Access to Myopia Care in the United States—A Narrative Review

Abstract

This review describes the evidence related to the burden of myopia and the status of access to myopia care, including detection, treatment, and management, in the United States. It examines the societal impact of myopia, vision screening guidelines from professional organizations, and state mandates on vision screening. Using the Anderson–Newman framework, the review evaluates access to and utilization of myopia care. It identifies knowledge gaps and barriers, offering strategies to improve access to myopia care and management. Improving access to comprehensive myopia management will require collaboration among stakeholders to address research gaps and develop policies that promote equitable access to the detection, treatment, and management of myopia, particularly for populations at high risk of adverse outcomes.

 

Key Recommendations for Enhancing Access to Myopia Care

 

The following strategies are recommended to improve access to comprehensive myopia care, based on the findings from this review:

 

Societal Impact of Myopia

 

• • Gather more data on myopia to understand its impact on…  
  • • The burden of visual impairment
  • • Mental health effects
  • • Learning and educational outcomes
  • • Financial implications
• • Examine the relationship between socioeconomic status and myopia progression

 

Screening Guidelines & Policies

 

• • Improve consistency of vision screening guidelines across professional organizations
• • Align state mandates with established guidelines
• • Enhance early detection of myopia and its progression, with clear referral criteria and more frequent monitoring
• • Implement an integrated data system to improve care coordination, ensure timely follow-up, and monitor program effectiveness

 

Access to Myopia Care

 

• • Address barriers within the social determinants of health to imprvoe access to vision care
• • Raise public awareness about the importance of vision and myopia care to increase utilization
• • Increase practitioner knowledge to encourage the adoption of myopia management
• • Reclassify myopia as a medical diagnosis to improve insurance coverage and the affordability of long-term management
• • Conduct economic evaluations to assess the cost-effectiveness of various care models and myopia management treatments
• • Evaluate the impact of myopia management treatments on quality of life

Myopia has increasingly become a topic of interest in clinical care, among researchers and within the broader public. The World Health Organization (WHO) defines myopia as “a refractive error in which rays of light entering the eye parallel to the optic axis are brought into focus in front of the retina when ocular accommodation is relaxed. This usually results from the eyeball being too long from front to back, but can be caused by an overly curved cornea, a lens with increased optical power, or both.”¹ 

By 2050, half of the world's population is projected to have myopia, 10% of whom are projected to have high myopia.^2–4 The prevalence of myopia in North America is estimated to be up to 42% in children ages 10 to 15 years.⁵ These numbers are not precisely characterized in the United States, although national statistics have found an increase in the prevalence of myopia.⁶ The increasing prevalence of myopia has led to an exponential rise in myopia research since 2006, focusing on treatments to slow myopia progression. 

With the increasing pervasiveness of myopia, public health efforts are needed to help identify, treat, and manage the condition if more severe manifestations are to be mitigated. This paper seeks to understand the status of access to myopia detection and management and to discuss potential strategies to improve access to myopia care. The Anderson–Newman framework of health services utilization will be used to guide the analysis of access to care. 

Methods

A narrative review was conducted with the following overarching research goal: to review the literature regarding access to myopia care. The Anderson–Newman framework was used to understand barriers to access and utilization and inform strategies for improving access to vision care in the United States. The following research questions were prioritized by a committee of eyecare professionals and stakeholders from the National Academy of Science, Engineering, and Medicine (NASEM): 

• 1. What is known about the societal impact of myopia in the United States?
• 2. Is there consensus among vision screening guidelines from the following organizations: American Academy of Pediatrics (AAP), American Academy of Ophthalmology (AAO), American Academy of Optometry (AAOpt), American Association for Pediatric Ophthalmology and Strabismus (AAPOS), American Optometric Association (AOA), U.S. Preventative Services Task Force (USPSTF), WHO, and other relevant organizations?
• 3. What is the extent of research on access to vision screening in the United States?
• 4. What is the extent of research on the effectiveness of vision screening policies?
• 5. What research has been undertaken on access to myopia care, including myopia management?

This review includes all study designs, editorials, and opinion pieces to capture a diversity of research to address the broad research questions. A search of the gray literature was performed for discussion and comparison purposes but was not included in the initial search. The searches were conducted during November 2023. PubMed was searched using terminology specific to each research question. The terminology was determined by consensus of the authors and expert opinion. Major topics searched included myopia, myopia care and management, refractive error, myopia care, myopia control, myopia prevention, vision screening policy, vision impairment, healthcare access, blindness, low vision, and vision impairment. The search was limited to English-language publications and human research and was initially limited to research from 2006 to November 2023. The year 2006 was chosen as it marked the onset of a sharp increase in the number of journal articles published about myopia. Additionally, the articles had to be US based and address one of the identified research questions. PubMed was chosen for its broad citation scope, controlled vocabulary (MeSH), and flexible search options that ensure precision and relevance. 

PICO Portal, a platform for literature and systematic reviews, was used to conduct the review (PICO Portal, St. Petersburg, FL, USA; www.picoportal.org). Abstract screening and subsequent full text reviews were performed by two independent reviewers, and any conflicts were resolved by a third adjudicator. Data extraction and analysis were performed by a single reviewer using a pre-specified data extraction tool that included the following categories: publication year, methods (population, sample size, setting), key findings, other relevant notes, article type, and study type. 

The search retrieved 5091 articles with 249 duplicates removed before the initial screening. After the remaining 4842 articles were screened, 240 were deemed eligible for inclusion in the review. During the review and writing process, additional articles were identified and included through reference lists and expert recommendations to provide further insights into answering the research questions. Some of these articles predated the original 2006 search criteria. The process was iterative and inclusive to capture the breadth of the literature. The following is a narrative analysis of the articles included in the review. In describing the research findings, various racial and ethnic identities are identified in the literature. Acknowledging the social construction of race and ethnicity and their evolving definitions, the authors of this paper have used categories as defined by the U.S. Census Bureau, but when referencing specific studies, they maintained the language used by the authors of each study. 

Results

Societal Impact of Myopia

The risk of visual impairment from all causes differs based on race, ethnicity, immigration status, and other social and cultural factors, including social determinants of health. For children, increased likelihood for visual impairment is associated with being female; having public health insurance; belonging to Black, Hispanic, or White racial or ethnic groups; having mothers in poorer physical and mental health; residing in single-parent households; and having parents with lower median income and lower educational attainment.^7–10 Access to care and utilization of services has an impact on eye health outcomes, particularly as it relates to populations that experience health disparities. 

