When a patient doesn’t respond to Orthokeratology

What do you do when a patient doesn't respond to your orthokeratology (orthoK) treatment? Have you ever experienced the confusing moment when a patient tells you he’s wearing his orthoK lenses yet his vision is barely improved from unaided levels? KG shared a case describing such a situation with the Myopia Profile community. Here is the case:

Top Left: Baseline L topo
Top Right: After one week OK, all going well (note this is a single tangential map, not a difference map
Bottom left: Today's map. Swears black and blue that he's wearing his lens and his mum does too. hmmmm. Looks terribly like the baseline map!
bottom right: After 40 min closed eye time in the waiting room, for me to prove that the lens will have some effect on the cornea; if it's actually worn.

The topography maps at the review appointment after supposedly two months of orthoK wear look so similar to those from pre-orthoK treatment. This suggests that either the orthoK lenses are not creating sufficient correction (though this is unlikely as the 1-week review suggests the lenses are effective) or the lens is not on his cornea during his sleeping hours. Here is what the commenters suggest:

• The child is not wearing the lens to bed, possibly due to poor compliance or difficulties with lens comfort
• Lens dislocates to the sclera during sleep
• Warpage lens/dirty lens

Most commenters agreed that it is likely that this patient has simply not been wearing the lens to sleep, considering that the lens is only two months old and both the one week and 40 minutes of waiting room wearing time indicated topographical change.

Given the history of poor compliance with glasses due to good RE unaided acuity, we may have a child who has very skilfully won his mother over with his fibbery. His likely lack of willingness to wear the L orthoK lens at night could be exacerbated by initial comfort issues or struggles with lens handling, as he's still a relatively new wearer

This presents a challenge as we need to manage both the patient and his mother. It can be tricky insinuating to a mother that her child has not told the truth about lens wear, especially when such behaviour is not perceived to be typical of the child.

• Asking mum to directly supervise her son during lens application and removal. Sometimes a little micromanagement is necessary.
• Scheduling a review whereby the patient does not remove the lens upon waking so that the practitioner can get a good idea of lens position in the morning.

Cases such as these test our communication and investigative skills in getting to the bottom of why patients may not be compliant in the way we expect them to. Every child behaves differently so there is no universal solution. We need to understand why the child does not want to wear orthoK, explain the purpose of the lens and consequences of non-compliance, and ultimately determine if this is still the best form of management to match the capabilities of the child and family. Discussing the alternative options - including their advantages and disadvantages in comparison to the current option - will help in decision making.

Sharing the decision making process with the pre-teen patient can improve compliance. The evidence suggests that participatory relationship between practitioner and patient can promote compliance.¹ Clinically, we may find ourselves discussing a child’s visual status over their heads, directly with the parent. Ensuring the child joins the discussion and helping them understand their vision and eye health can inspire more initiative on their part. Even then, it could be very difficult for the child to grasp the 'why' of myopia correction and management as well as their parent does. To help form habits, as every parent knows, providing reward and recognition for when children follows instructions is useful¹ - bribery has its benefits!

1. Sometimes, it is useful to be healthily suspicious of what patients (and even their parents!) report regarding their vision correction and myopia treatment. Clinical outcomes need to align with what patients say, and when they don’t, check compliance.
2. Effective communication is the best way to manage non-compliance. Tips include sharing the decision-making process with young patients. In this case the demonstration of the orthokeratology lens having an effect on topography after only 40 minutes of closed-eye waiting room wear helped to confirm the non-compliance for both practitioner and parent. Collaborative communication afterwards was aimed to confirm the ongoing commitment to orthokeratology wear or determine if another treatment was a better choice to match the capabilities and willingness of both child and family.

• Why isn't the myopia control strategy working?

• Non-responders to myopia control treatments

• Case study: What to do when a patient doesn't respond to atropine