Myopia Control in Children: A Complete Patient's Guide to the 2023 Cochrane Review

Table of Contents

• Key Points
• Understanding Myopia (Nearsightedness)
• Why Slowing Myopia in Childhood Matters
• How the Research Was Conducted
• Key Findings: Changes in Blurred Vision (Refractive Error)
• Key Findings: Eyeball Length (Axial Elongation)
• What Happens When Treatment Stops? (The 'Rebound' Question)
• Safety and Side Effects
• What This Means for Patients and Families
• Study Limitations
• Recommendations for Parents and Caregivers
• Frequently Asked Questions
• Source Information

Key Points

• Atropine eye drops, especially high-dose, were the most effective at slowing myopia and eyeball growth in children.
• Multifocal soft contact lenses and multifocal spectacles showed consistent, modest benefits at one and two years.
• Undercorrected single-vision glasses and rigid gas-permeable lenses showed little or no benefit for myopia control.
• The rebound effect after stopping treatment is uncertain; evidence at two years is limited and adverse events were poorly reported.
• No randomized trials of environmental interventions like outdoor time were found for children who already had myopia.

Understanding Myopia (Nearsightedness)

Myopia—commonly called short-sightedness or nearsightedness—is a condition where the eyeball grows too long. Because of this elongation, light entering the eye focuses in front of the retina instead of directly on it, making distant objects appear blurred while nearby objects remain clear.

This is not a rare problem. The review notes that myopia affects more than half of all children in China and South-East Asia, and its prevalence is rising worldwide. For many children, myopia is first detected before age 10, which matters because younger onset typically means faster progression and a higher final level of nearsightedness.

Clinicians measure myopia in two important ways:

• Spherical equivalent refraction (SER), measured in diopters (D), which describes how much corrective power the eye needs to see clearly. A higher negative number (for example, going from −2.00 D to −4.00 D) means the myopia is progressing.
• Axial length, measured in millimeters (mm), which is the physical length of the eyeball from front to back. Longer eyes mean the retina is stretched, increasing future risk.

Why Slowing Myopia in Childhood Matters

Slowing myopia progression is not just about avoiding thick glasses. Because myopic eyes are longer, the retina (the light-sensitive tissue at the back of the eye) becomes stretched and thinned. This puts children at greater risk—when they become adults—of serious eye diseases including glaucoma (optic nerve damage), maculopathy (damage to the central retina), and retinal detachment (where the retina peels away from the eye wall).

Myopia can also affect daily life during childhood itself, including educational and occupational activities. The review's authors emphasize that because myopia is usually detected before age 10 and can progress rapidly, any effective intervention needs to be delivered during childhood to have the greatest impact.

Conventional eyeglasses and standard contact lenses correct the blur but do nothing to slow the underlying progression. That is where "myopia control" interventions come in.

How the Research Was Conducted

This is a living systematic review and network meta-analysis, which means the researchers continuously update their findings as new evidence becomes available. It follows the rigorous methodology of the Cochrane Collaboration, an international organization widely considered a gold standard for evidence-based medicine.

The researchers searched CENTRAL (containing the Cochrane Eyes and Vision Trials Register), MEDLINE, Embase, and three trials registries. The search date was February 26, 2022.

What studies were included?

• 64 randomized controlled trials (RCTs)—the most reliable type of medical evidence
• 11,617 children aged 4 to 18 years
• 39 studies (60.9%) conducted in China or other Asian countries
• 13 studies (20.3%) conducted in North America
• Study durations ranged from 12 to 36 months
• 57 studies (89%) compared a myopia control intervention against an inactive control (such as placebo drops or standard single-vision glasses)

All studies were randomized controlled trials of children aged 18 years or younger. The researchers focused on outcomes measured at one year or longer: the difference in change in SER (in diopters) and axial length (in millimeters) between the intervention and control groups. They also examined what happens after treatment stops, sometimes called the "rebound" effect.

What interventions were studied?

