1. Vision is important for a child’s development and overall wellbeing.
  2. Obtaining as sharp vision as possible in childhood is important. Children’s vision system is not fully formed especially at 8 years and below. Equally sharp vision in both eyes is important for the brain’s vision centres to develop normally. If a child’s eyes cannot send clear images to the brain, vision may become limited irreversibly even though his or her eyes are normal.
  3. 4 hidden signs of vision problems in kids
    – Having a short attention span
    – Difficulty tracking where they are reading on a page
    – Avoiding reading or other activities requiring near vision such as drawing
    – Turning their head to one side
  1. Screening is important. if problems are detected early, it is usually possible to treat them effectively.
    – Uncorrected refractive error, which includes myopia, is the #1 cause of visual impairment in the world.
    – 50% increased chance of your child’s myopia going unnoticed if their last vision test and health assessment was more than 2 years ago.
    – 3x increased risk of irreversible vision loss of every year that myopia goes undiagnosed.



Babies (Age 3 and below)

Babies should have their eyes screened during regular paediatric follow-ups. The conditions we need to look out for include:

  • Squint or Strabismus: where they eyes are not aligned properly or appear “cross-eyed”.
  • Amblyopia or “Lazy eye”
  • Rarer conditions such as
    – Congenital cataract or childhood cataract

– Retinoblastoma: a type of cancer that forms in the retina (the light-sensitive tissue at the back of the eye). The disease usually occurs in children younger than 5 years and may be in one eye or in both eyes. Retinoblastoma is a serious, life-threatening disease. However, with early diagnosis and timely treatment, in most cases, a child’s eyesight and life can be saved.

Children and Teenagers (Age 3 to 19)

It is advisable to have an eye check every one to two years either as part of regular health screening or when visiting the optician or optometrist for glasses. for corrective eyewear, such as for myopia.Ambylopia or “lazy eyes”

  • can also occur in children below 8 years of age
  • due to undetected or inaccurately corrected short-sightedness, long-sightedness or astigmatism.


What is Myopia?

  • Myopia (shortsightedness) is form of refractive error.
  • Refractive error is when the eye is unable to focus the light sharply onto the retina.
  • In myopia, the eyeball is longer than it should be, so light is focused in front of the retina instead of on the retina.
  • This causes distant objects to be blur while near objects remain clear.
  • Singapore has the highest number of people with myopia in the world. Surveys show that in Singapore, myopia affects:
    – one in four 7 year olds
    – a third of 9 year olds, and
    – half of 12 year olds.

What causes Myopia?

The actual cause of myopia is not known.

But we know that several factors may contribute to the development of myopia:

  • Genetics: risk of myopia is higher if one or both parents are short-sighted
  • Environmental:
    • Long hours of near work (reading, computer games and time spent on mobile devices) contribute
    • Lack of outdoor activities and exposure to sunlight
      • Outdoor time has been shown to protect against the early development of myopia in children.
  • Myopia usually develops in children of school-going age and continues to worsen until they reach their early 20s, after which the condition usually stabilises.
  • Early onset of myopia is associated with high myopia in adult life.

Symptoms of Myopia

Some of the signs and symptoms of myopia include:

  • eyestrain,
  • headaches,
  • squinting to see properly, and
  • difficulty seeing objects far away, such as road signs or a whiteboard at school.

Complications of Myopia

Myopia is not just a condition that causes blurring of vision which can be corrected with glasses. It is a condition that affects the structure of the eyeball, because the eyeball is longer in myopia.

As the myopia increases, the risk of complications from myopia increases. The highest risk of complications occur when myopia is 600 degrees or more.

So although we cannot “cure” myopia, we should aim to reduce the progression of myopia as much as possible in our children.


Complications from myopia include:

Retinal Detachment
Myopic macular degeneration

What are the treatments for Myopia?

Unfortunately, there are no treatments currently to reverse myopia.

However, there are treatments that can reduce progression of the myopia.

