Evidence Library

The Evidence Behind Every Claim: 98 Studies, Annotated for Parents

This page is Appendix 1 of the book No More Myopia Panic, published openly. Every argument made on this website and in the book carries a superscript number that traces back to one of the references below. Wherever a DOI exists, we link it — so you (or a search engine, or an AI) can verify the source yourself.

How to read this library. Each entry gives the full citation first, then a plain-language note on what the study actually found and why it matters for your child. No paywall, no jargon filter — the same evidence we use, in the open.
98 references 87 with verified DOI links 10 topics Updated October 2026
Myopia Epidemiology Mechanisms of Myopia Onset Outdoor Activity for Myopia Prevention & Control Light Environment & Illumination Low-Level Red-Light Therapy Vision Function Training Nutritional Supplementation Comprehensive Intervention & Personalized Management Risks of Myopia-Related Complications Outdoor Light Exposure and the Choroid

Myopia Epidemiology 2

  1. [1]

    Holden BA, Fricke TR, Wilson DA, et al. (2016). Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050. Ophthalmology, 123(5): 1036–1042. DOI ↗

    In plain language: Projects that by 2050 nearly half of the world's population (49.8%) will have myopia, with about 938 million people (nearly 1 billion) having high myopia. This study established the understanding of myopia as a global public-health issue and is widely cited in myopia prevention and control guidelines worldwide.

  2. [2]

    National Health Commission of the People's Republic of China. (2020). Results of the 2020 National Survey on Myopia Among Children and Adolescents in China (in Chinese). no DOI — print/Chinese-language source

    In plain language: Authoritative data officially released by China, showing an overall myopia rate of 52.7% among Chinese children and adolescents in 2020—35.6% for elementary school students, 71.1% for middle school students, and 80.5% for high school students. A core data source for Chapters 1 and 3 of this book.

Mechanisms of Myopia Onset 4

  1. [3]

    Grosvenor T. (2007). Primary Care Optometry, 5th ed. Butterworth-Heinemann. DOI ↗

    In plain language: A classic optometry textbook that establishes that every 1 mm of axial length growth corresponds to roughly 2.50D–3.00D of myopia, providing the theoretical basis for the book's central argument that "axial length is the gold standard."

  2. [4]

    Chiang ST, Phillips JR, Backhouse S. (2015). Effect of retinal image defocus on the thickness of the human choroid. Ophthalmic and Physiological Optics, 35(4): 405–413. DOI ↗

    In plain language: Demonstrates that retinal image defocus can rapidly alter choroidal thickness—myopic defocus thickens the choroid while hyperopic defocus thins it—providing direct evidence for the mechanisms behind low-level red-light therapy and optical correction.

  3. [5]

    Smith EL 3rd, Hung LF, Huang J. (2009). Relative peripheral hyperopic defocus alters central refractive development in infant monkeys. Vision Research, 49(19): 2386–2392. DOI ↗

    In plain language: A classic animal study proving that even when central vision is clear, the axial length grows rapidly as long as peripheral hyperopic defocus is present. This study laid the foundation for "peripheral defocus theory" and explains the design flaw of ordinary single-vision lenses.

  4. [6]

    Nickla DL, Wallman J. (2010). The multifunctional choroid. Progress in Retinal and Eye Research, 29(2): 144–168. DOI ↗

    In plain language: A systematic review of the choroid's multiple functions, clarifying its role as a "sponge cushion" in eyeball development and myopia progression, and confirming that changes in choroidal thickness can serve as an early indicator of myopia intervention.

Outdoor Activity for Myopia Prevention & Control 8

  1. [7]

    He M, Xiang F, Zeng Y, et al. (2015). Effect of Time Spent Outdoors at School on the Development of Myopia Among Children in China: A Randomized Clinical Trial. JAMA, 314(11): 1142–1148. DOI ↗

    In plain language: The Guangzhou outdoor-activity intervention study, which demonstrated that adding 40 minutes of outdoor activity per day reduced the 3-year cumulative incidence of myopia from 39.5% to 30.4% (an absolute reduction of 9.1 percentage points, a relative reduction of 23%). This study provides the highest level of randomized controlled trial evidence for outdoor activity in myopia prevention and control.

  2. [8]

    Xiong S, Sankaridurg P, Naduvilath T, et al. (2017). Time spent in outdoor activities in relation to myopia prevention and control: a meta-analysis and systematic review. Acta Ophthalmologica, 95(6): 551–566. DOI ↗

    In plain language: Including 25 studies and more than 34,000 participants, this analysis confirmed that increased daily outdoor time is significantly associated with a reduced risk of myopia onset, and that about 76 additional minutes of outdoor activity per day can cut the risk by 50%. It established that outdoor light intensity is 100–1,000 times that of indoors, and that light-stimulated dopamine release is the core mechanism.

  3. [9]

    Kido A, Miyake M, Watanabe N. (2024). Interventions to increase time spent outdoors for preventing incidence and progression of myopia in children. Cochrane Database of Systematic Reviews, (6): CD013549. DOI ↗

    In plain language: A Cochrane systematic review (the highest level of evidence in evidence-based medicine), suggesting that increasing time spent outdoors may reduce the incidence of myopia in children, with low-certainty evidence—providing the most authoritative evidence in support of behavioral interventions.

  4. [10]

    Wu PC, Chen CT, Lin KK, et al. (2018). Myopia Prevention and Outdoor Light Intensity in a School-based Cluster Randomized Trial. Ophthalmology, 125(8): 1239–1250. DOI ↗

    In plain language: A Taiwan school-based cluster RCT (16 schools, 693 children) that pioneered the finding that mandatory outdoor activity during recess can significantly slow myopia progression (myopic shift of 0.35D vs 0.47D in controls, with a 54% reduction in the risk of rapid progression; the same team's 2013 study showed an annual myopia incidence of 8.4% in the intervention group vs 17.6% in controls). It laid the evidence-based foundation for the global consensus that "increasing outdoor time prevents myopia" and has been widely cited by subsequent research.

  5. [11]

    He X, Sankaridurg P, Wang J, et al. (2022). Time Outdoors in Reducing Myopia: A School-Based Cluster Randomized Trial with Objective Monitoring of Outdoor Time and Light Intensity. Ophthalmology, 129(11): 1245–1254. DOI ↗

    In plain language: A Shanghai school-based cluster RCT (24 schools, 6,295 students wearing light-sensor wristbands to objectively record outdoor time and light intensity), demonstrating that cumulative outdoor light dose (rather than time alone) is the key metric for preventing myopia—providing evidence-based support for precise intervention shifting from "outdoor time" to "light dose."

  6. [12]

    Dolgin E. The myopia boom. Nature, 2015, 519(7543): 276–278. DOI ↗

    In plain language: A Nature feature article that systematically reviews the global myopia boom and its environmental drivers, identifying insufficient outdoor light exposure as the key reason for high myopia rates; it proposes that children need to spend roughly 3 hours a day at light levels of at least 10,000 lux to effectively prevent the onset and progression of myopia. An authoritative basis for the "outdoor light dose" concept.

