Myopia Management
Evidence-based clinical pathway for comprehensive myopia management in Singapore, developed in accordance with International Myopia Institute guidelines.
Last updated: February 2026
Purpose: This clinical pathway provides evidence-based guidance for optometrists in Singapore to deliver comprehensive myopia management services. The pathway has been developed in accordance with International Myopia Institute (IMI) guidelines and adapted for the Singapore regulatory context, where optometrists cannot prescribe pharmacological interventions such as atropine or cycloplegic agents.
Scope of Practice Note: Singapore optometrists are not permitted to prescribe diagnostic or therapeutic pharmaceutical agents including atropine or cycloplegic medications. This pathway focuses on optical interventions, environmental modifications, and appropriate referral protocols for cases requiring pharmaceutical management.
Clinical Pathway Overview
Risk Assessment and Identification
Patient Identification
Initiate myopia management assessment for children presenting with:
- New onset myopia (≥ -0.50D spherical equivalent refraction)
- Pre-myopia: Hyperopic reserve less than age-expected norms
- Documented myopia progression (≥ -0.50D per year or ≥ 0.20mm axial elongation per 6 months)
- Parental myopia (one or both parents)
- Age 6-16 years (period of most rapid progression)
Key Evidence: Every additional diopter of myopia increases the risk of myopic maculopathy by 40%, regardless of final refractive error. Early intervention and slowing progression by even 1.00D provides significant long-term benefit.¹
Age-Expected Refractive Norms for Pre-Myopia Identification
| Age (years) | Expected Spherical Equivalent | Pre-Myopia Threshold |
|---|---|---|
| 4-5 | +1.00D to +1.50D | < +0.75D |
| 6-7 | +0.75D to +1.00D | < +0.50D |
| 8-9 | +0.50D to +0.75D | < +0.25D |
| 10+ | +0.25D to +0.50D | < +0.00D |
Adapted from Zadnik et al., JAMA Ophthalmology 2015²
Baseline Examination Protocol
Required Baseline Measurements
A. Refraction
- Non-cycloplegic autorefraction: Perform as initial screening measurement
- Subjective refraction: Best corrected visual acuity for distance and near
- Cycloplegic refraction: Refer to ophthalmologist for cycloplegic refraction if:
- Age < 10 years (mandatory for baseline)
- Suspected latent hyperopia or accommodative spasm
- Significant difference between subjective and objective findings
Evidence: Cycloplegic refraction is the gold standard for baseline refractive measurement in children. In Singapore, cycloplegic agents must be administered by ophthalmologists. Standard protocol: 2 drops of 1% cyclopentolate or tropicamide given 5 minutes apart, with refraction performed 30-45 minutes after instillation.³
B. Axial Length Measurement
- Preferred method: Optical biometry (IOLMaster, Lenstar, or equivalent)
- Frequency: Minimum every 6 months
- Clinical significance:
- Normal growth: ~0.10mm per year
- Myopic progression: 0.20-0.30mm per year
- Rapid progression: >0.30mm per year
C. Corneal Topography
- Essential for orthokeratology candidacy assessment
- Ideal parameters:
- Flat K: 40.00-46.00D
- Corneal astigmatism: ≤1.50D (preferably ≤1.00D with-the-rule)
- Regular corneal surface without significant irregularities
D. Binocular Vision Assessment
- Cover test (distance and near)
- Near point of convergence
- Accommodative amplitude and facility
- Phoria measurements
Important: Identify and treat any accommodative or vergence dysfunction before initiating myopia control treatment, as these conditions may affect treatment tolerance and compliance.⁴
E. Anterior and Posterior Segment Health
- Slit lamp biomicroscopy
- Fundus examination (refer to ophthalmologist for dilated examination if unable to perform adequately)
- Document:
- Posterior staphyloma presence
- Optic disc characteristics
- Retinal periphery assessment
- Any myopic degenerative changes
F. Lifestyle and Environmental Factors
- Average daily outdoor time (hours)
- Near work habits (duration, working distance)
- Screen time (total daily hours)
- Parental myopia history and age of onset
Treatment Selection and Initiation
Evidence-Based Treatment Options for Singapore Optometrists
A. Orthokeratology (OK)
Indications
- Myopia: -1.00D to -6.00D
- Astigmatism: ≤1.50D
- Age: 7-16 years
- Motivated patient and parent
- Good hygiene practices
Contraindications
- Corneal disease or dystrophy
- Dry eye disease (moderate-severe)
- Active anterior segment inflammation
- Poor hygiene or compliance
- Irregular corneal topography
Efficacy Evidence: Orthokeratology reduces axial elongation by approximately 0.24mm over 2 years compared to single vision spectacles, representing approximately 40-60% reduction in myopia progression. Treatment effect remains stable over 3-5 years of continuous wear.⁵⁻⁷
OK Follow-up Schedule:
- Dispense/Overnight Trial: Initial lens assessment
- Day 1: Morning assessment of lens fit, vision, and corneal response
