Hot topics in myopia for 2025

Perhaps we can’t prevent myopia onset, just like we can’t stop progression - but we can slow both down. The clinical impact of delaying myopia onset by one year is the potential to reduce a patient’s final level of myopia by around 0.75D, which is comparable to the impact of two to three years of treatment to slow down myopia progression after onset.

Children at risk of developing myopia, known as pre-myopes, have risk factors like family history, specific binocular vision issues, and habits involving excessive near work and limited outdoor time. The most reliable predictor of pre-myopia is being less hyperopic than age norms. The CLEERE study identified less than +0.75D at ages 6–7 as a pre-myopia marker in North America. However, in China, this threshold appears to be higher, as shown in new studies - between +1.50D and +2.00D for the same age group. It’s unclear how East Asian ethnicity outside China impacts this ‘hyperopic reserve.’ Once identified, emerging research on treatments to delay onset of myopia include an evidence-base for low-dose atropine, repeated low-level red light (RLRL) therapy, and plano spectacle lenses with highly aspherical lenslets.

Repeated low-level red light (RLRL) therapy has proven highly effective in slowing myopia progression, with promising results in populations such as those with high myopia or fast progression in orthokeratology wear. While combination treatments with other optical devices show potential, RLRL is not recommended alongside atropine. Key questions remain about possible rebound effects after stopping therapy and its long-term safety.

Other light therapies, like cyan light-emitting glasses and bright (white) light desktop devices, are also under investigation. A pre-commercial VR-like headset delivering targeted light to the optic nerve has shown comparable results to myopia control spectacles, with combination trials underway.

Our knowledge on the use of low-concentration atropine as a monotherapy and in combination with optical treatments is still growing. A raft of recently published studies have investigated commercially prepared, verified stable formulations of atropine 0.01% for myopia control in non-Asian populations for the first time. These have shown some impacts for children with blue irises and/or European ethnicity, although without consensus. The first data on atropine 0.05% in a European cohort, including a tapering schedule for 0.01%, has just been published. We are learning more about these factors influencing success and where various atropine concentrations may fit best in first-line monotherapy.

In combination therapy, the strongest evidence-base is still for ortho-k plus 0.01% atropine to boost efficacy, although the effect is only pronounced in the first 4 to 6 months. There are no other randomized controlled trials showing the same benefit, yet - the picture on combination treatment with spectacle lens treatments is building from retrospective clinical data, with more expected to come. 

The contrast theory for myopia hypothesises that artificial or high retinal contrast (such as black text on a white background and urban environments) leads to overstimulation of the retina; this overstimulation is then thought to signal to the eye to continue growing. Low or more natural-scene retinal contrast, on the other hand, signals the eye to slow or stop growing. 

One myopia control spectacle lens (Diffusion Optics Technology or DOT lens) employs this technology, and we’ve learnt a lot in the past year about efficacy in various populations, dynamic vision and other measures of visual function in this design. As a ‘new kid on the block’ in myopia theories, how this compares and contrasts (pun intended!) with other optical mechanisms for myopia control will be a fascinating area for learning more. 

Some of the first randomized controlled trials for myopia control spectacles (DIMS / HOYA MiYOSMART) and contact lenses (dual-focus / CooperVision MiSight 1 day) have now reached a stage of maturity such that data over 6, 7, 8 and even 10 years is being reported. This has some major benefits in firstly verifying long-term success and acceptance of these treatments from childhood through to early adulthood, and in the case of daily disposable contact lenses, enduring safety - indicated by no changes to ocular health markers or corneal endothelium over long-term, full-time wear. 

Adult myopia management remains a challenging area of clinical practice with minimal data on treatment options. It is unlikely that we can expect randomized controlled trials in young adult myopia interventions, simply because of the much slower rate of progression which would necessitate very long studies. Hence, we rely on extrapolation of the long-term data mentioned above, which provides evidence for continued successful wear into early adulthood. For newly commencing myopia management in this patient base, research-minded clinicians may start to report their treatment observations. In the meantime, new research using combined analysis and large-scale clinical record data builds on the 2023 IMI Report to help further characterize the frequency of onset and typical progression of adult myopia - delineating the size of the problem, which hopefully encourages more research into treatments. 

There is much to look forward to in 2025, in these and many more topics in the field of myopia management. We also hotly anticipate the publication of the fourth volume of International Myopia Institute new reports and updates this year! Stay tuned to Myopia Profile for the latest on these hot topics, the latest science, and most importantly, what it all means for your patients and your practice.