Journal of
Clinical Medicine
Article
Axial Length Shortening and Choroid Thickening in Myopic
Adults Treated with Repeated Low-Level Red Light
Guihua Liu 1 , Bingqin Li 1 , Hua Rong 1 , Bei Du 1 , Biying Wang 1 , Jiamei Hu 1 , Bin Zhang 2, * and Ruihua Wei 1, *
Citation: Liu, G.; Li, B.; Rong, H.; Du,
B.; Wang, B.; Hu, J.; Zhang, B.; Wei, R.
Axial Length Shortening and Choroid
Thickening in Myopic Adults Treated
with Repeated Low-Level Red Light.
J. Clin. Med. 2022, 11, 7498. https://
doi.org/10.3390/jcm11247498
Academic Editors: Paulo Fernandes
and Alireza Karimi
Received: 22 November 2022
Accepted: 16 December 2022
Published: 17 December 2022
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Attribution (CC BY) license (https://
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4.0/).
J. Clin. Med. 2022, 11, 7498. https://doi.org/10.3390/jcm11247498
1 Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research
Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital,
Tianjin 300384, China
2 College of Optometry, Nova Southeastern University, Davie, FL 33314, USA
* Correspondence: bz52@nova.edu (B.Z.); rwei@tmu.edu.com (R.W.)
Abstract: This study aimed to explore the effect of repeated low-level red light (RLRL) on axial length
(AL), choroid blood flow, and anterior segment components in myopic adults. Ninety-eight myopic
adults were randomly divided into the RLRL group (n = 52) and the control group (n = 46). Subjects
in the RLRL group completed a 4-week treatment composed of a 3-min RLRL treatment session twice
daily, with an interval of at least 4 h. Visits were scheduled before and on 7, 14, 21, and 28 days
after the treatment. AL, subfoveal choroidal thickness (SChT), choroidal vascularity index (CVI),
and anterior segment parameters were measured at each visit. A linear mixed-effects model showed
that the AL of the subjects in RLRL decreased from 24.63 ± 1.04 mm to 24.57 ± 1.04 mm, and the
SChT thickened by 18.34 µm. CVI had a slight but significant increase in the 0–6 zone. However, all
the anterior segment parameters did not change after RLRL treatment. Our study showed that the
choroid’s thickening is insufficient to explain the axial length shortening. The unchanged anterior
segment and improved choroid blood flow suggest that the AL shortening in this study is mainly
related to changes in the posterior segment.
Keywords: repeated low-level red light therapy (RLRL); myopia; adults; axial length; choroidal
thickness; choroidal vascularity index
1. Background
Myopia is a common ocular disorder that has been dramatically elevated worldwide
over the past several decades [1,2]. It is a significant factor for visual impairment, and
high myopia can increase the risk of pathologic ocular changes [3]. Axial elongation is
an essential indicator of myopia progress. Previous studies have shown that eyes with
axial length (AL) of 26 mm or greater had a significantly higher risk for visual impairment
than eyes with AL shorter than 26 mm in Europeans under 60 [4]. Therefore, intervention
methods have been explored to slow down myopia progression and reduce the incidence
of high myopia.
Recently, a new intervention—repeated low-level red light (RLRL) therapy—showed
a significant myopia control effect in myopic Chinese children [5–9]. It was administered
at home for 3 min per session, twice daily with a minimum interval of 4 h, five days per
week. Jiang et al.’s study showed that, compared with the non-treatment group, the RLRL
group represented a 69.4% reduction in axial elongation after one year of treatment [5].
More interestingly, they found axial length shortening (>0.05 mm change) in 39.8% of the
participants at one month and 21.6% at 12 months. The proportion of children showing
axial length shortening may have been underestimated because of the physiological growth
in the axial length. Therefore, exploring this phenomenon in adults with stable axial length
may be more appropriate.
The mechanism underlying the observed axial length shortening remains unknown.
Choroid thickening was found in children who underwent RLRL treatment [5,6]. However,
https://www.mdpi.com/journal/jcm
J. Clin. Med. 2022, 11, 7498 2 of 11

it could not explain the axial shortening entirely as the scale of choroidal thickening was
much smaller. An alternative hypothesis is that the RLRL treatment might increase choroid
blood flow and metabolism of the fundus, thus ameliorating scleral hypoxia and restoring
scleral collagen levels [5]. However, the blood flow changes of the fundus in myopic
adults after RLRL treatment have not been examined. Changes in other ocular components
could also contribute to the short-term axial length change. Hughes reported that anterior
chamber depth (ACD), crystalline lens thickness (LT), anterior segment length (ASL), and
vitreous chamber depth (VCD) altered significantly during accommodation, resulting in an
increment in axial length [10]. Moreover, such changes were more prominent in the myopic
group and existed in adults and children [10–12]. Whether short-term RLRL treatment can
cause changes in anterior segment parameters in myopic adults is currently unknown.
Therefore, this study aimed to explore whether axial length shortening exists in myopic
adults who received RLRL after one month of treatment and to quantify changes in choroid
flow and ocular components in the anterior segment.

2. Materials and Methods

2.1. Subjects
This prospective study was conducted at the Tianjin Medical University Eye Hospital
(Tianjin, China) between July 2022 and September 2022. All enrolled participants signed
informed consent forms. All procedures adhered to the tenets of the Declaration of Helsinki
and were approved by the Tianjin Medical University Eye Hospital ethics committee. Partic-
ipants underwent a complete ophthalmic examination, including visual acuity, intraocular
pressure, slit-lamp ophthalmic examination, and fundus examination. The inclusion criteria
were age between 18 and 35 years; myopia refractive error power between −6.00 D and
−0.50 D, with the rule of astigmatism less than −1.50D, and best corrected monocular
optical visual acuity better than 20/20. The exclusion criteria included acute and sub-acute
inflammations or infection of the anterior chamber of the eye, history of surgery or contact
lens use, severe insufficiency of tears, corneal hypoesthesia, allergic eye diseases, retinal
diseases, and any significant systemic illness. Eligible subjects were randomly allocated to
either the RLRL group or the control group, according to a randomization list pre-generated
by a computer program. All technicians involved in the study did not know the grouping.

