Is Treatment Needed for Accommodative-Convergence Issues Before Myopia Control?

Share

Tweet

Share

Share

Email

December 2, 2025

By Rohit Dhakal BOptom, PhD; Safal Khanal, OD, PhD, FAAO

Interest in accommodative–convergence function in myopia is largely driven by epidemiological evidence linking prolonged near work with myopia development.¹ A meta-analysis reported that children who spent more time on near tasks had higher odds of developing myopia, with the risk increasing by 2% for every additional diopter-hour per week.² 

Additionally, accommodative–convergence function has the potential to influence retinal image defocus, the presumed signal for axial elongation.³ This raises a critical question: Should accommodative–convergence issues be addressed before initiating myopia control? To explore this, this article examines evidence across three domains.

Effects on Refractive Development

Myopes typically demonstrate lower accommodative amplitudes and flatter stimulus–response curves compared with emmetropes, with more pronounced deficits in progressive myopia.^4,5 Although accommodative lag is considered a putative risk factor for myopia, evidence is mixed, with some studies showing higher lag at near in myopes^4,6,7 and others showing no association.^8–10 The CLEERE study found no greater lag in children who became myopic before or at myopia onset than in those who remained emmetropic.¹¹ Another study reported no relationship between initial lag and subsequent myopia progression.⁹

While higher accommodative convergence per unit of accommodation (AC/A) ratios are often associated with greater myopia,^12,13 the causal relationship remains unsubstantiated. In the CLEERE study, AC/A ratios were not different between children who became myopic and those who remained emmetropic five years before myopia onset, nor were they associated with the rate of myopia progression.¹⁴ Inherently linked with higher AC/A ratios are greater accommodative lag¹⁴ and near esophoria,¹⁵  which appear only after the onset of myopia. Moreover, emmetropic children who later develop myopia typically exhibit a wide range of phorias and AC/A ratios, weakening their predictive value.^15,16 

The association of higher AC/A ratios with flatter lens shape suggests they are likely due to increased tension on the crystalline lens, requiring greater effort to accommodate.^13,17 Together, these data imply that accommodative–convergence issues are downstream effects of myopia rather than causal factors in emmetropization failure.

Effects of Interventions

Studies of bifocal or multifocal soft contact lenses in adults are mixed: some report a lead of accommodation;¹⁸ others report greater lag and near exophoria;¹⁹ yet others show similar accommodative behavior to single-vision soft contact lenses.²⁰ In children, while bifocal²¹ or multifocal²² contact lenses reduce accommodation response and increase exophoria, possibly because children relax accommodation while viewing through the peripheral plus zone, dual focus lenses do not affect binocular and accommodation function, including phoria and AC/A ratio.^23,24 Soft contact lenses designed to induce spherical aberration have sometimes been associated with reduced accommodative response and increased exophoria,²⁵ which correlates with faster progression, though their effects on accommodation seem inconsistent.²⁶ 

Orthokeratology lenses have been reported to improve accommodative function and reduce lag in adults²⁷ and children,²⁸ leading to the suggestion that these lenses may be better for those with binocular vision disorders,²⁷ although these changes may stabilize within months.²⁹ Spectacle lenses with multiple segments³⁰ or aspheric lenslets³¹ generally do not alter binocular vision,^32,33 dynamic accommodation,³⁴ or accommodative lag,³⁴ and in some cases may even improve lag.⁷ 

On the contrary, low-concentration atropine eye drops reduce accommodative function dose-dependently,^35,36 produce a shift toward esophoria,³⁷ and diminish the ability to diverge.³⁷  Overall, interventions can affect accommodative–convergence status, but the direction and magnitude of these changes are highly design-specific.

Effects on Treatment Efficacy

Few trials directly address this question, as many exclude children with binocular vision disorders. Progressive addition lens trials (PALs), designed to reduce accommodative lag, produce only small and clinically insignificant treatment effects overall.^38–40 Although subgroups with high lag and near esophoria initially show greater benefit,³⁸ follow-up trials in this population still find modest treatment effects,^41,42 suggesting that modifying accommodative function is insufficient in achieving effective myopia control.

