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December 1, 2022
In part one of this two-part series, Monica Jong, BOptom, PhD, Global Director of Professional Education, Myopia, Johnson & Johnson Vision, and Glenda Aleman, OD, Director of OK Love, discussed why orthokeratology is so beneficial to myopia patients.
Now, the pair of leaders in the myopia management field is back for part two of this series. In this video, Dr. Jong and Dr. Aleman get into the specific details of fitting OrthoK, including insertion and removal training, what a typical OrthoK follow-up schedule looks like, and how to communicate with patients to ensure the greatest levels of success with OrthoK lenses.
Below is a transcript of the interview. Click here to watch the video interview.
John Sailer: Hello, and welcome to the Review of Myopia Management video series. I am John Sailer, Editor-in-Chief of Review of Myopia Management, and we are here today with Dr. Monica Jong, Global Director of Professional Education, Myopia, at Johnson & Johnson Vision, which has recently introduced ACUVUE Abiliti Overnight Therapeutic Lenses for Myopia Management. We also have Dr. Glenda Aleman, optometrist and founder of OKLove Myopia Control Experts. In this second of a two-part series, Dr. Jong and Dr. Aleman will discuss OrthoK fitting tips, everything you need to know to get started or to continue on your journey of using orthokeratology in your practice to manage your patients’ myopia. We would like to thank Dr. Jong and Dr. Aleman for sharing their insights into OrthoK today, and we’d also like to thank Johnson & Johnson Vision for sponsoring this video. So, Dr. Jong and Dr. Aleman, please share all your tips about fitting your patients with OrthoK lenses.
Monica Jong: Hello, Dr. Aleman, it’s wonderful to see you again for part two of the video interview series. And today we’re really going to find out all your Ortho- fitting tips and also your own experience with the Abiliti Overnight lens. So, welcome back.
Glenda Aleman: Thank you. Thank you for having me back. It’s a pleasure again to be here with you, and I love sharing tips with other practitioners so that we can get everyone involved and started doing OrthoK.
Dr. Jong: Now the Abiliti Overnight lens was only released about mid last year, and you are a seasoned orthokeratologist, and you’ve used a number of different OrthoK lens designs. Now, please tell us what made you want to partner with Johnson & Johnson for OrthoK?
Dr. Aleman: When I heard that Johnson & Johnson was coming out with an OrthoK lens, I got really excited because I remember that when I first started fitting OrthoK, one of the, I would say challenging conversation pieces, was that parents would ask me, “How long has this been around?” or “I haven’t heard of this.” So, I think that a lot of us that have been passionate about myopia management and OrthoK have been waiting around to have one of these big companies kind of back up the process of OrthoK. So, when having the conversation about OrthoK, “Do you know Johnson & Johnson?” everybody nods their head, and they say, “Oh yes, I know Johnson & Johnson.” So, I was very excited to try the new lens from Johnson & Johnson, because number one, as a consultant, I wanted to have experience with a lot of the lenses that are out there so I can give feedback to my clients based on my clinical experience.
So, for me, that was a big push to try out the new Johnson & Johnson lens. But the second one was really having the backup of a company with the reputation of Johnson & Johnson backing up OrthoK, which can be something that can be intimidating sometimes for parents. I felt that that was a benefit and likewise will be beneficial for new practitioners to be able to present to parents a brand name that they’re very familiar with. A lot of our parents know the ACUVUE brand, so I think having that association really makes it easier to be able to present that to parents.
Dr. Jong: There’s been a lot of clinical trial data published about the positive benefits of orthokeratology. So, I think Johnson & Johnson having a myopia management portfolio and getting behind orthokeratology is something that will really support practitioners in offering myopia management solutions to all the patients. So, tell us about the trial lens fitting versus software guided OrthoK fitting approach and the differences, because a lot of practitioners who haven’t done OrthoK before wouldn’t really understand the benefits and differences.
Dr. Aleman: Yes. Trial fitting, which is how I started with OrthoK, was fun because if you’re a hands-on person, it’s nice to be able to try on different lenses, but it was very tedious. It was a time-consuming process that sometimes takes up to two hours. Let’s keep in mind that when we are trying these hard lenses on children, we need to sterilize them. We need to make sure that we’re not exposing them to any harm. So, that was part of what made trial lens fitting a very time-consuming process, because we need to make sure that we sterilize the lenses in-office. And sometimes it could take up to two or three different trials in office in one visit to arrive to the conclusion where I had a lens that was okay to dispense. So, I would say that is trial lens fitting.
