Myopia Profile

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Selecting a contact lens for astigmatic myopia

 Posted on April 24th 2020 by Connie Gan

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In this article:

A clinical case with a dilemma for a patient whose myopia and astigmatism exceeded the parameters of the more common forms.

A clinical case of high astigmatism with myopia was discussed, where the author STW faced a myopia managing dilemma for a patient whose myopia and astigmatism exceeded the parameters of the more common forms of myopia control with contact lenses. Here's what the Myopia Profile community suggested in this post,

STW Hello all, looking for some reassurance. I have an 11yo female Px, R: -6.00 / -4.00 x 3 6/6 L -6.00 / -3.25 x 172 6/6. Her parents are very keen for the best myopia control option for their daughter (and she is hyper-intelligent and also understands the benefit). I offered Ortho-K versus NaturalVue with top-up specs, and they've opted for the latter. I fitted -7.50 R+L, and her first follow up was today. She's doing well with VAs of 6/12 in each eye, 6/9.5+ BEO. Over-refraction is as expected, + with the cyls, VA comes up to 6/6-. Mum is fretting a bit that we're over-complicating things and may be doing more harm than good, and it's planted the seed of doubt in my mind! Do you think I'm doing the right thing here? The patient is happy with the idea of top-up specs, and can see well enough without them for sports etc. Any thoughts gratefully received!

Which contact lens option to prescribe?

Option 1: Spherical MFCLs + top up specs

This strategy involves using a spherical multifocal / myopia control contact lens (MFCL) with top up specs to account for the over-refraction. The original post author STW chose NaturalVue, which is a daily hydrogel lens with an extended depth of focus design. In addition to NaturalVue, one may opt for other forms of soft multifocal contact lenses or OrthoK.

Pros:Cons:
  • Spherical contact lenses are generally more comfortable

  • Concern for over-minusing (see below for discussion)

  • Wider variety of lenses to choose from and are easier to fit

  • Some may consider it cumbersome to have two forms of optical correction

  • One can easily take off specs for sport


PR It’s what would do. I have a very similar rx and use spherical scl for the occasions I wear them because I just can’t get comfy with daily topics.LA I personally think you're doing the right thing. Multifocal torics aren't technically proven to control myopia, though logic says they should. Naturalvue is proven, they are dailies, and the patient is happy. Tell mum to stop worrying! The myopia control effect will definitely be better than SVDMC Agreed. CD Toric Multifocal could be a ball ache. Top up specs for school/cinema etc and take them off for rough play/sports. Job doneSD STW, I have had great success with your approach in many children. It works and it is simple for the patient. There are other options as well but I think you are on the right trackDB There is in this case uniquely no research that specifically adresses the parental concerns and one ought to be cautious (as I’m sure u are) as to the likelihood of the final outcome. What all of then above comments are utterly speculative as to the final outcome, as no one could be expected to predict precisely the final Rx or the final acuity. What we DO know that genetically your px is programmed to become highly myopic. What you are doing is peer sensible and no one has the holy grail. 🙂ND I’d do exactly the same. You are doing the right thing! Just monitor the topography / Ks.

Option 2: Toric MFCLs

An alternative to STW's strategy was to instead prescribe toric multifocal contact lenses. Discussion included considering which lenses were clinically available.

Pros:Cons
  • One lens does everything, there no need for top up specs

  • Toric lenses can be less comfortable for the patient

  • Theoretically can achieve the best acuity

  • Toric MFCLs can harder to fit as both fit and toric stability must be optimized

SD My preferred choice would have been monthly toric MF with centre distance (starting with a +2.00 add), along the lines of a saphir toric MF. Seems like your patient is likely to have been quite compliant with care management. Also would eliminate the need for over specs and would also have achieve best acuity (in theory).GS ... Like SD I would recommend Mark Ennovy’s Saphir Toric MF CL!BT Another option I have used in similar Rx ( actually higher minus Sph ) is Relax custom made Torics. One lens does all.JK Looks like the cylinder is corneal so I would fit the Duette Progressive, center distance, 3.0 mm, +3.00 add and adjust from there...DB I agree with BT. I have also had good results with Pascal's SwissLens.DG I’d have probably gone down a similar line to SD, with a Toric CD Multifocal, although perhaps with Gentle 80 material because of the lower modulus and the young, tender eyelids.HLP I have a patient who started with 13 yo using Relax Toric (SwissLens). Today 16 years old uses the same prescription with a VA of 6 / 3.8PT Hi STW, just a thought - Duette CD multifocal if corneal?AD I've had great success with corneal RGPs in similar cases. BrienHolden MC Design on the front surface. Better vision, no need for extra glasses, less dry eye symptoms. But if it should be a soft CL, I'd go with the fully customizable RELAX of Swisslens as some others stated before.

Toric multifocal SCLs - what's available

Availability of these lens designs mentioned above will vary by your country of practice.

  • Saphir MF by mark'ennovy: A monthly silicon hydrogel lens with a centre distance design.
  • Gentle 80 by mark'ennovy: A monthly hydrogel lens with centre distance design
  • RelaxTM by Swiss Lens: A centre distance design lens, replaced 3-6 monthly.
  • Proclear Toric MFs by CooperVision: A hydrogel monthly multifocal lens with both centre distance and centre near options
  • Duette MF by SynergEyes: A hybrid lens (RGP with soft skirt) that is replaced every six months. The GP centre is useful for masking corneal astigmatism
  • Toric RGP MFCLs: custom designed by you, with your local lab.

What the research tells us

Currently, there are no studies showing the efficacy of toric MFCLs in slowing myopia progression specifically. The ones that do address toric corrections instead involve OrthoK lenses.

  • Chen et al1, Luo et al2 and Lyu et al3 showed that toric OrthoK lenses could slow down axial elongation and provide clear unaided acuity
  • Fan et al4 showed that higher astigmatism was associated with more myopic refraction and more myopic shift as well as axial length growth.

Hence, it is important to provide options for controlling myopic progression in children even when their refractive error falls outside the parameter of common contact lens options.

Take home messages

  • The conundrum arises when a patient's refractive error exceeds the parameters available for single corrections: eg. high myopia/astigmatism outside of OrthoK parameters or high astigmatism that excludes daily disposable myopia controlling contact lenses like MiSight or NaturalVue. Hence you will need to consider a combination of optical corrections and myopia control strategies, that may not be currently backed by the evidence.
  • At the end of the day, some form of myopia control is always going to be better than a single vision distance correction. Ultimately, it depends on which contact lens to which you have access, and the patient's lifestyle and preferences, as to which option will suit best.

Read more about multifocal contact lenses for myopia control

Meet the Authors:

About Connie Gan

Connie is a clinical optometrist from Kedah, Malaysia, who provides comprehensive vision care for children and runs the myopia management service in her clinical practice.

Read Connie's work in many of the case studies published on MyopiaProfile.com. Connie also manages our Myopia Profile and My Kids Vision Instagram and My Kids Vision Facebook platforms.

About Kimberley Ngu

Kimberley is a clinical optometrist from Perth, Australia, with experience in patient education programs, having practiced in both Australia and Singapore.

Read Kimberley's work in many of the case studies published on MyopiaProfile.com. Kimberley also manages our Myopia Profile and My Kids Vision Instagram and My Kids Vision Facebook platforms.

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