The prevalence of correctable visual impairment from all causes nationwide has been estimated at 4.1% if including both children and adults¹¹ and 3.7% to 4.4% when considering adults solely.¹² An estimate of the level of correctable visual impairment from myopia specific to the US population was not found in this review. However, the prevalence of myopia in the US population has significantly increased over the last 50 years.¹³ In the school-based Collaborative Longitudinal Evaluation of Ethnicity and Refractive Error (CLEERE) study, approximately 9.2% of children ages 5 to 17 years were found to be myopic, with the prevalence rising to 18.5% among Asian children.¹⁴ This suggests that 1 in 11 children in the United States has myopia. Moreover, according to a meta-analysis, myopia ranked as the primary cause of uncorrected refractive errors in female children ages 12 to 17 years.¹⁵ There is also evidence that COVID-19 pandemic–associated lockdowns accelerated the progression of myopia in children.¹⁶ 

As a mosaic of innumerable ethnicities and cultures, the United States is a challenging country to compare with most countries in terms of refractive error. This is demonstrated by studies that have found the prevalence of myopia to be measured at varying levels across age, gender, ethnicity, and class structure in the United States.^17–26 For example, Chinese Americans were found to have a significantly higher prevalence of myopia (35.1%) compared to White, Hispanic, and Black Americans (21.0%–25.9%, 17.6%, and 18%, respectively).¹⁹ Data from the Chinese American Eye Study revealed that 7.4% of participants had high myopia, which was defined as a spherical equivalent of greater than −5.00 diopters (D).¹⁹ Studies have also found that the Asian American population increased by 48% between 1990 and 2000^27,28 and that Asian American children have the highest incidence and prevalence of myopia compared to other minoritized groups in the United States.^18,19 

Other studies have found differences in the rate of increase in the prevalence of myopia among racial and ethnic groups and differences in associated risk factors. Chiang et al.²⁹ found high odds of myopia development in Hispanic and Mexican American groups. Risk factors for high myopia in the adult Latino population include higher educational status and more acculturation to the United States.³⁰ Interestingly, the prevalence of myopia has increased significantly in both Black and White populations in the United States between 1971 and 2004, with a relatively higher increase observed in Black Americans.¹³ This was speculated to be due to the decrease in educational inequities and subsequent increase in near work. With the rising prevalence of myopia, especially among this expanding segment of the population, one can understand how researchers and clinicians have characterized myopia as an epidemic. 

Complications of Severe Myopia

Pathologic myopia is defined by the International Myopia Institute (IMI) as “excessive axial elongation associated with myopia that leads to structural changes in the posterior segment of the eye (including posterior staphyloma, myopic maculopathy, high myopia-associated optic neuropathy, and retinal detachment) and can lead to loss of best-corrected visual acuity.”³¹ The IMI has proposed standardized definitions and classifications for pathologic myopia to improve research consistency.^31,32 High myopia affects an estimated 3.92% of the population, with myopic choroidal neovascular membrane occurring in 0.017%.³³ Additionally, a study found that 17.3% of children with retinal detachment also had myopia.³⁴ Based on the Los Angeles Latino Eye Study, pathologic myopia was the third leading cause of blindness.³⁵ Myopia has also been linked to primary open-angle glaucoma (POAG),^36–40 with stronger associations observed in moderate cases of myopia.³⁸ An examination of the literature reveals a stronger association between myopia and POAG in minoritized individuals and populations experiencing health disparities.^36,41 

Mental Health and Quality of Life

The potential for visual impairment due to severe myopic progression raises important considerations regarding its impact on quality of life. Evidence shows that visual impairment is associated with depression, anxiety, and other psychological factors,^42,43 although the available research on this topic is limited. Children with visual impairment from various causes are known to participate in fewer physical activities⁴⁴ and be more socially isolated.^45,46 

Individuals with high myopia and particularly those with pathologic myopia are reported to experience a lower quality of life due to financial constraints and the psychological burden resulting from their reduced visual experience.^42,47,48 Furthermore, parents often perceive a lower quality of life for their child when their child has high myopia.⁴⁹ 

Visual correction can improve quality of life and well-being across diverse age groups and identities.^50–53 Evidence shows that successful vision screening and the provision of spectacles can significantly enhance children's educational well-being and quality of life, mitigate anxiety, and bolster mental health.^51,54 However, wearing spectacles can also negatively impact the quality of life for both children and parents.^55,56 

Learning and Educational Attainment

There is concern about the impact of reduced vision on education and learning in children. Among those struggling academically, a study found that 34% had hyperopia, 12% had myopia, and 14% had emmetropia.⁵⁷ Other studies have found that providing corrective lenses has a positive impact on school function and academic performance, although these results should be taken with caution due to small sample sizes and the presence of confounding variables.^50,58–60 The IMI and others have suggested that higher levels of education are a risk factor for myopia.^52,61,62 This complexity makes it challenging to assess the direct impact of uncorrected myopia on learning. Further research is needed to better understand this association. 

Financial Burden

Uncorrected refractive error is a significant cause of lost labor productivity worldwide.⁶³ In 2015, the global productivity loss associated with visual impairment from myopia was estimated at $US244 billion in 2015, and the loss resulting from myopic macular degeneration was projected to be $US6 billion.⁶⁴ The greatest losses were projected to occur in Southeast Asia. This review did not identify any studies specifically addressing loss of productivity from myopia isolated to the United States. 

In the United States, an estimated 58.7% of adult men with visual impairment and uncorrected refractive error are employed compared to 76.2% of men with “normal” vision.⁶⁵ The disparity is even greater for women, with an estimated 24.5% with visual impairment and 56% with uncorrected refractive error being employed as compared to 62.9% of with “normal” vision. A 2006 analysis found that the annual direct cost of correcting distance visual impairment for individuals 12 and older in the United States was at least $3.9 billion, with $967 million accounting for the cost associated with providing an individual's first pair of glasses.¹¹ The costs associated with using refractive aids as well as the impact on the workforce place a significant burden on individuals and on society.⁶⁶ It is important to note that these estimates do not isolate myopia from other types of refractive error. Even without myopia-specific data, some organizations have concluded that the potential gains in productivity, quality of life, and reduced socioeconomic impact of treating myopia far outweighs the cost for correcting it.⁴⁸ 

Overall, there appears to be an increasing societal impact of myopia as it relates to ocular complications, visual impairment, mental health, quality of life, and financial burden. More information is needed to determine the specific impact in the United States. The first step in this process is an examination of how we screen for myopia. 

Vision Screening Guidelines

According to the WHO, vision screening is defined as “the presumptive identification of unrecognized disease or defect by the application of tests, examination, or other procedures which can be applied rapidly.” Screening tests sort out apparently well persons who probably have disease from those who probably do not.⁶⁷ Vision screenings are not a substitute for a comprehensive eye exam; rather, the primary goal of vision screening is to identify potential issues that warrant further assessment such as significant refractive errors, amblyopia, strabismus, and other ocular abnormalities⁶⁸ in the absence of broad access to comprehensive vision exams. 

Early detection and treatment of eye and vision disorders can mitigate or prevent issues related to impaired vision. Many pediatric eye and vision problems are asymptomatic, and some, such as amblyopia, can have irreversible long-term consequences if not treated promptly. Addressing amblyogenic factors early is important in preventing and managing amblyopia; similarly, it is also essential to detect and manage myopia early. 

Myopia commonly manifests in children during the early school years and typically progresses with age. Although blurry distance vision is a typical symptom of myopia, it may not be immediately noticeable or significant enough, or it may be perceived as normal, leading to a delayed diagnosis. Although the average prevalence of myopia is 3% among preschoolers,⁶⁹ screening for myopia in this population can lead to early detection and management. 

Variations in Vision Screening Guidelines

In the United States, vision screening guidelines established by various professional organizations exhibit certain commonalities, such as the importance of vision screening in childhood. However, there is variability in the components of these guidelines, including the age at which vision screenings are recommended, intervals between screenings, vision disorders targeted, screening settings, and personnel involved (Table). Ambrosino et al.⁷⁰ summarized the goals and components of pediatric vision screening in the United States and the guidelines for several professional organizations. The review of vision screening guidelines in this paper focuses on screening as it relates to myopia. 

Table.

