Sustained myopia control effects following cessation of multifocal soft contact lenses

Introduction

When evaluating myopia control treatments, it is important to consider not only their efficacy during active intervention, but also the extent to which these benefits are maintained after discontinuation (1). The recent study by Berntsen et al. [2025] (2) provides valuable evidence by examining whether cessation of multifocal soft contact lens wear in myopic children enrolled in the Bifocal Lenses in Nearsighted Kids (BLINK) 2 study resulted in a rebound effect. This work prompts a broader discussion on how treatment rebound should be assessed in clinical trials of myopia control treatments, including the need for a consensus on defining treatment efficacy and what constitutes a clinically meaningful rebound.

Soft contact lenses are a key optical myopia control treatment, when specific designs are used to alter retinal image or quality by inducing retinal defocus or modifying ocular aberrations to reduce the stimulus for excessive axial elongation that underlies myopia development and progression (3,4). While clinical trials have demonstrated favourable treatment effects for various soft contact lens designs, only a few have extended their investigations to examine whether rebound myopia progression occurs after treatment cessation. This is particularly relevant as evidence from other modalities, including higher concentrations of atropine eyedrops (5) and red-light therapy (6), have shown greater axial length growth upon treatment cessation compared with that expected in an age-matched group (7,8). Understanding if treatment effects are maintained provides critical insight into the long term benefits of treatment and helps inform potential adjustments to treatment that may be needed to avoid the risk of accelerated progression following early discontinuation.

Evaluating myopia control treatment efficacy

To assess whether treatment effects are maintained upon discontinuation, it is first necessary to understand how treatment outcomes are measured. Myopia control treatments including soft contact lenses are most commonly evaluated in randomised controlled trials against single-vision correction as the control condition, with axial length and cycloplegic refractive error used as the primary outcome measures (9). Clinical trials of myopia control treatments often report annualised changes or changes over the investigated treatment period, and the relative difference in myopia progression, defined as the percentage difference in axial length or refractive error change between the myopia control and control treatment groups (10-14). However, these approaches provide only a simplified overview of treatment efficacy and offer limited insight into how treatment evolves over the course of the intervention period (15,16). Treatment response varies over time, and the greatest effect is generally observed within the first 6 to 12 months when assessed over a 36-month treatment period. These temporal characteristics are critical for accurate interpretation of study results, comparison across interventions, and setting realistic clinical expectations, but are masked when reporting absolute or relative annualised, or overall treatment effects (16).

Some studies have adopted proportional or categorical outcome measures, applying various definitions such as classifications of no, slow, moderate and fast progression, or treatment responder and non-responder categories (15). However, there is ongoing debate regarding the appropriateness of applying uniform classifications to heterogeneous cohorts, as such approaches do not account for key patient factors, including age, sex and ethnicity, that are known to influence myopia progression and treatment response. Further, as a child’s untreated progression is unknown, it cannot be definitively determined whether they had responded to treatment (17). Acknowledging these limitations, more recent analyses have provided adjusted axial length and refractive error outcomes (10,12). Some clinical trials have adopted alternative strategies, including stratification by age, comparison with normal physiological ocular growth using age-, sex-, and ethnicity-adjusted normative axial length growth curves, or examination of progression patterns in treated and untreated eyes within comparative cohorts. These approaches enable differentiation between accelerated axial elongation beyond expected physiological age-related ocular growth, providing a more comprehensive assessment of treatment efficacy (15,18). For example, data from the 3-year randomised clinical trial of MiSight 1 day soft contact lenses were compared with virtual cohorts developed using data from myopic and emmetropic children in two large cohort studies, the Orinda Longitudinal Study of Myopia (OLSM) and the Singapore Cohort Study of the Risk Factors for Myopia (SCORM) and matched to MiSight clinical trial participants by age distribution at baseline. Children treated with MiSight contact lenses demonstrated axial elongation comparable to that predicted for age-matched emmetropic virtual cohorts derived from OLSM and SCORM growth models, indicating effective myopia control (18). While this is not a direct comparison, it provides additional contextual information for interpreting the observed treatment effects.

BLINK studies

The BLINK study (12) was a 3-year randomised clinical trial of 7- to 11-year-old myopic children (cycloplegic spherical component of −0.75 to −5.00 D). Participants were randomised in a 1:1:1 ratio to receive single-vision contact lenses (control), or Biofinity Multifocal D soft contact lenses with either medium add power (+1.50 D) or high add power (+2.50 D) (CooperVision, USA). The two different add powers were evaluated to determine whether multifocal soft contact lenses produced a dose dependent treatment effect, whereby a higher peripheral add, and thus greater peripheral myopic defocus, would result in enhanced treatment. Cumulative 3-year treatment effects in 292 children demonstrated that the higher add (+2.50 D) Biofinity Multifocal D soft contact lens resulted in significantly less myopia progression compared with both the lower add (+1.50 D add; 0.29 D and 0.16 mm less change) and single-vision control groups (0.45 D and 0.23 mm less change). The authors also reported the proportion of participants who progressed −1.00 D or more (16.8% high add power group, 36.5% medium add power group, and 51.0% single-vision control group) and had eye growth greater than 0.36 mm over 3 years (47.4% high add power group, 61.5% medium add power group, and 80.2% single-vision control group) (12).

