August 15, 2025
By Ashley Tucker, OD, FAAO, FSLS, ABO Diplomate
In the exam room, it’s becoming increasingly common to see a six-year-old child with 20/20 visual acuity, a low hyperopic prescription of +0.25D, and two myopic parents. Technically, the child is emmetropic—or even slightly hyperopic—but any seasoned clinician knows this child is likely on a path toward myopia. These children represent the growing population living in what we might call “the gray zone” – not yet myopic, but clearly not risk-free. The question is: what should we do with them?
Pre-Myopia
This population is at the heart of a developing conversation around pre-myopia, a term defined as a refractive state between +0.75D and plano in children with additional risk factors. While this framework is useful conceptually, it leaves clinicians without a clear protocol for action. There are no standardized guidelines, no specific reimbursement pathways, and often, no consensus among providers. The result? Many of these children are monitored—but not managed.
Yet, early risk factors such as low hyperopia, parental myopia, excessive near work, and limited outdoor time are well-documented predictors of future myopia.1 Axial length measurements can be revealing, but even with this data, we’re often left without clear direction. Should we educate the family about lifestyle interventions? Begin low-dose atropine proactively? Initiate behavioral changes and monitor closely? Or is intervention overstepping when the child technically doesn’t have myopia?
The Clinical Gray Zone
This clinical gray zone presents both an opportunity and an ethical challenge. On one hand, we know from a public health standpoint that delaying the onset of myopia—or possibly even preventing it—can have long-term benefits for reducing the lifetime risk of ocular complications. On the other hand, initiating a medical treatment in an asymptomatic, emmetropic child can be a difficult message to deliver, particularly in a health care environment where overtreatment is rightly scrutinized.
Clinicians are left walking a tightrope. We don’t want to wait until -1.00D before taking action, but we also don’t want to intervene without clear evidence or consensus.
Communication becomes key. Educating families about the risk factors, encouraging regular follow-ups, and using tools like axial length measurement to personalize risk assessment can help bridge the gap. But we need more: more research on pre-myopia interventions, more clinical guidelines that reflect risk-based care, and more tools to help predict and stratify who is most likely to convert—and when.
Start the Myopia Conversation Early
In the meantime, there are practical steps we can take. Monitor these children at more frequent intervals – perhaps biannual versus annual. Provide anticipatory guidance about healthy visual behaviors, including outdoor time and limiting prolonged near work. Consider integrating biometric data like axial length into your routine assessments. Utilize the predictor tools we currently have available to us. Most importantly, engage families early. This will be particularly fruitful for patients of myopic parents as they will likely be the most responsive to early intervention. If we can reframe the conversation around long-term visual wellness rather than waiting for a problem to appear, we may be able to shift the trajectory for countless children.
As the field of myopia management evolves, so too must our comfort with clinical nuance. The black-and-white days of refractive thresholds as the sole trigger for action are behind us. Today, we live in the gray zone. The challenge—and the responsibility—is to recognize it, respect it, and respond with thoughtful, evidence-informed care.
Often the most meaningful interventions are the ones we make before the problem fully arrives.
References
1 Jones-Jordan LA, Sinnott LT, Manny RE, Cotter SA, Kleinstein RN, Mutti DO, Twelker JD, Zadnik K; Collaborative Longitudinal Evaluation of Ethnicity and Refractive Error (CLEERE) Study Group. Early childhood refractive error and parental history of myopia as predictors of myopia. Invest Ophthalmol Vis Sci. 2010 Jan;51(1):115-21. doi: 10.1167/iovs.08-3210. Epub 2009 Sep 8. PMID: 19737876; PMCID: PMC2869059.
