Repeated low-level red-light therapy: a guide for clinicians

At the completion of this article, the reader should be able to discuss RLRL with their myopia patients,  including:

• Understand the efficacy of RLRL in clinical studies, particularly for high myopia.
• Explore the underlying mechanisms behind RLRL’s effect and its role in axial shortening.
• Report on the efficacy of RLRL in an Australian multiethnic population.
• Understand how to identify appropriate patients for RLRL.
• Assess and monitor patients on RLRL to ensure ongoing efficacy and safety.

Nellie Deen
Doctor of Optometry, CertOcTher, FACO,
General manager city clinics, Australian College of Optometry, Melbourne

Zeinab Fakih
BOptom MPH GradCertUniversityTeaching,
Manager paediatric and rehabilitative services, Australian College of Optometry, Melbourne

Philip Cheng
B Optom FIAOMC
Clinical director of Eyecare Concepts, The Myopia Clinic, Melbourne

Jagrut Lallu
Optometrist MSc Specialty Lenses (Hons), BOptom (Hons) FIAOMC
Partner, Rose Optometry, Hamilton, New Zealand

Over the past year, repeated low-level red-light therapy has been commercially available in Australia and New Zealand for the slowing of myopia progression. But how effective is it, and how should optometrists begin incorporating it into their practices? Four leading Australasian myopia authorities share insights on this emerging treatment.

Myopia is an increasingly global issue, projected to affect one in two people worldwide by 2050.¹ Through a combination of genetic and environmental risk factors, such as increased screen time and less time spent outdoors, the growing epidemic of myopia requires effective myopia control treatments to slow progression in childhood, ideally before it progresses to high myopia with its accompanied sight-threatening risks. Indeed, every diopter counts, as even a 1.00 D increase has been shown to increase the later risk of myopic maculopathy by 67%.² 

The rise of red-light therapy

One of the newest myopia control interventions to be introduced is repeated low-level red-light (RLRL) therapy. This involves young patients using a home-use device that emits visible red light at 650nm through a low-level laser. The therapy requires two sessions per day, each lasting three minutes, five days a week, with a mandatory four-hour interval between sessions. The device tracks each time it is used and is connected to an online portal where parents and clinicians can log on to access real-time compliance monitoring.

The first randomised controlled trial of RLRL was published in 2021, demonstrating a 69.4% efficacy in slowing myopic progression in terms of axial length and 76.6% efficacy in terms of spherical equivalence. The efficacy was even higher at 87.7% for children who were more than 75% compliant, which is similar to completing treatment seven to eight times per week.³ Since then, numerous studies and systematic reviews have demonstrated strong efficacy of this non-invasive intervention.

Key studies have highlighted the effectiveness of RLRL, with a two-year follow-up study to the landmark trial showing a 75% reduction in myopic progression over two years.⁴ Another study comparing RLRL to the well-established 0.01% atropine found that RLRL was significantly more effective in slowing myopic progression over 12 months.⁵

Additionally, studies on RLRL in highly myopic populations – often overlooked in myopia research – have shown promising results. Two studies of patients of -4.00 D and -6.00 D or higher found that RLRL achieved over 100% efficacy in slowing myopia and even caused axial shortening.^6,7 Notably, while RLRL can be used effectively as a standalone treatment, it can also be combined with all other therapies except atropine, and has shown considerable effect in slowing myopia progression when combined with orthokeratology.^8,9

Safety of RLRL

A recent systematic review evaluating the safety of RLRL reported a side effect rate of 0.088 per 100 patient-years, far lower than other myopia control treatments like atropine or orthokeratology, with the main side effect noted being a temporary afterimage.¹⁰ Only one case report of an adverse event was noted from the literature, with a complete recovery of the patient noted on later follow-up.^11,12

Although the exact mechanism of RLRL has yet to be elucidated, a common significant finding across numerous studies of RLRL is that it causes significant choroidal thickening, as well as an increase in retinal and choroidal blood flow.^3,13 Studies have also shown that this choroidal thickening correlates to the degree of clinical efficacy and may be related to alleviating scleral hypoxia which is involved in the pathogenesis of myopia.^3,13

