For much of modern optometric practice, myopia was viewed primarily as a refractive error: a largely genetic and inevitable condition that could be corrected with spectacles or contact lenses. According to pediatric optometrist Nathan Bonilla-Warford, OD, however, that paradigm is changing rapidly.
The Surgeon General’s identification of myopia among the physical health concerns that are associated with increasing screen use in children, coupled with the AMA’s recognition of myopia as a significant public health concern, both of which were released earlier this year, represents a meaningful shift, he said, in a recent conversation with Optometric Management. For optometrists, the question is increasingly moving to what clinicians should do next.
He spoke first about the distinctions between screens vs books: 3 hours spent reading a printed book may not be equivalent to 3 hours spent using a smartphone or tablet, he said. Books tend to be held further away, allow more variation in posture, and lack the interactive features that encourage prolonged engagement. Children, in particular, often hold screens closer because they are touching and gesturing on the device, he said.
Digital content is specifically designed to sustain attention through notifications and prolonged scrolling. Plus, “a lot of kids like [their surroundings] very dim because it feels cozy,” Dr. Bonilla-Warford said, but “for long-term vision, that’s not ideal.” Screen use also often displaces outdoor activity, which is encouraged for myopia prevention in children because their eyes are still developing. In other words, the concern is not simply accommodative demand or near working distance, but the behavior surrounding device use.
Working with parents helps reinforce healthier screen behavior to kids, though," he said. “Ten or 15 years ago, a lot of parents would have loved that their kids were so sophisticated, that at 2 years old they knew how to use a tablet or a smartphone, and there was legitimate debate about whether that was a good or a bad thing because kids were learning about technology.” That evolved into seeing kids’ behavior when their devices were taken away and thinking that wasn’t ideal, to now enforcing strict rules around device use, which he can corroborate during visits. “But it is genuinely hard because these things are literally designed to be entertaining, to be appealing, to have people want to stay engaged.”
“Kids have a big disincentive to rock the boat at all,” he continued. “On a basic level, they're not super self-aware because they’re kids, so they are pretty unlikely to just report blurriness or headaches from screen use on their own. They’re also super aware that if they give their parents any reason to have them not allow them to use technology, that's giving their parents ammunition to take it away, which they don't want, so they will deny everything. They'll say, ‘No, it's great. Everything is fine. I have no problems.’”
For these reasons, one of the most consequential changes for optometric practice is the ability to identify children who are at risk before conventional distance acuity reveals a problem. “We can legitimately identify premyopia or we can see it coming,” Dr. Bonilla-Warford said. “We can take measurements and say confidently their eyes are growing faster than they should be,” even while the child retains normal distance visual acuity and would therefore pass a typical screening. Subtle warning signs during the premyopic period may include intermittent squinting, increasing fatigue with near work, moving progressively closer to near targets, or routine postural changes, he described.
Dr. Bonilla-Warford recommends comprehensive examinations during childhood, including an exam by kindergarten at the latest if earlier recommended examinations have not occurred. The objective is to evaluate visual development, visual skills, and refractive status with an eye toward future risk. He noted that early-onset myopia changes the clinical picture considerably: A child whose myopia is identified at age 6 presents a very different long-term management challenge from one whose myopia begins at 12.
The familiar 20-20-20 rule—looking 20 feet away for 20 seconds every 20 minutes—may still have value for adults working at computers. Dr. Bonilla-Warford, however, argues that it is insufficient for developing children. Instead, he discusses a “30/5” approach: Roughly every 30 minutes, children should take a 5-minute break from near work. Ideally, that means standing up, moving around and, when possible, going outside because it takes substantially longer than 20 seconds for the eyes to fully relax, he says. Further, a child told to take a 20-second break may simply look at a phone, which won’t give their eyes the break they need.
“The Surgeon General’s report also mentioned how screens are bad for sleep and circadian rhythm, and we know that if people's overall health isn't as good, they're more likely to be myopic and sleep's good for overall health, so it's kind of putting a lot of pieces together. If kids put their devices away earlier, they go to sleep faster, they sleep better, they feel better the next day,” he said.
The expanding number of myopia management options also changes the clinical conversation. Rather than asking whether a patient should receive myopia control or considering myopia to only be a refractive error, optometrists can consider which intervention best fits a particular child and how that strategy should evolve. Lifestyle, personality, family circumstances, and treatment adherence all influence the treatment decision. A travel-team athlete and an avid reader may value different treatment characteristics, as would a child who is enthusiastic about contact lenses compared with one who is terrified by the idea, Dr. Bonilla-Warford explained. Or in a family dynamic where one parent supports a decision to use orthokeratology and another does not, another option may prove more practical to ensure adherence. Conversely, chronological age alone should not dictate treatment: He has successfully managed highly motivated 5- and 6-year-olds with ortho-k.
He added that management may need to change throughout childhood and adolescence. A rapidly progressing young child may initially require a more aggressive approach that will need to be adjusted later as their progression, lifestyle, and preferences evolve. Alternatively, a conservative approach may be better at first, but the child may require more aggressive treatment as they grow.
“We would like to be in a place where everybody who's at risk for myopia, especially higher myopia, just automatically got treatment. That would put everybody in a better position in the long run. We're not there or even close to it, but the fact that we can predict, monitor, and tailor treatment to individuals can make them much more accepting of it,” he says.
Schools can identify some vision problems, but Dr. Bonilla-Warford cautions that screening is unlikely to identify premyopia and should not be substitutes for comprehensive examination. Schools may have another important role, however, he says: reducing unnecessary classroom technology and preserving meaningful outdoor time, particularly for younger children. “I think if there was one thing we can do, it would be to rethink as a society about being outside in natural environments more as early as infancy or toddlerhood: going for walks, visiting parks, not being so dependent on cars, having more unstructured outside time at school, and policies that encourage all of that. It seems like this is very far removed from myopia, but these lifestyle adjustments are in the same sphere. I don't see how you change any one thing and move the needle very much. It's just so intertwined that we should think about all of it.”
Optometrists may also increasingly find themselves educating pediatricians and other health care professionals on myopia. Dr. Bonilla-Warford describes outreach to pediatricians as both a means of improving interdisciplinary understanding and giving physicians a trusted destination for children whose visual findings raise questions.
Ultimately, he sees myopia management approaching an inflection point. The central challenge is becoming less about accumulating evidence and more about implementing what is already known. Parents increasingly understand that excessive screen time is problematic and outdoor time is beneficial. Clinicians have better tools for identifying risk and more treatment choices. Public awareness is catching up.
Going forward in optometry it’s a paradigm shift, concluded Dr. Bonilla-Warford. “Myopia is not going away. Now we have the tools to delay and reduce its effects. We just need to use them."