The review covered three broad categories of treatment:

1. Optical treatments (glasses and contact lenses): multifocal spectacle lenses, peripheral plus spectacle lenses (PPSL), undercorrected single vision spectacles, multifocal soft contact lenses (MFSCL), orthokeratology (special lenses worn overnight that temporarily reshape the eye's surface), and rigid gas-permeable contact lenses (RGP)
2. Pharmacological treatments (eye drops): high-dose atropine (HDA), moderate-dose atropine (MDA), low-dose atropine (LDA), pirenzepine, and 7-methylxanthine
3. Environmental interventions: time outdoors, reduced screen time, or other behavioral approaches. Notably, no studies reporting environmental interventions for children with existing myopia met the inclusion criteria.

The authors assessed the risk of bias using the Cochrane Rob 2 tool and rated the certainty of the evidence using the GRADE approach. According to the review, the overall certainty of the evidence ranged from very low to moderate. Because the networks connecting different treatments were poorly connected, the authors mostly report results from direct pairwise comparisons—meaning head-to-head comparisons between one treatment and a control group.

Key Findings: Changes in Blurred Vision (Refractive Error)

To understand these results, it helps to know that a larger positive difference means the treatment slowed myopia better than the control. For example, a mean difference (MD) of 0.90 D means the treated children's myopia worsened by 0.90 diopters less than the control group's over one year.

Results at One Year

At one year, in 38 studies with 6,525 children analyzed, the median change in SER for children in the control groups was −0.65 D—meaning their myopia worsened by about two-thirds of a diopter during the year.

Compared with controls, the following interventions slowed the worsening of myopia:

• High-dose atropine: MD 0.90 D (95% CI 0.62 to 1.18)
• Moderate-dose atropine: MD 0.65 D (95% CI 0.27 to 1.03)
• Peripheral plus spectacle lenses: MD 0.51 D (95% CI 0.19 to 0.82)
• Low-dose atropine: MD 0.38 D (95% CI 0.10 to 0.66)
• Pirenzepine: MD 0.32 D (95% CI 0.15 to 0.49)
• Multifocal soft contact lenses: MD 0.26 D (95% CI 0.17 to 0.35)
• Multifocal spectacles: MD 0.14 D (95% CI 0.08 to 0.21)

By contrast, there was little or no evidence that the following slowed myopia progression at one year:

• Rigid gas-permeable contact lenses: MD 0.02 D (95% CI −0.05 to 0.10)
• 7-methylxanthine: MD 0.07 D (95% CI −0.09 to 0.24)
• Undercorrected single vision spectacles: MD −0.15 D (95% CI −0.29 to 0.00)—in fact, these may have allowed slightly more progression than full correction

Results at Two Years

At two years, in 26 studies with 4,949 children analyzed, the median change in SER for controls was −1.02 D—meaning untreated children typically worsened by roughly one full diopter over two years.

The following treatments still showed a benefit at two years:

• High-dose atropine: MD 1.26 D (95% CI 1.17 to 1.36)—the strongest effect of all treatments at any timepoint
• Moderate-dose atropine: MD 0.45 D (95% CI 0.08 to 0.83)
• Pirenzepine: MD 0.41 D (95% CI 0.13 to 0.69)
• Multifocal soft contact lenses: MD 0.30 D (95% CI 0.19 to 0.41)
• Low-dose atropine: MD 0.24 D (95% CI 0.17 to 0.31)
• Multifocal spectacles: MD 0.19 D (95% CI 0.08 to 0.30)
• Peripheral plus spectacle lenses: MD 0.34 D (95% CI −0.08 to 0.76)—may help, but results were inconsistent across studies

For rigid gas-permeable lenses, one study found a benefit while another found no difference compared with control. Undercorrected single vision spectacles showed no meaningful benefit at two years (MD 0.02 D, 95% CI −0.05 to 0.09).