 

Summary of Vision Screening Guidelines for Children

 

Methods for Vision Screening

The battery of vision screening tests for myopia can vary widely, ranging from a single test to multiple tests. Monocular distance visual acuity and instrument-based screenings are the predominant approaches. However, conducting monocular distance visual acuity screening can be challenging in young children as they often do not have the attention span required to complete the test.⁷¹ Studies have shown that only one-third of children 3 years old and one-half of children 4 years old can complete a visual acuity test of each eye.⁷² In such cases, instrument-based screening using devices such as photoscreeners^73–76 and retinal polarization scanners⁷⁷ is recommended.^78–86 Instrument-based screening offers a rapid objective assessment, requires minimal cooperation from the child, and can be particularly valuable in preverbal and preliterate children.^73–77 Despite the frequently observed elevated false-positive rate associated with instrument-based screening, its benefits for younger children (i.e., those under 5 years of age) have been noted.⁸⁷ Furthermore, this type of screening has been shown to be useful for children with developmental disabilities.⁸⁸ 

Instrument-based screening focuses on identifying significant refractive errors and detecting risks for amblyopia; however, current referral criteria may fail to detect early onset and lower amounts of myopia. The consensus-based referral guidelines for myopia have remained somewhat consistent over the last decade (e.g., <−3.00 D for <4 years and <−2.00 D for 4 years and older),^83,89 but considerations for a lower criteria threshold should be made due to faster myopia progression typically occurring at younger ages.⁹⁰ A balance between sensitivity and specificity of the criteria must be explored to avoid over-referrals while ensuring that children most at risk of developing or progressing myopia are not missed. The development of new screening instruments to detect onset and progression of myopia is crucial for improving access to myopia care. 

Researchers have explored strategies to enhance the accuracy of vision screening by incorporating multiple elements into the screening battery. The combined sensitivity of utilizing multiple screening tests is notably higher than that achieved by relying on a single test, especially when these tests are tailored to an age group.⁹¹ Furthermore, indirect evidence supports the utility of multiple screening tests for identifying preschool children at increased risk for vision problems.⁹² Alternatively, integrating screening tests with risk predictors could be beneficial. For example, when refractive error in first graders was combined with the number of myopic parents as predictors for myopia onset, the sensitivity and specificity were found to be 62.5% and 81.9%, respectively.⁹³ Relying on children to provide reliable data about their parents’ myopic history would be challenging; however, as data-sharing practices continue to evolve, integrating parental data from broader sources may become increasingly feasible to support approaches like this in the future. 

Vision Screening Age and Interval Recommendations

The Table summarizes the recommended ages and intervals for vision screening throughout childhood, revealing similarities and differences among the organizations. The USPSTF recommends a vision screening at least once in children ages 3 to 5 years but concluded that there was insufficient evidence to support vision screening in children younger than 3 years.⁸⁵ Other organizations, based on expert opinion and consensus, recommend screenings to begin in the first year and to continue throughout childhood.^82,86,94,95 The AAP Periodicity Schedule recommends a risk assessment from infancy until 2.5 years of age, with a vision screening to be performed each year from 3 to 6 years of age and every 2 years thereafter.⁷⁸ 

The natural history of myopia development necessitates consistent vision screening throughout the school-age years to identify the onset and progression of myopia. In the CLEERE study, 23.4% of children developed new cases of myopia (0.50 D or more) during the study period.¹⁸ The highest percentage of new cases occurred at age 11 years, with the onset spanning from 7 to 16 years. Given the progressive nature of childhood myopia and effective interventions available, screening examinations encompassing visual acuity are recommended every 1 to 2 years⁸²; however, not all guidelines align with this recommended frequency. The National Center for Children's Vision and Eye Health (NCCVEH) suggests establishing consensus on a systems-based approach to children's vision and eye health (i.e., a single set of inter-organizational guidelines).⁷⁹ 

Vision Screening Settings and Personnel

Several organizations suggest primary care settings (e.g., pediatricians’ offices) as access points for screenings. Additionally, community settings such as daycare programs, churches, schools, and health departments are recognized for their significant role in increasing access to vision screening. Personnel involved in conducting these screenings encompass a range of professionals, including healthcare providers such as physicians and nurses in clinical settings and trained screeners in community settings, as the personnel available often depends on the screening setting. 

Myopia and Vision Screening Guidelines

In 2022, the Joint Policy Statement by the AAO and AAPOS highlighted “myopia as a high-priority cause of visual impairment.”⁹⁶ The WHO also highlights the importance of detecting myopia in preschool-aged and school-aged children.⁹⁴ However, they did not provide criteria specifically for myopia detection. In summary, there exists a degree of consensus among vision screening guidelines regarding the importance of screening in childhood; however, there is variability in the components of vision screening programs, including the age at which vision screening is conducted, screening interval, vision disorders targeted by vision screening, screening settings, and personnel qualifications. These vision screening guidelines may lack the necessary sensitivity in identifying the onset of mild myopia and myopic progression. 

State Vision Screening Policies

State Mandates

In addition to the recommended guidelines established by various professional organizations, many states have legislation mandating vision testing; however, there is considerable variability among the states, including differences in where testing occurs, screening frequency, and the tests used.^100–104 Forty states and the District of Columbia have a vision testing requirement (41/51, 80%).¹⁰⁴ Although the majority of states require schools to conduct screenings, some states require a comprehensive eye exam prior to school entry. Of the states with mandates, nearly all require vision screening for school-aged children (40/41, 98%), and most extend vision screening requirements to preschool children (33/41, 80%). However, a significant number of states still do not require preschool vision screening, limiting access for this group. Despite the lower prevalence of myopia in this age group compared to hyperopia,^17,20,69,105 vision screening is essential not only for detecting amblyopia but also for initiating myopia treatment strategies early for those with risk factors.^106–110 

Vision screening policies vary widely in recommended frequency, ranging from once to annually across different states.¹⁰⁴ In states with a screening mandate, all require vision screenings in elementary school or a vision test prior to entry, with fewer mandating screenings in middle school and even fewer in high school. Considering the potential rapid progression of myopia during these years,^14,111,112 current screening practices do not effectively detect myopia or changes in myopia. A study conducted in Maryland, where vision screenings are mandated upon first entry, in first grade, and either in 8th or 9th grade, found worse presenting visual acuity with increasing age and a significantly higher failure rate in non-mandated grades compared to mandated grades.¹¹³ These findings suggest that the current frequency requirement may be inadequate for detecting vision problems. 

In the 10 states without vision screening mandates, some recommend screenings or reference vision screening guidelines.^101,104 Despite the absence of state requirements, South Dakota was conducting vision screenings in most of the public-school districts surveyed,¹⁰¹ although it was noted that their survey focused on the 14 largest school districts, which may have more resources. Despite vision screenings occurring, accessibility is not uniform as some schools may not implement them. Another consideration is that private schools are not obligated to adhere to state-mandated vision screening policies and have the flexibility to establish their own guidelines for vision screening. As such, determining the specific practices regarding vision screening is challenging. 

One study examined the relationship between state mandates and parent-reported vision testing in preschool children using the 2016 National Survey of Children's Health and found a significant association between states with mandates and higher vision testing rates.¹⁰⁰ Vision testing rates ranged from 41% (in Idaho, which lacks vision screening requirements) to 84% (in Minnesota, where vision screening is mandatory before school entry). This observed association was found in states with mandates at any childhood age, rather than specifically in those requiring preschool screening, yet it impacted vision testing rates in preschool children. This suggests that state policies contribute to improving timely screening for preschoolers. 

