Candid conversations on Myopia Management – Q&A with Professor Ian Flitcroft and Professor Nicola Logan

Progressive myopia is not a benign refractive condition, we know it’s associated with an increased risk of sight-threatening ocular pathology, including myopic maculopathy, retinal detachment, glaucoma, and cataract, in later life.¹  Even low levels of myopia elevate this risk, and the likelihood increases with axial elongation.²  I think it’s important that clinicians communicate this clearly and consistently to both patients and colleagues.

When speaking with families, it is important to use language that is accessible and reassuring, while still conveying the seriousness of the condition. Visual aids and analogies can help illustrate the long-term implications of uncontrolled myopia progression. Emphasising that myopia control is a preventive strategy and not simply about reducing the need for spectacles, can help parents understand the value of early intervention. Another important point to convey is that because myopia tends to progress over time, our goal is to reduce the frequency with which a child’s spectacle prescription needs to be updated to a stronger one. Many parents find this aspect particularly relatable, as they’ve often experienced the frustration of frequent prescription changes and the associated costs and concerns. Discussing myopia in terms of slowing this progression helps families understand the practical benefits of treatment in everyday terms.

With colleagues, particularly those who may underestimate the risks, sharing current evidence and consensus guidelines is essential. Presenting myopia management within the context of long-term ocular health and public health burden reinforces its clinical importance.

Ultimately, transparent and informed communication is key. By acknowledging the risks and presenting the benefits of intervention, clinicians can support families in making proactive decisions. The goal is to shift the narrative from passive correction to active management thus ensuring better visual outcomes for children over their lifetime.

When comparing the potential risks of a myopia control intervention against the risks of untreated myopia, it is more effective to contrast the benefits of myopia management to the potential risks of any intervention. The higher the degree of myopia a child develops, the greater the risk of serious and irreversible ocular complications later in life.³  Large population studies have shown that with each dioptre increase in myopia, the risk of sight-threatening disease rises substantially.²  But important as that concept is, it is not the only benefit and perhaps not the benefit most relevant or understandable for parents. It certainly won’t resonate with children. If you get the chance to intervene at a low level of myopia, treatment also helps to preserve unaided vision which is great for independence, sports and getting out of bed in the morning. Keeping uncorrected vision within certain limits can also be important for career choices and means simpler laser correction could be considered when progression has fully stabilised.¹ 

 The optimal risk-benefit comes from the most effective treatment with the lowest level of risk. The risks associated with established myopia control treatments are generally mild and manageable. Low-dose atropine eye drops have been shown in multiple randomized controlled trials to slow progression, to a degree, with minimal side effects, limited largely to mild light sensitivity or near blur that is dose-dependent and reversible on stopping treatment.^4,5  Orthokeratology lenses, which are worn overnight to reshape the cornea, carry a known risk of microbial keratitis, but this risk is comparable to or only slightly higher than that seen with conventional daily wear contact lens use. Proper hygiene and monitoring can minimize those risks.^6,7  Myopia controlling soft contact lenses have safety profiles similar to standard daily wear lenses, with a very low incidence of serious infection.⁸  Spectacle-based interventions present minimal medical risk beyond issues of adaptation or comfort. Newer modalities such as red-light therapy have raised the greatest concerns of any myopia treatment to date, due to the intensity of the light exposure.^9,10 

 Another consideration is what treatment is going to be acceptable and actually used by the child. Therefore, the best balance of benefits and risks can be obtained by choosing lowest risk treatment that best suits the lifestyle and interests of the parents and the child.

While visual side effects such as reduced contrast sensitivity and halos are often raised in discussions around myopia control treatments, the clinical impact of these effects is typically modest and well tolerated. Optical interventions, such as myopia control spectacle lenses, dual-focus and multifocal soft contact lenses and orthokeratology, can produce mild disturbances like halos around lights or ghosting of high-contrast text, particularly under low-light conditions. These effects are largely attributable to the optical design required to induce peripheral defocus.

 However, the evidence, from multiple studies, consistently shows that children adapt quickly to these lens designs, and such symptoms rarely result in discontinuation when expectations are clearly communicated.^11,12  Importantly, these side effects do not compromise the quality of distance or near vision that children experience with these interventions.

