Why This Article Matters
Summary
Brennan and colleagues provide a 2025 update of their 2019 review examining commonly held beliefs in myopia and myopia control that may not be supported by robust evidence. This narrative, evidence-focused review revisits the original 10 topics and introduces nine additional beliefs, drawing primarily on peer-reviewed literature published during the intervening five years, without a prespecified systematic review methodology. The authors critically examine pharmacological, optical, behavioural, epidemiological, and methodological issues, including the efficacy of 0.01% atropine, peripheral hyperopic defocus, undercorrection, the interpretation of percentage treatment effects, digital-device exposure, outdoor time, the definition and classification of myopia, adult progression, treatment initiation, “nonresponse,” contact-lens safety, red-light therapy, and rebound after treatment cessation. The review concludes that several widely repeated claims are unsupported or require substantial qualification. In particular, 0.01% atropine is judged unsuitable as a sole frontline treatment; treatment efficacy is better expressed in absolute rather than percentage terms and generally diminishes over time; progression may continue into adulthood; prior progression is an unreliable prerequisite for initiating treatment; contact-lens wear in children can be considered acceptably safe with appropriate practice; rebound should be assessed against progression or axial elongation expected in an untreated matched group, rather than against the suppressed progression observed during treatment. Other questions, including the causal role of handheld devices and relative peripheral hyperopia, remain unresolved. The authors emphasise that clinical beliefs should be updated only when supported by convergent, high-quality evidence.
Commentary
Limitations
The main limitation is methodological. This is a narrative, author-selected review rather than a systematic review with a prespecified search strategy, eligibility criteria, formal risk-of-bias assessment, or certainty-of-evidence grading. As a result, readers cannot readily determine whether all relevant evidence was captured or how study selection may have influenced the direction and strength of individual conclusions. Consequently, the classification of beliefs as “resolved,” “partially resolved,” or “unresolved” depends partly on expert interpretation, and the strength of some conclusions remains dependent on the quality and heterogeneity of the underlying evidence. The article’s intentionally provocative style improves readability but occasionally compresses nuanced debates into binary labels. In addition, the study was supported by Johnson & Johnson, two authors are employees, one is a former employee, and several authors report extensive industry relationships. These disclosures do not invalidate the analysis, but they should be considered when interpreting an author-selected narrative review addressing competing therapeutic modalities.
Clinical relevance
Clinically, the paper should be used as a corrective framework rather than as a stand-alone guideline. It supports earlier treatment rather than waiting to document rapid progression, careful longitudinal assessment of myopia progression, continued surveillance into young adulthood, cautious interpretation of apparent “nonresponse,” and a prudent approach to red-light therapy until adequate long-term retinal safety data are available.
Unanswered questions
Future research should use standardised outcomes, age-matched untreated comparators, prospective cessation designs, and head-to-head trials capable of resolving the remaining controversies.
Key Take-Home Messages
- Do not adopt widely repeated myopia-management claims without checking whether they are supported by robust, convergent evidence. - Do not use once-daily 0.01% atropine as sole frontline therapy when more effective evidence-based options are available. - Report and interpret treatment benefit primarily as an absolute reduction in axial elongation and refractive progression, not as a transferable percentage. - Do not delay treatment solely to document prior rapid progression; continue monitoring beyond adolescence, and do not equate fast progression during treatment with nonresponse. - Paediatric contact-lens wear should not be considered inherently unsafe; appropriate lens selection, fitting, hygiene, and surveillance remain essential.
Conflict of Interest Statement
The author declares no conflict of interest related to this article.
Strengths
The principal strength of this review is its clinical relevance. It focuses on statements that directly influence prescribing, counselling, follow-up, and the interpretation of treatment response. The authors repeatedly distinguish association from causation, absolute from relative efficacy, and observed progression during treatment from the counterfactual progression that would have occurred without treatment. These distinctions are particularly valuable in a field where percentage treatment effects may be misleading when extrapolated across different ages, populations, baseline progression rates, or treatment durations, whereas absolute treatment effects provide a more clinically meaningful basis for comparison. The discussion of 0.01% atropine, adult progression, treatment initiation, paediatric contact-lens safety, and rebound provides clear examples of how recent evidence can correct entrenched practice patterns.