A Cochrane review, which is a systematic review of the studies and trials that looked at various methods to reduce the progression of myopia in children was published in 2018. Cochrane reviews are respected for their thoroughness and wide-ranging review of studies for treatments and are used to guide evidence-based practice.

In this review, Cochrane researchers found:

  • 41 studies of treatments to slow myopia progression
  • These studies included a total of 6772 children

The review found that the following treatments may slow the progression of myopia, compared with wearing ordinary spectacles:

  • Eye drops, antimuscarinic drugs such as atropine, pirenzepine gel, and cyclopentolate (moderate-certainty evidence).
  • Multifocal spectacles (either bifocal or progressive addition lenses) (moderate-certainty evidence).
  • Bifocal soft contact lenses (low-certainty evidence).
  • Orthokeratology contact lenses (moderate-certainty evidence).
  • Combinations of eye drops and multifocal spectacles (moderate-certainty evidence).

The review found that the following treatments may have a small effect, or no effect, on myopia progression.

  • Spherical aberration soft contact lenses (low-certainty evidence).
  • Systematic adenosine antagonists (moderate-certainty evidence).

The review found the following may INCREASE the chance of progression:

  • Children who wear undercorrected spectacles may have an increased chance of myopia progression compared with children who wear fully corrected spectacles (low-certainty evidence).

Authors’ conclusions:

  1. Atropine eyedrops is effective in slowing myopia progression in children.


  1. Multifocal lenses, either spectacles or contact lenses, may also confer a small benefit.


  1. Orthokeratology contact lenses, is not intended to change the amount of myopia, were more effective than single vision ordinary spectacles in slowing the physical lengthening of the eyeball.


  1. Not much evidence to support Rigid Gas Permeable Contact Lenses and sperical aberration soft contact lenses.

What is the response rate of Atropine eyedrops?

First, it is important to remember that once there is myopia, we cannot reverse the myopia. With each year, a child’s myopia will increase as the eye grows until the teenage years when it will start to stablise:

  • The rate of progression is estimated to be around −1 D (or 100 degrees) per year in Asians and around −0.5 D (or 50 degrees) per year in Caucasians.

We may consider starting Atropine when the progression is more that -1.5D (or 150 degrees) per year.

When we look at the response rate of Atropine, we can turn to a Singapore study called ATOM 2 which stands for Atropine for the Treatment of Myopia 2 Study. In ATOM 2, researchers found that:

  • Low-dose (0.01%) atropine for periods up to 5 years is a clinical viable treatment of myopia with the best sustained effect on slowing myopia progression.


  • Atropine 0.01% slowed myopia progression by 50%


  • Non-responders were low: 3% of children in the 0.01% group continued to have myopia progression ≥−1.5 D (more than 150 degrees) over the initial 2-year of active treatment.

What are the side-effects of Atropine eyedrops?

The side-effects of atropine eyedrops display a dose-dependent response. This means that higher concentrations have more side-effects the lower concentrations. The concentrations of atropine eyedrops come in: 1%, 0.5%, 0.1%, 0.05%, 0.025%, and 0.01%.

The most frequent eye side effects with atropine eye drops include

  • Photophobia: sensitivity to bright light,
  • Blurriness of near vision, and
  • Local allergic response such as redness, swelling or itching of the eyes.

Side-effects affecting the body systemically are very rare and include:

  • dry mouth,
  • face flush,
  • headache,
  • increased blood pressure,
  • constipation, difficulty in urination, and
  • central nervous system disturbances

What are the key steps in managing your child’s myopia?

