Practical tips and tricks: Drs Jeffrey J. Walline, Erin Tomiyama weigh in on myopia management

Myopia prevalence continues to rise globally, and with it, clinical pressure on optometrists to intervene earlier and communicate risk more effectively to families. But myopia management is rarely straightforward — questions around when to treat, how to measure success, and how to counsel parents of borderline cases remain common points of uncertainty in practice. In this Q&A, Jeffrey J. Walline, OD, PhD, and Erin Tomiyama, OD, PhD, FAAO, share their clinical approaches to some of the field's most persistent challenges, from selecting the right treatment modality to defining meaningful outcomes for individual patients.

Transcript

Edited lightly for clarity and length.

How do you approach the “borderline” child with slow progression—treat or wait?

Jeffrey J. Walline, OD, PhD: Past progression does not predict the rate of future progression at all, so I strongly believe that the parents of all myopic children younger than 16 years (the typical age myopia progression ends) should at least be educated on the benefits of myopia control.

Erin Tomiyama, OD, PhD, FAAO: We know that prior progression does not always predict future progression, so I generally recommend treatment for any child who is already myopic. With the growing emphasis on pre-myopia, we are also initiating conversations about myopia management in low hyperopic children who present with associated risk factors. This allows families to better understand risk profiles and potential management strategies before myopia onset.

What language or visuals help parents understand long-term risks (ie, retinal detachment, myopic maculopathy)?

Walline: The most basic message to tell parents is, “Reducing the amount of myopia as an adult reduces the chance of having poor vision even when wearing glasses or contact lenses.” From there, you can tailor the message for the individual, depending on their level of understanding and expertise.

Tomiyama: When discussing long-term risks, I focus on the common ocular diseases associated with higher levels of myopia, including cataracts, glaucoma, retinal detachment, and myopic maculopathy. Most parents are already familiar with these conditions, even if they do not fully understand the underlying pathophysiology. Framing the conversation around preserving long-term vision, ocular health, and quality of life tends to resonate well and helps families understand that myopia management is about more than just reducing dependence on glasses.

How do you interpret variability in refraction or axial length over time?

Tomiyama: Accurate and precise measurements are critical, while also recognizing the practical challenges of testing young children. For refractive error, we use cycloplegic autorefraction to minimize accommodative responses and provide a more objective assessment. For axial length, we obtain multiple measurements so we can evaluate repeatability and calculate standard deviation. This helps us determine whether observed changes represent true progression versus expected instrument or measurement variability.

Walline: I tell parents that on average children progress faster in the winter and slower with age, but it is impossible to predict how fast a child will progress or even know how well the treatment is working for an individual child. All we can say is that on average, this treatment is expected to slow myopia progression or eye growth by a given percentage and that none of them really work meaningfully better than another.

How would you suggest ODs choose between atropine, orthokeratology, soft multifocal lenses, or spectacle options?

Walline: We can’t predict which treatment will work the best for any individual child, but we know that the treatment is only effective if the child uses it. The choice of treatment should be made based on the treatment that best fits the child’s lifestyle and improves compliance.

Tomiyama: The most important consideration is selecting a treatment that both the patient and family are willing and able to consistently adhere to. Beyond that, we individualize recommendations based on lifestyle factors, visual demands, and family preferences. We discuss considerations such as sports participation, near work demands, comfort with contact lens wear, and the level of parental involvement desired for daily tasks such as lens application or drop instillation.

For ODs that have myopia management programs, what would metrics would you suggest to be used to define “success”?

Tomiyama: The primary metric we use to define success is axial length progression. Monitoring axial elongation over time, particularly in the context of a patient’s age and ethnicity, allows us to compare outcomes against published growth curves and normative data. While changes in refractive error can help support whether a treatment is effective, refractive measurements tend to be less precise and more variable than axial length. Ultimately, the goal of myopia management is to slow axial elongation, as this is a direct assessment of the structural changes associated with increased risk of ocular pathology later in life.

Walline: Based on what we know today, it is impossible to determine the effectiveness of a treatment for any given individual patient. Therefore, success should be defined by the patient’s compliance and comfort with the treatment regimen.

What’s a common mistake clinicians make when starting myopia management?

Walline: The most common mistake for clinicians starting myopia management is to believe that success is defined by stopping eye growth. Even emmetropic eyes grow in a coordinated fashion, so we must realize that all we can do is provide a treatment and encourage compliance for best results.

Tomiyama: One of the most common mistakes is offering myopia management without the appropriate instrumentation, monitoring protocols, and follow-up structure in place. Effective myopia management requires more than simply prescribing a treatment modality. Axial length measurements should ideally be obtained at least every 6 months to accurately monitor progression. Successful myopia management depends on the ability to detect progression early, assess treatment efficacy, and make evidence-based adjustments over time.