ORTHOKERATOLOGY (OK) can slow the rate of myopia progression while allowing children to see clearly during the day.1 This can be exciting for both children and parents.
Practitioners are very familiar with the value that OK provides to a patient, but parents may be learning about it for the first time in the exam room. Their response may range from excitement to apprehension based on previous knowledge. As practitioners, we play a critical role in enabling patients and their families to understand OK and its role in myopia management. This clinical guide outlines how to counsel and educate parents and children through the OK process to enable long-term success.
How to Communicate Goals
Why manage myopia? When recommending OK, begin by explaining why myopia control or management is beneficial to the patient. Explain to parents that myopia is a progressive condition that can worsen over time. Educate parents that, after careful consideration, we are choosing a device to slow the progression of their child’s myopia to keep the lens prescription as low as possible. Discuss the long-term effects of myopia in relation to the development of ocular diseases like cataracts, glaucoma, and retinal detachment.2 By reducing the progression of myopia, we likely reduce the risk of future eye disease in adults.2
Explaining OK: Once parents understand the importance of myopia management, the recommendation of OK can be introduced as follows:
“Orthokeratology is a therapy that uses an overnight contact lens to gently reshape the surface of the eye, so your child can have clear vision during the day.3 It also reduces the progression of myopia over time. The treatment is reversible, so it does not permanently change the eye.” A familiar comparison is how braces or a retainer changes the position of the teeth.
Referring to OK as a therapy sets the expectation that OK is a medical treatment that involves follow-up visits, careful monitoring, and the patient’s compliance. The use of visuals to describe the process can be very useful (Figure 1). You may choose to counsel the parents on the fitting process and what the visits entail. The schedule should be structured to maximize safety and success for the patient.
Discussing the Efficacy
Practitioners should feel confident when discussing the efficacy of OK to families. In the most recent International Myopia Institute (IMI) white paper, 10 OK randomized clinical trials were summarized.1 The data showed that the median 1-year axial length progression reduction of OK was 0.17 mm (0.13 mm to 0.2 mm) and the 2-year median was 0.30 mm (0.26 mm to 0.33 mm).1 The authors concluded that OK remains one of the most effective forms of myopia control.1 Convey this information in a simplistic form to parents so they can feel secure in the choice of treatment.
Explaining Candidacy
Efficacy is extremely important, but it no longer is the sole driver of determining the ideal candidates for OK. Explain to parents that the efficacy of many myopia management devices is strong. It is important to choose the modality of myopia control based on the lifestyle of the child. For example, OK offers great benefits to athletes who may not want to wear soft lenses during sporting activities. OK is also beneficial for children who don’t want to wear glasses or contact lenses during waking hours.
Traditionally, the best OK candidates have been those who had –0.75 D to –5.00 D of myopia and up to –1.50 D of corneal cylinder.4 In recent years, computer-aided lens fitting approaches have become increasingly popular, demonstrating clinical efficacy similar to that of trial-lens fitting while improving fitting efficiency.5
Some have suggested that high myopes experience better control with OK than low myopes, and authors hypothesize that greater corneal reshaping may induce stronger peripheral myopic defocus.6,7 Keep in mind, when fitting high myopes, that there is an increased risk of complications due to lens binding and decentration.8,9
Beyond refractive error, your discussion with parents and patients should include certain behavioral factors, including:
• Hygiene practices,
• Ability to follow instructions,
• Good sleep habits,
• Parental involvement and communication, and
• Maturity of the child: many clinicians use age 6 as a minimum age for commencing treatment.
If one of these criteria is not met, then OK may not be the ideal myopia management method for the patient at this time, and other options should be explored.
Explaining the Science to Families
Practitioners must understand the optics of OK designs, mechanisms of myopia control, and effects of OK on the cornea and ocular surface; however, patients and parents only require a simplified explanation.
Be clear and concise in your recommendation. Data suggest that peripheral myopic defocus, higher-order aberrations, pupil dynamics, and eccentricity of the cornea may have an impact on myopia control.10-12 Simplify these factors by stating, “The lenses provide clear central vision while creating a signal to the back of the eye to slow the progression of myopia.” Too many details may cause parents to become overwhelmed with information.
Support your recommendation with printed and online material combining visuals, studies, manufacturer material, or other resources to further educate the families.
Assigning Responsibilities
Waking up to clear vision is exciting for children; however, children need to be empowered with the responsibility to properly care for and use the OK lenses:
Wear time: Children should be instructed to wear the lenses at least 6 to 8 hours (ideally 8 hours) per night.13 Families should be re-educated if sleep time decreases consistently.
Good hygiene: Depending on the age of the child, the parents or the child may be applying and removing the lenses. The following should be demonstrated and understood before the child leaves with the lenses.
• Wash hands before handling the lenses.
