Managing Juvenile-Onset Myopia When an Optical Biometer is Unavailable

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With our expanding knowledge of juvenile-onset myopia, the accurate diagnosis and treatment of the disease is paramount to reduce the burden of disease in the future.

October 1, 2025

By Dr. Loren Rose

The incidence of myopia is increasing at a younger age around the world. This ultimately results in a greater risk of high myopia with more years of progression.^1-3 Optical biometry has become an important tool for assessing axial length. It provides a reproducible and accurate assessment of myopia progression and any treatment effect.⁴ As the diopter measurement of the eye includes the corneal and lenticular power, the axial length allows the true culprit of progressive juvenile myopia to be directly assessed.

Before initiating myopia intervention, it is important that the child has a detailed review. This includes a slit lamp examination to exclude myopia progression mimickers such as keratoconus or intraocular lens pathology. The accuracy of small changes in elongation with biometry allows for an objective measure of axial length between reviews. Additionally, it allows practitioners to track the effect on this when a new treatment is initiated. Biometry is also helpful in assessing the association between a long axial length with the long-term risk of pathology.⁵

Cycloplegia

Interferometry is still not widely available in some practices, and refraction becomes the only measure of the progression and effect of any myopia control treatment. When myopia is suspected due to behavior or a significant family history, it is important that careful review, including cycloplegic refraction, is obtained. Cycloplegia allows accurate diagnosis of the grade of myopia in diopters, which will allow rehabilitation for good vision and an initial benchmark for the level of myopia, especially if biometry is unavailable.

Cycloplegic refraction allows for the paralysis of the accommodation system, which is highly active in young children and can lead to overestimating the degree of myopia.⁶ Recent evidence has suggested that tropicamide 1% instead of cyclopentolate 1% may afford enough cycloplegia to obtain accurate refraction in non-strabismic patients.^6-8 This would allow cycloplegia to act faster and wear off faster, increasing patient tolerability. However, it is important that enough medication is instilled, and a patient is checked for dilation and cycloplegia, given that it is difficult to instill drops, especially in younger patients.

Once appropriate cycloplegia is achieved, either retinoscopy or autorefraction allows a baseline to be obtained. The measure of progression can be indicated with diopter change. However, a referral for interferometry may be indicated if the diagnosis of axial myopia requires review or there is concern over the treatment response.

Orthokeratology

The use of orthokeratology contact lenses to treat myopia and reduce its progression has some specific considerations for monitoring progression. The most accurate measure of progression with orthokeratology is with axial length interferometry measurements due to the corneal changes that are altering refraction. However, if this is not available, a practical baseline can be set at lens dispensing by recording the refraction with lenses on eye. At each review, repeat over-refraction with lenses in place provides a repeatable comparator, as this is relatively stable across the day.

Alternatively, if lenses are removed, refraction should be performed at a consistent time of day to minimize variability from diurnal regression. A full washout is rarely practical in children and is not recommended for routine review, though it may be considered in select cases where results are unclear. Cycloplegic refraction remains useful at the initial baseline, and later only if findings are unexpected or if other pathology or accommodative factors are suspected.

Monitoring Myopia Progression

 Appropriate lifestyle advice is given early to promote the best chance of slow myopia progression, including more outdoor natural light exposure with appropriate UV protection and reduced recreational near work.^9-11 Regular review is recommended to monitor visual acuity and compliance with the prescribed myopia management strategy. If vision continues to be suboptimal or a high amount of myopia (a degree in diopter greater than the patient’s age), a review with a pediatric ophthalmologist is recommended to exclude syndromic myopia, which includes collagen disease and retinal dystrophies.¹²

Assessment of progression can be reviewed with regular (usually) yearly cycloplegic refraction in a young child. Epidemiological research has demonstrated that axial elongation naturally slows down from age 10.¹³ The yearly assessment with cycloplegic refraction or, once older, subjective refraction should reflect the slowing down of the myopic power shift.¹⁴ Therefore, close supervision of this power change can indicate fast progression. 

Reducing the Burden of Disease

Myopia control is now available to retard progression and reduce the lifelong risk of sight-threatening eye disease as an adult. Certain risk factors such as ethnicity, age of onset, the amount of refraction and a family history of high myopia are associated with fast progression.¹³ Generally, younger Asian patients are known to progress faster.^13,15,16

Lifestyle advice continues to be important, combined with various interventions, from refractive peripheral defocus lenses, dual focus contact lenses and orthokeratology to various atropine drop concentrations¹⁷ and, most recently, red light therapy.¹⁸ With our expanding knowledge of juvenile myopia, the accurate diagnosis and treatment of juvenile myopia is paramount to reduce the burden of disease in the future.

 

Dr. Loren Rose completed her ophthalmic training at the Royal Eye and Ear Hospital in Victoria and a fellowship in paediatric ophthalmology at the Royal Children’s Hospital, Melbourne. She is a Clinical Senior Lecturer at Macquarie University and has completed her PhD at Macquarie University titled Myopia Progression in Children in 2021. Dr. Rose has also been appointed Adjunct Associate Professor at the University of Canberra. She is the founder of Myopia Australia, her new project which helps patients and eye health providers best manage myopia progression in children.

 

References

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