Orthokeratology Obstacles And How To Meet Them

Now that we’ve dispelled the myths surrounding orthokeratology, we need to discuss the present obstacles the modality faces, and there are plenty. Over ortho-k’s short lifespan in our industry, we’ve ironed out the big concepts and techniques needed for adequate treatment. But there is still a lot of nuance to fitting ortho-k lenses: just go to any ortho-k meeting. It’s not uncommon to get a half dozen proposed solutions to a single problem. And more often than not, they contradict one another.

Most of the blame for the inconsistency lies in the fact that we just simply don’t have the information we need in order to know the true answer.

For example, orthokeratology is the only contact lens modality that is dependent on two lens/ocular tissue interfaces: the corneal/posterior lens interface and the palpebral conjunctiva/anterior lens interface. Both are critical to lens centration in the closed eye system. Yet no one has ever investigated whether modifications to the front surface of an orthokeratology lens would affect lens centration. Lenses continue to be manufactured with a front surface similar to that of a normal corneal GP that is worn in the open eye. 100% of the industry is ignoring 50% of the lens when they design lenses. That’s kind of a lot. That’s just one of a number of issues still to be resolved.

Obviously, we still have a long way to go in our understanding of how ortho-k lenses fit. That said, the obstacles that ortho-k faces fall into two categories: obstacles individual docs can overcome and those that require some help from industry and research to help flesh out. Our focus is going to be on the problems that practitioners can address in the clinic to help ensure success throughout the fitting process with the current technology we have.

The hardest part of any ortho-k fit is almost always getting buy in. Often, the parent is the most critical player for the initial decision, but the patient will be the one who determines the long term success (more on this in the following sections).

Parents have to feel comfortable from both a psychological standpoint as well as a monetary one. They need to feel like ortho-k is one of the best options for their child and that it is worth the price ($1500 at some practices). There are a couple of steps in helping them understand the benefits. The first thing you need to do is start the conversation.

For example, a script used at the end of a child’s comprehensive exam might sound like this:

" Based on Tim’s exam results, it looks like he would be a great candidate for orthokeratology or ortho-k. Ortho-k involves using a contact lens to temporarily modify the outer layer of the cornea to correct nearsightedness or myopia. Tim would apply the lenses each night before bed and remove them each morning. He would be free from contacts or glasses at school and would only be handling his lenses when at home under your supervision. Aside from providing clear vision during the day, the goal with ortho-k is also to slow the progression of nearsightedness. Ideally, ortho-k treatment would help prevent Tim from needing a new set of glasses every year as well as decrease his risk of retinal problems associated with high degrees of myopia.”

In a few sentences you addressed what ortho-k is, how it works, and what the benefits to the patient are from a convenience, monetary, and ocular health standpoint. Think about it as your 30 second elevator speech (OK, it took 35 seconds). You can then give them some more detailed information in print and ask when they would like to schedule a consultation.

And you need to have a consultation. You don’t go to the dentist for a cleaning, find out you need braces, and get them put on in the same visit. So why would you try to do a full exam and ortho-k fitting in a single day? It’s true that you often have all the information you need from a patient’s initial visit to fit lenses, but the real purpose of the consultation is to guarantee buy in.

The consultation gives parents and patients time after the initial presentation of the concept of ortho-k to think about it and do some self-directed learning. Everyone loves Dr. Google these days. Letting parents spend time looking up the good, the bad, and the ugly prior to coming in for the meeting builds a huge amount of trust, especially if you’re prepared to answer all the questions they have. Once you’ve allayed all of their fears, you can discuss all the details (pricing, visit schedule, lens warranty information, etc). Spending a little extra time up front being totally explicit about your ortho-k services will save an exponential amount of time and money in the long run.

Regardless of how you structure your consults and education, the most important thing is your belief in the modality. The most well written script is worthless in the hands of an individual who doesn't believe that ortho-k is a good option. You have to buy in before you can expect your patients to. You can also build credibly among your staff by offering to fit family members so they can see the effects first hand. If your office is excited about ortho-k, your patients will be too.

