Myopia Profile


Which is best? Myopia Management for an astigmatic myope

Posted on August 29th 2021 by Connie Gan

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In this article:

Contact lens options are ideal for higher myopes. What about when they have moderate astigmatism as well? Considerations are discussed.

The benefit of optical treatments for myopia are that they both correct refractive error and control progression. Here we have a case involving an astigmatic myope presented by AA on the Myopia Profile Facebook group.

AA Advice please: 8y old girl, presenting Rx R-5.50/-3.0 X5 L -4.50/-3.00x175 Rx increase of 1D in 1 yr. Slight well compensated near expophoria and 1 D lag of accommodation. What management would you suggest? ( Can't do atropine in the UK). Away from mf soft toric CL what are people's experience on efficacy of tx with ortho k or misight and SV specs on top to sort residual astigmatism?

Option 1: orthokeratology

PC OrthoK, if the cornea is suitable, will correct all the myopia and probably most of the cyl in that case. So that’s what I would do. Just fitted a girl in similar situation, R -7.00/-3.00 L -5.00/-3.00. Functional vision unaided. SVD for residual cyl of around -1.00.MLM is where I am at on this case as well...KG Agree with OK. Considering toric lens stabilisation and likely smaller optic zones, if the cornea is steep enough and has similar cyl to spec cyl then VA will likely be better too.

Most commenters suggested fitting orthokeratology lenses. There are two key reasons to consider orthokeratology:

  1. Full correction of astigmatism is possible, if the refractive and corneal astigmatism are similar
  2. Orthokeratology (OK) is the only optical intervention for which there is evidence of myopia control in higher levels of astigmatism. Toric OK for myopes with astigmatism up to 3.50DC appears to be just as effective for myopia control as spherical OK for myopes with minimal astigmatism.1-3 The Menicon Bloom Night Toric lens was the first for which this efficacy in controlling myopia with moderate to high astigmatism was demonstrated.1

A simple rule-of-thumb for OK fitting is that the refractive astigmatism should not exceed the corneal astigmatism by more than 0.75D. Since OK only corrects astigmatism on the cornea, any additional refractive astigmatism will be likely to be residual after treatment. This is an important rule for beginner and intermediate OK fitting eye care practitioners; experienced OK fitters using specific designs may be able to manage corneal-to-refractive astigmatism mismatch to still achieve a good visual outcome for the patient.

Option 2: soft contact lenses

KG MiSight and SV specs for residual cyl is a back up option, if parents and kid are 100% on board with wearing the specs too and not leaving them off and squinting!

If OK is not a suitable choice for the patient or their family, soft contact lens options could be considered. This may be required if the patient's refractive and corneal astigmatism are not in close alignment.

The CooperVision MiSight 1 day contact lens, as mentioned in the comment, appears to show similar myopia control efficacy to OK,4 but only children with up to 0.75D of astigmatism were included in the clinical trial.5

For this patient, fitting MiSight 1 day would mean that the full astigmatism amount would need to be corrected with spectacles, worn over the contact lenses. As mentioned by KG, the child and parent would need to understand the imperative to wear the astigmatism-correcting spectacles PLUS the soft contact lenses. To not wear the spectacles whilst wearing the glasses could both impede reading and learning performance6 as well as lead to more myopia progression due to undercorrection.7

Option 3: atropine

MLM …I would consider Atropine.

As this patient is 8 years of age and hence in the time of fastest progression (between 7 and 10 years of age),it is worthwhile considering the combination of atropine with an optical intervention. Orthokeratology again holds a special distinction here, as the only intervention for which increased efficacy when combined with low-concentration atropine has been shown.9

One meta-analysis of primarily 0.01% atropine combined with OK showed a mean 0.25mm axial elongation in a year, compared to 0.35mm in OK alone, giving a mean difference of 0.09mm additional efficacy provided by the combination.9 The longest clinical study of 0.01% atropine combined with OK, though, showed a significant effect only for 1-3D myopes and not for 3-6D myopes.10 In atropine monotherapy, stronger concentrations of 0.025% to 0.05% appear to be needed to achieve effective myopia control.11 This concentration-dependent efficacy has not been investigated or demonstrated when atropine is used in combination with OK.

Considering this patient has spherical component of myopia of R -5.50D and L -4.50D, the combination may not be effective. Monotherapy with OK alone could be considered first, and combination treatment could be discussed at the outset for parental informed choice or considered based on future outcomes.

Considering more than myopia control

Orthokeratology has the largest volume of evidence for myopia control - as arguably the first optical intervention to show a significant impact for slowing myopia progression, back in 2005,12 there are simply more studies on OK which have been published since compared to other treatments. The evidence for soft contact lens options, so far, indicates that the MiSight is likely to have similar efficacy to OK while other multifocal options may have slighly lower efficacy.4

In addition to efficacy, though, it's important to consider what is going to best suit the patient. This case highlights the example of astigmatism, for which the best monotherapy could likely be achieved with OK. There are numerous other considerations in comparing the practicalities and wearer experience of both options, which are important to discuss with the patient and their parent(s). The table below provides a brief summary.


OrthokeratologySoft contact lenses
Wearing scheduleWorn to sleep Only worn at homeWorn during waking hours Worn to locations outside the home
BenefitsClear vision through the day without optical aids

Best option for water sports and other sports / activities where debris could reach the eye (eg. gymnastics, football)

May be better for dry eye and ocular allergies

Can correct higher levels of astigmatism
Can be worn part time

Best option if there is concern about lens handling, loss or breakage

Daily disposables are safest; reusable soft lenses have similar safety to OK

Simple for practitioner to fit

Simple for patient to maintain (especially daily disposables)
ConsiderationsMust be worn full time

More complex to fit, requiring a topographer

Take more time for patient to clean and maintain lenses
Need up-to-date back up glasses for regular use, when contact lenses are removed

Limited options for astigmatism

Not recommended for water sports
Replacement scheduleBy practitioner discretion or as recommended by manufacturer: typically 6-12 monthlyDaily or monthly depending on the lens type

Take home messages

  1. Orthokeratology has a large volume of evidence for myopia control and the only evidence for myopia control with astigmatism up to 3.50D.
  2. Consider what best suits the patient and their family as well as selecting the best option for myopia control
  3. Combining atropine (typically 0.01%) with orthokeratology has evidence for an additive myopia control effect, but this might be most effective in lower myopes under 3D.

Further reading on orthokeratology

If you'd like to get started fitting orthokeratology yourself, check out our Myopia Profile Academy online course Orthokeratology Fundamentals, which is structured to step you through your first handful of fits with safety and success.

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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