Now, empirical fitting really cuts down the chair time. There’s no trial lens to sterilize. There is also no initial investment into starting with OrthoK. Those trial lenses used to cost anywhere from $800 to $1,500. So, that was an additional expense that we needed to make at the beginning of our practices with myopia management. Where now, with the FitAbiliti software, and other companies that offer the ability to fit empirically, it has reduced that initial cost or that initial financial investment for practitioners. But I think what I find the most fascinating about the FitAbiliti software is that it is user-friendly. You could really train your myopia champion, your myopia liaison, to them inputting all the information in the system, and then you, as the practitioner, of course always want to review to make sure that the maps look good, that all the information is accurate.
Dr. Jong: So, the FitAbiliti advantage is that it allows the practitioner or the assistant to walk through the whole OrthoK fitting process. So, it takes you through uploading the topography, entering the refraction, and it takes you through every single visit, and it allows you to troubleshoot the lens. Is that correct?
Dr. Aleman: Correct. So, it really takes a lot of us having to calculate or figure out what we need to do next; it takes all of those thoughts and models out of the equation. With the FitAbiliti software, it really has your visits programmed for you. So, the system, the initial visit, it tells you this is the information that we need to collect from the patient, which is not going to be a lot different than all the information you collect in a comprehensive exam. We need to scan the cornea to make sure the cornea’s healthy and we don’t have any concerns or any contraindications. And really the only two additional steps that we’re doing to be able to order a lens through FitAbiliti is that we want to make sure that we take a high-quality topography at the beginning, and that we are measuring the horizontal iris diameter. And really besides that, in staining the cornea, it is no different than what we’re going to be doing on a comprehensive exam. We need refraction. We need horizontal iris diameter. We need topographies and to make sure that the cornea is healthy. That’s basically all we need to get started.1*
Dr. Jong: I find all the new technology for myopia management absolutely wonderful. It allows us to really provide really excellent personalized patient care. And then we also know that with assessing OrthoK treatment in terms of the correction on the cornea, corneal topography is really the gold standard, and that’s been published. How important is corneal topography for OrthoK fitting in your practice, Dr. Aleman?
Dr. Aleman: Corneal topography is everything when you’re doing OrthoK. If you are doing OrthoK without corneal topography, I tell practitioners it’s like managing glaucoma without an OCT. We need the OCT. We do know that glaucoma medications work, but the way to know that we are giving the patient an effective treatment is by monitoring, doing OCT. So, that’s how similar the topographer plays a role when we’re doing OrthoK. When my patients come in for their follow-up visits, the first thing we do every time is to take the topography. The topography is going to give me so much information as to how the lens is fitting on the eye. So, it has really changed the way that I do OrthoK because in the beginning, I would make sure that at every visit, I would look at the patient with the lens, but now if I have a perfect topography and the patient is coming for not a first fitting, I don’t necessarily have to see that patient with that lens in the eye. The first day I can look at the topography and know that the fitting is good, the lens is centered, and that all the parameters and the lens are adequate.
Dr. Jong: Yeah, that’s very true because there have been studies that have been reported by John Mountford that said that fluorescein fitting is good to do, but actually topography is going to give us more information and more accuracy in assessing the OrthoK fits.2 So, you can see that the knowledge in this area is changing over time. Now, we have a lot of people completely new to topography. Since corneal topography is so important in orthokeratology, can you give us topography tips for capturing really high-quality images in kids?
Dr. Aleman: Yes. So, in order to have a best fitting lens, we need to have the best topos to start with. So, a few fitting tips or tips to get the best topographies are to instill an artificial tear on your patient before taking the topos. Number two is you want to make sure that there’s no artificial artifact, that there are no eyelashes that are blocking the image on the corneal topography. We need to make sure that the eyelids are not in the way of the topography. So, we could use different things like telling the patient to open their eyes really wide and coaching the patient through the process of doing the topography. Another thing that we can do if necessary, that doesn’t really happen often in my office, but you could also tape the eyelid open if you have a child that is just not very cooperative.
Like I said, that has only happened maybe a couple of times in my office. Usually by giving very good instructions to the patient, telling them exactly what to expect when they’re sitting in the topographer and how the exam is going to go, instructions on where to look, I have found that just doing that and staying proactive and giving feedback to the patient as to how they’re doing gives rise to really good topographies.