Although vision screening guidelines have been developed by various organizations, state mandates often do not align with these recommendations. The American Academy of Pediatrics and Bright Futures recommends vision screening at ages 3, 4, 5, 6, 8, 10, 12, and 15 years, with a risk assessment to be performed in all other years.⁷⁸ Only seven states meet this recommended schedule for vision screening in schools.¹⁰² There are alternative access points for vision screening, such as community screenings and wellness visits, but vision screenings are not consistently done. A study examining Medicaid claims for well-child checks found that children do not consistently attend these visits and providers do not consistently adhere to the recommended vision screening frequency.¹¹⁴ The attendance for well-child visits peaked at 57% for 4-year-olds, but the vision screening rate was only 23%. After this age, vision screening increased to 50%; however, attendance at these visits declined. 

In addition to the lack of standardization in screening age and frequency, there are variations in the screening tests utilized (e.g., some allow the use of instrument-based screening and others do not specify) and in referral criteria. Another factor to consider is the availability of personnel to conduct screenings, as challenges such as nursing shortages can hinder compliance with these mandates.¹¹⁵ Better consensus on guidelines and closer alignment of state mandates with established guidelines can play a crucial role in addressing these gaps to ensure that children are being screened. 

Vision Screening Outcomes

Despite established guidelines and state mandates, many children continue to experience correctable visual impairment. National Health and Nutrition Examination Survey (NHANES) data from 2005 to 2008 found that one in 10 adolescents 12 to 21 years of age had correctable distance visual impairment.¹¹⁶ In the 2018 to 2019 National Survey of Children's Health, which includes children 12 to <18 years old, vision testing was reported in 74% of adolescents.¹¹⁷ However, it was also observed that this percentage declined with age due to a decrease in reported testing at primary care visits and at school. 

Screening failure rates range from 5% to 34% based on various studies.^{58,76,112,113,118–122} The variability is attributed to differences in screening protocols and the demographics of the screened population. Distance visual acuity testing contributes to the highest number of failures, with studies finding 12% to 34% of screened children having reduced visual acuity that is largely correctable.^{58,112,113,116,119–122} In one study, 85% of children who failed the vision screening were prescribed glasses.⁵⁸ Another vision screening program found 84% of those with decreased visual acuity to be correctable, and within this group 73% were diagnosed with myopia.¹¹² Guo et al. also identified myopia as the most common refractive error, with a prevalence of 56% among those who did not pass the vision screening.¹¹¹ In a mobile clinic program for preschoolers, 87% of those requiring correction did not have any correction, and among this group 21% were found to have myopia.¹¹⁸ These examples underscore the importance of comprehensive vision screening programs and access to corrective measures in ensuring optimal visual health among children. 

An effective screening program must also ensure adherence to screening recommendations and prescribed treatments. Although vision screenings aim to identify individuals who might have vision problems, a comprehensive eye exam is necessary for accurate diagnosis and management. Unfortunately, adherence to screening recommendations has been observed to be poor, ranging from 25% to 65% as reported by studies that confirmed with scheduling or with exams.^{76,118–120,123} Another study found a higher rate of follow-up of 78%, although this was based on parent report and not directly confirmed.¹²⁴ Despite annual vision screenings, Bodack et al.¹²¹ observed a high failure rate in their program and attributed it to the lack of follow-up care. Another factor to consider is the timeliness of these follow-up visits. One study found that the average time for a referred child to see an eyecare provider was almost 2 years, with younger children having more significant delays than older children.¹²⁵ Studies examining barriers to follow-up care have identified various contributing factors affecting adherence, which are addressed in the next section.^{50,115,123,124,126–132} 

Evidence has shown that screening programs that provide glasses to children improve the utilization rate of glasses.¹³³ Although this addresses financial and logistical barriers to obtaining glasses, the challenge of ensuring compliance with spectacle wear remains, with reported rates ranging from 19% to 67%.^134–136 Several factors influence compliance with glasses wear, including addressing concerns such as discomfort or adaptation, encouragement from both parents and teachers to wear glasses, having a positive attitude toward their glasses, and having multiple pairs of glasses.¹³⁷ Programs incorporating many of these strategies have demonstrated improvement in compliance rates. Ethan et al.¹³⁵ improved compliance rates for glasses wear from 22% to 47%. Other programs have reported even higher rates, reaching as high as 87%.^138,139 The most common reasons for not wearing glasses include lost or broken glasses.^{129,134,138,139} In one study, 66% of participants needed replacement glasses within the first year, with nearly half of these students needing replacement two or three times.¹³⁸ To improve compliance with glasses wear, it may be beneficial to examine policies related to the provision of multiple pairs of glasses and replacements. 

Effectiveness of Vision Screening Mandates

Assessing the effectiveness of state mandates is challenging due to the substantial variability in screening requirements. For vision screening programs to be effective, they must not only detect vision problems early but also ensure follow-through with vision screening and exam recommendations. Unfortunately, low follow-up rates diminish the overall effectiveness of screenings. There is a need for economic evaluation studies to evaluate various care models for vision screening programs. These studies play a significant role in informing policy decisions and offering guidance on resource allocation. For example, the CLEERE study group highlighted the potential cost-effectiveness of providing free eye exams and glasses, particularly for individuals with poorer unaided vision, underscoring the importance of addressing financial and logistical barriers.¹⁴⁰ In a study examining the cost-effectiveness of providing onsite exams in detecting amblyopia, relatively similar follow-up rates were observed when students who failed a screening were referred to a community provider (59%) compared to those who underwent a comprehensive eye exam through an onsite mobile clinic (55%).^141,142 Given that the mobile clinic had a higher cost per case of amblyopia, community-based eye care was deemed more cost effective. However, the follow-up rate for the mobile clinic was low due to consent issues. Implementing modifications to improve consent rates could increase the cost-effectiveness of a mobile clinic in detecting amblyopia. No studies examining cost-effectiveness for detecting myopia or progression of myopia in the United States were identified from the literature reviewed. Given that treatment of progressive myopia necessitates early detection and diagnosis, further investigation is needed on how to best conduct screenings and provide basic access to vision care. 

Access to Vision Care

The accessibility of vision care impacts myopia detection and management. Access refers to the “timely use of personal health services to achieve the best possible health outcomes.”¹⁴³ Basic access to vision care facilitates early detection of myopia and equitable access to myopia management interventions to slow its progression. Vision care is typically accessed by undergoing a vision screening and by directly seeing an eyecare professional in various practice settings. The most frequently reported locations for vision testing were with a primary care provider (66%), an eyecare provider (31%), and at school (22%).¹⁰⁰ Although vision screening is not intended to replace a comprehensive eye exam, it is meant to be a cost-effective way to detect vision problems early with the purpose of referring screening failures for comprehensive care.¹⁴⁴ 

Barriers Affecting Access to Care

The literature describes several barriers people face in accessing eye care. These challenges are often associated with social determinants of health, such as limited access to health insurance, long wait times for care, lack of transportation, low eyecare provider-to-patient ratios, lack of economic stability, and various health beliefs and behaviors.⁹ Among the articles included, three main barriers emerged that impact access to vision screening and eye care. 

