Myopia Profile


Managing a teenager with very high myopia

Posted on August 3rd 2021 by Connie Gan

In this article:

How do you manage a teenager with over 15D of myopia? This case covers systemic and ocular health, contact lens options and more.

How do you manage a very high myope? SD presented a case of extremely high myopia in a 13-year-old child, within the Myopia Profile Facebook group. Would myopia control necessary in this case? What else should be considered? Let's explore the case details and the advice from colleagues.

SD Help please! 13yr old px first visit with us this morning. Rx: R: - 16.00/-2.00x30 L: - 14.00/2.50 x152 Px has been myopic since 3yrs old with no family history. Currently wearing single vision. Any ideas for myopia control options for this huge rx?SD No idea on rate of progression. Fundus shows signs of thinning but no maculopathy. VA R: 6/15 (0.4) L: 6/12 (0.3)

1. Consider systemic associations and ocular health

DH …That is pathological myopia… CK Νo idea. This is malignant myopia due to scleral weakening and stretching…DCF .... with this very high myopic power the myopic crescent will be present on the optic disc and susceptible to retinal stretching and glaucomaKG …Ian Flitcroft said ‘if you have more dioptres than years, you need to be properly diagnosed first.” Ian mentioned this more in terms of younger children, as paediatric high myopia is often accompanied by systemic syndromes….

This is not an ordinary case of myopia. With such severe myopia, the patient may have associated systemic health concerns.1 Hence, it is important for her to evaluated by a paediatric ophthalmologist if this hasn't occurred already. The cause of the reduced acuity could be due to myopia-associated fundus changes - pathologic myopia - or it could be due to other reasons. Understanding this is important to setting expectations for optical outcomes of management (eg. fitting with contact lenses) and also for any ongoing co-management between optometry and ophthalmology.

While the axial length is not given, 26mm equates to around 5D of myopia so the axial length can be expected to exceed this value where the risk of ocular disease and vision impairment in the patient's lifetime is at least 25%. If axial length is over 30mm, this risk increases to 90%.2 Hence, this patient needs close ocular health monitoring now as well as across their lifetime - annual review with retinal health check through dilated pupils is recommended by the International Myopia Institute.3

It is also important for the patient to be counselled on the symptoms of retinal tears and detachment so they can recognise this ocular emergency and know how to respond, should it occur.

What is pathologic myopia?

The second volume from the International Myopia Institute, published in April 2021, include one report entitled IMI - Pathologic Myopia. It states that:

"Pathologic myopia is distinctly different from high myopia. High myopia is a high degree of myopic refractive error, whereas pathologic myopia is defined by a presence of typical complications in the fundus (posterior staphyloma or myopic maculopathy equal to or more serious than diffuse choroidal atrophy). Pathologic myopia often occurs in eyes with high myopia, however its complications especially posterior staphyloma can also occur in eyes without high myopia."

2. Consider contact lenses for myopia correction (and maybe control)

CK … Essentially all myopia control studies were done in subjects with 'normal' myopia. No data on this patient group. Thus, even the use of atropine and orthokeratology - which the American Academy of Ophthalmology endorsed - are off label in malignant myopia, with unknown benefits and side effects. I would just fit RGP lenses.DCF yes this is Total Astigmatism based on Refraction ...if corneal astigmatism is the same based on Keratometry findings then RGP sphere can be fitted .... KW Less a comment about myopia control but rather acuity and self confidence.. I personally have a similar Rx, and CLs at age 15 changed my life. RGPs at the time (and your Px may well do well with RGPs with those cyls) improved VA by more than 2 lines. Change to self confidence off the scale. The fitting did coincide with Rx slow down, but perhaps that was most likely with my age. If RGPs not an option then custom soft toric. Good options available. I currently use Mark E’nnovy Saphir Rx Toric.. So less myopia control (because we likely can’t and don’t know enough for this kind of myopia) but my strong recommendation would be a CL conversation for the reasons I mention.SS … Change her life with CLBR Wow poor child, as above not sure about Myopia Control but with vertex rx drops. Could try biofinity XR Toric to start with before jumping to tailor made or RGP?KG It’s pretty clear that this child needs contact lenses, and that with that Rx they will be lifechanging - as KW has said from hard won experience. I would be concerned about compromising his/her acuity with a MFCL … However if this child’s acuity doesn’t improve loads with RGP fitting then I’d consider referral; and someone needs to be evaluating her retina now and then annually, whether you or an ophthalmologist.MZ I had similar dilemma yesterday. 11 yo girl with OR -8.50, -3.75 x 10 VIS barely 0.7; OL -8.50, -3.75 x 170 VIS barely 0.7.Corneal astigmatism OR / OL -2.75, according to her ophthalmologist no any significant fundus findings, on atropine since a year, but myopia is still progressing. Nevertheless I've ordered soft multifocals for myopic kids (Relax by SwissLens) just to have a try, probably we end up with bitoric RGP...

The benefits of prescribing contact lenses for a very high myope include:

  • The magnification of the retinal image that comes with contact lens wear can improve acuity by 1-2 lines in very high myopia3
  • Contact lenses are cosmetically more acceptable than very thick glasses3
  • High myopes experience contrast sensitivity loss with spectacle correction whereas no contrast sensitivity loss occurs with contact lens4

The next discussion point… Rigid gas permeable (RGP) or soft contact lenses (SCLs)? Studies showed a patient preference for SCLs over RGPs after 6 weeks of experience with both - comfort and handling of SCLs being the winning factors.6,7

Patients with moderate to high astigmatism, however, can prefer RGPs over SCLs, due to superior vision outcomes.8,9 When optical quality of RGPs, SCLs and spectacles were compared, RGPs achieved the best outcomes through reduction of the eye's aberrations.10 Therefore, to achieve the best acuity for this patient - and hopefully improve their reported spectacle acuity which currently meets the definition of vision impairment - RGPs are likely to be the superior option. The example of KW's personal experience as a very high myope and eye care practitioner reinforces this.

3. Is myopia control necessary?

As this child falls outside the range of all myopia control studies, the prognosis of myopia control is very uncertain, so prioritizing good visual acuity is the primary clinical focus. Myopia control options can be communicated, though, as long as expectations of the parent and patient are appropriately managed. The best possible options could be adding low-concentration atropine to contact lens wear, and/or a multifocal RGP design although none of these have been studied in clinical trials. It would be important to not compromise acuity for the patient, especially considering the starting acuity which meets criteria for vision impairment. There would be a careful balance of risks and impacts to the potential benefits which would need to be made, to ensure the patient and their parents are fully informed.

BM Would scleral crosslinking be an option?SS I wouldn't have scleral crosslinking without knowing more about effects… DE I’ve seen a few kids where they have implanted a lens overseas life changing

A handful of commenting colleagues suggested surgery to help the patient. Scleral crosslinking aims to increase the stiffness of the sclera to prevent axial elongation. Animal trials have been promising,11 but the IMI Pathologic Myopia report explains that scleral re-enforcement treatments in humans have yielded mixed results. Finally, one commenter suggested implantable contact lenses, however these should be considered only when a child is older and refractive error has stabilized.12

Take home messages:

  1. Rule out possible systemic associations causing the high myopia in this patient. Monitor the patient's ocular health annually.
  2. Achieving good visual acuity is the first priority. Rigid contact lenses provide the best visual acuity in high myopes due to the reduction in aberrations.
  3. Myopia control is not the first priority in this case - the outcomes are difficult to predict and there is no evidence base upon which to base a treatment selection. Adding atropine could be a consideration if parents and patient are well-informed on expectations and keen to proceed.

Further reading on high myopia

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.

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