The conceptual evolution of myopia management: from refractive correction to axial-length-based risk modulation

This article synthesizes the major conceptual and therapeutic transformations in myopia management from the early twentieth century to the present era of designed defocus and multimodal care, examining how myopia evolved from a simple refractive inconvenience into a measurable disorder of ocular growth and a global public-health concern.

This article presents a conceptual synthesis of the historical evolution of myopia management using PubMed and Scopus (through 14 February 2026), supplemented by selected historical ophthalmology texts. The search included combinations of the terms "myopia", "axial elongation", "atropine", "orthokeratology", "defocus lenses", "myopia control", and "epidemiology". Priority was given to landmark trials, historical publications, and studies representing conceptual or methodological advances. Evidence was selected based on methodological rigor and historical or conceptual impact. The identified literature was synthesized into six interpretative phases reflecting progressive shifts in theoretical models, outcome measurement, and clinical objectives.

Six major conceptual phases were identified, marking a transition from optical compensation (1900-1950) to early therapeutic experimentation (1950-1980), biometric and experimental consolidation (1980-2000), conceptual paradigm shift (2000-2010), evidence-based myopia control (2010-2020), and the current era of designed defocus and multimodal strategies (2020-present). The introduction of axial length as a structural endpoint, together with large-scale epidemiology and randomized controlled trials, reframed myopia as a dynamic growth disorder. Pharmacologic modulation with low-dose atropine, corneal reshaping techniques, multifocal and dual-focus contact lenses, and defocus-incorporated spectacle designs have consistently demonstrated reductions in axial elongation. Even modest annual slowing of eye growth may translate into substantial reductions in lifetime risk of myopia-related complications. While interventions are primarily applied in childhood, their ultimate objective is the reduction of adult myopia-related morbidity.

Over the past century, myopia management has shifted from an optical correction to a careful control of axial elongation. The convergence of structural measurement, experimental evidence, and rigorous clinical trials has redefined therapeutic goals, aligning individual patient care with population-level risk reduction. This evolution highlights current preventive and personalized strategies and predicts further advances toward anticipatory modulation of ocular growth.