Myopia is a refractive error in which parallel light rays from infinity focus in front of the retina. It is a condition where the refractive power of the eye is excessive relative to the axial length, characterized by reduced distance vision.
The diagnostic criterion for childhood myopia is a spherical equivalent of -0.5 D or more myopic under cycloplegic refraction. 4)
Pseudomyopia (false myopia) is a temporary myopic state due to accommodative spasm, which resolves with administration of cycloplegic agents. The theory that sustained near work causes pseudomyopia, which then progresses to true myopia, was proposed in Japan around 1940.
Myopia is classified according to pathogenesis, severity, age of onset, and etiology as follows.
Refractive myopia and axial myopia: Refractive myopia is caused by increased refractive power of the lens. Axial myopia is caused by elongation of the axial length, and the majority of myopia belongs to this type.
Non-pathological myopia and pathological myopia: Non-pathological myopia (physiological, simple, school myopia) is less than 6D, develops during school age to adolescence, and stabilizes in the early 20s. Pathological myopia presents with spherical equivalent >6D and axial length >26.5 mm, accompanied by progressive fundus changes.
Severity classification in Japan (Shoji classification): Classified into four grades: mild (≤ -3D), moderate (> -3D to ≤ -6D), high (> -6D to ≤ -10D), and very high (> -10D).
Congenital myopia and acquired myopia: Congenital myopia is hereditary and develops soon after birth. Acquired myopia (school myopia) develops at school age triggered by near work.
The diagnostic criteria for pathological myopia in Japan differ by age.
| Age | Spherical equivalent | Corrected visual acuity |
|---|---|---|
| 5 years or younger | > -4.0D | 0.4 or less |
| 6 to 8 years | > -6.0D | 0.6 or less |
| 9 years or older | >-8.0D | 0.6 or less |
Pathological myopia accounts for about 5% of all myopia.
Infants and young children rarely complain of decreased vision due to refractive errors. The following are guidelines for normal refractive values (under 1% cycloplegia) in young children.
| Age | Normal refractive value | Refractive value requiring glasses prescription |
|---|---|---|
| 3 months | S+4D | S+6D or more |
| 1 year | S+2D | S+4D or more |
| 2 years old | S+1D | S+3D or more |
| 3 years old | S+1D | S+3D or more |
Since myopia always has a world in focus, there is no risk of amblyopia even in young children. For mild to moderate myopia, there is no need to rush into wearing glasses. For moderate to high myopia (greater than -3D), explain to parents the benefits of wearing glasses to broaden the child’s world.
More than one-fifth of the world’s population has myopia, and it is predicted to reach about half by 2050. 2) Productivity loss is estimated at $250 billion annually, and loss due to myopic macular degeneration at $6 billion. 2)
The global prevalence of myopia in children is projected to increase from 24.32% in 1990 to 35.81% in 2023 and 39.80% in 2050. 3) The population with high myopia is expected to surge from 160 million in 2000 to 940 million (5.8 times) by 2050. 5)
The proportion of children with uncorrected visual acuity less than 1.0 is increasing (high school: 55.5% in 1980 → 62.9% in 2014; junior high: 38.1% in 1980 → 53.0% in 2014; elementary: 19.7% in 1980 → 30.2% in 2014). The prevalence of high myopia (≤-6.0D) in junior high students is 11.3%. 5) The Hisayama study confirmed an association between increased prevalence of myopic maculopathy and longer axial length. 4)
More than one-fifth of the world’s population has myopia, and it is predicted that about half will be myopic by 2050. 2) Prevalence is particularly high in Asia, with about 80% of children in Taiwan affected. The global prevalence of myopia in children is expected to increase from 24.32% in 1990 to 39.80% in 2050, and the population with high myopia is projected to reach 940 million (5.8 times the 2000 level) by 2050. 5)
Infants and young children rarely complain of reduced vision due to refractive errors. When myopia progresses rapidly, the optic disc may become hyperemic on the temporal side with blurred margins and tilt toward the posterior pole, and hemorrhage may occur in the retinochoroid near the disc. Posterior staphyloma is usually seen after adulthood, and atrophy of the retinochoroid is rare in childhood.