Financial Barriers

The US healthcare system is a mixed system with both public and private financing sources. At an individual level, employment status and financial means influence the kind of health benefits a person can afford. Insurance inaccessibility thus becomes a barrier to accessing screening through pediatric medical providers. The 2019 National Compensation Survey on Employee Benefits found that only 26% of privately insured individuals had vision care benefits, principally through add-on and unsubsidized insurance plans.^145,146 Moreover, the cost of treatment poses a significant concern, given that many public and private plans do not cover the cost of an eye exam or durable medical equipment such as glasses or assistive devices without additional vision insurance or incurring out-of-pocket costs.¹⁴⁷ Saydah et al.¹⁴⁸ analyzed eyecare utilization among adults at high risk for vision loss and found that “more than 8 million adults who know they need glasses said they could not afford them.” Due to these financial barriers, adults in low-income households are more likely to have under-corrected refractive error due to the cost of glasses.^149,150 In the case of myopia care, for children whose refractive error progresses and require more frequent updates to their lenses, the frequency and replacement schedule covered by insurance may be inadequate.^151,152 

Socioeconomically disadvantaged areas and people of historically marginalized identities face a higher risk of inadequate access to eye care. Numerous programs have found greater odds of uncorrected refractive errors among non-Hispanic Black and Hispanic children, as well as other races and ethnicities, in comparison to non-Hispanic White children.¹¹⁸ However, Hispanic and non-White children, along with those from families with incomes less than 200% of the federal poverty level, were found to be less likely to receive follow-up care compared to their non-Hispanic White counterparts.¹²⁴ Several studies demonstrated a higher prevalence of vision loss in Mexican American, Black, Indigenous, unhoused, and migrant communities, as well as among the elderly and among those experiencing poverty.^{10,148,153–161} In another study, data from the 2003–2008 NHANES were analyzed to compare vision status between US citizens and noncitizen residents ages 12 years and older.¹⁰ The findings revealed that noncitizens had worse visual acuity, both when corrected and notably worse when uncorrected, compared to US citizens. Additionally, they were more likely to lack correction for myopia. The authors proposed that these outcomes could be attributed to disparities in access to quality eye care, including infrequent or absence of care, as well as differences in vision insurance status. To illustrate, jobs that do not provide a living wage or employer-sponsored health insurance could lead to financial hardship that would make the basic needs of eye care and refractive correction difficult to afford.¹⁰ Soares et al.¹⁶² found that, in a migrant farmworker community in Georgia, the most prevalent barriers to eye care were language, transportation, financial, and insurance. The reasons for these health disparities are complex, and the literature relates them to the history of colonization, racial and ethnic discrimination, and the existence of a social gradient of power and privilege.^155,163 The resulting effects on the social determinants of health pose barriers to accessing vision care. These conditions exacerbate the existing problem, emphasizing the need to address said disparities to ensure equitable access to eye care for all segments of the population. 

Financial barriers also impact access to and the effectiveness of vision screening. According to a study on clinic attendance after community-based vision screening, health insurance status most strongly predicted successful clinic attendance.¹⁶⁴ In Ohio, for example, a lack of access or affordability of transportation was also a main reason for missing follow-up exams among a clinic population serving low-income patients.¹³⁰ Financial barriers also drive healthcare system behavior. One example is the challenge of adopting instrument-based screening, as many third-party policies do not cover it as a screening tool, which poses a considerable barrier to implementation.^117,165 Moving toward myopia care with an upstream approach where overall social determinants of health are improved would support increased access and effectiveness of myopia care. 

Accessibility of Screening Methods

Studies evaluating vision screenings found barriers to completing screenings in people with intellectual disabilities, autism spectrum disorder, Down syndrome, behavioral problems, younger children, or language barriers. The challenges faced in accessing vision care in these populations lead to unmet healthcare needs.^{111,119,144,166} One study found that preschoolers who were unable to complete the vision screening were more likely to have a vision condition and were often excluded from the analysis.¹⁶⁷ Moreover, pediatricians do not uniformly conduct vision screenings on children, further reducing access to regular vision screening.¹⁵¹ Even when screening is done, children who are unable to complete it may be managed as if they passed and not referred for a comprehensive exam.¹⁶⁷ Furthermore, although there are guidelines that support the referral of these patients for further care, some providers may not be comfortable seeing these more complex patients. 

Repeated screening over time is necessary to identify newly developed refractive errors or outdated prescriptions as children grow and vision changes.^168,169 A study in New York found that 50% of school-age children tested with glasses failed their screening.¹²¹ Similar findings were seen in a Baltimore screening where 95.7% of children wearing glasses were found to need updated prescriptions.¹⁶⁸ According to one study, vision screening failure was frequently associated with age (with the highest rates of failure in 9 to 11 year olds), and ethnicity, as African American and Hispanic children failed more frequently than White children (14.1% and 14.2% vs. 11%).¹⁷⁰ 

Knowledge and Awareness

Given that parents and caregivers have the greatest influence on a child's ability to access and utilize eye care, education to improve their knowledge and awareness of the importance of vision care is critical. In a study of preschool children in San Francisco, CA, fewer than 25% of parents whose children failed the screening were aware of their child's vision impairment before the screening.¹³⁹ In a study related to diabetic care for children, parental educational level was correlated with adherence to diabetic eye exams.¹⁷¹ Additionally, cultural and community-specific nuances play a role in influencing the level of awareness and understanding of eye care. Parents and caregivers may not understand the importance of the screening recommendations and the potential detrimental consequences of delayed care.¹⁷² A study that conducted focus groups with Hispanic immigrant parents to explore their perceptions of eye care found a lack of knowledge about healthcare coverage for eye exams, even when the children were insured.¹³² Additionally, there was an expressed belief among some parents that wearing glasses could worsen vision. Two studies also found that children with correctable distance vision impairment may be unaware of their need for correction and, as a result, are unlikely to seek care.^116,173 Beyond noticing symptoms of refractive error, parents are often key facilitators in getting children to vision screenings and eye exams. A study found that 29.3% of children failed to attend follow-up exams after a failed visual acuity screening because parents were unaware of the screening results.¹⁷⁴ Finally, providers’ knowledge and attitudes also have an influence on the access and quality of the vision screening. Kemper et al.¹⁵¹ found that the depth of vision screening in preschool-aged children varied by provider. Children with public insurance were less likely to report having a vision screening by their pediatricians compared to those with private insurance. According to a survey of pediatricians across three states, better knowledge and attitudes about preschool vision screening were more likely to reflect good pediatric vision screening behavior.¹⁵² 

Methods of Accessing Vision Care

The literature demonstrates several ways people access vision care, aside from direct care in a traditional medical office setting. These include school-based programs, community partnerships, and community health centers. 

School-Based Programs

Most states in the United States utilize schools to administer vision screening to children.¹⁰¹ Several school-based programs provide a range of services, encompassing various levels of screening, comprehensive exams, provision of glasses, and referrals to tertiary care. The community partnership with schools provides the needed link between vision and learning. Vision screenings are often provided by school nurses, and exams are sometimes provided onsite by visiting health professionals.^118,128,175 The infrastructure and equipment vary widely, with some programs opting for portable equipment set up within a school room, others utilizing mobile vans, and yet others establishing more permanent school-based vision centers. 

The See Well to Learn Program (San Francisco, CA) worked with several local Head Start preschool programs to provide vision screening using an autorefractor.¹³⁹ Children who failed the screening received comprehensive exams in a mobile van onsite and were provided with two pairs of glasses if correction was needed. The Vision for Baltimore Program collaborated with Baltimore public schools on both the elementary and junior high levels to provide screening, eye exams and glasses through a mobile clinic. Parents and teachers in these communities viewed programs such as these that provide access to vision care as beneficial.^50,128,175 The mobile van model brings vision screenings and eye care at low or no cost directly to the school community where children already are, eliminating financial and transportation barriers to care. 

