Refractive
Spring 2025

by Liz Hillman
Editorial Co-Director

Progressive pediatric myopia, its increasing prevalence, and possible treatments are important topics for eyecare providers, even if their primary patient population isn’t pediatric.

Regardless of specialty within ophthalmology, Michael Repka, MD, who is a pediatric ophthalmologist, said it’s important to understand the research that’s going on in this area because it affects a large percentage of the population globally and is associated with long-term vision-threatening complications.

“I think that the more we talk about it, the better off we are. Having ophthalmologists understand that myopia should not be viewed as a fact of life, that it’s something that could be adjusted, may help them in their day-to-day conversations with their patients who are parents,” he said. “But first and foremost, it’s knowing what’s going on in the field and the interest in an area that hasn’t been traditionally mainstream.

Dr. Repka shared his perspectives regarding myopia, especially in the West, and his thoughts on recent research and treatments for myopia control in an interview with EyeWorld.

Myopia status

While it’s well documented that pediatric myopia has been on the rise in East Asia and some of Southwest Asia, the dramatic increase in prevalence is (at least not yet) mirrored in the West.

The prevalence of myopia in East Asia can be as high as 80–90% among young adults, compared to 20–40% in Western countries.¹ High myopia among the Asian population ranges from 6.8–21.6%, compared to 2.0–2.3% in non-Asian populations.²

Dr. Repka said that myopia and factors associated with progression in the West are not perfectly understood.

“In much of Asia there’s clearly been a dramatic increase in the prevalence of amblyopia. … It’s not as clear that the prevalence in the U.S. has increased dramatically over the same period of 30–40 years,” he said. “Part of that is we don’t have the kind of surveillance and universal collection of data that they have in other parts of the world or in smaller countries. … There are some data that suggest prevalence is increasing, but I do think more of that evidence is supportive elsewhere in the world, not necessarily reflecting what is happening in the U.S. There are places or pockets where it seems to be anecdotally increasing, but I do want to caution that it’s not perfectly clear.”

Dr. Repka said that the difference in myopia prevalence between the East and West could be due to incomplete data, a lag of increase in prevalence, or it could be due to differences in environmental risk factors. “There’s no question that people are trying to understand and determine what are the predictors of myopia progression.”

The most mentioned risk factors for myopia onset and progression are long periods of reading, reading at a close distance, and limited exposure to sunlight.³ Work is being done to create tools to assess risk of multiple factors related to myopia development and progression.⁴

Myopia control efforts

Atropine is among the most publicized and researched treatments for stemming progressive myopia. A 2006 study in an Asian population found 1% atropine to be well tolerated and effective, and later research evaluated lower doses, finding 0.1% and 0.5% to be safe and effective.^5,6 Research into even lower concentrations found 0.05% atropine to be “most effective in controlling [spherical equivalent] progression and [axial length] elongation” over 1 year.⁷ Dr. Repka said that low-dose atropine has been a “game changer in East Asia.”

However, in Western populations, low-dose atropine had “less than exciting results,” Dr. Repka said. A study published in 2023, of which Dr. Repka was the lead investigator, found that, among school-age children in the U.S., 0.01% atropine “did not slow myopia progression or axial elongation” compared to placebo.⁸

“We don’t know what 0.05% would do in the West,” Dr. Repka added, explaining that 0.05% is the concentration that many Asian countries have begun to use. Dr. Repka said “it’s not the end of the day for atropine research” in the West. He said that it’s time to pursue additional studies to evaluate higher doses. “The problem with higher dosages is they may work, but they may cause more symptoms; 0.01% is fairly innocuous,” he said.

Dr. Repka said that there are some reports of minor statistically significant effects being detected with 0.01%, though it was not clinically meaningful, in his opinion. “Maybe this is a signal that there is something here, and we just have to find the right dose,” he said.

