Real-World Myopia Control: Successes, Failures, and Lessons Learned

Myopia is rising worldwide, with projections estimating that 50% of the global population will be myopic by 2050.¹ In the United States, myopia prevalence is estimated at 42%, a significant increase from 25% nearly 50 years ago.²

While myopia management is a highly rewarding aspect of clinical practice, it is not without challenges. Barriers related to treatment initiation, patient compliance, visual quality, quality of life, and safety often arise and require individualized, thoughtful management.

This article reviews four real-world myopia cases that highlight these challenges and offers practical guidance and key lessons learned from clinical experience.

A shift in the standard of care for myopia

Known risk factors for myopic progression include family history of myopia, prolonged near work, limited outdoor time, earlier age of onset, and ethnicity.³

Each additional diopter of myopia is associated with an increased risk of retinal detachment, myopic maculopathy, open-angle glaucoma, and posterior subcapsular cataract, all of which negatively impact quality of life and productivity, and increase lifelong healthcare costs.^4,5

Over the past decade, the standard of care for myopia management in the United States has shifted significantly, driven in part by the availability of more FDA-approved treatment options, such as Coopervision MiSight 1 Day contact lenses and the recently approved Essilor Stellest lenses.

Although not yet FDA-approved specifically for myopia control, additional interventions for myopia management include low-dose atropine, orthokeratology, and other soft multifocal contact lens designs.

Eyecare providers today have a growing array of tools to slow myopia progression. Collectively, these interventions have been shown to reduce myopic progression by approximately 27 to 87% per year, depending on the modality and randomized control trial demographic evaluated.⁶

Case 1: Strategies to explain the value of intervention

A 10-year-old Caucasian female presented for a new-patient urgent visit with a 2-week history of itchy, dry, red eyes. Uncorrected visual acuity was 20/70 OU. Ocular history was notable for myopia, and medical history included seasonal and dust mite allergies.

She was diagnosed with allergic conjunctivitis and treated with topical antihistamines and preservative-free artificial tears. During the history, the patient reported she had glasses at home but rarely wore them because her parents believed glasses would worsen her vision. Her mother also shared concern that the prescription had increased from -1.00D to -2.00D over the prior year, per an exam 2 months earlier.

At the 2-week follow-up, symptoms had resolved. I revisited the family’s concern about myopia progression and used the visit to better understand their experience with myopia and the patient’s visual habits before presenting data or treatment options.

The patient spent roughly 4 hours daily on screens (smartphone and tablet), did not enjoy outdoor activities, and was first diagnosed with myopia at age 9. Family history was limited: the father was emmetropic, and the mother had low myopia that developed in graduate school.

Using visuals, I explained the mechanism of myopia and discussed risk factors for progression—near work, limited outdoor time, and earlier age of onset, and undercorrection of the patient’s current myopia—explicitly connecting each point to what the family had already shared.⁷

When I reviewed treatment options, the mother expressed strong hesitancy toward contact lenses due to the patient’s age and perceived maintenance. Additionally, given the patient’s recent flare-up of allergic conjunctivitis, daily contact lens wear was contraindicated.

Although she agreed with the information, she was not ready to initiate therapy immediately and wanted to discuss it with her husband. We scheduled a formal myopia management consultation to allow time for deliberation.

The family returned 1 month later. Refraction confirmed -2.00D OU and myopia management was initiated with 0.05% low-dose atropine to be used 7 nights per week. Atropine 0.05% was prescribed in accordance with the LAMP Study,⁸ to provide the highest level of treatment efficacy and minimize the potential cycloplegic side effects of photophobia, glare, and near blur. Additionally, the patient’s full correction in glasses was prescribed for full-time wear.

Case 1 takeaways

Learn the patient and family context: A meaningful recommendation requires understanding ocular history, visual habits, daily routines, and the family’s beliefs and level of concern.
Personalize education: Tie risk factors and progression concepts directly to details the family has provided to make the rationale clearer and more relevant.
Give families time to decide: Too much information can create confusion and decision paralysis.^9,10 Many families are hearing about myopia management for the first time and may need time to research, process, and align with a spouse before committing to treatment.

Case 2: Early intervention in action

A 7-year-old South Asian male and his 9-year-old brother presented for myopia management. The younger child was a -3.75D myope, while the older brother was a -2.50D myope with 2.00D of astigmatism. The father had a history of myopia and prior refractive surgery, and the mother was emmetropic.

