A systematic review examined the efficacy of optical, pharmacological, and environmental interventions in slowing myopia progression in children. The living review has thus far included data from 64 studies and 11,617 children in North America and Asia and highlighted key findings to inform clinical decision-making for myopia management.

As the researchers explained, myopia is established as a risk factor for other ocular pathologies including cataracts, glaucoma, and retinal detachment. Higher degrees of myopia can also increase the risk for sight-threatening conditions, such as posterior staphyloma and myopic maculopathy, due to the stretching of the outer coat of the eye. Interventions in childhood, the researchers wrote in their review published in the Cochrane Database of Systematic Reviews, “have the potential to reduce future visual impairment.”

The analysis included studies that compared interventions to controls (placebo, single-vision spectacles, or contact lenses) or to other interventions. Included interventions were:

• Undercorrection of myopia with single-vision spectacle lenses
• Multifocal (bifocal or progressive addition) spectacle lenses, peripheral defocus spectacle lenses
• Multifocal soft contact lenses (concentric ring or progressive designs), rigid gas‐permeable contact lenses, or corneal reshaping (orthokeratology) contact lenses
• Atropine, stratified according to dosing regime as high (≥0.5%), moderate (0.1% to <0.5%), and low (<0.1%)
• Other pharmaceutical agents (e.g. pirenzepine, 7‐methylxanthine)
• Environmental interventions (e.g. time spent outdoors, modifications to the performance of near work)

Pharmacological Interventions

High-dose atropine (≥0.5%) showed the most significant reduction in myopia progression at one year (mean difference 0.90 diopters [D]) and at two years (mean difference 1.26 D).

Low-dose atropine (<0.1%) provided smaller benefits with fewer side effects, such as photophobia and blurred near vision (1-year mean difference 0.38 D).

Pirenzepine, an antimuscarinic gel, demonstrated moderate efficacy (1-year mean difference 0.32 D).

Optical Interventions

Multifocal spectacle lenses reduced myopia progression modestly at one year (mean difference 0.14 D). Peripheral plus spectacle lenses showed inconsistent results across studies, though certain designs, such as Defocus Incorporated Multiple Segments (DIMS) lenses, showed significant benefits (1-year mean difference 0.55 D). Multifocal soft contact lenses provided significant reductions in axial elongation (1-year mean difference −0.11 mm) and refractive error.

Temporarily reshaping the cornea through overnight lens wear with orthokeratology effectively reduced axial elongation (1-year mean difference −0.19 mm). Change in axial length, the investigators described, is finding its place as an endpoint for studies exploring the efficacy of interventions, in addition to refractive error changes. However, while "axial length may be a better predictor of future progression and consequent risk of posterior pole complications," they noted, “Ortho‐k may also require more specialized knowledge by the eye care practitioner, and therefore it may not be as available as some of the other treatment modalities.”

Environmental Interventions

Increased outdoor time reduced myopia onset but had limited effects on progression once myopia was established.

Clinical Implications

Combining interventions, such as low-dose atropine with orthokeratology, may enhance efficacy and reduce side effects, but this approach still requires additional trials. “Based on the best available evidence, topical antimuscarinic agents and orthokeratology (ortho‐K) currently appear to be the most effective treatments for slowing childhood myopia progression,” the researchers wrote. “Although higher doses slow overall axial elongation by approximately 0.5 mm over two years, corresponding to an approximate 1.00 D reduction in myopia, higher concentrations are more likely to cause adverse events and may increase the risk of rebound following cessation of treatment. The current review found limited evidence that rebound could potentially be reduced by tapering the treatment prior to termination.”

Adherence and the management of side effects also remain critical for long-term success. Indeed, the optimal dose, “which balances efficacy, safety and propensity to rebound,” is still being explored. Most of the included studies had limited follow-up of between 1 to 2 years, and few reported adverse events or quality-of-life outcomes. More studies are also needed to understand the sustainability of benefits and potential rebound effects following treatment cessation, as well as the economic impacts of each therapy.

“Epidemiological evidence has shown that the age of onset and rate of myopia progression in children varies considerably," the researchers wrote. "There is a need to develop better predictive models to identify children who are most likely to progress rapidly and will therefore potentially derive most benefit from treatment. The absence of long‐term data provides little evidence as to when myopia control interventions can be stopped or modified during treatment.”

A full list of author disclosures can be found in the published research.