  7. [13]

    Wu PC, Chen CT, Chang LC, et al. Increased time outdoors is followed by reversal of the long-term trend to reduced visual acuity in Taiwan primary school students. Ophthalmology, 2020, 127(11): 1462–1469. DOI ↗

    In plain language: A real-world study of Taiwan's "Outdoor 120 Every Day" program (120 minutes outdoors daily), using the rate of poor uncorrected visual acuity as the measure. After the program's implementation, the long-term rising trend in the rate of poor vision among elementary school students was reversed, falling from 50.01% to 46.12%. It proves that outdoor intervention is feasible and effective at a large-population level, providing national-scale population evidence for this book's behavioral-intervention recommendations.

  8. [14]

    Rose KA, Morgan IG, Smith W, et al. Myopia, lifestyle, and schooling in students of Chinese ethnicity in Singapore and Sydney. Arch Ophthalmol, 2008, 126(4): 527–530. DOI ↗

    In plain language: A classic cross-city comparative study. Among ethnic Chinese children aged 6–7, the myopia rate was only 3.3% in Sydney but as high as 29.1% in Singapore; the key difference lay not in near-work load (Sydney children actually spent more time reading) but in outdoor time—13.75 hours per week versus 3.05 hours. It powerfully demonstrates that outdoor time is a core modifiable factor in myopia prevention and control, independent of study load, supporting this chapter's central theme that "outdoor light is the main force; indoor lighting is the understudy."

Light Environment & Illumination 7

  1. [15]

    Standardization Administration of China. (2022). GB/T 9473-2022: Performance Requirements for Table Lamps for Reading and Writing Tasks. China Standards Press (in Chinese). no DOI — print/Chinese-language source

    In plain language: A Chinese national standard specifying technical requirements for reading and writing desk lamps—including illuminance, uniformity, and color rendering index—providing the standards basis for the lighting upgrades in Chapter 5 of this book.

  2. [16]

    International Commission on Illumination (CIE). (2020). CIE S 017/E:2020 ILV: International Lighting Vocabulary. CIE Central Bureau. DOI ↗

    In plain language: The authoritative international lighting standard, defining the metrics for light measurement and providing the theoretical basis for evaluating spectral quality.

  3. [17]

    Karouta C, Thomson K, Morgan I, Ashby R. (2025). Light Inhibits Lens-Induced Myopia through an Intensity-Dependent Dopaminergic Mechanism. Ophthalmology Science, 5(5): 100779. DOI ↗

    In plain language: A chick lens-induced myopia model study with two major findings: ① Light inhibits myopia through an intensity-dependent dopaminergic mechanism—axial length grew rapidly at 500 lux, was significantly slowed at 20,000 lux, and was suppressed by about 50% at 40,000 lux (per the paper's figure data); the higher the light intensity, the more retinal dopamine (DOPAC) is released, providing molecular-mechanism-level evidence for "bright outdoor light for myopia prevention and control." ② Using the "Total Effective Photons" method, the paper also compared the photoreceptor activation patterns of fluorescent light (500 lux), white LED (10,000 lux), halogen light (10,000 lux), and sunlight (90,000 lux): LED and sunlight showed similar activation patterns (balanced activation across cone types), while fluorescent and halogen light skewed markedly toward long-wavelength cones and away from natural light—providing direct support for Chapter 5's "Question 2: Photoreceptor Activation Patterns" and for the lamp-selection logic that "high-quality full-spectrum LEDs come closest to sunlight."

  4. [18]

    Smith EL 3rd, Hung LF, Arumugam B, et al. Effects of Long-Wavelength Lighting on Refractive Development in Infant Rhesus Monkeys. Invest Ophthalmol Vis Sci, 2015, 56(11): 6490–6500. DOI ↗

    In plain language: A monochromatic-light refractive development study in rhesus monkeys (the animal model closest to the human visual system), demonstrating that infant monkeys raised under long-wavelength red lighting developed refraction clearly biased toward hyperopia. This suggests that the long-wavelength (red) component of the spectrum can guide the eye to develop in an anti-myopia direction, providing primate experimental evidence for this book's "red-enriched" lighting strategy.

  5. [19]

    Gawne TJ, Siegwart JT Jr, Ward AH, et al. The wavelength composition and temporal modulation of ambient lighting strongly affect refractive development in young tree shrews. Exp Eye Res, 2017, 155: 75–84. DOI ↗

    In plain language: A tree shrew study confirming that the wavelength composition of ambient lighting strongly influences the direction of refractive development: tree shrews raised under narrow-band red light remained persistently hyperopic. This suggests that spectral shape itself is the "conducting signal" of eyeball development, providing experimental support for Chapter 5's principle that "spectral shape is the first criterion in choosing a lamp."

  6. [20]

    Gawne TJ, Ward AH, Norton TT. Juvenile Tree Shrews Do Not Maintain Emmetropia in Narrow-band Blue Light. Optom Vis Sci, 2018, 95(10): 911–920. DOI ↗

    In plain language: A narrow-band blue-light study in tree shrews, finding that juvenile tree shrews could not maintain emmetropia in narrow-band blue light—first shifting briefly toward hyperopia, then gradually sliding into myopia. From the opposite direction, this confirms that a spectral shape with "a high share of blue light and insufficient red" is unfavorable for refractive development, and together with [18] and [19] forms an evidence chain showing that "whether red light is sufficient determines which way the eyeball grows."

  7. [21]

    Swiatczak B, Schaeffel F. Myopia: why the retina stops inhibiting eye growth. Sci Rep, 2022, 12(1): 21704. DOI ↗

    In plain language: A human experiment at the University of Tübingen, Germany. Participants watched digitally filtered films in which only the relative sharpness of red versus blue imagery was subtly adjusted (simulating the human eye's longitudinal chromatic aberration), while the picture content was virtually identical. Results: when the red imagery was sharper, emmetropes' axial lengths shortened within 45 minutes (with choroidal thickening); when the blue imagery was sharper, axial lengths elongated; and the retinas of myopes responded sluggishly to the "stop growing" signal. This directly confirms that the human retina judges the direction of defocus by comparing the sharpness of the red and blue ends and regulates axial growth accordingly, providing human evidence for Chapter 5's spectral mechanism of "high red-light share → myopic defocus → inhibition of axial length growth."

Low-Level Red-Light Therapy 39

  1. [22]

    Jiang Y, Zhu Z, Tan X, et al. (2022). Effect of Repeated Low-Level Red-Light Therapy for Myopia Control in Children: A Multicenter Randomized Controlled Trial. Ophthalmology, 129(5): 509–519. DOI ↗

    In plain language: A multicenter randomized controlled trial confirming that repeated low-level red-light (RLRL) therapy effectively slows myopia progression and axial length growth in children; the OCT subgroup showed an average choroidal thickness increase of 16.1 μm at 1 month and an adjusted mean increase of 12.1 μm over the 12-month follow-up, suggesting choroidal thickening may be one mechanism by which RLRL controls axial growth—providing high-level evidence for red-light therapy.

  2. [23]

    Dong J, Zhu Z, Xu H, et al. (2023). Myopia Control Effect of Repeated Low-Level Red-Light Therapy in Chinese Children: A Randomized, Double-Blind, Controlled Clinical Trial. Ophthalmology, 130(2): 198–204. DOI ↗

    In plain language: The first double-blind, sham-controlled RCT to date: among 112 myopic children aged 7–12, 6 months of RLRL treatment produced axial length growth of only 0.02 mm (vs 0.13 mm in the control group), 23.2% experienced axial shortening >0.05 mm, and there were no treatment-related adverse events.

