Some of the most challenging patients are those with higher myopia, astigmatism, or binocular vision issues, as these are overlooked areas of research. Parents of young children with high myopia should be counselled about potential genetic causes. If parents still elect treatment, doctors should carefully educate and document lowered expectations for efficacy.

Children with more than 1.00 D of astigmatism may not have sufficient acuity with the MiSight lens and may be better served with a soft toric multifocal. Generally, orthokeratology is more successful with less than 1.75 D of with-the-rule astigmatism, and when the astigmatism is not greater than the myopia. Bifocal glasses and atropine are options for nearly any refractive error. Children can become more exophoric with multifocal or orthokeratology lenses. Children who are exophoric or demonstrate signs of convergence insufficiency should be questioned as to any symptoms and treated for their binocular vision disorder prior to initiating myopia control since treatments may exacerbate underlying conditions.