Real-world cases with red light therapy

Read the full series of case studies from Eyerising International.

Repeated low-level red light (RLRL) therapy has emerged as a promising intervention to delay onset or slow myopia progression in recent years. 

It offers a unique approach to treatment, being home-based and minimally invasive. RLRL is administered using a desktop device (Eyerising Myopia Management Device) equipped with semiconductor laser diodes that emit red light at a wavelength of 650nm. RLRL therapy is performed twice daily, 3 minutes per session, five days per week, with a minimum 4-hour gap between sessions.1 

It can be used as monotherapy or in combination with an optical treatment, such as orthokeratology (ortho-k) contact lenses or defocus incorporated multiple segments (DIMS) spectacle lenses.2-6

The basic principle of RLRL therapy is to use red light of specific wavelengths to mitigate the retinal and choroidal structural changes in myopic eyes that classically lead to axial elongation. These include choroidal thinning and reduced blood flow which is seen in line with the scleral hypoxia hypothesis for myopia. RLRL may then alleviate scleral hypoxia by enhancing blood flow at the choroid, as it has been consistently shown to increase choroidal thickness.7 This may help to inhibit axial elongation and even in some patients, cause axial shortening.8

A substantial amount of interest in RLRL therapy is due to its outstanding myopia control efficacy results.6 In a 1-year clinical trial, RLRL treatment reduced axial elongation and myopia progression by 66% (0.26mm) and 75% (0.59D) compared to controls.1 Interestingly, around 20-25% of children even showed post-treatment axial length shortening (>0.05mm).8 The subsequent 2-year follow-up study showed sustained efficacy with axial elongation slowed by 57% in children who continued RLRL treatment, though a rebound effect was noted in children who discontinued RLRL after one year.9

To date, over 40 clinical trials and numerous systematic reviews have now investigated this pronounced treatment effect including the potential for axial shortening, which has been replicated in various other studies since. Crucially, no adverse events have been reported in any of these studies. Furthermore, several studies of RLRL have demonstrated a paradoxically even stronger efficacy and axial shortening effect in highly myopic children, necessitating further exploration as RLRL could become a key solution for fast progressors and high myopes.  

In the first case, contributed by Professor Junwen Zeng, a 7-year-old Chinese boy with bilateral low myopia presented with rapid myopia progression and axial length elongation, despite 1 year of low-dose atropine. Given his young age and fast progression profile, his risk of developing high myopia was substantial. RLRL therapy was therefore initiated in May 2021 after a washout period for atropine.

Over nearly 4 years of continuous treatment, he showed minimal axial length elongation, clinically stable refraction, and no adverse events. After switching from low-dose atropine, his axial elongation slowed to only 0.06 mm per year, with no further myopia progression, indicating highly effective myopia control. This degree of stability is noteworthy given his risk factors for progression as well has his ‘pre-treatment’ fast progression while using low-dose atropine.

At a time when clinicians are seeking long-term data to guide decision-making in myopia management and in particular with relation to RLRL, this case provides real-world insight that extends beyond what is currently available in the published evidence. As RLRL remains a relatively new treatment modality, most clinical studies to date have been limited to 12 months. 

The longest series of data published so far was a 3-year multicentre real-world study, in which RLRL demonstrated satisfactory myopia control (annual axial elongation ≤0.10 mm) in 72% of participants.10 Reassuringly, there were no changes in best-corrected visual acuity or full-field electroretinography (ERG). In four eyes, there was a minimal, reversible change on optical coherence tomography (OCT) that did not impact visual function. 

Understanding of long-term efficacy and safety is crucial, given that children may require myopia control over extended periods.

In the second case report, contributed by Philip Cheng, a 6-year-old boy of Chinese ethnicity (living in Australia) presented with early-onset myopia and strong familial risk, with both parents having high myopia. He was initially treated with MiYOSMART spectacle lenses, and 0.025% atropine was subsequently added to bolster efficacy. Despite these efforts, his axial length continued to progress rapidly at 0.3-0.4 mm per year, and the child reported visual symptoms associated with atropine. This prompted escalation to RLRL therapy in combination with MiYOSMART.