  3. [24]

    Liu LP, Hu YS, Chen HC, Tang Y, Mao XM, et al. (2025). Repeated low-level red-light therapy vs. conventional treatments for myopic control in children: a systematic review and meta-analysis. Scientific Reports, 15: 30794. DOI ↗

    In plain language: The latest meta-analysis, including 7 studies and 691 children, confirming that axial length progression in the RLRL group was significantly lower than in control groups, that combination therapy works even better, and that it significantly thickens the choroid.

  4. [25]

    Sun JR, Du ZQ, Wu GY. (2024). Efficacy comparison of repeated low-level red-light therapy and orthokeratology lenses for myopia control: a systematic review and meta-analysis. Optometry and Vision Science, 101(11): 660–665. DOI ↗

    In plain language: An updated meta-analysis confirming that red-light therapy is significantly effective in controlling axial length, providing the latest high-level evidence for Chapter 6 of this book.

  5. [26]

    Bullimore MA, Saunders KJ, Baraas RC, et al. (2025). IMI—Interventions for Controlling Myopia Onset and Progression 2025. Investigative Ophthalmology & Visual Science, 66(12): 39. doi:10.1167/iovs.66.12.39 DOI ↗

    In plain language: The official white paper of the International Myopia Institute (IMI), systematically reviewing randomized controlled trial evidence across all categories of myopia-control interventions (optical, pharmacological, environmental/behavioral, colored light, and surgical). It lists RLRL as one of the effective interventions for delaying myopia onset in high-risk children and provides guidance on its potential and safety monitoring; it also includes a dedicated section summarizing the evidence on undercorrection—three well-designed RCTs consistently show that undercorrection of 0.50–0.75D offers no benefit and may accelerate myopia progression, emphasizing that myopia must be fully corrected.

  6. [27]

    Lee SH, Tseng BY, Wang JH, et al. (2025). Efficacy of Myopia Prevention in At-Risk Children: A Systematic Review and Network Meta-Analysis. Journal of Clinical Medicine, 14(5): 1665. DOI ↗

    In plain language: A network meta-analysis focused specifically on myopia prevention, showing that low-level red light can reduce myopia incidence by 41% (RR 0.59, comparable to low-dose atropine at RR 0.55), providing high-level evidence for the preventive use of red light.

  7. [28]

    Zheng Z, Jiang X, Chen R, Dong L, et al. (2025). Efficacy comparison of atropine, orthokeratology and repeated low-level red-light therapy for myopia control in children: a systematic review and network meta-analysis. British Journal of Ophthalmology, 109(11): 1215–1220. DOI ↗

    In plain language: A network meta-analysis including 41 RCTs and 6,434 eyes, showing that red light ranks first in controlling axial length, providing the latest basis for clinical decision-making.

  8. [29]

    Zhou W, Liao Y, Wang W, et al. Efficacy of Different Powers of Low-Level Red Light in Children for Myopia Control. Ophthalmology, 2024, 131(1): 48–57. DOI ↗

    In plain language: A single-center randomized controlled trial of 200 myopic children aged 6–15, directly comparing the axial-control effects of three power levels: 0.37 mW, 0.60 mW, and 1.20 mW. After 6 months, all three groups significantly outperformed the control group (axial length change +0.04/0.00/-0.04 mm vs. +0.27 mm in controls; choroidal thickening of 22.63/36.17/42.59 μm), with no statistically significant difference in efficacy among the groups (adjusted P>0.05), and no adverse events were observed at any of the three power levels. This provides direct evidence for Chapter 6's principles of "low power for the long term" and "combination therapy over increasing power."

  9. [30]

    Sankaridurg P, Berntsen DA, Bullimore MA, et al. (2023). IMI 2023 Digest. Investigative Ophthalmology & Visual Science, 64(6): 7. DOI ↗

    In plain language: The IMI 2023 annual consensus digest, summarizing updated myopia definitions, clinical trial progress, and new evidence on optical and pharmacological interventions, confirming that myopia-control treatments have minimal impact on visual function and a good safety profile.

  10. [31]

    Xiong R, Zhu Z, Jiang Y, Wang W, et al. Longitudinal Changes and Predictive Value of Choroidal Thickness for Myopia Control after Repeated Low-Level Red-Light Therapy. Ophthalmology, 2023, 130(3): 286–296. DOI ↗

    In plain language: A longitudinal OCT study of children receiving red-light therapy, tracking choroidal changes continuously for 12 months. Choroidal thickening followed a dynamic curve of "an initial peak (1 month, +14.76 μm), then a decline (3 months, +5.29 μm; 6 months, +1.54 μm), followed by a steady rise (12 months, +9.09 μm)," while the choroid in the control group continued to thin. The degree of choroidal thickening at 3 months predicted 12-month myopia-control outcomes (accuracy 71%-79%). This provides the mechanistic basis for Chapter 6's "monthly follow-ups during the first 3 months" and evidence that "the 3-month choroid is a weather forecast for 12-month efficacy."

  11. [32]

    Martinez-Perez C, Oliveira AP. Impact of Myopia Control Interventions on Choroidal Thickness in Children: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Ophthalmology Science, 2026, 6: 101039. DOI ↗

    In plain language: A PRISMA-compliant systematic review and meta-analysis (PROSPERO registered; literature search through August 2025) including 11 randomized controlled trials covering 2,190 myopic children's eyes, for the first time comparing the effects of mainstream myopia interventions on choroidal thickness on the same scale: repeated low-level red light produced the strongest thickening effect (mean 24.1 μm, 95% CI 19.8–28.5)—2.3 times that of low-dose atropine (10.6 μm) and 1.8 times that of orthokeratology lenses (13.3 μm) and microlens defocus spectacle lenses (13.2 μm); the evidence for most interventions was of high certainty. This confirms red light as currently the strongest myopia intervention for choroidal thickening, providing cross-comparison evidence for Mechanism 1 in Chapter 6.

  12. [33]

    Liu G, Liu L, Rong H, et al. (2025). Axial Shortening Effects of Repeated Low-level Red-light Therapy in Children With High Myopia: A Multicenter Randomized Controlled Trial. American Journal of Ophthalmology, 270, 203–215. DOI ↗

    In plain language: A multicenter RCT of children with high myopia (≤-6.00D), involving 202 children aged 7–12: in the red-light group, axial length regressed by an average of 0.11 mm at 12 months (versus 0.32 mm growth in controls), and 59% of children experienced axial length regression exceeding 0.05 mm (versus 0 in controls). Choroidal thickening could not fully explain the magnitude of regression, suggesting the involvement of other mechanisms such as scleral remodeling.

  13. [34]

    Peng Y, Wang D, Ma N, et al. (2025). Exploration of correlated factors of axial length changes after repeated low-level red-light irradiation in the real world. BMC Ophthalmology, 25: 530. DOI ↗

    In plain language: A real-world study of 323 cases (Wuhan Children's Hospital, 2-year follow-up): the longer the baseline axial length, the higher the degree of myopia, the thinner the choroid, and the older the age, the more pronounced the axial length regression; the high-myopia group (axial length ≥26 mm) showed significantly greater regression than the mild-to-moderate group—providing direct evidence that "the longer the axial length, the greater the room for regression."

