Myopia: Assessing Management Efficacy

As myopia progression leads to long-term ocular risks, such as myopic macular degeneration, retinal detachment, and glaucoma, the clock is ticking to diagnose it and slow its progression. Slowing myopia progression requires us to keep tabs on management efficacy. This article outlines how we can determine whether management is working, recognize warning signs of management failure, and implement protocols that optimize outcomes for young patients.^1-8

DETERMINING WHETHER MANAGEMENT IS WORKING

Two primary clinical indicators guide efficacy assessment: (1) axial length (AL) change and (2) refractive error progression.

(1) AL Change. Management is generally considered effective if axial elongation is significantly slower than expected for a child of similar age and ethnicity.^5-16The practical benchmarks often cited, which must be interpreted cautiously, include:

• < 0.30 mm/year for younger children (6 to 9 years of age)
• < 0.20 mm/year for older children (10 to 13 years of age)

This is all assuming the child falls within expected physiological growth ranges (Figure).

The reason these benchmarks must be interpreted cautiously is that normal axial growth varies widely among individuals, as it can correlate with body growth, age, and developmental stage. The growth of the eyes is not linear. AL changes faster during a growth spurt, which can occur at different ages. Therefore, AL data should always be considered alongside refractive changes, age, patient sex, and overall physical development.¹⁷ As an example, a 0.30 mm/year increase in AL may be entirely attributable to physiological ocular growth in a 6-year-old child but would represent significant myopic progression in a patient 18 years of age.

(2) RE Progression. Refraction remains an essential metric, especially in practices without access to optical biometers. Cycloplegic refraction minimizes accommodative influences, especially in younger children who are premyopic or borderline myopic.

As a general reference, a myopic shift ≤ -0.50 D/year is often considered good myopia control.¹⁸ That said, progression should not be interpreted as an all-or-nothing outcome.

For example, a child progressing -1.50 D/year before management who slows to -0.75 D/year after has still benefited significantly from management.

Evaluating change relative to premanagement progression provides a more meaningful assessment than relying on fixed thresholds alone.

RECOGNIZING WARNING SIGNS OF MANAGEMENT FAILURE

Early identification of inadequate response to management is essential to limit permanent ocular stretching. This does not necessarily mean incorrect prescribing; rather, it suggests the current intervention may not address the child’s biology, environment, or treatment adherence sufficiently:

• Biology. Some breakthrough progression is expected, but rapid change may indicate the underlying mechanism is ineffective. Particular concern arises when refractive progression exceeds -0.75 D/year or axial elongation exceeds ~ 0.20 mm within 6 months.¹⁷

Environment. Children who develop myopia before 7 years of age, have two myopic parents, and spend extensive time on near work and little time outdoors often have myopia that progresses rapidly. Clinical trial averages may underestimate progression in these patients, so expectations and monitoring should be adjusted accordingly.

Management Adherence.Management failure can reflect inconsistency rather than lack of efficacy. In orthokeratology, inconsistent corneal topography changes suggest irregular wear or poor fit. Regarding atropine therapy, this appears as minimal pupil dilation, rapid light response, or absence of expected near blur (with higher concentrations). Finally, when it comes to the use of specialized spectacles, scratches in treatment zones or habitual viewing over the frames can indicate nonadherence to regular wear.

Discussing adherence openly with both parents and children is critical. This discussion should focus on the impact of poor adherence on treatment efficacy and explore alternative solutions, rather than pressuring the child to acknowledge nonadherence.

IMPLEMENTING PROTOCOLS THAT OPTIMIZE OUTCOMES

Standardized monitoring helps detect insufficient management before substantial myopia progression occurs. The following steps comprise my standardized monitoring protocol:

1. Establish a Robust Baseline.

Before initiating treatment, I obtain: 

• Cycloplegic refraction to rule out accommodative spasm.
• Baseline AL measurements with high reproducibility to establish accurate and objective starting points for assessing changes.
• Baseline binocular vision, including accommodative and vergence function, to help interpret future symptoms of myopia progression and potential management interactions. An example of a symptom is near blur in the initial stage of orthokeratology treatment in patients who have accommodative insufficiency. An example of a potential management interaction: The efficacy of a low-dose atropine-novel spectacle combination may be less predictable in patients who have intermittent exotropia, as atropine-induced changes in accommodation and accommodative vergence may affect these patients differently.

Axial Length Centile Charts

2. Review Patient Lifestyle.

Clinical management alone cannot fully counteract a strong myopiagenic environment, so I review the patient’s lifestyle. This includes discussion points that evidence supports, including:

• Increased outdoor light exposure, both for the duration and the frequency of outdoor breaks. Shorter and more frequent outdoor breaks protect myopia much better than longer, but less frequent, breaks.
• Regular visual breaks during near work.
• Appropriate working distance and posture. One study of grade 7 students shows that a ≤ 3 m TV viewing distance, use of a fluorescent desk light, a ≤ 20 cm reading distance, and a ≤ 2 cm nib-to-fingertip distance were significantly linked with longer axial length (P < 0.01).¹⁹

Without addressing environmental factors, treatment effectiveness may be limited.

3. Schedule a 6-Month Efficacy Review.

Unlike routine adult comprehensive eye examinations, myopic children benefit from a 6-month follow-up visit, with quarterly visits for higher-risk patients. During these follow-up appointments, I:

• Repeat the AL measurement (be cautious about measuring first thing in the morning, as diurnal variation can typically make the AL appear longer. For example, axial elongation approaching 0.15 mm in 6 months may signal the need to reassess the management strategy.).
• Perform an autorefraction for objective comparison.

4. Switch or Combine Treatment.

If progression exceeds expectations, I:

• Review patient adherence to their management regimen first.
• Consider switching the treatment modality.
• Prescribe combination (“stacked”) treatment in select cases.

Individualized care is essential, as responses vary widely.

5. Communicate Clearly With the Patient's Family.

Managing expectations is critical. Parents should understand:

• The goal is slowing progression, not stopping it entirely.
• Outcomes are measured in percentage reduction relative to expected progression.

Documentation and consistent communication improve adherence and satisfaction.

A SHIFT IN MINDSET

Assessing myopia management efficacy requires a shift in mindset from vision correction, to disease management.

Monitoring axial elongation, tracking refractive progression, identifying early warning signs (such as squinting), and following a structured pro-tocol enables us to influence long-term ocular health meaningfully.

Ultimately, success in myopia management is not defined by how clearly a child sees today, but by the preservation of retinal health decades into the future. Through careful monitoring, patient education, and evidence-based intervention, modern optometrists play a vital preventive role in safeguarding lifelong vision (see “Myopia: Getting Parent Buy-In to Treatment,” in the July/August 2026 issue).