 Clinicians must weigh these transient visual experiences against the long-term benefits of slowing axial elongation and reducing the risk of future ocular pathology. With atropine therapy, side effects such as photophobia and near blur are dose-dependent and significantly reduced at lower concentrations (e.g., 0.05%), which still provide meaningful efficacy.¹³ 

 Ultimately, transparent communication with families to acknowledge potential side effects while emphasising the protective value of treatment, is key to promoting adherence with the treatment. The clinical significance of these side effects is minor when compared to the lifelong benefits of myopia control.

Low-dose atropine has one of the strongest evidence bases among myopia control interventions in terms of the number of trials, but the results vary by concentration and population. This has certainly led to a rather confusing picture. Multiple randomized controlled trials, most notably the LAMP study in Hong Kong,⁴  have demonstrated a clear dose–response effect: 0.01%, 0.025% and 0.05% atropine all slowed refractive progression and axial elongation, with 0.05% showing the greatest and most durable benefit over several years, while remaining well tolerated. In Western populations however, the evidence is more mixed. The large CHAMP phase 3 trial found that 0.01% atropine significantly increased the proportion of treatment “responders” compared with placebo, whereas 0.02% did not meet its primary endpoint.¹⁴  By contrast, the U.S.-based PEDIG trial reported no effect of 0.01% over two years with the same formulation.¹⁵  A recently completed UK trial has shown benefits of 0.33 D in terms of refraction and 0.14mm in axial length over 2 years with a preserved formulation of 0.01% atropine.¹⁶  The European Medicines Agency (EMA) has also just (June 2025) approved a low dose atropine formulation, which appears to have comparable efficacy. In keeping with the studies from Hong Kong, the Dublin-based MOSAIC trial, has also shown that 0.05% is well tolerated and has better efficacy than 0.01% in European children.¹⁷ 

 Another complicating factor is the variability of the preparations that have been studied. Comparison of the impact on pupil size and accommodation definitely indicate that not all 0.01% preparations are equal in terms of intra-ocular impact. No peer review publication has yet appeared for the preparation approved by the EMA, so that should hopefully help to clarify what remains a rather muddled picture for low dose atropine in myopia.

Clinicians should interpret industry-funded research with a balanced and pragmatic view. While it is essential to recognise the potential for bias, it is equally important to acknowledge the vital contribution such research makes to the advancement of clinical practice. This is very evident in fields like myopia control, where large-scale, longitudinal studies are both costly and operationally demanding. In many cases, these studies would simply not be possible without industry support, as academic and public funding rarely stretch to meet the scale and duration required for robust data generation. Additionally, industry-funded trials are subject to a level of external oversight, typically involving independent monitors who ensure compliance with regulatory standards, protocol adherence, and data integrity. This layer of accountability is not always a feature of academic-led trials, adding an additional safeguard to the credibility of the findings.

 Rather than dismissing industry-funded studies outright, clinicians should evaluate them critically. Attention should be given to the rigour of the study design with key considerations being randomisation, masking and appropriate control groups as well as relevance of outcomes, transparency in reporting, and the strength of the statistical analyses. Disclosure of funding and potential conflicts of interest must be considered but should not automatically undermine the integrity of the findings.

 Importantly, when industry-funded findings align with independent research and clinical experience, confidence in their validity strengthens. Peer-reviewed publication in reputable journals adds further credibility.

 Industry-funded studies often drive innovation and provide early evidence for new interventions. By critically appraising these studies, rather than rejecting them, clinicians can make informed, evidence-based decisions that balance scientific integrity with real-world feasibility and patient benefit.

