Modern myopia management is no longer a matter of updating a minus prescription. The child arrives because distance vision is blurred; the clinician must decide whether the eye is growing too fast, whether that growth can be slowed, and how to judge whether care is working. Higher myopia and longer eyes are associated with a greater probability of myopic maculopathy and other complications. Treatment decisions must still be individualized: a low degree of myopia alone does not automatically justify years of intensive treatment. The clinically relevant point is that reducing the final myopic burden, particularly in children at risk of progressing to higher myopia, can reduce lifetime ocular risk (1, 2).

Start before progression becomes history

Prevention and treatment should be separated. In a child who is not yet myopic but has low hyperopic reserve, suspicious biometric development, strong family history or lifestyle-related risk, the aim is to reduce the probability of onset and monitor closely. The International Myopia Institute concept of pre-myopia captures this clinical territory: not yet myopic, but at sufficient risk to justify preventive counselling and follow-up. Operationally, the transition to childhood myopia is generally defined by cycloplegic spherical equivalent refraction of −0.50 D or less; above this threshold, counselling and surveillance remain preventive, whereas confirmed myopia shifts the discussion toward active treatment (3).

Once childhood myopia is confirmed, the threshold for action changes. Waiting six or 12 months merely to prove progression may appear cautious, but in a young child it can be biologically late. A seven-year-old with −0.75 D has already entered a risk trajectory. Management should therefore be discussed at diagnosis, especially when onset is early, axial length is high for age, hyperopic reserve was low before onset, or family history is strong (4, 5).

Baseline assessment: turn refraction into risk assessment

A useful first visit should not stop at spectacle prescription. Cycloplegic refraction remains essential, particularly in younger children, suspected pseudomyopia, accommodative spasm or inconsistent subjective findings. Orthoptic status should also be documented: ocular alignment and motility, near phoria, vergence function, and accommodation where clinically appropriate. These findings influence symptoms, visual comfort, treatment choice, and interpretation of refraction (6, 7).

Axial length should be measured whenever available. The 2025 IMI (International Myopia Institute) intervention report reinforces why: the measurement is non-contact, safe, highly repeatable, and does not require cycloplegia, whereas refraction is influenced by the cornea, crystalline lens, and accommodation (8). In younger children, lenticular changes may partially compensate for axial elongation; clinically, this means that relevant eye growth may not be reflected by an equivalent refractive shift and may be missed if follow-up relies on refraction alone.

Risk assessment should be based on age, cycloplegic refraction, absolute axial length, the axial length/corneal radius relationship and, after follow-up has begun, annualized axial change. Axial-length centile curves can provide useful descriptive context, but their limitations should be recognized. They should not be used as the sole basis for treatment decisions, because many curves combine myopic and nonmyopic eyes, and may therefore underestimate clinically relevant myopic eye growth (9). Use the same biometer and protocol whenever possible, and create a new working baseline if the device changes.

The same examination should look for red flags: very early onset, high or asymmetric myopia, reduced best-corrected visual acuity, abnormal ocular biometry, suspicious fundus findings or syndromic features. These cases require broader diagnostic thinking, not routine myopia control alone.

Anatomical documentation should become a stronger part of routine care. Dilated fundus examination remains essential; widefield fundus imaging and OCT of the macula, optic nerve and posterior pole are desirable additions, particularly in high myopia, long axial length, asymmetry, reduced best-corrected visual acuity or suspicious fundus findings. Where available, OCT angiography may add complementary information on retinal and choroidal microvasculature. These images do not replace axial length as the main growth metric. They add anatomical context by documenting peripheral retinal changes, posterior-pole morphology, choroidal thickness, early myopic maculopathy, staphylomatous configuration, and tractional alterations (10-12).

Structured longitudinal imaging datasets may later support AI-assisted analyses and help identify anatomical biomarkers — including choroidal thickness, posterior-pole morphology and subtle retinal changes — that refine risk stratification beyond refraction and axial length alone (13, 14).

By the end of the baseline visit, the clinician should know whether the refraction is reliable, how long the eye is, whether binocular function or posterior-segment anatomy raises concern, and how follow-up will detect excessive growth.

Use a biological target

Children’s eyes grow, so zero axial growth is not the universal standard. The relevant target is age-appropriate growth. It has been proposed that emmetropic, age-matched axial eye growth should be considered a meaningful treatment goal (15).

