Practical tips and tricks: Myopia management advice for peers

Managing myopia in pediatric patients involves decisions that extend well beyond updating a glasses prescription. As rates of myopia continue to rise globally, clinicians face increasingly complex questions about when to intervene, how to communicate risk to families, and how to measure whether treatment is working. In the following Q&A, Erin Tomiyama, OD, PhD, FAAO, addresses the practical challenges that arise in everyday clinical practice — from handling borderline cases and interpreting measurement variability to selecting among treatment options and defining what success actually looks like.

Transcript

Edited lightly for clarity and length.

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

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)?

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.

How do you choose between atropine, orthokeratology, soft multifocal lenses, or spectacle options?

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.

What metrics define “success” in your myopia management program?

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.

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

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.