Stopping Myopia Treatment Safely: Understanding and Managing the Rebound Effect
核心洞察
Rebound is defined by the International Myopia (搜索) Institute as accelerated axial elongation and myopic progression after treatment cessation relative to a matched comparison group, assessed over at least one year.
A review of 19 studies found mean first-year rebound of +0.05 ± 0.10mm axial length and -0.09 ± 0.24D myopia (搜索) progression, with the largest effects following higher-concentration atropine and repeated low-level red-light therapy.
Treatment should be maintained until refractive and axial length stability is achieved, typically at least until age 15, with stability documented over 12 to 24 months before discontinuation.
Rapid advancements in myopia (搜索) management have produced novel optical, pharmacological and light-based interventions capable of slowing or halting myopia progression in children. Yet as a growing number of children undergo prolonged treatment, clinicians face an increasingly pressing question: how and when should therapy be safely discontinued, and what risks—including treatment rebound—accompany cessation? Success in myopia control is determined not only by the ability to slow progression during therapy, but also by how well these benefits are maintained after treatment stops.
Defining Rebound
Rebound represents a significant clinical concern, as benefits accumulated over years of myopia (搜索) control treatment may be partially or completely lost after discontinuation, compromising long-term outcomes. The International Myopia Institute (IMI) defines rebound as an accelerated rate of axial elongation and myopic refractive progression following cessation of a myopia control treatment relative to a matched comparison group, which should be investigated over a minimum of one year post-cessation to account for seasonal variation in progression.
Inconsistent definitions of rebound throughout the literature complicate interpretation of study findings. Some recent reviews have defined rebound by comparing myopia (搜索) progression after treatment cessation with progression during treatment, an approach that compares outcomes from different treatment phases without an appropriate matched comparison group. Because axial length elongation may not cease entirely after treatment stops—particularly in younger children—studies evaluating progression over a predefined post-treatment period may underestimate rebound, and the timing and duration of follow-up may influence the observed magnitude.
Quantifying Rebound Across Modalities
A recent literature review summarized rebound following cessation of various myopia (搜索) control treatments across 19 studies. In alignment with the IMI definition, treatment rebound was calculated as the difference in axial elongation and myopia progression between a treatment group in the year following cessation and a comparison group. The mean rebound during the first year after treatment cessation was +0.05 ± 0.10mm for axial length and -0.09 ± 0.24D for myopia progression.
The largest rebound effects were reported following repeated low-level red-light therapy (>+0.14mm) and atropine treatment. Although atropine studies demonstrated wider variability (-0.04mm to +0.22mm), larger rebound effects were generally associated with concentrations greater than 0.1%. Rebound following orthokeratology ranged from +0.11mm to +0.14mm in two studies, whereas rebound appeared lower with other optical interventions. Soft contact lenses demonstrated mean rebound ranging from -0.05 to +0.01mm, while spectacle lens interventions ranged from -0.02 to +0.06mm.
Rebound was positively correlated with treatment efficacy in the first year (r² = 0.43), suggesting that more effective treatment modalities may be associated with greater rebound following cessation. In contrast, rebound was not significantly associated with age at treatment cessation (r² = 0.05). However, the authors noted that these analyses were based on study-level mean values, which would obscure variation at the individual participant level.
The estimated magnitude of rebound appears to be influenced by both treatment modality and the duration of post-cessation follow-up. Studies with shorter follow-up periods may overestimate rebound due to seasonal variation in axial growth, measurement variability and transient biometric changes. When analyses were restricted to studies with at least 10 months of follow-up, the average rebound effect was reduced to +0.03 ± 0.07mm and -0.04 ± 0.26D for axial length and myopia (搜索) progression, suggesting minimal rebound across all modalities.
Guiding Treatment Cessation
Current reviews and clinical guidelines recommend that decisions regarding treatment cessation be individualized and based on a combination of factors, including the patient's age, duration of treatment stability and the specific myopia (搜索) control modality being used.
Age. The observation that post-cessation axial length growth generally returns toward age-expected untreated growth rates suggests that treatment should not be discontinued solely because progression has been successfully controlled. Rather, treatment should be maintained until the patient's underlying risk of further clinically meaningful progression has substantially reduced. Evidence indicates that myopia (搜索) progression generally slows with increasing age, with the COMET study showing that approximately half of children achieve refractive stability by age 15, 77% by age 18 and up to 90% by age 21. Given that only about half of children have achieved refractive and axial growth stability by 15 years of age, treatment should be maintained at least until this age unless there is clear evidence of earlier stability.
