Presenting OrthoK to patients and parents can be an uphill climb. You often need to communicate the very concept of OrthoK, describe the process it entails, set expectations, and establish its overall value.
Those are complex and time-intensive steps, and the road to success starts with breaking down the hesitations and misconceptions that patients and parents may have with OrthoK. The following are common questions for which doctors and staff need to be prepared.
‘You want to what, flatten my kid’s eyeballs?’
This is a common fearful reaction, and I explain in simple terms that we are just changing cell hydration within the corneal epithelium. The result is a temporary flattening of corneal tissue so the patient can see clearly without needing eyeglasses or contact lenses all day long.
I further explain that lenses used in OrthoK do not touch the cornea; they rest on the tear film. The back of the lens is separated from the apex of the cornea by about 5 microns, while the mid peripheral cornea is separated from the back of the lens by about 50-60 microns. This difference in fluid reservoir thickness generates hydraulic cells centrally and increased hydration of epithelial cells in the mid periphery.
To put this in terms patients understand, I say this is like squishing down center cells and inflating mid-peripheral cells. I also explain that this is not a permanent treatment, it’s temporary, which helps to put parents and patients at ease. I explain that they must continue to wear their lenses routinely or the epithelial cells will return to their original state of hydration.
Many parents ask if there are any permanent changes that result from OrthoK. I explain that, yes, some clinical literature suggests that Bowman’s Layer experiences subtle permanent changes with OrthoK over 10-15 years, but these are very small thickness changes and not clinically relevant.
‘Why is myopia such a concern when we can just get glasses?’
This is a common reaction: What’s the big deal? We explain that the development of high myopia can increase later development of a few sight-threatening conditions, such as retinal detachments and macular disease.
These increased risks result from an increased axial length. Fortunately, I have access to the same instruments for measuring axial length as our cataract surgeons, and I make axial length change an outcome measure. Axial length becomes particularly important when doing OrthoK for myopia management because the manifest refraction is altered.
In addition to ocular pathology risks, high myopia can cause a functional issue. If we can keep a patient below -3.00D, they are going to have a functional focal point that might later serve them well in their presbyopic years. If they end up a -6.00D, that’s simply not the case.
‘This all sounds very complicated, does it work?’
OrthoK does, indeed, work. All a patient must do is use the lenses one night to experience a noticeable improvement in vision created by the treatment. The more difficult question involves OrthoK slowing the progression of myopia.
When all the clinical trials of OrthoK are reviewed, the average reduction in myopia progression is approximately 50%. In other words, the patients wearing OrthoK lenses progressed into their myopia half as much as the control group. So, if the control group averaged -1.00D of progression over a two-year period, the OrthoK group would be predicted to progress an average of approximately -0.50D.
That’s what we explain to parents. We cannot guarantee a total stop to the patient’s myopia. Once we begin treatment, we have no way of knowing how much a patient would have progressed if they had not started OrthoK. The closest thing we can provide as “proof” to an individual patient is refractive error progression history (usually a series of old glasses prescriptions from the patient) compared to progression rate during treatment. This is often confounded by age and the natural course of myopia progression making absolute statements about effectiveness more difficult.
That said, patients and parents understand this and elect to proceed. The parents are often myopic themselves and want to give their child every chance they can to avoid the fate that they experienced by simply getting a new set of glasses every six months.
‘OrthoK sounds dangerous, is it safe?’
Safety is always a primary concern, and putting contact lenses on kids’ eyes scares a lot of parents. Concern breaks down into several areas: risk of hypoxia, potential infection, and comfort.
Hypoxia: Hypoxia was a major concern when extended-wear contact lenses came on the market and were promoted for the convenience of sleeping in lenses. At that time, soft contact lens materials did not transfer a lot of oxygen, leading to various issues. Modern materials used for OrthoK have extremely high oxygen transmissibility and have been approved by the FDA for overnight use by children. Just make sure the OrthoK lenses you order are manufactured in these approved materials.
Infection: Infection is a real risk. Studies show that infection rates with OrthoK are about the same as with extended wear soft lenses. A retrospective review of microbial keratitis cases as a result of OrthoK wear estimated the rate of infection as approximately 7.7 cases per 10,000 patient years. In other words, if you had 100 patients wearing lenses, you would see an average of one case every 13 years. The cause of these rare events is almost always the result of poor compliance of the patient.
We find compliance is pretty good: 80-85%, and our patients do well as long as they wash hands and disinfect lenses. For kids, we almost exclusively recommend a hydrogen peroxide solution system. If a patient can’t use a hydrogen peroxide system, we’ll change them to a multipurpose solution. Sometimes there are rare deposits that hydrogen peroxide cannot get off. Then, we recommend a cleaning system such as Progent from Menicon. At regular checkups, we have the patient go through their care process and demonstrate their routine without prompting. We’ll check their lenses for deposits and scratches.
Comfort: Discomfort in OrthoK lenses isn’t something that can be spun for patients. They know what it feels like when there is a GP lens on their eye for the first time. I am honest and tell the patient the initial experience with the lenses won’t be painful, but it will be uncomfortable. To keep patients motivated we often joke at the one-day follow-up that the first night of lens wear is always the worst. Usually that proves to be true.
Studies show that the first time GP lenses are worn, comfort is about 5-6 on a 10-point scale. After a month, comfort is closer to 8-9. If patients can stick with consistent lens wear for 30 days, they are often able to fully adapt.
For ECPs: ‘Is my office set up for OrthoK?’
In achieving success with OrthoK, there is one other caveat, and this pertains to clinicians: Be prepared to provide OrthoK services, and have your staff prepared to schedule for it. There are different needs for patients who come in a half-dozen times, requiring instruction and corneal topography and axial length measurements.
Also, OrthoK provides a different revenue model than with kids who are seen annually, with a corresponding purchase of eyeglasses or contact lenses. You can do OrthoK a little, but practices that really succeed with OrthoK do it a great deal and are well set up for it.