Myopia Profile


Should we fit orthokeratology to a child with trichiasis?

Posted on September 5th 2022 by Connie Gan

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In this article:

Orthokeratology is effective for myopia control but is it suitable for a child with trichiasis and corneal staining? Check in this case.

Orthokeratology (ortho-k) contact lenses are one of the most effective treatments for myopia control.1,2 Candidates for contact lens myopia control options, such as soft contact lenses or ortho-k, need to have a healthy ocular surface to avoid undue risk of complications or infections with contact lens wear.3

Here, SL shared a case involving an 8-year-old child who has fast progressing myopia, enquiring about ortho-k to reduce this rate of progression. However, she also has moderate corneal staining secondary to trichiasis. What would you do to ensure you focus on safety, while properly considering myopia control?

SL Dear group, looking for advice on an 8yo girl from Hong Kong with progressing myopia. Her parents are both myopic (Dad -7.00, Mum -5.00) and brought her in asking about ortho-K for myopia control. 12 months ago she had SV Dist prescribed with R -2.25/-0.75x175 L -1.50/-0.75x180. Today subjective Rx and ret gave R -4.00/-0.50x180 L -3.50/-1.25x5. I would normally consider ortho-K here, BUT... look at her corneas: both show moderate staining secondary to trichiasis (which is asymptomatic to her) due to her Asian lid profile. So, do we risk fitting ortho-K on a compromised cornea (knowing that baseline topog and subsequent topog will be a bit rubbish), or consider other options? Do I give atropine instead, or consider MF SCL (which may act as a bandage CL in this situation, though what about correcting the left cyl??) or both?. Keen to hear others thoughts... Thanks in advance.

The first order of business in fitting contact lenses to a compromised cornea is to address corneal staining. In this case, trichiasis is the root problem that requires attention. Commenters from the Myopia Profile Facebook community have shared a few interesting ideas:

Part 1: Addressing the eyelids and eyelashes before fitting contact lenses

KC I'd probably first take care of the trichiasis and compromised cornea before doing anything with CL fitting (regardless of orthoK or SCL). That way, you'd be ensured that the result would not be confounded by persistent SPK or other issues…PC What would be the best way to take care of this kind of trichiasis in a young child?KC Gently pull down the skin of the lower lid until the malpositioned eyelash(es) slightly everted and pointed to a regular position. Then apply adhesive tape at the lower lid margin to maintain normal lid contour.WW how long do you tape, what type of tape and how temporary are the results?KC As others have suggested - bandage CL is typically good enough. I’ve used medical adhesive tape (as long as pts aren’t allergic to specific adhesive material). Duration may vary- several hrs each day, or whenever pts are comfortable with. The results may last hrs, or pts may no longer need to apply taping if trichiasis were minor enough to be malleable or asymptomatic.

Lid taping can reduce the signs and symptoms of triachiasis temporarily.4-7 This can be done by gently everting the lower eyelid to redirect the eyelashes away from the cornea and applying a piece of tape to hold it in place whilst ensuring the patient is able to open and close the eyes naturally.6 This is a short-term fix and may not necessarily command good patient compliance.

Eyelash fix 1: Epilation

PC Could one possibility be just to attend to epilating her lashes at each OrthoK aftercare visit?...

One can remove the lashes by forceps (epilation). However, recurrence can occur within 4-6 weeks depending on the growth of lashes.7

Eyelash fix 2: Surgery

Unlike the above methods, surgery is a long-lasting solution for triachiasis. There are several types of surgery which all essentially aim to tighten the eyelid and redirect the eyelashes away from the cornea. Recurrence is relatively low (0-30% depending on technique) with good patient selection.8 One can consult a specialist ophthalmologist for guidance on the most suitable treatment.

Part 2: Discussion about myopia control options

Soft contact lens as a bandage

cs If you put a lens on it will protect the cornea from the lashes & staining will likely disappear. This is quite common in Asian eyesJC Hi, this is common in Hong Kong. Trichiasis from lower eyelid is not easy to handle. I would fit the soft contact lens first. Monitor for 6mth. And further discuss with parents later.JC If the VA is not good due to residual cyl, prescribe glasses for cyl. I have several cases in this condition. Although it seems complicated to use SCL and glasses, we sometimes do different combinations (atropine and orthok, orthok and glasses etc).HA Hi. Do u mean the left cyl if you want to do a daily multifocal lens?SL Yes, that's correct. Probably better to give a multifocal toric lens rather than spherical to improve acuity? Else specs over the top of spherical multifocal soft CL as others have suggested.PC …in the meantime make do with something like a daily myopia control lens.

