Good clinical practice in orthokeratology

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Abstract

Overnight orthokeratology is becoming more and more popular especially in the Asia-Pacific region where the treatment is primarily used for myopic control in young children. Risk of complications in contact lens wear increases during overnight wear and may further increase when the treatment is used on children. The aim of this paper is to provide a comprehensive guideline for practitioners to improve their orthokeratology practice and minimize unnecessary or preventable complications.

The fundamental requirement for starting an orthokeratology practice is to have proper education in the area and to equip the practice appropriately. Overnight trial fitting is recommended to confirm the physiological response prior to commencement of the treatment. Practitioners should provide adequate information, both oral and written, to patients before and after the commencement of treatment to avoid any legal dilemmas and to improve patients’ compliance. Costs for the treatment should be transparent and provision of an emergency contact number is a must. Patients should be regularly recalled for aftercare visits and all communication with patients should be properly documented. In this paper, patient selection and the clinical procedures were discussed and a standard of practice in orthokeratology proposed.

We believe that the key to providing a safe orthokeratology practice is to continually update knowledge in the field, and to practice to the highest professional standards.

Introduction

Optometry is a primary care health profession, yet it has the unique dichotomy of providing a professional service as well as supplying the required optical aids at a profit. It would therefore be prudent to open this discussion with reference to the “rights” of “patients” compared to those of “customers”. In terms of the optometrist's professional relationship with the patient, this is governed to a large degree by whether the relationship is contractual or not. With respect to orthokeratology (ortho-k), legal responsibility is usually established under tort law, whereby the practitioner's duty of care, legal obligation, or standard of care is not necessarily dictated by a formal, written agreement between both parties, but is reflected by the common law system. Any sub-standard practice may result in a civil claim for compensation arising from professional negligence. However, some practitioners may prefer to establish a contractual relationship with their patients, in terms of services and goods provided, and this in turn would be governed by contract law [1]. In this case, the patient would appear more like a customer. Nevertheless, whatever the relationship, the legal responsibilities of the optometrist are set in law and cannot be ignored, as the law protects the patient/customer in both cases.

Overnight wear ortho-k is becoming increasingly popular for myopic reduction in many parts of the world [2]. Recent studies have shown the treatment to be effective for slowing the progress of myopia [3], [4] and this is likely to increase the use of ortho-k. Modern ortho-k involves the use of RGP lenses worn on an overnight wear basis. The advantages of this modality are less lens awareness, easier adaptation, lower risk of lens loss and a faster reduction in refractive error compared to daytime wear [5]. Also, the patient benefits from the freedom of having to wear optical correction during the day which may interfere with sports and recreational activities.

The major drawback of overnight wear ortho-k is the potentially higher risk of corneal ulceration [6], [7], [8], [9], [10]. In many Asian countries, where myopia has a high prevalence, ortho-k is mainly prescribed for slowing myopic progression in children, and in most cases, overnight therapy is used. The Internet is replete with unsubstantiated claims regarding the efficacy of the procedure and this, unfortunately, is the most common source of information for patients and parents interested in the treatment for their children. This can lead to unrealistic expectations and inappropriate or misleading information which can lead to unhappy patients and/or serious complications. A patient may claim compensation if the practitioner makes unsubstantiated statements which result in harm, as this may constitute negligence, or if the practitioner is unable to provide reasonable care and skill in diagnosis, advice and treatment resulting in injury to the patient [1].

Guidelines have been established for silicone hydrogel contact lenses for continuous wear [11]. In view of the increasing popularity of overnight ortho-k, where children may be involved, there is a need to develop guidelines for this specialized treatment for the ortho-k practitioners [1]. Therefore, this paper aims to provide guidance for practitioners on the standards required for competent clinical practice in ortho-k. The authors also see the paper as a means of initiating discussion between practitioners so that a universally acceptable code of practice can be adopted internationally.

Section snippets

Clinical setup

In the early days of revived interest in ortho-k in the late 20th century, there was little or no structured education available. Practitioners had to educate themselves via trial and error, or apprenticeship with a colleague experienced in the procedure. However, ortho-k practice has since evolved rapidly with improvements in the technique, including higher Dk lens materials, advanced lens designs and corneal topography for monitoring corneal shape changes. There has also been a concomitant

Clinical pearls in ortho-k practice

Some simple clinical pearls that can act as a guide to ‘best practice’ in ortho-k are listed below.

Conclusion

Overnight ortho-k is gaining popularity and the interested practitioners need to be well prepared. Practitioners need to equip themselves well to practice ortho-k and diligent and vigilant care is essential. There is still a lot we do not understand about ortho-k, and rightly a lot of research is still going on to seek further understanding and to increase the safety of ortho-k practice. It is therefore important that practitioners keep abreast of latest developments in ortho-k and continue to

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