  14. [35]

    Zhu Q, Cao X, Zhang Y, et al. (2023). Repeated Low-Level Red-Light Therapy for Controlling Onset and Progression of Myopia-a Review. International Journal of Medical Sciences, 20(10): 1363–1376. DOI ↗

    In plain language: An authoritative review of red-light mechanisms, systematically sorting out the candidate mechanisms: improved mitochondrial function and bioenergetics, retinal dopamine release, nitric oxide (NO) production, choroidal thickening, scleral remodeling, and more—the dopamine pathway is one of the important hypotheses for the mechanism of red light.

  15. [36]

    Bao J, Huang Y, Li X, et al. (2022). Spectacle Lenses With Aspherical Lenslets for Myopia Control vs Single-Vision Spectacle Lenses: A Randomized Clinical Trial. JAMA Ophthalmology, 140(5), 472–478. DOI ↗

    In plain language: Spectacle lenses with an aspherical lenslet design can effectively slow myopia progression over two years, providing high-level evidence for the effectiveness of defocus spectacle lenses.

  16. [37]

    Dong XF, Li WZ, Liu H. (2026). Effectiveness of orthokeratology in controlling myopia in adolescents aged 6–18 years: a systematic review and meta-analysis. International Ophthalmology, 46(1), 93. DOI ↗

    In plain language: The latest 2026 meta-analysis (15 studies, 1,065 children), confirming that orthokeratology lenses can slow axial elongation by 0.15 mm in the first year, with the effect sustained through 3 years.

  17. [38]

    Xi W, Li H, Qi W, Tan T, Wang L. (2025). Long-Term Efficacy of CRT, Lucid, Euclid, and IBright Orthokeratology Lenses in Controlling Myopia Progression in Children and Adolescents: A 36-Month Retrospective Cohort Study. Clinical Ophthalmology, 19, 2423–2430. DOI ↗

    In plain language: A 36-month retrospective cohort study confirming that all four orthokeratology lens brands—CRT, Lucid, Euclid, and IBright—effectively control axial elongation in children aged 8–16 with mild-to-moderate myopia.

  18. [39]

    Cho P, Cheung SW, Edwards M. (2005). The longitudinal orthokeratology research in children (LORIC) in Hong Kong: a pilot study on refractive changes and myopic control. Current Eye Research, 30(1), 71–80. DOI ↗

    In plain language: An early landmark study of Ortho-K, confirming that orthokeratology lenses can slow axial elongation by about 46% (0.29 mm vs. 0.54 mm in controls), providing early follow-up data on their effectiveness.

  19. [40]

    Lam CSY, Tang WC, Zhang HY, et al. (2023). Long-term myopia control effect and safety in children wearing DIMS spectacle lenses for 6 years. Scientific Reports, 13: 5475. DOI ↗

    In plain language: A 6-year long-term follow-up of DIMS lenses: the continuous-wear group showed only 0.60 mm of total axial elongation over 6 years, with a stable effect and no rebound; there was no rebound effect after discontinuation, and the safety profile was good.

  20. [41]

    Chen Z, Yang X, Liu L, et al. (2026). Randomized Clinical Trial of Diffusion Optics Technology Spectacle Lenses in a Chinese Population (CATHAY): 12-Month Results. Ophthalmology Science, 6: 101150. DOI ↗

    In plain language: China's first multicenter RCT of DOT lenses (5 hospitals, 195 children): axial elongation slowed by 0.26 mm at 12 months (P<0.0001), confirming that contrast-modulation technology is significantly effective for myopia control in Chinese children. The 24-month data announced at ARVO 2026: across the full population, two-year myopia progression slowed by 0.78D (67%) and axial elongation by 0.40 mm (62%); 59% of children in the DOT group progressed no more than 0.50D over two years (versus only 19% in controls), and the younger subgroup aged 6–10 gained more than 1.00D less progression on average over two years—the effect persisted without attenuation.

  21. [42]

    Cho P, Cheung SW. (2012). Retardation of Myopia in Orthokeratology (ROMIO) Study: A 2-Year Randomized Clinical Trial. Investigative Ophthalmology & Visual Science, 53(11): 7077–7085. DOI ↗

    In plain language: A classic RCT of Ortho-K (102 children aged 6–10): axial elongation slowed by 43% over 2 years; younger children (aged 7–8) benefited more, with the proportion of fast progressors in this subgroup dropping from 65% to 20%.

  22. [43]

    Ganesh SC, Armentano M, Rao SG, et al. (2026). Comparative Effectiveness of Myopia-control Spectacle Lenses: Clinical Setting Performance from a Retrospective Cohort Study. Ophthalmology Science, 6: 101103. DOI ↗

    In plain language: A real-world head-to-head comparison of three myopia-control lenses (retrospective cohort study, 899 children, 1,780 eyes, India): HALT lenses performed best, with annual axial elongation of 0.054 mm, significantly outperforming DIMS (0.098 mm) and CARE (0.088 mm).

  23. [44]

    D'Andrea L, Rinaldi M, Piscopo R, et al. (2026). Efficacy of spectacle lenses for myopia control: a meta-analysis of randomised controlled trials. British Journal of Ophthalmology, 110(2), 125–132. doi:10.1136/bjo-2025-327629 (published online September 2025) DOI ↗

    In plain language: The largest meta-analysis of myopia-control spectacle lenses to date (23 RCTs, 13,315 children): overall axial elongation slowed by 0.15 mm and refractive progression by 0.31D, with HAL showing the most prominent effect.

  24. [45]

    Wang M, Ma R, Kuang L, et al. (2025). Myopia Control Efficacy of Asymmetric Multipoint Defocus Technique Spectacle Lenses: One-Year Double-Masked Randomized Controlled Trial. Ophthalmology, 132: 972–979. DOI ↗

    In plain language: A double-masked RCT of AMDT lenses (144 children enrolled, 140 completed): 74% refractive control efficacy at 1 year; 42% of children showed no progression at all; the asymmetric design increases the defocus coverage area.

  25. [46]

    Wen L, Yang Y, He Y, et al. (2026). Efficacy of Diversified Segmental Defocus Optimization Lenses on Axial Length Growth in Children and Adolescents with or without Myopia. Ophthalmology, 2026. DOI ↗

    In plain language: A multicenter clinical practice study of DSDO lenses (8 Aier Eye Hospitals, 1,541 children): the myopic group's 12-month axial elongation of 0.17 mm outperformed DIMS's 0.19 mm, and the non-myopic group also showed a preventive effect.

  26. [47]

    Wang T, Chen ZY, Qiu KK, et al. (2023). Meta-analysis of the effect of peripheral defocus spectacles in controlling myopia progression in adolescents. Glass Enamel & Ophthalmic Optics, 51(7): 10–19 (in Chinese). no DOI — print/Chinese-language source

    In plain language: A meta-analysis of peripheral defocus spectacles (6 studies, 1,021 children), confirming a significant slowing of refractive and axial growth versus single-vision lenses, though the effect may weaken after 12–24 months.