• Clean lenses every morning with the prescribed cleaner.
• Change lens solution daily and never top up the case.
• Never use tap water to clean or rinse lenses.
• The case should air dry at night.
• Replace the case with each new container of solution.
• Discard cases with each new bottle of solution.
• If the instructions seem complicated to the child, provide nighttime and daytime checklists that they can put in their bathroom.
Ability to apply and remove the lenses: Children should be able to apply and remove the lenses at least 2 times in each eye prior to leaving the clinic. Many children become independent within the first month.
Complication awareness: Educate children and parents on the signs of potential complications, including redness, pain, irritation, blurred vision, and discharge (Figure 2). Patients and parents should be told to call immediately if experiencing any of these symptoms. Practitioners should train the staff to triage these complaints appropriately. Children should stop lens wear if any of these symptoms arise and see their optometrist as soon as possible.
Lifestyle recommendations: Clinically, if children are prescribed myopia management devices and don’t adjust their behavior, the intended myopia targets may not be met. The following lifestyle adjustments should be discussed to optimize treatment:
• Encourage at least 2 hours of outdoor time per day. Practical ways to achieve this is through outdoor play, walking to school, outdoor sports, and family activities.14
• Discuss the impact that near work has on myopia progression. Counsel parents about taking breaks from near work and trying to maintain a working distance of 40 cm.14
• Adequate lighting during near work is recommended, as poor illumination may increase visual strain and contribute to myopia risk.15
What Children Experience
Explain to parents and children that the child’s vision when using OK will improve over the first few days, but full stability may take up to a month. During the first week, children should wear either their old glasses or soft daily disposable lenses during the day to correct the residual refractive error. Soft lenses can be labeled based on an estimation of refractive error for the following days. When the child wakes up with clear vision, they no longer need the soft lenses. For older children, reinforce that the lenses need to be worn at least 6 hours per night. Older children and teens tend to sleep less due to later bedtimes and more daytime demands.
Inform children and parents that the OK lenses will be uncomfortable for the first few days, but children tend to adapt very quickly. Demonstrate in office how it feels to sleep with a lens by placing the OK lens on the eye and asking the patient to close their eyes. Most patients state that they are aware of the lens, but it is not painful. Reassure them that the awareness will improve after a few days (Figure 3).
What Success Means
Families measure OK success based on visual acuity. Clinically, the reduction of axial length and refractive error progression is an important goal. Parents likely will better appreciate the myopia progression component if the process of monitoring is explained thoroughly. To help families understand, practitioners should:
• Take axial length measurements and share the graphs with parents and patients.
• Show baseline and treatment topographies, as necessary (Figure 4).
• Show baseline and expected trajectories if possible. With OK, this is monitored with axial length measurements because refractive error changes cannot be measured.
• Explain why growth changes occur due to either emmetropization or the progression of myopia.
What if myopia progression targets are not met?: If progression targets are not met, explain to parents that atropine can be added. In studies, OK lenses in combination with 0.01% atropine produced a synergistic effect in myopia control.16 Recent data suggest that when the desired effects of this combination therapy are not achieved, sequential increase of the atropine concentration from 0.01% to 0.025% to 0.05% may provide improved efficacy.17 Many practitioners will commence combination therapy with 0.05% atropine.
Alternatively, if targets are not met, practitioners may choose to pivot to another myopia management strategy, such as glasses or soft contact lenses. There is no current data to support the value of switching from one modality to another, but clinically, many practitioners have observed success in slowing myopia by doing this. Reassure parents that myopia management is not a “one-size-fits-all” treatment, and sometimes we need to deviate from our original choice of treatment.
Address Safety Concerns
Parents often have initial concerns about their children sleeping in contact lenses. OK has been shown to be a safe myopia management modality, with studies demonstrating a low incidence of serious complications comparable to other overnight contact lens modalities.18,19 Safety was questioned more than 2 decades ago when several cases of microbial keratitis (MK), primarily in East Asia, emerged in OK wearers.20,21
Since that time, multiple studies have demonstrated strong safety profiles for OK. The MK incidence associated with OK was previously reported as 7.71 cases per 10,000 patient-years.18 A more recent pediatric study reported approximately 5 cases of MK per 10,000 patient-years.19 To put this into context, daily-wear soft lenses show approximately 2 to 5 cases of MK per 10,000 patient-years.22
Although MK is often the most important concern with contact lens wear, patients should also be made aware of symptoms of corneal abrasions, decentered lenses, dirty lenses, allergies, and other general irritations. Patients should be seen immediately if any of these symptoms arise. However, reassure parents that when lenses are fit properly, monitored regularly, and cared for with prescribed lens care regiments, OK is a safe modality of myopia management.19-21
Long-Term Management
OK requires a long-term commitment. For myopia management, it is ideal to keep children in OK through their teen years; however, approximately 25% of myopes may progress beyond the age of 18.23 In these situations, it would be prudent to continue OK for longer periods of time. Clinically, 2 consecutive years of no change in myopia (axial length and refractive error) can act as a guideline for discontinuation of myopia control. However, children may also choose to continue OK wear well into their adult years.
