Spectacle prescription (spectacle prescription) means selecting and prescribing the appropriate lens power, type, and frame to correct refractive errors (myopia, hyperopia, astigmatism, and presbyopia). It is not just deciding the power; it is a comprehensive medical procedure that also considers wearing comfort, binocular vision, and aniseikonia.
Refractive errors are diseases, and refractive correction is a medical procedure1). Unlike prescriptions from an optical shop, prescriptions from an ophthalmology clinic are directly linked to finding and ruling out eye diseases.
A visual acuity of 0.7 is considered a guideline for thinking about prescribing or re-prescribing glasses. In the Ministry of Education’s visual acuity classification, if visual acuity is 0.7 or higher, the letters on the blackboard can be read from a seat at the back of the classroom. The passing standard for a regular driver’s license is also 0.7 in both eyes.
Classification
Visual acuity
Meaning of the classification
A
1.0 or higher
Can clearly see the writing on the blackboard from the back row
B
0.9 to 0.7
Can mostly see the writing on the blackboard from the back row
C
0.7 to 0.3
It is hard to see the writing on the blackboard from the back row
D
Less than 0.3
Even from the front row, the writing on the blackboard is not clear enough
The rate of glasses use among adults is reported to be 74.2% (including full-time wear, as-needed wear, and combined use with CL), and full-time wearers were 40.4% of men and 21.8% of women1). Use most often began in middle school to high school, followed by the 40s to 50s (when near glasses are needed because of presbyopia)1). More than half of Japanese people have myopia, and glasses are the most widely used method of refractive correction.
Worldwide, the prevalence of refractive errors in adults has been reported at 24–35% (United States, Western Europe, and Australia)15), and myopia prevalence is especially high in Asian countries. In Japan, progression of myopia has become an important public health issue, and the formulation of guidelines for glasses for myopia management (2025) is promoting active myopia measures in ophthalmology2).
QWhy should glasses prescriptions be obtained from an ophthalmologist?
A
In an ophthalmology prescription for glasses, in addition to determining the appropriate power for refractive correction, early detection of eye diseases such as cataract, glaucoma, amblyopia, and strabismus is performed at the same time. Refractive error is a disease, and correcting it is a medical procedure1). Vision checks at eyeglass shops cannot diagnose or rule out disease, so a visit to an ophthalmologist is recommended for the first prescription and when changing power.
Undercorrection: poor vision, eye strain, headache, difficulty seeing up close
Overcorrection (myopia): eye strain from excessive use of accommodative power, especially fatigue during near work
Overcorrection for hyperopia: discomfort, poor vision
Astigmatic axis shift: sensation of tilt, distortion, and awkwardness in depth perception
In adult spectacle prescriptions, while basing the prescription on the best visual acuity achieved with full correction, it is important to prescribe a power that can be worn comfortably in daily life. Fully correcting strong myopia or oblique astigmatism as is can cause distortion and make wearing difficult1).
Aniseikonia is a condition in which the image size differs between the two eyes. Convex lenses magnify, and concave lenses reduce image size, so it tends to occur when anisometropia is corrected with glasses.
Latent hyperopia can be overlooked in childhood because uncorrected vision is often good. As accommodative ability declines with age, compensation can fail, beginning with blurred near vision and spreading to intermediate and distant vision. It typically worsens from evening to night.
QWhat is aniseikonia?
A
Aniseikonia is a condition in which the image size differs between the two eyes because of a difference in the power of the spectacle lenses worn by each eye. When aniseikonia exceeds 4% (about 3 D in power terms), binocular vision is affected. A lens power difference of 1.5 D or less is desirable. It may be accompanied by characteristic symptoms such as a rotating-door feeling or a slanting feeling, and it disappears when one eye is covered, which can help with diagnosis.
Myopia: Parallel rays focus in front of the retina. The main cause is increased axial length (axial myopia). Corrected with concave lenses
Hyperopia: Parallel rays focus behind the retina. If accommodative ability is insufficient, both distance and near vision become difficult. Corrected with convex lenses
Astigmatism: The curvature of the cornea and lens differs by meridian, so the focus does not come together at one point. Corrected with cylindrical lenses
Presbyopia: Due to age-related loss of lens elasticity, accommodation becomes insufficient and near focus is difficult. It is managed with an add power (addition of plus lenses).