Key Findings: Eyeball Length (Axial Elongation)

Axial length is arguably the most important measure for long-term eye health, because stretching of the eyeball is what drives the future risk of glaucoma, maculopathy, and retinal detachment. Here, a negative difference is good: it means the treated eye grew less than the control eye. The median axial length increase in control children was 0.31 mm at one year and 0.56 mm at two years.

Axial Length Results at One Year

In 36 studies with 6,263 children analyzed, the following treatments reduced eyeball elongation compared with controls:

• High-dose atropine: MD −0.33 mm (95% CI −0.35 to −0.30)
• Moderate-dose atropine: MD −0.28 mm (95% CI −0.38 to −0.17)
• Orthokeratology: MD −0.19 mm (95% CI −0.23 to −0.15)
• Low-dose atropine: MD −0.13 mm (95% CI −0.21 to −0.05)
• Peripheral plus spectacle lenses: MD −0.13 mm (95% CI −0.24 to −0.03)
• Multifocal soft contact lenses: MD −0.11 mm (95% CI −0.13 to −0.09)
• Pirenzepine: MD −0.10 mm (95% CI −0.18 to −0.02)
• Multifocal spectacles: MD −0.06 mm (95% CI −0.09 to −0.04)

There was little or no evidence that these reduced axial length at one year:

• Rigid gas-permeable contact lenses: MD 0.02 mm (95% CI −0.05 to 0.10)
• 7-methylxanthine: MD 0.03 mm (95% CI −0.10 to 0.03)
• Undercorrected single vision spectacles: MD 0.05 mm (95% CI −0.01 to 0.11)

Axial Length Results at Two Years

In 21 studies with 4,169 children analyzed, the following treatments reduced eyeball elongation at two years:

• High-dose atropine: MD −0.47 mm (95% CI −0.61 to −0.34)—the strongest effect on axial length
• Moderate-dose atropine: MD −0.33 mm (95% CI −0.46 to −0.20)
• Orthokeratology: MD −0.28 mm (95% CI −0.38 to −0.19)
• Low-dose atropine: MD −0.16 mm (95% CI −0.20 to −0.12)
• Multifocal soft contact lenses: MD −0.15 mm (95% CI −0.19 to −0.12)
• Multifocal spectacles: MD −0.07 mm (95% CI −0.12 to −0.03)
• Peripheral plus spectacle lenses: MD −0.20 mm (95% CI −0.45 to 0.05)—may help, but results were inconsistent

Undercorrected single vision spectacles (MD −0.01 mm, 95% CI −0.06 to 0.03) and rigid gas-permeable contact lenses (MD 0.03 mm, 95% CI −0.05 to 0.12) showed little or no benefit for controlling eyeball growth.

What Happens When Treatment Stops? (The 'Rebound' Question)

A major concern with any myopia control treatment is whether the eye "rebounds"—that is, whether myopia progresses faster than normal after the treatment is discontinued. The review looked specifically at changes in SER and axial length during the year after stopping treatment.

The authors report there was inconclusive evidence on whether treatment cessation increases myopia progression. In other words, we still do not know for certain whether the benefits last after treatment ends, whether there is an acceleration of myopia, or how best to taper treatments to prevent rebound. This is an important area for future research.

Safety and Side Effects

The review found that adverse events and treatment adherence were not consistently reported across the included studies, creating significant uncertainty about the safety profile of these treatments. Only one study reported quality of life outcomes, which is a major gap in the evidence.

Based on what is known from the trials and the plain language summary, the key side effects to be aware of include:

• Atropine eye drops: can cause increased sensitivity to glare and difficulty reading (because the drops dilate the pupil and affect the eye's ability to focus up close). These problems are more common and more severe at higher doses.
• Soft contact lenses and orthokeratology: any contact lens wear increases the risk of infections on the surface of the eye (the cornea). Orthokeratology lenses are worn overnight, which adds additional considerations for hygiene and eye health.

The review authors specifically call for "improved methods for monitoring and reporting adverse effects" in future studies.

