Pre-myopia: Can we intervene in time?

Due to the increasing prevalence of myopia and the impact it has on society and individuals, prevention and early intervention play an important role. When children are diagnosed with myopia, control through myopia management is key, but the ideal approach would be to intervene even before the onset of myopia. To do this, a pre-myopic eye must be recognized as such. In this article, you will learn how pre-myopia is defined, how it can be identified and what it means for eye care professionals in their everyday practice.

The following risk factors are relevant when determining pre-myopia:

• Age-dependent refraction values: Guidelines suggest eyes with cycloplegic refractive values of < +0.75D for children at six years, ≤ +0.50D for children between seven and eight years and ≤ +0.00D from ten years are likely to become myopic.
• Documented progression: If regular eye tests done from a young age indicate rapid progression, this is a definite and documented risk factor.³
• Parental myopia: One myopic parent doubles the risk of the child also developing myopia. This increases significantly if both parents are myopic (more than five times higher risk).⁴
• Asian ethnicity: Data shows that 18 percent of four to six-year-old children living in Asia are already myopic. The statistic is more than 30 percent for ten-year-old children.⁵ Combined with Asian ethnicity, borderline refraction values should therefore still be interpreted as a high risk for myopia development.
• Extensive and recurring close work: Children who spend long hours reading, writing, or interacting with digital devices such as tablets and mobile phones are at risk of developing myopia.

Early and regular monitoring of the child's eye health is therefore crucial, also because progression is particularly strong in the year before the child becomes myopic.⁶ If detected early enough, this sharp increase can be mitigated.

The causes of myopia and the underlying mechanisms are not yet fully understood. This situation will hopefully improve as the range of studies increases and research findings become more conclusive. The experts at ZEISS are actively researching many aspects of development and progression of myopia, and are in close contact with the scientific community, including via the ZEISS Myopia Advisory Board, so that new findings are always incorporated into strategy and recommendations and updates are made on an ongoing basis.  

The most sensible approach, especially in borderline cases, is to recommend the following behaviors:

• Daily time outdoors: Children should spend a minimum of two hours outside. Those who spend significant time outdoors can decrease their risk of developing myopia.⁷
• Good near work habits: Keep close work to a minimum, incorporate regular breaks, and look into the distance regularly

In individual cases, it may also make sense for a pre-myopic child to receive interventions such as special spectacle lenses. ZEISS is supporting an investigator initiated randomized clinical trial, evaluating the effectiveness and safety of cylindrical annular refractive elements (CARE) spectacle lenses in preventing the onset of myopia in emmetropic and low-hyperopic children, aged 6- to 9-years and results are expected in the second half of 2025.

Most importantly, the scientific community and practitioners need to consider the body of evidence and work on the acceptance of these measures, and support families in implementing mitigating behaviours. This is because children who have good vision and have not been affected by impaired vision yet, or whose parents do not understand the need, will be reluctant to take the necessary steps conscientiously. For this reason, it’s particularly important to inform parents that it is not just about preventing visual impairment, but also about mitigating potential long-term health consequences.

It's also important to note that the use of cycloplegia is standard in the refraction of children's eyes.⁸ This means that, depending on country-specific regulatory and organizational aspects, refraction may not be carried out by opticians or optometrists. Close cooperation with ophthalmologists is recommended in these cases.

So, can we intervene in time? The answer is yes. Pre-myopic eyes can be recognized as such. Even at an early stage, documented successful interventions can be implemented to slow down progression. In addition, parents must be regularly made aware of the most important aspects of healthy eye development, both inside and outside of an eyecare practice environment. Families should be educated about the risks of regular close work and the importance of spending time outdoors, thus contributing to myopia prevention.