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Orthokeratology Fit by Heather E. Buist, O.D. Cornea and Contact Lens Resident Michigan College of Optometry History A 27 year old male presented to the clinic with a chief complaint of distance blur OU since he lost his spectacles 2 weeks prior. He also expressed interest in ortho-K. His last eye exam was 9 months ago outside our office. He had no medications and no known allergies. His past family and social history was unremarkable, as well as his review of systems. Diagnostic Data The patient's unaided visual acuities at distance were 20/100 OD, 20/50 OS, and 20/50 OU. At near, his acuities were 20/30 OD, 20/15 OS, 20/15 OU. Cover test revealed a mild esophoric posture at distance and near, but confrontations, EOM's, and pupils were all normal. The patient's K-readings were [email protected]/[email protected] OD and [email protected]/[email protected] OS. A subjective refraction of -1.25-0.75x095 OD and -1.00 DS OS resulted in 20/15 OU. Non-contact tonometry gave IOP's of 13mmHg OU. All anterior segment biomicroscopy findings were normal. A dilated fundus exam revealed normal findings including small C/D ratios, bright foveal reflexes, as well as some cobblestones and RPE hyperplasia OS. Since the patient was interested in ortho-k, I performed two other tests. I measured his pupils in scotopic lighting, and found them to be 7.0mm OU. Corneal topography was done and revealed no corneal irregularities, although the sim-k axis was oblique in each eye. Assessment and Treatment Plan The exam assessment included myopia OU, astigmatism OS, and cobblestones OS. The ortho-k screening resulted in the patient being a marginal candidate for the procedure based on his large pupils and possible oblique corneal cylinder. The patient was given an updated spectacle prescription, and he was educated that the cobblestones were a benign finding and that he has healthy eyes. He was also told that he was a marginal candidate for ortho-k because he may have trouble with glare or halos. The patient was told he should be followed yearly, and to return prn for an ortho-k fitting if he chooses to do so. The Ortho-K Fitting The patient returned one week later requesting an ortho-k fitting. I chose to start with Paragon CRT overnight ortho-k lenses. Using the fitting slide rule, I determined the starting lenses with the patient's flat k's and sphere power from his spectacle Rx. This resulted in starting with 79-525-34 OD and 78-525-34 OS. These were placed on the patient's eyes and evaluated with fluorescein. In the right eye, there was about a 3mm treatment zone with peripheral bearing and good edge lift (bull's eye pattern). Movement was adequate with

digital push-up. The lens had a tendency to ride up a bit when the eyes were closed. Those same findings were found in the left eye as well, but there was inadequate edge lift. To flatten the edge lift, I changed the left lens to 78-525-33, and the edge lift was better. The patient's VA's through the lenses were 20/20 OU, and a -0.50 spherical over-refraction OU gave the patient a subjectively better 20/20. I deemed these lenses to have an acceptable fit OU. The patient was given application, removal, and CL hygiene training, along with a sample of Unique PH solution. He was told to wear the lenses for at least 8 hours the night before his follow-up visit and to return with the lenses still on his eyes. Follow-Up: First Overnight Wear The patient returned a few days later after wearing the lenses for the first time the night before for 7.5 hours. VA's with the lenses still on were 20/20-1 OD and 20/15-2 OS. An over-refraction of -0.50 OD and -0.75 OS gave the same VA's respectively, but subjectively better. Fluorescein analysis of the lenses showed faint central touch, 360 degree bearing, tear debris under the lenses, and they seemed to ride superiorly. There was good movement on digital push-up. The left eye also had some small bubbles and several vertical corneal track marks. There was no punctate staining, although mild central edema was noted. When the lenses were removed, the patient had uncorrected VA's of 20/20-2 OD and 20/15-1 OS. Again, the patient liked the minus and over-refracted with -1.00 (20/15) OD and -0.50 (20/15) OS. Sphereo-cylindrical OR was -0.75-0.50x085 (20/15) OD and -0.50-0.25x103 (20/15) OS. Corneal topography was performed. The treatment zone appeared to be well centered with no apparent "smiley-face" presentation. The patient got about 1.00 diopter of correction OD and about 1.25 OS. Even though the lens rode higher than expected, and there was not much apical touch, the topography and uncorrected VA's showed the procedure was going well. The patient was instructed to continue wear of the lenses at night, and to return in one week. Unfortunately, the patient has since cancelled twice. The latest cancellation was because he was unable to get the lenses in his eyes the previous night. (The patient has deep set eyes and a prominent brow.) He was instructed, by phone, to return for further application and removal training. Discussion This was my first ortho-k fit, and I learned quite a bit from it! The main pearl I walked away with was that the fit need not, and will not, always be textbook. Since this patient was a low myope, the smaller fluorescein pattern treatment area was sufficient. And even though the lens appeared to ride high, topography still showed a centered treatment zone. It was exciting to see the patient return and see 20/20 uncorrected--I can't wait to do it again!

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