In theory, the volume of the choroid at age 12 to 14 is the best predictor of the development of maculopathy and high myopia at a more advanced age. However, in practical clinical terms, it is not easy to evaluate. The next best predictor then becomes the axial length (AL) measurement and, certainly, not refractive error. AL as an easy data to acquire should dictate clinical decisions regarding the management of myopia, stressed Drs. Langis Michaud, Remy Marcote-Collard, and Patrick Simard, during their lecture at the 2026 Global Specialty Lens Symposium. The reason: AL translates the eye’s growth, which impacts myopia progression sometimes years later and, thus, the patient’s risk of eye diseases, such as glaucoma, retinal detachment, etc. To acquire AL and manage myopia effectively, the lecturers suggested the following course of action.
Establish the Baseline AL
The presenters advised attendees to establish a baseline AL measurement at the patient’s first visit, compare it to published age-based growth charts, and recheck it every 6 months (even sooner for patients whose myopia is progressing fast) for progressive eye length.
Regarding initial treatment, all methods being equally efficient, the pupil diameter must be an important factor to consider. As a fair percentage (50% to 60% minimum) of the pupil must be covered by defocus optics (plus power ratio [PPR]). Smaller pupils may be better fitted with dual-focus or other myopia management soft lenses, if customizing orthokeratology (ortho-k) lenses with software is not possible. Younger children must be exposed to a higher defocus dose to be better controlled. A high add is then mandatory for them. Atropine may help to dilate the pupil and to improve PPR.
Take Immediate Action
The goal to manage the myopic patient is to mimic emmetropic eye growth. This means an average progression of 0.2 mm/year (< 10-12 years), 0.1 mm/year (12-16 years), and no evolution after. When this target is not achieved, the strategy must be reviewed and a second one added, or the method changed (from contact lenses to glasses or from soft lenses to ortho-k, etc.). Since patients' responses are individual and depend on a threshold, what is appropriate for one person may be ineffective for another and vice versa.
For example, when optical interventions fall short, the lecturers explained that eyecare providers are finding success low-dose atropine—typically 0.05% (< 12 years) or 0.025% (>12 years)—while avoiding 0.01% found inefficient in most cases, especially when used as monotherapy in children < 10 years. Adjustments must be made accordingly since atropine may freeze the diopters while axial length is still growing uncontrolled. Another good reason to monitor AL instead of the refraction.
"A colleague may be completely misled by the fact that they are assessing stability or progression solely on the basis of refraction," Dr. Langis said. "Axial length may continue to progress uncontrolled, yet refraction may barely change at the same time. It will follow later, but it will be too late to react. It's like treating glaucoma solely by relying on intraocular pressure without looking at the optic nerve, the irido-corneal angle, or visual fields. Half of these glaucoma cases would become legally blind before we had time to react. The same applies to axial length. It is simply the metric to evaluate myopia progression and its associated risk."
Drs. Michaud, Marcote-Collard, and Simard also provided education on needed binocular vision assessments before implementing myopia management strategy (particularly in cases of intermittent exotropia, convergence insufficiency or excess), and patient behavior and lifestyle modifications (eg, 90 minutes of daily outdoor time, physical exercise, healthy diet, etc). Further, they stressed the importance of frequent follow-ups to assess and instill patient compliance.