  27. [48]

    Chamberlain P, Peixoto-de-Matos SC, Logan NS, et al. (2019). A 3-year Randomized Clinical Trial of MiSight Lenses for Myopia Control. Optometry and Vision Science, 96(8): 556–567. DOI ↗

    In plain language: A 3-year RCT of MiSight defocus soft contact lenses (multicenter, 4 countries): refractive progression slowed by 59% and axial elongation by 52%; the daily-disposable design had no serious adverse events, and the lens is FDA-approved for myopia control in children.

  28. [49]

    Rappon J, Chung C, Young G, et al. Control of myopia using diffusion optics spectacle lenses: 12-month results of a randomised controlled, efficacy and safety study (CYPRESS). Br J Ophthalmol, 2023, 107(11): 1709–1715. DOI ↗

    In plain language: The CYPRESS study, a prospective randomized controlled double-masked trial across 14 clinical centers in North America with 256 myopic children aged 6–10. Diffusion optics (DOT) lenses scatter light through thousands of microscopic dots, reducing retinal contrast; at 12 months, myopic refractive progression was slowed by 74% and axial elongation by 50%. The mechanism derives from retinal contrast theory (the finding that high-contrast signals, as in Bornholm eye disease, accompany high myopia), confirming that reducing retinal contrast can slow axial elongation—providing optical-intervention counter-evidence for Chapter 5's point that "homogenizing the light environment (turning on the ceiling light) reduces high-contrast stimulation."

  29. [50]

    Ma L, Li X, Hu J, et al. Influence of a long-distance optical imaging workbench on accommodation and choroidal response in myopic children. Clinical and Experimental Optometry, 2024, 107(4): 420–427. DOI: 10.1080/08164622.2023.2228810 DOI ↗

    In plain language: A self-controlled study of 35 myopic children aged 8–10: reading for 30 minutes on the LOIW (virtual image at 3.42m) shifted accommodation from lag to lead (-0.54D) and thickened the choroid by 13.40 μm; traditional near (0.33m) reading produced an accommodative lag of 0.88D and choroidal thinning of 10.19 μm. All differences between the two groups were P<0.001.

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    Ruan YM, Yao DW, Li B. Study on the effect of hyperboloidal distance-viewing lenses on axial length changes in pre-myopic children. Chinese Journal of General Practice, 2024, 22(7): 1146–1149 (in Chinese). no DOI — print/Chinese-language source

    In plain language: A 12-month prospective study of 120 pre-myopic children aged 6–10: hyperboloidal distance-viewing lenses reduced axial elongation by 43.9%-48.8%, and the longer the lenses were used, the better the effect (a dose-response relationship). One of the largest prospective studies of distance-viewing lenses to date.

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    Yeh SM, et al. Reduction in Accommodative Response of Schoolchildren by a Double-Mirror System. Int J Environ Res Public Health, 2021, 18(19): 9951. DOI: 10.3390/ijerph18199951 DOI ↗

    In plain language: In 57 children aged 7–12, the double-mirror system (DMS) extended the viewing distance from 0.4m to 2.285m, reducing accommodative response from 1.34D to 0.20D, with no significant difference from a real 2.285m distance. This confirms that DMS can effectively achieve viewing-distance extension, switching the eyes from strained near viewing to relaxed distance viewing.

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    Lin SY, et al. Effects of Extended Viewing Distance on Accommodative Response and Pupil Size of Myopic Adults by Using a Double-Mirror System. Int J Environ Res Public Health, 2022, 19(5): 2942. DOI: 10.3390/ijerph19052942 DOI ↗

    In plain language: In 60 myopic adults aged 18–22, DMS reduced accommodative response by 1.58D, with more stable accommodative microfluctuations. The low-myopia group decreased by 1.47D and the high-myopia group by 1.83D—the higher the myopia, the greater the accommodative relaxation benefit from distance-imaging technology.

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    Yi Z, et al. Effects of Virtual Distant Viewing Technology on Preventing Nearwork-Induced Ocular Parameter Changes. Digital Health, 2024, 10: 20552076241259868. DOI: 10.1177/20552076241259868 DOI ↗

    In plain language: A rigorous 4-hour crossover study of 26 subjects: reading on a virtual distance-imaging display increased choroidal thickness from 217.7 μm to 243.0 μm (+25.3 μm), with no significant change in spherical equivalent; reading traditional paper books caused a myopic shift of 0.19D with no choroidal thickening. There was no difference in the number of pages read between the two groups—learning efficiency was not affected.

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    Zhen Y, Zhang W, Shen J, et al. The clinical value of using a distance simulation screen for reading and learning. Chinese Journal of Ophthalmology, 2022, 58(12): 1045–1050 (in Chinese). no DOI — print/Chinese-language source

    In plain language: A reading-task comparison of 39 subjects (23 myopic + 16 emmetropic): the distance simulation screen (RIOS) showed no significant difference in reading speed or efficiency versus traditional printed materials, but effectively avoided the vision decline caused by near reading.

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    Zhen Y, Gao J, Zhang W, et al. A preliminary study on the preventive effect of a desktop virtual reality display against digital eye strain. Ophthalmology in China, 2022, 31(3): 225–230 (in Chinese). no DOI — print/Chinese-language source

    In plain language: A 10-minute viewing task in 31 subjects: the desktop virtual reality display (converting a real image at 30 cm into a virtual image beyond 3m) can prevent digital eye strain caused by near smartphone use; the mechanism is projecting the image into the distance, thereby reducing the accommodative load of near viewing.

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    Zhang Y, Tian J, Shen W, Wang N. The Ocular Parameter Changes Caused by Reading With Remote Image Optical Screen. Translational Vision Science & Technology, 2025, 14(7): 12. DOI ↗

    In plain language: A comparative study of 35 adult participants performing 20-minute reading tasks; the remote-image optical screen (RIOS) effectively alleviated the anterior-segment parameter changes and choroidal thinning induced by traditional electronic screens (TES), confirming that distance-image technology protects ocular parameters associated with electronic screen use.

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    Yang K, et al. One-year changes in axial length and refraction in children using low-level red light and distant-image screen for myopia control: a RCT. Frontiers in Medicine, 2025, 12: 1542620. DOI: 10.3389/fmed.2025.1542620 DOI ↗

    In plain language: A 1-year RCT of 116 myopic children aged 8–10 with 4 arms (RL+DIT / RL / DIT / control). The combined RL+DIT group showed axial elongation of only 0.04 mm, 79.3% experienced a hyperopic shift, and the choroid thickened by 15 μm. DIT alone limited axial elongation to 0.30 mm (vs 0.42 mm in controls), suggesting a synergistic advantage of distance-image plus red-light therapy in improving refraction.

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    Zou L, Li X, Zhou J, Xu M. Effect of Distant-Image Screen Technology (DIST) on Delaying Myopia Onset in Pre-myopia Children: Study Protocol. Trials, 2026. DOI: 10.1186/s13063-026-09696-2 DOI ↗

    In plain language: A 1-year RCT protocol in 192 pre-myopic children (ChiCTR2400082078) with 3 arms (DIST / DIST+defocus / control), evaluating the effect of distant-image screen technology (DIST) alone and in combination with optical defocus on delaying myopia onset. Initiated by Wenzhou Medical University.

