(Editors note: We asked these doctors whether they would recommend LASIK or orthokeratology for a motivated 37-year-old male who wants to eliminate or reduce his dependency on glasses. The patient has an Rx of -3.25D O.D. and -3.00 -0.50 x 180 O.S., and K readings of 44.00/44.00@90 O.D. and 44.25/44.50@90 O.S. His cornea is pristine, and he has good ocular surface wetting. Topography is quite regular, and pachymetry by Orbscan measures 537 O.D. and 540 O.S. The rest of the exam is normal as well.)

Ortho-K: Patient may one day need to reverse the effects. By John Rinehard, O.D.
Its understandable that this patient would want to reduce his dependence on glasses, but would he always want to remain an emmetrope?

Not necessarily. If the patients occupation or hobbies require close-up visual demands, in 5-8 years he may want to become more myopic. Suppose, for example, he enjoys fly-fishing and ties his own fishing flies. As an emmetropic 37-year-old, he would have enough amplitude of accommodation to do that, but at age 45 he would need to become a -3.00D myope.

Ive already seen this in other patients. For example, one 47-year-old female, a doctor who was a -0.50D myope after successful orthokeratology, found that she would rather have near vision. So, I took her out of the lenses. She returned to her myopic condition and is now happier.

I, myself, was an ortho-K patient, but found that I wanted a bifocal effect without wearing reading glasses. So, I switched from reverse geometry lenses to an aspheric multifocal, which served my needs better. Such options may not be available to this patient after refractive surgery.

We must avoid matching only the patients eyes to the procedure. Instead, we should match the treatment to the patient and his lifestyle. If he insists on seeing as clearly and comfortably as I do with my contact lenses, he may not be a good LASIK candidate. With living tissue, you cant guarantee the exact end result.

Perhaps the biggest advantage orthokeratology offers over LASIK is that its reversible. If we dont get the results we hoped for or if the patients visual demands change, we can start over, because we have not removed any corneal tissue. Once the patient discontinues wearing the retainer lenses, the cornea rebounds to its original shape (although it will take a few days for visual acuity to return to baseline). We can then prescribe another form of vision correction.

Although LASIK is a viable option for many patients, Im reluctant to encourage that they remove healthy corneal tissue. I do refer patients for LASIK, but I first make sure they understand the potential downsides and that the procedure is not reversible.

With ortho-K, however, the risks arent any greater than they are with regular contact lens wear, assuming the patient remains compliant, and practices good hygiene and lens care. In fact, I would not recommend ortho-K to a patient who already is a noncompliant contact lens wearer.

In effect, these two modalities arent necessarily competing with each other. While ortho-K is ideal for a patient who is not an appropriate LASIK candidate or does not want to undergo surgery, other patients who want zero dependence on glasses or contact lenses might be more satisfied with LASIK.

Dr. Rinehart is in private practice in suburban Phoenix. He also lectures on reverse-geometry orthokeratology.

LASIK: Patient is in the slam dunk range. By Paul Karpecki, O.D.
One of the biggest advantages we have as optometrists is that we have so many options available for our patients. So now we must fit the best procedure to the individual patient.

Whether I would recommend LASIK or orthokeratology for this patient depends, in part, on the patients motivation, ability to tolerate contact lenses and even financial considerations. One reason I would recommend LASIK here: The -3.25D spherical equivalent in both eyes and sufficient corneal thickness make LASIK a slam-dunk for this patient. This patients vision is decreased enough that he would notice substantial improvement with LASIK, but because hes not a high myope, and has normal keratometry readings and pupils, hes less likely to have night vision problems after the procedure.

For this patient, the LASIK procedure would be quick, have a low chance of complications and be permanent. The patient would not have to deal with the extra time and effort of wearing contact lenses in the evening or overnight.

If this patient does not have the time that will be involved in contact lens insertion and removal, and the lens-care regimen, he might best be served with LASIK. From a financial point of view, LASIK may also be less costly in the long term.

Further, this patient is 37, and will likely enjoy the visual results for a long time. Hes also in the ideal prescription range for LASIK. The ideal LASIK patient should have normal pupils, predictable Ks above 36.00 after surgery and pachymetry of more than 420. One concern: Hes about five years away from presbyopia, so eventually we would need to address this issue with monovision LASIK, an enhancement or contact lenses.

I also believe orthokeratology is a good option, especially if the patient has a low-risk tolerance for LASIK. Neither procedure is better; our choice always comes down to the individual characteristics and preferences of the patient.

Dr. Karpecki is a consultant, and writes and lectures on refractive surgery. He is author of Review of Optometrys Research Review column. 

LASIK or Ortho-K for Children?

We also asked our two panelists whether they would recommend LASIK or orthokeratology for pediatric patients who want less dependence on glasses or contact lenses. Here are their answers:

Ortho-K: Young Eyes are Still Changing
For pediatric patients, I agree that orthokeratology is more appropriate. Ortho-K has the potential to reduce the progression of myopia in children, and the prescribing doctor need not concern himself with the final Rx.
The reality: These patients Rxes will change over time, so its difficult to do LASIK. Also, younger patients can be suc-cessful contact lens wearers because their
tear film and oxygen levels are well-suited to lens wear.
As optometrists, we can evaluate the options and choose the most appropriate based on the patient profile.P.M.K.

Ortho-K: Child Still Has Freedom
Orthokeratology is an ideal option for children who are able to handle their lenses and comply with the lens-care regimen. We might be able to slow the progression of the childs myopia using the gas permeable lenses. Even if we dont slow the progression, we still offer the child more freedom from glasses and regular contact lens wear, especially if the patient participates in sports.J.M.R.

Vol. No: 139:10Issue: 10/15/02