  1. Accurate refraction(“degree check”): at the first visit, an accurate refraction is critical.
    • The “gold standard” is a cycloplegic refraction where special eyedrops are given to relax the eye muscles.
    • This is done in children because their eye muscles can tense up and induce
    • Pseudomyopia is not true myopia but myopia induced by tense eye muscles in children and can lead to overcorrection of the myopia.
    • For the same reason, autorefraction where a machine is used to measure the myopia should never be used to prescribe glasses in children, at best, only as a reference.
  2. Examinations of the eye include:
    • non-contact axial length: to measure the length of the eyeball,
    • funduscopy: to look inside the eye to screen for myopia-related retinal issues such as retinal breaks, and
    • intraocular pressure measurement: to measure the eyeball pressure.
  3. Monitoring:
    • Monitoring the myopia every 3–6 months according to child’s age and parent’s myopia history is recommended
    • Once myopia has developed, the rate of progression is estimated to be around −1 D (or 100 degrees) per year in East Asians and around −0.5 D (or 50 degrees) per year in Caucasians
  4. Managing progression:
    1. Atropine treatment can be offered with the aim to slow down myopia progression if progression is too much
    2. Course of treatment is expected to be a minimum of 2 years initially
    3. Outdoor activities should continue to be encouraged
    4. 20-20-20 rule
      • Regular eye breaks after 20 minutes of near work
      • Looking out 20 feet at a distant target
      • For 20 seconds
    5. Starting with the lowest concentration: 01% atropine, would be preferable as this is associated with the least ocular side effects
      • frequency is once daily at bed time
      • record of the baseline myopia before treatment
      • post-atropine baseline myopia after 2–4 weeks
      • follow-up every 3 months with the cycloplegic refractionStarting with the lowest concentration: 01% atropine, would be preferable as this is associated with the least ocular side effects
        • frequency is once daily at bed time
        • record of the baseline myopia before treatment
        • post-atropine baseline myopia after 2–4 weeks
        • follow-up every 3 months with the cycloplegic refraction
    6. Children on atropine who experience near vision blurring:
      • offered multi-focal glasses
  5. If still progressing at >0.5D (or 50 degrees) at 6 months:
    • increasing the concentration of atropine, or
    • continue the same concentration of atropine combined with more outdoors time, or,
    • change to a different treatment, such as orthokeratology.


A child’s vision system develops in the first few years of life and continues to do so until about 8 years of age.

  • During this time, the brain and the eye are learning to work together.
  • It is important during this time that the brain receives sharp images from the eye.

Amblyopia is when vision in one or both eyes does not develop properly during childhood. It is sometimes called lazy eye.

  • Up to 3 out of 100 children have it.
  • The good news is that early treatment works well and usually prevents long-term vision problems.
  • It is therefore important to identify causes of lazy eye early and to correct them early.
  • This needs to be done before 8 years of age, otherwise, lazy eye may become permanent.

What are the causes of amyblyopia?

Strabismus or Squint

Strabismus is when the eyes are not aligned properly so they appear to point in two different directions.

  • One eye may be looking straight ahead while the other is turned in a different direction. Either in, out, up or down.
  • To avoid double vision, the child’s brain may ignore the image from the eye that is not looking straight ahead.
  • When this happen: that eye may become “lazy” and not develop normally.

Refractive errors

A refractive error is when the eye cannot focus an image clearly without the help of glasses. There are different types of refractive error:

  • Shortsightedness, longsightedness or astigmatism
  • Lazy eye can occur in 2 situations:
    • Either due to undetected refractive error so that the child does not have glasses and has blur vision for some time
    • One eye has much worse refractive error than the other eye. Usually a difference of more than “200 degrees” difference
  • In both these situations the eye can “turn off” and vision will not develop properly
    • If this is not corrected before 8 years’ of age, it can become permanent
    • When this happens, even if you make glasses, the child will not be able to see perfectly and will have some blurring of vision, regardless of what power lenses you use.

Media opacity: Cloudiness in the normally clear parts of the eye

The 2 parts of the eye responsible for focusing light are the cornea and the lens.

In some children, either the cornea or the lens can become cloudy and cause less light to be able to reach the back of the eye.

Cloudy cornea: the transparent front surface of the eye is cloudy
Congenital Cataract: the normally transparent lens of the eye is cloudy

This deprives the eye of vision and causes a type of lazy eye called sensory deprivation ambylopia.

Droopy eyelid

Ptosis, or a droopy eyelid, can block vision in a child’s developing eye and lead to amblyopia.

If the droopy eyelid is blocking vision, this may need to be corrected to prevent amblyopia.