Tell parents that if OK is suddenly stopped without guidance from the eyecare practitioner, myopia can rebound.24 Patients hoping to discontinue OK should be education on other myopia control methods, including glasses, soft lenses, and atropine that can be used. The axial length and refractive error should be monitored for progression until stability is achieved.
Many clinicians recommend replacement of lenses every 1 to 2 years depending on the myopic change and the condition of the lenses.
Final Thoughts
Orthokeratology remains a valuable tool to correct vision while reducing the progression of myopia. When properly fit and managed, OK is a safe and effective therapy. Long-term success relies on regularly scheduled appointments, patient awareness and compliance, and open communication between the family and the office. This partnership between the practitioner and the family is necessary to empower the patient throughout their myopia management journey.
References
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5 Sun Y, Peng Z, Zhao B, et al. Comparison of trial lens and computer-aided fitting in orthokeratology: A multi-center, randomized, examiner-masked, controlled study. Cont Lens Anterior Eye. 2024;47(5):102172. doi: 10.1016/j.clae.2024.102172
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8. Gispets J, Yébana P, Lupón N, et al. Efficacy, predictability and safety of long-term orthokeratology: an 18-year follow-up study. Cont Lens Anterior Eye. 2022 Feb;45(1):101530. doi: 10.1016/j.clae.2021.101530
9. Hu P, Zhao Y, Chen D, Ni H. The safety of orthokeratology in myopic children and analysis of related factors. Cont Lens Anterior Eye. 2021 Feb;44(1):89-93. doi: 10.1016/j.clae.2020.08.011
10. Lau JK, Vincent SJ, Cheung SW, Cho P. Higher-order aberrations and axial elongation in myopic children treated with orthokeratology. Invest Ophthalmol Vis Sci. 2020;61(2):22. doi: 10.1167/iovs.61.2.22
11. Guo Y, Zhang M, Tong Y, et al. Impact of pupil and defocus ring intersection area on retinal defocus. Ophthalmic Physiol Opt. 2024;44(2):472-480. doi: 10.1111/opo.13276
12. Chen M, Zhang R, Zhu C, Peng L, Zhao S, Mao X. Analysis of corneal surface shape following overnight orthokeratology with different optical zone diameters. Front Med (Lausanne). 2024;11:1421361. doi: 10.3389/fmed.2024.1421361
13. Hu X, Wang Z, Sun B, et al. Orthokeratology for myopia control: a three-year longitudinal study on axial length modulation influenced by baseline age and spherical equivalent. BMC Ophthalmol. 2025;25(1):466. doi: 10.1186/s12886-025-04303-5
14. Morgan IG, Wu PC, Ostrin LA, et al. IMI risk factors for myopia. Invest Ophthalmol Vis Sci. 2021;62(5):3. doi:10.1167/iovs.62.5.3
15. Lanca C, Saw SM. The association between digital screen time and myopia: A systematic review. Ophthalmic Physiol Opt. 2020;40(2):216-229. doi:10.1111/opo.12657
16. Xu S, Li Z, Zhao W, et al. Effect of atropine, orthokeratology and combined treatments for myopia control: a 2-year stratified randomised clinical trial. Br J Ophthalmol. 2023;107(12):1812-1817. doi: 10.1136/bjo-2022-321272
17. Guo Z, Wei Z, Ming H, et al. Efficacy and safety of orthokeratology sequentially combined with escalating atropine concentrations for myopia control in children. Sci Rep. 2025 Nov 6;15(1):38911. doi: 10.1038/s41598-025-22722-8
18. Bullimore MA, Sinnott LT, Jones-Jordan LA. The risk of microbial keratitis with overnight corneal reshaping lenses. Optom Vis Sci. 2013 Sep;90(9):937-944. doi: 10.1097/OPX.0b013e31829cac92
19. Bullimore MA, Mirsayafov D, Khurai A, et al. Pediatric microbial keratitis with overnight orthokeratology in Russia. Eye Contact Lens. 2021;47(7):420-425. doi: 10.1097/ICL.0000000000000801
20. Watt KG, Swarbrick HA. Trends in microbial keratitis associated with orthokeratology. Eye Contact Lens. 2007;33(6 Part 2):373-377. doi: 10.1097/ICL.0b013e318157cd8d
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24 Cho P, Cheung SW. Discontinuation of orthokeratology on eyeball elongation (DOEE). Contact Lens Anterior Eye. 2017;40:82-87. doi: 10.1016/j.clae.2016.12.002
