Clinical Scorecard: Myopia Management: Focus on Axial Length Measurement, Not Refractive Error

At a Glance

Key Highlights

• Baseline axial length measurement at first visit is critical for myopia management decisions.
• Axial length progression is a more reliable indicator than refractive error for monitoring myopia progression.
• Management strategies should be tailored based on pupil size, age, and individual response, including optical and pharmacologic interventions.

Guideline-Based Recommendations

Diagnosis

• Establish baseline axial length measurement at initial visit.
• Compare axial length to published age-based growth charts.
• Perform binocular vision assessments before initiating myopia management.

Management

• Recheck axial length every 6 months or sooner for fast progressors.
• Use defocus optics covering at least 50-60% of pupil diameter; consider pupil size when selecting lens type.
• Younger children require higher defocus dose (high add power).
• Consider low-dose atropine (0.05% for <12 years, 0.025% for >12 years) when optical methods are insufficient.
• Adjust treatment strategy if axial length progression targets are not met, including combining or switching methods.

Monitoring & Follow-up

• Monitor axial length progression rather than relying solely on refractive error changes.
• Frequent follow-ups to assess compliance and treatment efficacy.
• Evaluate binocular vision status regularly.

Risks

• Uncontrolled axial length growth increases risk of glaucoma, retinal detachment, and maculopathy.
• Relying solely on refractive error may delay detection of progression and risk.
• Low-dose atropine may freeze diopters but not axial length growth, necessitating axial length monitoring.

Patient & Prescribing Data

Children and adolescents with progressing myopia

Optical interventions must cover sufficient pupil area; atropine dosing varies by age and is more effective than very low doses; individualized treatment adjustments are essential.

Clinical Best Practices

• Use axial length as the primary metric to evaluate myopia progression and associated risks.
• Establish and monitor axial length baseline and progression regularly.
• Customize myopia management based on pupil size, age, and binocular vision status.
• Incorporate lifestyle modifications such as daily outdoor time and physical exercise.
• Ensure frequent follow-ups to monitor treatment response and patient compliance.

References

• 2026 Global Specialty Lens Symposium Lecture by Drs. Michaud, Marcote-Collard, and Simard