2.2. Measurement
Lenstar and SS-OCT were measured before the treatment, seven days, 14 days,
21 days, and 28 days after the treatment. All evaluations were performed from 9 to
11 am to avoid diurnal variation [13].

2.3. Repeated Low-Level Red Light Therapy (RLRL)

A low-level red light therapy device (Eyerising; Suzhou Xuanjia Optoelectronics Tech-
nology, Suzhou, China) was used in this study. It consists of semiconductor laser diodes,
which deliver low-level red light with a wavelength of 650 ± 10 nm at an illuminance level
of approximately 1600 lux through the pupil to the fundus. A recent study has shown
it to be safe for a 2-year treatment period [8]. In the control group, a neutral density
attenuator was placed between the laser emitter and the eyepiece to lower the red light
power by three log units. The average red light power was 1.63 mW and 1.92 µW before
and after attenuation, measured by the Laser power meter (UT385, UNI-Trend Technology,
Dongguan, China).
Subjects wore spectacles to complete treatment twice daily with an interval of at least
4 h, with each treatment lasting 3 min, during weekdays (5 days per week). All subjects
were required to continue treatment for one month. To ensure an accurate measure of
compliance, the date and time of treatment sessions were automatically captured by the
device and transferred to the server through the internet. A reminder message was sent
to both the supervisor and the subject upon noticing that the subject had not logged into
the system for two days consecutively. The supervisor would confirm with the subject to
J. Clin. Med. 2022, 11, 7498 3 of 11

ensure the number of treatments required by the test (twice a day, more than 4 h intervals,
5 days a week).

2.4. Ocular Biometric Parameters

Ocular biometric parameters were measured with a non-contact optical low-coherence
reflectometry device (Lenstar LS-900; Haag-Streit AG, Berne, Switzerland) before and
after the treatment. Previous studies reported that Lenstar had good repeatability and
stability, and had been used to monitor subtle changes in ocular biometric parameters
such as axial length after intervention [14–18]. Subjects were advised to fixate on the target
during the measurements and blink several times for an intact tear film. Only the intra-
session differences of three repeated measurements no greater than 0.02 mm were kept on
each measurement occasion. The average was used as a representative value for further
analysis. Biometric parameters that included axial length (AL), center cornea thickness
(CCT), anterior chamber depth (ACD), lens thickness (LT), flat meridian (K1 ), and steep
meridian (K2 ) were collected.

2.5. SS-OCT/OCTA
A swept-source OCT (VG200, SVision Imaging, Ltd., Luoyang, China) was performed
for SS-OCT and SS-OCTA images with radial and raster patterns. It contains a central
tunable laser with 1050 nm wavelength by 200,000 A scan per second [19]. A cross-pattern
light was the indicator for the patient to make the fixation, and the radial and raster
patterns were built into the software to capture the images. B-scan (55◦ ) images that
were 16 mm-wide demonstrated fundus structures to rule out the abnormal structures.
A total of 512 × 512 scans of OCTA images obtained in a 6 mm x 6 mm macular cube
pattern were captured by Angio Retina mode for retinal vascularity assessments. The
choroidal boundary and large/medium choroidal vessels were accurately segmented in
three dimensions using the segmentation algorithm based on deep learning. The subfoveal
choroidal thickness (SChT) was defined as the vertical distance between Bruch’s membrane
and the choroid−sclera interface in the macular zone. The choroidal vascularity index
(CVI) was defined as the ratio of choroidal vascular luminal volume to total choroidal
volume (Figure 1). The macular zone was interested in that study, and divided into three
circular concentric areas on the base of the Early Treatment Diabetic Retinopathy Study
(ETDRS) grid [20]. In this study, three chosen rings ranged from 0 to 1 mm, 0 mm to 3 mm,
J. Clin. Med. 2022, 11, 7498 4 of 11
and 0 mm to 6 mm. A well-trained operator performed all scanning operations, and all the
pictures reserved for the study’s signal strength were higher than 7.

Methods
Figure1.1.Methods
Figure to measure
to measure choroidal
choroidal vascularity
vascularity index(A)
index (CVI). (CVI). (A) The
The ETDRS gridETDRS
dividedgrid
the divided the
macular region into three concentric rings (1, 3, and 6 mm in diameter [purple lines]). (B) Raw image
macular region into three concentric rings (1, 3, and 6 mm in diameter [purple lines]). (B) Raw image
acquired by SS-COT. (C) Based on deep learning, the system recognizes the boundary of cho-
acquired by SS-COT. (C) Based on deep learning, the system recognizes the boundary of choroid(blue
roid(blue lines) and identifies the choroid’s large and medium blood vessels (orange zone) and
lines) andCVI.
quantifies identifies the choroid’s large and medium blood vessels (orange zone) and quantifies CVI.