What This Means for Patients and Families

This review provides the most comprehensive picture to date of which myopia control strategies actually work in children. The practical takeaways are clear:

• Atropine eye drops work, and higher doses work better. High-dose atropine slowed myopia progression by about 0.90 D at one year and more than 1.25 D at two years, and was the most powerful treatment for reducing eyeball elongation. The trade-off is more side effects at higher doses, such as glare and difficulty with near vision.
• Several optical options are genuinely effective, though modestly. Multifocal soft contact lenses and multifocal spectacles produced consistent, measurable benefits at one and two years for both blur progression and eyeball length. Peripheral plus spectacle lenses also appear promising, though results were less consistent.
• Orthokeratology is effective at slowing eyeball growth. Even though the review could not measure SER changes for orthokeratology (because the lenses reshape the cornea in a way that confounds standard refraction measurements), they clearly reduced axial elongation (−0.19 mm at one year and −0.28 mm at two years). Since axial length is what drives long-term eye disease risk, this is clinically meaningful.
• Some older treatments appear ineffective. Undercorrecting a child's glasses—deliberately prescribing a weaker prescription—does not slow myopia and may even allow slightly more progression. Rigid gas-permeable contact lenses (as traditionally fitted) also showed no benefit for myopia control.
• The durability of benefit is uncertain. The evidence is strongest for one year of treatment, with a smaller body of evidence at two or three years. Longer-term data are especially important because children typically remain myopic for many more years after treatment begins.

Importantly, the review did not find any randomized trials of environmental interventions (like increasing outdoor time) in children who already had myopia, and found no economic evaluations of myopia control interventions. This means we cannot yet draw conclusions about the cost-effectiveness of these treatments or whether lifestyle measures can slow progression once myopia has already developed.

Study Limitations

It is important to understand what this review could not tell us:

• Modest certainty of evidence. The overall certainty of the evidence ranged from very low to moderate, meaning future research may change these conclusions.
• Poorly connected network. Because the studies did not compare treatments directly against one another in a well-connected network, the researchers could not rely on the network meta-analysis results and had to use simpler direct comparisons. This limits their ability to rank all treatments against each other with precision.
• Results were often heterogeneous (inconsistent). Children in different studies had different ages, ethnicities, baselines amounts of myopia, and treatment durations, and results sometimes varied even for the same treatment.
• Poor reporting of harms and adherence. Most studies did not consistently report side effects or how well children stuck with their treatment, so the true safety picture is incomplete.
• Sparse long-term data. Most evidence is at one year; far fewer studies extended to two or three years. The question of whether benefits persist after treatment stops remains unresolved.
• No data on quality of life. Only one study measured how treatment affected children's daily lives, comfort, or satisfaction.
• Economic information is missing. No economic evaluations met the inclusion criteria, so we cannot compare the cost-effectiveness of these treatments.

These limitations do not invalidate the findings, but they explain why the review authors urge caution and call for better, longer-term research.

Recommendations for Parents and Caregivers

If your child has been diagnosed with myopia, here are practical steps based on this review's findings:

1. Talk to an eye care professional about myopia control options early. Because myopia progresses fastest in childhood, early intervention matters. Ask specifically about atropine eye drops, multifocal soft contact lenses, multifocal spectacles, peripheral plus lenses, and orthokeratology.
2. Ask about the dose if atropine is recommended. Higher doses are more effective but cause more glare and difficulty reading. Low-dose atropine is less effective but may have fewer side effects. The decision should be individualized for your child.
3. Consider combining treatments. The review notes there is limited evidence on combinations (for example, orthokeratology plus atropine), but combined approaches are increasingly used in practice and are an important area of study.
4. Insist on proper hygiene for contact lenses. Both soft multifocal lenses and orthokeratology increase the risk of eye infections. Follow cleaning, replacement, and wearing schedules exactly, and report any redness, pain, or blurred vision promptly.
5. Do NOT accept undercorrected glasses as a myopia control strategy. The evidence shows this approach does not work. Children should wear their full, accurate prescription.
6. Expect to be part of ongoing monitoring. Myopia control is not a one-time fix. Long-term follow-up is necessary to assess whether treatment is working and to watch for rebound when treatment is eventually discontinued.
7. Ask about lifestyle measures, but understand the current evidence gap. Outdoor time is widely recommended to help prevent myopia from developing, but this review found no randomized trials testing environmental interventions in children who already have myopia. It is still reasonable to encourage outdoor activity for general health, but do not rely on it as sole treatment.

