Myopia is a disease (1) that has reached epidemic proportions (2), for which the World Health Organization had been endeavoring, for more than 10 years, to convene all relevant stakeholders to mitigate its impact on public health (3).
Substantial time, resources, and energy have been dedicated to elucidating the mechanisms underlying the onset of myopia and comprehending its developmental stages, while also investigating optical and pharmacological methods of decelerating its progression.
Recent research has elucidated that the process of myopia initiates when emmetropization natural process fails (4). This disruption occurs particularly in the presence of significant risk factors [genetics (5), under-exposure to outdoors light (6), prolonged reading and screen time (7) at close range under low lighting conditions, urban living environment (8), diet rich in carbs (9)and sodium (10), etc.] and when the retina is unable to adequately interpret the optical signal transmitted to it.
The quality of the visual signal is a pivotal factor in guiding ocular growth beyond the standard physiological growth of the human eye (11). From a practitioner’s perspective, this represents the only factor that he can manipulated directly to affect the progression of myopia.
As an eyecare professional, the standard of practice requires the prevention of ophthalmic diseases or to limit their complications. In the case of myopia, the initial step is to accurately measure the refractive error, which includes a binocular vision assessment. This is followed by a diagnosis and characterisation of the myopia. The treatment of myopia is then undertaken using contemporary myopia control methods. The cooperation of patients and parents is ensured by providing them with adequate information about the condition. Recommendations are made regarding appropriate treatments, lifestyle, schooling, diet, and care of prescribed lenses. Finally, a follow-up schedule is established based on whether the patient’s condition is progressive or not and the severity of their impairment.
The study by Lu et al. (12) provides further insight and suggests an effective means of intervention to prevent or delay myopia. This concerns a group of patients at risk, i.e., with low hyperopia before the age of 8 years old (13), for whom few methods are sufficiently documented. It has been shown that delaying the onset of myopia greatly influences final refraction in adulthood (14), and each month gained reduces the risk of blinding pathologies in the future.
Critical analysis of the study
The study’s design is commendable in terms of randomisation, blinding, and measurements. However, its duration is limited, which is a notable drawback given the transient nature of intervention outcomes (15), particularly after the first year. It would have been advantageous to extend the measurement period to ascertain the cohort’s evolution.
The participants of the study were required to wear either defocus glasses or single vision glasses. Additionally, a group was administered low-dose atropine medication while wearing glasses. The first element to consider here is the capacity of the optical device to modify the visual signal. The design of the lens used is similar to known technologies [Defocus Incorporated Multiple Segments (DIMS), Highly Aspherical Lenslet (HAL)] and has proven effective in other randomized studies (16). It provides a sufficient dose of defocus to influence axial progression.
The article makes no mention of the criteria for fitting the defocus lenses, including selecting an appropriate frame, which represents a significant shortcoming. Defocus glasses can lose almost all their effectiveness if the frame is too small or if the eye is poorly centered, the visual system being underexposed to peripheral defocus as a result. In addition, it is imperative that the glasses are worn consistently. It has been proven that children who do not wear their glasses consistently experience a more significant progression of myopia than others (17). There is no indication of measures to control lens wear, which may alter the study’s conclusions.
The data demonstrate that wearing diversified segmental defocus optimization (DSDO) lenses, with or without atropine, reduces the transition from emmetropia to myopia in the cohort under study. It is interesting to express the results in terms of axial length and choroidal volume, rather than as a percentage, as the latter can be misleading.
There are several possible reasons why atropine does not provide any additional benefit. Firstly, it should be noted that the medication is a compound, and as such, its concentration may vary from one bottle to another, and from time to time. Unfortunately, no mechanism was put in place to verify the accuracy of the concentration of atropine provided during the study.
Second, the prescribed dose was most likely lower than what the participants needed to control their axial length progression. Atropine generates a dose-response with the retina (18). It has been demonstrated that higher concentrations provide enhanced control. In this study, the clinical population consisted of a mix of participants, including both pre-myopes (+1.00D to −0.50D) and low-myopes (>−0.50D). It is therefore possible that this mix affected the efficacy of the 0.01% concentration, whereas in another study , 0.01% was associated with positive results when used in combination with other defocus glasses (19). Another study showed that a 0.025% concentration demonstrated modest but significant efficacy in pre-myopic children (20), reinforcing the concept of a dose-response relationship and the benefits of using higher concentrations in younger patients. Third, as constant lens wear is crucial, compliance with atropine instillation must be monitored, which was not done. This pharmaceutical agent generates a few side effects (photophobia, reduced accommodation—difficulty to read at close distance—and burning sensation upon instillation) that result in low treatment adherence. The burning sensation comes from the need to lower the pH of the compound medication to keep its stability over a month. This makes instillation uncomfortable, and many children may decline to take the medication or space out the doses to avoid discomfort. Other barriers include parental neglect, lack of understanding of long-term drug use, lack of friendly medical service (21). It would have been interesting to monitor compliance during the study.
This is why authors must adopt a humbler stance when making assertions such as “These findings highlight DSDO’s exceptional efficacy rather than disproving atropine’s value in other contexts.” This assertion is not supported by the results of the study. Statistical significance must be differed from clinical significance when results are analyzed.
In relation to the analysis of the choroidal response, it should be noted that although the device employed (Topcon Triton) is generally reliable, it does not possess an eye tracker to ensure that the measurement is consistently taken at the same location. Consequently, the result varies depending on the quality of the fixation. It is questionable that the young children in this cohort consistently fixated their gaze at precisely the same location during each of the tests over a 12-month period. This is unfeasible. Therefore, the choroid data should be interpreted with caution. Furthermore, when examining the raw data, beyond statistical significance, the differences are negligible and are less than the measurement error inherent in the device. Consequently, the choroidal findings should be interpreted with caution and should not be overemphasized in clinical interpretation, given the inherent measurement variability.
Finally, I find the study’s conclusion overwhelming optimistic. “Thus, DSDO lenses present a safer and more acceptable option for children without myopia, with strong efficacy and minimal adverse effects.” It is true that, based on this study, DSDO lenses help delay myopia. However, the absence of a statistically significant additive effect of atropine in this study should be interpreted cautiously, as it does not exclude a potential benefit under different concentrations, populations, or longer follow-up. This statement from the authors should not be considered supported by the data presented. They should adopt a much more measured tone when discussing the benefits of the lens under study.
Conclusions
That being said, this type of defocus lens for myopia control seems to be effective. It could be even more efficient by using other concentrations of atropine or by studying it in combination with other populations. This means that further research is needed before the evaluation of this lens can be considered complete. In the meantime, it may remain an option to prevent myopia onset if compliance, frame selection and fitting are assured.
Acknowledgments
None.
Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Translational Medicine. The article has undergone external peer review.
Peer Review File: Available at https://atm.amegroups.com/article/view/10.21037/atm-2026-1-0007/prf
Funding: None.
Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-2026-1-0007/coif). L.M. reports grants from Bausch and Lomb, Essilor, and Rimonchi Capital to the institution, consulting fees from Johnson and Johnson and Bausch and Lomb, and honoraria from Bausch and Lomb. The author has no other conflicts of interest to declare.
Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
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Cite this article as: Michaud L. Comments on Diversified segmental defocus optimization lenses with and without atropine for myopia prevention: a randomized clinical trial. Ann Transl Med 2026;14(4):58. doi: 10.21037/atm-2026-1-0007
