Prescribing for the progressing myope with astigmatism

Originally published April 4, 2020
Updated July 10, 2023

Whilst each individual child has their own circumstances and situation to consider when prescribing myopia control, children with astigmatism present a unique set of challenges when selecting the best option for not only slowing down the progression of their axial growth, but also providing them with good vision. Simply ignoring the astigmatism when selecting a prescribing choice runs the risk of undercorrection, which can promote myopia progression.¹

Ortho-k has been shown to slow down the progression of myopia in school age children and is one of the most effective myopia control options.^{2, 3} Spherical orthokeratology can easily treat up to  -1.50D of astigmatism without specialised fitting.^4,5 Research has shown that ortho-k correction in myopia with up to -3.50D of astigmatism can provide a myopia control result equivalent to spherical ortho-k outcomes.^5,6 Read more in this case study on Fitting orthokeratology successfully on a patient with astigmatism.

Soft contact lenses in myopia control designs include dual-focus, multifocal and other novel designs. The dual-focus CooperVision MiSight 1 day lens may be tolerated in low levels of astigmatism (up to -0.75DC) and should be trialled for measured visual acuity whilst wearing the lenses. In patients with higher levels of astigmatism who are very keen on MiSight or other spherical soft contact lens designs for myopia control, spectacle correction with the residual astigmatism correction may be used, however compliance may be difficult in these patients.

The multifocal soft contact lens Visioneering Technologies NaturalVue 1 Day has been reported for use in higher levels of astigmatism, however the fitting guide recommends patients have astigmatism of -1.00DC or less. Read more in our article The NaturalVue Multifocal Contact Lens - Astigmatism 'Masking' or 'Correcting'?

Multifocal soft toric lenses with a centre distance modality are uncommon, and for most countries, only available in a monthly wearing schedule, which does slightly increase the (relatively low) risk of contact lens-related infections in children (for more information on this please read our article Contact lens safety in children). CooperVision Biofinity Toric Multifocal offers this option up to a -5.75 cyl with a range of Add powers. It is important to note that while the BLINK study showed that the spherical Biofinity Multifocal contact lens with a +2.50 Add had efficacy for myopia control, the toric design has not been studied. Another option is Mark'ennovy Toric Multifocal lenses, available in silicon hydrogel, custom made monthly designs. For more, read this case study entitled Which soft multifocal contact lens to choose for astigmatism?

Topical atropine may be suitable for children who do not tolerate contact lenses or who have high levels of astigmatism. If spectacles are worn full time during atropine treatment to provide clear vision, astigmatism can be treated as per normal refractive correction. The LAMP study has indicated 0.05% as the most effective concentration based on comparison to 0.025% and 0.01% in that study.⁷

We know that single vision lenses do not provide any form of myopia control for children,⁸ and progressive lenses have a minimal effect while bifocal lenses have a moderate effect to slow the progression of myopia.^9,10 The best option in myopia control spectacle lenses are new designs with lenslets or diffusion technology, which offer myopia correction with a range of astigmatism correction, as well as robust myopia control. Read more about these in The next generation – DIMS, H.A.L.T. and DOT Technology spectacle lenses for myopia control.

Population research has shown that astigmatism progression in children with progressive myopia is NOT normal. Corneal power and curvature is typically stable in children, even where the spherical component of their myopic refraction is progressing. Generally, if you observe more than 0.50DC or more of astigmatic progression over three years in children aged 6-12 years, this is NOT typical and should raise a red flag for potential ectasia, necessitating keratometry and/or corneal topography measurement. Read more in our article Measuring the whole eye in myopia.

Every dioptre counts in myopia management. It's been shown that a 1D reduction in myopia reduces the risk of myopic maculopathy by 40%,¹¹ and astigmatism is very commonly found with myopia,¹² so will need correction as part of the full myopia management picture. Using a myopia control strategy to reduce the end myopia result by even a small amount can reduce the end pathology results for your patient immensely, and is worth the extra effort to work around their astigmatism.

CooperVision does not endorse off label prescribing of interventions for myopia control.