How to Manage Progressive Myopia in Very Young Children

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May 1, 2025

By Dr. Loren Rose

The management of progressive myopia in young children has many specific challenges. Special considerations include, first, the diagnosis of myopia and its progression; next, potential systemic comorbidities; and finally, determining which intervention may best suit your patient. This group of patients theoretically benefits most from progressive myopia control by reducing elongation and their risk of sight-threatening eye disease as adults.¹

Diagnosing Myopia

Unfortunately, the diagnosis is occurring in younger children, leading to a greater incidence of high myopia.² The first challenge is the accurate diagnosis of young children. Children have a significant ability to accommodate, and they are not always reliable with subjective refraction. Cycloplegic refraction requires drops to paralyze the accommodation system to perform an accurate retinoscope or autorefraction.³

The Risks of High Myopia

Suppose a young child is diagnosed with high myopia; it is important to consider systemic associations with progressive myopia, including retinal dystrophies and collagen disease.⁴ Certain collagen diseases, such as Marfan Syndrome, Ehlers-Danlos Syndrome, Stickler Syndrome and Loeys-Dietz Syndrome, may present with high myopia and may have life-threatening systemic consequences. Consequently, if myopia exceeds what is appropriate for the child’s age, if the fundus examination reveals pathology, or if there is a significant family history of systemic disease, practitioners should consider referring the patient to a pediatrician and/or a pediatric ophthalmologist.

Fast Progressors

The next hurdle is accurately considering the fast progression in very young myopes. Research demonstrates that the younger the child, the faster the progression.⁵ It would be useful to know that when the overall rate of progression compared to the age norm is determined, specific treatment protocol can be tailored or amended based on how each individual responds to the treatment effect accordingly. Given the difficulties with diagnosis without cycloplegia, cycloplegic refraction or axial length interferometry is considered the most accurate method to assess progression.⁶ Children as young as 4 years old may cooperate with interferometry and negate the use of recurrent drops.

Choosing a Myopia Treatment

Finally, what intervention is best to consider for the very young? I usually start with the patient’s lifestyle. The family must understand that this diagnosis has no cure, but we are now lucky enough to know a little about how progression works. Additionally, given that the child is young, we can use as many tools as possible to reduce progression over time. 

I start by recommending an increase in outdoor time to hopefully at least two hours daily.⁶ I also stress that the child should reduce near work, as this can confound the result we hope to achieve with the other forms of intervention.

Next is the prescription for the glasses. It is important to give the full script, as there is no evidence that undertreatment reduces progression.⁷ The child may need visual rehabilitation with the possible treatment of amblyopia, especially if there is significant anisometropia. Therefore, accuracy is important for the best vision to be achieved. If there are concerns regarding amblyopia, consider starting with single-vision glasses to ensure best-corrected vision is achieved promptly and the child wears the glasses well.

Similarly, single-vision glasses may be best if there is a con-current strabismus. However, the correct script alignment needs to be obtained, especially with divergent strabismus. If there are no such comorbidities, I consider starting with a peripheral defocus lens early, given the current research.^8-10 Even though most studies do not include patients younger than 6 years old, children 4 years and older will often wear them well.

Considering Combination Therapy

I may be able to gauge how the child’s eyes respond to the treatment used at a six-month period accordingly. At times, some children may take more than multiple axial length measurements periodically to ascertain the reproducibility and validity of the measurement data. Treatment protocols warrant vigilant and periodic monitoring and analysis for the best possible steps for each child.

If their axial growth is significant, I consider combination treatment with the addition of low-dose atropine. In my practice in Australia, I sometimes start my initial dose of atropine at 0.01%, especially combined with a peripheral defocus lens, as this has been found to be sufficient to reduce progression, with at least one study showing similar results.¹¹ However, some children will experience rapid progressive myopia, and a higher dose of atropine is required — up to 0.05%. The dose-response effect has been widely published. However, the side-effect profile is also dose dependent.^12-15 My main concern with higher doses is rebound if the drop is stopped too early, negating the benefits of intervening in the first place. Therefore, patient education and compliance is key for long-term treatment success.

Start Treatment Young

In summary, myopia in a very young child requires skill, patience and sometimes more regular review. However, intervention in this group of patients may result in the biggest effect as they are at the greatest risk of potential vision loss in later life.

 

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

1. Ohno-Matsui K, Wu PC, Yamashiro K, et al. IMI Pathologic Myopia. Invest Ophthalmol Vis Sci 2021;62(5):5. doi: 10.1167/iovs.62.5.5 [published Online First: 2021/04/29]
2. Sankaridurg P, Tahhan N, Kandel H, et al. IMI Impact of Myopia. Invest Ophthalmol Vis Sci 2021;62(5):2. doi: 10.1167/iovs.62.5.2 [published Online First: 2021/04/29]
3. Flitcroft DI, He M, Jonas JB, et al. IMI – Defining and Classifying Myopia: A Proposed Set of Standards for Clinical and Epidemiologic Studies. Invest Ophthalmol Vis Sci 2019;60(3):M20-M30. doi: 10.1167/iovs.18-25957
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5. Tideman JWL, Polling JR, Vingerling JR, et al. Axial length growth and the risk of developing myopia in European children. Acta Ophthalmol 2018;96(3):301-09. doi: 10.1111/aos.13603 [published Online First: 2017/12/22]
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8. Bao J, Huang Y, Li X, et al. Spectacle Lenses With Aspherical Lenslets for Myopia Control vs Single-Vision Spectacle Lenses: A Randomized Clinical Trial. JAMA Ophthalmol 2022;140(5):472-78. doi: 10.1001/jamaophthalmol.2022.0401 [published Online First: 2022/04/01]
9. Lam C, Tang. W.C, Zhang. H.Y., Tse. D.Y., To. C. Myopia control in children wearing DIMS spectacle lens: 6 years results. Proceedings ARVO 2022 2022
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14. Yam JC, Zhang XJ, Zhang Y, et al. Three-Year Clinical Trial of Low-Concentration Atropine for Myopia Progression (LAMP) Study: Continued Versus Washout: Phase 3 Report. Ophthalmology 2022;129(3):308-21. doi: 10.1016/j.ophtha.2021.10.002 [published Online First: 2021/10/11]
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