Although bifocal contact lenses prescribed to neutralize near esophoria have shown larger treatment effects,²¹ whether this benefit arises from heterophoria correction or from altered peripheral optics is unclear. A randomized controlled trial of executive bifocal and prismatic executive bifocal spectacle lenses found similar treatment effects, which were unrelated to near phoria status and high lags of accommodation. Although prismatic bifocals perform better for low lags, this efficacy seems unrelated to accommodative response, as contradictory results were found in another trial of executive bifocals with no treatment benefits.⁴³ 

In an orthokeratology lens study, myopia control outcomes were unrelated to accommodative or binocular function changes.²⁹ 

Overall, the influence of accommodative–convergence issues on myopia control efficacy remains inconsistent and inconclusive.

Clinical Implications

Given the lack of evidence establishing temporality or causality, it remains uncertain whether accommodative-convergence issues must be treated before initiating myopia control. Current data suggest that deficits in accommodative–convergence function are more likely consequences of myopia, typically appearing after onset rather than preceding it.⁴⁴ Although their influence on myopia control efficacy is uncertain due to limited and inconsistent evidence, the variable effects of interventions on accommodative-convergence function underscore the need to consider its status when implementing myopia control to ensure optimal visual function and comfort.

 

Dr. Rohit Dhakal is a postdoctoral fellow in the Khanal laboratory at the University of Alabama at Birmingham School of Optometry. He received his doctorate degree from City, University of London in the year 2024. His current research work at UAB focuses on understanding the mechanisms of childhood myopia development and progression, particularly by decoding the retinal signals of ocular growth. Dr Dhakal is a co-author in Cochrane’s living systematic review and network meta-analysis of myopia control interventions in children.

Dr. Safal Khanal is an assistant professor at the University of Alabama at Birmingham School of Optometry. His research program focuses on mechanisms of eye growth and refractive development in animal models and humans, with emphasis on myopia onset, progression, and control. He is the lead author of the NASEM myopia treatment commissioned paper and co-author of the IMI myopia and BCLA CLEAR presbyopia white papers. Dr. Khanal is a fellow of the American Academy of Optometry (AAO) and a recipient of the Borish Award, Career Development Award, ISCEV Dodt Award, and the Emerging Vision Scientist Award.

 

