July 15, 2025
By Ashley Tucker, OD, FAAO, FSLS, ABO Diplomate
Photo Credit: Getty Images
The 2025 update by Brennan et al., published in Contact Lens and Anterior Eye, reexamined the original 10 commonly held myopia beliefs and introduced nine new ones, evaluating each through the lens of recent peer-reviewed research.
Original Commonly-Held Beliefs
Here’s a breakdown of the 10 previously discussed beliefs in the paper:
- Low-Dose (0.01%) atropine slows myopia progression (Resolved: Barely)
Because 0.01% atropine offers limited long-term benefits, clinicians now favor higher concentrations—such as 0.05%—to achieve meaningful myopia control. - Relative peripheral hyperopia leads to myopia development and progression in children (Unresolved)
There is insufficient evidence to support peripheral hyperopia as a primary driver of myopia progression. - Undercorrection slows progression–Unresolved?
There is no strong evidence that undercorrection slows myopia progression, but consistent full-time wear of myopia control lenses—especially during near work—is likely critical to maximize treatment efficacy. - Percentage treatment effect remains constant over time–Resolved (False)
Treatment efficacy typically declines after the first year, making fixed percentage estimates misleading over the long term. - Percentage effect applies uniformly across patients–Resolved (False)
Absolute treatment effects are more consistent across individuals, while percentage effects can overstate benefits in fast progressors. - Screen time directly causes myopia – Unresolved
Screen use is not a proven cause of myopia, though it may contribute as part of overall near work habits. - More outdoor time slows progression – Unresolved
Outdoor time modestly slows myopia progression and may be a helpful adjunct, though its main benefit remains in preventing onset. - The impact of outdoor activity on myopia incidence is due to daylight (Partially Resolved: Not Entirely)
Although researchers often credit outdoor light exposure as the key factor in preventing myopia, current evidence suggests that optical clarity and visual experience—not daylight alone—play a more significant role in modulating eye growth. - Subclassifications for myopia are effective (Partially Resolved: False)
The risk of vision impairment increases with every diopter of myopia—regardless of severity—making the focus on “high myopia” alone misleading, as even low and moderate myopia contribute significantly to long-term visual complications. - Myopia is a condition with a negative dioptric number (Resolved: False)
Myopic eye growth begins before refractive error turns negative, making early identification and intervention in pre-myopes essential.
New Commonly-Held Beliefs
Additionally, the researchers broke down nine new commonly held beliefs for consideration:
- Myopia is an optical disorder, not a disease. (Partially Resolved: False)
Despite lingering debate, growing evidence and public health consensus support classifying myopia as a disease due to its long-term risks. - Accommodative lag leads to myopia onset and progression. (Partially Resolved: False)
Studies show no causal relationship between accommodative lag and myopia development and progression. - Myopia stabilizes in the teenage years. (Resolved: Not necessarily).
Although average progression slows by age 16, many individuals continue to progress into their 20s and beyond. - Only fast-progressing myopes need to be treated. (Resolved: False)
Waiting for rapid progression before initiating treatment risks missing the opportunity to reduce long-term severity and associated disease. - Fast progression during treatment means the child is a non-responder. (Resolved: Not necessarily)
Ongoing progression does not imply that the treatment has failed, since clinicians must assess benefits relative to the progression they would expect without treatment. - Soft contact lenses cause myopia progression. (Partially resolved: False)
Contrary to early concerns, soft lenses do not worsen myopia and may even reduce peripheral hyperopia in some cases. - Red light therapy is safe and effective. (Partially resolved: Not necessarily)
While early results are promising, safety concerns about retinal exposure and high rebound rates raise significant caution. - Orthokeratology, or any contact lens wear in children, is dangerous. (Partially resolved: False)
With proper hygiene and fitting, contact lenses—especially OrthoK—are safe for children and carry low rates of serious complications. - Rebound is the difference between growth during treatment and after cessation (Resolved: False)
True rebound should be measured against untreated controls, not prior treatment rates, and is minimal for most interventions except atropine and red light.
Abstract
Commonly Held Beliefs About Myopia That Lack a Robust Evidence Base: 2025 Update
Noel A Brennan, Xu Cheng, Monica Jong, Mark A. Bullimore
Purpose
To subject a number of areas of contention in the myopia field to evidence-based scrutiny.
Method
The 10 topics from our previous review were revisited, and nine new topics were also critiqued with emphasis on the recent peer-reviewed literature.
Results
The following observations were made: 0.01% atropine should not be considered a frontline myopia control treatment; the role of relative peripheral hyperopia in myopia development and progression remains unclear; undercorrection probably does not slow myopia progression; treatment efficacy diminishes with time; percentage is a misleading metric of efficacy; handheld digital devices have not been proven to be myopiagenic; more time outdoors may slow myopic shift to a similar extent in children with and without myopia; daylight is responsible for only part of the impact of outdoor time; all myopia, not just high myopia, carries the risk of visually threatening complications; premyopia is a real condition.
Furthermore, myopia may be considered a disease; accommodation lag may be a measurement artifact; adult myopia progression is significant; past progression is a flawed indicator to initiate myopia control; fast progression does not mean nonresponse to treatment; single vision soft contact lenses are not myopiagenic; red light therapy may not be safe; contact lens wear in children may be considered safe; rebound cannot be assessed by comparing progression during and following treatment.
Conclusions
The myopia field continues to evolve with some conflicts resolved, ongoing areas of confusion, and new uncertainties emerging.
DOI: 10.1097/ICL.0000000000001191