The examiner operates the autorefractor (autorefractometer) to objectively measure the patient’s refractive status. This corresponds to the objective refraction measurement with an autorefractor discussed in section “4. Diagnosis and examination methods”.
This shows a patient resting their face on the eyepieces of a phoropter (comprehensive refraction device) and undergoing subjective refraction while looking at the visual target. It corresponds to the subjective refraction described in section 4, “Diagnosis and Examination Methods” (final prescription determination after objective measurements with an autorefractor).
Adult examination flow
Understanding the intended use: Identify the situations in which the glasses will be used and the viewing distance, such as driving, computer work, playing musical instruments, and sports.
Checking existing glasses: Use a lensmeter to check the power of the current glasses.
Refraction test: Measure the objective power with an autorefractor, then determine the final prescription with a subjective refraction test.
Accommodation test: Evaluate the amount of accommodation and use it to calculate the near addition power.
PD measurement: Measure the interpupillary distance and record it on the eyeglass prescription.
Pediatric examination flow
Cycloplegic refraction: The first choice is 1% cyclopentolate (Cyclogyl®), instilled twice at 10-minute intervals, with refraction performed 45–60 minutes after the first instillation 3). For severe hyperopia or treatment-resistant cases, atropine 1% solution is used twice daily for 7 days.
Axial length measurement: Measurement by laser interferometry is recommended 2). It is used to monitor myopia progression.
Binocular vision assessment: Evaluate the cover test, near stereopsis, and accommodative lag.
Fundus examination: Essential for ruling out amblyopia and organic disease.
Pre-prescription examination for myopia-control spectacles
The following assessments are required before prescribing myopia-control spectacles (multisegment lenses)2).
The guidelines for refractive surgery (8th edition) specify the ages, refractive powers, and contraindications for refractive correction7), and ophthalmologists decide the prescription plan by comprehensively considering glasses, contact lenses, and surgical correction. In an era that calls for active myopia management, a large RCT by Jiang et al. reported that repeated low-level red light (RLRL) therapy is effective in suppressing myopia progression8). Combining multiple approaches together with glasses is likely to become the standard strategy for future myopia management.
QWhy are cycloplegic drops needed when prescribing glasses for children?
A
Young children lack the ability to maintain proper focus at distance, so cycloplegic drops are essential for refraction testing3). Without cycloplegia, accommodation can interfere, causing errors that overestimate myopia and underestimate hyperopia. The first choice is 1% cyclopentolate drops, but when severe hyperopia or amblyopia treatment is needed, atropine 1% drops (twice daily for 7 days) are used.
5. Standard treatment methods (types of glasses and practical prescription)
This shows the appearance of a trial frame used to check vision while wearing corrective lenses for refractive errors. It corresponds to the subjective refraction and power setting discussed in section “5. Standard treatment methods (types of glasses and practical prescription).”
In childhood, accommodative power exceeds 10 D, and sensory adaptability is also strong. In principle, refractive errors can be fully corrected. However, accommodative power decreases with age, and optical considerations become necessary.
Exceptional adult cases in which undercorrection of myopia is appropriate1):
When the spectacle magnification effect is large in high myopia and satisfactory vault cannot be obtained
If myopia is helping with near vision at the age when presbyopia begins (myopia within -3D can be beneficial at that age)
Young people with strong accommodation who are prone to overcorrection
The following shows approximate age-based near add power for emmetropic eyes.
Age
Approximate add power
52 years
+0.50D
56 years
+1.00D
60 years
+1.50D
64 years old
+2.00D
68 years old
+2.50D
If there is existing myopia, subtract the myopia power to calculate the addition power (e.g., at age 56 with -0.5D myopia, the near-vision lens power is +0.50D, not +1.00D).
Indications: Basic correction for myopia, hyperopia, and astigmatism. Prescribed separately for distance and near.
Features: Simple prescription and easy to get used to. Distance and near lenses are often made separately.
Material: With ultra-high refractive index (1.74–1.76) double-sided aspheric lenses, prescriptions up to -20D are possible.
Progressive addition lenses
Indications: Standard multifocal glasses for presbyopia.
Features: There is no boundary line, so there is no image jump. However, areas of astigmatic aberration appear on both sides of the progressive corridor.
