The global prevalence of myopia is anticipated to reach 40% of the population worldwide in the next 25 years.1 Countries with more sophisticated education systems tend to be affected at a higher rate than underdeveloped countries. The growing global prevalence is indicative of environmental factors playing an increasingly important role in myopia onset and progression.1,2
Complications of high myopia often occur due to axial elongation, resulting in a compromised ocular anatomy. Currently, myopic maculopathy is a leading cause of vision loss in both China and Japan.3,4 Interventions to prevent the onset and slow the progression of myopia have become increasingly important.
Genetics and lifestyle play the primary role in determining the risk of developing myopia.5,6 Early myopia control studies have proven the efficacy of treatments to slow down myopic progression.7-10 Ongoing studies are exploring the use of low dose atropine to prevent the onset of myopia.11-12 Cognizant eyecare practitioners can start educating parents on prevention strategies before onset.
Why is it important to delay the onset of myopia?
Physiologic axial elongation is expected in children’s eyes. The average 8-year-old child’s eye will grow by 0.2mm per year. Younger children’s eyes grow slightly more and older grow slightly less, ultimately stabilizing around 13 to 16 years old.13 When an eye grows faster than the physiologic expectation, this is called “myopic elongation.”
Myopic elongation leads to myopic progression. The earlier the onset of myopia, the higher risk there is of developing high or pathologic levels of myopia as the eye continues to grow and the sclera becomes further compromised.14-16
Myopia control interventions are effective at slowing progression, but some progression is anticipated. Treatments may be more protective when administered prior to myopia onset. As of 2024, the World Health Organization recognizes myopia as a disease. Primary eyecare practitioners should know the risk factors and treatments to prevent any disease.
Myopia risk factors17-18
- Parental history of myopia
- 1 parent with myopia increases the risk by 1.75x
- 2 parents with myopia increases the risk by 2.27x
- A family history of high myopia increases the risk by 3.08x
- Avid readers/excessive near work
- Excessive screen time
- Limited time outdoors
A pound of prevention: The patient conversation
If a patient has one or more of the above risk factors, a myopia prevention conversation should be a priority. The first step of the conversation involves lifestyle modifications.
Step 1: Lifestyle modifications
Lifestyle modifications should be discussed with every child, regardless of refractive status:
- Spend at least 1 to 2 hours outside daily19
- It’s best to split that time throughout the day. Spending 1 to 2 hours in 20- to 30-minute intervals may be more effective than spending 1 to 2 hours straight. The idea is to have frequent exposure to the higher lux levels provided by the outdoors.
- Limit screen time and take frequent breaks from near work (reading)
- The American Academy of Pediatrics recommends no screen time under the age of 2 years and up to 1 hour of monitored screen time from 2 to 4 years. Five year olds and older can spend up to 2 hours daily.
- From an ocular perspective, frequent breaks are important. Historically, we have recommended the 20/20/20 rule. However, we have learned that 20 seconds is not a long enough break.
- We now adapt the 20/20/2 rule: after every 20 minutes, look at something 20 feet away for 2 minutes. Focusing on something close causes the choroid to temporarily thin.
- Taking a 2-minute break while looking at something in the distance (or better yet, looking out the window or stepping outside) results in a thickening of the choroid, making the eye less susceptible to stretching.
- Employ a good working distance
- Encourage children to hold reading material (or screens) at arm's length. I encourage parents to have tablets propped up on a table rather than allowing kids to hold them in their hands.
- Diet
- Dietary omega-3 supplementation has shown a protective effect in both animal and human models.20 Studies are limited, but encouraging a well-rounded diet, including omega 3 supplementation, may be beneficial.
- There is a link between myopic progression and dry eye syndrome.21 Omega 3 supplementation may benefit both.
An overview of pre-myopia
According to the International Myopia Institute, pre-myopia is “a refractive state of an eye of ≤0.75D and >0.50D in children where a combination of baseline refraction, age, and other quantifiable risk factors provide a sufficient likelihood of the future development of myopia to merit preventative interventions.”25 A good cycloplegic refraction can indicate pre-myopia.
Pre-myopia, in conjunction with the other risk factors, is a red flag for myopia control providers. Patients with a higher risk of developing myopia would benefit from lifestyle modifications, but this may not be enough.
Step 2: Myopia interventions
Low dose atropine
The Low-Concentration Atropine for Myopia Progression (LAMP) study, published in 2021, was a phase 3 study that investigated the efficacy of various concentrations of low dose atropine for slowing myopia progression. The group most recently studied the efficacy of atropine 0.05% and 0.01% for preventing the onset of myopia in patients with “pre-myopia” defined as +0.50D to -0.50D.26
The study found that patients on atropine 0.05% had significantly less risk of developing myopia compared to those on placebo after 2 years. There was no significant difference between 0.01% atropine and placebo.
This is consistent with a Pediatric Eye Disease Investigator Group (PEDIG) study that found that 0.01% does not slow myopic progression compared to placebo. The study suggests that ECPs may use atropine 0.05% to prevent or delay myopia onset in patients between 4 to 9 years of age.
Aspheric glasses
Myopia control glasses in varying designs are currently available outside of the United States. Sightglass (CooperVision) is predicted to make its debut in the United States as early as Spring 2026. Its design is based on retinal contrast theory, which states that high artificial contrast overstimulates the retina, leading to an overstimulation of eye growth and myopic progression.
Sightglass utilizes DOT (Diffusion Optics Technology), in which a clear central aperture is surrounded by thousands of irregularly spaced light-scattering microdots. The microdots mimic natural outdoor contrast, which elicits lower-level retinal activity, slowing axial elongation.27 Though studies have not explored its efficacy for preventing myopia onset, in theory, it could work.
Red light therapy?
Another study explored red light therapy for delaying the onset of myopia.28 Though the results were less robust, red light therapy appeared to be more effective than the control at delaying myopia onset over 2 years.
Red light therapy for myopia control is not available in the US and is still under investigation in Asia. There have been a few case reports of damage to the retina due to red light therapy. It is still being investigated as a potential treatment.
Conclusion
Key takeaways on identifying pre-myopia and myopia in children include:
- To maximally prevent progression, prevent myopia onset
- Younger onset = greater risk of progression
- Importance of lifestyle modifications and diet
- Patient and parent education is key
- Consider low dose atropine or myopia control glasses (soon!) for prevention