Clinical trials of myopia control interventions typically evaluate treatment effects over 2- or 3-year periods (10-14). However, in clinical practice, children with myopia may remain on treatment for substantially longer durations. Average age for axial length stabilisation is approximately 15 years of age (8,19) and depending on the age of myopia onset, children may require myopia control treatment for more than 10 years. Some clinical trials have extended their treatment periods to investigate longer treatment effects, although control arms have generally not been maintained, including the BLINK study.

The BLINK2 study (2) enrolled children who had previously completed the BLINK study and were aged 11–17 years. All children were fitted with the Biofinity Multifocal D soft contact lenses with high add power (+2.50 D; CooperVision, USA) which was confirmed as the lens with greatest treatment effect in the original BLINK study and children were monitored for two additional years. During this time, axial length increased by 0.05 mm/year and refractive error by −0.17D/year, and treatment effects were not dependent on the original treatment assignment during the first 3 years of the BLINK study. The third year of the BLINK2 study required all participants to switch to single vision lenses, to determine whether the benefit of reduced myopia progression experienced during active treatment was lost after treatment discontinuation, also called rebound.

Rebound of myopia control treatment

Rebound following cessation of myopia control treatment has primarily been investigated using two approaches. Some assessments have compared myopia progression in the washout period following treatment cessation to that observed during active treatment (20,21). However, this may overestimate rebound effects as myopia progression during treatment is reduced, making it an inappropriate comparator. Similar to assessments of treatment efficacy, some investigators have evaluated and categorised myopia rebound using a range of definitions (1), which, as previously described, have inherent limitations.

In the BLINK2 study, following cessation of multifocal soft contact lens wear, children exhibited an increase in axial elongation to 0.08 mm/year and the annual rate of refractive error progression increased to −0.22 D/year (12). Although axial length and refractive error progressed slightly faster than during treatment, the rate of change was consistent with age-expected progression. Therefore, the authors concluded that there was no rebound effect after treatment discontinuation. While the BLINK2 study provides valuable insight into rebound of multifocal soft contact lens treatment for myopia, the investigated cohort consisted predominantly of Caucasian children, limiting the generalisability of the findings to other populations. In addition, treatment adherence was not monitored, and the post cessation follow-up period was limited to 1 year.

Alternatively, some earlier studies have compared myopia progression during the washout period to untreated children with myopia in the control group (5,22). However, as inclusion of comparable single vision control cohort becomes increasingly controversial (23), others have extrapolated expected ocular growth from untreated controls to act as a comparison point. The 7-year clinical trial of MiSight 1-day contact lens included a control group during the first 3 years, after which they switched to a treatment arm for the next 3 years, followed by a year of no treatment (24). The authors extrapolated untreated myopia progression data from the initial 3 years to the entire 7-year duration of the study, to assess rebound on cessation of treatment during the final year. Like the BLINK2 study, no significant difference was observed between myopia progression after treatment cessation and extrapolated untreated progression, with mean axial growth rates only approximately 0.01 mm greater. Importantly, the accrued benefits of treatment were maintained following discontinuation (24).

Future considerations

Assessment of myopia control treatment rebound is complex. The optimal duration to monitor post-treatment effects remains unclear, as rebound may be time dependent, with the greatest effects occurring in the months immediately following treatment cessation (25). In routine clinical practice, treatment discontinuation is typically considered when patients demonstrate stability with no evidence of progression, or when they reach an age at which physiological eye growth is expected to stabilise. Due to the structured and prescriptive nature of clinical trials, treatment discontinuation is generally initiated after a fixed treatment period, regardless of whether this timing is appropriate for an individual patient. Assessment of rebound effects often does not account for important patient specific factors, such as baseline axial length and age. Future treatment rebound investigation should consider changes in visual environment which are believed to trigger myopic growth across adolescence. Individuals may continue education into young adulthood and progression has been reported in young adults particularly those engaging in vocations or activities which require intensive near work. Understanding whether treatment benefits are maintained after discontinuation is critical for the appropriate long-term management of children with myopia.

Conclusions

Soft contact lenses offer a safe and effective treatment option for managing progressive myopia in children, with multiple lens designs demonstrating promising outcomes. The BLINK2 study, described by Berntsen et al. 2025 (2), found no evidence of treatment rebound following cessation of multifocal soft contact lens wear, indicating that benefits accrued over 5 years of treatment were largely maintained. Future studies of myopia control treatments need to similarly address key questions regarding the longer-term effects of these treatments, as well as whether benefits are maintained following discontinuation, as understanding treatment rebound is critical for the appropriate long-term management of individuals with myopia.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Eye Science. The article has undergone external peer review.

Peer Review File: Available at https://aes.amegroups.com/article/view/10.21037/aes-2026-1-0007/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aes.amegroups.com/article/view/10.21037/aes-2026-1-0007/coif). P.K. has received research funding from Johnson & Johnson VisionCare (USA) and CooperVision (USA), and academic gifts from Meta Reality Labs Research to support the author’s research program. P.K. has also received honorarium for presentations/workshops and consulting fees from Optometry Australia, Aspen Pharmacare, Asia Optometric Congress and Fudan University Eye ENT Hospital. P.K. has also received orthokeratology contact lenses from Eyespace (Australia) to support research projects. P.K. was also on an advisory panel for Aspen Pharmacare, and EssilorLuxottica. R.D. received payments for speaking, lecture fees and travel reimbursement from Asia Optometric Congress. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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