Adult myopia progression is frequently encountered in practice, yet we have almost no evidence base to guide management. Here we explore how often and how much myopia progression occurs in adulthood, and management options.
When it comes to myopic teenagers and stabilization of their myopia progression, we have some research data available. Studies such as Myopia stabilization and associated factors among participants in the COMET trial, the Discontinuation of orthokeratology on eyeball elongation (DOEE) and Visual activity and its association with myopia stabilization have indicated that myopia management should likely not cease before age 15-16. But it's not quite as simple as flicking the switch back to single vision corrections. How to treat adult myopia progression?
The consensus developing is that 50% of patients will stabilise by 15-16,1-3 which half of these older teenagers and young adults still progressing. Studies have been conducted on university students before, most with a mean age of around 20, with studies finding around half progress by at least -0.50 across a few years.4,5
There is less data about young adult myopia progression (and for the sake of argument, and my feelings, let’s set that age range as 20-40 years of age). A study by Mark Bullimore and colleagues titled A retrospective study of myopia progression in adult contact lens wearers (full text available via the link) followed 815 soft contact lens wearers' right eyes for over five years. They found that progression of more than -1.00D over five years occurred in 21.3% of eligible study participants, but was strongly dependent on age.
|Baseline Age (y)||Frequency of Progression of At Least −0.75 D (%)||Frequency of Progression of At Least −1.00 D (%)|
|20–25||48.2 (40/83)||34.9 (29/83)|
|25–30||35.3 (36/102)||19.6 (20/102)|
|30–35||27.3 (18/66)||13.6 (9/66)|
|35–40||25.0 (10/40)||10.0 (4/40)|
|Total||35.7 (104/291)||21.3 (62/291)|
Table 1 from Bullimore et al. 2002: The Rate of Myopia Progression in Different Age Groups (at Baseline) and the Sample as a Whole; from A retrospective study of myopia progression in adult contact lens wearers.
As you can see those in their 20s progressed much more than those in their 30s. Now keep in mind, this was a retrospective report with different clinicians performing the refractions, no controls for near work and occupation and no cycloplegia. But it is certainly valuable data to indicate that adult myopia progression does happen, and perhaps more frequently than we'd expect.
Bullimore and colleagues also conducted the SPAN (Study of Progression of Adult Nearsightedness) study, which suggested that the highest risk factor for progression in adults was extensive near work,6 which was also alluded to in the data on teenage stabilization in the paper Visual activity and its association with myopia stabilisation.3
The longest follow up on this topic is a series of studies which encompassed at 23-year follow up from Finland, which showed that mean myopia progression in the 20's decade was -0.45 D ± 0.71D. In 45% of cases, progression was ≥0.5 D and in 18% of cases, myopia increased by ≥1.00 D.7
There appears to be consensus between these studies that one-fifth of myopes in their 20s will experience significant progression of at least 1D.
How should you manage adult myopia progression?
1. Monitor progression and eye health in adult myopes
Keep in mind that myopia can still progress in young adults. Even stable adult myopia requires ongoing monitoring for eye health. Axial length measurement, if available, can be a useful indicator of pathology risk. Undertake annual retinal examination for your young myopes, with dilated pupils exams for higher myopes and especially for eyes 26mm or longer.
2. Consider contact lenses, and communicate
Myopia progression CAN still occur in the late twenties, much to the disappointment of some patients. Myopia control strategies should be continued (if this is the case), or even implemented if the patient shows fast progression and is concerned, but we don’t have the same large body of evidence and prediction tools to apply to this patient group compared to in children. Hence its crucially important to explain that myopia control strategies MAY work for them but it can't be guaranteed. The logical first choice would be contact lens options as they both correct and control myopia, and this age group will likely be amenable to contact lens wear if they've not tried it already.
3. Consider treatment side effects
We’ve considered how the efficacy profile of treatments may be different for adults when compared to children, and that may also apply to side effects. Atropine 0.01% is considered to have low side effects in children8,9 however we don’t know if that is the case in adults. Niathi Kona considered this in an 8 Hour Survey of 0.01% Atropine Induced Changes in Pupil Size and Accommodative Function, where she found half of their young adult subjects found their accommodation was most impaired at the 8 hour mark after instillation.10 Along with adults night driving and frequently having high visual demands - as university students and/or in screen based work - this could mean that adults may not tolerate atropine as well as children.
