What are the treatment options for myopia (nearsightedness)?

Treatment Options for Myopia

The primary treatment options for myopia include optical correction with eyeglasses, contact lenses, or refractive surgery for symptomatic correction, while children with progressive myopia should receive myopia control interventions including low-dose atropine (0.01-0.05%), multifocal contact lenses (particularly FDA-approved MiSight), or orthokeratology, combined with increased outdoor time. 1, 2

Optical Correction for Symptomatic Myopia

Standard Correction Methods

• Eyeglasses remain the safest and most straightforward option for correcting myopic refractive error in patients of all ages 1
• Contact lenses provide an alternative, with daily disposable lenses having the lowest rate of adverse events of any soft lens type 1, 2
• Refractive surgery (LASIK, PRK) is appropriate for adults seeking permanent correction, with LASIK having performed over 13 million procedures in the United States 1

Contact Lens Safety Considerations

• Extended (overnight) wear increases infection risk regardless of lens type, including newer silicone hydrogel lenses, and this risk must be discussed with patients 1
• Hydrogen peroxide disinfection systems have the lowest adverse event rates compared to multipurpose solutions 1
• Rigid gas-permeable lenses continue to have the lowest complication rates overall, though patient discomfort limits their use 1

Myopia Control in Children (Slowing Progression)

First-Line Interventions for Progressive Myopia

The combination of low-dose atropine (0.01-0.05%) plus multifocal daily disposable contact lenses (MiSight) provides maximum benefit for children who can safely handle contact lenses 2. This approach addresses both pharmacological and optical mechanisms of myopia progression.

• MiSight daily disposable soft contact lenses are FDA-approved and have demonstrated safety without complications during 6 years of monitoring in children aged 8-12 years 2
• Low-dose atropine (0.01-0.05%) provides effective myopia control with far fewer cycloplegic and mydriatic side effects than 1.0% atropine 3, 4
• Orthokeratology is an alternative option for compliant children who can maintain proper lens hygiene, though it carries microbial keratitis risk similar to other overnight contact lens wear 1, 2

Environmental Modifications

• Increasing outdoor time to at least 1-2 hours daily reduces myopia progression in children already myopic and can delay myopia onset in at-risk children 1, 2
• Outdoor time is more effective for preventing myopia onset than slowing existing progression, but remains a valuable adjunctive measure 3, 4

Efficacy Hierarchy

The evidence demonstrates a clear hierarchy of effectiveness: atropine provides the highest efficacy, orthokeratology and peripheral defocus contact/spectacle lenses provide moderate efficacy (approximately 40-50% slowing), and increased outdoor activities provide lower but meaningful efficacy 5, 3, 6.

Refractive Surgery Options

Photorefractive Keratectomy (PRK)

• PRK is most predictable for low to moderate myopia (less than 6.00 D), with 70% achieving 20/20 uncorrected vision and 92% achieving 20/40 at 12+ months 1
• Wavefront-guided PRK achieves 81% of patients at 20/20 or better, with excellent long-term safety over 10-12 years 1
• Mitomycin-C is used off-label to reduce corneal haze risk, particularly for high corrections or eyes with prior corneal surgery 1

LASIK Considerations

• LASIK provides faster visual recovery than PRK (88% vs 48% at 20/20 at 1 month), though outcomes equalize by 6 months (92% vs 94%) 1
• Over 13 million LASIK procedures have been performed in the United States with established safety profiles 1

Orthokeratology for Temporary Correction

• Overnight orthokeratology using reverse-geometry rigid gas-permeable lenses can temporarily reduce up to 6.00 D of myopia (with up to 1.75 D astigmatism) 1
• The effect reverses when lens wear stops, requiring nightly or every-other-night use to maintain correction 1
• Microbial keratitis risk is similar to other overnight contact lens modalities, with Acanthamoeba keratitis particularly concerning when tap water is used in care regimens 1

Interventions to Avoid (Ineffective or Harmful)

Proven Ineffective Approaches

• Pressure-lowering eyedrops (timolol) do not retard myopia progression and are not recommended 1, 2
• Visual training exercises (near-far focusing) lack scientifically acceptable evidence of clinical effectiveness 1, 2
• Acupuncture has insufficient evidence, with no conclusions possible from Cochrane review 1, 2
• Nutritional interventions remain largely anecdotal without scientifically valid studies 1, 2
• Undercorrection of myopic refractive error is ineffective for myopia control 3

Clinical Decision Algorithm

For Children with Progressive Myopia:

1. Start with low-dose atropine (0.01-0.05%) combined with MiSight multifocal daily disposable contact lenses if the child can safely handle lenses (typically age 8+) 2
2. If contact lenses are not feasible, consider orthokeratology for compliant families who understand infection risks 2
3. Add environmental modification: prescribe 1-2 hours daily outdoor time regardless of other interventions 2
4. Avoid bifocal/progressive spectacles as monotherapy, as efficacy is lower than other options 5, 3

For Adults Seeking Permanent Correction:

1. Offer LASIK for faster recovery in appropriate candidates with adequate corneal thickness 1
2. Offer PRK for thinner corneas or patients preferring surface ablation, accepting slower initial recovery 1
3. Reserve orthokeratology for those wanting reversible, non-surgical correction who accept nightly lens wear 1

Critical Pitfalls to Avoid

• Never prescribe extended (overnight) wear soft contact lenses without thoroughly discussing increased infection risk, as this applies even to highly gas-permeable silicone hydrogel lenses 1
• Do not use tap water in orthokeratology lens care regimens due to Acanthamoeba keratitis risk 1
• Avoid recommending ineffective interventions (visual training, undercorrection, nutritional supplements) that waste time and resources while myopia progresses 1, 2, 3
• Counsel patients with high myopia (≥6.00 D) about increased risk of retinal detachment, choroidal neovascularization, glaucoma, and macular degeneration 1, 4, 7

Quality of Life Considerations

• Myopia significantly reduces vision-related quality of life, with high myopia (≥10.00 D) causing substantially worse outcomes than lower myopia 1
• Uncorrected refractive error is the leading cause of moderate to severe visual impairment globally (52% of cases), emphasizing the importance of accessible correction 1
• Refractive correction improves quality of life measures across all age groups when properly implemented 1