In addition to studying higher doses of atropine in a Western population, he said other methods to stem or slow myopia progression are needed. He discussed the only FDA-approved product for myopia control, MiSight (CooperVision), which are contact lenses approved for patients as young as 8 years old. This lens was successfully able to slow progression compared to the control, single-vision contact lens. He mentioned the BLINK study, which found that “off-label treatment with high-add power multifocal contact lenses significantly reduced the rate of myopia progression over 3 years compared with medium-add power multifocal and single-vision contact lenses” in pediatric patients with myopia.⁹ The study noted the need for further research to better understand “the clinical importance of the observed differences.”

As Dr. Repka put it, “there is some evidence in our population that you can slow progression, in this case with two different forms of contact lenses (one that’s FDA approved and one that would be off-label use of an FDA-approved product). That remains exciting. The effects are modest, and we should not oversell these effects. Having an effect is good, having a stronger effect would be better; we are in the early days of treatment development.”

Dr. Repka also brought up research being conducted with spectacles to slow myopia progression. “A number of large eyeglass manufacturers are looking at lenses that are in some cases designed to do something similar to what the contact lens model did to achieve slowing of myopia progression. The advantage of these lenses is you can treat younger children, and it’s better to treat younger based on what we know because the younger you are at onset, the more severe the myopia typically is at the end of the teenage years,” he said.

Takeaway message

From the increasing prevalence standpoint, Dr. Repka said “the story is not clear” in the West, but he emphasized that even if it’s not an epidemic, there is “a sizable percentage of our population” who are myopic.

“There are still a lot of people wearing glasses who maybe don’t have to be wearing glasses as strong, and there is a large number of people who might be at risk for the retinal complications of myopia 50 years down the road,” he said, adding that myopia progression remains an important area of research globally.

As treatments to slow myopia progression become available, Dr. Repka said he’s interested to see how the healthcare market sorts out coverage. He said he thinks these treatments should be considered medical eyecare, rather than vision care, which currently covers glasses and contact lenses.

“I think the biggest change has been myopia has gone from the, ‘You just change the glasses’ statement of a decade ago to, ‘There are things we can do.’ We’re learning more about it every day, but there are things we could consider doing. That’s a big change,” Dr. Repka said.

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About the physician

Michael Repka, MD
Division Director, Pediatric Ophthalmology and Adult Strabismus
Wilmer Eye Institute
Johns Hopkins School of Medicine
Baltimore, Maryland

References

1. Morgan IG, et al. The epidemics of myopia: etiology and prevention. Prog Retin Eye Res. 2018;62:134–149.
2. Wong YL, Saw SM. Epidemiology of pathologic myopia in Asia and worldwide. Asia-Pacific J Ophthalmol. 2016;5:394–402.
3. Martinez-Albert N, et al. Risk factors for myopia: a review. J Clin Med. 2023;12:6062.
4. Manoharan MK, et al. Myopia progression risk assessment score (MPRAS): a promising new tool for risk stratification. Sci Rep. 2023;13:8858.
5. Chua WH, et al. Atropine for the treatment of childhood myopia. Ophthalmology. 2006;113:2285–2291.
6. Chia A, et al. Atropine for the treatment of childhood myopia: safety and efficacy of 0.5%, 0.1%, and 0.01% doses (Atropine for the Treatment of Myopia 2). Ophthalmology. 2012;119:347–354.
7. Yam JC, et al. Low-Concentration Atropine for Myopia Progression (LAMP) study: a randomized, double-blinded, placebo-controlled trial of 0.05%, 0.025%, and 0.01% atropine eye drops in myopia control. Ophthalmology. 2019;126:113–124.
8. Repka MX, et al. Low-dose 0.01% atropine eye drops vs. placebo for myopia control: a randomized clinical trial. JAMA Ophthalmol. 2023;141:756–765.
9. Walline JJ, et al. Effect of high add power, medium add power, or single-vision contact lenses on myopia progression in children: The BLINK randomized clinical trial. JAMA. 2020;324:571–580.

Relevant disclosures

Repka: None

Contact

Repka: mrepka@jhmi.edu