4. Orthokeratology seems to be effective in adult myopia stabilization
Two small studies have indicated as such. The first, published by Kate Gifford et al. in 2020,11 found that twelve months of orthokeratology (OK) wear in 18-29 year old myopes stabilized refraction and axial length. Prior progression was not quantified for comparison and there was no other adult control group. Gonzalez-Meijorne and his team found similar results in 201612 in a case series of three adults wearing OK over three years.
The take-home messages
- Young adult myopia progression can and does happen, by up to 1D in 35% of adults in their early 20s.
- Every dioptre matters for lifelong disease risk, so some attempt at myopia control is worthy, but we cannot be guaranteed of the same results as those seen in children.
- Contact lens wear is likely the best first line choice, as a dual correction and control strategy, and likely to be very well accepted by this patient group.
- Finally remember to monitor eye health annually in your adult myopic patients, even if they're stable, with annual retinal exams through dilated pupils where indicated or in higher myopes and those with axial length over 26mm.
Further reading on adult myopia
- Myopia stabilization and associated factors among participants in the Correction of Myopia Evaluation Trial (COMET). Investigative ophthalmology & visual science 54, 7871-7884, doi:10.1167/iovs.13-12403 (2013).
- Cho, P. & Cheung, S. W. Discontinuation of orthokeratology on eyeball elongation (DOEE) Cont Lens Anterior Eye 40, 82-87, doi:10.1016/j.clae.2016.12.002 (2017).
- Scheiman, M. et al. Visual activity and its association with myopia stabilization. Ophthalmic & physiological optics : the journal of the British College of Ophthalmic Opticians 34, 353-361, doi:10.1111/opo.12111 (2014).
- Kinge, B., Midelfart, A., Jacobsen, G. & Rystad, J. The influence of near-work on development of myopia among university students. A three-year longitudinal study among engineering students in Norway. Acta ophthalmologica Scandinavica 78, 26-29, doi:10.1034/j.1600-0420.2000.078001026.x (2000).
- Zadnik, K. & Mutti, D. O. Refractive error changes in law students. Am J Optom Physiol Opt 64, 558-561, doi:10.1097/00006324-198707000-00015 (1987).
- Bullimore, M. A. et al.The Study of Progression of Adult Nearsightedness (SPAN): design and baseline characteristics. Optometry and vision science : official publication of the American Academy of Optometry 83, 594-604, doi:10.1097/01.opx.0000230274.42843.28 (2006).
- Parssinen O, Kauppinen M, Viljanen A. The Progression of Myopia From Its Onset at Age 8-12 to Adulthood and the Influence of Heredity and External Factors on Myopic Progression. A 23-year Follow-Up Study. Acta Ophthalmol 2014;92:730-9.
- Gong, Q. et al. Efficacy and Adverse Effects of Atropine in Childhood Myopia: A Meta-analysis. JAMA ophthalmology 135, 624-630, doi:10.1001/jamaophthalmol.2017.1091 (2017).
- Fu, A. et al. Effect of low-dose atropine on myopia progression, pupil diameter and accommodative amplitude: low-dose atropine and myopia progression. The British journal of ophthalmology, doi:10.1136/bjophthalmol-2019-315440 (2020).
- Kona, N. 8 Hour Survey of 0.01% Atropine Induced Changes in Pupil Size and Accommodative Function. American Academy of Ophthalmology Online Abstracts (2018).
- Gifford, K. L., Gifford, P., Hendicott, P. L. & Schmid, K. L. Zone of Clear Single Binocular Vision in Myopic Orthokeratology. Eye Contact Lens 46, 82-90, doi:10.1097/icl.0000000000000614 (2020).
- Gonzalez-Meijome, J. M. et al. Stabilization in early adult-onset myopia with corneal refractive therapy. Cont Lens Anterior Eye 39, 72-77, doi:10.1016/j.clae.2015.06.009 (2016).