- 1 Week: Assess treatment zone, visual acuity, corneal health
- 1 Month: Comprehensive evaluation, refine fit if needed
- 3 Months: Routine assessment
- 6 Monthly thereafter: Comprehensive review including axial length
B. Myopia Control Spectacle Lenses
Available Technologies:
- Defocus Incorporated Multiple Segments (DIMS): Multiple +3.50D lenslets creating myopic defocus
- Highly Aspherical Lenslets (HAL): 11 concentric rings of aspherical lenslets
- Diffusion Optics Technology (DOT): Scatter elements reducing retinal contrast
Efficacy Evidence:
- DIMS lenses: 52% reduction in myopia progression and 62% reduction in axial elongation over 2 years. Six-year data shows sustained efficacy without rebound effect.⁸⁻⁹
- HAL lenses: 67% slowing of progression (with ≥12 hours daily wear) over 2 years. Five-year data demonstrates treatment effect of approximately 0.80D and 0.35mm reduction.¹⁰⁻¹²
- DIMS vs HAL: European studies show equivalent efficacy over 2 years in non-Asian populations.¹³
Indications
- Myopia: -0.50D to -10.00D
- Any level of astigmatism
- Age: 6-18 years
- Non-contact lens candidates
- Parental preference for spectacles
Wear Requirements
- Full-time wear: ≥12 hours daily
- 7 days per week
- Good spectacle fit essential
- Regular cleaning and maintenance
Myopia Control Spectacle Follow-up Schedule:
- Dispense: Verify fit, centration, and visual acuity
- 2 Weeks: Adaptation check, assess compliance
- 3 Months: First efficacy assessment
- 6 Monthly thereafter: Comprehensive review including axial length and refraction
C. Soft Myopia Control Contact Lenses
Available Designs:
- Dual-focus multifocal soft contact lenses
- Extended depth of focus (EDOF) designs
- Peripheral defocus designs
Efficacy Evidence: Myopia control soft contact lenses demonstrate approximately 25-50% reduction in myopia progression compared to single vision correction. Treatment effect varies by design, with center-distance multifocal designs showing consistent efficacy across multiple studies.¹⁴⁻¹⁵
Indications
- Myopia: -0.75D to -10.00D
- Age: 8+ years (maturity dependent)
- Adequate tear film
- Good hygiene capability
- Motivation for contact lens wear
Wear Requirements
- Daily wear: ≥10 hours per day
- 6-7 days per week minimum
- Proper lens care compliance
- Hand washing and hygiene
Soft Contact Lens Follow-up Schedule:
- Dispense: Lens insertion/removal training, initial fit assessment
- 1 Week: Assess adaptation, wearing time, comfort, vision
- 1 Month: Comprehensive contact lens evaluation
- 3 Months: Routine follow-up
- 6 Monthly thereafter: Comprehensive review including axial length
D. Lifestyle Modifications (Adjunctive to All Treatments)
Outdoor Time Prescription
Evidence-Based Recommendation: Prescribe minimum 2 hours (120 minutes) of outdoor time daily for all children, particularly those at risk for myopia development.¹⁶⁻¹⁸
- Mechanism: Bright outdoor light (>1000 lux) stimulates retinal dopamine release, which inhibits axial elongation
- Efficacy: Each additional hour of outdoor time per week reduces myopia risk by 2%. Children spending >14 hours outdoors per week have approximately 50% lower odds of developing myopia compared to those spending <13 hours per week¹⁶⁻¹⁷
- Implementation:
- Divide into 2-3 sessions of 30-40 minutes
- Any outdoor activity counts (not limited to sports)
- Cloudy days still effective (outdoor light still >1000 lux)
- UV protection (sunglasses, hats) does not negate benefit
- Avoid near work outdoors (does not count as outdoor time)
Near Work Recommendations
- Working distance: Maintain ≥30cm (elbow distance) for all near tasks
- 20-20-20 rule: Every 20 minutes, look 20 feet (6 meters) away for 20 seconds
- Continuous near work: Limit to 30-45 minute blocks with breaks
- Lighting: Ensure adequate illumination (reduce contrast strain)
- Posture: Encourage upright posture for reading and device use
Evidence: Reading at distances <20cm and continuous near work >45 minutes are significantly associated with myopia development and progression.¹⁹
Ongoing Management and Monitoring
Standard Follow-up Protocol
| Time Point | Assessments Required | Clinical Actions |
|---|---|---|
| 6 Months | • Distance and near visual acuity • Subjective refraction • Axial length measurement • Treatment compliance assessment • Anterior segment health • Accommodation and binocular vision | • Assess treatment efficacy • Counsel on compliance • Reinforce lifestyle modifications • Address any adverse effects |
| 12 Months | • All 6-month assessments PLUS: • Consider cycloplegic refraction (via ophthalmology referral) • Dilated fundus examination (or referral) • Corneal topography (for OK wearers) | • Comprehensive efficacy evaluation • Treatment modification if needed • Update prescription if indicated • Document myopia progression rate |