Caution: The stronger the addition power and the shorter the progressive corridor, the more noticeable the astigmatic aberration problem becomes.
Intermediate-near / near-near glasses
Indications: For use only at intermediate to near distances, such as PC work, handcraft work, and playing musical instruments.
Features: Provides a wide near-vision area with little astigmatic aberration.
Myopia control glasses (multisegment lenses)
Indications: Myopia of −0.5 D or more in both eyes, under cycloplegia, ages 5–182).
When the difference in prescription exceeds 1.5 D, measures for aniseikonia are needed. If it exceeds 4% (about 3 D), binocular vision is adversely affected.
The following three measures are typical:
Reduce cylinder power: To keep the circle of least confusion constant, add half of the cylinder power to the spherical power (example: change −1.00D=−cyl2.50D A135° to −1.50D=−cyl1.50D A135°)
Shift the axis: Shifting it toward 90° or 180° reduces shearing disparity. Because residual astigmatism increases, keep the axis shift to 15° or less
Shorten the vertex distance: Moving the frame closer to the face reduces the magnification effect
Used to correct strabismus and diplopia. Built-in prisms can be prescribed up to 10Δ per eye (3–6Δ for progressive lenses), and Fresnel membrane prisms up to 40Δ. The prescription should state the prism type, power, and base direction.
With spectacle correction for highly myopic eyes, image minification occurs. Compared with contact lenses (CL), soft CLs increase higher-order aberrations, and rigid CLs can make vision unstable because of lens movement. Spectacles have apparent accommodation and prism effects, which are especially useful in middle age and older.
Notes for spectacle prescription for high myopia (−6D or more)1):
Vertex distance effect: Moving the glasses forward or back changes the effective power. In high myopia, even a small change in vertex distance has a large effect
Image minification: Strong concave lenses make images smaller, and objects can appear smaller and farther away. Be careful when walking and judging steps, especially when you first start wearing new glasses
Prism effect: Concave lenses create a prism effect when viewed off-center. Proper glasses fitting is important
Choosing thin lenses: Ultra-high-refractive-index lenses (1.74–1.76) reduce thickness and improve appearance and weight
How to prescribe glasses for eyes with various diseases
The Adult Spectacle Prescription Guide (2025) gives a detailed explanation of prescribing for eyes affected by disease1).
Corneal diseases (such as keratoconus, etc.): In mild cases that cannot be managed with RGP lenses, spherical glasses can still be helpful. Irregular astigmatism cannot be corrected with glasses
Pseudophakic eye: After cataract surgery, residual refractive error may occur depending on the IOL power setting. Residual axial hyperopia or myopia can be addressed with single-vision glasses or progressive lenses
Retinal diseases (AMD, RP, etc.): Prescriptions for low-vision eyes should aim to maximize visual function, and combining them with tinted glasses or magnifiers should be considered when needed
Benefit coverage for glasses used to treat childhood amblyopia
For children with amblyopia, strabismus, or after congenital cataract surgery, about 70% of the cost of glasses or contact lenses needed for treatment is reimbursed3). The renewal interval for coverage is as follows3):
First time: When an ophthalmologist deems it medically necessary based on a prescription
Renewal: For children under 5, after at least 1 year has passed; for children 5 and older, after at least 2 years have passed, if there is a significant change in prescription
To apply for the benefit, you need an ophthalmologist’s prescription, receipt, and insurance card, and you submit the application to your health insurance union or municipality.
Polycarbonate and Trivex materials are 10 times more impact-resistant than ordinary plastic lenses. In amblyopia, strabismus, or monocular cases, it is desirable to explain and recommend impact-resistant lenses to reduce the risk of blindness from eye injuries.
Examination flow for spectacle prescriptions (adults, detailed version)
Outpatient examination workflow based on the 2025 adult vision testing and spectacle prescription guide1).
Use history: Get a detailed understanding of the settings and viewing distances, such as driving, desktop PCs (monitor distance 40–80 cm), smartphones (30–40 cm), playing musical instruments (sheet music distance 50–70 cm), and near work (around 30 cm).
Check current glasses: Measure the power and prism of the current glasses with a lensmeter. Ask about wearing habits, satisfaction, and any complaints.
Objective refraction: Measure sphere power, cylinder power, and axis with an autorefractometer. Take at least three measurements to confirm reproducibility.