Following the introduction of RLRL, his axial length showed early responsiveness. Remarkably, he demonstrated evidence of axial length shortening at 1-month follow-up, achieved with a moderate level of treatment compliance at 72%. Importantly, no structural or functional changes were reported, including side effects.

This case illustrates several practical challenges when it comes to managing young myopes in clinical practice. The child had multiple risk factors for fast progression – early-onset myopia, two myopic parents, East Asian ethnicity, which necessitated urgent myopia control. However, there were limited prescribing options in this case. For atropine, there were psychological and physiological barriers, and he was unlikely to tolerate contact lenses, perhaps for similar reasons. 

With RLRL, the ease of use for both the child and parents appeared to support compliance, which is important for extracting efficacy from a treatment.

The third case report was contributed by Dr Takashi Kojima, involving a 12-year-old Japanese boy presenting with already high levels of myopia. Due to his initial refractive error, myopia control was initiated with a combination of extended depth of focus (EDOF) soft contact lenses and 0.025% atropine. Even so, he continued to progress quickly, prompting a switch from atropine to RLRL.

After 1 year of RLRL and wearing EDOF soft contact lenses, the response was surprising. He exhibited substantial axial shortening nearly back to his original baseline, and a reversal of myopia by around 1 D in each eye. OCT imaging demonstrated a marked increase in choroidal thickness in both eyes, which could potentially correlate with myopia control efficacy.11

Importantly, this case highlights that RLRL therapy can be an effective tool in managing children with high myopia, a group for whom treatment options are limited from both a prescribing and evidence standpoint. 

Most established myopia control interventions have been validated primarily in children with low-to-moderate myopia. Historically, there has been some evidence for partial-correction ortho-k and low-dose atropine, though not to this degree of effect.12,13 Moreover, this case study corroborates the effects observed in two randomized trials of RLRL in high myopia, which reported strong treatment effects, with 53-59% experiencing substantial axial shortening >0.05 mm.14,15

The final case, contributed by Jonathan Cohen, involves a 10-year-old boy of Asian ethnicity (living in the UK) who was first diagnosed with myopia at age 4. By the time he attended the clinic at age 8, he had already been wearing MiSight contact lenses and MiYOSMART (dual wear, alternate days), combined with 0.01% atropine for one year. He was refit into ortho-k lenses and 0.01% atropine was increased to twice daily (effectively 0.02%), but this did little to curb his rapid axial elongation of 0.5 mm per year. Atropine was discontinued and RLRL therapy was introduced.

Following the cessation of atropine and initiation of RLRL, the child showed consistent axial shortening, with the most recent follow-up indicating no further axial elongation and no myopic progression over the previous 1.5 years. As observed in his axial length journey, this represented a dramatic departure from his previous trajectory. There were no concerns in terms of structure, function, or side effects, and treatment compliance was reasonable considering the efficacy observed.

Among all the cases in this series, this one exemplifies the challenge of managing a non-responder across multiple modalities. Despite being under well-structured, evidence-based care, and trying nearly every available myopia control modality, there appeared to be no recourse for this child until RLRL was introduced. While it is uncertain why RLRL led to profoundly better outcomes, a possible reason is that it provided an additional mechanism – beyond those achievable by optical or pharmacological interventions - for myopia control. 

Ultimately, it demonstrates that in the real world, changing the myopia control strategy (sometimes more than once) may be needed when progression is inadequately controlled.

1. Long-term use: Repeated low-level red-light therapy can provide sustained and nearly complete control of myopia progression and axial elongation over multiple years, even in children at high risk of progression.
2. Young age: For young children or children who cannot tolerate atropine or contact lenses, RLRL can offer an easy-to-use and non-invasive alternative to myopia control.
3. High myopia: In high myopia, where evidence and treatment options are limited, RLRL can produce substantial levels of myopia control not typically seen with other modalities.
4. Non-responders: Finally, RLRL can offer an alternative myopia control mechanism that may help to stabilize progression in children who have insufficient response to optical or pharmacological treatment modalities.