| 18+ Months | • Continue 6-monthly comprehensive reviews • Annual cycloplegic refraction and dilated fundus exam | • Long-term efficacy monitoring • Consider treatment continuation vs discontinuation • Plan transition to adult care |
Defining Treatment Success and Failure
Treatment Success:
- Myopia progression ≤0.25D per year (spherical equivalent)
- Axial elongation ≤0.15mm per year
- Good compliance and tolerance
- No significant adverse effects
Treatment Modification Required if:
- Myopia progression >0.50D per year despite treatment
- Axial elongation >0.25mm per 6 months
- Poor compliance (<70% adherence)
- Significant adverse effects or complications
- Patient dissatisfaction with visual quality
Treatment Modification Strategies
- Optimize current treatment:
- Increase wearing time (if suboptimal)
- Adjust lens parameters or design
- Reinforce lifestyle modifications
- Switch modality:
- Spectacles → Orthokeratology or soft myopia control lenses
- Soft lenses → Orthokeratology
- Orthokeratology → Different design or soft lenses
- Consider combination with pharmacological treatment:
- Refer to ophthalmologist for atropine adjunctive therapy
- Evidence supports additive effect of low-dose atropine (0.01-0.05%) with optical interventions²⁰
Referral Protocols
Ophthalmology Referral Indications
Urgent Referral (Within 1-2 Weeks):
- Sudden vision loss or significant visual acuity decrease
- Retinal pathology (breaks, detachment, hemorrhage)
- Acute anterior segment complications (microbial keratitis in contact lens wearers)
- Significant corneal staining or infiltrative events
Routine Referral (Within 1-3 Months):
- Cycloplegic refraction requirement (baseline and annual for children <10 years)
- Dilated fundus examination (annually or as indicated)
- High myopia (<-6.00D) with pathological changes
- Rapid progression despite maximal optical intervention (for atropine consideration)
- Complex cases: early onset (<6 years), unilateral high myopia, syndromic features
- Posterior segment abnormalities (posterior staphyloma, lacquer cracks, myopic CNV)
Pediatric/General Practitioner Referral:
- Syndromic features suggesting systemic disease (Marfan syndrome, Stickler syndrome)
- Suspected underlying metabolic or endocrine disorders
Co-management with Ophthalmology
For patients on atropine therapy prescribed by ophthalmologists:
- Monitor for side effects (photophobia, near vision difficulty)
- Assess compliance and tolerance
- Coordinate optical intervention alongside pharmacological treatment
- Communicate progression data and treatment efficacy
- Provide shared care reports every 6 months
Treatment Discontinuation and Long-term Considerations
When to Consider Treatment Discontinuation
- Myopia stabilization: <0.25D progression over 2 consecutive years and age >15-16 years
- Completion of growth: Minimal change in axial length over 12-18 months
- Patient/family decision: After counseling on risks and benefits
Important: The Correction of Myopia Evaluation Trial (COMET) found that 50% of myopes are still progressing at age 15. Consider individual progression patterns rather than age alone when deciding on treatment cessation.²¹
Monitoring After Discontinuation
- 6-month follow-up after stopping treatment
- Annual reviews until age 21-23 years
- Watch for rebound progression (typically minimal with optical interventions)
- Lifetime monitoring for myopic complications recommended for all moderate to high myopes
Patient Education on Long-term Eye Health
- Risk stratification based on final refractive error:
- -1.00 to -3.00D: Low risk
- -3.00 to -6.00D: Moderate risk
- >-6.00D: High risk for pathological myopia
- Importance of regular eye examinations throughout life
- Awareness of symptoms requiring urgent care (flashes, floaters, peripheral vision changes)
- UV protection and healthy lifestyle habits
Clinical Decision Algorithm
Documentation and Communication
Essential Clinical Documentation
- Baseline measurements (refraction, axial length, keratometry)
- Treatment rationale and informed consent
- Myopia progression rate calculations
- Compliance and adverse events
- Lifestyle modification counseling provided
- Referral communications and co-management notes
Patient and Family Communication
- Explain myopia as a chronic progressive condition
- Discuss long-term risks of high myopia (maculopathy, retinal detachment, glaucoma)
- Set realistic expectations: treatment slows progression, does not reverse myopia
- Emphasize importance of compliance and lifestyle modifications
- Provide written treatment plans and follow-up schedules
- Encourage questions and shared decision-making
References
1. Bullimore MA, Brennan NA. Myopia Control: Why Each Diopter Matters. Optometry and Vision Science. 2019;96(6):463-465.
2. Zadnik K, Sinnott LT, Cotter SA, et al. Prediction of Juvenile-Onset Myopia. JAMA Ophthalmology. 2015;133(6):683-689.
3. Gifford KL, Richdale K, Kang P, et al. IMI – Clinical Management Guidelines Report. Investigative Ophthalmology & Visual Science. 2019;60(3):M184-M203.
