Childhood myopia is projected to affect 49.8% of the global population by 2050, with 9.8% reaching high myopia.1 Every additional diopter raises the lifetime risk of retinal detachment, myopic macular degeneration, and glaucoma.1
Observation alone is no longer defensible. This article compares the three most common management strategies and offers practical guidance on patient selection, combination therapy, and parent communication.
What is available in the US
Two products now carry FDA authorization specifically for slowing myopia progression in children: a dual-focus soft contact lens and a lenslet-based spectacle lens. Everything else is used off-label.
Low-dose atropine
Low-dose atropine blocks muscarinic receptors in the sclera and choroid, disrupting the signaling cascade that drives axial elongation.2 Compounded concentrations of 0.01% to 0.05% are instilled once at bedtime.
Myopia-control spectacles
Myopia-control spectacles replace peripheral hyperopic defocus, a retinal growth signal, with myopic defocus.3
- Stellest (EssilorLuxottica): Features Highly Aspherical Lenslet Target (HALT) technology. FDA market authorized for myopia control in children ages 6 to 12 and the only myopia-control spectacle lens available in the US.
- The pivotal trial enrolled children ages 8 to 13 with spherical equivalent refraction (SER) of −0.75 to −4.75D and astigmatism ≤1.50D, so the efficacy data come from a slightly older cohort than the authorized range.4
- Not available in the US: MiyoSmart (Hoya, DIMS), MyoCare (Zeiss, CARE), and SightGlass Vision (DOT), all of which have published clinical data.5,6,7
Specialty contact lenses:
- MiSight 1 Day (CooperVision): Dual-focus daily disposable with +2.00D concentric defocus zones. The pivotal trial enrolled contact-lens-naïve children with SER of −0.75 to −4.00D and astigmatism <1.00D.8 FDA-approved in 2019 as the first soft contact lens indicated to slow myopia progression in children ages 8 to 12 at initiation of treatment.9
- NaturalVue Multifocal (VTI): Extended-depth-of-focus (EDOF) daily disposable, FDA-cleared as a multifocal, used off-label for myopia control.10
- Biofinity Multifocal D and Proclear Multifocal D: Center-distance designs with a +2.50D add, used off-label. Center-near designs produce the opposite peripheral effect and should be avoided.11,12
- Orthokeratology (ortho-K): Overnight rigid GP lenses that reshape the cornea, giving spectacle-free daytime vision and peripheral myopic defocus. Used off-label for myopia control.
Atropine: What the evidence shows
Efficacy is concentration-dependent, confirmed by a 2026 systematic review of eight randomized clinical trials (RCTs) encompassing 1,756 children:
- 0.01%: 0.291D of SER slowing at 1 year, 0.174 D at 2 years13
- 0.05%: 0.520D of slowing13
- 0.04% vs. 0.01%: 0.18mm less axial growth in a 2025 JAMA Ophthalmology RCT, but photophobia in 22.9% vs. 2.1%14
CHAMP-UK is the first large placebo-controlled trial in a predominantly white European population (289 children ages 6 to 12, 72% white ethnicity).15 Over 2 years, 0.01% reduced SER progression by 0.33D and axial elongation by 0.14mm, with no subgroup differences by age, ethnicity, sex, or myopia severity.15
North American CHAMP found a 0.13mm axial reduction with 0.01% over 3 years.16 LAMP2 showed 0.05% cut 2-year myopia incidence to 28.4% versus 53.0% for placebo, while 0.01% (45.9%) did not differ significantly.17
LAMP found 0.05% atropine was the most effective of the three low concentrations tested and remained well tolerated in the studied cohort, though both efficacy and side effects were dose-dependent, and tolerability of 0.05% may differ in non-Asian populations.18,19
Atropine side effects are concentration-dependent:
- Pupil size: In CHAMP-UK, pupil diameter was the only secondary outcome that differed, at 0.36mm greater with 0.01%. No serious adverse events were drug-related.15
- Photophobia and blurred vision: The adverse events most plausibly drug-related in North American CHAMP.16
- Accommodation: A 2026 meta-analysis of 13 RCTs found a small reduction at 0.01% (−0.84D) with substantial heterogeneity and no consistent effect at individual time points, versus a consistent and clinically meaningful −1.96D at 0.05%.20
Individual trials report larger accommodative effects at 0.01%. One randomized trial in children with myopia and intermittent exotropia found a 3.18D greater loss versus placebo, though only 6.0% reported blurred near vision and binocular function was preserved.21
Practical step: Check accommodative amplitude at follow-up, particularly when moving above 0.01% or when a child reports near symptoms.