3. Statistics
The means and standard deviations of measured parameters were computed for de-
scriptive purposes. Data were first tested for normality using the sample Shapiro–Wilk
test. Independent t-tests and chi-square tests were used to assess the differences between
J. Clin. Med. 2022, 11, 7498 4 of 11

3. Statistics
The means and standard deviations of measured parameters were computed for
descriptive purposes. Data were first tested for normality using the sample Shapiro–Wilk
test. Independent t-tests and chi-square tests were used to assess the differences between
the RLRL group and control group at baseline. Two-way repeated-measures ANOVA was
used to analyze the group, time, and group*time interaction. Pearson correlation was used
to analyze the relationship between age, baseline AL, SChT changes, and AL changes. All
statistical analyses were performed using R software (version 3.2.2). Only data from the
right eye of each subject were included in the analysis. A p-value < 0.05 value was defined
as statistically significant.

4. Results
There were 110 subjects enrolled initially, and 98 subjects completed all follow-up
examinations, with 52 subjects (28 males and 24 females; mean age 26.08 ± 2.13 years,
range: 23–31 years) in the RLRL group and 46 subjects (26 males and 20 females; mean age
22 years, range: 23–31 years) in the control group. No significant differences in age, sex,
SChT, CVI, and all ocular biometric parameters were identified between the two groups at
baseline (Table 1).

Table 1. Demographics and baseline ocular characteristics between the RLRL group and control
group (mean ± SD).

Characteristics RLRL Group (n = 52) Control Group (n = 46) p

Age (years) 26.08 ± 2.13 25.60 ± 2.42 0.43
Sex (male/female) 28/24 26/20 0.79
SChT (µm) 365.73 ± 81.74 358.13 ± 72.61 0.63
CVI01 0.389 ± 0.054 0.384 ± 0.058 0.66
CVI03 0.386 ± 0.050 0.387 ± 0.051 0.11
CVI06 0.361 ± 0.049 0.365 ± 0.042 0.26
CCT (µm) 522.77 ± 47.96 519.65 ± 42.83 0.74
ACD (mm) 3.02 ± 0.24 3.05 ± 0.27 0.58
LT (mm) 3.72 ± 0.20 3.69 ± 0.15 0.49
K1 (D) 42.85 ± 1.60 42.68 ± 2.08 0.66
K2 (D) 44.01 ± 1.82 44.00 ± 2.19 0.97
AL (mm) 24.63 ± 1.04 24.63 ± 1.19 0.98
SChT = subfoveal choroidal thickness; CVI = choroidal vascularity index; CCT = center cornea thickness;
ACD = anterior chamber depth; LT = lens thickness; K1 = flat meridian; K2 = steep meridian; AL = axial length.

4.1. Change in Axial Length

In the RLRL group, AL was shortened steadily within one month of treatment. By
the end of the first month of treatment, AL decreased by an average of 0.06 mm (from
24.63 ± 1.04 mm to 24.57 ± 1.04 mm, range: 0–0.13 mm). In the treated group, 69.23% of
subjects’ AL decreased by more than 0.05 mm. In the control group, AL had no significant
changes during the follow-up. There was a statistically significant group*time interaction
by a two-way repeated ANOVA (p < 0.001). In other words, the AL in the RLRL group
(red line) decreased gradually with the treatment time, while AL in the control group (blue
line) did not change. The post-hoc analyze indicated that there were statistically significant
differences between the RLRL group at two different time points (all p < 0.001) except the
comparison between 21 days and 28 days (p > 0.05). There was no significant difference in
the control group (all p > 0.05). (Figure 2A).
 by a two-way repeated ANOVA (p < 0.001). In other words, the AL in the RLRL gr
(red line) decreased gradually with the treatment time, while AL in the control gr
(blue line) did not change. The post-hoc analyze indicated that there were statistically
nificant differences between the RLRL group at two different time points (all p < 0.
except the comparison between 21 days and 28 days (p > 0.05). There was no signifi
J. Clin. Med. 2022, 11, 7498 5 of 11
difference in the control group (all p > 0.05). (Figure 2A).

24.63±1.19 24.64±1.20 24.63±1.20 24.63±1.19 24.63±1.19 365.73±81.74 369.08±79.05* 377.52±79.41* 382.19±78.75* 384.12±78.67*

358.13±72.61 358.13±72.61 355.10±74.53 357.00±73.30 355.83±74.83

24.63±1.04 24.61±1.04* 24.59±1.04* 24.57±1.05* 24.57±1.04*

Figure 2. Time course of axial length and choroidal thickness in two groups. Compared with the
control group (blue line), the RLRL group (red line) had decreased axial length (A) and increased
Figure
choroid thickness (B) 2. Time
after course of
treatment. * paxial length
< 0.05 whenand choroidal
compared thickness
to the in two groups. Compared with
baseline.
control group (blue line), the RLRL group (red line) had decreased axial length (A) and incre
4.2. Change inchoroid
SChT thickness (B) after treatment. * p < 0.05 when compared to the baseline.
In the RLRL group, the subfoveal choroidal thickness increased significantly after
treatment. The4.2.thickening
Change in SChTwas most significant in the second week of treatment and then
In thethe
increased slowly until RLRL group,
average SChT the subfoveal
thickened bychoroidal
18.34 µm in thickness increased
one month significantly a
of treatment
± 81.74 µm
(from 365.73treatment. 384.12 ± was
Thetothickening 78.67most
µm).significant in the
In contrast, second
there wasweek of treatment and t
no significant
difference inincreased
SChT in slowly
each follow-up and control
until the average SChTgroup.
thickenedTwo-way
by 18.34repeated
μm in oneANOVA
month of treatm
analysis showed
(from a significant group*time
365.73 ± 81.74μm interaction
to 384.12 (p < 0.001).
± 78.67μm). This showed
In contrast, that no
there was SChT in
significant di
the RLRL group (red line) increased over time, while there was no change in
ence in SChT in each follow-up and control group. Two-way repeated ANOVA anal the control
group (blue line)
showed(Figure 2B).
a significant group*time interaction (p < 0.001). This showed that SChT in
RLRL group (red line) increased over time, while there was no change in the control gr
4.3. Change in(blue
CVI line) (Figure 2B).
In this study, we divided the subfoveal CVI into 0–1 mm, 0–3 mm, and 0–6 mm
zones referring
4.3.to the early
Change treatment of diabetic retinopathy study (ETDRS) to evaluate
in CVI
the changes in subfoveal choroidal bloodthe
In this study, we divided flow from the
subfoveal CVIcenter to mm,
into 0–1 the whole.
0–3 mm,Aand two-
0–6 mm zo
way repeated ANOVA revealed that the statistically significant CVI 0–6 changes in
referring to the early treatment of diabetic retinopathy study (ETDRS) to evaluate RLRL
group increased from 0.361 ± 0.049 to 0.375 ± 0.054 after one month of RLRL treatment
(group*time interaction p = 0.001). However, there was no statistical change in CVI01 and
CVI03 and all zones of the control group (all p > 0.05) (Table 2).

