Myopia Profile

Clinical

Orthokeratology: Is it a compliance issue or lens fitting problem?

 Posted on September 6th 2022 by Connie Gan

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In this article:

In this case of a poor outcome in orthokeratology wear which appears to indicate non-compliance, a systematic approach highlighted the cause.

Orthokeratology lenses are an effective treatment to slow myopia progression. When they are treating effectively, ortho-k provides clear vision without correction during waking hours, enabling numerous vision and lifestyle benefits for patients.1 Other times, the outcomes can be puzzling. Here is one such case where a patient reports blurry vision despite reportedly consistent use of her ortho-k lenses.

PC Compliance with treatment is usually better with CLs than atropine due to positive feedback of clear vision so this is an interesting one. This teenage patient today come in for a second opinion of her Ortho K lenses, complaining of blurred vision for more than 6 months. She had prior comfort issues with OK. She claims to be wearing her lenses nightly, including last night. Over the past 3 years she had progressed R from -0.75 to -2.75 and L from -1.50 to -3.75 (glasses from time of original OK fitting vs subjective refraction today). Current AXL R 25.45 L 25.80mm. Corneas are quite flat. From these topography maps, it doesn’t look like she’s been wearing OrthoK at all?! Surely even poor-fitting OK would create some corneal impression. But she appeared to be genuine. If she’s been going around basically uncorrected that might also explain her progression. Anyhow I decided to review her in a week without OK (“washout” even though there’s probably nothing to wash out of) then decide on her management. Given her flat corneas and questionable wear compliance I’m thinking if a better option is switching her to MFSCL.71761684_10157793101725159_1250645329284431872_n.jpeg

Corneal topography 

Is this a case of non-compliance or improper lens fit? Each of these have a few supporting reasons that suggest it might be one or the other.

The case of non-compliance:

  • Insignificant degree of corneal change
  • Blurred day-time vision
  • Discomfort with OK lens wear
  • -0.75D Myopia progression per year

The case for improper lens fit:

  • Insignificant degree of corneal change
  • Blurred vision
  • Flat corneas
  • -0.75D Myopia progression per year

Both of the above are likely scenarios and it is tricky to distinguish whether what you have is an untruthful patient or a lens that needs refitting. In order to figure this out, PC advised a washout for one week - ceasing any ortho-k wear - and then took another set of corneal topography images to compare the difference.

Here is the update

PC A month ago I posted a curious case where I had a suspicion about Ortho K wear compliance, as the patient presented with no evidence of corneal shaping on topography even after apparently wearing them nightly for 6 months. Here’s an update. After a full week without OK, her topography was remeasured, showing small but insignificant differences. She was asked to insert her existing lenses and wear them for 30 mins in-room, which she did without any fuss. After this short trial there were definite topographic changes (about -1.00 change in a small area). She came across as telling the truth about her regular OK wear. Anyhow, after a discussion about refitting her OrthoK or switching to MFSCL we decided to proceed with a refit using a customised design on the new maps and new refraction. With her flat corneas I aimed for a smaller treatment zone and more asphericity. VA now 6/6 R&L after 1 week on new lenses, correction on target at 4pm and she’s very happy to be seeing better! So it appears she wasn’t non-complaint after all! Just needed a better set of OrthoK lenses.72478163_10157793102130159_3190106582809575424_n.jpeg
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After the problem-solving process of the follow up appointment, the poor treatment issues were resolved by refitting the ortho-k lenses, as shown by the corneal topography maps above.

What if this was a case of non-compliance?

Patients are rarely non-compliant without reason: in fact, non-compliance mostly stems from incomplete or improper performance of lens handling and care protocols.2 When dealing with non-compliance, going back to the fundamentals of wearing time and handling protocols can help to address the root issues.

Incomplete performance of protocols can be the result of inadequate patient education, or simply inattention and forgetfulness.2 For this reason, it is helpful to remind patients and their parents of these essential processes at every follow-up appointment, and to reinforce their importance.

Non-compliance can also be influenced by perceived suitability of the treatment for the patient. In this case, alternative treatments were discussed (multifocal soft contact lenses: MFSCL), but on consideration of what best suited that patient, the decision was made to continue with ortho-k. This highlights the importance of collaborative treatment decision making with patients and their parents or carers.

A recent study on long-term outcomes in children wearing ortho-k revealed that 88% were satisfied with their outcomes. Adherence to regular follow-up appointments decreased from 97% in primary school users to 77% in senior high school wearers. Clear daytime vision was significantly associated with adherence with regular follow-up, indicating the importance of regular clinical care in ensuring the best possible outcomes. While over one-third reported regular symptoms of tearing, excessive blinking and itching with ortho-k wear, these were graded as mild and 98% were willing to continue wearing their ortho-k lenses.3

Take home messages

  1. Troubleshooting poor outcomes in myopia treatments can be complex. It is important to consider non-compliance as an issue in these cases; taking a collaborative and systematic approach to determine the cause.
  2. Most cases of non-compliance are not necessarily intentional, but resulting in incomplete performance of processes. Effective communication with the patient and their parents is key in identifying potential reasons for non-compliance.
  3. Ensuring that a treatment is still suitable and manageable for the patient and their family is important, and can help to turn a poor outcome and unsuccessful patient into an enthusiastic and successful one.

Further reading

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 MyopiaProfile.com. 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 MyopiaProfile.com. 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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