Non-pathological Myopia
Fundus findings: Mild myopic crescent (atrophic crescent around the optic disc) may be observed. Initially, atrophy of the retinal pigment epithelium leads to a tessellated fundus, and a conus forms on the temporal side of the disc.
Axial length: Often less than 26.5 mm.
Corrected visual acuity: Maintained well.
Pathological Myopia
Posterior staphyloma: Localized outward bulging of the posterior pole of the eyeball. Occurs as a result of axial elongation.
Myopic macular degeneration: Macular lesions including Fuchs spot, choroidal neovascularization (CNV), retinal hemorrhage, and atrophy.
Myopic retinoschisis (MRS): Observed in 9–34% of pathological myopic eyes with posterior staphyloma. 1)
Others: Retinal tear/detachment, tilted optic disc, vitreous opacity/liquefaction.
OCT is useful for detecting decreased macular volume associated with increased axial myopia.
In pathologic myopia, axial elongation leads to fundus changes such as posterior staphyloma, Fuchs spot, choroidal neovascularization, retinal tears, detachment, and optic disc tilt. Myopic retinoschisis (MRS) is observed in 9–34% of pathologic myopic eyes with posterior staphyloma and may be an indication for vitrectomy. 1)
The etiology of myopia is multifactorial, involving a complex interplay of genetic and environmental factors.
Outdoor activity is the most important preventive factor, reducing the onset of myopia by up to 50%. 3) A meta-analysis found that increasing outdoor time by 76 minutes per day reduces onset by 50%, and at least 2 hours of outdoor activity per day is recommended. 3)
An association with near work has also been reported. It is recommended to avoid reading in dark rooms and to avoid getting too close to screens. Maintaining a distance of at least 30 cm and taking breaks every 30 minutes are considered beneficial. 3) As a prevention for school myopia, instruct to take a 5-minute break from near work every hour.
The following are listed as risk factors for myopia. 4)
Increased outdoor activity has been reported to reduce the onset of myopia by up to 50%. 3) A meta-analysis found that an increase of 76 minutes of outdoor time per day reduced onset by 50%, and a Taiwanese RCT showed that 80 minutes/day of outdoor activity reduced the one-year incidence by 52%. 3) Bright outdoor light (at least 2000 lux) is thought to stimulate retinal dopamine release and suppress axial elongation. It is the simplest and most side-effect-free intervention for myopia control.
Vision screening at school health checkups is often the first opportunity for detection. Photoscreening and autorefractometers can detect myopia, but are insufficient for determining quantitative refractive error.
Data from 410 schools in the US School-Based Vision Program (SBVP) showed a median screening failure rate of 38.4% and a spectacle prescription rate of 25.2%. 8) Failure and prescription rates were significantly higher in high schools than in elementary schools, and schools in low-income areas tended to have a greater need for eye care. 8)
Cycloplegic refraction is the gold standard for children. Without eliminating accommodation, children with strong accommodative ability are prone to over-minusing.
Young children lack the concentration to maintain proper focus at distance, so cycloplegic eye drops are essential for refraction. Procedure: Instill cyclopentolate hydrochloride (Cyplegin® 1%) twice at 10-minute intervals, and perform automated refractometry 45–60 minutes after the first instillation. 4) If difficult, overrefraction using retinoscopy without cycloplegia is an option. 4) Atropine (1% solution, twice daily for 7 days) provides more reliable cycloplegia but requires a longer examination period.
To rule out amblyopia, confirm age-appropriate visual development. 4) In young children with high myopia, secondary myopia (e.g., congenital night blindness, retinitis pigmentosa) should also be excluded. 4)
Axial length measurement is useful for accurate assessment and management of myopia progression. 4) Laser interferometry is recommended. 5) It allows comparison with annual progression rates without treatment and management using percentile curves. 4)
Treatment of myopia is broadly divided into two categories: ① securing visual acuity through refractive correction, and ② suppressing myopia progression.
Glasses (concave lenses) are the first-line correction method for childhood myopia. Prescription is based on refractive error under cycloplegia. For mild to moderate myopia, there is no urgency to wear glasses. For moderate or higher myopia (greater than -3D), explain the benefits of glasses to parents to broaden the child’s world. Follow-up after prescription is recommended at around 3–4 months for myopic cases.