Now that we have convinced the parents, we have to convince the patient. The first step in that journey is addressing comfort. Ortho-k lenses are uncomfortable at first. They don’t hurt, but you won’t forget that you’re wearing lenses like you might with a daily disposable soft lens. Children who have never worn lenses before can be especially difficult to work with. The population has a very hard time understanding that the lenses will benefit them.

The average initial comfort score for an ortho-k lens is 5/10, but generally climbs to a 7 after one week and then averages out to about an 8 or 9 after 4 weeks. Telling young patients, “This lens won’t be as uncomfortable as it is the first night. It only gets better,” is an easy way to help them understand lens adaptation. You can also liken it to wearing a new pair of shoes. At first you are aware of them on your feet but that awareness fades over a short period of time.

Another easy thing to take advantage of is having the patient close their eyes. Almost all sensation created by a GP lens is a result of lid/lens interaction. The times the lens is most uncomfortable is during the blink. If the lids are shut, the lens is static. Instantly, the lens becomes more comfortable. Reminding the patient that their eyes will be closed 98% of the time when they wear ortho-k lenses is a powerful way to overcome issues with initial comfort.

When talking about comfort, the question of topical anesthetic during initial lens fitting always comes up. Some swear by it, while others avoid it like the plague. If you choose to use it, it’s going to aid in the initial application and removal process as well as allow for adequate lens evaluation (the patient will actually be able to keep their eyes open). Just keep in mind that you must educate the patient that the lenses will be a little more uncomfortable when they apply them that evening. That will prevent you from getting calls at 9:00 PM from frantic parents reporting their child applied the lenses wrong and is very uncomfortable.

Speaking of applying and removing ortho-k lenses, this may be the biggest barrier to lens wear. Teaching children as young as 7 years old to handle and care for lenses is not an easy task. There are a million different approaches and 2 million justifications. Here are the ones that have some time tested success.

Application and removal training starts not at the dispensing visit, but at the consultation. When all the details have been worked out and contracts signed, give the patient and parent some homework. The homework consists of the patient practicing touching their own eyes prior to the dispensing visit.

Instruct the patient to first immobilize the upper lid by pinning their upper lashes to their brow/orbit. This is done with the opposite hand of the eye they are working on (if manipulating the right eye, left hand used on upper lid). Then instruct the patient to pull down their lower lid with the middle finger of their other hand (if working on the right eye, pull lower lid down with right middle finger). Instruct the patient to look up slightly and use the index finger of the hand manipulating the lower lid to gently touch the conjunctiva below the cornea with the pad of their index finger.

Obviously you want to have the patients wash their hands with soap and water thoroughly before doing any of this. Have them try and practice 5 minutes per day every day before returning to the office. And make sure to confirm both the patient and parent have a full understanding of the procedure and that it occurs under the parent’s supervision only.

If patients are able to master this, application at the office is a breeze. The only difference when applying an actual lens will be that the patient looks in the mirror and applies the lens directly to their cornea. But this is easy to teach. Other tips and tricks include filling the bowl of the lens with a drop of preservative free artificial tear prior to application to improve application comfort and reduce the likelihood of getting bubbles under the lens.

Removal is a whole other process. Ideally, patients should be able to remove their ortho-k lenses with no accessories (i.e. DMV contact lens removal tools). Some practitioners refuse to give any children the DMV plungers because of the risks. Some practitioners will use the plungers as the primary method of removal. Some argue that it is in the patient's best interest to instruct them to remove the the lens with and without the tools. You can choose which camp you fall into.

For removal without the plunger, instruct the patient to open their eye as wide as they can. If looking in a flat mirror placed on the counter, they should be able to see white conjunctiva above and below their iris. Have them pull the skin on their temporal canthus toward their ear in order to increase the tension of their upper and lower lid. Then instruct the patient to forcefully blink. The upper and lower eyelids should pass beneath the contact lens and pop it out. Everyone does this technique a little differently depending on their anatomy, but the principles are all the same.

