This comprehensive review analyzed 64 studies involving over 11,600 children to determine which treatments effectively slow myopia progression. High-dose atropine eye drops showed the strongest effect, reducing refractive error progression by 0.90 diopters and axial elongation by 0.33 mm at one year. Multifocal contact lenses, orthokeratology, and specialized spectacle lenses also demonstrated benefits, while undercorrection of regular glasses proved ineffective. The evidence quality varied from very low to moderate, highlighting the need for longer-term studies and better reporting of side effects.

Effective Treatments to Slow Childhood Myopia Progression: A Comprehensive Guide

Table of Contents

• Understanding Myopia and Why Controlling It Matters
• How This Comprehensive Review Was Conducted
• One-Year Results: Which Treatments Worked Best
• Two-Year Results: Sustained Benefits and Emerging Patterns
• Axial Length Results: Measuring Eye Elongation
• Safety Concerns and Side Effects
• Treatment Combinations and Rebound Effects
• Important Limitations to Consider
• What This Means for Patients and Families
• Practical Recommendations for Parents
• Future Research Needs
• Source Information

Understanding Myopia and Why Controlling It Matters

Myopia, commonly known as nearsightedness or shortsightedness, is a vision condition where distant objects appear blurry while close objects remain clear. This occurs when the eyeball grows too long, causing light to focus in front of the retina instead of directly on it. Myopia has become a global public health concern, affecting over half of children in China and Southeast Asian countries.

The condition typically develops in children before age 10 and can progress rapidly during childhood. Beyond the inconvenience of blurred distance vision, myopia poses serious long-term risks because the elongated eyeball stretches the retina, increasing the likelihood of sight-threatening conditions later in life including glaucoma, macular degeneration, and retinal detachment.

While conventional glasses and contact lenses correct the blurred vision, they do not slow the underlying progression of myopia. This systematic review examined whether specialized treatments could actually slow the worsening of myopia and reduce dangerous eye elongation in children.

How This Comprehensive Review Was Conducted

Researchers conducted an extensive analysis of all available randomized controlled trials (the gold standard in medical research) published through February 2022. They included 64 studies involving 11,617 children aged 4-18 years, with most studies conducted in China/Asia (39 studies, 60.9%) and North America (13 studies, 20.3%).

The review compared various interventions against control groups who typically received standard single-vision glasses or placebo treatments. Studies lasted between 1-3 years, allowing researchers to assess both short and longer-term effects. The team evaluated two critical outcomes:

• Change in spherical equivalent refraction (SER) - measuring the degree of nearsightedness in diopters
• Change in axial length - measuring the elongation of the eyeball in millimeters

Researchers used rigorous statistical methods including network meta-analysis to compare treatments both directly and indirectly, and assessed the quality of evidence using the GRADE system, which ranged from very low to moderate certainty across different comparisons.

One-Year Results: Which Treatments Worked Best

At the one-year mark, researchers analyzed data from 38 studies involving 6,525 participants. The control groups (children using standard single-vision glasses) showed a median progression of -0.65 diopters, meaning their vision worsened by this amount typically.

The most effective treatments for reducing refractive error progression included:

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

Treatments that showed little to no benefit included rigid gas-permeable contact lenses (0.02 D, 95% CI -0.05 to 0.10), 7-methylxanthine (0.07 D, 95% CI -0.09 to 0.24), and undercorrected single vision lenses (-0.15 D, 95% CI -0.29 to 0.00). Interestingly, undercorrection (giving children weaker prescriptions than needed) actually showed a trend toward worse outcomes than full correction.

Two-Year Results: Sustained Benefits and Emerging Patterns

At the two-year mark, 26 studies with 4,949 participants provided longer-term data. Control groups showed a median progression of -1.02 diopters, demonstrating how myopia typically worsens over time without intervention.

The treatments maintaining effectiveness at two years included:

• High-dose atropine (HDA): 1.26 D reduction (95% CI 1.17 to 1.36)
• Moderate-dose atropine (MDA): 0.45 D reduction (95% CI 0.08 to 0.83)
• Pirenzipine: 0.41 D reduction (95% CI 0.13 to 0.69)
• Peripheral plus spectacles (PPSL): 0.34 D reduction (95% CI -0.08 to 0.76) - though results were inconsistent
• Multifocal soft contact lenses (MFSCL): 0.30 D reduction (95% CI 0.19 to 0.41)
• Low-dose atropine (LDA): 0.24 D reduction (95% CI 0.17 to 0.31)
• Multifocal spectacles: 0.19 D reduction (95% CI 0.08 to 0.30)

Rigid gas-permeable lenses showed mixed results between studies, while undercorrected single vision lenses continued to show no benefit (0.02 D, 95% CI -0.05 to 0.09). The sustained effect of high-dose atropine was particularly notable, with its benefit actually increasing from 0.90 D at one year to 1.26 D at two years.

Axial Length Results: Measuring Eye Elongation

Perhaps more important than refractive error changes are measurements of axial length (eye elongation), since this physical change drives the serious sight-threatening complications of high myopia.