Table 2. Change in choroidal vascularity index at different periods (mean ± SD).

Characteristics RLRL Group (n = 52) Control Group (n = 46)

CVI01
Baseline 0.389 ± 0.054 0.384 ± 0.058
7 days 0.395 ± 0.052 0.383 ± 0.060
14 days 0.403 ± 0.048 0.384 ± 0.061
21 days 0.402 ± 0.053 0.385 ± 0.060
28 days 0.404 ± 0.053 0.384 ± 0.061
P-Group 0.35
P-Time 0.16
P-Group*Time interaction 0.27
CVI03
Baseline 0.386 ± 0.050 0.387 ± 0.051
7 days 0.390 ± 0.053 0.388 ± 0.050
14 days 0.396 ± 0.053 0.390 ± 0.050
21 days 0.398 ± 0.056 0.390 ± 0.048
28 days 0.398 ± 0.056 0.388 ± 0.048
J. Clin. Med. 2022, 11, 7498 6 of 11

Table 2. Cont.

Characteristics RLRL Group (n = 52) Control Group (n = 46)

P-Group 0.62
P-Time 0.10
P-Group*Time interaction 0.07
CVI06
Baseline 0.361 ± 0.049 0.365 ± 0.042
7 days 0.368 ± 0.052 0.365 ± 0.041
14 days 0.369 ± 0.052 0.363 ± 0.042
21 days 0.374 ± 0.055 0.362 ± 0.041
28 days 0.375 ± 0.054 0.363 ± 0.042
P-Group 0.67
P-Time 0.001
P-Group*Time interaction 0.001
CVI = choroidal vascularity index.

4.4. Change in Other Ocular Biometric Parameters

Table 3 demonstrates the alterations in anterior segment parameters of the two groups
at each follow-up. The two groups’ biological parameters of the anterior segment were
similar. During the one-month follow-up, CCT, ACD, LT, K1, and K2 did not change
significantly (all p > 0.05). RLRL therapy did not cause changes in anterior segment
parameters (Table 3).

Table 3. Change in anterior segment parameters at different time points (mean ± SD).

Characteristics
CCT (µm) ACD (mm) LT (mm) K1 (D) K2 (D)
RLRL Control RLRL Control RLRL Control RLRL Control RLRL Control
522.77 ± 519.65 ± 3.02 ± 3.05 ± 3.72 ± 3.69 ± 42.85 ± 42.68 ± 44.01 ± 44.00 ±
Baseline
47.96 42.83 0.24 0.27 0.20 0.15 1.60 2.08 1.82 2.19
521.71 ± 528.87 ± 3.01 ± 3.04 ± 3.72 ± 3.69 ± 42.87 ± 42.64 ± 44.01 ± 44.00 ±
7 days
47.32 42.92 0.27 0.27 0.23 0.17 1.61 2.07 1.85 2.10
521.62 ± 522.11 ± 3.01 ± 3.05 ± 3.72 ± 3.69 ± 42.84 ± 42.58 ± 43.95 ± 43.91 ±
14 days
47.40 43.47 0.25 0.27 0.21 0.16 1.64 2.07 1.85 2.17
522.04 ± 520.89 ± 3.02 ± 3.04 ± 3.72 ± 3.70 ± 42.83 ± 42.59 ± 43.96 ± 43.85 ±
21 days
47.68 42.48 0.25 0.27 0.21 0.17 1.64 2.06 1.88 2.15
521.69 ± 516.57 ± 3.01 ± 3.04 ± 3.71 ± 3.69 ± 42.81 ± 42.66 ± 44.04 ± 43.91 ±
28 days
48.07 42.87 0.24 0.28 0.20 0.16 1.62 2.07 1.80 2.16
P-Group 0.94 0.97 0.74 0.38 0.64
P-Time 0.49 0.22 0.72 0.63 0.49
P-Group *
0.19 0.09 0.96 0.69 0.31
Time
CCT = center cornea thickness; ACD = anterior chamber depth; LT = lens thickness; K1 = flat meridian;
K2 = steep meridian.

4.5. Relationship between the AL Changes and Other Parameters

Age, baseline AL, and SChT alterations were used to analyze the effect on AL changes
after one month of treatment. The results indicated that SChT thickening was significantly
associated with AL shortening (r = 0.51, p < 0.01), whereas age and baseline AL were not
associated with AL changes (p = 0.92 and p = 0.94, respectively).

