Myopia Profile


Managing a myopic anisometropic amblyopic child

Posted on April 30th 2020 by Connie Gan

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In this article:

This case is not your typical astigmatic myope. There are several features to this patient that require careful consideration.

SN shared a clinical case on our Facebook group that involved managing extreme anisometropia. This involved a 9-year-old anisometropic amblyope with dry eyes. Given the complex presentation, this was an interesting case for the Myopia Profile community to discuss.

SN Another one for the smarties 😁 9 year old. Mum is a -11.00 on both eyes. R -13.00/-1.50x130 VA 6/48, and L -1.00/-2.00x70 VA 6/9 Dry eyes/partial blinker Full suppression in the right eye. Has tried patching under ophthal for years... Mum keen on myopia control options for the left eye... what would you recommend?

This case is not your typical astigmatic myope. There are several features to this patient that require careful consideration.

Step 1: Investigate the pathology behind the high myopia and amblyopia before deciding on myopia management

Considerations for the right eye

DS I think a macual OCT is in order for the right eye to rule out any myopic pathology...CC Is there a poserior staphyloma present in that RE? Best to ascertain before treatment plan decided.

Considerations for the left eye

PC I would want to establish progression first before jumping in with anything. Why is the LE vision only 6/9?PR 6/9...... if patched for years has this caused a ‘developmental delay’ in VA because of deprivation?DW Need to rule out early Keratoconus

As the patient has high myopia on the right eye, extra tests need to be carried out as unilateral high myopia is often associated with abnormality of the eye1. On the other hand, the slightly reduced VA on left eye warrants investigation.

  • OCT (macula): to rule out myopic pathology in RE and other causes for reduced VA in LE
  • A-scan: axial length difference between eyes
  • B-scan: to rule out posterior staphyloma in RE
  • Topography: to investigate whether irregular astigmatism is contributing to reduced VA in LE

Step 2: Myopia correction and management

Due to the large degree of anisometropia, contact lens treatment was considered the first option for vision correction as it would eliminate image size issues that come with glasses. The very high RE myopia is also likely to benefit from contact lens wear to achieve better acuity than spectacle lens wear, presuming no other cause to the amblyopia such as strabismus or pathology. The community proposed both soft contact lens and OrthoK to SN. The thought process for each eye is different, so let's look at them individually.

Options for the right eye

DS … there is no evidence that MFCLs are effective in very high degrees of myopia.DS … I would not do myopia control on the [right] eye unless there is strong evidence of significant myopia progression.BS If no pathology in the right eye. I would consider a contact lens for that eye. Some kind of multifocal. I would be trying VT too to try and improve the VA in the right eye (assuming no pathology)

This is the amblyopic eye with very high myopia. Considerations before deciding on management for this eye include:

  1. Is there any pathology?
  2. Is the myopia in this eye still progressing?
  3. Is it worthwhile initiating myopia control strategies on an eye that is amblyopic?

There was significant discussion as to whether it is worthwhile fitting a MFCL to this eye. Doing so may potentially retard further myopic progression even though current literature for myopia control efficacy does not cover this power range. However, the optics of a MFCL could influence any possible improvement in VA in that eye - achieving optimum acuity may be the first priority.

Options for the left eye

PC What do you think of using a NaturalVue in the LE, hoping the virtual aperture might mask some cyl but also have over specs for the residual astigmatism?KG Great thought and I’ve trialled this before, but in the small number of cases where I’ve tried to mask cyl >1D I’ve had mixed results. I believe the ‘masking’ is just about how bothered they are with the cyl being uncorrected... And I’m more concerned about visual quality and undercorrection in myopic kids than presbyopes.BR NaturalVue… goes up to -12.25... I’d fit a lens to both eyes as “well why not?” Couldn’t make things any worse. DW …Could offer toric OrthoK for left eye with strong hygiene instructions and warnings. DS …I do wonder if you should start with monofocal in the left until the acuity is improved…

Options for myopia control include:

Soft contact lens

  • A toric soft MFCL was suggested but may be difficult to fit. There are also no daily disposable options for this.
  • Spherical MFCLs may able to mask some astigmatism, particularly the NaturalVue due to its specific small central optic, depth of focus design. However, the anecdotally reported results vary between individuals.


  • Whether to undertake spherical OrthoK or toric OrthoK depends on the result of topography. Research by Zhang et al2 suggests toric periphery OrthoK designs give similar visual acuity, better treatment zone centration and lower incidence of corneal staining in myopic children with moderate-to-high corneal astigmatism.
  • Before commencing this, make sure keratoconus is ruled out.
  • This may better correct the astigmatism compared to soft contact lens options, depending on corneal shape.

Step 3: Considering and Communicating Safety and Risk

KG Any CL fitting should be done with extreme safety measures in place because he’s basically monocular, but CLs will be the way to go from an optical perspective, even before considering myopia control. DW …Could offer toric OrthoK for left eye with strong hygiene instructions and warnings.

Amblyopia effectively leaves this patient with only one good 'seeing' eye. Dry eyes and partial blinking could elevate the risks associated with contact lens wear, hence the safety and risk profile must be communicated clearly with the patient and parent before commencing treatment. The risk of microbial keratitis between the various CL options differ - similar for OrthoK and reusable MFCLs, and less for daily disposables - it is important to assess the potential benefit against the risk of the CL option chosen. More references to help you with this are below.

What the research says:

  • Currently, there is no research available that investigates the efficacy myopia control strategies in extremely high myopia. Most myopia control clinical trials do not study myopia worse than -7.00D3.
  • There are also no studies available that investigate myopia control strategies in the context of myopia in an amblyopic eye.
  • The incidence rate of microbial keratitis (MK) in daily disposables CL wearers is 1 per 5,000 patient wearing years.4 The risk of MK in reusable, silicon hydrogel daily wear contact lenses is around 1 per 1,000 patient wearing years,4 and this is similar to the risk of paediatric OrthoK wear.See the 'References to help' section below for more.

Take home messages:

  • Check for ocular pathology in unilateral high myopia
  • There is currently no evidence on the efficacy of myopia control strategies in power ranges exceeding -7.00D. While some effort to control myopia is better than none, it is important to communicate this effectively to parents and properly weigh up the risk, cost and benefit to initiating myopia control in this power range. You may instead wish to simply focus on achieving the best corrected visual acuity in a highly myopic, amblyopic eye
  • Ensure acuity makes sense. The slightly reduced acuity in the left eye mustn't be overlooked as this could influence safety of various contact lens choices
  • The stakes are higher with an amblyopic patient! The importance of hygiene and safe contact lens wear must be communicated clearly to the patient and guardian.

References to help:

Read more on contact lens safety in children here, and check out our Myopia Management Guidelines Infographic for help on clinical communication of contact lens risks and safety.

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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