Subjective refraction: Refine sphere power → cylinder power → axis with a phoropter or trial frame. Aim for MPMVA (maximum plus for maximum visual acuity).
Accommodation testing: Evaluate accommodative amplitude. Used to calculate near add power. If there is accommodative lag, consider near addition.
Visual acuity measurement: Record corrected visual acuity for distance and near (33 cm).
PD (interpupillary distance) measurement: Accurately measure distance PD and near PD. PD errors can lead to prism errors.
Write the prescription: Record sphere, cylinder, axis, add, prism, PD, and vertex distance.
Weak cycloplegic effect. Used for pupil dilation in adults
When using atropine, watch for fever, tachycardia, dry mouth, and facial flushing (hypersensitivity/systemic absorption). In children, make sure to press on the lacrimal sac thoroughly 3).
QCan myopia control glasses cure myopia?
A
Myopia control glasses do not cure myopia; they suppress its progression. MiYOSMART® and Essilor® Stellest® showed an average 55–59% suppression of myopia progression in 2-year clinical trials 2). Because the effect disappears if wear is stopped, continued use is recommended until the late teens, when myopia progression settles. Regular follow-up with refraction and axial length measurements is needed.
Because eyeglass lenses are placed away from the corneal apex, images appear magnified (convex lenses) or reduced (concave lenses) depending on the prescription. Convex lenses bring near objects within the focal distance and move the focus that would form behind the retina in hyperopic eyes onto the retina. Concave lenses diverge parallel light rays and move the focus that would form in front of the retina in myopic eyes backward so it forms on the retina.
If there is a difference in refractive power between the eyes, prescribing fully corrected glasses causes a difference in image size between the two eyes (aniseikonia). Convex lenses magnify and concave lenses reduce, and the greater the distance between the lens and the eye, the stronger the magnification effect. Cylindrical lenses used to correct astigmatism cause meridional aniseikonia, in which magnification differs by meridian direction.
In presbyopia, decreased lens elasticity causes insufficient accommodation, making it hard to focus on near objects. Add power (add) compensates for this lack of accommodation with added plus power for near vision, and the needed amount increases step by step with age. Pointer’s study showed that add power for the non-dominant eye tends to be slightly greater than for the dominant eye14), and this may be considered when prescribing.
Accommodation occurs through contraction of the ciliary muscle → relaxation of the zonules → bulging of the lens. In adults, accommodative amplitude decreases by about 0.27D per year. It is about 6D at age 40, about 3D at age 50, and about 1D at age 60 (Duane accommodation chart). Glasses that compensate for this physiological decline with add power are presbyopic glasses and progressive addition lenses.
Accommodation lag is a state in which the actual focus lies behind the viewing distance (Near Lag), and it is especially a problem in young myopes. Hyperopic defocus in the retinal periphery is thought to be a signal for axial elongation and to promote myopia progression. Myopia-control spectacles (multisegment lenses) suppress axial elongation by converting this peripheral defocus into myopic defocus10).
The main mechanism of myopia progression is axial elongation (axial myopia). When axial length increases by 1 mm, the refractive error changes by about -2.5 to -3.0D. Axial elongation is mainly due to stretching of the sclera, and retinal defocus signals are thought to regulate eye growth11). Bullimore et al. showed that suppressing myopia progression by 1D significantly reduces the future risk of vision impairment and pathological myopia9), so even a small reduction in myopia progression has major long-term value.
Myopia-control spectacles (multisegment lenses) have an optical design that controls peripheral defocus. DIMS technology (MiYOSMART®) and HALT technology (Stellest®) are thought to send signals that suppress axial elongation by providing myopic defocus to the peripheral retina. They are designed to maintain good central vision with full correction while also controlling defocus in peripheral vision2).
Evidence for the effectiveness of myopia-control spectacles:
MiYOSMART® (HOYA, DIMS technology): In a 2-year RCT, spherical equivalent progression was suppressed by 52% and axial length elongation by 62%5)
Essilor Stellest® (Nikon-Essilor, HALT technology): In a 2-year RCT, spherical equivalent progression was suppressed by 67% (wear time ≥12 hours/day)6)
If wear is stopped, there is a rebound effect, and continued use is recommended until the late teens when myopia progression settles (guideline recommendation)2)
Unlike contact lenses, eyeglass lenses do not form a tear lens. Therefore irregular astigmatism cannot be corrected with spectacles, and RGP lenses or scleral lenses are required.
