GP lens eye Rounds

MYOPIA MANAGEMENT: Adult Ortho-K Case

Allison Jussel Zagst OD, MS, FAAO

History

• HPI: 53-year-old Asian male with a history of orthokeratology (Ortho-K) wear who discontinued wear due to near blur several years ago. Most recently he was fit into soft sphere contact lenses OU, and then self-discontinued lens wear OD to allow improved near visual acuity.
• CC: Blur at distance without contact lenses; blur at near when wearing two distance contact lenses. The patient has worn many multifocal contact lenses without success over the course of several years. He also noted itching from ocular allergies which creates soft contact lens intolerance.
• Modifying factors: Prefers no correction OD. Uses Lastacaft drops QAM

Examination

• Entering visual acuities (VAs):
  • (cc) OD: 20/20
  • OS: 20/20
• Refraction:
  • OD: -2.75 -0.25 x 170, 20/20
  • OS: -2.25 -0.50 x 002, 20/20
  • Eye Dominance: OS
• Slit Lamp Examination:

• Corneal Topography (Figure 1):

Decision-Making Process

Patient elected to return to ortho-K wear OS only due to success with ortho-K wear in the past and current success with monovision modality. Patient preferred ortho-K as a result of the improved comfort with ocular allergies and dry eye syndrome symptoms as compared with soft contact lenses. He briefly considered refractive surgery but was concerned about the permanent nature of surgery. The patient was educated about the potential for increased glare and halos during night time driving.

Fitting and Evaluation

• The ortho-K lens was designed empirically from the topography map, horizontal visible iris diameter (HVID) and refraction, with a Jessen Factor of +0.75D.
• First dispense: Lens was centered, with good movement and coverage of the pupil axis. ORx: +0.75DS, VA: 20/20 OS
• One week follow-up visit: Treatment zone was mildly inferior-temporally decentered on topography maps as the lens was mildly inferiorly decentered on eye, ORx: +0.75DS, VA: 20/20 OS. The plan was to increase the lens diameter by one step to improve centration.
• Second dispense: Lens was centered, with good movement and coverage of the pupil axis. ORx: +0.75DS, VA 20/20 OS
• One week follow-up visit: Treatment zone was better centered with only mild inferior-temporal centration (Figure 2), lens appeared well centered on eye, ORx: +0.75DS, VA 20/20 OS. DVA OU 20/20, NVA OU 20/20. Slit lamp examination: Cornea was clear and intact, no staining with fluorescein.
• One month follow-up visit: All lens findings were the same as noted at the one week follow-up visit. The patient was happy with the quality of vision and comfort of eyes during the day. The patient did note mild glare and halos while driving at night, but does not feel that visual acuity was impacted negatively. Plan: Lens was finalized.

Figure 2: Tangential Power Map OS (left), Comparison Map OS (right)

Clinical Pearls

• Ortho-K is a viable option for adults with dry eye or ocular allergies that cause discomfort with soft contact lenses
• Glare and halos may impact night driving in adults who wear ortho-K lenses and they should be counseled appropriately before fitting
• Proper centration of ortho-K helps to improve visual quality and reduce unwanted side effects