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    Visual Health Medicine Branch of the China International Exchange and Promotive Association for Medical and Health Care, et al. Expert Consensus on the Application of Distance-Image Technology in Myopia Prevention and Control (2026). Chinese Journal of Optometry Ophthalmology and Visual Science, 2026, 28(6): 401–409. DOI: 10.3760/cma.j.cn115909-20260214-00064 (in Chinese). DOI ↗

    In plain language: China's first expert consensus on the clinical application of distance-image technology (2026), led by Zhou Jiawei of Wenzhou Medical University and Wang Kai of Peking University People's Hospital, with nearly one hundred experts participating. It clearly defines recommended indications (individuals with existing myopia and high-intensity near work, adults with screen-related eye strain), populations that may benefit (pre-myopia, family history of high myopia), usage standards (vision function assessment, 50%-70% of near-work video time, follow-up every 3–6 months), and technical standards.

Vision Function Training 12

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    Convergence Insufficiency Treatment Trial (CITT) Study Group. (2008). Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Archives of Ophthalmology, 126(10): 1336–1349. DOI ↗

    In plain language: The landmark CITT randomized controlled trial; office-based vision therapy combined with home reinforcement produced the best outcomes for improving symptoms of convergence insufficiency in children, with about 75% of patients showing significant symptom improvement.

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    Scheiman M, Mitchell GL, Cotter S, et al. (2005). A randomized clinical trial of vision therapy/orthoptics versus pencil pushups for the treatment of convergence insufficiency in young adults. Optometry and Vision Science, 82(7): 583–595. DOI ↗

    In plain language: An RCT confirming that vision therapy/orthoptics is significantly superior to pencil push-ups in reducing symptoms and improving the clinical signs of convergence insufficiency.

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    Lü Jia, Wang Linhong. (2015). Study on the Correlation Between Accommodative Lag and Myopia Progression in Adolescents. Journal of Clinical Ophthalmology, 23(4): 363–364 (in Chinese). no DOI — print/Chinese-language source

    In plain language: A 1-year follow-up of 121 adolescents aged 10–12; the accommodative-lag group showed significantly greater myopia progression than the normal-accommodation group (P<0.05), confirming that accommodative lag is a risk factor for myopia progression.

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    Meng ZY, Wang H, Wang DD, et al. (2026). Visual Training for Myopia Control: An Independent and Additive Inhibitor of Axial Growth. Clinical Optometry, 18: 598467. DOI ↗

    In plain language: A retrospective cohort study of 208 myopic children; vision training reduced annual axial length growth from 0.38 mm to 0.23 mm (P<0.001), with independent additive effects when combined with orthokeratology lenses, defocus lenses, or atropine; children with faster baseline progression benefited more (r=0.57).

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    Tao Yanting, Chen Li, Hao Xiaojun, et al. (2018). Study on the Effect of Accommodative Training on Adolescent Myopia Combined with Accommodative Lag. Journal of Anhui Health Vocational & Technical College, 17(4): 23–24 (in Chinese). no DOI — print/Chinese-language source

    In plain language: In 200 children aged 7–15 with myopia and accommodative lag, the accommodative-training-plus-spectacles group showed significantly smaller six-month increases in refractive error (0.41D) and axial length (0.19 mm) than the spectacles-only group (0.47D / 0.22 mm), with a significant reduction in the magnitude of accommodative lag.

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    Lü Yinyue, Zhou Chao. (2014). Analysis of the Controlling Effect of Vision Training on Myopia Development in Adolescents with Accommodative Lag. Medical Information, 2014(26): 549 (in Chinese). no DOI — print/Chinese-language source

    In plain language: In 100 adolescents with myopia and accommodative lag, the vision-training group showed significantly smaller 1-year increases in spherical equivalent (-0.51D) and axial length (0.57 mm) than the control group (-0.72D / 0.93 mm).

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    Xie R, Zhao F, Yu J, et al. (2024). Naked-Eye 3-Dimensional Vision Training for Myopia Control: A Randomized Clinical Trial. JAMA Pediatrics, 178(6): 533–539. DOI ↗

    In plain language: A multicenter RCT of 263 children; six months of naked-eye 3D training slowed axial elongation by 0.06 mm (P<0.001). Published in a JAMA specialty journal, it represents high-quality evidence in the field of 3D vision training.

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    Xu Z, Zou A, Li L, et al. (2024). Effect of virtual reality-based visual training for myopia control in children: a randomized controlled trial. BMC Ophthalmology, 24: 358. DOI ↗

    In plain language: An RCT of 65 children; three months of VR vision training slowed axial elongation by 0.066 mm (P=0.037) and increased macular choroidal thickness by 22.6 μm (P=0.005), suggesting that VR training may control axial growth by thickening the choroid.

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    Camilleri R, Pavan A, Ghin F, et al. (2014). Improving myopia via perceptual learning: is training with lateral masking the only (or the most) efficacious technique? Attention, Perception, & Psychophysics, 76: 2485–2494. DOI ↗

    In plain language: Ten individuals with mild myopia underwent 8 weeks of perceptual-learning training, with mean visual acuity improving by 0.16 logMAR, confirming that enhanced cortical processing efficiency can partially compensate for retinal image blur.

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    Huang Xinhui, Wang Mingjin, He Xiangui, et al. (2017). Observation of Accommodative Lag and Accommodative Response at Different Reading Distances and Reading Durations in 184 Children Aged 8–12. Journal of North Sichuan Medical College, 32(1): 33–37 (in Chinese). no DOI — print/Chinese-language source

    In plain language: WAM-5500 measurements in 184 children showed that accommodative lag during 20 cm reading (1.27–1.42D) was significantly greater than at 33 cm (1.00–1.21D), confirming that reading distance and duration are key factors influencing accommodative lag.

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    Allen PM, Radhakrishnan H, Rae S, et al. (2009). Aberration Control and Vision Training as an Effective Means of Improving Accommodation in Individuals with Myopia. Investigative Ophthalmology & Visual Science, 50(11): 5120–5129. DOI ↗

    In plain language: A dual-therapy RCT involving 93 teenagers with myopia; modifying spherical aberration combined with vision training effectively improved accommodative accuracy and dynamic accommodative speed, with significant improvements in both near and distance accommodative facility.

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    Lin Z, Xiao F, Cheng W. (2024). Eye Exercises for Myopia Prevention and Control: A Comprehensive Systematic Review and Meta-Analysis. Eye (London), 38(3): 473–480. (Preprint: medRxiv 2023, doi:10.1101/2023.01.29.23284986) DOI ↗

    In plain language: A meta-analysis of 11 studies with 921 participants found that traditional eye exercises are ineffective for preventing myopia or controlling its progression, challenging the evidence base for school eye-exercise policies and underscoring the need to replace them with effective vision function training.

Nutritional Supplementation 13

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    Li T, Li J, Deng C, et al. (2025). Effect of lutein ester supplement on choroidal thickness in children: A randomized controlled trial. Translational Vision Science & Technology, 14(12): 7. DOI ↗

    In plain language: The first double-blind RCT to date evaluating the effect of lutein ester on choroidal thickness in myopic children. A total of 180 children aged 8–12 received 8 mg/day of lutein ester for 6 months. It significantly reduced subfoveal and temporal choroidal thinning, but no significant differences in axial length or refraction were observed.