Additional factors such as educational and vocational demands may predispose patients to ongoing myopia (搜索) progression. Myopia progression during adulthood remains relatively common among university students and individuals engaged in intensive near-work activities, so treatment cessation may need to be delayed in some adolescents and young adults.
Duration of stability. A practical clinical approach is to demonstrate documented evidence of stable refractive error and/or axial length measurements over a period of at least 12 to 24 months, based on reliable and repeatable assessments across multiple visits. For patients younger than approximately 15 years of age, stability should ideally be demonstrated over a longer period (approximately two years or more) before treatment is discontinued. For older adolescents and young adults (15 years and older), a period of confirmed stability of approximately one to two years may be sufficient.
Modality-Specific Considerations
Atropine. Higher concentrations of atropine (>0.1%) may be associated with greater rebound following treatment cessation. Additional factors linked to rebound include younger age at cessation, shorter treatment duration and higher baseline myopia (搜索). The strongest evidence favors tapering strategies for higher-concentration regimens (e.g., 0.5% to 1%), with stepwise reductions in concentration (e.g., from 0.5% to 0.25% to 0.1% to 0.01% at fixed intervals) to minimize rebound.
Evidence supporting tapering of lower-concentration 0.05% atropine is provided by the LAMP extension study. Children who completed the five-year LAMP study were invited to participate in an additional three-year extension study and, at approximately 13 years of age, were randomized to either a tapering or non-tapering group. In the tapering group, children received 0.05% atropine daily for six months followed by 0.025% atropine daily for a further six months in the sixth year. In the non-tapering group, children continued 0.05% atropine daily for the entire sixth year. Both groups then ceased treatment and were followed for a further two years.
Overall, children in the tapering group experienced less myopia (搜索) progression, as measured by both refractive error (-0.54D vs. -0.78D) and axial elongation (0.33mm vs. 0.44mm), compared with those in the non-tapering group. Younger age and greater myopia at baseline were associated with more myopia progression at atropine cessation.
For children using 0.01% atropine, evidence for tapering strategies remains limited and mixed. A recent study investigating tapering of 0.01% atropine following two years of treatment found that the rate of myopia (搜索) progression during the one-year washout period was significantly lower than that observed during the second year of treatment, but the absolute magnitude of progression was comparable between tapering and non-tapering groups, with neither group demonstrating clinically meaningful rebound.
Optical interventions. Myopia (搜索) control spectacles and soft contact lenses appear to demonstrate minimal rebound following treatment cessation, so cessation of these interventions can generally be considered once refractive and axial length stability has been established. Orthokeratology, in contrast, may be associated with rebound following cessation, though researchers have acknowledged that reported rebound estimates are derived from studies with relatively short follow-up periods, which may have led to overestimation. It has been suggested that orthokeratology should not be discontinued prematurely, particularly before approximately 14 years of age.
Red-light therapy. Repeated low-level red-light therapy is a relatively new myopia (搜索) control intervention and appears to be associated with the greatest rebound following cessation, though more longitudinal studies are required to better understand its long-term efficacy, safety and optimal discontinuation strategy.
Monitoring for Rebound
Axial length is the most sensitive biomarker of myopia (搜索) progression and is considered the primary outcome measure in contemporary myopia management. Consequently, monitoring axial length following treatment cessation provides the most direct method of detecting progression and assessing potential rebound. Spherical equivalent refractive error remains a clinically useful measure and can be monitored alongside axial length to capture both structural and refractive changes.
Ongoing monitoring following treatment cessation is recommended to detect renewed myopia (搜索) progression, particularly during the early post-treatment period when rebound is most likely to occur. Consider follow-up visits approximately three months after treatment cessation, followed by reviews at gradually increasing intervals over time, with subsequent review intervals individualized according to the patient's age, previous rate of progression, treatment modality and overall risk of future progression.
There is currently limited evidence regarding specific thresholds for reinitiating myopia (搜索) control treatment following cessation. In clinical practice, consider renewed treatment when ongoing axial elongation or refractive progression exceeds age-expected physiological growth and is judged to be clinically meaningful. A clinical threshold to consider is axial length growth of >0.05mm/year or spherical equivalent refraction progression of >-0.25D/year based on adult myopia progression rates.
In general, myopia (搜索) control treatment should be continued until the patient has achieved refractive and axial length stability, characterized by little or no measurable change over time and a low risk of further progression. Following cessation, close monitoring is recommended, and if clinically meaningful progression is detected, reinitiation of myopia control treatment should be considered.