5. Discussion
In this current study, we found that the AL of myopic adults was significantly short-
ened after one month of RLRL therapy, along with increased choroid thickness and im-
proved choroid circulation. Since no significant changes were found in the anterior segment,
we reasoned that the AL shortening observed in this study was mainly associated with
changes in the posterior segment.
J. Clin. Med. 2022, 11, 7498 7 of 11

5.1. Adult Vs. Children Findings

Recent studies have reported that RLRL can effectively retard myopia progress in my-
opic Chinese children by shortening the axial length [5–7]. Xiong et al. reported that, after
6-month of RLRL treatment, the mean axial length change was −0.06 ± 0.15 mm, compared
to 0.20 ± 0.06 mm in subjects wearing single-vision spectacles [7]. Zhou et al. reported
that at nine months, axial length changes were −0.06 ± 0.19 mm and 0.26 ± 0.15 mm in the
treatment group and control group (p < 0.001), respectively [6]. Jiang reported that 39.8%
of myopic children in the RLRL group at one-month follow-up achieved an axial length
shortening of ≥0.05 mm [5]. In this current study, 69.23% of the adult subjects demon-
strated axial length shortening ≥ 0.05 mm after one month of RLRL treatment. In children,
usually up to 15 years of age, the eyeball is still growing, and the axial length constantly
changes [21–23]. Therefore, RLRL’s axial length shortening effect may be partially masked
by the axial growth and was underestimated by the previous studies.
Among myopic children who received RLRL treatment, elder children with greater
baseline axial length tended to have more significant axial length shortening [5,6]. However,
in this study’s adult subjects, there was no significant association between axial length
change and age or baseline axial length after one month of treatment. One possibility for
such a discrepancy may be the short follow-up duration, one month, in this study. The other
possibility may be the age-dependent axial length change observed in children. Therefore,
a study with a more extended follow-up period is needed in the future.

5.2. Choroid Thickened, but Not Enough

Based on existing studies, the observed axial length shortening could be partially
attributed to the thickening of the choroid layer. In Xiong’s study, the axial length de-
creased to 25.01 ± 1.14 mm from 25.06 ± 1.14 mm, while choroid thickness increased to
311.84 ± 67.08 µm from 288.61 ± 59.59 µm [7]. In Jiang’s study, axial length shortened
by 0.04 mm on average, while choroid thickness increased by 16.1 µm [5]. This number
was very close to the value reported in the present study, an 18.34 µm increase in choroid
thickness. Therefore, the effect of RLRL on choroid thickness after one month is very similar
in children and adults.
On the other side, the change in choroid thickness cannot fully explain the axial length
shortening observed. The secondary changes following increased choroid thickness include
increased circulation volume and speeded-up metabolism, improved sclera hypoxia, and
recovery of the depleted collagen level [5,6,24,25]. We measured the CVI before and after
the RLRL treatment to test if such a hypothesis is true. Our data revealed a slight but
significant increase in CVI following one month of treatment of RLRL. This finding is
consistent with the idea that improved choroid circulation is the underlying reason for
shortened axial length. Moreover, agreeing with other studies [5–7], this current study
did not find any significant changes in the anterior segment. Therefore, the axial length
shortening occurs mainly in the posterior segment of the eye.

5.3. Alternative to Natural Outdoor Lights

Outdoor activities and exposure to natural light were closely associated with myopia
prevention, which suggests that light exposure plays a protective role in myopia devel-
opment [26,27]. Therefore, another approach for myopia control could be an alternative
to sunlight that can slow down myopia progress. Much debate still exists on the effect of
light with different wavelengths on ocular parameters and its relevance to myopia control
in animal models and clinical studies [18,28–32]. Red light-induced refractive develop-
ment alterations were associated with reduced vitreous chamber elongation and increased
choroidal thickness in a rhesus monkey’s model [29,32]. However, the results from other
species, such as mice and guinea pigs, indicated that violet (380 nm) and blue light (470 nm)
inhibited eye growth [31,33]. Thakur et al. reported that, in human subjects, exposure to
red lights and green lights led to elongated axial length, while exposure to blue lights led
to shortened axial length [28]. Similar conclusions were also confirmed in Lou’s study [30].
J. Clin. Med. 2022, 11, 7498 8 of 11

Other studies investigated the effect of luminance levels on ocular biometrics. Chakraborty
measured the axial length and choroid thickness changes when the human eye was exposed
to low luminance (500 Lux), moderate luminance (1000 Lux), and darkroom level (<5 Lux)
briefly. Axial length shortened in the low and moderate luminance level, but not at the
dark room level. The axial length shortening is much greater with the moderate luminance
level (−0.013 mm) when compared to the shortening (−0.006 mm) observed in the low
luminance level, although not statistically significant. In future studies, a higher luminance
level might be needed to quantify the relationship between luminance level and axial length
growth [17]. In animal models, elevated lighting levels significantly reduced the degree of
axial myopia induced by form deprivation in chickens, tree shrews, and macaques [34–37].
In RLRL treatment, more light energy and intensity are projected to the retina when red
light enters the eyeball as a laser beam, compared to scattered lights in a lab environment.
Future studies should map axial length changes to light within various bandwidths at
different luminance levels.

