Not all myopia is the same: Noha Ekdawi, MD, FAAP, on individualized management

Myopia in children is increasingly understood not as a static refractive error to be corrected but as a progressive disease to be managed—one that raises the lifetime risk of retinal detachment, myopic maculopathy, and glaucoma.

With various marketed interventions now available in the United States (MiSight contact lenses, Stellest spectacle lenses, and the Ability OK lens), as well as low-dose atropine widely used off-label, clinicians face growing complexity in selecting, sequencing, and combining therapies for individual patients. Questions of screening, adherence, long-term monitoring, insurance coverage, and MD-OD comanagement remain unsettled, making practical guidance from clinicians who manage these children daily especially valuable.

In this Q&A, Noha Ekdawi, MD, FAAP, discusses an individualized approach to pediatric myopia management—arguing that progression, family history, and axial length define distinct myopia types that warrant distinct strategies. Ekdawi shares practical pearls for improving adherence, framing risk conversations with parents, sequencing treatments, and the role of the AAPOS Myopia Task Force in pursuing an ICD-10 code that could unlock insurance coverage for progressive myopia.

Note: transcript edited lightly for clarity and length.

Myopia is often treated as a simple refractive error to be corrected rather than a progressive disease to be managed, and many progressing children walk out with only single-vision correction. Where do you see the biggest gap between how myopia is handled today and how it should be handled, and what's the one change in practice you'd most want every clinician seeing these kids to adopt?

Noha Ekdawi, MD, FAAP: I don’t think all myopia is the same. Progression and family history, as well as other risk factors such as axial length, really define the different types of myopia. The management should be individualized to each child.

When and how should myopia screening begin, and where do you think the current handoffs between pediatricians, optometrists, and ophthalmologists are breaking down?

Ekdawi: Vision screening should begin at the pediatrician's office as early as birth with a direct ophthalmoscope. Pediatric screenings are the mainstay for detecting childhood eye disease.

Parents often don't grasp that myopia control is about reducing the lifetime risk of retinal detachment, myopic maculopathy, and glaucoma, not just about thinner lenses. How do you frame that conversation, so families understand the stakes without feeling alarmed?

Ekdawi: This is a very difficult conversation to not overly alarm parents. I usually frame it as the higher myopia does have consequences beyond just glasses and contacts. The serious ones are what the pediatric ophthalmologists are trying to prevent, and we now have several treatment options.

Adherence is a major challenge in pediatric myopia management, whether it is nightly atropine drops, orthokeratology wear, or full-time use of specialty spectacles. What practical strategies have you found to improve adherence over months and years?

Ekdawi: I find explaining these are a habit that I equate to brushing their teeth. I find it easiest to place low-dose atropine drops next to their bed as a way to remember to place them at night. The spectacle defocus lenses by far are the easiest for adherence because they help the child see, and the parents can easily tell if they are on or not. I do not recommend orthokeratology in my practice.

How do you counsel families on the modifiable lifestyle factors, particularly increased outdoor time and reduced near work, and how do you keep those recommendations realistic for busy parents?

Ekdawi: I start with outdoor activities, which are the most important for myopia control. This can be as easy as part of daily activities, such as eating lunch or dinner outside. Walking the family dog should include the children. Walking to school when possible is also a favorite recommendation. The importance of making it part of their daily routine and lifestyle makes adherence to this treatment method easier.

With low-dose atropine, specialty contact and spectacle lens designs, and orthokeratology all in the mix, how do you approach selecting and sequencing a treatment plan for an individual child?

Ekdawi: I treat each patient individually. In a young child, I prefer to start with spectacle defocus lenses for 6 months and then watch carefully for progression. I will start with low-dose atropine in an older child with astigmatism and already in contacts.

There's growing interest in combining therapies, such as pairing atropine with optical interventions. When do you consider combination treatment, and what does the current evidence tell us about which pairings are worth employing?

Ekdawi: At this time the evidence is lagging clinical treatments. I will often add on low-dose atropine as a second line of treatment with spectacle defocus lenses or MiSight contacts. The Stellest lenses and Misight lenses are FDA approved in the US, but low-dose atropine is not. Now that we have those options, I find low-dose atropine to be a second add-on treatment. The combination does seem to improve efficacy.

What does appropriate long-term monitoring look like, and what signs tell you a child's current strategy isn't working and needs to be escalated or changed?

Ekdawi: Long-term monitoring is challenging because myopia can continue to progress into adulthood. I usually taper my treatment after 2 years of stability.

Access and cost remain real obstacles, since many myopia control options aren't well covered by insurance. How does that shape your recommendations, and what can the field do to make effective care more equitable?

Ekdawi: The American Association for Pediatric Ophthalmology and Strabismus (AAPOS) does have a Myopia Task Force. This task force is currently working on an ICD 10 code that will make progressive myopia a medical diagnosis. Once this is established, it is hoped that insurance carriers will start covering treatment.

Much of closing these gaps depends on ophthalmologists and optometrists working in partnership rather than in silos. How do you see that collaboration working best, and what would stronger MD-OD comanagement look like in pediatric myopia care?

Ekdawi: In my practice, pediatric ophthalmology and optometry have always worked closely together, so we have had no change in collaboration. I continue to perform cycloplegic refractions annually, alternating with optometry for 6-month visits. My optometry colleagues fit the child with contacts and follow along their myopic progression.