Links to Case Studies:
Case 1: Ortho-K for Kids
By: Dr. Michael J. Lipson
A 7 year-old Asian girl was brought in for an eye exam by her mother stating she was having a hard time reading the board in school.
Unaided VA was 20/100 in each eye and 20/80 together. Binocularity was good and the rest of the exam showed excellent internal and external ocular health.
Refraction showed:
OD -1.75 -.25 x 180 20/20+
OS -1.75 sph 20/20+
I discussed options for correction including: spectacle correction, overnight corneal reshaping (OCR), RGP and soft lenses. We agreed spectacle Rx would be best at that time. Spectacle Rx was prescribed with instructions to wear glasses for school and distance activities and to remove them for reading and computer. In addition, I prescribed a "vision break" after every 20 minutes of reading or computer use. We scheduled a follow-up appointment for 6 months later.
At the 6 month follow-up, her mother reported that she was wearing the glasses only in school and reported tired eyes and headaches after wearing the glasses for thirty minutes. VA with the glasses was 20/50 in each eye and 20/40 together. New refraction was -2.50 sph 20/20 OU. Her mother was concerned about the rate of change and that her daughter was missing out on distance clarity when she was not wearing the glasses. The parents wanted to pursue OCR as they had seen the success their 12 year-old son was enjoying with OCR.
Even though the parents were the initiating force for OCR, his child was very motivated for OCR and did not present fear or anxiety over lens wear. We explained to the parents and the child the importance of care and cleaning of lenses, that OCR lenses have to be worn on a regular basis to maintain good vision and that we could not guarantee myopic progression would be halted. We proceeded with diagnostic fitting with ParagonCRT lenses after taking topography, axial length, manual keratometry and corneal diameter readings. The child reacted exceptionally well to the lenses and both lenses centered perfectly with "textbook" flourescein pattern.
K readings: OD 42.25 x 43.75 D0 , OS 42.25 x 43.75 D0
Refraction: OD -2.50 sph , OS -2.50 sph
Corneal Diameter: 11.9 mm OU
Shape factor: (Atlas) OD .29 , OS .32
Axial Length/Posterior Chamber Depth: OD 24.41/17.35 , OS 24.45/17.49
Lenses Dispensed:
OD Paragon CRT 8.6 525 33
OS Paragon CRT 8.6 525 33
The child was able to insert, remove and clean the lenses herself and was seen at 24 hours, one week and one month. Her next follow-up is scheduled in 2 months.
At the one month visit, she was wearing lenses an average of 10 hours/night every night. Eight hours after removal, unaided VA was OD 20/15- and OS 20/20 with a refraction of OD pl sph and OS -.25 sph. Manual K's were: OD 41.25 x 42.62 and OS 41.25 x 42.62. Pre and post topography is included below.
Discussion
Working with young children and overnight corneal reshaping presents a number of challenges:
- Initial adaptation and anxiety about wearing lenses and the process of insertion and removal. Careful explanation to both parents and child is critical. In addition, reinforcing your message with video demonstration and written materials helps remind them of the information they have been told.
- Young children may have difficulty answering questions regarding comfort, vision and feeling they have with lenses. Children may also have difficulty expressing their feelings in differentiating between awareness and pain. It must be impressed on both parents and the child of the importance of relaying changes in vision or comfort to parents and to the doctor.
- Family relationships – Some parents are very dominating and do not allow the kids to talk to the doctor directly. Others may not be involved enough to know if something is wrong. Children must be encouraged to express their observations about changes in comfort with and without lenses so that problems are dealt with in a very timely manner.
- Patient selection – I like children to be able to handle lenses themselves as they feel like they are more in control of the situation and not just having a process "done to them." Also, I rule out patients and /or parents who show strong tendencies not to be compliant with instructions on lens care or follow-up appointments.
- Safety – Even with the best compliance and care, problems can occur. Spell out your office procedures for emergency visits and what constitutes an emergency.
With that said, children like this seven year old can be very good and compliant patients. They can also be very gratifying for the doctor on an individual basis and for the wonderful referrals they can generate.
OCR Outcomes Study [PDF]
Case 2: Corneal Reshaping Case
By: Dr. Bruce Morgan
CHx: A 10 year old female, presented with complaints of distance blur OU, particularly at school when sitting at the back of the room. The blur is constant and has been worsening over the last 6 months. Her activities besides school were dancing, soccer, gymnastics and she was an avid reader. Her last eye exam had been 6 months previously and her unaided acuity at that time was 20/40 OD and 20/30 OS that was corrected to 20/20 OU with a refraction of -1.00 DS OD and -0.75 DS OS. All ocular health signs were normal both anteriorly and posteriorly OU. No treatment was given at that time. Her entrance acuities at this visit were 20/70 OD and 20/40 OS and refraction yielded -1.00 DS OD and -0.50 DS OS to obtain 20/20. After confirming corneal health, Corneal Reshaping was discussed as an option due to her fairly active lifestyle and the fact that recent evidence in the literature suggests that orthokeratology may slow down the progression of myopia in children. The patient was enthusiastic and the parents liked the idea but were doubtful that their daughter could tolerate a rigid contact lens in her eye because she tended to "over dramatize" every little injury she had ever had. Despite this concern, they agreed to proceed and we then conducted a full screening to determine likelihood of success.