School-based vision centers place a more permanent site of care within school communities, thereby improving access to services by making distance and availability of providers less of a barrier. They are also located within a trusted and familiar institution and provide comprehensive care, usually at no out-of-pocket cost. Additionally, they can coordinate resources and expertise to support students.^128,176 Although none of the articles mentioned assessment of myopia progression over time, referrals for further care or even providing treatment for progressive myopia using the infrastructure of school-based vision centers would be an opportune way to increase access to myopia treatment. 

Community Partnerships

Community partnerships also play an important role in providing access to vision care. Beyond school-based care, afterschool programs provide another avenue for increasing access. After-school programs such as those offered by the Boys and Girls Club of America, which primarily serve individuals facing socioeconomic disadvantages, have collaborated with eyecare providers to offer an alternative way to provide vision screenings to children when school-based programs are not available.¹⁷⁷ Alternatively, event-based screenings are a common way to provide care to greater numbers of patients at a singular point in time. In Philadelphia, an annual one-day vision care event provides free screenings to approximately 1200 uninsured or underinsured children.¹⁷⁸ These types of programs often require significant resources, relying on various levels of financial support. The sustainability of the care is unknown, and it may not provide the regularity of screening or care required to detect myopia progression. However, these programs reduce many of the common barriers to accessing vision screenings in a particular community and bring together community partners and stakeholders to provide care with a limited scope. 

Clinics associated with teaching institutions are another example of a community partnership that provides care to underserved communities. In Indianapolis, IN, a teaching clinic partnered with Indiana University's School of Ophthalmology to provide free screening services and referrals to the local county hospital for care.¹⁷⁹ In Philadelphia, another teaching clinic provided eye exams monthly within a long-term homeless shelter.¹⁵³ However, like many of the screening programs, follow-up rates from referrals were low, limiting the effectiveness of the programs in connecting patients to the care they need. 

Proximity to care, whether it be housing communities, shelters, or afterschool programs, reduces an key barrier for vulnerable patients in accessing care. Communities in subsidized housing face financial barriers, making accessing care and transportation to care challenging, thereby impeding overall access.^112,180 Like school-based vision centers that provide more regular care to the student population, eye clinics located within homeless shelters can provide easier access to continuity of care. The Kansas City Free Eye Clinic is located inside a homeless shelter and provides regular access to eye exams and glasses to unhoused and low-income community members.¹⁸¹ These clinics have an important positive impact on access to care for vulnerable populations. In another program serving the homeless population in Wisconsin, recycled eyeglasses were utilized to reduce the financial barrier and increase access to vision correction.¹⁸² The evidence suggests that a program that provides care at the location of an established community congregation is convenient and effective in serving communities with high rates of vision impairment.¹⁸² 

Community Health Centers

Community health centers are federally funded facilities that serve the healthcare needs of underserved communities through an integrated care model in a team-based practice setting.^147,182 They provide care on a sliding fee scale or free of charge, addressing many of the financial barriers patients face in accessing care; however, as of 2022, fewer than 30% of community health centers provided vision care services,¹⁸³ highlighting a significant opportunity to fulfill this crucial healthcare need. Community health centers are specifically located in high-need areas, provide free or low-cost care, and make a variety of health services available in one location. Community-governed, these centers not only address access to care barriers for underserved populations but also enhance the acceptability of care and promote the utilization of services. Like school-based vision centers, they facilitate more holistic care, incorporating eye care as an important aspect of a patient's care and increasing the ability to coordinate care for overall health. 

Access Versus Utilization

Having access to care does not always translate to utilization. Follow-up rates for referrals after a vision screening are low, particularly among low-income and marginalized communities, demonstrating that there are barriers to utilization as well.^{128,130,155,184,185} Children with public insurance are more likely than those with private insurance to have a visual impairment, particularly an impairment that cannot be fixed with optical correction.⁸ One study found that having insurance coverage through Medicaid does not necessarily improve access to care, as pediatric eye examinations are underutilized in high-poverty areas.¹²⁹ Reasons for underutilization include the difficulty of obtaining an appointment with an eyecare provider and concerns about the quality of the exam and glasses offered through public insurance.¹²⁹ Another way to evaluate access is through the patient's perspective on utilizing eye care. According to the Anderson–Newman framework¹⁸⁶ for health service utilization, factors that influence whether a patient seeks care include predisposing factors, enabling factors, and need factors. These three factors can either facilitate or impede healthcare utilization or, in this instance, obtaining vision care. This framework will be used to further examine access to care and utilization. 

Predisposing Factors

Predisposing factors in this framework are defined as “the socio-cultural characteristics of individuals that exist before their illness.”¹⁸⁶ Perceptual barriers to utilization involve different priorities and beliefs, such as the perception of the parent or caregiver that their child does not require an eye exam or skepticism toward screening results, indicating a sense of distrust.^124,126 These factors were shown to have a disproportionate impact on African American families, as well as those with children participating in the free and reduced lunch program and those covered by Medicaid.^126,123 In focus groups conducted among Hispanic immigrant parents about their perceptions of vision care, glasses were not well accepted culturally.¹³² Parents noted that the frequency with which children wore glasses was higher than what they saw in their home countries, and they associated this with something potentially harmful in this new environment. In many Indigenous communities, distrust of the healthcare system and lack of cultural safety contributed to vision disparities.¹²⁷ Another survey of patients in a free clinic in Michigan found that, in addition to financial barriers, previous negative experiences and lack of trust in the healthcare system were reasons for not acquiring glasses.¹²⁹ Health beliefs also played a role, with participants expressing a lack of symptoms and lack of interest as reasons they did not seek vision care.¹³² 

Predisposing factors can also increase utilization. A study on eyecare utilization in Chinese Americans found that predisposing characteristics including female sex, higher educational attainment, older age, having a usual place of care, and having a greater number of comorbidities were linked to increased utilization.¹⁸⁷ Another study found that comorbidities such as arthritis, blindness, and very low birth weight were associated with a higher rate of vision screening.¹⁰⁰ 

Enabling Factors

Enabling factors are the “logistical aspects of obtaining care,” including personal, family, and community-level considerations.^126,186 During the COVID-19 pandemic, the strain on various care systems, coupled with the shutdown of non-essential services, exacerbated the challenges in obtaining vision care, thereby forming a negative factor influencing health service utilization. In an analysis of 5-year trends in pediatric screening and access to vision care in the United States, there were declines in vision screening and vision care specialist use from 2016 to 2020, and this trend worsened with the onset of the COVID-19 pandemic.¹⁸⁸ Additionally, the eyecare workforce size and the resulting geographic proximity to eyecare providers are also factors in access to and utilization of care, with longer drive times found in remote communities compared to more urbanized cities.¹³¹ 

Financial barriers encompass concerns related to cost and insurance coverage.^50,124,126 Social and economic structures, including occupations that do not provide time off, insurance coverage, or adequate compensation, contribute to time and financial constraints preventing people from utilizing eye care.¹²⁶ Notably, although some families are covered by Medicaid or private insurance, others could qualify for assistance programs but are unaware of them.¹²⁶ Others are unsure about where to go or how to proceed,^{50,124,126,128} revealing a communication gap between the program and parents/caregivers. Logistics presented challenges in scheduling appointments, such as finding suitable availability that did not conflict with parents’ work hours, as well as transportation difficulties.^50,123,126 Family and social barriers included navigating unpredictable family schedules and coordinating with other family members, making it difficult to schedule appointments.¹²⁶ 

