Introduction
The IMI provides biennial white papers to offer evidence-based consensus guidance that is both scientifically rigorous and clinically practical. The accompanying Digests offer targeted updates on topics from earlier white papers. The 2025 Digest1 presents focused updates in six areas: definitions and classification of myopia, clinical management guidelines, risk factors, accommodation and binocular vision, experimental models, and onset and progression in young adults.
Two areas are covered in this section including pre-myopia and a new consensus nomenclature for surgical retinal conditions.
Pre-myopia: Hyperopic reserve has become a primary focus in pre-myopia research, with cycloplegic spherical equivalent error established as the single best predictor of myopia onset.2-7 Hyperopic reserve refers to the age-appropriate level of hyperopia that offers a protective buffer against the development of myopia, with higher levels required at younger ages to reduce the risk. Evidence suggests that Asian children may require a greater hyperopic reserve than children of other populations to reduce their risk of developing myopia.8 9
Evidence supports preventative interventions in pre-myopic children. Outdoor time remains a strongest protective factor, while emerging data show potential benefits of low-dose atropine, repeated low-level red-light therapy, and novel spectacle designs for delaying onset.
Retinal nomenclature: An international expert panel has developed a new OCT-based classification system for Myopic Traction Maculopathy to standardize diagnosis, monitor disease progression, and guide management. This framework improves consistency in both clinical care and research reporting.
Clinical management guidelines
This section highlights four key areas:
Preventative management: Delaying onset is critical, with each year of delay comparable to 2–3 years of treatment with current modalities.10 While prevention offers clear long-term benefits, clinicians must weigh potential treatment risks and costs against uncertain outcomes in pre-myopic children, taking into account individual risk profiles, motivation, lifestyle, and resources.
Proactive management: Stronger evidence and global consensus have established proactive myopia management as the standard of care to reduce long-term vision and quality-of-life risks. Long-term studies confirm safety and sustained efficacy of optical interventions (e.g., dual-focus contact lenses, and peripheral defocus/contrast reduction spectacle lenses), with no rebound. Treatment selection should be personalized, with optical interventions often considered first-line due to their dual role in vision correction and myopia control. Patient experience and adherence to treatment remain central to optimizing outcomes, underscoring the importance of shared, informed decision-making.
Understanding treatment efficacy: New approaches incorporate comparisons with emmetropic growth patterns to distinguish physiological from abnormal elongation. These provide useful clinical context, though randomized controlled trials (RCTs) remain the gold standard. Future studies are encouraged to use established myopia control comparators rather than single vision lenses in their control groups.
Long-term management: Success is defined by slowed progression, sustained safety, good vision, quality of life, and treatment acceptance. Monitoring with cycloplegic refraction and axial length (where available) is essential, alongside ocular health surveillance given the strong association between axial length and morbidity. Recent longitudinal studies from Asia highlight the early onset of retinal changes in high myopia and the role of tessellated fundus as an early marker of myopic macular degeneration. Proactive retinal monitoring, even in younger patients, is therefore a core component of long-term care.
Risk factors for myopia
Beyond RCTs, newer analytic approaches have strengthened causal evidence linking environmental exposures with myopia development.
Education versus age: Studies from China show that school grade, rather than chronological age, correlates most strongly with refractive error,11 12 reinforcing the environmental impact of educational exposure.
Time outdoors: Remains the most reliable protective factor supported by extensive observational evidence and RCTs.13 14 In Taiwan, policies promoting outdoor activity during school hours have been associated with stabilization or reversal of prevalence trends, as shown in population-based surveys and school studies.15-17 The COVID-19 lockdowns offered further evidence, with sharp increases in myopia among younger children when outdoor activity was curtailed,18-26 except where structured outdoor exposure was preserved.17 27
Near work and screen use: Screen use from television to smartphones has been linked with myopia in some studies, but findings remain inconsistent28 29 and it is unclear whether digital devices pose a greater risk than other forms of near work. Importantly, the rise in myopia in East Asia predated widespread device use,30 31 suggesting that reducing screen time alone is unlikely to impact prevalence without increasing outdoor activity.
Sleep: studies to date have examined associations between myopia and short or insufficient sleep duration, late bedtimes, delayed wake times, and sleep disturbances. However, findings to date are inconsistent.32-40
Accommodation and binocular vision
Current evidence indicates that changes in accommodative and binocular function with myopia control interventions are minimal and not associated with progression. While short-term studies suggest optical treatments (e.g., multifocal contact lenses, orthokeratology) can alter accommodation or vergence, long-term trials in children show these effects stabilize and do not impair function. Atropine at low concentrations has negligible impact.
Experimental models of emmetropization and myopia
Recent animal studies have expanded understanding of emmetropization and myopia, with models ranging from mice to primates. Findings reinforce the importance of light characteristics, with spectral composition, flicker, and spatial frequency all influencing eye growth, though results vary by species. Novel opsins (OPN3, OPN4, OPN5) have been implicated in non-image-forming pathways, highlighting potential links between circadian regulation, dopamine, and refractive development. The choroid and sclera are increasingly recognized as key sites of signaling and remodeling, with inflammation and extracellular matrix changes identified as potential therapeutic targets. These insights provide biological plausibility for clinical observations and help direct future translational therapies.
Onset and progression of myopia in young adults
Longitudinal and clinic-based data confirm that while most adults myopia remains stable, a proportion of young adults continue to progress. Average progression rates are modest (≈ –0.05 to –0.25 D/year), but progression is more common in academic environments and in high myopes, with cumulative shifts of up to –1 D reported between ages 20 and 50. Risk factors include baseline myopia, female sex, lower sun exposure, greater screen time, and genetic susceptibility. Clinically, ongoing monitoring into early adulthood is warranted, especially for higher-risk patients.
CONCLUSION
The IMI 2025 Digest emphasizes earlier identification and prevention, particularly through assessing hyperopic reserve and promoting outdoor time. Evidence supports proactive, individualized myopia management with safe, effective optical interventions. Accommodative and binocular vision effects of myopia control are minimal. Experimental models highlight new light-mediated and molecular mechanisms, and data confirm that some young adults, especially high myopes, continue to progress. Together, these updates reinforce a proactive, lifelong approach to myopia care.
ACKNOWLEDGMENTS
This IMI White Paper was summarised by Dr Nina Tahhan. A full list of the IMI taskforce members and the complete IMI white papers can be found at myopiainstitute.org. The publication and dissemination costs of the International Myopia Institute reports were supported by donations from the Brien Holden Vision Institute, Carl Zeiss Vision, CooperVision, EssilorLuxottica, Hoya, Thea, Alcon, and Oculus.
CORRESPONDENCE
Brien Holden Vision Institute Ltd
Level 4, North Wing, Rupert Myers Building, Gate 14 Barker Street,
University of New South Wales, UNSW NSW 2052
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