For removal with the plunger, you have to instruct the patient to first confirm the lens is on their cornea. Children can often see the lenses in the mirror if they look very closely. They can also reach up and gently touch the edge to confirm it’s directly on the cornea. Make sure to emphasize that patients should NEVER try to remove a lens if they have not made sure it is on their cornea. They could end up sticking the plunger directly to the cornea which is not a fun experience and may cause an abrasion. This is why some doctors won’t provide plungers in the first place.

In order to remove the lens, instruct the patient to immobilize their lids in the same way they did when applying the lens. Have them use the index finger and thumb of the hand that’s pulling down the lower lid to manipulate the plunger. Instruct the patient to lightly press the plunger to the middle of the lens surface and then slowly pull the plunger away from their eye.

Again, it’s critical that both the patient and the parents understand how to perform both application and removal. That way, there is very little chance of failure getting ortho-k lenses in and out. With a number of different strategies at hand, it’s very rare to find a case where someone totally fails the application or removal. But it does happen. You may need to have the patient and parent practice touching their eyes at home for another period of time before doing the real A&R training.

Regardless of the evidence, some parents (and practitioners) still have a hang-up about having children sleep in lenses. We’ve already discussed the risks (infection and hypoxia) in part I. The biggest issues come from improper use of the lenses. So it really becomes the practitioner's responsibility to provide proper instruction and education to the patient.

And overnight wear isn’t all bad. It’s actually advantageous in a number of ways for ortho-k. As we discussed above, GP ortho-k lenses are not very comfortable initially. A lot of that discomfort is a result of lid/lens interaction. The discomfort and sensation of the lens almost always disappears when the eye is closed.

Another advantage is wear time. Patients wear ortho-k lenses for an average of eight hours every evening. While we don’t have an exact number of hours required to reach full treatment effect (probably somewhere around 5), we do know that overnight wear definitely meets the requirement.

So while overnight wear is an obstacle, it is one of the smaller ones. Be prepared to explain risks and strategies to mitigate them with your patients

Probably the biggest advantage of ortho-k lenses are their ability to slow axial growth. What started as a pleasantly unexpected side effect has now become the modality’s main topic of investigation. The problem is, we still don’t know exactly why it works. We are just scratching the surface of myopia controlling optics and have no definitive answer on the exact mechanism.

That presents two main obstacles. First, it makes it more difficult to explain to parents. We can tell them how we “think” ortho-k lenses control myopia, but that it may be due to some unknown element we haven’t entirely figured out. This can put some parents off a bit. They don’t like the idea of a treatment not totally understood being used on their children. You can allay some of these fears by explaining that we do have a very good idea of the risks, just not the exact mechanism of slowing axial length growth. The same could be said of drugs like Tylenol, where the mechanism of action is still unknown.

Second, ortho-k has technically only been approved by the FDA for correction of ametropia. Explicitly marketing ortho-k lenses as a myopia control technique in your practice can be a bit of a slippery slope. The chances of getting approval from the FDA are also very slim. The studies required are very expensive and nearly impossible to perform. Any patient wearing “placebo” ortho-k lenses will know immediately because it will not correct their vision. As a result, the patients cannot be masked as to whether or not they have the treatment. So no double-blind, randomized control trials and likely no FDA approval.

That said, you can tell ortho-k candidates the truth about the myopia controlling efficacy of ortho-k. Evidence has shown that kids wearing ortho-k lenses progress about 50% slower than those wearing spectacles.1 There are no false and shady claims in that statement. Again, we don’t know exactly why, but we know it works. As long as you explain that to patients and parents, you’re in the clear.

Obviously, ortho-k lenses have a lot to overcome. At this point in time, orthokeratology remains a “fringe” vision correcting technique. This will likely change as more and more information on myopia development and progression comes out of research centers. It’s up to you to arm yourself with tools to overcome the barriers that affect individual practitioners so that you can be on the forefront of ortho-k treatment, not straggling in the back of the pack. Next, we’ll discuss some of the more advanced topics in ortho-k and how to use the information to help you succeed after mastering the basics.