BRACE Refractive Therapy
BY MICHAEL FELDMAN, OD, FIOS
I've started using the term BRACE when referring to orthokeratology. I created this acronym, which stands for Beneficial Reversible Adjustment of Corneal Eccentricity, with the hope that practitioners will recognize BRACE as new technology.
practitioners will recognize BRACE as new technology. From a patient's standpoint, BRACE also clearly and simply describes what this new procedure is all about. Braces on teeth have long been associated with a safe, efficacious and non-invasive means of changing anatomy. Many orthokeratologists use this analogy when describing how ortho-k accomplishes its goals.
A Wide Open Market Exists
Orthokeratology has been around for over 40 years, and still no more than several hundred eyecare practitioners in the United States take this procedure seriously. Reasons for not getting involved could include practitioner misinformation about efficacy, lack of RGP experience, perception that it's too complicated to learn and lack of interest due to lack of public demand. There just aren't enough of us out there to help spread the word. This field remains wide open and virtually untapped. Fees per case are typically high, and patient retention and satisfaction score even higher. These patients receive a unique service from a specialist who has virtually no competition.
Upgrade Ortho-k's Image
I'm sure most practitioners would agree that there is a world of difference between older and newer refractive surgery techniques. LASIK has proven to be a dramatic advancement over earlier RK and even PRK.
There is also a world of difference between early and modern orthokeratology. I feel it's time to project a new image in the field of modern orthokeratology because of the dramatic technological advancements that have taken place over the last several years. These changes have allowed practitioners to present a viable, non-invasive alternative to candidates who are now considering refractive surgery as their only option for unaided vision improvement. It is our obligation to make patients aware of every option available, including BRACE Refractive Therapy.
There is typically great misunderstanding surrounding ortho-k. In the eyes of many eyecare professionals, this procedure is still associated with fitting a hard lens flat, which can cause corneal distortion and abrasions, to elicit a small, temporary refractive improvement of poor image quality.
Modern orthokeratology is quite different from its earlier counterpart. Over the last 10 years, it has evolved to a higher level of safety, efficacy and predictability due to the development of sophisticated lens designs made of modern high Dk materials. Three, four and even five curve reverse geometry lenses, designed by software programs that utilize topographical information, differentiate BRACE Refractive Therapy from earlier orthokeratology. These "vision retainers" are specifically designed to create rapid visual improvement not in a year or so (which was typical of early orthokeratology), but in most cases weeks, days or even hours.
While refractive error improvement of five diopters or more is possible with these sophisticated designs, the most consistent results are usually achieved with up to three diopters of myopia. Mild to moderate amounts of astigmatism can also be reduced or eliminated. These lenses are mostly "nightwear only" retainers and provide excellent results with virtually little or no complications. Well-designed lenses rarely cause problems, but you should monitor patients on a regular basis. Change the lenses every year, as warping, deposits and polishing will all cause changes to fit tolerances and can affect performance.
Nightwear Isn't Extended Wear
Do not confuse ortho-k's nightwear with extended wear. Patients wear nightwear retainers for an average of eight hours and remove them in the morning, compared to extended wear lenses that are worn continuously for up to seven days. Actually, these high Dk retainers are on the eye for considerably less time than the average 12- to14-hour schedule of a daily-wear patient.
Properly designed BRACE nightwear retainers normally center and perform extremely well. In some cases, they can reduce up to several diopters of myopia overnight. Recent scientific evidence seems to indicate that most of the refractive change is induced by a simple, harmless redistribution of tissue from a 50 micron average layer of corneal epithelium. This tissue redistribution effectively flattens the central cornea, with a corresponding degree of steepening in the mid-periphery. Since the cornea represents the greatest refractive component of the eye, only a small change in curvature is normally required to create the desired visual improvement.
An analogy I use to demonstrate tissue redistribution would be the lines and dimples found on the skin after removing tight shoes and patterned socks. These temporary patterns disappear over time as displaced tissue gradually fills back in. Since BRACE Refractive Therapy involves ongoing reinforcement, the results are gradually sustained for longer periods of time. After a brief period of stabilization, most individuals experience clear, functional, natural vision all waking hours (or even longer).
Children and BRACE Refractive Therapy
I've often been torn between types of lenses to provide for emerging myopic children. An RGP lens would certainly be beneficial for myopia containment, but a child's active lifestyle often conflicts with the benefits provided by this type of lens. BRACE Refractive Therapy is an ideal solution. Kids don't have to worry about RGPs popping out or debris getting trapped under their lenses during athletic activities.
Recent myopia studies have suggested what many practitioners have suspected all along...that RGP lenses help retard axial elongation during the growth years. BRACE Refractive Therapy may hold back myopia throughout these years, even if therapy were discontinued at a later date. Many of my ortho-k colleagues would agree that patients who discontinue long term ortho-k therapy rarely regress to their starting prescription.
B = Beneficial
R = Reversible
A = Adjustment of
C = Corneal
E = Eccentricity
Only time and ongoing research will reveal the true, long-term picture, but for the time being I see no downside. Prescribing glasses or soft contact lenses will do absolutely nothing to retard myopic creep. Soft lenses are often implicated as a factor responsible for promoting myopic progression. Don't just sit back and accept that myopia will just run its normal course. When children or parents ask, "Isn't there something that can be done to stop the eyes from getting worse?"... include BRACE Refractive Therapy along with standard RGP wear. Once my patients experience the results of BRACE Refractive Therapy, they are amazed that other practitioners don't offer this procedure.
The field of myopia prevention is wide open, and getting involved in ortho-k will help differentiate you as a true specialist among your peers. You will provide a beneficial service to patients who usually become extremely loyal and love to brag about their experiences. Plus you will add to your bottom line and retain patients who may otherwise have gone to alternative dispensers.
Dr. Feldman has a private practice on Long Island limited to BRACE refractive therapy and contact lenses. He is a Fellow of the International Orthokeratology Section.