In the 2025 Guidelines for Visual Acuity Testing and Spectacle Prescription in Adults, spectacle fitting is emphasized as part of the prescription1). The following are outpatient fitting checkpoints.
Vertex distance (BVD): usually 12–14 mm. The shorter it is, the more the image-size effects of convex lenses and concave lenses change
Pantoscopic tilt: the vertical angle of the frame. The greater the pantoscopic tilt, the more the astigmatic power increases
Interpupillary distance (PD) and decentration of the lens optical center: if prismatic error occurs, it can cause double vision and eye strain
Nose pad height and frame width: slippage during wear changes the lens power effect
Coordination with a certified eyeglass technician (national qualification) is recommended. For myopia-control spectacles, a certified eyeglass technician is considered desirable as the maker2).
The global myopia population is projected to increase from 1.3 billion in 2000 to 4.9 billion in 2050 (including 940 million people with high myopia)4). The two products currently recommended in guidelines are MiYOSMART® and Essilor® Stellest®, and MYOGEN®, MyoCare®, and DOT lenses are scheduled for reevaluation in future revisions2). Bullimore et al. showed that suppressing myopia progression by 1 D significantly reduces the future risk of visual impairment9).
Establishment of the certified eyeglass technician system
A system for certified eyeglass technicians (national qualification) has been established to standardize frame fitting. In the myopia-control spectacle guidelines, a certified eyeglass technician is considered desirable as the maker of myopia-control spectacles2).
The 11.3% prevalence of high myopia in junior high school students exceeds the 8.2% in adults2), making worsening myopia in younger people a public health issue. The IMI (International Myopia Institute) 2023 digest provides a comprehensive summary of the natural history of myopia10). Active myopia management from school age is needed.
The prevalence of refractive errors in adults varies greatly by country and ethnicity. In a report by Kempen and colleagues, the prevalence of refractive errors among adults in the United States, Western Europe, and Australia was 24% to 35%15). Refractive errors, including presbyopia, are an issue that affects almost all adults, and the importance of spectacle prescriptions will continue to grow.
Advances in custom-designed lenses and progressive lenses
Lens manufacturers are developing progressive designs specialized for short to medium distances for HMDs (head-mounted displays) and smartphones. With “custom-designed” lenses that take wavefront aberrations into account, it is possible to optimize the lens design by measuring the frame shape, vertex distance, pantoscopic tilt, and pupil height with 3D scanning. This helps improve wearing comfort in high myopia and high astigmatism. Methods for dealing with aniseikonia in spectacle prescriptions for anisometropia are described in detail in the Adult Spectacle Prescription Guide12). The physiological principles for setting addition power for presbyopic eyes are also explained in detail in the same guide13). Addition power usually starts in the mid-40s, and the average age at which +1.0D is needed has been reported to be around 55 to 60 years14).
Holden BA, Fricke TR, Wilson DA, et al. Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmology. 2016;123(5):1036-1042.
Bao J, Huang Y, Li X, et al. Spectacle lenses with aspherical lenslets for myopia control vs single-vision spectacle lenses: a randomized clinical trial. JAMA Ophthalmol. 2022;140(5):472-478.
Jiang Y, Zhu Z, Tan X, et al. Effect of repeated low-level red-light therapy for myopia control in children: a multicenter randomized controlled trial. Ophthalmology. 2022;129(5):509-519.
Bullimore MA, Brennan NA. Myopia control: why each diopter matters. Optom Vis Sci. 2019;96(6):463-465.
Sankaridurg P, Berntsen DA, Bullimore MA, et al. IMI 2023 digest. Invest Ophthalmol Vis Sci. 2023;64(6):7.
Troilo D, Smith EL 3rd, Nickla DL, et al. IMI - Report on experimental models of emmetropization and myopia. Invest Ophthalmol Vis Sci. 2019;60(3):M31-M88.
Pointer JS. The presbyopic add: the non-dominant eye’s fine time. Clin Exp Optom. 2007;90(2):100-107.
Kempen JH, Mitchell P, Lee KE, et al. The prevalence of refractive errors among adults in the United States, Western Europe, and Australia. Arch Ophthalmol. 2004;122(4):495-505.
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