Is Myopia Management
Still "Optional"?

The Research Focus

The IMI 2025 Digest, published in Investigative Ophthalmology & Visual Science (IOVS) in September 2025, represents a targeted update across six clinical topics — building on the IMI's foundational 2019 white paper series. A separate IMI 2025 Interventions paper was published in the same issue. Together, these publications represent the current global clinical consensus on myopia management, and the shift they formalize is harder to ignore than ever.

Why Axial Length Is Now the Vital Sign

The IMI 2025 Digest makes a decisive case: diopter-based prescription alone is no longer sufficient as the sole measure of myopia severity. Axial length — the physical elongation of the eyeball — is what determines long-term pathological risk. One important nuance the Digest does flag: cycloplegic refraction still has stronger predictive value for identifying which children will develop myopia in the first place. But once myopia is established, axial length becomes the gold standard metric for monitoring progression and stratifying risk.

This reframing has a direct clinical implication: practices that only record refraction are missing the metric that matters most for long-term risk. The IMI 2025 Digest cites longitudinal Singapore cohort data showing that a greater risk of myopic retinopathy was associated with axial length ≥26.5mm, myopia over 8.00D, and age over 19 years. Separately, high axial myopia is associated with elevated open-angle glaucoma risk — but importantly, these are distinct risk profiles at different thresholds, not a single linear relationship. The clinical imperative is to track axial length over time, not just measure it once.

Start Early: The Pre-Myopia Window

One of the most significant shifts in the 2025 publications is the formalization of the "Pre-Myopia" stage as a legitimate clinical target. The IMI defines pre-myopia as a refractive state of ≤ +0.75D and > −0.50D in children — meaning the intervention window opens while the child is still slightly hyperopic or emmetropic, well before the first myopic prescription is written. The target is onset itself (−0.50D), not some later –1.00D milestone. If a child presents with any of the following risk factors:

• High levels of near-work activity
• Low outdoor time (<90 minutes/day)
• One or both myopic parents
• Relative peripheral hyperopia on retinal topography

...the 2025 standard is to open the myopia management conversation immediately — before refractive thresholds are crossed. Being proactive rather than reactive is no longer aspirational — it is the stated benchmark.

A note on ethnicity-adjusted thresholds: The IMI 2025 Digest acknowledges that the existing ≤+0.75D upper threshold was derived from the CLEERE study, which used a multi-ethnic cohort based in the United States. The Digest explicitly notes that a recent study using comparable methods in China and Europe found that Chinese children appear to need a greater hyperopic reserve than European children to avoid becoming myopic. A separate study of over 870,000 Chinese children (Chen M et al. 2023, PMC10630697) found that the risk of myopia onset increased rapidly when cycloplegic spherical equivalent refractive error fell below +1.50D — suggesting a potentially higher safety threshold for this population. The Digest does not revise the formal ≤+0.75D definition, but calls for population-specific thresholds to be considered in clinical decision-making.

Combination Therapy: What the Evidence Actually Says

The IMI 2025 Interventions paper reviews the emerging literature on dual-protocol management — combining two modalities simultaneously for high-risk patients. The most studied pairing is Ortho-K with low-dose 0.01% atropine, with the evidence base currently limited to five randomized clinical trials.

The effect size is real but modest: the median additional benefit of adding 0.01% atropine to Ortho-K was +0.12mm over two years compared to Ortho-K alone. Worth discussing with families — but not the dramatic leap the marketing language around "dual-protocol" sometimes implies. Importantly, the only atropine concentration studied in combination is 0.01% — higher concentrations have not been evaluated in this context.

Clinical Pearls + How MyopiaTracker Implements This

The chart above shows exactly how MyopiaTracker operationalizes the IMI 2025 framework. Rather than manually consulting percentile tables, the risk percentile bands are plotted dynamically, and intervention events are logged directly on the growth curve — so you can see whether the Ortho-K fitting actually bent the axial length trajectory.

The Bottom Line

The IMI 2025 papers don't introduce a single dramatic discovery. What they do is solidify the consensus that was building across the last half-decade into a formal, globally endorsed standard. Three things are now unambiguous:

1. Axial length is the metric that matters. Diopters alone are insufficient for risk stratification.
2. Intervention belongs in the pre-myopia window. Waiting for progression to start is missing the most impactful clinical moment.
3. Combination protocols have real — but modest — evidence. Ortho-K + 0.01% atropine adds a median +0.12mm benefit over two years. Discuss rebound risk on discontinuation. It's not experimental, but it's not a silver bullet either.

If your current workflow doesn't reflect these three points, the IMI 2025 publications offer the clearest possible mandate to update it. MyopiaTracker has IMI 2025 risk percentile bands built into the growth chart — see it with your next patient →