At one year (36 studies, 6,263 participants), control groups showed a median axial elongation of 0.31 mm. The most effective treatments for reducing eye elongation included:

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

At two years (21 studies, 4,169 participants), control groups showed 0.56 mm of elongation. Effective treatments included:

• High-dose atropine (HDA): -0.47 mm reduction (95% CI -0.61 to -0.34)
• Moderate-dose atropine (MDA): -0.33 mm reduction (95% CI -0.46 to -0.20)
• Orthokeratology: -0.28 mm reduction (95% CI -0.38 to -0.19)
• Multifocal soft contact lenses (MFSCL): -0.15 mm reduction (95% CI -0.19 to -0.12)
• Low-dose atropine (LDA): -0.16 mm reduction (95% CI -0.20 to -0.12)
• Multifocal spectacles: -0.07 mm reduction (95% CI -0.12 to -0.03)

Peripheral plus spectacles showed potential benefit (-0.20 mm, 95% CI -0.45 to 0.05) but with inconsistent results, while undercorrected single vision lenses (-0.01 mm, 95% CI -0.06 to 0.03) and rigid gas-permeable lenses (0.03 mm, 95% CI -0.05 to 0.12) showed no meaningful effect.

Safety Concerns and Side Effects

The review found significant limitations in how studies reported adverse events and treatment adherence. Only one study reported on quality of life impacts, creating substantial gaps in our understanding of the day-to-day experience with these treatments.

Based on available evidence and clinical experience:

• High-dose atropine commonly causes light sensitivity (photophobia) and difficulty with near vision (accommodation), which can affect reading and school performance
• Contact lenses (both multifocal and orthokeratology) carry infection risks, particularly corneal ulcers, requiring strict hygiene practices
• Orthokeratology involves overnight lens wear, which carries additional risks compared to daytime wear
• Most specialized optical treatments are more expensive than standard glasses

The inconsistent reporting of side effects means families should have detailed discussions with their eye care providers about potential risks and monitoring requirements for any chosen treatment approach.

Treatment Combinations and Rebound Effects

The review found inconclusive evidence regarding whether stopping treatment leads to "rebound" effects (accelerated progression). Some studies suggested that after discontinuing atropine, particularly higher doses, children might experience faster progression, but the evidence was not consistent across studies.

Few studies examined combination therapies (using multiple approaches simultaneously), which represents an important area for future research. The network meta-analysis was limited by poor connectivity between studies, meaning most estimates versus control were as, or more, imprecise than direct comparisons.

No studies evaluated environmental interventions like increased time outdoors or reduced near work, despite some evidence suggesting these factors might influence myopia development and progression.

Important Limitations to Consider

This comprehensive review had several limitations that affect how we interpret the results:

• The evidence certainty ranged from very low to moderate across different comparisons
• Most studies were conducted in Asian populations, limiting generalizability to other ethnic groups
• Inconsistent reporting of adverse events and treatment adherence
• Limited long-term data beyond 2-3 years
• Poorly connected networks in the meta-analysis limited comparison between treatments
• No economic evaluations were available to assess cost-effectiveness
• Only one study measured quality of life impacts

These limitations mean that while we can identify treatments that show promise, we have less certainty about how they compare directly to each other and their long-term safety profile.

What This Means for Patients and Families

This review provides the most comprehensive evidence to date that several interventions can effectively slow myopia progression in children. The findings suggest that:

• Pharmacological treatments, particularly atropine eye drops, show the strongest effects, with higher doses being more effective but causing more side effects
• Specialized optical treatments including multifocal contact lenses, orthokeratology, and certain spectacle designs provide meaningful reduction in progression
• Undercorrection (prescribing weaker glasses than needed) is ineffective and potentially harmful
• Treatment decisions should balance efficacy, side effects, cost, and lifestyle factors
• Regular monitoring remains essential regardless of treatment approach

Families should understand that these treatments slow progression but typically don't stop it completely, and that children will still need vision correction throughout treatment.

Practical Recommendations for Parents

Based on this evidence, parents of myopic children should:

1. Initiate early discussion with an eye care professional about myopia management options
2. Consider treatment initiation especially if the child is young and progressing rapidly
3. Evaluate options holistically - consider efficacy, side effects, cost, and practicality for your child's lifestyle
4. Prioritize safety - particularly with contact lens options, ensure your child can handle hygiene requirements
5. Maintain regular follow-up - most treatments require ongoing monitoring every 4-6 months
6. Combine approaches - while evidence is limited, combining treatments with behavioral modifications (increased outdoor time, visual breaks) may provide additional benefit
7. Manage expectations - these treatments slow but don't stop progression; your child will still need updated prescriptions

Future Research Needs

This review identified critical gaps in our knowledge that require future research:

• Long-term studies (5+ years) to understand sustained effects and safety
• Direct comparisons between active treatments rather than just against controls
• Combination therapy studies evaluating synergistic effects
• Better reporting of adverse events and quality of life impacts
• Economic evaluations to understand cost-effectiveness
• Studies in diverse ethnic populations
• Research on environmental interventions and their potential role
• Standardized outcome measures to improve comparability between studies

The authors are maintaining this as a "living systematic review" that will be updated as new evidence emerges, ensuring that patients and clinicians have access to the most current information.

Source Information

Original Article: 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

This patient-friendly article is based on peer-reviewed research from the Cochrane Database of Systematic Reviews, which represents the highest standard in evidence-based medicine.