The use of contact lenses for myopia management represents a fundamental shift in contemporary pediatric eye care. Rather than correcting refractive error alone, modern contact lens designs are intended to slow excessive axial elongation by modifying the optical environment of the eye while maintaining good visual performance (1).

Soft myopia-control lenses and orthokeratology should therefore no longer be regarded simply as alternatives to spectacles. Instead, they should be considered optical interventions designed to influence the retinal cues involved in the regulation of ocular growth. By altering the retinal image profile, these lenses modify the optical signals believed to guide emmetropization and axial eye growth (1-3). Consequently, prescribing extends beyond correcting refractive error to selecting an optical treatment strategy intended to slow excessive axial elongation.

Targeting the retinal image

The rationale for optical myopia control is based on experimental evidence demonstrating that retinal image quality influences ocular growth. Animal studies have consistently shown that retinal defocus can locally regulate eye growth: hyperopic defocus promotes axial elongation, whereas myopic defocus inhibits it (2, 3). Although retinal defocus remains the best-established mechanism, it is now evident that contemporary contact lens designs influence several components of the retinal image simultaneously, including contrast, depth of focus, higher-order aberrations and the spatial distribution of image quality across the retina (1, 4).

Emerging evidence also indicates that the choroid is an active component of the signalling pathway linking retinal image quality to ocular growth. Experimental and clinical studies have demonstrated that myopic defocus induces rapid choroidal thickening, whereas hyperopic defocus results in choroidal thinning. These changes occur within a short period of optical treatment and may precede measurable changes in axial elongation, suggesting that choroidal thickness could become an early biomarker of treatment response (5).

Optical interventions for myopia management are therefore designed to achieve more than clear central vision. Their aim is to create an optical environment that reduces the stimulus for excessive axial elongation while maintaining good visual function. This concept also changes how these lenses should be evaluated clinically. In addition to conventional fitting parameters, such as power, base curve, diameter and replacement schedule, clinicians should consider the optical treatment profile, how power is distributed across the optic zone, how it is influenced by pupil size, lens centration and movement (1, 6).

Importantly, lenses developed for myopia management should not be regarded as interchangeable simply because they share the same clinical objective. Different optical designs employ distinct treatment strategies and therefore generate different retinal image profiles, which may translate into differences in clinical performance and treatment efficacy (1, 7).

Orthokeratology: the first optical intervention for myopia control

The first successful clinical application of optical myopia management was orthokeratology. Using reverse-geometry rigid contact lenses worn overnight, it temporarily reshapes the anterior cornea by flattening the central cornea while steepening the mid-periphery. This allows children to achieve clear unaided daytime vision while simultaneously creating an optical treatment profile designed to slow excessive axial elongation (2).

Orthokeratology should therefore be regarded as an optical treatment rather than simply a method of refractive error correction. Its clinical effectiveness depends not only on the refractive change achieved, but also on the geometry and centration of the treatment zone, the pattern of mid-peripheral corneal steepening and the resulting peripheral refractive profile created by corneal reshaping (1). Consequently, corneal topography serves not merely as a fitting tool but as an objective method of evaluating the optical treatment delivered.

Randomized clinical trials and meta-analyses have consistently shown that orthokeratology slows axial elongation by approximately 40-60% over two years, although considerable inter-individual variability remains (7-9).

Although retinal defocus is widely considered a key component of its mechanism of action, increasing evidence suggests that treatment efficacy results from the interaction of multiple optical and biological mechanisms rather than a single optical effect. Changes in higher-order aberrations, retinal image quality, accommodation, visual behaviour and choroidal responses may all contribute to treatment efficacy.

The clinical objective therefore extends beyond achieving spectacle-free daytime vision. Successful treatment depends on establishing a stable, well-centred corneal treatment profile that delivers a consistent optical treatment signal while maintaining good visual quality over time.

Soft contact lenses: diverse optical strategies for myopia control

Soft myopia-control contact lenses employ different optical strategies to achieve the same therapeutic objective. Their optical architectures differ considerably, reflecting distinct approaches to generating an effective treatment profile.