The family was educated on the mechanism of myopia, associated risk factors, and available treatment options. Both children enjoyed activities such as soccer and amusement park rides, and the parents wished to prioritize visual freedom while slowing myopia progression.

For these reasons, the family elected orthokeratology (ortho-K) for myopia management. The family was educated on the FDA-approval limitations of orthokeratology to correct the oldest son’s 2.00D of astigmatism. Despite these limitations, the family agreed to proceed with orthokeratology.

After 1 week of ortho-K wear, both patients achieved 20/30 vision or better and expressed satisfaction with not needing glasses at school. By the 1-month follow-up, they reported improved confidence participating in sports and recreational activities without concern for spectacle wear. At the 12-month visit, both patients maintained 20/25 or better vision, and axial length measurements remained stable throughout the year.

Case 2 takeaways

Early intervention reduces long-term risk: Each diopter of myopia prevented lowers the lifetime risk of myopia-associated ocular pathology, which is particularly important in younger children with moderate to high baseline myopia.^4,5
Prioritize functional benefits: Early myopia control—especially with contact lens–based therapies—can significantly improve quality of life by offering better visual function and greater flexibility for sports and outdoor activities.

Case 3: Handling challenges with compliance

An 11-year-old Black female presented for a comprehensive eye exam and was found to have progressed from -2.25 -1.50 × 170 OD and -2.75 -1.25 x 010 OS to -2.75 -2.00 × 170 OD and -2.75 -1.50 x 010 OS over 1 year. She was a competitive dancer and avoided wearing glasses during performances due to fear of breakage or loss.

After counseling, she was prescribed off-label Biofinity Multifocal Toric Center D +2.00 Add, monthly-replacement lenses for myopia management. Despite the BLINK study supporting the use of a +2.50 Add, the +2.00 Add offered less visual compromise for the patient.

Due to her high astigmatism, she was not a good candidate for MiSight. At the 3-month follow-up, she reported wearing the lenses only during dance activities. The patient and her parents were reeducated on recommended daily wear time to achieve optimal myopia control.

At the 6-month visit, she admitted to continued limited wear despite satisfactory vision, citing lens insertion difficulty and discomfort. She was refit into NaturalVue Multifocal 1 Day, a lens capable of correcting up to 3.00D of astigmatism,¹¹ and received additional training to improve her lens handling technique and confidence. The daily disposable modality was selected to improve comfort and eliminate potential disinfecting solution-related irritation.

By the 12-month visit, compliance and wear time improved, and refractive error and axial length were stable. However, by the 18-month visit, she again reduced wear to approximately 3 days per week, stating that glasses were more convenient to wear to school.

After reeducation on treatment purpose and goals for myopia control, nightly 0.025% atropine was added as combination therapy to provide a treatment effect independent of daytime contact lens wear and reduce the impact of her inconsistent compliance.

At the 24-month visit, her myopia had progressed to -3.50 -2.00 x 170 OD and -3.50 -1.75 x 010 OS. The patient admitted to very minimal atropine use but claimed to wear her NaturalVue contact lens Monday through Friday, though reliability was uncertain. Orthokeratology was recommended as a modality better aligned with her habits and motivation.

To address her parents' concerns around compliance, and given the patient's already poor compliance with her daytime contact lenses, we discussed how corneal topography can be used as an objective indicator of compliance and emphasized the immediate visual consequence of missed wear. If ortho-K lenses are not worn, it will be evident in both the topographies and the patient’s visual acuity.

After transitioning to ortho-K, the patient reported clear daytime vision and visual satisfaction. She was most impressed with having the ability to take a nap after school and see well as soon as she opened her eyes. Her parents noted improved adherence also. At the 27- and 30-month follow-ups, she maintained good vision, stable axial length, and consistent compliance.

