Myopia Profile


Thinking beyond myopia - managing the very high childhood myope

Posted on May 11th 2020 by Connie Gan

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Children with more than 5-6D of myopia can require special consideration to ensure safe management of their ocular and systemic health. In this fascinating case, AJ is looking for treatment recommendations for her 7-year-old patient who has very high myopia and astigmatism that has progressed quickly in the last 3 months. Here's the link to the post.

AJ So 7-year- old patient today who is RE-10.00/ -2.50 x 170 and LE -10.50 / -3.00 x 160. They got new glasses three months ago elsewhere- SV distance and told to review in a year..... I'm feeling rather frustrated with that. He has progressed during this time by 1D and I've discussed atropine 0.01% with the mother and the possibility of contact lenses too. I'm interested to hear other thoughts on using "off label" proclear multifocal toric lens. I've used Biofinity Multi D lens "off Label" for those not wanting to look at Ortho-K and when it centres well, it seems to have good results... has anyone used the toric lens?? Thanks in advance for everyone's expert opinionsAJ Axial Length was 27mm yesterday

What are the considerations?

1. This is not your normal myope - Consider possible ocular disease or syndromes

The possiblity of retinal or systemic health issues

DS Frankly if we assume that there is a posterior staphyloma I don't know that there is much that could be done. The atropine studies are not dealing with staphyloma patients or this degree of axial elongation. So employing atropine runs some ethical risks in terms of encouraging cost and side effects for no clear gain...
  • It is rare to see a child who is so young with such a high refractive error and axial length, so further investigation is warranted. Depending on your scope of practice in your country, this may include co-management with ophthalmology to rule out any ocular structural or general health syndromic issues before continuing on with your refractive and long term eye health management. Read more on this below.
  • High axial length is associated with abnormal fundus changes which includes optic nerve crescent, retinal atrophy, Fuchs's spot, lacquer cracks, retinal degenerations and posterior staphyloma.1 Therefore, fundus examination is important, especially when it involves a patient with an axial length of 27mm as in this case. An axial length over 26mm has been associated with increased risk of vision impairment across a lifetime.2

The possiblity of corneal ectasia

  • Given the high degree of astigmatism, it is important to check for keratoconus, other corneal ectasia or irregularity
  • The presence of corneal ectasia or lack thereof will influence your decision on myopia management, as DS discusses below in consideration of OrthoK.
DS You wouldn't do orthoK as a 10 year old with ectasia has a reasonable chance of Bowman's layer scarring as part of their pathophysiology. They don't need me accelerating that through accidental corneal touch with a contact lens on top of everything else. In addition corneal cross-linking would be an important step in limiting progression as the axial elongation of the eye can occur anteriorly as well as posteriorly. I think if you see a steeper K with some irregularity your first obligation is to sit tight and monitor that cornea for progression. Use atropine if you feel it's absolutely necessary for you to act regarding the myopia. Myopia is unfortunate, undiagnosed and progressive corneal ectasia and axial myopia is even worse. They do occur in combination and at times of events such as corneal transplant the anisometropia between the myopic grafted eye and the fellow eye can be very disabling. So manage both, But I would prioritise diagnosing the ectasia over orthokeratology.

2. To manage myopia or not?

With your very high myope, it is important to remember that myopia isn't always the only condition that requires your attention. It is important to rule out any eye disease and even systemic syndromic conditions before making a decision on myopia management.

PP The myopic progression...would put his risk of eye diseases at a much higher level. Some sort of myopia progression control needs to be instituted NOW, I feel.DS Honestly, I didn't think I would do myopia control. This patient's risk profile is already high and he may be better of in terms of quality of life in saving the money towards ICL impantation as an adult.

The community was split as to whether myopia management is necessary in this case. On one hand, the patient is young, and any myopia management is potentially better than none. On the other hand, current literature lacks information on myopia management in cases with very high myopia and since the typical myopia control results can't be expected, the benefit of managing myopia may not necessarily outweigh its risks and cost.

If it is decided to commence myopia management, the options include:

  1. Multifocal soft contact lenses
  2. Partial orthoK with top-up spectacles
  3. Low-dose atropine, plus best refractive correction

Achieving good acuity is the utmost priority for this patient. If myopia control is the parent's option, make sure the patient is seeing well. Contact lens options provide an important opportunity here to achieve the best possible acuity for such a high refraction. Potential risks and outcome of any of these strategies should be properly discussed with the parents. If myopia management is not implemented, both soft CLs and RGPs are options for best correcting the patient's vision.

What the research says:

  • Patients with keratoconus have been shown to have a greater posterior segment length compared to emmetropes. There is significant relationship between keratoconus and axial myopia,3 which suggests there is a good chance this patient does have or will develop keratoconus.
  • 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).4  
  • There is currently no evidence on the efficacy of myopia management strategies in patients with myopia as high as this.
  • There is also no information available on the natural course of myopia progression in patients with high myopia.

Take home messages:

  1. Monitor eye health - when you are presented with abnormally high myopia and axial length in younger children, remember to consider other possible drivers behind the high myopia - both ocular and systemic - and continuously monitor retinal health over time.
  2. Consider ophthalmology referral - in children under 10 with high myopia (over 6D), a single referral to paediatric ophthalmology at minimum is important to rule out underlying ocular pathology or systemic conditions; or consider co-management with ophthalmology dependent on your scope of practice. Remember though, that primary eye care / optometry is best placed to manage this patient's vision in the long term - whether you end up just managing the refraction for best acuity, or managing for myopia control as well.
  3. Remember ectasia - consider corneal ectasia in cases of high and especially progressive astigmatism. If ectasia is suspected but not confirmed, it is prudent to wait and watch before potentially fitting OrthoK to an undiagnosed ectactic cornea.
  4. Educate for informed consent - managing myopia at high degrees fall outside the range covered by current literature. This does not suggest that one should not attempt to manage myopia in these power ranges. It is important, however, to be upfront with the patient's parents about the lack of literature in that regard - typical myopia control results can't be expected - and involve them in the discussion regarding management.
  5. Consider contact lenses - once other conditions are ruled out, and as long as risks and costs are acceptable to the parent, there is unlikely to be any harm in instigating a myopia management strategy in a case like this. Contact lens options provide an important opportunity to both provide the best refractive correction for such a high refraction, as well as offer the potential to slow myopia progression.

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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