References

1. Morgan, I. G. et al. IMI risk factors for myopia. Invest. Ophthalmol. Vis. Sci. 62, 3 (2021).
2. Huang, H. M., Chang, D. S.-T. & Wu, P.-C. C. The association between near work activities and myopia in children – A systematic review and meta-analysis. PLoS One 10, e0140419 (2015).
3. Schaeffel, F. & Swiatczak, B. Mechanisms of emmetropization and what might go wrong in myopia. Vision Res. 220, 108402 (2024).
4. Gwiazda, J. E., Thorn, F., Bauer, J. & Held, R. Myopic children show insufficient accommodative response to blur. Invest. Ophthalmol. Vis. Sci. 34, 690–694 (1993).
5. Gwiazda, J. E., Bauer, J., Thorn, F. & Held, R. A dynamic relationship between myopia and blur-driven accommodation in school-aged children. Vision Res. 35, 1299–1304 (1995).
6. Abbott, M., Schmid, K. & Strang, N. Differences in the accommodation stimulus-response curve of adult myopes and emmetropes. Ophthalmic Physiol Opt 18, 13–20 (1998).
7. Aissati, S., Zou, T., Goswami, S., Zheleznyak, L. & Marcos, S. Visual quality and accommodation with novel optical designs for myopia control. Transl. Vis. Sci. Technol. 13, 6 (2024).
8. Berntsen, D. A., Sinnott, L. T., Mutti, D. O., Zadnik, K. & CLEERE Study Group. Accommodative lag and juvenile-onset myopia progression in children wearing refractive correction. Vision Res. 51, 1039–1046 (2011).
9. Weizhong, L., Zhikuan, Y., Wen, L., Xiang, C. & Jian, G. A longitudinal study on the relationship between myopia development and near accommodation lag in myopic children. Ophthalmic Physiol. Opt. 28, 57–61 (2008).
10. Rosenfield, M., Desai, R. & Portello, J. K. Do progressing myopes show reduced accommodative responses? Optom. Vis. Sci. 79, 268–273 (2002).
11. Mutti, D. O. et al. Accommodative Lag before and after the Onset of Myopia. Investigative Opthalmology & Visual Science 47, 837 (2006).
12. Gwiazda, J., Grice, K. & Thorn, F. Response AC/A ratios are elevated in myopic children. Ophthalmic Physiol. Opt. 19, 173–179 (1999).
13. Mutti, D. O., Jones, L. A., Moeschberger, M. L. & Zadnik, K. AC/A ratio, age, and refractive error in children. Invest. Ophthalmol. Vis. Sci. 41, 2469–2478 (2000).
14. Mutti, D. O. et al. The response AC/A ratio before and after the onset of myopia. Invest. Ophthalmol. Vis. Sci. 58, 1594–1602 (2017).
15. Goss, D. A. & Jackson, T. W. Clinical findings before the onset of myopia in youth, 3: heterophoria. Optom Vis Sci 73, 269–278 (1996).
16. Goss, D. A. Clinical accommodation and heterophoria findings preceding juvenile onset of myopia. Optom. Vis. Sci. 68, 110–116 (1991).
17. Avies, L. N. et al. BCLA CLEAR presbyopia: Mechanism and optics. Cont Lens Anterior Eye 47, (2024).
18. Tarrant, J., Severson, H. & Wildsoet, C. F. Accommodation in emmetropic and myopic young adults wearing bifocal soft contact lenses. Ophthalmic Physiol. Opt. 28, 62–72 (2008).
19. Kang, P. & Wildsoet, C. F. Acute and short-term changes in visual function with multifocal soft contact lens wear in young adults. Cont. Lens Anterior Eye 39, 133–140 (2016).
20. Madrid-Costa, D., Ruiz-Alcocer, J., Radhakrishnan, H., Ferrer-Blasco, T. & Montés-Micó, R. Changes in accommodative responses with multifocal contact lenses: a pilot study. Optom. Vis. Sci. 88, 1309–1316 (2011).
21. Aller, T. A., Liu, M. & Wildsoet, C. F. Myopia Control with Bifocal Contact Lenses. Optom. Vis. Sci. 93, 344–352 (2016).
22. Gong, C. R., Troilo, D. & Richdale, K. Accommodation and phoria in children wearing multifocal contact lenses. Optom. Vis. Sci. 94, 353–360 (2017).
23. Anstice, N. S. & Phillips, J. R. Effect of dual-focus soft contact lens wear on axial myopia progression in children. Ophthalmology 118, 1152–1161 (2011).
24. Ruiz-Pomeda, A. et al. Binocular and accommodative function in the controlled randomized clinical trial MiSight® Assessment Study Spain (MASS). Arbeitsphysiologie 257, 207–215 (2019).
