Article

BUILDING AN ORTHOKERATOLOGY PRACTICE

A step-by-step guide

Building an orthokeratology (ortho-k) practice begins with the motivation to make a difference in patients’ lives as it relates to their vision and quality of life. In the past, ortho-k was used primarily to obviate the need for wearing corrective lenses for some time during the day. For many adult patients that was transformative, yet, today ortho-k promises much more. Ortho-k is a tool for addressing the myopia epidemic with myopia control. Reducing the need for corrective lenses is still beneficial but preventing high myopia and the ocular complications that arise from large myopic shifts is arguably more important. If ortho-k is in your wheelhouse, the challenge is making this subspecialty a viable business.

BUSINESS BASICS

The first step is to build your expertise. Your skill in ortho-k will attract, retain, and delight patients. Businesses that delight their customers rarely fail. High professional skill enables profitability for ortho-k but also requires substantial investments in materials, technology, training, people (staff), infrastructure, and operations. Excessive chair time and multiple remakes will quickly erode patients’ confidence and your profits. Becoming an ortho-k expert is, therefore, the foundation for success. With ortho-k, your skill is the product, and it must be spectacular. In addition, the support of your staff and your environment reflects on you. The process of ortho-k justifiably involves a substantial financial commitment by patients, and those in a position to take advantage of ortho-k expect a superior product delivered by white-glove service. Make sure your staff and your physical space are up to the task. Assuming you are willing to make the investment, the next step is a business reality check.

Successful businesses have a plan that includes not only the motivation driving the vision but also more mundane aspects that support the viability of the venture. Honestly assessing the need in your addressable patient base is critical. The process for determining the need, called customer discovery, is essential for deeply understanding the patients you could be reaching. There are multiple techniques for customer discovery but basic demographics is an easy way to start. For example, are you located in an area with a preponderance of people who have medical insurance? Is your practice located near an established ortho-k provider? The goal of customer discovery is to understand how your potential patients consume eye care, and the power is in how it shapes your responses to the results.

One benefit of ortho-k is its flexibility; that is, you could tailor your practice to adults seeking to reduce dependence on spectacles, or you could focus on myopia control in kids. Let your customers be the guide. After figuring out what your patients need, make sure you can deliver on that need better than anyone else in your market. Delivering outstanding results with high-touch customer service in a pleasant environment will create a barrier that protects you from competition.

ORTHO-K BASICS

In ortho-k, learning equals earning. This includes your professional training in addition to the education of your staff and your patients. Basics include the history of ortho-k, technical requirements, capabilities, limitations, and risks of ortho-k.

In 1962, during the International Society of Contact Lens Specialists meeting, contact lens pioneer George Jessen introduced the concept of “orthofocus,” which was the first deliberate attempt to mold the cornea to reduce myopia. At this meeting, Newton Wesley termed this method “orthokeratology.” Jessen’s method consisted of fitting a conventional design polymethyl methacrylate (PMMA) corneal lens flatter than K by the amount of the necessary myopia correction with an additional overcorrection (about 1.00D). This overcorrection, or Jessen factor, compensates for myopic regression toward the end of the day. Because PMMA does not transmit oxygen, the lenses were fitted flat in an effort to deliver more oxygen to the cornea. Unfortunately, lenses fitted in this manner were originally thought to flatten the underlying corneal tissue. We now know that the corneal epithelium is redistributed through this process rather than overall corneal flattening. Myopic patients did, however, experience improved uncorrected vision for some time after contact lens wear was discontinued.1 Overall, early attempts at ortho-k, although safe, were plagued by unpredictable refractive outcomes and minimal myopia correction (1.00D on average), and it would take months to achieve the target treatment goal.2-7

Modern ortho-k employs reverse-geometry gas permeable (GP) lenses. A reverse-geometry lens has a flat central curve and an adjacent reverse curve that is steeper than the central radius. This reverse curve is connected to a flatter peripheral curve that aligns with the midperipheral cornea. A basic 4-curve reverse geometry lens is shown in Figure 1. This design centers well and is highly stable, allowing rapid correction of higher amounts of myopia. The use of GP materials enables overnight wear of ortho-k lenses in a closed eye state, which adds to the convenience and comfort of this procedure.8-10 Using corneal topography to guide the treatment further differentiates the modern practice of ortho-k.11 Corneal topographers can map a large area of the cornea, providing an accurate and complete view of the pre- and post-treatment ortho-k region (Figure 2). These data are crucial for troubleshooting any problems when the fit is not optimal.

Figure 1. Representation of modern reverse-geometry GP lens used for ortho-k. Reverse-geometry lenses have a flat central curve (BOZR) and an adjacent reverse curve (RC) that is steeper than the central radius. This reverse curve is connected to a flatter curve that aligns with the midperipheral cornea (AC). A final peripheral curve is added for tear exchange (PC).

Figure 2. Corneal topography difference map pre- and post-orthokeratology. Corneal topography is essential for monitoring ortho-k treatment progress.

Owing to the advent of computer-driven lathing systems, a wide variety of ortho-k lens designs are now manufactured with high accuracy and repeatability. Obtaining a lens is as easy as providing keratometry values, manifest refraction, and horizontal visible iris diameter to suitable contact lens laboratories. Ortho-k lens designs are informed by data collected from thousands of fits, promising good results. Most manufacturers offer an empirically designed ortho-k lens, and their consultants are available to help with lens modification and troubleshooting. Ortho-k lens sets are also available to facilitate same-day fitting and dispensing. As a wide variety of parameters are available instantly, these sets increase initial fitting success, thus reducing chair time.

Orho-k design software linked to corneal topography is also available when a high degree of customizability is desired.11,12 This enables practitioners to design their own lenses using additional factors such as optimum tear fluid thickness (Figure 3).