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    Williams KM, Bentham GC, Young IS, et al. (2017). Association between myopia, ultraviolet B radiation exposure, serum vitamin D concentrations, and genetic polymorphisms in vitamin D metabolic pathways in a multicountry European study. JAMA Ophthalmology, 135(1): 47–53. DOI ↗

    In plain language: A multicountry European observational study (n=3,168) found that greater UVB exposure was associated with a lower risk of myopia (especially in adolescents and young adults), and this association was independent of years of education; no direct role of vitamin D in myopia risk was found. After adjustment, the highest quintile of plasma lutein was associated with reduced myopia risk (OR=0.57, 95%CI 0.46–0.72).

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    Tong N, Zhang W, Zhang Z, Gong Y, Wooten B, Wu X. (2013). Inverse relationship between macular pigment optical density and axial length in Chinese subjects with myopia. Graefe’s Archive for Clinical and Experimental Ophthalmology, 251: 1495–1500. DOI ↗

    In plain language: An observational study in a Chinese myopic population (n=173, MSE≤-1.00D) confirming that MPOD is inversely correlated with axial length.

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    Yoshida T, Takagi Y, Igarashi-Yokoi T, Ohno-Matsui K. (2023). Efficacy of lutein supplements on macular pigment optical density in highly myopic individuals: A randomized controlled trial. Medicine, 102(12): e33280. DOI ↗

    In plain language: A randomized, double-blind, placebo-controlled trial in highly myopic adults; 22 eyes were enrolled and received 20 mg/day of lutein for 6 months. Overall, there was no significant between-group difference in MPOD; a significant increase was seen only in the subgroup with axial length <28.25 mm (P=0.02). No significant effect on axial length or refraction was found.

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    Ma L, Liu R, Du JH, et al. (2016). Lutein, zeaxanthin and meso-zeaxanthin supplementation associated with macular pigment optical density. Nutrients, 8(7): 426. DOI ↗

    In plain language: A meta-analysis (pooling 20 RCTs) confirming that lutein, zeaxanthin, and meso-zeaxanthin supplementation improves MPOD in both AMD patients and healthy populations, with a dose-response relationship.

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    Wilson LM, Tharmarajah S, Jia Y, et al. (2021). The effect of lutein/zeaxanthin intake on human macular pigment optical density: A systematic review and meta-analysis. Advances in Nutrition, 12(6): 2244–2254. DOI ↗

    In plain language: A systematic review and meta-analysis pooling multiple RCTs, confirming that MPOD increases with lutein/zeaxanthin intake in a dose-dependent manner, with clear evidence of benefit at daily intakes above 10 mg, while doses below 5 mg remain uncertain.

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    Age-Related Eye Disease Study 2 (AREDS2) Research Group. (2013). Lutein + zeaxanthin and omega-3 fatty acids for age-related macular degeneration: the Age-Related Eye Disease Study 2 (AREDS2) randomized clinical trial. JAMA, 309(19): 2005–2015. DOI ↗

    In plain language: A landmark RCT of nutritional intervention in ophthalmology (n=4,203). Adding lutein + zeaxanthin and/or omega-3 to the AREDS formulation did not further reduce the risk of progression to advanced AMD in the primary analysis. Subsequent analyses suggested that lutein + zeaxanthin may be protective in individuals with low baseline dietary lutein/zeaxanthin intake.

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    Zhang XJ, Zhang Y, Zhang YJ, et al. (2025). Dietary omega-3 polyunsaturated fatty acids as a protective factor of myopia: the Hong Kong Children Eye Study. British Journal of Ophthalmology, 2025, 110(1): 101–106. doi: 10.1136/bjo-2024-326872. DOI ↗

    In plain language: The Hong Kong Children Eye Study, n=1,005, children aged 6–8. This cross-sectional observational study found that children in the highest quartile of dietary omega-3 intake had shorter axial lengths (23.08 mm vs 23.29 mm) and more hyperopic refraction (+0.23D vs -0.13D).

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    Pan M, Zhao F, Xie B, et al. (2021). Dietary omega-3 polyunsaturated fatty acids are protective for myopia. Proceedings of the National Academy of Sciences (PNAS), 118(43): e2104689118. DOI ↗

    In plain language: Animal experiments combined with a human intervention study. Omega-3 PUFAs were shown to inhibit axial elongation in form-deprivation myopia models in guinea pigs and mice; in healthy adults, they alleviated the decline in choroidal blood perfusion caused by near work.

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    Omar IAN. (2018). Effect of bilberry extract on slowing high-myopia progression in children: 2-year follow-up study. Clinical Ophthalmology, 12: 2575–2579. DOI ↗

    In plain language: A prospective case-control study from Egypt, n=64 children with high myopia. Oral Difrarel (a bilberry-extract anthocyanin compound formulation) slowed axial elongation and myopia progression, with effects persisting one year after discontinuation. Non-randomized design, small sample, and compound formulation mean the evidence level is limited.

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    Sekikawa T, Kizawa Y, Takeoka A, et al. (2021). The effect of consuming an anthocyanin-containing supplement derived from Bilberry (Vaccinium myrtillus) on eye function: A randomized, double-blind, placebo-controlled parallel study. Functional Foods in Health and Disease, 11(3): 116–146. DOI ↗

    In plain language: An RCT of 32 healthy adults; six weeks of bilberry anthocyanins at 43.2 mg/day suppressed the decline in accommodative function caused by VDT use.

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    Lin T, Hu J, Wen Q, et al. (2024). Protective effects of docosahexaenoic acid combined with bilberry extract on myopic Guinea pigs. Frontiers in Medicine, 11: 1502612. DOI ↗

    In plain language: An animal experiment; DHA combined with bilberry extract delayed myopia progression in myopic guinea pigs, with the combination outperforming either DHA or bilberry extract alone.

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    Zhu MH, Wen Q, Lin TN, et al. (2025). The impact of bilberry extract combined with docosahexaenoic acid on the expression of Chrnb4 gene in the sclera of myopic guinea pigs. Frontiers in Medicine, 12: 1590362. DOI ↗

    In plain language: An animal experiment; bilberry extract combined with DHA inhibited scleral remodeling through multiple pathways: upregulating Chrnb4 gene expression, modulating the TGF-β/MMP-2/TIMP-1 signaling pathway, and enhancing dopamine levels.

Comprehensive Intervention & Personalized Management 10

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    Chia A, Chua WH, Cheung YB, et al. (2012). Atropine for the treatment of childhood myopia: safety and efficacy of 0.5%, 0.1%, and 0.01% doses (Atropine for the Treatment of Myopia 2). Ophthalmology, 119(2): 347–354. DOI ↗

    In plain language: Two-year results of the ATOM2 study in 400 children aged 6–12, confirming that atropine at 0.5%, 0.1%, and 0.01% is effective at all three concentrations, with a concentration-dependent effect. The 0.01% concentration had the fewest side effects; its 3-year post-discontinuation follow-up (Chia 2016, Ophthalmology 123: 391–399) showed the weakest rebound with 0.01%, establishing its place in clinical use.