4. Rosenfield M, Logan N, Edwards K (eds). Optometry: Science Techniques and Clinical Management. 2nd ed. Edinburgh: Butterworth Heinemann Elsevier; 2009.
5. Cho P, Cheung SW. Retardation of Myopia in Orthokeratology (ROMIO) Study: A 2-Year Randomized Clinical Trial. Investigative Ophthalmology & Visual Science. 2012;53(11):7077-7085.
6. Jakobsen TM, Møller F. Myopia control with orthokeratology lenses. A 3-year follow-up study including a cross-over design: Clinical study Of Near-sightedness; TReatment with Orthokeratology Lenses 2 (CONTROL2 study). Acta Ophthalmologica. 2024. doi:10.1111/aos.15824
7. Sankaridurg P, Donovan L, Varnas S, et al. A new look at the myopia control efficacy of orthokeratology. Contact Lens and Anterior Eye. 2024;47(4):102181.
8. Lam CSY, Tang WC, Tse DY, et al. Defocus Incorporated Multiple Segments (DIMS) spectacle lenses slow myopia progression: a 2-year randomised clinical trial. British Journal of Ophthalmology. 2020;104(3):363-368.
9. Lam CS, Tang WC, Lee PH, et al. Myopia control effect of defocus incorporated multiple segments (DIMS) spectacle lens in Chinese children: results of a 3-year follow-up study. British Journal of Ophthalmology. 2022;106(8):1110-1114.
10. Bao J, Huang Y, Li X, et al. Spectacle Lenses With Aspherical Lenslets for Myopia Control vs Single-Vision Spectacle Lenses: A Randomized Clinical Trial. JAMA Ophthalmology. 2022;140(5):472-478.
11. Huang Y, Yin Z, et al. Myopia Control Efficacy of Spectacle Lenses with Aspherical Lenslets: Results of a 3-year Follow-up Study. American Journal of Ophthalmology. 2023;250:160-168.
12. Zhang H, Lam CSY, Tang WC, et al. Myopia control efficacy of spectacle lenses with highly aspherical lenslets: results of a 5-year follow-up study. Eye and Vision. 2025;12:8.
13. Vagge A, Giannaccare G, Scarinci F, et al. Comparison of the performance of myopia control in European children and adolescents with defocus incorporated multiple segments (DIMS) and highly aspherical lenslets (HAL) spectacles. British Journal of Ophthalmology. 2025;109(1):87-91.
14. Sankaridurg P, Bakaraju RC, Naduvilath T, et al. IMI—Interventions for Controlling Myopia Onset and Progression 2025. Investigative Ophthalmology & Visual Science. 2025;66(1):1.
15. Chamberlain P, Bradley A, Arumugam B, et al. Long-term Effect of Dual-focus Contact Lenses on Myopia Progression in Children: A 6-year Multicenter Clinical Trial. Optometry and Vision Science. 2022;99(3):204-212.
16. Xiong S, Sankaridurg P, Naduvilath T, et al. Time spent in outdoor activities in relation to myopia prevention and control: a meta-analysis and systematic review. Acta Ophthalmologica. 2017;95(6):551-566.
17. He M, Xiang F, Zeng Y, et al. Effect of Time Spent Outdoors at School on the Development of Myopia Among Children in China: A Randomized Clinical Trial. JAMA. 2015;314(11):1142-1148.
18. Wu PC, Chen CT, Lin KK, et al. Myopia Prevention and Outdoor Light Intensity in a School-Based Cluster Randomized Trial. Ophthalmology. 2018;125(8):1239-1250.
19. Morgan IG, Wu PC, Ostrin LA, et al. IMI Risk Factors for Myopia. Investigative Ophthalmology & Visual Science. 2021;62(5):3.
20. Kinoshita N, Konno Y, Hamada N, et al. Additive effects of orthokeratology and atropine 0.01% ophthalmic solution in slowing axial elongation in children with myopia: first year results. Japanese Journal of Ophthalmology. 2018;62(5):544-553.
21. The COMET Group. Myopia Stabilization and Associated Factors Among Participants in the Correction of Myopia Evaluation Trial (COMET). Investigative Ophthalmology & Visual Science. 2013;54(13):7871-7884.
Document Version: 1.0 | Last Updated: February 2026
This clinical pathway is based on current evidence and International Myopia Institute guidelines. Practitioners should use clinical judgment and consider individual patient circumstances. Regular updates will be provided as new evidence emerges.