Is Tapering Myopia Management Therapy Necessary Before Discontinuation?

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September 1, 2025

By Dr. Gareth Lingham Morth

Clinicians now have access to a range of myopia control therapies that have been proven to be effective in slowing myopia progression. Unfortunately, evidence supporting when and how a myopia management therapy should be discontinued remains relatively sparse. 

Rebound myopia progression

Rebound myopia progression is a major challenge in myopia management and occurs when the rate of progression after ceasing myopia management treatment is faster than it would have been in the absence of treatment.¹ Because there is an age-related slowing of myopia progression, an untreated control arm is required to accurately assess rebound effects. However, with the gradual phasing out of placebo control arms in myopia management clinical trials,² untreated control groups will, by necessity, be replaced with virtual control groups when assessing rebound progression.¹ 

What is the evidence on rebound progression?

Atropine

Rebound progression upon cessation of atropine eye drops is a well-known phenomenon that exhibits a dose-dependent effect, with cessation of stronger doses of atropine leading to faster rebound progression (Figure 1).³ Indeed, there is debate over whether low concentrations of atropine, such as 0.01% atropine, lead to rebound progression at all. The Australian WA-ATOM study, which included an untreated control arm, found myopia progression was 1.5 times faster (+0.07mm/year in axial elongation) than in the untreated control group, after ceasing 0.01% atropine. However, studies in Japan,⁴ Ireland⁵ and China⁶ reported no apparent rebound progression after ceasing 0.01% atropine. Yet, each study had its own limitations, such as low retention or no untreated control arm. 

 

Figure 1: Mean rates of change in refractive error in D/year across treatment arms of the ATOM1 and ATOM2 studies during the treatment phase (solid lines, baseline to 24 months) and after ceasing treatment (dashed lines, 24 to 36 months). Note, rates of change must be faster (more negative) than the placebo group to indicate rebound progression.

Repeated low-level red light therapy

Repeated low-level red light (RLRL) therapy also exhibits a notable rebound effect upon cessation. In a Chinese randomized clinical trial, participants assigned to discontinue RLRL therapy after 12 months of use had 1.5- to 1.7-times (+0.14mm/year in axial elongation) faster myopia progression over the subsequent 12 months than a control group assigned to single vision lens wear throughout.⁷

Optical myopia control interventions

Rebound myopia progression after cessation of optical myopia management interventions appears to generally be lower than with atropine or RLRL therapy.^1,8,9 Orthokeratology may be an exception, with one small study reporting an increase in six-month axial elongation after ceasing OrthoK wear (+0.14mm/year), relative to untreated controls.¹⁰ Current evidence suggest rebound progression upon cessation of peripheral defocus interventions such as contact lenses is negligible to non-existent.^1,8,9 However, relative to the abundance of contemporary peripheral defocus spectacle and soft contact lens therapies, there is a lack of large studies assessing rebound myopia progression after long-term use of these interventions.

Should we taper myopia management therapies?

Atropine

While the mechanism of action of atropine is unknown,¹¹ it is likely that cellular adaptions, such as the up-regulation of target cell receptors, occur in response to atropine treatment, and could explain rebound progression after drug cessation.¹² Based on this, it is reasonable that tapering the dose of atropine – either by reducing concentration or by reducing frequency of administration – would mitigate rebound. 

In the Irish MOSAIC study,⁵ children randomly switched from 0.01% atropine to a tapering regimen–three months each of 0.01% atropine every second day, twice weekly, once weekly then cease—had lower 12-month mean axial eye growth than participants switched from 0.01% atropine to placebo, but this was not significantly different (+0.10 vs +0.14mm, p=0.76). The remaining evidence around tapering atropine in myopia management is anecdotal.^3,13

RLRL and optical therapies

The rationale for tapering RLRL or optical therapies remains less clear. A variety of mechanisms could mediate cellular interactions with light therapy¹⁴ and the biological adaptations occurring in response to RLRL therapy—implied by the presence of rebound—are not certain. Despite this, it is possible that tapering RLRL therapy will reduce rebound progression, but clinical studies are required.

Where there is no evidence of rebound myopia progression, such as in peripheral defocus interventions, there is no rationale to taper a therapy. Further, tapering some optical therapies may be challenging. For example, wearing an OrthoK lens every second night is likely to impact the patient’s visual acuity as the cornea returns to its untreated state.

Conclusions

Rebound myopia progression is a significant issue that threatens to undo successes in myopia control. Eye care practitioners should be aware of the higher likelihood of rebound myopia progression with atropine, particularly with higher doses, and RLRL therapies. While evidence to support tapering of RLRL therapy is absent, there is some clinical evidence and, as importantly, sound theoretical reasoning to support tapering the dose of atropine during discontinuation to mitigate rebound myopia progression. Negatives to tapering relate to the extra time and cost of using myopia control interventions during the tapering period, but this seems a small price to pay to prevent loss of hard-won gains in myopia control over years of treatment.

 

Dr. Gareth Lingham is an orthoptist and currently holds positions as a postdoctoral research fellow at the Lions Eye Institute, clinical data analyst with Ocumetra and Honorary Researcher at the Centre for Eye Research Australia. Dr. Lingham completed his PhD at the University of Western Australia on the benefits of childhood outdoor time for myopia prevention and was a postdoctoral scholar at the Centre for Eye Research Ireland, Technological University Dublin working on clinical trials of low-concentration atropine eye drops for myopia management. His current research areas include myopia management, sun-related eye conditions and ophthalmic epidemiology.

 

References

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