An Eye on IMI: The Latest on Myopia Control

IMI – interventions for controlling myopia onset and progression 20251 confirms that myopia management is now an evidence-based standard of care, with multiple effective treatment categories available. The review focused on mature interventions – those with randomised controlled trials, concurrent controls, axial length outcomes, and long-term follow-up.

Axial Length: Central to Judging Efficacy

As evidence and awareness for myopia control increases, the IMI emphasised that efficacy should be judged by both refractive progression in dioptres, and where possible, axial elongation in millimetres, with axial length given increasing importance compared to the past.

Efficacy is also time-dependent, so one-year and two-year results should not be directly compared without considering treatment duration.

Myopia Control: Spectacle Lenses

Modern myopia control spectacle lenses now have stronger clinical evidence than earlier generations. The IMI identified 10 randomised clinical trials, with some spectacle lens designs showing efficacy of up to 0.35 mm reduction in axial elongation over two years. Beyond the time of print of the IMI, there have also been new generations of myopia control spectacle lenses that offer even better control for myopia.

Clinical implication. Spectacle lenses are a legitimate first-line option, particularly for younger children, children not ready for contact lenses, or families wanting a lower-maintenance intervention.

Soft Multifocal / Dual-Focus Contact Lenses

Soft contact lenses with more than one focal power were evaluated across 14 randomised clinical trials. Reported efficacy was up to 0.19 mm over one year and 0.28 mm over three years.

Clinical implication. Soft myopia-control contact lenses remain a strong option for motivated children and families, especially where lifestyle, sport, cosmesis, or daytime correction are important.

Orthokeratology: Consistently Effective

Orthokeratology (OK) showed high consistent outcomes across 10 randomised clinical trials. Median efficacy was 0.17 mm at one year and 0.30 mm at two years for slowing axial elongation.

Clinical implication. OK remains one of the stronger evidence-based options, especially for children who want spectacle-free daytime vision, but it requires careful fitting, compliance, hygiene, and risk management.

Atropine: Dose Matters

The IMI noted that 21 randomised clinical trials of 0.01% atropine have been published since 2019. Median efficacy for 0.01% atropine was 0.08 mm at one year and 0.12 mm at two years. Higher concentrations showed stronger efficacy, with some two-year outcomes reaching up to 0.50 mm.

Clinical implication. 0.01% atropine has a modest axial-length effect compared with some optical treatments. Higher concentrations may be more effective, but clinicians must balance efficacy against photophobia, near blur, adherence, availability, and rebound risk.

Combination Therapy

Combination therapy, the IMI noted, is promising, but the evidence remains narrower. The strongest combination evidence currently relates to OK plus 0.01% atropine. Five randomised trials were identified, with two-year data suggesting that adding atropine to OK increased efficacy by a median of 0.12 mm.

Clinical implication. Combination therapy is reasonable for higher-risk or faster-progressing children, but the evidence base is still more limited than for single established modalities.

Red-Light Therapy: Cautiously Promising

Repeated low-level red-light therapy (RLRL) showed the highest reported efficacy in the review, with a median one-year effect of 0.40 mm reduction in axial elongation; greater than other treatment categories reviewed. As a new treatment, close monitoring is advised to ensure no adverse effects.

Clinical implication. RLRL is highly promising, but as an emerging treatment, it should be approached with close monitoring to ensure its safety. Although the IMI stated practitioners should adopt a cautious approach to RLRL therapy, and it needs more investigation on safety, other extensive studies have shown that it has an extremely robust safety profile. For RLRL therapy, monitor retinal and foveal changes with optical coherence tomography. Patient compliance and long-term retinal safety must be closely monitored by eye care practitioners. Practitioners should also note that RLRL therapy is contraindicated in conjunction with atropine.

Outdoor Time

For children at risk of becoming myopic, increased outdoor time reduced incident myopia by up to a 9% absolute reduction in randomised trials. The IMI also noted that 0.05% atropine reduced the likelihood of becoming myopic by about half over two years in one randomised clinical trial.

Every child should receive lifestyle advice, regardless of the chosen treatment.

The IMI guidelines support assessing visual environment, including near work and outdoor exposure, as part of clinical myopia management.

Clinical implication. Lifestyle advice remains essential, especially before onset.

Recommend:

• Increase outdoor time where possible, ideally around two hours daily,
• Avoid prolonged uninterrupted near work.
• Encourage breaks during reading and device use,
• Maintain a longer working distance,
• Improve lighting for reading and study.
• Balance academic, recreational, sleep, and outdoor routines, and
• Review general wellbeing, sport, and family habits.

Rebound Differs by Modality

The IMI reported no evidence of rebound for myopia-control spectacles and soft contact lenses, consistent with prior IMI statements. In contrast, five of the six highest rebound values were reported in studies of atropine or RLRL.

Clinical implication. Stopping treatment needs to be managed thoughtfully, especially with atropine and possibly RLRL. Tapering, age, stability, and ongoing axial length monitoring matter.

The Ethical Threshold has Shifted

One of the strongest messages is that, because multiple effective options now exist, a clear discussion of myopia control is the new minimum standard of care from an eye care practitioner. Withholding proactive treatment from myopic children is no longer considered acceptable.

Practical Clinical Takeaways

The 2025 IMI paper supports a proactive, risk-based approach:

Low to moderate risk. Myopia-control spectacle lenses or soft myopia-control contact lenses, plus lifestyle advice.

Moderate to high risk/faster progression. OK, higher-efficacy spectacle or contact lens designs, or atropine depending on age, lifestyle, ocular surface, binocular vision, and family preference.

High risk/rapid axial elongation. Consider combination therapy, especially OK plus atropine, with careful monitoring.

Emerging/high-efficacy option. RLRL therapy may be powerful, but close monitoring and informed consent are essential.

Table 1. Myopia management options, according to age and risk factors.