An Australian Optometrist’s Perspective on Choosing Myopia Treatment

The evolution of treatment selection with increasing options.

Dr. Mark Joung

The growing prevalence of childhood myopia has prompted a welcome expansion in evidence-based interventions. Orthokeratology, peripheral defocus spectacle lenses, soft multifocal contact lenses, and low-dose atropine each demonstrate efficacy in slowing myopia progression. However, the availability of multiple modalities introduces a challenge that is often underappreciated: no single intervention suits every child, and appropriate treatment selection requires careful consideration of several interdependent factors.

Axial Length as the Foundation

Axial Length as the Foundation

In contemporary myopia management, refraction alone provides an incomplete picture of risk. Two children presenting at −1.50 dioptres may follow vastly different courses depending on their rate of axial elongation. A child whose axial length tracks above the 75th centile for their age warrants a more assertive approach than one whose growth is stable, even at the same refractive endpoint.

Optical biometry and centile charts allow clinicians to identify accelerating eye growth before substantial myopia develops, and to monitor intervention efficacy over time. Without biometric data, treatment decisions are necessarily less precise.

Pre-Myopia: An Under-Recognised Opportunity in Australia

The International Myopia Institute defines pre-myopia as a refractive state of +0.75 D or less where risk factors increase the likelihood of future myopia development (Flitcroft et al., 2019). In Australian practice, routine identification of pre-myopia remains uncommon. Many children present only when heavily symptomatic, with a prescription of approximately −1.50 D or greater and miss the opportunity for early intervention.

The evidence for early monitoring is becoming increasingly specific. The Singapore Cohort Study of Risk Factors for Myopia (SCORM) found that myopia onset tended to occur at a similar axial length regardless of age — approximately 24.0 mm in boys and 23.7 mm in girls (Saw et al., 2005). The CLEERE study identified axial length growth exceeding 0.2 mm per year as an indicator of impending myopia onset (Mutti et al., 2007). These thresholds provide clinicians with actionable benchmarks for identifying at-risk children before manifest myopia develops — provided axial length monitoring is part of routine paediatric care.

Matching Treatment to the Child

Once a decision to intervene has been made, the choice of modality depends on several interacting factors.

Age and maturity. A young child with rapid axial elongation may be well suited to myopia control spectacle lenses employing DIMS technology (~60% slowing; Lam et al., 2020) or H.A.L.T. technology (67%; Bao et al., 2022), with or without adjunctive low-dose atropine. Contact lens options require handling competence and hygiene compliance that cannot be assumed at any age — some six-year-olds manage orthokeratology capably, while some twelve-year-olds do not.

Refractive status. Children with low myopia are generally better served by myopia control spectacle lenses, soft multifocal contact lenses such as MiSight, or atropine, as achieving sufficient peripheral myopic defocus with orthokeratology is more challenging at lower prescriptions. Conversely, children with moderate to high myopia may be better suited to orthokeratology, MiSight, or atropine, as spectacle-based myopia control lenses at higher prescriptions present practical challenges — thicker lenses and associated fitting issues can compromise both comfort and efficacy.

Contact lens preference. Parents are increasingly seeking glasses-free solutions for their children and contact lens-based options such as MiSight and orthokeratology are becoming more popular, particularly among older children for whom lens handling is feasible. It’s also important to note that, with orthokeratology, biometry is essential as the spectacle prescription can no longer be measured.

Rate of progression. In cases of rapid axial elongation despite single-modality treatment, combination therapy warrants consideration. The LAMP study demonstrated atropine efficacy at 0.05%, 0.025%, and 0.01%, with a dose-dependent response (Yam et al., 2019).

Next-Generation Spectacle Lenses: Promise and Prudence

The spectacle lens landscape is evolving rapidly. Essilor Stellest 2.0, employing H.A.L.T. MAX technology, launched in Australia in 2026. HOYA’s MiyoSmart IQ is expected to follow. Both report improved efficacy in slowing axial elongation compared with their predecessors.

However, clinicians should note that the evidence base for these designs currently rests on twelve months of data or less. Stellest 2.0 was evaluated in a one-year contralateral crossover study of 50 children (Raveendran et al., 2025). MiyoSmart IQ twelve-month data from 196 children was presented at ARVO 2026. These are encouraging but early results. The original MiyoSmart and Stellest lenses, by contrast, are supported by multi-year follow-up. Practitioners recommending newer designs should communicate this distinction to families.

The Atropine Landscape in Australia

Australia is well positioned with respect to low-dose atropine access. Eikance 0.01% (Aspen Pharmacare) received TGA registration in 2021, and Eikance 0.025% was registered in February 2026, providing commercially manufactured options alongside compounded formulations. A TGA-registered product may alleviate concerns some parents hold regarding off-label prescribing, though concentration selection should remain guided by the child’s progression profile rather than product availability alone.

With compounded formulations, there have been incidents (in New South Wales, for example) of the wrong dosage of Atropine being administered, including 0.1% and even 1.0% in some cases. The TGA-registered products provide an extra level of safety against this error occurring.

Conclusion

Treatment selection in myopia management is not a linear algorithm. It is a considered clinical judgement integrating biometric data, developmental readiness, family preferences, and an evolving evidence base. The clinician’s role is to guide families through shared decision-making — where realistic expectations and honest communication about the limitations of current evidence are as important as the intervention itself.

References

1. Bao J, Huang Y, Li H, et al. Spectacle lenses with aspherical lenslets for myopia control vs single-vision spectacle lenses: a randomized clinical trial. JAMA Ophthalmol. 2022;140(5):472-478.

2. Flitcroft DI, He M, Jonas JB, et al. IMI – Defining and classifying myopia. Invest Ophthalmol Vis Sci. 2019;60(3):M20-M30.

3. Lam CSY, Tang WC, Tse DY, et al. Defocus Incorporated Multiple Segments (DIMS) spectacle lenses slow myopia progression: a 2-year randomised clinical trial. Br J Ophthalmol. 2020;104(3):363-368.

4. Mutti DO, Hayes JR, Mitchell GL, et al. Refractive error, axial length, and relative peripheral refractive error before and after the onset of myopia. Invest Ophthalmol Vis Sci. 2007;48(6):2510-2519.

5. Raveendran RN, Ong WS, Drobe B, et al. Effect of increased power and asphericity of highly aspherical lenslets on myopia control efficacy: a contralateral crossover study. Transl Vis Sci Technol. 2025;14(11):9.

6. Saw SM, Tong L, Chua WH, et al. Incidence and progression of myopia in Singaporean school children. Invest Ophthalmol Vis Sci. 2005;46(1):51-57.

7. Yam JC, Jiang Y, Tang SM, et al. Low-Concentration Atropine for Myopia Progression (LAMP) study. Ophthalmology. 2019;126(1):113-124.

 

About the Author

Dr Mark Joung is the principal optometrist at Concord Eyecare in Sydney, Australia, where he leads the Myopia Clinic — a dedicated paediatric myopia management service offering all four evidence-based treatment modalities. His clinical focus is on axial length-guided treatment planning and early intervention for children at risk of progressive myopia.