Dual-focus and concentric-ring lenses combine central distance correction with treatment zones that simultaneously present different focal planes to the retina (10). Centre-distance multifocal lenses, originally developed for presbyopia, have also demonstrated efficacy in slowing myopia progression (11), whereas extended-depth-of-focus (EDOF) lenses employ a fundamentally different optical strategy to manipulate multiple characteristics of the retinal image, including contrast, depth of focus and image quality (1, 12).

These designs should not be viewed simply as variations of the same optical concept. Rather, they represent distinct optical treatment strategies that differ in how they influence the retinal image and, consequently, the biological signals regulating ocular growth (1, 4).Their clinical performance is therefore determined not only by lens design but also by how that design interacts with the optical characteristics of the individual eye.

The intended optical profile of a lens does not necessarily correspond to the optical treatment delivered in clinical practice. Lens centration, pupil size, higher-order aberrations, accommodation, illumination, wearing behavior and visual demands all influence the retinal image experienced by the patient. Consequently, careful fitting and regular follow-up remain essential, as the same lens design may produce different treatment effects in different children (1, 6).

Despite this patient-specific variability, randomized clinical trials and meta-analyses have consistently demonstrated that soft myopia-control contact lenses reduce axial elongation by approximately 30–60%, depending on optical design and treatment profile (10, 12).

^{Table 1: Caption: Representative examples of contact lens options for myopia management in Europe Products are listed as representative examples of contact lens approaches used, developed, or marketed for myopia management in Europe. Conventional multifocal lenses designed primarily for presbyopia are included only where they have been evaluated in myopia-control studies, and should be distinguished from purpose-designed myopia-control lenses.}
 

From optical design to patient care

The success of contact lens-based myopia management depends not only on optical design but also on its effective clinical implementation. Appropriate patient selection, accurate lens fitting, education on lens wear and handling, and regular follow-up are all essential for achieving optimal treatment outcomes. As with any contact lens modality, safety relies on good compliance, appropriate hygiene and the prompt recognition and management of complications, particularly in overnight orthokeratology (13, 14).

Perhaps the most important advance in contemporary myopia management has been the routine incorporation of axial length measurements into clinical practice. Refractive error alone no longer provides a sufficient measure of treatment success, as relatively small refractive changes may mask clinically meaningful differences in axial elongation. Monitoring axial length enables clinicians to determine whether the selected optical intervention is effectively limiting excessive axial elongation and to modify treatment when necessary (2, 7).

If axial elongation exceeds the expected rate, management should extend beyond updating the refractive correction. Wearing compliance and treatment adherence should first be verified, followed by reassessment of lens fit, centration and, in orthokeratology, the characteristics of the corneal treatment zone. Where the response remains suboptimal despite these measures, alternative optical designs or combination therapy, such as low-dose atropine, may be considered for selected patients (14).

Contact lenses have evolved from devices that simply correct refractive error to sophisticated optical interventions for myopia management. Whether achieved through corneal reshaping or purpose-designed soft lens optics, the therapeutic objective remains the same: to slow excessive axial elongation by delivering an effective optical treatment profile (1).

The ability of contact lenses to slow myopia progression is now well established (7-12). The next challenge is no longer simply to demonstrate efficacy, but to understand how optical treatment strategies interact with the anatomical, optical and behavioral characteristics of individual children to influence treatment outcomes (15). Such knowledge will underpin a more personalized approach to myopia management, enabling clinicians to select the most appropriate optical strategy for each child. Ultimately, the future of contact lens-based myopia management lies not only in developing increasingly sophisticated optical designs, but in optimizing their clinical application to support the physiological mechanisms that regulate ocular growth.

The European Myopia Network (EMN) is an open educational and scientific initiative that brings together experts from across the majority of European countries (https://myopianetwork.eu/ ). The network conducts innovative research, shares key developments in myopia through curated educational content, and fosters collaboration among clinicians and researchers.