventions aimed at preventing, delaying onset, and slowing myopic progression.

Lifestyle Modifications

Lifestyle modifications have been shown to prevent or delay the onset of myopia in children.3-5

All children, regardless of refractive status will benefit from:

Outdoor time. At least 90 minutes daily, ideally two hours.

Near work hygiene. Regular breaks (use of 20-20-20 rule), limit to less than three hours of near work outside of school time, appropriate posture, working distance, and lighting.

Digital device management. Using a larger screen at a greater working distance generally reduces visual strain.

Specialty Myopia Control Spectacle Lens

Both HOYA’s MiyoSmart and Essilor’s Stellest lens have shown significant efficacy in slowing down myopia progression as well as axial length elongation in children.

MiyoSmart utilises defocus incorporated multiple segments (DIMS) technology with its two-year study demonstrating a 52% slowing in myopic progression, and 62% retardation in axial length elongation. The results of its six-year study further support these findings.6,7

Similarly, the highly aspheric lenslet target (HALT) technology in Stellest lenses has proven to be very effective, showing a 57% and 52% reduction in myopia progression and axial length elongation respectively.8

Contact Lenses

Soft myopia control contact lenses and orthokeratology are effective treatment options for controlling myopia progression in children.

CooperVision’s MiSight is a dual-focus soft contact lens, with studies demonstrating up to 59% effectiveness. Long-term data show high rates of compliance and excellent safety.9 MiSight is well tolerated in children as young as eight years old, making it a viable and safe option for long-term myopia management in paediatric patients.

Johnson and Johnson’s newly approved Abiliti 1-Day contact lens employs RingBoost technology within a silicone hydrogel material. Early data from a six-month clinical study have shown promising results in reducing axial elongation, indicating its potential as an effective option for managing paediatric myopia. Its smaller diameter enhances comfort and handling, and the high oxygen permeability of silicone hydrogel supports long-term ocular health.

Orthokeratology (OK) is a well-established and highly effective treatment option for myopia control with reported efficacy ranging from 40–60%.10 Worn overnight, these rigid gas-permeable lenses temporarily reshape the cornea, eliminating the need for daytime vision correction. When appropriately fitted and closely monitored, the safety profile of OK is comparable to that of daily wear soft contact lenses.11

Pharmacological Treatments

Topical low-dose atropine (LDA) is currently the only effective pharmacological intervention for managing childhood myopic progression. Although its exact mechanism remains under investigation, it is believed to exert its effects by modulating retinal signalling and scleral remodelling.

LDA (0.01–0.05%), administered nightly, has been shown to effectively reduce both myopic progression and axial elongation in children. The treatment effect is concentrationdependent, with higher concentrations offering greater efficacy but also a slightly increased likelihood of side effects. Common side effects include photophobia, reduced near vision, ocular irritation, and less commonly, allergic reactions. That said, LDA is generally well tolerated, with a strong ocular safety profile and minimal systemic absorption. The LAMP study demonstrated that 0.05% atropine was the most effective concentration tested, reducing refractive progression by 67% over two years compared to placebo.12

Repeated Low-Level Red-Light Therapy

Repeated low-level red-light (RLRL) therapy has received growing attention in recent years. It is a non-invasive treatment for myopia control that involves exposure of the retina to low-energy red light. It works through stimulation of retinal mitochondria, increased choroidal perfusion, and a proposed neuromodulatory effect on scleral remodelling.

Recent clinical trials have shown up to 70% reduction in axial elongation, with some cases even showing axial length shortening.13,14

As with all myopia control treatments, patient compliance is critical to achieve optimal outcomes. Practitioners must ensure proper adherence to the recommended dosing protocol – three minutes per session, twice daily, five days per week. Initial baseline optical coherence tomography (OCT) scans are recommended before initiating treatment with ongoing retinal monitoring to ensure safety. RLRL can be considered as a monotherapy or in combination with optical intervention for enhanced myopia control, however, it cannot be used in conjunction with atropine drops.

WHEN TO START AND SHIFT TREATMENT

Early detection of both pre-myopic and myopic children is critical for effective myopia management.

A comprehensive consultation should include a detailed family history, a lifestyle assessment (including time spent outdoors and near work habits), refractive status, ocular health examination, and ideally, a baseline axial length assessment. Baseline data sets the foundation for monitoring and guiding timely interventions.

Pre-Myopes

Pre-myopic children are those who, while not currently myopic, exhibit a combination of risk factors that indicate a high likelihood of developing myopia soon.