Contact lenses (CL) are generally indicated from the early teens onward. Correction is possible, but careful management is required in children.
The goals of myopia progression suppression treatment are as follows: 4)
| Intervention | Refractive suppression effect | Axial length suppression effect | Main evidence |
|---|---|---|---|
| Low-concentration atropine 0.05% | Up to 67%3) | — | LAMP study |
| Low-concentration atropine 0.025% (Rijusea® Mini) | Domestically approved drug4) | — | Domestic clinical trial |
| Orthokeratology | — | 32–59%3) | Multiple RCTs |
| MiSight 1 day (+2.00D) | 59%2) | 52%2) | Chamberlain 2019 |
| DIMS spectacle lens (MiYOSMART®) | 52%5) | 62%5) | Lam 2020 |
| HAL spectacle lens (Stellest®) | 55–67%5) | 51–60%5) | Bao 2022 |
| Multifocal soft CL (general) | SE -0.22 to -0.81D vs -0.50 to -1.45D6) | AL 0.05 to 0.39mm vs 0.17 to 0.67mm6) | AAO OTA 12 studies |
Low-concentration atropine eye drops are the most evidence-based pharmacotherapy for myopia progression control.3)
Approval information: Rijusea® Mini Eye Drops 0.025% (Santen Pharmaceutical) was first approved in Japan on December 27, 2024, for the indication of myopia progression control.4) The Japanese Society of Myopia has developed treatment guidelines (2025).
Mechanism of action: It is thought to suppress axial elongation by involving scleral remodeling via muscarinic receptors (mainly M1/M4 receptors), but the detailed mechanism is under investigation. 4)
Comparison of concentration and efficacy: In the LAMP study (Yam 2019), 0.05% was the most effective, showing up to 67% progression suppression. 3) 0.01% (ATOM2 study, Chia 2012) may have limited efficacy when used alone. 3)
Prescription procedure: 4)
Follow-up: 4)
Side effects: 4)
Rebound and treatment cessation: 4)
Guidelines for myopia management glasses (multi-segment lenses) (1st edition) have been established by the Myopia Management Glasses Guideline Committee. 5)
Target lenses:
Indications: 5)
Prescriber qualifications: Ophthalmologist with expertise in pediatric visual development and ocular optics. 5)
Contraindications and cautious prescribing: 5)
Prescribing considerations: 5)
Follow-up and treatment discontinuation: 5)
Informed consent: This treatment does not cure or reduce myopia, only slows its progression. Requires full-time wear and long-term proper use. No adverse effects reported to date. 5)
The AAO OTA report (Cavuoto 2024) is a systematic review of 11 Level I evidence studies and 1 Level II study. 6)
Main lenses:
Safety (risk of CL complications in children): 7)
A method in which special rigid lenses are worn during sleep to temporarily flatten the central cornea. The effect is temporary, and nightly wear is required to maintain correction. Since patients can go without glasses during the day, it is suitable for active children.
Effect: Suppression of axial elongation by 32–59% over 2 years. 3)
The “Orthokeratology Guidelines” state that the indicated age is 20 years or older. However, 19.2% of elementary school CL users use ortho-K, and this number is increasing year by year. Concerns include decreased night vision, increased higher-order corneal aberrations, and risk of serious corneal infections such as Acanthamoeba keratitis. Effects such as corneal oxygen deficiency due to overnight wear and decreased corneal endothelial cells are also a concern.
Safety: In a Japanese multicenter study (1,438 patients), the incidence of MK (microbial keratitis) was 5.4/10,000 patient-years. 3) A US FDA-commissioned study reported an MK incidence of 14/10,000 patient-years in children. 7) Long-term prognosis is unknown, and careful management is required.
Refractive surgeries such as PRK, LASIK, and LASEK are only indicated after eye growth has stopped (late teens to early twenties). In principle, they are not performed in children and adolescents.
