Myopia Profile


Managing a child with very high myopia

Posted on June 13th 2022 by Connie Gan

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In this article:

Here is a case of an 8-year-old child with very high myopia. Management is discussed in view of the International Myopia Institute Reports.

Here is a case regarding a child with high myopia, which was presented by NK to the Myopia Profile Facebook Community. What should you do to best manage a patient like this? The findings and recommendations of the International Myopia Institute (IMI) are applied to this complex case, with links provided to the Clinical Summaries of these papers, each of which is available to download in multiple languages. Here are the clinical details of this case.

NK 8 yrs old sweet little girl presents for eye exam. OD -10.75-1.75 20/30- OS -10.75-0.50 20/30- I’m starting atropine 0.025%, follow up 3 months. Any additional thoughts?NK According to little girls mom, she is completely healthy and generally her ocular health was unremarkable (except few peripheral retinal findings) in one eye.

Discuss ocular health and consider systemic conditions

Syndromic myopia is defined as when myopia is associated with at least one other systemic condition.1 A referral to a paediatric ophthalmologist is warranted to investigate for possible systemic disease in cases of high myopia in children, especially children under 10 years of age.

JH "In a clinical ophthalmology study of 112 children under age 10 with myopia of more than 6D, only 8% had 'simple high myopia' with no other associated ocular or systemic associations. 54% had an underlying systemic condition (eg. developmental delays, Marfan, Stickler, Downs syndrome) and the remaining 38% had further ocular problems associated with high myopia such as lens subluxation, coloboma, retinal dystrophy)" Given this information alone, I would first consider that an ophthalmology referral (if you haven't already) would be appropriate. It also discusses the pros and cons of myopia management for this high refractive power.JL if the spherical myopia power is higher than the child's age then this should be investigated prior to initiating myopia control treatment. In this case the child is only 8 and myopia is > 10D.

A key educational message for patients with high myopia (and their parents or carers) is the risk of ocular disease and pathologic myopia. Whilst often misconstrued as synonymous with high myopia, pathologic myopia is defined by the International Myopia Institute (IMI), is 'an excessive axial elongation associated with myopia that leads to structural changes in the posterior segment of the eye'. These changes include myopic maculopathy, posterior staphyloma, high-myopia-associated optic neuropathy and retinal degenerations, and can occur even in eyes with lower levels of refractive myopia.2

The IMI Pathologic Myopia Report states that "83% of adults with pathologic myopia and myopic maculopathy had already had diffuse choroidal atrophy around the optic disc in their childhood. This finding suggested the possibility that children who eventually develop pathologic myopia may be different, even at an early age."2

Around half of patients with high myopia will go on to develop pathologic myopia.2 In practice, this means that even young patients with high myopia should have their ocular health closely monitored. The IMI Clinical Management Guidelines Report recommends annual retinal health examination, through dilated pupils, for patients with high myopia.3

Does atropine work for high myopes?

PC I would be starting on 0.05% atropine. Need to try to maximise treatment outcomes for these cases. Also need axial length monitoring which will allow you to monitor the effectiveness of the treatment more precisely than from refraction alone.DS …Atropine might be worth a try, but it would be an off-label crossed fingers use even in terms of myopia control.JK …Combined with 0.05% atropine but yes, we don’t know the efficacy in a possible syndromic myopia…PP Wouldn’t this be pathological myopia rather than myopia created by hyperopic peripheral retinal focus? Atropine of value with this type of myopia? Papers on this treatment?

Commenters suggested to change the atropine dosage to 0.05%, instead of 0.025% as originally suggested, to increase the efficacy of myopia control. The LAMP Study showed that 0.05% atropine is most effective concentration for slowing myopia and axial elongation with minimal side effects, when compared with lower concentrations.4

However, the commenters also raised the caveat pertaining to the effectiveness of low-dose atropine in very high myopia. Most myopia control studies exclude very high myopes, like this patient. Stronger concentrations of 0.5% have been employed in a clinical protocol set forward by a Netherlands research group, with the focus on treating children at risk of high myopia based on their axial length percentiles. No comment was made of treatment for children who already present with high myopia.5

The LAMP Study specified no higher limit to myopia in their inclusion criteria, but the mean level of myopia at commencement of the study was just under -4.00D, and no correlations between level of myopia and myopia control efficacy.4

All of this means that parents must be made aware of the lack of evidence for atropine's effectiveness in very high myopia, if this treatment is to be selected.

Optical correction for high myopes

When refracting and prescribing spectacles for high myopes, it's important to control the vertex distance to achieve the best possible visual outcome. High index lenses will improve visual quality and comfort for high myopes. More tips on refraction and dispensing can be found in this Points de Vue article entitled High Myopia: the specificities of refraction and optical equipment.

DS I think that consideration should be given to fitting corneal RGP contact lenses as soon as possible…. My priorities are to allow this child so have a comparable visual experience to her peers, and this will be only possible in contact lenses, and to minimise any potential for amblyopia…

Contact lenses can improve distance acuity and field of view in high myopia, and hence are an important correction option. For both spectacles and contact lenses, there are options available which can both correct the myopic refractive error and control myopia progression. More details are provided in the IMI Prevention of Myopia and its Progression Report.6

As mentioned above with respect to atropine, it is rare that a child with such high myopia is included in myopia control studies of spectacle or contact lens treatments. Without a strong evidence-base, it could be prudent to prioritize the child achieving their best possible visual acuity ahead of a myopia control treatment, as suggested by the commenter above. The final decision on this will depend on the individual child, what treatments the eye care practitioner has available to them, and other clinical and patient-specific factors. Read more on this topic in How Should We Manage High Myopia?

Take home messages:

  1. A key message for patients with high myopia is the need for ongoing monitoring of ocular health. In children, this includes working with paediatric ophthalmologists to rule out any systemic associations of childhood high myopia.
  2. Typical myopia control strategies may or may not work for high myopes - there are few instances where children with high myopia have been included in these studies. Parents need to be aware that the 'average' expected results may not apply for their highly myopic children.
  3. It is important to ensure high myopes can achieve the clearest vision possible. This can be achieved through careful control of the vertex distance during refraction and spectacle dispensing; prescribing high index spectacle lenses; and considering contact lens fitting.

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 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 Kimberley also manages our Myopia Profile and My Kids Vision Instagram and My Kids Vision Facebook platforms.

This content is brought to you thanks to unrestricted educational grant from


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