November 17, 2025
By Ashley Wallace Tucker, OD, FAAO, FSLS
Photo Credit: Getty Images
This scoping review investigates how astigmatism influences the onset, progression and control of myopia, a condition increasingly recognized as a global epidemic due to excessive axial elongation in childhood. Although myopia’s mechanisms are well studied, the relationship between astigmatism and myopic eye growth remains unclear.
In this study, the authors reviewed 47 studies (30 examining myopia and astigmatism; 17 examining astigmatism and myopia-control interventions), most conducted in Asia, to synthesize current evidence and highlight research gaps.
Background
Astigmatism, caused by unequal corneal or lenticular curvature, blurs vision along different meridians and is highly prevalent worldwide (~40% of adults). It is common in infancy, stabilizes in youth and increases again with age. Like myopia, both its prevalence and magnitude appear to have risen with lifestyle changes such as reduced outdoor time and increased screen use, which are both trends accentuated during COVID-19 lockdowns. Because both refractive errors may share environmental and biological pathways, understanding their interaction is critical for effective management.
Astigmatism and Myopia Development
Evidence suggests that myopia and astigmatism often coexist and may influence each other’s course. Several longitudinal studies in East Asian children found that increasing astigmatism correlated with faster axial elongation and greater myopic progression, particularly with against-the-rule (ATR) or oblique astigmatism. For example, children whose astigmatism increased showed greater axial length growth (~2 mm over five years) and larger myopic shifts than those with stable astigmatism. High baseline astigmatism also predicted more rapid myopic progression in some cohorts. Conversely, a few European and U.S. studies failed to find significant associations, reflecting variability in age, ethnicity, measurement methods and study design.
Animal studies imply that uncorrected astigmatic blur may disrupt emmetropization, leading to excessive axial growth, yet some data suggest it might provide cues that help regulate it. Thus, whether astigmatism causally promotes myopia or merely accompanies it remains unresolved. Uncorrected astigmatism in early childhood appears particularly detrimental, supporting the need for early optical correction.
Astigmatism and Myopia Control
Most myopia-control trials have excluded children with moderate-to-high astigmatism, leaving uncertainty about treatment effects in this group. Limited data indicate that optical interventions may interact with astigmatism. For example, children with astigmatism wearing DIMS (Defocus Incorporated Multiple Segments) or HAL (Highly Aspherical Lenslet) spectacle lenses showed slightly greater axial elongation or cylindrical change than non-astigmats, suggesting an influence of baseline astigmatism on efficacy. Studies of toric orthokeratology, rigid gas permeable multifocals or atropine therapies generally found no clinically meaningful differences in outcomes, but most had small samples or short follow-up.
Conclusions
Astigmatism and myopia progression appear interdependent, but causation is uncertain. Research diversity—different definitions, refractive techniques and populations—limits comparability. The authors emphasize the need for prospective, multiethnic studies including children with varying degrees of astigmatism to clarify whether and how astigmatism alters the effectiveness of myopia-control treatments. Establishing this evidence base is essential for evidence-based clinical decision-making in managing myopic children with astigmatism, particularly in non-Asian populations where data are sparse.
Key Takeaways
Astigmatism may influence both the development and control of myopia, but inconsistent methodologies and population biases prevent firm conclusions. More inclusive, standardized and long-term studies are critical to guide management of myopic children with astigmatism.
Abstract
The Role of Astigmatism in Myopia Development, Myopia Progression and Myopia Control
Stephanie Kearney, Rakhee Shah, Natalia Vlasak
Aims/purpose
Myopia arises primarily due to excessive axial elongation and is associated with an increased risk of ocular complications and visual impairment, particularly in high myopia. Although astigmatism may have implications on refractive development, the role of astigmatism in myopic eye growth and the effectiveness of myopia control strategies is unclear.
Methods
A scoping review was conducted in March 2025 and updated in August 2025, using MEDLINE and PubMed to explore myopia prevalence and onset, progression and astigmatism (Aim 1) and myopia control and astigmatism (Aim 2). Literature was initially screened by title, abstract and finally by the relevance of the full manuscript.
Results
A total of 1004 studies were identified; 26 duplicates were removed; 911 were excluded following title screening and 20 were excluded following abstract screening. A total of 47 studies were included (Aim 1 = 30, Aim 2 = 17), with most conducted in Asia (n = 31). A higher prevalence of astigmatism was associated with myopia. Myopia progression and astigmatism may be related, although there is limited research on the effects of uncorrected astigmatism on the course of myopia. Additionally, there is limited research regarding the influence of astigmatism on the effectiveness of myopia control strategies, with conflicting findings between studies.
Conclusions
Myopia progression and astigmatism may be interdependent. However, a causative role of astigmatism in promoting myopia is unclear. The diverse range of study designs and methodologies impairs the comparability of findings. Prospective research in children of differing ethnicities with a range of astigmatism is required to determine if astigmatism influences the effectiveness of myopia control interventions. This would provide an evidence base to inform clinical decision-making and management plans for myopic children with astigmatism, particularly in non-Asian populations where research is limited.
DOI: 10.1111/opo.70030