Figure 3. Example of ortho-k software linked to corneal topography for customizable lens design.
Courtesy of Jaume Paune PhD, OD, MOVS, FIAO

Currently, ortho-k is most commonly used for myopia correction. It is most effective with myopia less than 5.00D, with-the-rule astigmatism less than 2.00D, and against-the-rule astigmatism less than 1.00D. When starting out, select highly motivated patients who have low amounts of myopia and with-the-rule astigmatism. This will help you achieve better outcomes while you learn the basics of ortho-k. With experience, high myopia and astigmatism can also be successfully corrected with newer lens designs. These enhanced designs include lenses with five curves, double-reverse curves, and dual-geometric designs.11,12

Progressive myopia is on the rise globally.13 High myopia is a leading cause of blindness and is associated with retinal comorbidities, such as early-onset cataract, glaucoma, and macular degeneration.14 Preventing high myopia through myopia control now offers a solution. Ortho-k and other contact lens-based interventions aim to create a peripheral defocus retinal cue that slows myopic progression.15 According to the American Optometric Association, myopia control can be offered to patients with progressive myopia,16 and practicing orthokeratologists are best positioned to combat this epidemic (although this remains an off-label use).

Although correction of myopia is the primary indication for ortho-k, correction of other refractive errors is achievable with alternate lens designs and fitting philosophies. Ortho-k for hyperopia creates central steepening by gently reshaping the midperipheral cornea (Figure 4). Regular astigmatism is correctable through designs that offer back toric curves.11,12 Ortho-k correction for patients who have undergone LASIK is also available. Other new fascinating applications for ortho-k include corneal crosslinking to prolong the effects of ortho-k and corneal reshaping using alternative lens designs such as corneal scleral lenses and soft contact lenses.12

Figure 4. Example of ortho-k for hyperopia, which creates central steepening by gently reshaping the midperipheral cornea. Various refractive errors can be corrected with alternate ortho-k lens designs.

As with any contact lens modality, potential risks exist with ortho-k. Symptomatic flare, glare, and reduced contrast sensitivity from higher-order aberrations, particularly when treating high myopia, are common. Fortunately, these symptoms usually decrease with treatment progression, unless the lens is decentered.17-20 Of greater importance is the risk of microbial keratitis (MK) in overnight ortho-k. Vision loss from MK has occurred in children while wearing overnight ortho-k lenses.21,22 Nevertheless, one retrospective study showed the risk of MK in ortho-k was no higher than with any other lens modality.23 Patient education regarding hygiene, proper cleaning techniques, handling, and wearing schedule is imperative for reducing the risk of infection. Regularly reinforcing good contact lens habits during follow-up visits is effective at mitigating the risk of MK.

Staff education is essential for a successful ortho-k practice. To best represent the practice, all staff members, even those in reception, should be conversant in ortho-k. Ideally, key staff members are assigned specialized tasks, such as performing the initial workup, obtaining informed consent, and teaching patients proper lens handling and care for ortho-k. This will ensure that data collection, such as corneal topography, is performed efficiently and accurately. By consistently delivering highly structured service, you and your staff will build patients’ confidence that your practice is the best place to receive their ortho-k treatment.

Patient education is also key to a successful ortho-k practice. For patients who are moving forward with treatment, it needs to be absolutely clear what you are offering: the indications, benefits, limitations and risks, and the financial policy you have in place for the service and materials. The most effective way to deliver this information to patients is through documented informed consent. This form should be explained to patients in person and signed in-office before proceeding with treatment. Having a solid informed consent will protect against any confusion between you and the patient.

Educating yourself on how to become the best orthokeratologist is by far the most challenging and important feat for building an ortho-k practice. Before immersing yourself in ortho-k design, you must have a fundamental understanding of basic GP lens design and corneal topography. Consultants and educational programs offered by contact lens laboratories are excellent resources to help you learn about ortho-k. Patients will go out of their way to seek excellence, so commit yourself to being the expert at ortho-k, and your practice will grow organically.

MARKETING BASICS

Your individual marketing and communication strategy will differ in the details from another’s plan but should be built on your ortho-k expertise. That is because, without a doubt, word-of-mouth marketing will be key to your success. Word-of-mouth marketing is controllable, but without happy patients it cannot be used. Just like your overall business plan, your marketing and communication strategy is founded upon deep understanding of your practice and the environment in which it functions. Knowing how and where your customers find out about and consume eye care, and ortho-k specifically, is key to reaching them when they are decisional.

Start small, build your expertise, and allow the ortho-k practice to grow organically. Too much too soon will overwhelm you, the staff, and the practice. Build into it with one ortho-k patient per month, then one per week, then perhaps one day you will have a clinic totally built around ortho-k. If you keep total costs in check, patients are happy, and if marketing and advertising continuously grow the patient base then at some point a fruitful ortho-k practice will naturally emerge.

SUMMARY

Ortho-k offers a multitude of opportunities that can sustain an optometric practice. Ortho-k gives patients the opportunity to experience uncorrected daytime vision, and by preventing high myopia through myopia control, it directly addresses the myopia epidemic. For practitioners, ortho-k is professionally rewarding and a potential foundation for a successful business.

Becoming an expert in ortho-k is a life-long pursuit. If you fully commit yourself and your practice to it, patients will seek you out. Education is the starting point and the key to building a successful ortho-k practice. If you have the will to educate yourself, and if the environment will support it, entering the ortho-k field may be the best business decision you will ever make. CLS

AUTHOR’S NOTE: I would like to thank Jon Andresen, MBA, PhD, San Antonio, and Jaume Paune, PhD, OD, MOVS, FIAO, Catalonia, Spain, for taking time away from their busy schedules to provide information and support for this article.

REFERENCES

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