AOA 2026: Puzzling cases in myopia management

Langis Michaud, OD, MSc, FAAO, FSLS, FBCLA, FEAOO, from the University of Montreal School of Optometry discussed contemporary understanding and practical management of myopia, with a special focus on challenging pediatric cases. He emphasized that myopia development is driven by retinal regulation of eye growth in response to image quality. Multiple optical factors—such as defocus, contrast, spherical aberrations, and chromatic aberrations—interact to influence this process. Because the retina responds to the quality of the image delivered by optical devices, clinicians can actively manage myopia by optimizing that image quality rather than relying on traditional single-vision correction.

A central message is that myopia management must be individualized. The straightforward -2 D child in single-vision lenses is less of a challenge than syndromic myopia, very early onset high myopia (eg, −6 D at 3 years old), significant astigmatism, or patients who continue to progress despite evidence-based interventions. For these complex cases, Michaud advocates careful case-by-case analysis and a stepwise approach: introduce changes one at a time to determine which interventions are truly effective.

He strongly recommends axial length (AL) measurement as the standard metric to monitor progression, likening it to glaucoma care where clinicians do not rely on intraocular pressure alone but incorporate visual field and structural assessments. Refraction is excellent for diagnosing myopia but suboptimal as the primary measure of disease evolution and treatment efficacy.

Compliance emerges as a critical determinant of success. Michaud noted that orthokeratology, soft multifocal contact lenses, and anti-myopia glasses can be broadly equivalent in effect, but poor adherence can negate any benefit. He illustrated this with a child prescribed atropine who continued to progress because she was applying drops to closed eyelids rather than into the eye. Simple, targeted checks on real-world use of devices and drops should be part of every follow-up.

Environmental and lifestyle factors also complicate management. In hot climates like Phoenix, Arizona, where AOA 2026 is being held from June 17-20, standard advice of prolonged outdoor exposure may be impractical, requiring clinicians to adapt recommendations while still promoting healthy visual habits. Michaud cautions that rapidly progressing myopes cannot be stabilized over just a few months; evaluation must be long-term and iterative.

Finally, he urged practitioners not to delay intervention, even in low myopia. Waiting “to see how it goes” risks losing the window to meaningfully influence long-term outcomes. He is unequivocal that single-vision glasses for children with myopia are no longer acceptable as stand-alone treatment, likening them to “sugar for diabetic patients” or “a pack of cigarettes for asthmatic patients.” Instead, clinicians should promptly implement evidence-based myopia control strategies to help prevent future pathology.