Finally, keep in mind that every child is different. What works well for one child may not be ideal for another due to age, the severity of myopia, lifestyle, comfort with contact lenses, and tolerance of side effects. A shared decision between you, your child, and their eye care professional is the best approach.

Frequently Asked Questions

What is myopia and why is it important to slow it down in children?

Myopia, or nearsightedness, happens when the eyeball grows too long so distant objects look blurry. Slowing it in childhood matters because myopic eyes are longer, stretching the retina. This raises a child’s future risk of serious eye diseases such as glaucoma, maculopathy, and retinal detachment.

What was the most effective treatment for slowing myopia in children?

High-dose atropine eye drops were the most effective at slowing both blurred vision and eyeball elongation. At one year, they slowed myopia progression by about 0.90 diopters more than controls, and at two years, by about 1.26 diopters. However, higher doses cause more side effects like glare and difficulty reading.

Do eyeglasses help control myopia progression in children?

Some do. Multifocal spectacles and peripheral plus lenses slowed myopia at one year, with effects continuing at two years. But deliberately undercorrecting a child’s glasses—giving a weaker prescription—did not slow progression and may even allow slightly more worsening. Children should wear their full, accurate prescription.

What are the side effects of atropine eye drops for myopia control?

Atropine eye drops can cause increased sensitivity to glare and difficulty reading because they dilate the pupil and affect near focusing. These problems are more common and more severe at higher doses. Lower doses may have fewer side effects but are less effective in slowing myopia.

If my child stops myopia control treatment, will the myopia get worse?

The review found inconclusive evidence on whether stopping treatment causes a 'rebound' acceleration of myopia. It is still unknown if benefits last after treatment ends, if progression speeds up, or how to taper treatments to prevent rebound. This is an important area for future research.

Are contact lenses safe for children with myopia?

Contact lenses, including multifocal soft lenses and orthokeratology, increase the risk of eye infections. Orthokeratology lenses are worn overnight, adding hygiene concerns. The review noted that adverse events were not consistently reported. Proper hygiene, following replacement schedules, and reporting redness or pain promptly are essential.

My child's doctor recommended atropine drops for myopia control. Should I get a second opinion on the treatment choice?

A second opinion is reasonable when deciding among myopia control options because there are meaningful trade-offs. High-dose atropine slows progression most (about 0.90 D at one year) but causes glare and reading difficulty. Multifocal soft contact lenses and spectacles give smaller benefits with fewer side effects. Overall evidence certainty is only low to moderate, and side-effect reporting is inconsistent, so no single option is clearly superior. A second opinion can help confirm that the recommended dose or lens type fits your child's age, lifestyle, and tolerance. Diagnostic Detectives Network provides independent expert second opinions.

Source Information

This patient-friendly article is based on the following peer-reviewed research:

Original Title: Interventions for myopia control in children: a living systematic review and network meta-analysis

Authors: Lawrenson JG, Shah R, Huntjens B, Downie LE, Virgili G, Dhakal R, Verkicharla PK, Li D, Mavi S, Kernohan A, Li T, Walline JJ

Publication: Cochrane Database of Systematic Reviews 2023, Issue 2. Art. No.: CD014758. DOI: 10.1002/14651858.CD014758.pub2

Disclaimer: This article is a translation of the original scientific paper for patient education purposes. It does not replace professional medical advice. Always consult a qualified eye care professional before making decisions about your child's treatment.