A popular option was to use a multifocal or myopia control soft contact lens as a bandage lens ,as well as to slow the myopia progression. It has been shown that a combination of lubricating eye drops with a bandage contact lens can promote corneal healing.9 Given the degree of astigmatism in the patient's left eye, a toric multifocal soft contact lens may be necessary, but there is no evidence base for any such designs.

All multifocal10,11 and myopia controlling12,13 soft contact lenses currently available are spherical designs, and their research studies typically recruit participants with up to 0.75DC.10-13 Off-label considerations can also be required: read more in Understanding on- and off-label prescribing. Only ortho-k has evidence for myopia control in the presence of higher levels of astigmatism; up to 3.50DC.14


JS I assume as the parents came in asking about Ortho k, they would not be keen on Executive Bifocals?PC Perhaps tell them about the new myopia controlling spectacle lenses, if they're available?

In addition to the benefit of myopia control, contact lenses offer numerous benefits to children compared to spectacles, such as increased confidence, ability to participate in activites, and satisfaction with their vision. This is true for both soft contact lenses15 and ortho-k.16

The risk-benefit balance is different, though, for a child with corneal epithelial defects.1 This is where spectacle options are a worthy contender as they mitigate the risk involved with fitting a contact lens on a compromised cornea. The newest designs of myopia controlling spectacle lenses appear to have similar efficacy to ortho-k and the more effective myopia controlling soft contact lenses.Spectacles, though, do not address the corneal impact of trichiasis whereas a soft contact lens can be used as a bandage lens to support corneal healing.9

Would atropine suitable in this case?

KC …Atropine may not be ideal until the condition is resolved since it generally contains BAK preservatives. It may make the compromised cornea feel even more irritatable (although doable)…JS …so if corneas look good in six months then I would be discussing atropine therapy as well…

Low-dose atropine may be suitable, but in the context of an intact cornea. While atropine with spectacle lens wear does not expose the patient to the risks of contact lens wear, commenters suggest that the preservatives (typical in bottled and compounded formulations) may increase ocular irritation, especially if the epithelial defects have not been resolved. Levrat et al corroborate this, as they found that patients treated with preserved eye drops exhibited more signs and symptoms of ocular surface compromise when compared to those treated with unpreserved eye drops.17

A case example

KG Soft MF sounds like the way to go for the corneal bandage effect. I’ve got one kid like this for whom the trichiasis and staining hasn’t improved over several years of my following her - I was hoping her lashes might drop away from her cornea with time / age but no such luck. Saw an ophthalmologist years back who offered surgery but they declined. Patient absolutely NOT BOTHERED despite her corneae and me both being extremely bothered! I actually fit her with OrthoK several years ago when we didn’t have the MFSCL options or research evidence available, and have watched her closely. I epilated her lashes every 3/12 for a while which she hated, and it didn’t make much difference to staining. She’s had a very successful OK treatment over the years with no complications, being well informed of the risks. If I saw her again today as a new patient I’d rather her be in MFSCL.

Incidentally, KG shared her experience with a similar patient suffering from chronic, although asymptomatic, trichiasis with corneal staining. This patient was wearing ortho-k, being watched closely, and had her trichiatic eyelashes epilated every three months. While this patient was wearing ortho-k successfully, without incident, a soft contact lens option could be preferable in the current day, with more evidence and options now available.

Take home messages:

In summary, it is easiest to consider the options depending on whether the patient's cornea is compromised or not.

  1. One could concentrate on resolving the epithelial defects by applying short-term or long-term solutions to address the trichiasis then proceed to manage the patient as normal.
  2. If the epithelial defects are not first resolved, then ortho-k and preserved atropine options become less favourable, with multifocal or myopia controlling soft contact lens and spectacle options having a higher safety profile.
  3. Ultimately, parents have to be aware of the risks involved with contact lens wear on a compromised eye, be alert for any signs of complications, and be informed of the importance of regular follow up to monitor the child's ocular health.

Meet the Authors:

About Connie Gan

Connie is a clinical optometrist from Kedah, Malaysia, who provides comprehensive vision care for children and runs the myopia management service in her clinical practice.

Read Connie's work in many of the case studies published on Connie also manages our Myopia Profile and My Kids Vision Instagram and My Kids Vision Facebook platforms.

About Kimberley Ngu

Kimberley is a clinical optometrist from Perth, Australia, with experience in patient education programs, having practiced in both Australia and Singapore.

Read Kimberley's work in many of the case studies published on Kimberley also manages our Myopia Profile and My Kids Vision Instagram and My Kids Vision Facebook platforms.

This content is brought to you thanks to unrestricted educational grant from


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