Need Factors

Perceived need is influenced by various factors, including the understanding of an illness and the importance of seeking care. Some studies have found that parents were skeptical of the results, unaware of the need for follow-up, or they did not prioritize it.^126,123 During a focus group with Hispanic immigrant parents, participants shared that the lack of information about the importance of eye care for children, along with language and transportation barriers, were reasons they had not sought eye care, suggesting that lack of effective communication can negatively impact the perceived need to seek care.¹³² 

Mitigating Barriers to Accessing Care

Different programs have addressed barriers to care in multiple ways. Many programs have mitigated logistical barriers by providing onsite care.^{112,118–120,123} On the level of community enabling factors, some studies have included the use of a social worker and patient navigators to help with overcoming barriers to follow-up care.^112,119,163 For example, in one study, a social worker assisted parents in scheduling appointments, obtaining necessary referrals, and reviewing insurance coverage with families.¹¹⁹ This resulted in a 72% adherence rate for completing the exam. Although this program addressed some of the logistical barriers associated with obtaining follow-up care, suggestions were made for additional strategies to improve adherence. These included providing no-cost care, offering transportation assistance, implementing email/text reminders, and improving communication about the program itself. Others have suggested strategies such as collecting multiple forms of contact information to ensure effective patient outreach.^112,126 For the Philadelphia-based Give Kids Sight Day, social workers helped ensure that accurate contact information was collected.¹⁷⁸ They arranged follow-up appointments, assisted with insurance enrollment, and provided transportation vouchers, reducing many of the commonly cited barriers to completing follow-up care. 

Myopia Care and Myopia Management

Early identification of myopia is crucial to inform subsequent treatment and management options to slow myopia progression. The primary goals of slowing myopia progression are to maintain a lower prescription and reduce elongation of the eyeball, ultimately helping to prevent the ocular complications associated with high myopia.^42,189 

Genetic and Environmental Factors in Myopia Development

The mechanism of progressive myopia in school-age children is multifactorial, influenced by both genetic and environmental factors,^66,109,190 whereas, in adults, progression may be more strongly associated with the environment.¹⁹¹ Parental myopia has been found to be a meaningful risk factor, where children with one or two myopic parents have a higher risk of myopia development than those without a myopic parent.^26,62 Additionally, a significant association between myopia and parental education has been established, with higher educational achievement being correlated to a higher prevalence of myopia.¹⁹² 

Adjustable environmental risk factors, such as increased near work, decreased time spent outside, and potentially urban versus rural living, are associated with higher myopic progression and complex interactions with one another.^{26,110,193–195} Consideration of these numerous environmental influences may contribute to a better risk estimation of myopia development and help determine the priority of treatment in individuals.¹⁹⁶ 

Myopia Progression Treatment Options

When deciding on a treatment, consideration should be given to the child's age and lifestyle, the rate of progression, and the treatment that best promotes adherence to achieve the greatest effect.¹⁹⁷ Additionally, there may be higher efficacy in preventing onset versus treating a child when their myopia has developed; thus, early identification via screenings and/or comprehensive exams is vital and can help predict which patients should begin treatment based on their rate of progression.^{106–110,198,199} 

The two main therapeutic methods for managing progressive myopia are optical therapy and pharmacologic therapy. Optical treatments include orthokeratology rigid contact lenses,^200–202 multifocal soft contact lenses,^90,203,204 and spectacles with defocusing lenslets in periphery (not yet available in the United States).²⁰⁵ Pharmacologic therapy typically involves low-dose atropine, although the optimal dose is still under study.^{43,90,206–210} Further research on combination therapies and the long-term effectiveness of all therapies is needed.^189,211 The IMI recommends greater adherence to consensus guidelines for clinical trials to enable better comparison of results over time.¹⁹² 

Behavioral modifications, such as increased outdoor time, have been shown to delay the onset of myopia.^{189,194,212,213} Because myopia progresses more slowly in the summer than in the winter, increased time outdoors and less schoolwork likely play a major factor in progression.^214,215 Therefore, public health efforts and policies should consider these factors and use programs from countries such as Singapore as models.^216,217 Incorporating outdoor activities into school curriculums, afterschool programs, community opportunities, and subsidized activities may help delay onset or slow myopia progression; however, these programs must be culturally inclusive.^216,218 Ultimately, there is a public health need for myopia surveillance and treatment both within healthcare settings and in broader community contexts.²¹⁹ 

Factors Influencing Access to Myopia Management

The predisposing, enabling, and need factors described in the Anderson–Newman framework also apply to myopia management, influencing utilization of myopia care. 

Adoption of Myopia Management in Practice

Given the evidence of myopia risks and the availability of proven treatments, some argue that eyecare providers have an ethical duty to promote and perform treatment.¹⁰⁹ Despite this, reports indicate that most practitioners still prescribe single-vision glasses, with North American doctors being among the least proactive in addressing myopia progression.^220,221 The primary reasons for reluctance to initiate treatment are cost, followed closely by inadequate information and concerns about the unpredictability of outcomes. However, a 2023 survey showed that practitioners worldwide reported an increased willingness to begin treatment earlier when compared to a similar survey from 2019.²²¹ The future of myopia treatment seems promising, as most doctors agreed on the need for collaboration with policymakers, health regulatory bodies, and industry to improve accessibility and affordability of treatment.²²¹ 

A white paper from the IMI recommends that practitioners consider factors such as informed consent, off-label treatments, and patient management when treating myopia progression, but advises that these factors should not deter them from providing treatment.²²² For example, balancing short-term risks of pediatric contact lens wear with the long-term risks of myopia-related visual impairment can help both practitioners and parents to feel more comfortable in the informed consent process.^223,224 Although provider adoption is essential for advancing myopia management, the effectiveness of these efforts is hindered by another critical issue: the limited availability of eyecare providers. 

Provider Availability

A significant barrier to myopia management access is the limited number of providers offering this service. The literature does not specify the exact number of myopia management providers, but one study estimated that, in the United States, each optometrist or ophthalmologist, regardless of specialty, would need to manage 278 myopic children biannually.²²⁵ Another study found that only 6.5% of US counties have at least one pediatric optometrist, and 9.7% have at least one pediatric ophthalmologist, with considerable geographic overlap between these groups.²²⁶ However, none of the eyecare providers was noted as offering myopia management as part of their practice. This highlights the need for further research into access to providers as a barrier to care in myopia management. 

Cost of Myopia Management Treatment

There is a significant financial barrier to accessing myopia management treatment, as it is not typically covered by insurance. One key recommendation is to classify myopia as a disease, which would allow it to be recognized as a medical diagnosis and covered by medical insurance, rather than only by vision plans. Furthermore, the definition for medically necessary contact lenses may also have to be reviewed to reflect the importance of slowing myopia progression regardless of current prescription. 

Both low-dose atropine and outdoor activity were found to be cost-effective options in slowing myopia progression.²²⁷ Despite the demonstrated long-term safety of low-dose atropine treatment,²²⁸ monitoring of these patients for ocular changes and cognitive effects throughout their lifetime remains important.^205,229 Very few Medicaid programs currently provide coverage for the cost of the compounding process; some states, such as Washington, only cover one particular concentration (e.g., 0.01%).²³⁰ Regarding outdoor activity as a viable treatment option, safe and clean outdoor spaces available to all children in the United States must be considered. 