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    Yam JC, Jiang Y, Tang SM, et al. (2019). Low-Concentration Atropine for Myopia Progression (LAMP) Study: A Randomized, Double-Blinded, Placebo-Controlled Trial of 0.05%, 0.025%, and 0.01% Atropine Eye Drops in Myopia Control. Ophthalmology, 126(1): 113–124. DOI ↗

    In plain language: The LAMP study (438 myopic children aged 4–12) confirmed that atropine at 0.05%, 0.025%, and 0.01% all effectively slowed myopia progression and axial elongation in a concentration-dependent manner. The 0.05% concentration was the most effective, and all three concentrations were well tolerated.

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    Ohno-Matsui K, Igarashi-Yokoi T, Migita Y, et al. (2025). Efficacy and Safety of Low-Concentration Atropine in Slowing Myopia Progression in Children in Japan: The Randomized, Double-Blind Phase 2/3 ORANGE Study. Ophthalmology Science, 2025, 6(1): 100960. DOI ↗

    In plain language: Japan's ORANGE study confirmed that 0.025% atropine is more effective than 0.01%, with only a mild rebound effect after discontinuation.

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    Gebreselassie MG, Tefera Betru K, Alemayehu W, et al. (2026). The effectiveness of atropine 0.05% eye drops versus placebo on controlling myopia progression among school children in randomized controlled trials: a systematic review and meta analysis. BMC Ophthalmology, 26: 41. DOI ↗

    In plain language: The latest systematic review and meta-analysis (11 RCTs, 1,967 children) confirmed that 0.05% atropine slows annual myopia progression by 0.49D and axial elongation by 0.18 mm per year.

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    Zhangzhou Aiyan Eye Clinic. (2026). Clinical Efficacy Report of the 6S 3.0 Combination Protocol: Cohort Data from June 2025 to June 2026 (113 children/226 eyes). Internal clinical archives (in Chinese). no DOI — print/Chinese-language source

    In plain language: Real-world data based on the 6S 3.0 combination intervention protocol, covering children across the full spectrum from pre-myopia to moderate-to-high myopia. 70.3% achieved axial length regression ≥0.1 mm with refractive error reduced by ≥0.25D, 33.6% achieved strong regression, and 9.2% had refractive error fully cleared to 0.00D. (Note: Internal clinical data, not peer-reviewed; cite with caution.) (unpublished internal clinic data)

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    Xiong R, Wang W, Tang X, et al. (2024). Myopia Control Effect of Repeated Low-Level Red-Light Therapy Combined with Orthokeratology: A Multicenter Randomized Controlled Trial. Ophthalmology, 131(11): 1304–1313. DOI ↗

    In plain language: A multicenter RCT that enrolled 48 children aged 8–13 with poor myopia control on orthokeratology lenses (axial length growth ≥0.50 mm within 1 year). At 12 months, axial length change in the combination group was -0.02 mm (essentially zero growth), versus +0.27 mm in the Ortho-K-only group, a between-group difference of -0.29 mm (95% CI -0.44 to -0.14, P<0.001), confirming that RLRL combined with Ortho-K is highly effective for children whose myopia is poorly controlled on Ortho-K alone.

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    Wu G, Dai X, Tian J, Sun J. (2024). Efficacy of repeated low-level red-light therapy combined with optical lenses for myopia control in children and adolescents. Am J Transl Res, 16(9): 4903–4911. DOI ↗

    In plain language: This study shows that repeated low-level red-light (RLRL) therapy combined with optical lenses (such as Ortho-K lenses, defocus spectacle lenses, or single-vision lenses) can effectively control myopia progression in children and adolescents.

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    Yang Y, Liu S, Gao W, Wang L, Liu N, Zhang S, et al. (2025). Synergistic effect of defocus incorporated multiple segment glasses and repeated low level red light therapy against myopia progression. Scientific Reports, 15: 3996. DOI ↗

    In plain language: A retrospective cohort study (not an RCT), confirming that the effect size of DIMS combined with RLRL against myopia progression is significantly greater than RLRL alone (p=0.0009) or DIMS alone (p<0.0001).

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    Zhang XJ, Zhang Y, Yip BHK, et al. (2024). Five-Year Clinical Trial of the Low-Concentration Atropine for Myopia Progression (LAMP) Study: Phase 4 Report. Ophthalmology, 131(9): 1011–1020. DOI ↗

    In plain language: The 5-year follow-up report of the LAMP study. Continuous use of 0.05% atropine for 5 years showed good myopia control; if myopia progressed after discontinuation, as-needed (PRN) re-initiation of 0.05% atropine could effectively control progression. This confirms the long-term efficacy of low-dose atropine and the effectiveness of an as-needed restart strategy.

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    Lawrenson JG, Shah R, Huntjens B, et al. (2025). Interventions for myopia control in children: a living systematic review and network meta-analysis. Cochrane Database of Systematic Reviews, 2025, Issue 2, Art. No.: CD014758. DOI ↗

    In plain language: A Cochrane living systematic review that uses network meta-analysis to evaluate the relative efficacy and safety of myopia control interventions in children.

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    Haarman AEG, Enthoven CA, Tideman JWL, et al. (2020). The Complications of Myopia: A Review and Meta-Analysis. Investigative Ophthalmology & Visual Science, 61(4): 49. DOI ↗

    In plain language: A systematic review and meta-analysis of myopia complications covering studies worldwide, quantifying the risk of blinding complications at each diopter level: retinal detachment odds ratio (OR) 3.15x for low myopia, 8.74x for moderate, and 12.62x for high; myopic macular degeneration (MMD) OR 13.57x for low, 72.74x for moderate, and 845.08x for high—risk climbs exponentially with diopter level, providing an authoritative data source for the "high myopia complications" section of Chapter 2.

Outdoor Light Exposure and the Choroid 2

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    Read SA, Alonso-Caneiro D, Vincent SJ, Collins MJ. (2015). Longitudinal changes in choroidal thickness and eye growth in childhood. Investigative Ophthalmology & Visual Science, 56(5): 3103–3112. DOI ↗

    In plain language: A 15-month longitudinal study showing that the choroid normally thickens as children grow, and that greater choroidal thickening is associated with slower axial eye growth—establishing choroidal thickness change as an early biomarker of eye growth.

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    Ogawa M, Torii H, Yotsukura E, et al. (2025). Intensive outdoor activity for 1 week increases choroidal thickness in Japanese schoolchildren: a prospective observational study. BMC Ophthalmology, 25(1): 300. DOI ↗

    In plain language: A prospective observational study showing that just one week of intensive outdoor activity significantly increased choroidal thickness in Japanese schoolchildren—direct evidence that outdoor exposure produces rapid, measurable structural changes in the eye.

A note on the 11 entries without DOI links: they are Chinese-language journal articles, government survey reports, or national standards that do not register DOIs — we list them in full so readers with access to Chinese databases (CNKI, Wanfang) can locate them. Every other entry's DOI was individually verified against the Crossref registry in October 2026. Superscript numbers in the book's main text correspond to the [#] numbers here. References [9][16][30][38][39][46][47][59][72][95] are further-reading suggestions not directly cited in the main text.

By · 25 years in children's myopia prevention, creator of the 6S Method · This page is educational content, not medical advice.

Keep reading

5+ years of defocus-lens data

The long-term DIMS and Stellest evidence, translated for parents.

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What the trials show, and the monitoring that makes it responsible.

The book: No More Myopia Panic

The full method, with all 98 references annotated in Appendix 1.