This is the logic behind Age-Matched Myopia Control. Instead of asking only, “By what percentage did treatment reduce progression?”, we should ask whether the child’s eye has moved closer to normal ocular development. The IMI 2025 report makes a related point through the Emmetropic Progression Ratio, which compares treated axial elongation with both untreated myopic growth and age-matched emmetropic growth (8).

Percentage efficacy can mislead. A 50 percent reduction may be excellent in one child and inadequate in another. Brennan and colleagues therefore argued that efficacy should be interpreted in absolute terms and with attention to axial elongation (4). Age-matched analyses of children wearing myopia-control spectacle lenses show how this approach can reframe clinical judgement (16, 17).

Monitor with rhythm and consistency

For most treated children, follow-up approximately every six months is a reasonable rhythm. The exact interval should also reflect the treatment modality, expected safety profile, and practical need to verify correct use, for example after starting pharmacological therapy, contact lenses or a new spectacle-lens design. Shorter intervals may be appropriate when initiating a new intervention, checking safety or tolerability, or responding to unexpectedly high axial growth (6).

Every follow-up should ask the same questions: has axial length changed, was the measurement reliable, is adherence sufficient, is ocular health stable, and has the risk profile changed? Axial length should ideally be measured with the same biometer under comparable conditions. A single value should not be over-interpreted, but repeated excessive elongation should not be dismissed. A comparison of optical biometers in children supports intervals of at least six months when assessing progression (18).

The annual trajectory often provides the more robust judgement of control because progression and treatment response may vary across the year (8). Six-month visits remain valuable for safety, adherence and early warning signs. Cycloplegic refraction should be repeated periodically, commonly annually or when findings are inconsistent.

Define success without oversimplifying it

Success is not simply “no change in glasses” or the largest advertised percentage reduction. A more useful definition is axial elongation that is absent, minimal or within an age-appropriate physiological range, together with stable or acceptably slowed refraction and good tolerability.

This avoids two errors. The first is complacency: small refractive change can look reassuring while the eye continues to elongate. The second is panic: some growth is physiological, especially in younger children. Practical thresholds can still help. The IMI report notes that success may be expressed, for example, as less than −0.50 D of progression or less than 0.2 mm of axial elongation in a defined cohort (8). Such values are useful for counselling, but should not be applied identically to a six-year-old and a sixteen-year-old.

For families, time can be an intuitive communication tool: the aim is to slow risk accumulation during the years when the eye is most vulnerable.

When control is inadequate

If elongation remains excessive, the immediate task is to audit the plan before declaring non-response. Was the measurement reliable? Was the same biometer used? Was refraction cycloplegic? Is the orthoptic and accommodative status stable? Is the intervention being used as prescribed? Is wear time sufficient? Was the initial risk level underestimated?

Adherence deserves particular attention. The IMI 2025 report identifies it as a critical determinant of efficacy and notes that self-reported wearing times are vulnerable to bias (8). A child may own an intervention without truly using it. If growth remains excessive despite reliable data and good adherence, management should be adjusted. The details belong in modality-specific articles; the principle is that persistent excessive elongation should trigger action, not resignation.

Stopping is also a decision

Myopia does not stop because a child reaches a particular birthday. Many eyes slow during adolescence, but some continue to progress into later teenage years and early adulthood (19). Treatment may be reduced or stopped when stability is sustained, the child is older, and axial growth has remained low over repeated visits. After stopping, monitoring should continue for at least six to twelve months.

The word "rebound" should also be used carefully. Progression after stopping treatment is not automatically rebound. The IMI definition is stricter: rebound means axial elongation and myopia progression after cessation that are faster than expected in an age-matched untreated myopic group (8). The comparator is not the child’s treated growth rate, but the expected untreated trajectory for a similar child.

Conclusion

Good myopia management is built around timing, measurement, and judgement. Start early. Confirm the diagnosis carefully. Document orthoptic status and posterior-segment anatomy where indicated. Measure axial length. Build longitudinal data, not isolated snapshots. Interpret growth against age-appropriate expectations. Monitor consistently. Act when elongation remains excessive. And communicate honestly with families: the aim is not to promise emmetropia, but to reduce lifetime ocular risk.

This article was prepared by members of the European Myopia Network Council. The European Myopia Network is an open educational and scientific initiative bringing together experts across Europe to support education, prevention, screening, research and evidence-based management of myopia. EMN also supports scientific exchange through the online European Myopia Conference “Myopia 2026” on June 5, 2026.