25. Cheng, X., Xu, J. & Brennan, N. A. Accommodation and its role in myopia progression and control with soft contact lenses. Ophthalmic Physiol. Opt. 39, 162–171 (2019).
26. Price, H. et al. The Cambridge Anti-myopia Study: variables associated with myopia progression. Optom. Vis. Sci. 90, 1274–1283 (2013).
27. Gifford, K., Gifford, P., Hendicott, P. L. & Schmid, K. L. Near binocular visual function in young adult orthokeratology versus soft contact lens wearers. Cont. Lens Anterior Eye 40, 184–189 (2017).
28. Yang, Y., Wang, L., Li, P. & Li, J. Accommodation function comparison following use of contact lens for orthokeratology and spectacle use in myopic children: a prospective controlled trial. Int. J. Ophthalmol. 11, 1234–1238 (2018).
29. Zhu, S. et al. The relationship between accommodative and binocular function with myopia progression in myopic children undergoing orthokeratology. Cont. Lens Anterior Eye 47, 102171 (2024).
30. Lam, C. S. Y. et al. Defocus Incorporated Multiple Segments (DIMS) spectacle lenses slow myopia progression: a 2-year randomised clinical trial. Br. J. Ophthalmol. 104, 363–368 (2020).
31. Bao, J. et al. Spectacle lenses with aspherical lenslets for myopia control vs single-vision spectacle lenses: A randomized clinical trial. JAMA Ophthalmol. (2022) doi:10.1001/jamaophthalmol.2022.0401.
32. Lam, C. S. Y. et al. Effect of defocus incorporated multiple segments spectacle lens wear on visual function in myopic Chinese children. Transl. Vis. Sci. Technol. 9, 11 (2020).
33. Huang, Y. et al. Visual acuity, near phoria and accommodation in myopic children using spectacle lenses with aspherical lenslets: results from a randomized clinical trial. Eye Vis. (Lond.) 9, 33 (2022).
34. Lin, Z. et al. Dynamic accommodation responses in subjects wearing myopia control spectacles modifying peripheral refraction. Invest. Ophthalmol. Vis. Sci. 66, 55 (2025).
35. Yam, J. C. et al. Low-Concentration Atropine for Myopia Progression (LAMP) Study: A Randomized, Double-Blinded, Placebo-Controlled Trial of 0.05%, 0.025%, and 0.01% Atropine Eye Drops in Myopia Control. Ophthalmology 126, 113–124 (2019).
36. Lal, B., Queener, H. M. & Ostrin, L. A. Dose dependent effects of atropine on static and dynamic pupil and accommodation metrics in young adults. Invest. Ophthalmol. Vis. Sci. 66, 34 (2025).
37. Woodman-Pieterse, E. C. et al. Response of accommodation and vergence systems to low dose atropine. Ophthalmic Physiol. Opt. (2025) doi:10.1111/opo.70013.
38. Gwiazda, J. E. et al. A randomized clinical trial of progressive addition lenses versus single vision lenses on the progression of myopia in children. Invest. Ophthalmol. Vis. Sci. 44, 1492–1500 (2003).
39. Hasebe, S. et al. Effect of progressive addition lenses on myopia progression in Japanese children: a prospective, randomized, double-masked, crossover trial. Invest. Ophthalmol. Vis. Sci. 49, 2781–2789 (2008).
40. Edwards, M. H., Li, R. W.-H., Lam, C. S.-Y., Lew, J. K.-F. & Yu, B. S.-Y. The Hong Kong progressive lens myopia control study: study design and main findings. Invest. Ophthalmol. Vis. Sci. 43, 2852–2858 (2002).
41. COMET2 Study Group. Progressive-addition lenses versus single-vision lenses for slowing progression of myopia in children with high accommodative lag and near esophoria. Invest Ophthalmol Vis Sci 52, 2749–2757 (2011).
42. Berntsen, D. A., Sinnott, L. T., Mutti, D. O. & Zadnik, K. A randomized trial using progressive addition lenses to evaluate theories of myopia progression in children with a high lag of accommodation. Invest. Ophthalmol. Vis. Sci. 53, 640–649 (2012).
43. Grosvenor, T., Perrigin, D. M., Perrigin, J. & Maslovitz, B. Houston Myopia Control Study: a randomized clinical trial. Part II. Final report by the patient care team. Am. J. Optom. Physiol. Opt. 64, 482–498 (1987).
44. Logan, N. S. et al. IMI accommodation and binocular vision in myopia development and progression. Invest. Ophthalmol. Vis. Sci. 62, 4 (2021).