Myopia Profile


Should we start myopia control for an asymptomatic low myope?

Posted on May 10th 2021 by Connie Gan

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In this article:

When should we start myopia control for a low myope, especially if they have no symptoms? Read more in this clinical case.

How should a young asymptomatic low myope be managed? Should you monitor with no correction due to lack of symptoms, or start myopia control from the first indication of myopia? The case discussion is as follows.


Hi all, Some thoughts regarding a patient of mine would be appreciated. I saw an 8yo girl whose parents are both myopic SE Asian. Her refraction is R and L -0.75. 2 exophoric at near. MEM about plano OU. Failed -2 Flippers but passed +2. The child has no symptoms and is able to see the board at school but her mother wants to start some form of myopia control. I was wondering for a low myope what would be the best option? Also what are the 'entry' refractions for the various myopia control options? (Reading the myopia profile website it says for atropine 1D or more of myopia and it also mentions use of orthoK with 1D of myopia). Thanks in advance for responses.

What other clinical information is needed?

DC your patient has a borderline accommodative lead so if you think, after a proper BV workup, that they need an add, then go with PAL and 0.025% atropine and MiSight. If they don’t need an add go with myopia controlling spectacle lens plus MiSight. Monitor progression and adjust therapy upwards until good control is achieved.JC Thanks for that. She failed minus flippers but passed +2. I trust my Ret though which gave me more of a lead. Perhaps I'll retest BV again to confirm these results and if confident there's a lead then would go with PAL.DC Yes in this case we need to determine if we are managing a BV issue plus Myopia or just Myopia. At this point we don’t have enough data to know. Also measure NPA, and assess NPC, and look at AC/A to decide. Even though she passed +2, I would measure cycles/min (accommodative facility) with the same +2/-2 flipper and check for fatigue.

Binocular vision can play an important role in myopia onset and progression. Read more in our blog Four reasons why binocular vision matters in myopia management. Managing any potential binocular vision issues is in the patient’s best interest to ensure a comfortable, robust visual system.

The clinical findings indicate an accommodative lead and difficulty in accommodating through a -2D lens. This suggests a potential issue in the child’s accommodative system. Since childhood accommodation can influence refractive error results, an accurate refraction is required to confirm the low myopia. Read more about techniques, when to use cycloplegia and alternative options in How to achieve accurate refractions for children.

Should we correct the myopia?

There has been a school of thought suggesting that under-correcting myopia in children may reduce myopic progression, and indeed even in the current day around 20% of eye care practitioners still believe this. This has been disproven: under-correction of 0.75D (blurring the child’s vision to 6/12 or 20/40) has been shown to speed up myopic progression and axial elongation.1

However, Sun et al found that myopic progression and axial length elongation occurred at a lower rate in a group of children who were uncorrected for their myopia compared to their fully corrected counterparts.2

A systematic review published in 2020 found that there was overall no benefit to under-correcting myopic children, and their full correction should be prescribed. The review also highlighted the difficulties in fully evaluating the effect of under-correction, given that children will often experience this in between eye exams due to myopia progression.3

What should you do? Use your clinical judgement. Even if a child has no symptoms, their unaided acuity and binocular vision function may not be normal, and need correction.

  1. If the child has good unaided acuity and normal unaided binocular vision function, you could potentially review them again in six months. Six monthly reviews are recommended for myopia management by the IMI Clinical Management Guidelines.
  2. If the child has reduced unaided acuity they need vision correction. At that point you can then consider using a myopia correction which also provides myopia control - myopia controlling spectacle or contact lenses, or atropine as a first line treatment with spectacles.

We don't know the child's unaided acuity in this case. Clinically, it does appear that 6/12 or 20/40 unaided vision is the clear line in the sand where optical correction is necessary, to avoid under-correction and also ensure a child can function normally, given the World Health Organization defines this as 'mild vision impairment'.

Should we start myopia management?

Risk factors for myopia progression

The first consideration would be to assess the child’s risk factors for myopia progression, and she has three that indicate significant risk for progression, indicating the imperative for early intervention with a myopia control strategy.

  1. Her age - particularly being under age 9 at myopia onset4
  2. Both parents are myopic5
  3. South East Asian ethnicity.6

Ethnicity is important because Asian ethnicity is a key risk factor for myopia onset and progression, compared to other ethnicities, regardless of country of residence. Each of these three risk factors – age, parental myopia and ethnicity – are of course not modifiable, but important to identify as a myopia managing practitioner. You may choose not to discuss ethnicity as a risk factor with parents, where there may be sensitivity or it may not seem helpful, but even so it is worth keeping in mind clinically to help drive a proactive treatment strategy.

Myopia treatment options

PC I’ve fitted many kids with low myopia with MFSCL like MiSight, and recently prescribed myopia controlling spectacle lens for parents who want the earliest interventions. They do work. -0.50 is generally the lowest I would start. Some of these kids I was monitoring already for more-myopia and I could see their axial length rapidly increasing, indicating the need the start treatment.BM we are getting myopia controlling spectacle lens here in Feb. Was thinking to try it on my 8yo daughter AXL 23.89, cyclo rx plano. Managed to hold her steady past 2 years. Axl change 0.03 in that time, wearing readers for near work. Worth a shot do u think?PC That’s exactly the case with one of my patients who wears SVN for her large near esophoria but her mum is considering myopia controlling spectacle lens for other times. She’s obsessed with keeping her daughter at -0.25.JC To me it makes sense for it to work as a preventative assuming that the very genesis of myopia is triggered by the same mechanism as it's progression. Is that a fair assumption?PC If presenting the eye with simultaneous defocus reduces the stimulus for eye growth, then it could work.

The commenters mostly suggest prescribing myopia controlling spectacle or contact lenses. As the patient may have some accommodative issues, she could potentially benefit from spectacle lenses with a near addition while doing near work. Atropine was also initially suggested, with consideration given to possible side effects - any impact on accommodation or pupil size can be managed with progressive addition or bifocal spectacle lenses, with or without photochromatic treatment.8

What else can be done for low myopes?

As for all myopes, It is also important to emphasize the importance of managing near work and outdoor time in for both delaying myopia onset and reducing risk of progression. The key ‘rules’ to provide to parents are:

  • The outdoor rule: Spend at least 90 minutes a day outdoors, on average
  • The two hour rule: Try to limit leisure screen and near work time, after school, to less than two hours a day
  • The elbow rule: Keep a forearm (hand-to-elbow) distance between books or screens and the eyes
  • The 20/20 rule: Every 20 minutes take a break for 20 seconds and look across the room

For more help with the main messages on visual environment, read Keys to communication in myopia management.

Read the latest science on these visual environment topics in our exploration of the following key meta-analysis papers.

Take home messages:

  1. Myopia management can be implemented from the early stages when a child is pre-myopic or in the early stages of myopia. It is important to evaluate the child's visual function in cases of low myopia, and risk factors for myopia progression in determining the strategy to discuss with parents.
  2. Whether optical correction and/or myopia control is prescribed or not, asking questions and providing advice on near work and outdoor time habits is important.

Meet the Authors:

About Connie Gan

Connie is a clinical optometrist from Kedah, Malaysia, who provides comprehensive vision care for children and runs the myopia management service in her clinical practice.

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

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.

This content is brought to you thanks to unrestricted educational grant from

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