Case 3 takeaways

Know your options for astigmatic patients: Contact lenses used for myopia management induce peripheral myopic defocus in varying, unique ways. It is important to know the optical limitations of each modality when prescribing for astigmatic myopes.
- MiSight: Dual-focus concentric ring design providing clear central vision with surrounding treatment zones that induce peripheral myopic defocus. Best suited for patients with ≤0.75D of astigmatism.
- Biofinity Multifocal / Biofinity Toric Multifocal: Three-zoned concentric ring design providing clear central vision and surrounding zones that produce peripheral myopic defocus. Toric lens is offered in cylinder powers up to -5.75D. Of note, the Biofinity Toric Multifocal was not used in the BLINK Study and only the D lens has been studied.
- NaturalVue Multifocal: Distance-center, high-add aspheric design (Neurofocus Optics) creating extended depth of focus, peripheral myopic defocus, and a wider range of clear vision.¹² Proven to effectively correct 100% of astigmatism up to 2.00D and 83% of astigmatism up to 3.00D.¹¹
- Orthokeratology: Corneal reshaping flattens the central cornea and steepens the mid-periphery, producing a treatment zone of myopic defocus. Standard designs typically correct up to ~1.50D of cylinder, with customizable designs reaching ~3.50D.
Compliance drives efficacy: Regardless of modality, consistent wear is critical to successful myopia management. Vision quality, comfort, handling, and convenience are key determinants of compliance and satisfaction.¹³
Ask targeted questions early and often: Thoughtful questioning can uncover barriers to adherence and allow clinicians to intervene before treatment failure occurs.
- “Can you walk me through how you insert and remove your lenses?”
- “How many hours per day are your lenses comfortable?”
- “On a typical week, how often are you wearing your lenses or using prescribed therapy?”
- “Are there times during school or activities when your vision feels limited?”

Case 4: Adjusting treatment mid-stream

A 16-year-old Hispanic female was referred for myopia management after progressing by 0.50D over the past year. Her refraction was -6.25 -0.75 x 165 OD and -6.75 -0.50 x 015 OS. Her keratometry values were 44.00 / 45.25 @ 65 OD and 44.00 / 45.25 @ 100 OS. Her corneal eccentricity (e-value) for both eyes was around 0.2.

The patient was an honor student, athlete, and highly involved in extracurricular activities while preparing for the SAT. She was currently wearing -5.50D OD and -6.00D OS single-vision daily disposable contact lenses. Seeking greater visual freedom—particularly with plans to work as a lifeguard—she expressed interest in orthokeratology.

Prior to initiating ortho-K, the family was educated that due to the patient’s high refractive error it may be more challenging to achieve adequate vision correction. Ortho-K was initiated; however, at both the 1- and 2-week follow-ups, vision failed to improve beyond 20/30 despite reported compliance and appropriate technique.

After speaking with the ortho-K lens consultation team, her low e-values of 0.20, in addition to her high refractive error, both contributed to why it was difficult for her to achieve adequate correction. With this knowledge, new lenses with adjusted parameters were ordered, and daily disposable lenses were prescribed temporarily to correct residual refractive error.

Two weeks after receiving the revised lenses, vision remained suboptimal. At the visit, the patient disclosed averaging only 5 to 6 hours of sleep per night due to academic demands. Although she was encouraged to increase nightly wear time, she later acknowledged that she could not reliably commit to the recommended 7 or more hours of overnight lens wear and expressed concern that fluctuating vision could impact her SAT performance.

Given these constraints, the decision was made to transition her to the MiSight 1 Day contact lenses for her myopia management. At her follow-up 1-month later, the patient reported improved visual satisfaction, better compliance, and greater flexibility with the new modality. She also felt confident in her SAT performance.

Case 4 takeaways

Consider the corneal eccentricity: Eccentricity is the rate of corneal flattening from the center to the periphery. The average e-value of a normal cornea is 0.5, with typical ranges between 0.3 and 0.7.¹⁴ Higher e-values allow greater refractive change to the cornea, while lower e-values increase the risk of under-correction.
Match treatment to lifestyle, not just preference: Ortho-K success is highly dependent on consistent overnight wear. Understanding a patient’s sleep habits, academic demands, and ability to commit to wear time is critical before and during treatment.
Reassess early and pivot when needed: When desired outcomes are not achieved, timely reassessment and willingness to modify the treatment plan can improve both efficacy and patient confidence.

Conclusion

Myopia management is a highly rewarding aspect of clinical care, but, like any specialty service, it presents unique challenges. Successful myopia control extends beyond selecting an appropriate treatment modality; it requires thoughtful patient and family education and a clear explanation of the why behind the intervention.

By integrating clinical data with an understanding of the patient’s lifestyle, visual demands, and family beliefs, eyecare providers can deliver individualized recommendations that improve adherence, outcomes, and long-term ocular health. When approached with flexibility and open communication, challenges in myopia management become opportunities to strengthen patient trust and optimize care.