In the LAMP study (Yam 2019), 0.05% was the most effective, showing up to 67% suppression of progression. 3) Rijusea® Mini Eye Drops 0.025% was the first domestically approved in Japan in December 2024 for myopia progression suppression, and is currently the standard prescription dose. 4) 0.01% (ATOM2 study) may have limited efficacy when used alone. 3) The choice of optimal concentration should be individualized considering the balance between efficacy and side effects (photophobia, near vision impairment).
In a Japanese multicenter study (1,438 patients), the incidence of MK was 5.4 per 10,000 patient-years. 3) A US FDA-commissioned study reported 14 per 10,000 patient-years. 7) With proper care, it is a relatively safe treatment. However, rinsing lenses with tap water is strictly prohibited as it increases the risk of Acanthamoeba keratitis. Long-term prognosis is unknown, so careful management is required.
According to the Myopia Management Spectacle Lens Guidelines (1st edition), MiYOSMART® is indicated for ages 5–18, and Stellest® for ages 7–18. 5) Use under age 5 is not recommended. Indications include cycloplegic spherical equivalent of -0.5D or more myopia, and consideration is given when myopia progression is confirmed or there is a family history of high myopia. Contraindications or cautious prescribing apply in cases of binocular vision abnormalities such as strabismus, amblyopia, nystagmus, or abnormal head posture. 5)
The main pathology of myopia is axial elongation, and an elongation of 3 standard deviations or more from the mean of emmetropic eyes is considered the criterion for pathological myopia.
Axial elongation is thought to be regulated by optical signals from the retina.
The risk increase associated with each diopter of myopia progression is as follows: 7)
The number of years of visual impairment prevented by a 1 D reduction is estimated at 0.74 years/person for -3 D eyes and 1.22 years/person for -8 D eyes. 7) The NNT (number needed to treat to prevent one case of visual impairment over 5 years) is estimated at 4.1–6.8 persons, and the NNH (number needed to harm for one adverse event) for CL-related MK is estimated at 38–945 persons, indicating that the benefits of myopia progression control far outweigh the risks. 7)
When axial elongation progresses severely, mechanical stretching is applied to the choroid, retina, and sclera.
Gopalakrishnan et al. (2024) reported a case of MRS progression after intravitreal aflibercept injection (IVA) for myopic macular neovascularization. 1) The case was a 49-year-old woman (right eye -16D, axial length 28.16 mm; left eye -13D, axial length 27.35 mm). After IVA, MRS worsened, and a good outcome was achieved with 25G PPV + internal limiting membrane peeling + SF6 gas tamponade. Caution is needed for MRS worsening after anti-VEGF injection.
It is estimated that suppressing myopia progression by 1D reduces the risk of myopic maculopathy by 37% and prevents 0.74–1.22 years of visual impairment. 7) The number needed to treat (NNT) to prevent one case of visual impairment over 5 years is estimated at 4.1–6.8 people, indicating an efficient intervention. Compared to the NNH for CL-related MK (38–945 people), the benefit of myopia progression suppression far outweighs the risk. 7)
RLRL therapy using 650 nm red light is a novel intervention that suppresses axial elongation by increasing choroidal thickness. 3)
New optical design eyeglass lenses such as PLARI, NLARI, CARE, DOT, MYOGEN, and MyoCare are being developed and studied. 3)
Research on combination therapy aiming for greater myopia control effects than monotherapy is progressing. 3) Establishing individualized approaches for rapidly progressing cases remains a challenge.
In the US, school-based vision programs (SBVP) reported a screening failure rate of 38.4% and spectacle prescription rate of 25.2% across 410 schools, confirming higher eye care needs in low-income schools. 8) Large-scale outdoor activity programs in schools have been successfully implemented in Taiwan, Singapore, and China, and improvements to outdoor learning environments have been proposed. 3)
Correlations between saturated fat and cholesterol intake and axial length have been reported, and the potential for myopia control through nutritional intervention is being explored. 3)
Gopalakrishnan N, et al. Progression of macular retinoschisis following intravitreal aflibercept injection for myopic macular neovascularization. BMC Ophthalmology. 2024;24:224.
OTA Committee. Multifocal soft contact lenses for the treatment of myopia progression in children. Ophthalmology. 2024.
Yam JC, et al. Interventions for slowing the onset and progression of myopia. Prog Retin Eye Res. 2025;109:101410.
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