5.4. Axial Length Shortening in Orthokeratology

Axial length shortening is not only found in RLRL. Some myopic patients treated
with orthokeratology (OK) lenses have also demonstrated axial length shortening [38–40].
Lau et al. reported that during the first week of OK lens treatment, the mean AL short-
ening was 0.026 mm. However, after the first week, axial length changes were not sig-
nificantly different from the controls wearing spectacles [39]. Therefore, axial length
shortening was considered a phenomenon existing only in the early stage of OK treatment.
Swarbrick et al. reported a 0.04 mm AL shortening three months after lens-wearing. How-
ever, their data found no significant difference from spectacle-wearing controls six months
into treatment [40]. The two potential mechanisms leading to shortened axial length in
OK lens treatment are thinned cornea and thickened choroid. In RLRL and OK treatment,
choroid plays a vital role in myopia control. Whether choroid thickening associated with
RLRL could be used in myopia prevention remains to be studied. Moreover, Wang reported
that among children who underwent OK treatment, those who showed axial shortening
in the early stage often had a better myopia control effect (smaller axial length growth)
than those who did not show an axial shortening in the early stage [41]. In this study,
axial shortening was significantly correlated with choroid thickening after one month of
treatment. Whether choroid thickening at the early stage of RLRL treatment could be
utilized as a predictor for long-term success calls for more attention.
Until now, no serious complications have been reported in RLRL’s studies with periods
from 6 months to 2 years [6–8]. There was even a 12-month study reporting improved
accommodative function after RLRL treatment [9]. However, it is unknown whether
long-term RLRL treatment could cause retinal structural damage or functional damage.
Therefore, more long-term studies are needed to confirm RLRL treatment’s long-term safety.
In view of the current research status of RLRL treatment, clinicians should pay attention to
the examination results of macular OCT and mERG and other indicators during follow-up.
In addition, clinicians should also think highly of the change of afterimage duration after
treatment, so as to ensure the safety of the irradiated eye to the greatest extent.

5.5. Limitations
Our present study has several limitations. First, the follow-up duration of this study
is relatively short. It is not clear whether the subjects have reached the maximal potential
amount of axial shortening or choroid thickness. Second, axial length growth rebound has
been reported in children. Chen et al. reported that the AL increased by 0.16 mm after three
months of treatment cessation in myopic children [9]. Xiong’s study reported a second-year
axial elongation of 0.42 mm in the RLRL-SVS group when the RLRL treatment was stopped.
This progression rate was greater than the second-year progression (0.28 mm) in the SVS-
SVS group [8]. However, we do not know how the axial length will rebound after the RLRL
treatment stops in myopic adults. Third, it is not clear how the short-term axial shortening
J. Clin. Med. 2022, 11, 7498 9 of 11

correlates with long-term myopia control. Fourth, it is not clear if such short-term axial
shortening also occurs in emmetropic subjects or if it exists only in myopic adults.

6. Conclusions
In myopic adults who received one month of RLRL treatment, axial length was signifi-
cantly shortened, and choroid flow was increased considerably. However, the choroid’s
thickening is insufficient to fully explain the axial length shortening. In combination with
an unchanged anterior segment, our study suggests that the AL shortening in this study is
mainly related to changes in the posterior segment.

Author Contributions: Conceptualization, G.L. and B.Z.; methodology, G.L. and B.Z.; software, H.R.;
validation, B.L., H.R. and B.D.; formal analysis, B.Z. and H.R.; investigation, B.L.; resources, B.D.;
data curation, B.W. and J.H.; writing—original draft preparation, G.L.; writing—review and editing,
G.L.; visualization, G.L.; supervision, B.Z.; project administration, R.W.; funding acquisition, R.W. All
authors have read and agreed to the published version of the manuscript.
Funding: This study was funded by grant from National Natural Science Foundation of China
(funding number: 82070929), and Tianjin Key Medical Discipline (Specialty) Construction Project
(funding number: TJYXZDXK-037A).
Institutional Review Board Statement: The study was approved by the Ethics Committee of Tianjin
Medical University Eye Hospital (2021KY-11).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The datasets used and analyzed during the current study are available
from the corresponding authors upon reasonable request. The data are not publicly available due to
patient privacy.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Pan, C.W.; Dirani, M.; Cheng, C.Y.; Wong, T.Y.; Saw, S.M. The age-specific prevalence of myopia in Asia: A meta-analysis. Optom.
Vis. Sci. 2015, 92, 258–266. [CrossRef]
2. Holden, B.A.; Fricke, T.R.; Wilson, D.A.; Jong, M.; Naidoo, K.S.; Sankaridurg, P.; Wong, T.Y.; Naduvilath, T.J.; Resnikoff, S. Global
Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050. Ophthalmology 2016, 123, 1036–1042.
[CrossRef]
3. Wong, T.Y.; Ferreira, A.; Hughes, R.; Carter, G.; Mitchell, P. Epidemiology and disease burden of pathologic myopia and myopic
choroidal neovascularization: An evidence-based systematic review. Am. J. Ophthalmol. 2014, 157, 9–25 e12. [CrossRef] [PubMed]
4. Tideman, J.W.; Snabel, M.C.; Tedja, M.S.; van Rijn, G.A.; Wong, K.T.; Kuijpers, R.W.; Vingerling, J.R.; Hofman, A.; Buitendijk, G.H.;
Keunen, J.E.; et al. Association of Axial Length with Risk of Uncorrectable Visual Impairment for Europeans With Myopia. JAMA
Ophthalmol. 2016, 134, 1355–1363. [CrossRef]
5. Jiang, Y.; Zhu, Z.; Tan, X.; Kong, X.; Zhong, H.; Zhang, J.; Xiong, R.; Yuan, Y.; Zeng, J.; Morgan, I.G.; et al. Effect of Repeated
Low-Level Red-Light Therapy for Myopia Control in Children: A Multicenter Randomized Controlled Trial. Ophthalmology 2022,
129, 509–519. [CrossRef]
6. Zhou, L.; Xing, C.; Qiang, W.; Hua, C.; Tong, L. Low-intensity, long-wavelength red light slows the progression of myopia in
children: An Eastern China-based cohort. Ophthalmic. Physiol. Opt. 2022, 42, 335–344. [CrossRef] [PubMed]
7. Xiong, F.; Mao, T.; Liao, H.; Hu, X.; Shang, L.; Yu, L.; Lin, N.; Huang, L.; Yi, Y.; Zhou, R.; et al. Orthokeratology and Low-Intensity
Laser Therapy for Slowing the Progression of Myopia in Children. Biomed. Res. Int. 2021, 2021, 8915867. [CrossRef] [PubMed]
8. Xiong, R.; Zhu, Z.; Jiang, Y.; Kong, X.; Zhang, J.; Wang, W.; Kiburg, K.; Yuan, Y.; Chen, Y.; Zhang, S.; et al. Sustained and rebound
effect of repeated low-level red-light therapy on myopia control: A 2-year post-trial follow-up study. Clin. Exp. Ophthalmol. 2022,
50, 1013–1024. [CrossRef]
9. Chen, H.; Wang, W.; Liao, Y.; Zhou, W.; Li, Q.; Wang, J.; Tang, J.; Pei, Y.; Wang, X. Low-intensity red-light therapy in slowing
myopic progression and the rebound effect after its cessation in Chinese children: A randomized controlled trial. Graefes Arch.
Clin. Exp. Ophthalmol. 2022. [CrossRef]
10. Hughes, R.P.J.; Read, S.A.; Collins, M.J.; Vincent, S.J. Axial Elongation During Short-Term Accommodation in Myopic and
Nonmyopic Children. Investig. Ophthalmol. Vis. Sci. 2022, 63, 12. [CrossRef]
11. Drexler, W.; Findl, O.; Schmetterer, L.; Hitzenberger, C.K.; Fercher, A.F. Eye elongation during accommodation in humans:
Differences between emmetropes and myopes. Investig. Ophthalmol. Vis. Sci. 1998, 39, 2140–2147.
J. Clin. Med. 2022, 11, 7498 10 of 11