The cost of orthokeratology in pediatric myopia management has been understudied, but a report by the American Academy of Ophthalmology found that contact lens options, particularly orthokeratology, are more expensive and time consuming than spectacles or low-dose atropine due to the specialty fitting process.²³¹ Contact lens costs are generally not covered by insurance in the United States.²³¹ The only U.S. Food and Drug Administration (FDA)-approved treatment for myopia management in the United States, the MiSight 1 day lens (CooperVision, Victor, NY, USA), is also not widely covered by insurance.¹⁸⁹ Despite the upfront costs of treatment in childhood, data from other countries have shown that the benefits balance out or exceed the lifetime costs of myopia.^227,232 This review found no direct economic comparisons of treatment in the United States, which aligns with findings from a Cochrane review on myopia interventions.⁹⁰ 

Duration of Myopia Treatment

Another consideration of cost is the duration of treatment, as the ideal length of myopia treatment varies by patient. Practitioners must recognize when progression accelerates (typically approaching puberty) and when it stabilizes (often in mid- to late teens), although this timeline may not apply to all.¹⁸ For example, African American children tend to stabilize younger and with less myopia.²³³ Early onset is associated with faster progression, but some studies, such as the COMET study, have shown earlier stabilization in these cases.²³³ Regardless, treatment should continue until well after the myopia stabilizes and eye growth stops.¹⁹⁷ Given the variability, insurance must recognize myopia as a disease so that coverage can include long-term treatment and lifelong coverage. 

Myopia Management and Quality of Life

The impact of myopia treatment on quality of life is vastly understudied. One study found that parents of children with high myopia reported that they had a lower quality of life than those with low or no myopia.²³⁴ The only quality of life questionnaire focused on myopia management in the United States pertains to orthokeratology, and it has shown that children wearing these lenses had better vision-related quality of life than those using single-vision contact lenses.²²⁰ Because most treatment for progressive myopia occurs during early development years, future research should prioritize its impact on daily activities such as reading and learning.^18,197,233 

Discussion

This narrative review provides a comprehensive overview of the available literature regarding access to myopia care, including identification, treatment, and management of myopia in the United States. Several themes emerged from the review that have informed recommendations for enhancing overall access to myopia care. 

A Clear Estimate of the Prevalence of Myopia in the United States Is Necessary to Determine Its True Societal Impact, Although Some Trends Can Be Identified in the Literature

There is no clear estimate of the prevalence of myopia in the United States, although the available data show its increasing prevalence. The best estimates of myopia prevalence in the United States show a higher prevalence in Asian Americans, with the prevalence in Black and Hispanic populations rising rapidly. This surge in myopia prevalence in these specific populations is notable, as these and multiple other minoritized populations experience more health disparities overall. The disparities in access to vision care, overly borne by these populations, are further exacerbated by their lower utilization of services. Minoritized populations and populations that face health disparities have a disproportionate burden of myopia, and this disparity is likely to continue increasing. It is important to note that there is greater genetic diversity within racial categories than between them,²³⁵ rendering associations based solely on racial categories incomplete without acknowledging race as a social construct and considering the social determinants of health that impact different populations. The community of researchers investigating prevalence and access to care must delineate the distinctions between race and ethnicity. 

The Impact of Myopia on Quality of Life and Mental Health Requires Further Investigation

There is evidence that myopia can negatively impact the quality of life of children and parents of children with myopia. The type of optical correction and the impact of myopia progression treatments on quality of life warrant further study using assessment tools specifically developed for this population and condition.²³⁶ 

The Interplay Between Socioeconomic Status and Myopia Progression Warrants Further Investigation

As the prevalence of myopia rises among Americans, there will be an associated increase in the financial burden of myopia on individuals and society. Further complicating this issue is the mild association between higher socioeconomic status and myopia. As some inequities improve, the intricate relationship among myopia, socioeconomic status, and educational attainment may introduce additional challenges for populations facing health disparities. 

There Is Some Consensus Among Vision Screening Guidelines, Yet Emphasis on Myopia Remains Lacking

There is consensus among vision screening guidelines that the identification of refractive error is important and that children should be evaluated early; however, there is variation in screening methodologies and the frequency of screenings to monitor for refractive error changes. These guidelines may lack the sensitivity necessary to detect the onset of mild myopia and its progression. Furthermore, there is a lack of objective vision screening tools capable of identifying the onset and progression of myopia. The establishment of consistent guidelines for vision screenings, with a focus on detecting the onset and progression of myopia, could lead to early detection, swift implementation of myopia management treatment, and the prevention of progression to pathological myopia.¹⁹⁶ 

State Mandates Can Increase Vision Screening Participation, But They Are Not Well Aligned With Vision Screening Guidelines

Although most states have vision screening mandates, these mandates significantly vary and often do not align with guidelines from professional organizations. There is considerable variation in the frequency of vision screenings, impacting the ability to detect the onset and progression of myopia promptly. For a vision screening program to be successful, follow-through with screening and exam recommendations is essential. Policies addressing this issue, such as implementing an integrated data system for reporting results,^169,237,238 can improve care coordination, ensure follow-up, and help monitor program effectiveness in meeting public health targets.²³⁹ 

Collaborative Eye Care Models Show Promise in Their Ability to Provide Better Access to Myopia Care

The literature reveals significant barriers to vision care access, particularly for populations facing health disparities, such as geographic and structural barriers. Screening programs in schools, community centers, and areas with vulnerable communities are essential in detecting refractive error and connecting individuals to services. Programs that bring services directly to their communities have shown promise in reducing barriers in access to care. To improve the effectiveness of vision screening programs, it is crucial to improve access and address obstacles that prevent follow-through with screening and exam recommendations, including increasing public awareness about the necessity of vision care, recommended frequency of care, and established access points. Further analysis is needed to determine the cost effectiveness of these interventions. 

The Individual and Societal Financial Impacts of Myopia and Myopia Progression Warrant Further Investigation to Guide Policy Recommendations

A thorough understanding of myopia and its financial impact is necessary to comprehend the investment required to prevent myopia or slow myopia progression. Effectively communicating this economic burden to public health professionals and lawmakers will enhance awareness and prompt action. 

Although this review did not identify specific cost-effectiveness studies for vision screening programs related to myopia in the United States, frameworks from similar programs for amblyopia may provide useful guidance. Consistent cost analysis across studies is essential for making meaningful cross-disciplinary comparisons and encouraging greater participation in public health initiatives. Research on the impact of vision screening on myopia identification, progression, and its societal financial impact is vital to guide the optimization of existing programs and the creation of new ones.⁵⁴ 

As myopia is a chronic condition with significant lifetime consequences, an assessment of the costs associated with treatment and barriers to care is necessary to improve accessibility. Additionally, the reclassification of myopia as a medical diagnosis could help address its growing burden and ensure insurance coverage meets the needs of the myopia epidemic. 

Conclusions

This narrative review has identified gaps in our knowledge of myopia prevalence, its impact on physical and psychological health, and the financial implications of the condition on the individual and societal level in the United States. Uniform evidence-based guidelines and best practices on vision screening are important for informing state mandates. Additionally, leveraging innovative and community-informed ways to expand access to vision screening and comprehensive eye care will increase access to myopia care and management. Populations facing health disparities are at highest risk for experiencing adverse sequelae of myopia; thus, the priority should be to promote and ensure equitable access to the identification, treatment, and management of myopia. Collaboration among policymakers, clinicians, healthcare workers, and public health experts will be necessary to create a surveillance system to comprehensively manage myopia in the years to come. 

Acknowledgments

The authors thank Distinguished Librarian Elaine Wells at SUNY College of Optometry for assisting in the literature search. 

Disclosure: J. Harewood, None; M. Contreras, None; K. Huang, None; S. Johnson, None; J. Wang, None