Spectacle lenses for myopia control Part 1: Progressives, bifocals and binocular vision

Originally posted August 12, 2019
Updated July 29, 2025

Are progressive addition lenses and bifocals created equal for myopia control? When do they work and when do spectacles have minimal efficacy? How should we pick which lens type to prescribe, and what's on the horizon for our non-contact lens wearing young myopes?

We know that single vision spectacle lenses provide no useful efficacy for myopia control, and in fact are used as control corrections in myopia control studies, demonstrating the 'untreated' progression of childhood myopia.¹ Progressive addition (PAL) and bifocal spectacle lenses have shown reasonable research results for myopia control, and novel designs have been developed. It is important to be aware of the indications and evidence for spectacle lens myopia control, as this is likely the first correction we will prescribe - especially in younger children where the child (or perhaps more the parent!) is not ready for contact lenses. Spectacle lenses are also an important adjunct treatment in soft contact lens wearers - as a back up correction - and if atropine is being prescribed as a first line treatment. So let's get into the detail.

There is conjecture about PAL or bifocal spectacles having any useful effects for myopia control^2,3 just the same as there is conjecture about peripheral refraction being a factor in myopia development and progression.^4,5 For the individual patient, there could be one primary driver to myopia development and progression - genetics, environment, peripheral refraction, accommodation - or it could be a combination. This is what makes myopia such a fascinating area of research and clinical practice.

Progressive addition lens (PAL) studies for myopia control show negligible results when single adds are applied to all children, however when applied to children with esophoria and accommodative lag, the results become more impressive at 30-40% efficacy and start to approach that of contact lens studies.^6,7

By comparison, a three year bifocal study found a 40-50% efficacy for a +1.50 Add E-seg bifocal with 3 base-in (BI) prism incorporated.⁸ Does this make the bifocal or the prism the magic sauce? Perhaps, or maybe it was more to do with the study design which firstly ensured that all participants were demonstrated myopia progressors in the year prior to study entry, and secondly by considering binocular vision. The use of the BI prism was designed to balance accommodation and vergence systems - not to reduce the response of either system. In a prior study, these authors had tested a combination of adds and BI prism, measuring accommodative lag and exophoric shifts. The +1.50 Add with 3 BI R&L ensured that there was no change to either lag or phoria once wearing the bifocal, indicating perhaps a different mechanism of action was at play (see more below!).⁹ The base-in prism ensured the exophoric children didn't get more exophoric with the add, but wouldn't have necessarily provided the orthoptic correction for esophoria which is typically desired in prescribing a near add.

So how well did the bifocal work? Cheng et al’s study investigated a standard bifocal with a +1.50 Add, and the same add with the 3BI prism in each eye. After three years of wear, they found a moderate myopia control effect – around 35% for axial length and 50% for refractive change – in children who were orthophoric and exophoric in their baseline single vision correction. They found a minimal effect in the baseline esophoric children, but they were a small group so there was less statistical power.⁸  When analysed by accommodative lag, the two year results showed the similar effect of both bifocal types in children with high accommodative lag (over 1D), but a better result with the prismatic bifocals in children with low accommodative lag.¹⁰

If you measure esophoria and accommodative lag in single vision correction, a progressive addition lens or bifocal spectacle lens is an evidence based choice for providing a near add and managing binocular vision with the vision correction. In this case, better myopia control results are likely from also including atropine 0.025% or 0.05%, as the primary myopia control treatment.

If you measure orthophoria, exophoria or normal accommodation (lag <1D) in single vision correction, and you do not have myopia control spectacle lens designs available, a bifocal or prismatic bifocal is the better choice than a progressive addition lens. (Note that the new myopia control spectacle lens designs will not influence binocular vision function AND provide strong efficacy to slow myopia progression.) A child with low accommodative lag (<1D) may respond better to the bifocal lens with prism to minimise the influence of the add on binocular vision function. Keep in mind, though, that if an add makes an exophoric child break down into intermittent exotropia, this condition has been associated with myopia progression.¹¹

The concept of simultaneous defocus is employed in theories of myopia development and progression. Instead of thinking of peripheral refraction, think of how a distance-centred multifocal will cast zones of clear retinal focus (the distance portion/s) and also zones of myopic defocus (the ‘add’ portion/s) across the retina. In animal studies, creating these conflicted zones of retinal defocus appears to influence the retina to pay attention to the more myopic plane, essentially halting eye growth, rather than the eye averaging the two planes.⁴ In PAL or bifocal spectacle lenses, the large zone of ‘add’ in the inferior lens creates a relative peripheral myopic shift on the superior retina. One study has found a relationship between the amount of relative peripheral myopia created by the inferior add zone and the myopia control effect of PALs.¹²

Even though the numbers of esophores were small in the bifocal study, the fact that they didn’t work well for the esophores in a study design where the bifocal add was counteracted with BI prism  - to intentionally have a minimal influence on BV – indicates to me that binocular vision does play a role for some children, and contact lens research is confirming this.^13,14

If you want to apply a single add, then most PAL studies have used a +1.50 or +2.00 Add, and the bifocal study I've described used a +1.50 Add. In practice, though, I prescribe an add based on their presentation. In children with esophoria and/or accommodative lag, for example, we need to manage their binocular vision as well as think about the best myopia management strategy. Individualising the add is important for optometric management and visual comfort, and could be responsible for the difference between what's measured in research and what we observe in practice. 

You can read more about binocular vision assessment in our specific articles on measuring near lag of accommodation and assessing near phoria; and get help with prescribing adds (including flow charts) based on near esophoria and accommodative lag. 

The newest myopia controlling spectacle lenses as well as the most effective contact lens options. They include the Defocus Incorporated Multiple Segments (DIMS) lens by Hoya, the Highly Aspherical Lenslet Target (H.A.L.T.) lens by Essilor, Diffusion Optics Technology (DOT) lens by SightGlass Vision and Cylindrical Annular Refractive Elements (CARE) by Zeiss. These new lenses do not control myopia by way of an add: rather, they incorporate a treatment zone of lenslets, constrast diffusers or cylindrical refractive elements in order to cause a differential focus across the retina.^15-17 In the absence of binocular vision conditions that require treatment with an add, these lens options should be your first choice for the dual benefit of myopia correction and control. 

• When to prescribe spectacles for myopia control
• Back ups and dispensing considerations
• Should kids wear both myopia control glasses and contact lenses?