Axial ‘shortening’

A distinctive feature of RLRL, compared to other myopia control treatments, is its ability not only to slow the axial elongation of the eye associated with myopia but also to promote significant axial shortening (greater than 0.05 mm per year) in some patients^14,15 This phenomenon was observed in 21.9% of participants in the landmark trial at 12 months, and in 26.5% of participants in a separate real-world study of 434 myopic children aged between three to 17.^14,15 In addition, for the RLRL group that exhibited AL shortening, choroidal thickness thickening could only explain 28.3% of AL shortening.¹⁴ This suggests that the observed AL shortening may be related to true scleral remodeling, rather than an apparent shortening due to choroidal thickening, highlighting the potential for RLRL to directly influence structural changes in the eye.

International uptake

While RLRL research thus far has been largely published from China, the only RLRL device to have attained international regulatory approval to date is the Eyerising device. Excitingly, the first international studies of this device are now yielding results from countries like Japan, Australia and Spain. Commercial interest is also growing, with the Eyerising device now available in several regions (Europe, Australia, New Zealand, UK, Malaysia, Vietnam and Turkey). In Australia and New Zealand, patients are approaching the completion of up to two years of RLRL treatment. 

Below, four early adopters and users of RLRL in Australia and New Zealand discuss their experiences and insights into this new treatment modality, and where they see RLRL positioned into myopia management in future.

Assessing efficacy of RLRL in an Australian population

Nellie Deen and Zeinab Fakih are paediatric optometrists at the Australian College of Optometry in Melbourne, Australia, where they serve as general manager of city clinics and manager of paediatric services, respectively. Together, they led a pioneering 12-month study on RLRL in Australia, which investigated its efficacy in school-aged Australian children and concluded in December 2024. This study was the first to examine RLRL in a non-Chinese population and followed the same inclusion and exclusion criteria as the landmark trial in China, allowing for direct comparison.

Our trial recruited 34 multi-ethnic children aged eight to 13, who were randomly assigned to either use the Eyerising device or single-vision spectacles. Over 12 months, the RLRL group showed significantly less myopic progression, with mean axial shortening at one, three, six and 12 months, and a 12-month progression of -0.03 mm compared to controls at 0.12 mm. Spherical equivalence progression was also considerably less in the RLRL group, with 0.09 D of improvement, while the control group experienced a progression of -0.21 D. No adverse events or structural changes on OCT were reported, supporting the safety profile of RLRL in this population. Patient compliance was also good at an average of 60.0%, and generally they found the Eyerising device easy to tolerate.   

Going forwards, we are excited to be soon presenting and publishing this work. Furthermore, following the conclusion of the clinical trial, ACO Eye Health has since incorporated RLRL into its myopia clinic framework. As a public health provider, ACO Eye Health will offer RLRL at a reduced cost for eligible patients. The clinic will also continue to monitor and follow up the trial’s participants, particularly those continuing to use RLRL, for additional learnings as to RLRL’s continued efficacy and safety.

Patient Identification

Philip Cheng is a distinguished myopia control optometrist based in Melbourne, and is the founder and director of Eyecare Concepts | The Myopia Clinic Melbourne, dedicated to innovative myopia management strategies. With vast experience across a full spectrum of myopia control methods, including orthokeratology and atropine, he has recently introduced RLRL into his clinic as a novel approach.

For my initial RLRL patients, I have focused on high myopia, a subgroup where I have a large patient base, and for whom I am developing a specialised clinic. High myopia, defined as -6.00 D or more, affects 4% of the global population,¹ with projections of 9.8% by 2050 and up to 20% in parts of Southeast Asia.

It significantly increases the risks of complications such as glaucoma, retinal detachment and myopic maculopathy, which can lead to irreversible visual loss. Even a 1.00 D increase in myopia has been demonstrated to increase the risk of myopic maculopathy by 67%, ² therefore addressing progression in high myopes is critical.