A careful assessment of their risk factors is essential to guide early intervention. Delaying the onset of myopia by one year can reduce a child’s final myopic refractive error by approximately 0.75D, an effect comparable to two to three years of active myopia control treatment that is currently available.15

As a first step, all pre-myopic children should receive lifestyle modification advice. This is a simple and effective method for delaying and/or preventing myopia onset. Providing parents with educational materials can be highly effective. This stage is foundational. It encourages a collaborative approach and empowers both parents and children to take an active role in myopia management.

Several other proactive interventions are available to help manage the risk of myopia in pre-myopic children. These strategies should be considered when risk factors indicate a high likelihood of early-onset myopia. Key indicators include a significantly reduced hyperopic reserve, a rapid decline in hyperopia over 6–12 months, axial elongation exceeding 0.1 mm within six months,16-18 younger age (particularly under nine years), a family history of moderate to high myopia, high levels of near work, insufficient time spent outdoors, and Asian ethnicity.

Studies have suggested that LDA may be useful for delaying the onset of myopia in children at risk.19,20 A nightly dose of atropine 0.01% to 0.025% can be considered, as these concentrations have minimal impact on pupil size and accommodation. It is important to have a clear and open discussion with parents about the potential benefits and possible side effects. Informed consent should be obtained, and families should understand that this is a long-term commitment that requires ongoing monitoring to assess its effectiveness and continued suitability.

More recent studies have shown that both plano DIMS and HALT lenses can slow axial elongation and reduce the rate of myopic refractive change in pre-myopic children.21-23 A consistent finding across these studies is that treatment efficacy is closely tied to wearing time, with longer daily wear associated with better outcomes. These lenses may be considered where the child is borderline myopic or showing signs of rapid progression – particularly when pharmacological intervention is declined or not appropriate. However, ensuring consistent wear and gaining parental support can be challenging, especially in children who perceive their unaided vision as normal and may be resistant to wearing glasses.

Some early findings indicate that RLRL therapy may serve as a safe and effective intervention in pre-myopic children.24 This may be considered for young children with poor compliance to LDA or myopia control lenses. The data supporting its efficacy is growing. Safety appears favourable with short exposure times, although long-term data is still forthcoming.

Together, these interventions form a proactive toolkit for optometrists managing pre-myopic children. Selection should be tailored to the individual child’s risk profile, age, refractive status, and family preferences.

Pre-myopic children should be monitored regularly, with reviews scheduled at least every six months to promptly detect signs of progression towards myopia. Timely followup enables early intervention, which is critical to reducing the risk of rapid refractive or axial length changes.

Myopic Children and Progressing Myopes

Once a child develops myopia (-0.50D or more), treatment should be initiated promptly – without waiting for documented progression. Early intervention is critical and offers the best chance of achieving a more favourable long-term prognosis.

As for pre-myopic children, lifestyle modification advice is essential. These behavioural changes will support overall treatment efficacy.

Spectacles and Contact Lenses A common first-line intervention for myopia control is the use of specialty spectacle lenses, such as HOYA’s MiyoSmart or Essilor’s Stellest. These lenses are well-tolerated and are easy to prescribe. Achieving optimal efficacy depends on consistent daily wear – ideally exceeding 12 hours per day – and proper frame fitting. Ensuring that frames are well-fitted and that the lenses remain correctly positioned is critical, as misalignment can reduce the therapeutic effectiveness of the lens design.

While myopia control spectacle lenses are excellent first-line options, soft myopia control contact lenses or OK may be the preferred modality in certain situations. Contact lens options are particularly suited to children who engage in sports or active play, as they provide unobstructed peripheral vision and are less prone to fogging, slipping or damage. Some children or families also prefer contact lenses for cosmetic or lifestyle reasons.

The choice between a soft daily myopia control contact lens and OK depends on a combination of factors, including the child’s lifestyle, personal and family preferences, ocular health, and the availability or accessibility of OK fitting expertise.

Soft myopia control contact lenses are generally easier and quicker to fit, involve lower upfront costs, and offer the safety and convenience of daily disposable wear. These are especially suitable for children with active lifestyles, simple refractive prescriptions, or families seeking a lower-maintenance, hygiene-friendly solution.

Orthokeratology offers several advantages over soft myopia control lenses. It provides clear unaided daytime vision, which is a major benefit for sporty or highly active children, those who dislike wearing contact lenses during the day, or situations where contact lens wear is impractical, such as swimming or water-based activities. OK allows for correction of moderate astigmatism, making it suitable for children whose prescriptions fall outside the parameters of current soft myopia control contact lenses. When hygiene and compliance are well managed, OK is a safe and effective modality.

