Orthokeratology lens wear in lagophthalmos

It is not unusual to see someone blink or sleep with incomplete eyelid closure, called lagophthalmos.¹ This condition often causes staining across the inferior cornea due to corneal exposure and excessive evaporation of the tear film.¹ Here is a case by RS seeking a solution for a child with nocturnal lagophthalmos to help fully close her eyelid whilst sleeping with orthokeratology (OrthoK) lenses.

The corneal condition is important to assess regarding whether a patient is suitable for OrthoK lens wear. If corneal staining is already present before wearing contact lenses, can the staining worsen after OrthoK lens wear? It is common to see mild corneal staining (not more than Grade 2 by Efron grading) after overnight OrthoK lens wear due to lens binding, reduced tear stability or lens decentration.² This occurs most commonly in the central cornea, typically reaching a maximum in the first few weeks of lens wear and reducing thereafter.³

A review of children undergoing OrthoK in a university clinic showed that corneal staining was the most commonly observed complication, and more than 80 per cent of patients were advised to apply ocular lubricants to loosen the lens before lens removal. Corneal staining frequency reduced from 41% after the first night to 25% after 6 months, and most staining (84%) observed was graded as mild (Grade 1 or less).

Over six months of observation, 13% of observed staining was graded as Grade 2 and only 3% were graded as Grade 3 or Grade 4. Patients who had Grade 2 or higher level of staining in the central cornea were advised to cease lens wear until the condition subsided.⁴

Considering that mild staining in OrthoK is frequent and not serious, is this patient a suitable candidate for OrthoK? This depends primarily on assessing the severity of the corneal staining, as mentioned by the commenters above. The managing eye care professional cites the staining as being “inferior mild” – which sounds to likely fit the description of Grade 1 or less, positioned on the inferior cornea, indicating the link to lagophthalmos as the probable cause. If the corneal staining is worse than Grade 2, it may be better to consider a non-contact lens form of myopia control to avoid the elevated risk of corneal infection.^2,4

KG and PC reported anecdotally that mild inferior staining can be improved with OrthoK lenses with ocular lubricants acting as a bandage. Carracedo et al and Liu et al found that hyaluronic acid artificial tears provide comfort during OrthoK lens wear and also reduce the incidence of corneal staining.^5,6

Optimum lens cleaning is also recommended, to minimize the potential for corneal staining or other complications. Regular protein removal, such as with Menicon Progent, is an ideal inclusion to the lens care routine to achieve this.

Other strategies to manage lagophthalmos include taping the eyelids at night with hypoallergenic tape¹ or wearing an eye mask at night. In such cases, it would involve making sure it does not affect the patient's sleep. There is no available data on the success or otherwise on OrthoK wear in patients with lagophthalmos.

In addition to the chosen strategy, it is crucially important to follow up the patient closely given the initial mild corneal compromise. The International Myopia Institute Clinical Management Guidelines indicate that in orthokeratology fitting, the patient should be reviewed after 1 day, 4-7 days, 1 month, 3 months and then every 6 months. Additional examinations may be justified if there is any ocular health concern.

1. Lagophthalmos can lead to corneal staining. This does not preclude a patient from contact lens wear, but it is important to make sure the corneal staining is Grade 1 or below before fitting contact lenses.
2. Artificial tears in combination with OrthoK lens wear can improve corneal staining compared to pre-lens wear.
3. Closely observe any corneal staining during OrthoK lens wear and ensure good patient lens hygiene compliance to prevent worsening of corneal staining and reduce risk of infection.