Evidence for the efficacy of myopia control interventions in high myopia is limited, as these patients are often excluded from studies. A 2024 systematic review identified only 12 studies, with efficacy ranging from 50-60%.¹⁶ Treatments like orthokeratology are off-label for myopia above -6.00 D and often challenging to fit. Myopia management spectacle lenses, available up to -10.00 D, also have limitations, with thick lenses in high myopia cases that can be cosmetically unappealing.

In contrast, RLRL has demonstrated strong clinical efficacy in treating high myopia, with two studies showing exceptional results in slowing or even halting myopic progression.^6,7  Both studies showed mean axial shortening in RLRL patients of 0.06 mm and -0.11 mm, respectively, and a higher percentage of patients (50-60%) experiencing axial shortening compared to in normal myopia (20-30%). A further advantage of RLRL is that it can be administrated as an adjunctive treatment for patients using optical interventions such as orthokeratology, soft contact lenses and peripheral defocus spectacle lenses, with combination therapy often proving more effective than monotherapy.

Given these developments, I am prescribing RLRL for my highly myopic patients, as well as those who are rapidly progressing towards high myopia or continuing to demonstrate progression using mainstay myopia control treatments.

Examples of these patients include those who are progressing on even moderate-to-high doses of atropine well above 0.05%, and patients already treated with combined optical interventions with atropine. As RLRL is believed to involve a different mechanism to slow myopic progression, it is a promising new approach for treating these challenging patients.

Real world patient experiences of RLRL

Jagrut Lallu is a New Zealand-based optometrist and partner at Rose Optometry, as well as a clinical senior lecturer at Deakin School of Optometry. He has been active in myopia management for several years, acting as IMI ambassador for New Zealand and World College of Optometry Asia Pacific ambassador for myopia. He was one of the first clinicians to start using RLRL in New Zealand, with now over 60 patients on the therapy and 20 that have been using it for over a year.

Generally, I have found RLRL to be well-tolerated by my patients and I have seen some fantastic results including axial shortening and sustained choroidal thickening. In particular, I have found ideal results in patients who were progressing despite utilising myopia management options and as an adjunctive therapy for many of my patients on orthokeratology.

Through the addition of RLRL, these patients have seen virtually no myopic progression and need not wear glasses during the day, which they have responded very positively to. This ‘glasses-off’ finding is similarly reported in two published studies of combination use of RLRL and orthokeratology, where in patients who had been using orthokeratology for 12 months with continued myopic progression, the addition of RLRL resulted in -0.10 mm and -0.02 mm axial shortening over the following 12-month period respectively.^8,9 

In one case, I had been seeing an eight-year-old myopic boy on orthokeratology whose refraction had been controlled, but whose axial length was continuing to progress. In November of 2023, I therefore added on RLRL.

Since then, I have noticed slight reduction and later stabilisation of the axial length over the past year, with the child also exhibiting a 98% compliance to the treatment.

Speaking to the safety of RLRL, none of my patients have yet experienced any side effects. I am an advocate of regular follow-up and monitoring including OCT (which Eyerising International also recommends), finding it useful both from an efficacy perspective to see results from as early as the first month, and from a safety perspective for continued reassurance.

The way forward

Overall, RLRL represents a promising innovation in myopia control, with increasing international evidence supporting its efficacy and safety and steadily growing clinical uptake. Clinicians interested in trying out RLRL can be reassured of its maintained efficacy in international users, and when looking for their first patients, may find greater success in difficult-to-treat patients, such as the highly myopic or treatment-resistant patients, where RLRL can be used either as a standalone or combination therapy.

There is also continued research ongoing into all facets of RLRL, including its long-term efficacy over three years or more, and a better understanding of its underlying mechanism and retinal effect. In the future, it is anticipated this will strengthen the position of RLRL as a key player in myopia management. 

More reading

Eyerising International responds to China myopia red light regulatory changes

Tokyo Medical and Dental University introduces Eyerising red light therapy for myopic patients

Aussies report red light therapy shortens axial length in myopia

References

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