12. Mallen, E.A.; Kashyap, P.; Hampson, K.M. Transient Axial Length Change during the Accommodation Response in Young Adults.
Investig. Ophthalmol. Vis. Sci. 2006, 47, 1251–1254. [CrossRef] [PubMed]
13. Ulaganathan, S.; Read, S.A.; Collins, M.J.; Vincent, S.J. Daily axial length and choroidal thickness variations in young adults:
Associations with light exposure and longitudinal axial length and choroid changes. Exp. Eye Res. 2019, 189, 107850. [CrossRef]
[PubMed]
14. Rauscher, F.G.; Hiemisch, A.; Kiess, W.; Michael, R. Feasibility and repeatability of ocular biometry measured with Lenstar LS 900
in a large group of children and adolescents. Ophthalmic. Physiol. Opt. 2021, 41, 512–522. [CrossRef]
15. Cruysberg, L.P.; Doors, M.; Verbakel, F.; Berendschot, T.T.; De Brabander, J.; Nuijts, R.M. Evaluation of the Lenstar LS 900
non-contact biometer. Br. J. Ophthalmol. 2010, 94, 106–110. [CrossRef]
16. Sahin, A.; Gursoy, H.; Basmak, H.; Yildirim, N.; Usalp, Z.; Colak, E. Reproducibility of ocular biometry with a new noncontact
optical low-coherence reflectometer in children. Eur. J. Ophthalmol. 2011, 21, 194–198. [CrossRef]
17. Chakraborty, R.; Baranton, K.; Spiegel, D.; Lacan, P.; Guillon, M.; Barrau, C.; Villette, T. Effects of mild- and moderate-intensity
illumination on short-term axial length and choroidal thickness changes in young adults. Ophthalmic. Physiol. Opt. 2022, 42,
762–772. [CrossRef]
18. Yu, M.; Liu, W.; Wang, B.; Dai, J. Short Wavelength (Blue) Light Is Protective for Lens-Induced Myopia in Guinea Pigs Potentially
Through a Retinoic Acid-Related Mechanism. Investig. Ophthalmol. Vis. Sci. 2021, 62, 21. [CrossRef]
19. Zhang, Y.; Zhang, D.; Gao, Y.; Yang, L.; Tao, Y.; Xu, H.; Man, S.; Zhang, M.; Xu, Y. Retinal Flow Density Changes in Early-stage
Parkinson’s Disease Investigated by Swept-Source Optical Coherence Tomography Angiography. Curr. Eye Res. 2021, 46,
1886–1891. [CrossRef]
20. Wu, H.; Zhang, G.; Shen, M.; Xu, R.; Wang, P.; Guan, Z.; Xie, Z.; Jin, Z.; Chen, S.; Mao, X.; et al. Assessment of Choroidal
Vascularity and Choriocapillaris Blood Perfusion in Anisomyopic Adults by SS-OCT/OCTA. Investig. Ophthalmol. Vis. Sci. 2021,
62, 8. [CrossRef]
21. Truckenbrod, C.; Meigen, C.; Brandt, M.; Vogel, M.; Sanz Diez, P.; Wahl, S.; Jurkutat, A.; Kiess, W. Longitudinal analysis of axial
length growth in a German cohort of healthy children and adolescents. Ophthalmic. Physiol. Opt. 2021, 41, 532–540. [CrossRef]
22. Jin, P.; Li, M.; He, X.; Lu, L.; Zhu, J.; Chang, T.C.; Zou, H. Anterior-Chamber Angle and Axial Length Measurements in Normal
Chinese Children. J. Glaucoma 2016, 25, 692–697. [CrossRef] [PubMed]
23. Sanz Diez, P.; Yang, L.H.; Lu, M.X.; Wahl, S.; Ohlendorf, A. Growth curves of myopia-related parameters to clinically monitor the
refractive development in Chinese schoolchildren. Graefes Arch. Clin. Exp. Ophthalmol. 2019, 257, 1045–1053. [CrossRef] [PubMed]
24. Wu, H.; Chen, W.; Zhao, F.; Zhou, Q.; Reinach, P.S.; Deng, L.; Ma, L.; Luo, S.; Srinivasalu, N.; Pan, M.; et al. Scleral hypoxia is a
target for myopia control. Proc. Natl. Acad. Sci. USA 2018, 115, E7091–E7100. [CrossRef] [PubMed]
25. Metlapally, R.; Wildsoet, C.F. Scleral Mechanisms Underlying Ocular Growth and Myopia. Prog. Mol. Biol. Transl. Sci. 2015, 134,
241–248. [PubMed]