Pharmacological Intervention While optical interventions are typically considered first-line treatments, LDA used as monotherapy, paired with single vision lenses for refractive correction, remains a valuable option in myopia control. It is suited to situations where families are hesitant about contact lens wear, prefer a lower upfront cost, or when the child’s prescription falls outside the parameters of MiyoSmart or Stellest, such as in cases of high astigmatism. Among the concentrations studied, 0.05% atropine has demonstrated the highest efficacy in slowing myopia progression, with minimal side effects. LDA can be used to manage myopia in children from the age of four. While LDA monotherapy is effective for many, some children do experience rapid progression despite treatment. In such cases, combining atropine with other interventions or changing modality may enhance efficacy. For children using atropine who experience photophobia, photochromic lenses can be a practical and effective solution.

Red Light For children who do not respond adequately to LDA or show limited compliance, and where contact lenses or myopia control spectacle lenses are not indicated, RLRL therapy presents a promising alternative. Like LDA, RLRL does not correct refractive error so children will require single-vision spectacles for clear vision. As RLRL is a relatively new treatment modality, further long-term studies are needed to fully establish its efficacy and safety profile. For children previously treated with LDA, a washout period is recommended before initiating RLRL therapy.

Following the initiation of the selected treatment, regular six-monthly reviews are essential to assess the effectiveness of the chosen treatment strategy. These assessments should include both refractive error and axial length measurements to guide ongoing clinical decisions. Lifestyle modification advice should also be revisited and reinforced at each visit to support treatment outcomes.

For children who demonstrate poor compliance, or whose myopia continues to progress despite monotherapy, combination therapies may provide improved myopia control. Integrating two treatment modalities can offer a synergistic effect, particularly in high-risk or fast-progressing cases.

Combining Therapies Currently, the strongest evidence supports the combination of orthokeratology with 0.01% and 0.05% atropine to be more effective in slowing axial elongation than orthokeratology monotherapy alone.25-26 Studies highlighted that the additive effect was most pronounced in the first six months of the dual treatment.

Combination therapy is an evolving area in myopia management. While promising results have emerged from newer combinations – such as DIMS lenses with LDA, and RLRL therapy with orthokeratology – not all combinations demonstrate additive effects, and some are supported by limited or preliminary data. Further high-quality studies are needed to confirm the efficacy, safety, and long-term outcomes of these combined approaches.

WHEN TO REFER OR CO-MANAGE

Referral or co-management with a paediatric ophthalmologist is essential in specific cases of childhood myopia to ensure comprehensive evaluation and appropriate care. Optometrists should consider referral in the following scenarios.

High myopia in young children. Children under 10 years of age presenting with high myopia (>-5.00 to -6.00D) should be referred. At this age, significant myopia is uncommon and may be associated with underlying genetic or systemic disorders that warrant further investigation.

Myopia exceeding age norms. If a child’s myopic refractive error in dioptres exceeds their age in years, this raises concerns for potential systemic associations.

Associated ocular or systemic conditions. Referral is advised when myopic children present with strabismus or amblyopia, significant anisometropia, or systemic conditions associated with myopia such as Marfan syndrome, Stickler syndrome, Noonan syndrome, Down syndrome, and type 1 Diabetes Mellitus.

High axial length. Children under six years of age with axial length measurements above the 75th percentile are atypical and such cases may indicate underlying structural or systemic conditions.

For further information on red flags, turn to page 47.

Collaborative care between optometrists and ophthalmologists ensures that children receive timely interventions where needed.

THE IMPORTANCE OF A PERSONALISED APPROACH

Each child’s experience of myopia is unique, requiring a treatment plan tailored to their individual risk profile, lifestyle, and response to interventions. Factors such as genetic predisposition, environmental influences, age of onset, and rate of progression must all be considered when determining the most appropriate course of action.

Personalised care also involves close collaboration with families. Clear communication, shared decision making, and ongoing education are essential in building trust and ensuring long-term compliance. By initiating treatment at the right time and adjusting strategies as needed, we can make a meaningful impact on slowing myopia progression and safeguard a child’s long-term visual health.

As an optometrist in independent practice who sees children daily, I find this collaborative process deeply rewarding. The opportunity to guide families through proactive, evidence-based care, and to witness the positive outcomes over time, is one of the most meaningful aspects of my clinical work.

Emmy Cui BOptom ACO-ACCV graduated from the University of Melbourne in 2007, completing her Advanced Certificate in Children’s Vision in 2018. As the Principal Optometrist at Eye & I Optometrist in Melbourne, Victoria, she practises all aspects of optometry but has a special interest in children’s vision and myopia control.

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