Myopia Profile


How to understand myopia risk factors

Posted on November 18th 2023 by Kate Gifford

In this article:

Understand how the free-to-download, multi-language Managing Myopia Guidelines Infographic can be used as a chairside reference to identify risk factors for myopia development and progression, with the scientific basis of each described.

Identifying the pre-myope

Pre-myopia is defined by the International Myopia Institute1 as “a refractive state of an eye of ≤ 0.75 D and > 0.50 D 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.”

There are four key risk factors for a child becoming myopic, or being a pre-myope. These can be used in assessing risk of myopia onset:

  • Family history - one myopic parent increases risk by three-fold, while two myopic parents doubles this risk again2

  • Visual environment - less than two hours per day  spent outdoors increases risk,3 especially if combined with more than 3 hours a day spent on near work activities (outside of school time)4

  • Binocular vision - Children with higher accommodative convergence (AC/A) ratios, typically seen with esophoria, have an increased risk of myopia development within one year of over 20 times.5 Accommodative lag may also be a risk factor but there is conjecture.6 Intermittent exotropia has also been associated with onset of myopia.7

  • Current refraction - the most significant risk factor of this lot for future myopia is if a child exhibits less than +0.75D (cycloplegic) manifest hyperopia at age 6. See the highlight box below for more cut-offs based on age. This risk is independent of family history and visual environment.  These thresholds for myopia risk in older children are +0.50D or less at ages 7 to 8, +0.25D or less at ages 9 to 10 and plano or less at age 11. These children are highly likely to be myopic by age 13.8

In addition to these, the fastest rate of refractive change in myopic children occurs in the year prior to onset,9 so the child who is less hyperopic than age normal should be closely monitored, especially if concurrent risk factors are evident.


The most significant risk factor for becoming myopic, independent of all other factors, is being less than +0.75D at age 6, +0.50D or less at ages 7 to 8, +0.25D or less at ages 9 to 10 and plano or less at age 11. These children are defined as pre-myopes and should be monitored more closely, with modifiable risk factors (visual environment and binocular vision) addressed where possible.

Identifying the child at risk of myopia progression

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The principles of assessing a child’s risk for myopic progression is quite similar. The graphic above, from the free-to-download clinical resource Managing Myopia Guidelines Infographics, summarises the main aspects to consider when evaluating risks for myopia progression.

  • Age of myopia onset - the younger a child becomes myopic, the faster they will progress, with children 7 years of age progressing by at least 1D per year with this halving by age 11-12.10

  • Myopic parent(s) - children with two myopic parents have been shown to be the fastest progressors in single vision spectacle and atropine corrections, and children with one myopic parent progress less than the former but more than the child without such family history.11,12

  • Visual environment - near work at less than 20cm working distance and durations of longer than 45 minutes have been linked with more myopia progression. There is conflicting evidence regarding the efficacy of increased time spend outdoors in reducing myopia progression. It is still best practice to recommend outdoor time (minimum 2 hours per day) to improve a child’s visual environment.3,13 

  • Binocular vision disorders – watch for esophoria, accommodative lag and intermittent exotropia. In myopia control studies of progressive addition spectacle lenses (PAL), children with esophoria in single vision spectacle control groups were found to progress more quickly, 14 and children with a larger baseline accommodative lag in the PAL groups showed statistically greater treatment effect.15 Children with lower baseline accommodative amplitude have shown a greater myopia control response to orthokeratology contact lens wear compared to normal accommodators.16 Finally, while the effect of controlling IXT on controlling myopia has not yet been studied, 50% of children with intermittent exotropia (IXT) are myopic by age 10 and 90% by age 20.7 

In addition to the above, Asian ethnicity has been linked to faster myopia progression. 10,17

These risk factors can also be grouped in those that are modifiable and those that are not modifiable. Age of onset and parental history are unmodifiable and whilst useful to consider and communicate, no action is possible. Modifiable risk factors are the child’s visual environment, which includes time spent doing near work and outdoor time. Binocular vision disorders can also be  modifiable, depending on the issues at hand.

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The more risk factors the child has, the more likely he/she will progress. One may choose to initiate a more aggressive myopia management strategy if the risk factors suggest fast progression.

Essentially, any myopic child is a progressor until proven otherwise! The institution of a myopia control strategy as early as possible is evidence based practice, especially before age 10 when progression is fastest. The Myopia Profile Managing Myopia Guidelines Infographic and patient brochure  (free to download and available in numerous language translations) is designed to help you explain risk and the steps a parent or carer can take to modify risk factors, where applicable. 

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The Managing Myopia Guidelines Infographics

Myopia Profile’s popular and entirely free Managing Myopia Guidelines Infographics are designed to support clinical communication and decision making in myopia management. These engaging infographics are available to download and print in several formats and numerous language translations. 

There are two four-panel infographics which can be printed in large format as poster (ANSI-C or A2), or scaled down to US Letter or A4 to be used as a handheld infographic for in-room discussions and reference. 

  • The mostly blue infographic is a chairside reference guide for eye care professionals that guides you through: (1) Myopia risk factors, (2) What to prescribe, (3) Follow-up schedules and (4) Gauging success

  • The multi-colored infographic is designed to help you communicate with parents and patients on the following topics: (1) Visual environment advice, (2) What are my options? (3) Kids can wear contact lenses and (4) Why myopia management is essential. 

The Infographics can also be printed as individual panels (US Letter and A4 sizes) to use each page on its own if you prefer. As above, there are four which are parent- and patient-facing (multi-coloured) and four which are your chairside reference (mostly blue coloured). The image below shows various print formats, with all panels collated (at back) and single pages (foreground).

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Freshly updated in late 2023 and built from the ground up from continued feedback with eye care practitioners and industry advisers, these Managing Myopia Guidelines Infographics are designed to be used by eye care professionals, in discussion with patients and their carers, and as a clinical reference.

Meet the Authors:

About Kate Gifford

Dr Kate Gifford is an internationally renowned clinician-scientist optometrist and peer educator, and a Visiting Research Fellow at Queensland University of Technology, Brisbane, Australia. She holds a PhD in contact lens optics in myopia, four professional fellowships, over 100 peer reviewed and professional publications, and has presented more than 200 conference lectures. Kate is the Chair of the Clinical Management Guidelines Committee of the International Myopia Institute. In 2016 Kate co-founded Myopia Profile with Dr Paul Gifford; the world-leading educational platform on childhood myopia management. After 13 years of clinical practice ownership, Kate now works full time on Myopia Profile.

About Kimberley Ngu

Kimberley is a clinical optometrist from Perth, Australia, with experience in patient education programs, having practiced in both Australia and Singapore.

Read Kimberley's work in many of the case studies published on Kimberley also manages our Myopia Profile and My Kids Vision Instagram and My Kids Vision Facebook platforms.

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