Stopping atropine: Rebound and tapering
The rebound literature is split, and it should be understood before counseling a family:
- Reassuring: In MOSAIC year 3, children who stopped 0.01% progressed at −0.23D and 0.14mm per year, no faster than placebo.22 CHAMP year-4 data agree, with a 0.019D difference between stoppers and continuers (P = 0.82).23
- Cautionary: In LAMP at 3 years, continued treatment beat washout at every concentration, with rebound smaller in older children and at lower concentrations.18 At 5 years, 87.9% of the cessation arm eventually required re-treatment.19
- Restarting works: PRN restart with 0.05% matched uninterrupted therapy from years 3 to 5 (SER −1.00D vs. −0.97D, P = 0.55).19
- Cumulative 5-year progression on continued treatment:19
- 0.05%: −1.34D
- 0.025%: −1.97D
- 0.01%: −2.34D
How to stop may matter as much as when. The 8-year LAMP report found tapering the concentration produced less 3-year progression than abrupt cessation, with younger and more myopic children benefiting most.24
The authors caution that the roughly 0.25D difference is of uncertain clinical relevance, and MOSAIC found no significant difference between tapering and stopping 0.01%.24 Cochrane likewise notes that tapering evidence remains thin.25
Bottom line: Dramatic rebound at 0.01% is uncommon, most children need treatment again, and restarting works.
Spectacles: What the evidence shows
A 2025 meta-analysis of 23 RCTs (13,315 subjects) found myopia-control spectacles reduced axial elongation by 0.15mm and SER progression by 0.31D versus single-vision lenses, with HALT designs showing the largest pooled effect at 0.28mm and 0.52D.26
Findings from clinical trials on the efficacy of myopia-control spectacles:
- Stellest: 55% SER and 51% axial reduction in its 2-year pivotal RCT, with full-time wear of at least 12 hours daily outperforming part-time wear.4 A cross-over trial confirmed no rebound after discontinuation.27
- MiyoSmart: The 6-year extension is one of the longest myopia-control datasets published. Children who wore DIMS lenses throughout progressed just −0.92D with 0.60mm of axial elongation, and the control effect held steady rather than fading, with no rebound after cessation.5,28
- Head-to-head: A 1-year double-masked RCT of 120 Indian children found DIMS and HALT comparable (56.7% and 58.1%), both outperforming CARE (47%).29
- CARE, for international context: 0.21D less SER progression and 0.14mm less axial elongation at 12 months in the European CEME trial, and a 0.44D difference in a 2-year Chinese trial.6,30
Bottom line: Wear time is the variable most under a clinician's influence. Set the 12-hour expectation at dispensing.
Contact lenses: What the evidence shows
- MiSight: 0.73D (59%) less progression and 0.32mm (52%) less axial elongation over 3 years in 144 children ages 8 to 12, with 6-year data confirming durability.8,31
- The 2025 American Academy of Ophthalmology technology assessment reviewed 12 studies, 11 rated level I, and reported control effects of 69%, 59%, and 59% at 12, 24, and 36 months.9
- NaturalVue: 0.84D of slowing, roughly 85%, in a retrospective study of 196 patients. The absence of a concurrent control group warrants caution.10
- Biofinity D, +2.50 D add: 0.45 D (43%) and 0.23 mm (36%) less progression over 3 years in BLINK. Medium add was not effective.11
Orthokeratology reduced axial elongation by 0.28mm over 24 months in a meta-analysis of seven RCTs, and Cochrane reported a comparable 0.30mm at 2 years.25,32 Refraction is not a reliable ortho-K endpoint given the reshaped cornea, so judge efficacy by axial length.25
Counsel ortho-K families on three points: the control rate declines from 64% at 6 months to 47% at 24 months, rebound follows discontinuation, and overnight wear carries a microbial keratitis risk that, while serious, is low—estimated at 7.7 cases per 10,000 patient-years, comparable to other overnight lens wear.32,33
Most reported cases trace back to modifiable factors such as tap-water rinsing and poor lens hygiene, so careful fitting, follow-up, and patient education keep the absolute risk small.33
Choosing the right option for myopia control
Risk-stratify first. These findings point toward aggressive intervention:2
- Axial length above the 75th percentile for age
- Progression ≥0.50 D/year or ≥0.30 mm/year
- Onset before age 8
- Two myopic parents
- Minimal outdoor time
Match modality to age
- Ages 6 to 8, if not ready for contacts: Atropine or Stellest.
- Age 8 and up: MiSight, NaturalVue, off-label multifocals, and ortho-K all become viable. Younger age at ortho-K initiation and larger pupils predict greater effect.33,34
- Older adolescents: In the 2-year Xu trial (ages 8 to 15), 0.04% atropine slowed axial growth more than ortho-K or 0.01% atropine, though at the cost of more photophobia.14 In practice, a single lens-based modality—a soft myopia-control lens or ortho-K—is often the more practical choice for this age group, since it corrects vision and slows progression at once.