26. He, M.; Xiang, F.; Zeng, Y.; Mai, J.; Chen, Q.; Zhang, J.; Smith, W.; Rose, K.; Morgan, I.G. Effect of Time Spent Outdoors at School
on the Development of Myopia Among Children in China: A Randomized Clinical Trial. JAMA 2015, 314, 1142–1148. [CrossRef]
27. Wu, P.C.; Chen, C.T.; Lin, K.K.; Sun, C.C.; Kuo, C.N.; Huang, H.M.; Poon, Y.C.; Yang, M.L.; Chen, C.Y.; Huang, J.C.; et al.
Myopia Prevention and Outdoor Light Intensity in a School-Based Cluster Randomized Trial. Ophthalmology 2018, 125, 1239–1250.
[CrossRef]
28. Thakur, S.; Dhakal, R.; Verkicharla, P.K. Short-Term Exposure to Blue Light Shows an Inhibitory Effect on Axial Elongation in
Human Eyes Independent of Defocus. Investig. Ophthalmol. Vis. Sci. 2021, 62, 22. [CrossRef] [PubMed]
29. Hung, L.F.; Arumugam, B.; She, Z.; Ostrin, L.; Smith, E.L., 3rd. Narrow-band, long-wavelength lighting promotes hyperopia and
retards vision-induced myopia in infant rhesus monkeys. Exp. Eye Res. 2018, 176, 147–160. [CrossRef] [PubMed]
30. Lou, L.; Ostrin, L.A. Effects of Narrowband Light on Choroidal Thickness and the Pupil. Investig. Ophthalmol. Vis. Sci. 2020, 61,
40. [CrossRef]
31. Jiang, L.; Zhang, S.; Schaeffel, F.; Xiong, S.; Zheng, Y.; Zhou, X.; Lu, F.; Qu, J. Interactions of chromatic and lens-induced defocus
during visual control of eye growth in guinea pigs (Cavia porcellus). Vision Res. 2014, 94, 24–32. [CrossRef] [PubMed]
32. Smith, E.L., 3rd; Hung, L.F.; Arumugam, B.; Holden, B.A.; Neitz, M.; Neitz, J. Effects of Long-Wavelength Lighting on Refractive
Development in Infant Rhesus Monkeys. Investig. Ophthalmol. Vis. Sci. 2015, 56, 6490–6500. [CrossRef] [PubMed]
33. Strickland, R.; Landis, E.G.; Pardue, M.T. Short-Wavelength (Violet) Light Protects Mice From Myopia Through Cone Signaling.
Investig. Ophthalmol. Vis. Sci. 2020, 61, 13. [CrossRef] [PubMed]
34. Ashby, R.; Ohlendorf, A.; Schaeffel, F. The effect of ambient illuminance on the development of deprivation myopia in chicks.
Investig. Ophthalmol. Vis. Sci. 2009, 50, 5348–5354. [CrossRef] [PubMed]
35. Karouta, C.; Ashby, R.S. Correlation between light levels and the development of deprivation myopia. Investig. Ophthalmol. Vis.
Sci. 2014, 56, 299–309. [CrossRef]
36. Norton, T.T.; Siegwart, J.T., Jr. Light levels, refractive development, and myopia—A speculative review. Exp. Eye Res. 2013, 114,
48–57. [CrossRef]
37. Smith, E.L., 3rd; Hung, L.F.; Huang, J. Protective effects of high ambient lighting on the development of form-deprivation myopia
in rhesus monkeys. Investig. Ophthalmol. Vis. Sci. 2012, 53, 421–428. [CrossRef]
38. Chen, Z.; Xue, F.; Zhou, J.; Qu, X.; Zhou, X. Effects of Orthokeratology on Choroidal Thickness and Axial Length. Optom. Vis. Sci.
2016, 93, 1064–1071. [CrossRef]
J. Clin. Med. 2022, 11, 7498 11 of 11

39. Lau, J.K.; Wan, K.; Cheung, S.W.; Vincent, S.J.; Cho, P. Weekly Changes in Axial Length and Choroidal Thickness in Children
During and Following Orthokeratology Treatment with Different Compression Factors. Transl. Vis. Sci. Technol. 2019, 8, 9.
[CrossRef]
40. Swarbrick, H.A.; Alharbi, A.; Watt, K.; Lum, E.; Kang, P. Myopia control during orthokeratology lens wear in children using a
novel study design. Ophthalmology 2015, 122, 620–630. [CrossRef]
41. Wang, A.; Yang, C.; Shen, L.; Wang, J.; Zhang, Z.; Yang, W. Axial length shortening after orthokeratology and its relationship with
myopic control. BMC Ophthalmol. 2022, 22, 243. [CrossRef] [PubMed]