As the screening results revealed that the patient was a good candidate (despite the refractive error being slightly low in the left eye), the fitting process began. Corneal Refractive Therapy (CRT) lenses from Paragon were chosen from a diagnostic set using simulated K's from the topography and the fitting guide provided by the manufacturer.
Baseline Topography:
OD | OS |
 |  |
Fitting/Dispensing:
The parameters of the diagnostic lenses were:
OD: 7.5 BC/ 550 RZD/ 35 LZA
OS: 7.5 BC/ 550 RZD/ 34 LZA
SLE
OD: Centered lens with a classic bull's eye FL pattern, 5 mm central treatment and 0.5 mm of edge clearance. A small bubble was seen in the inferior return zone.
OR: + 0.50-0.50 X 105
OS: Centered lens with 3 mm central treatment and 0.5 mm of edge clearance.
OR: +0.25 -0.50 X 088
Due to small treatment zone, OS was refit with:
OS: 7.5 BC/ 525 RZD/ 34 LZA
SLE
OS: Centered lens with 5 mm central treatment, 0.75 mm edge clearance and excessive movement.
Due to excessive movement and edge clearance, OS was refit with:
OS: 7.5 BC/ 525 RZD/ 35 LZA
SLE
OS: Centered lens with 4 mm central treatment and 0.5 mm of edge clearance, 0.5 mm of movement
Lenses dispensed:
OD: 7.5 BC/ 550 RZD/ 35 LZA
OS: 7.5 BC/ 525 RZD/ 35 LZA
Although anesthetic was used for initial lens insertion, it was allowed to wear off and the patient tolerated the lenses very well.
The patient was instructed on insertion, removal and lens care (Boston Simplus) and scheduled to return to the clinic on the morning after her first night of wear with her lenses on. Her patient care instruction went very smoothly and she showed excellent ability to handle the lenses although insertion was a bit of a challenge.
1-Day Follow Up:
Hx: Patient was doing very well although insertion was a bit of a challenge. She slept well and is not experiencing any discomfort.
VA with lenses:
OD:20/20- OS:20/20
OR: OD:+0.25 -1.00X 090 OS: -0.25 -0.50 X 090
SLE
OD: Centered lens, 4.5 mm central treatment, 0.5 mm edge clearance, 1 mm of movement, mild inferior conjunctiva staining.
OS: Centered lens, 5.5 mm central treatment, 0.25 mm edge clearance, 1 mm of movement, mild inferior conjunctiva staining.
Unaided VA:
OD: 20/20- OS: 20/20-
Topography (Difference Map): Adequate centration and treatment for 1 day OU.
OD | OS |
 |  |
Plan: Continue with same parameters, return to clinic 1 wk in the afternoon without lenses on. Reinstruct on insertion of lenses.
One Week Follow Up:
Hx: Patient is very happy with her vision and is doing much better with insertion and no longer needs help from a parent.
SLE
OD: Mild grade 1 SPK at 3, 6 and 9 0'clock of peripheral cornea.
OS: Clear, no Na FL stain
Unaided VA
OD: 20/20- OS:20/20
M: OD: -0.25 -0.75 X 090 OS: -0.50 -0.50 X 090
Topography: Adequate centration (slightly Temp. OU) and adequate treatment for 1 week.
OD | OS |
 |  |
Topography (Tangential):
OD | OS |
 |  |
Plan: Continue with same parameters, return to clinic 3 wks.
Patient did not return to clinic until 3 months post-fitting
Three month follow Up:
Hx: Patient is very happy with vision and comfort – expresses no complaints.
SLE
OD: Clear, no Na FL stain
OS: Clear, no Na FL stain
Unaided VA:
OD: 20/20 OS: 20/15-2
M: OD: +0.50 -0.50 X 090 OS: +0.50 -0.50 X 090 OS
Topography: Adequate centration (slightly temporal OU) and adequate treatment.
OD | OS |
 |  |
Plan: Continue with same parameters, return to clinic 3 months.
Discussion
Although a fairly straightforward case, this is a good example of what we hope to be dealing with a lot in the future. Fitting low myopic children in Corneal Reshaping for the purpose of myopia control. If research continues to support the myopia control issue, then corneal reshaping becomes a true therapeutic procedure and not a feature of convenience. However, questions still remain, such as "How young can children be safely fit?" and "How much myopia triggers the procedure or do you fit it prophylactically with knowledge of family history?" etc.
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