I HAVE LEARNED MORE about low hyperopia in children as the concept of premyopia has expanded. The International Myopia Institute defines patients with premyopia as those who have a refractive error of +0.75 D or less (Flitcroft et al, 2019), a concept that finds it roots in the Collaborative Longitudinal Evaluation of Ethnicity and Refractive Error (CLEERE) studies, where cut points were defined for risk of future myopia at different ages (Zadnik et al, 2015) (Table 1).
When patients fit these categories, it is beneficial to explain the importance of 2 hours a day of outdoor time and to discuss myopia control to prepare them for when myopia does begin to progress (Jonas et al, 2021). This can raise the idea of contact lens wear in children, so parents are more receptive to myopia control contact lenses in the future. Several modalities, such as special spectacles and 0.05% atropine, have been shown to effectively slow the onset of myopia (Yam et al, 2023; Zhang et al, 2025), and could be used in patients who are looking to get in front of myopia. But how do we target the right candidates for education and early intervention?
Premyopia is based on cycloplegic refraction, and patients who have low hyperopia on noncycloplegic (dry) refractions tend to show a significant portion of hyperopia after cycloplegia (Guo et al, 2022). The same study showed that even those with emmetropia on dry refraction may reveal enough hypermetropia on cycloplegic refraction to no longer qualify as premyopes.
A +0.50 D 7-year-old on dry refraction will, on average, not fit the criteria for premyopia following cycloplegia, so educating this patient on the risks of future myopia prior to a cycloplegic refraction may be a waste. Wu and colleagues (2025) recently advocated for the use of atropine as a dilating agent to ensure that practitioners are not overestimating the prevalence of premyopia, and showed significantly less myopia (more hyperopia) when atropine was used as compared to cyclopentolate on refraction.
Although this appears to be a reasonable line of thought on its surface, it seems unlikely that the average practitioner will opt to conduct regular cycloplegic refractions with atropine. Of greater consequence, because the CLEERE study was the primary study to define premyopia, it’s worth noting that CLEERE used 2 drops of tropicamide for cycloplegia (Zadnik et al, 1999).
Cyclopentolate is still the standard of care for pediatric refractions, and it seems wise to continue with 1% cyclopentolate for a pediatric patient’s first examination at a minimum (a point recently articulated well by McDowell and Taub [2025]). Once a patient is officially a myope and pseudomyopia, strabismus/amblyopia, and other accommodative dysfunctions have been ruled out, annual examinations can continue with 1% tropicamide (Manny et al, 2001).
It is highly recommended to include a cycloplegic autorefraction or retinoscopy in any pediatric exam to determine whether the patient is a premyope. This way, the right patients are getting the proper education when they need it, and it avoids the overprescribing of premyopic treatments that might result if decisions were based on using dry, noncycloplegic findings.
References
1. Flitcroft DI, He M, Jonas JB, et al. IMI - Defining and Classifying Myopia: A Proposed Set of Standards for Clinical and Epidemiologic Studies. Invest Ophthalmol Vis Sci. 2019;60(3):M20-M30. doi:10.1167/iovs.18-25957
2. Zadnik K, Sinnott LT, Cotter SA, et al. Prediction of Juvenile-Onset Myopia. JAMA Ophthalmol. 2015;133(6):683-689. doi:10.1001/jamaophthalmol.2015.0471
3. Jonas JB, Ang M, Cho P, et al. IMI Prevention of Myopia and Its Progression. Invest Ophthalmol Vis Sci. 2021;62(5):6. doi:10.1167/iovs.62.5.6
4. Yam JC, Zhang XJ, Zhang Y, et al. Effect of Low-Concentration Atropine Eyedrops vs Placebo on Myopia Incidence in Children: The LAMP2 Randomized Clinical Trial. JAMA. 2023;329(6):472-481. doi:10.1001/jama.2022.24162
5. Zhang Z, Zeng L, Gu D, et al. Spectacle Lenses With Highly Aspherical Lenslets for Slowing Axial Elongation and Refractive Change in Low-Hyperopic Chinese Children: A Randomized Controlled Trial. Am J Ophthalmol. 2025;269:60-68. doi:10.1016/j.ajo.2024.08.020
6. Guo X, Shakarchi AF, Block SS, Friedman DS, Repka MX, Collins ME. Noncycloplegic Compared with Cycloplegic Refraction in a Chicago School-Aged Population. Ophthalmology. 2022;129(7):813-820. doi:10.1016/j.ophtha.2022.02.027
7. Wu H, Wang Y, Lu Q, et al. Atropine or Cyclopentolate to Diagnose Premyopia in Preschool Children. JAMA Ophthalmol. 2025;143(11):904-913. doi:10.1001/jamaophthalmol.2025.3243
8. Zadnik K, Mutti DO, Friedman NE, et al. Ocular Predictors of the Onset of Juvenile Myopia. Invest Ophthalmol Vis Sci. 1999;40(9):1936-1943.
9. McDowell P, Taub M. Point-Counterpoint: Cyclopentolate Versus Tropicamide for Cycloplegic Refraction. Clinical Insights in Eyecare. 2025;3(4):33-39. Accessed January 7, 2026.