In modern optometric practice, pediatric myopia rarely presents in a vacuum. As clinicians routinely observe, high numbers of myopic children present with clinically significant astigmatism. More than 40% of eyes carry at least 0.75 D of astigmatism,¹ with certain populations, most notably Hispanic children, exhibiting disproportionately high rates. In the Collaborative Longitudinal Evaluation of Ethnicity and Refractive Error (CLEERE) study, 36.9% of Hispanic children presented with 1.00 D or more of astigmatism, the highest prevalence among the groups studied.² The Multi-Ethnic Pediatric Eye Disease Study (MEPEDS) found that Hispanic children showed more than double the rate of high astigmatism (≥3.00 D) seen in other groups.^3,4

Uncorrected cylinder degrades visual performance, promotes asthenopia, slows reading speed,^5-7 and creates persistent visual blur that can undermine a child's compliance with treatment. Addressing both myopia progression and concurrent astigmatism demands sophisticated optical strategies. Today, 2 modalities lead the way in tackling this combined challenge: modern orthokeratology (ortho-k) and advanced soft toric contact lenses.

The Role of Ortho-k in Astigmatic Myopes

Ortho-k has long served as a well-established option in myopia management, offering daytime freedom from glasses and contact lenses while creating myopic peripheral defocus. For children who have low to moderate with-the-rule corneal astigmatism, traditional spherical reverse-geometry ortho-k lenses often mask cylinder effectively by creating a tear reservoir beneath the rigid lens and reshaping the central epithelium.

However, when corneal astigmatism exceeds 1.25 D to 1.50 D, standard spherical designs frequently decenter.⁸ Decentration induces uncorrected residual astigmatism, higher-order aberrations, and poor visual quality. To overcome this limitation, toric ortho-k designs have expanded pediatric fitting options. Modern ortho-k lenses that have toric peripheries feature distinct return and alignment zones 90° apart.

This alignment improves lens centration as the toric landing zone matches the toric contour of the peripheral cornea, locking the lens in place overnight to minimize lateral or vertical displacement. Precise alignment delivers an even 360°  midperipheral treatment ring, maximizing the peripheral plus defocus. Additionally, practitioners utilizing toric ortho-k can often manage 3.00 D or more of corneal astigmatism (not refractive), delivering clear, uncorrected daytime acuity for active children and student athletes.

Despite its benefits, ortho-k is not universal. It demands thorough patient and parental dedication to nighttime cleaning regimens, rigid lens handling, and regular topographies. Furthermore, high internal (lenticular) astigmatism often cannot be corrected with corneal reshaping, necessitating an alternative daytime optical approach.

The Expanding Role of Soft Toric Contact Lenses

When children present with high lenticular cylinder, irregular sleep schedules, or parent-child friction surrounding rigid nighttime lenses, soft toric lenses emerge as the primary clinical path. Until recently, the myopia toolkit faced a persistent barrier with an absence of daily disposable toric soft designs intended for myopia management. Practitioners were frequently forced to mask cylinder with spherical equivalent fits, leaving patients with residual blur that compromised visual function during classroom learning and digital device use.

Newer daily disposable soft toric designs are helping to close this gap. Silicone hydrogel materials that have high oxygen transmissibility support corneal health over years of daily wear, and single-use replacement simplifies hygiene for children and parents. Together, these features offer a practical, hygienic daytime option for astigmatic myopes who are not suited to overnight lens wear.

A Comprehensive Care Continuum

Managing the astigmatic myopic child requires tailoring the treatment to ocular anatomy, visual demands, and family lifestyle. Toric ortho-k excels for water sports, contact athletics, and children seeking daytime freedom, while daily disposable soft torics provide an accessible, low-friction, and stable alternative for daytime wear. By pairing both modalities in clinical practice, practitioners can address both visual acuity and myopia management needs, giving astigmatic children the clear, sustained sight they deserve.

References

1. Luensmann D, Schaeffer JL, Rumney NJ, Stanberry A, Fonn D. Magnitude of astigmatism—a comparison between eyes. Cont Lens Anterior Eye. 2022;45(5):101510. doi:10.1016/j.clae.2021.101510

2. Kleinstein RN, Jones LA, Hullett S, et al. Refractive error and ethnicity in children. Arch Ophthalmol. 2003;121(8):1141-1147. doi:10.1001/archopht.121.8.1141

3. Fozailoff A, Tarczy-Hornoch K, Cotter S, et al. Prevalence of astigmatism in 6- to 72-month-old African American and Hispanic children: the Multi-Ethnic Pediatric Eye Disease Study. Ophthalmology. 2011;118(2):284-293. doi:10.1016/j.ophtha.2010.06.038

4. Wen G, Tarczy-Hornoch K, McKean-Cowdin R, et al. Prevalence of myopia, hyperopia, and astigmatism in non-Hispanic white and Asian children: Multi-Ethnic Pediatric Eye Disease Study. Ophthalmology. 2013;120(10):2109-2116. doi:10.1016/j.ophtha.2013.06.039

5. Berntsen DA, Cox SM, Bickle KM, et al. A randomized trial to evaluate the effect of toric versus spherical contact lenses on vision and eyestrain. Eye Contact Lens. 2019;45(1):28-33. doi:10.1097/ICL.0000000000000528

6. Chao C, Skidmore K, Tomiyama ES, Wolffsohn JS, Richdale K. Soft toric contact lens wear improves digital performance and vision—a randomised clinical trial. Ophthalmic Physiol Opt. 2023;43(1):25-34. doi:10.1111/opo.13053

7. Wolffsohn JS, Bhogal G, Shah S. Effect of uncorrected astigmatism on vision. J Cataract Refract Surg. 2011;37(3):454-460. doi:10.1016/j.jcrs.2010.09.022

8. Tomiyama ES, Logan AK, Richdale K. Corneal elevation, power, and astigmatism to assess toric orthokeratology lenses in moderate-to-high astigmats. Eye Contact Lens. 2021;47(2):86-90. doi:10.1097/ICL.0000000000000721

Bobby "Chip" Wood, Jr., OD, is president/medical director of Wood Vision Source/Coyote Optical Vision Source in Texas. He has received remuneration from Bausch + Lomb, Alcon, and Euclid.

This content is supported by Euclid Vision Corporation