- Atropine monotherapy still requires separate optical correction, so higher-concentration atropine is better reserved for cases needing added control or used as an adjunct.14,25
Know the contraindications
Use atropine cautiously with light-colored irides, pre-existing accommodative insufficiency, or hypersensitivity, since photophobia, mydriasis, and reduced accommodation rise with concentration.14,20
Avoid ortho-K in patients with:33,35
- High myopia (SER beyond roughly −6.00D, which exceeds the FDA-approved correction range of the Euclid and Paragon CRT designs and leaves residual refractive error as central flattening plateaus)
- High astigmatism (corneal astigmatism above roughly 1.50D, which exceeds the FDA-approved range and predicts lens decentration)
- Extreme corneal curvatures (flat K outside about 41 to 45D)
- Poor lens hygiene
Address lifestyle in every visit
A cluster RCT of 6,295 children found 120 to 150 minutes of daily outdoor time at 5,000 lux reduced myopia incidence risk by 15 to 24%.36 A 2024 Cochrane review of five RCTs (10,733 children) found school-based outdoor interventions reduced 2-year incidence from 26.7 to 22.5%.37 Recommend 80 to 120 minutes outdoors daily for all children.
Combination therapy for fast progressors
- Atropine plus ortho-K: A 2-year age-stratified RCT of 164 children found the combination outperformed either monotherapy for axial elongation, though the advantage narrowed within age subgroups.34
- Atropine plus DIMS: In ASPECT, 0.025% atropine plus DIMS produced 0.11mm less axial growth at 12 months than atropine alone, with 39.6% showing no axial elongation versus 12.2%.38 A European observational study of 146 children reached the same conclusion.39
A practical sequence: Start monotherapy, reassess axial length every 6 months, then add a complementary modality or increase atropine concentration if progression exceeds 0.30mm/year.
Sample scripts for talking to parents about myopia
Introducing the concept. "Your child's eyes are growing faster than expected. Without treatment, there's a meaningful chance of high myopia, which raises long-term risk of retinal detachment and macular degeneration. We have treatments that slow this significantly."
On the FDA-authorized options. "Two products are cleared by the FDA specifically to slow myopia in children: a daily contact lens called MiSight and a spectacle lens called Stellest. Either is a reasonable place to start, and the choice usually comes down to whether your child is ready for contact lenses."
On atropine. "One drop at bedtime. Side effects are generally mild, mostly slightly larger pupils or light sensitivity, and more common at higher concentrations. Some children notice reading is a little harder at first, so we check focusing ability at each visit."
On contact lenses. "MiSight is approved for children ages 8 to 12 and slowed progression by 59% in its trial. Ortho-K reshapes the cornea overnight, so no correction is needed during the day, and it slows eye growth about as well as MiSight—roughly a quarter to a third less growth than glasses in head-to- head studies. Which one we choose usually comes down to whether your child would rather wear a lens by day or overnight."
On spectacles. "Stellest looks close to regular glasses—you may notice the
lens looks a little different up close, but not dramatically so—and it's designed to slow eye growth, with 55% less progression over 2 years. Children who wore them at least 12 hours a day did better."
On stopping. "When we stop, most children start progressing again and need to restart. That's expected, not a failure, and restarting works just as well. We may step the concentration down rather than stopping all at once."
Key takeaways
- Myopia management is essential for progressive pediatric myopia, as every diopter increases lifetime complication risk.
- Two FDA-authorized options anchor U.S. treatment: MiSight 1 day, approved in 2019 for ages 8 to 12 at initiation, and Stellest, market authorized for ages 6 to 12. NaturalVue, center-distance multifocals, ortho-K, and compounded low-dose atropine are used off-label.9,39
- Axial length is the cornerstone metric. Measure at baseline and every 6 months.
- Atropine efficacy is concentration-dependent. While 0.01% has shown benefit in both Asian and predominantly white cohorts, 0.05% is the more effective concentration and, in LAMP, delivered the highest efficacy of the low doses tested while remaining well tolerated.13,15
- Atropine side effects also rise with concentration. Mydriasis and reduced accommodative amplitude are modest at 0.01% but clinically meaningful at 0.05%, so monitor near function as the dose rises.15,18
- Plan for cessation. Dramatic rebound at 0.01% is uncommon, but 87.9% of LAMP children needed to restart, PRN re-treatment matched continuous therapy, and tapering may reduce rebound.20,23,24
- Center-distance designs are essential; center-near designs worsen peripheral defocus.12
- Ortho-K effect declines over time and rebound can follow discontinuation.25,32,33
- Combination therapy benefits fast progressors, strongest for atropine plus ortho-K and atropine plus DIMS.2,34,37,38
- Recommend 80 to 120 minutes of daily outdoor time for all children.35,36