It is true that myopia control studies are always shorter than the natural history of myopia progression which may continue for 5-10 years. Clinicians should therefore look carefully at several aspects when interpreting research. First, the length of follow-up matters: a minimum of two years follow up on treatment is a good threshold. A strong argument for this minimum length is that the second year of treatment often shows less benefit than the first. All the major trials have met this two-year standard and many have extended out to three years of active treatment. Another important aspect of myopia studies is whether the possibility of rebound, which is defined as an acceleration of myopic progression above that expected in untreated children, has been included in the study design. This first came about from early atropine studies, and again is a feature of most well-cited trials in this area, but there is some debate whether that is still needed in optical therapies, which have generally shown no evidence of rebound. Fourth, study design features such as randomized allocation, masking, adequate sample size, and appropriate control groups are critical for reliable interpretation. Another aspect of clinical studies that sometimes gets overlooked are the inclusion criteria and drop out. The inclusion criteria are important when considering how relevant the results of a trial are the patient you are treating. A high drop-out rate in a trial is concerning in terms of the tolerability of a treatment and can also lead to misleading results if, for example, participants in the control group are leaving due to fast progression and being offered a myopia control treatment outside of the trial. Most importantly I would encourage clinicians to read the final trial publications, they are nearly all open access, rather than just believe what they are told!

As clinicians, we rightly place emphasis on traditional good visual habits such as ensuring children have clear and comfortable vision through accurate, up-to-date prescriptions;¹⁸ promoting time spent outdoors;¹⁹  encouraging appropriate reading distances;²⁰  advocating for regular breaks during near work; and maintaining adequate lighting.²¹  These strategies are well established and play a valuable role in supporting overall visual hygiene. They may contribute to reducing the risk of myopia onset or delaying the onset of myopia, particularly in younger children.

However, when we are faced with cases of progressive myopia, these behavioural approaches alone are insufficient. While they remain important as part of a broader management plan, they do not offer the level of efficacy required to meaningfully slow axial elongation. Outdoor time, for instance, has shown strong evidence in delaying the onset of myopia, likely due to increased light exposure and greater dioptric distance. However, once myopia has begun, the evidence regarding its ability to slow progression is equivocal. Similarly, good reading habits and lighting may reduce asthenopia symptoms, but they don’t directly address axial elongation and myopia progression. 

Therefore, in children who have developed myopia, clinical intervention for myopia control becomes essential. Evidence-based treatments such as myopia control spectacle or contact lenses, orthokeratology, and low-dose atropine have demonstrated efficacy in slowing axial growth. These options should be considered the foundation for myopia management, while traditional methods serve as supportive lifestyle modifications. It should be noted that the optical interventions both correct the myopia and slow progression whereas a child using atropine will also need to have their vision corrected with spectacles or contact lenses.

In practice, we must move beyond simply correcting refractive error and adopt a proactive, multifaceted approach. Educating families about the limitations of traditional habits and the importance of targeted treatment can make all the difference in preserving long-term ocular health.

Axial length is certainly a critical aspect of myopia management and of clinical trials but should not be considered a barrier to myopia management in practice. You don’t need to know a child’s axial length to fit them with any treatment and clinicians can take reassurance that currently licenced myopia control products are all approved for myopia control not axial length control. The clinical trials in this area have all shown that myopic progression in children correlates closely with axial elongation,²²  therefore refraction (ideally cycloplegic, at least at baseline) is a perfectly good measurement for monitoring. Also consider the low availability of axial length devices in primary eye care settings. Saying that myopia management shouldn’t take place without axial length monitoring would severely limit children’s access to these treatments.

 I would therefore recommend that clinicians dip their toes in the water of myopia management by choosing one treatment that fits their practice and just start with refraction monitoring. As your myopia management service grows, as it certainly will, start thinking about how you might be able to budget for one of these devices. In the meantime, axial length estimation is a great way of starting to think about axial length and increase your understanding of what is normal for different age children. It is important to use a formula or webapp that includes age and sex into the calculations. Girls of all ages have eyes that are about 0.5mm shorted than boys.²³  Eyes, like feet, also grow throughout childhood, so the older estimators that only use keratometry and refraction are much less accurate than newer ones (e.g. Ocumetra’s free mEYE gauge). Axial estimation is particularly valuable when it comes to risk assessment. Knowing that an eye is heading towards a worrisome level, like 26 mm, should be a motivation for getting the optimal response to treatment.²⁴  At the opposite end of the spectrum an eye with an axial length shorter than normal for a child’s age and sex, should trigger an evaluation of what is causing the myopia with attention being directed first towards the cornea. Axial estimation is not really accurate enough to use for monitoring, but I would encourage clinicians without biometry to consider recording estimates at each visit. This will really help them build their knowledge about patterns of eye growth, which will make the transition to using biometric axial length measurements much easier.