Dr. Jong: Now, in terms of OrthoK for adults and kids, like the research says that kids are just as capable of inserting and removing and cleaning/disinfecting their lens as adults.2 Now, from your own experience, have you found that it’s just as easy for you to do OrthoK management in kids as well as adults?
Dr. Aleman: I have found that it’s easier to do OrthoK or any type of contact lenses in a child.† Children are amazing. They not only have very flexible joints and bones, but they also are very quick at learning, and OrthoK, after they get through the first night and they see the results, they are highly motivated. They love doing things on their own. It makes them feel . . . all children want to be grown up. So, OrthoK gives them the opportunity to prove to their parents that they can do it on their own. In my experience, usually with very young patients, my youngest in OrthoK is six years old, and what I have found is that usually parents of my patients do assist the child with putting in their OrthoK and helping them to remove them the first couple of weeks. But after the first couple of weeks, even the youngest child, they do it by themselves, of course, with the supervision of the parents. I do emphasize that parent supervision. It’s very important for my younger patients. Once the patient is 10 and older, I ask the parent how they feel. If the parent feels that they are responsible to do it on their own, then I do let them do it on their own without the parent’s supervision. As long as the parent gives me the clear that that patient is responsible to do it. But I have found that my children, my kid patients, pediatric patients, are amazing at learning how to insert the lenses and how to remove them and take care of the lenses properly. Like I said, just, they might need assistance the first few nights.
Dr. Jong: So, can you tell us if you have a patient coming in and they’re interested in orthokeratology, can you tell who will be successful with it? Is it about motivation?
Dr. Aleman: It is really about the motivation of the patient. A lot of the times what I have found is that the parent is highly motivated, but the child might not be ready. So, one thing that we need to understand is that a lot of children are afraid of someone or themselves or anything, touching their eyes. It is very important to make them feel safe. I do reassure my patients, and I tell them that the health of their eyes is my priority, and I will do anything and everything to make sure that their eyes stay healthy. I found that when I talk directly to the child and I tell them that my priority is to make sure that they can see well and their eyes stay healthy, that gives them peace of mind, and it makes them more likely to want to try. I do want to tell practitioners that it is really important to respect the child’s space and to respect their position on where they are as far as the treatments. If you are getting the sensation, you’re getting the feeling that the child is very apprehensive about starting OrthoK or other contact lenses, I do tell them, “I understand. I understand your concerns. So, I want you to tell me when you think you will be ready to do it.” And that is very, very important, because children are very smart these days, and they are the patient, and they want to be involved in the process. So, by me asking the child, “I want you to tell me when you are ready.” They usually come back to me and say, “I will try it at my next visit.” And usually they come back, and they are prepared. They’re mentally prepared to start the challenge.
Dr. Jong: Those insights are very, very useful, and it is true. We don’t give enough credit to the children because even an 8-year-old sometimes they do know what they want, and they do have a lot of understanding and intelligence. So, just speaking to them and involving them is part of being successful in communicating the whole orthokeratology management and myopia management. Now, if you’ve already got the patient who wants to do OrthoK, how do you prepare them for the first night of OrthoK? What should they expect? What if they’re really afraid and say, “OrthoK is going to hurt.”?
Dr. Aleman: Yes. So again, as practitioners, it’s really important to listen to the child. So, if I hear that they are afraid of how it is going to feel, or they are afraid that it might hurt, I let them know that actually you will feel the lens. It will feel a little bothersome, like if you have an eyelash or something in your eye, but it should not be painful. Also, when I first insert the lenses, and I think that’s important to make the experience easier for everyone, it’s easier on the parent, easier on the practitioner, and on the child, I always insert the lenses myself the first time. That way I am minimizing the time that the poor child is going to be poking themselves in the eye.
So, I put the lens in their eyes first. I let them sit for 15 to 20 minutes in the office with the lenses in, with their eyes closed. And that is a very important tip that I can give everyone. When they first close their eyes, I ask them, “How do you feel now?” And usually their response is, “Oh, I don’t feel them anymore.” And I say, “You see? Remember, we’re wearing these lenses only when you’re going to sleep. So, when you’re going to sleep, this is how you’re going to feel. And once you fall asleep, you don’t even know you have the lenses on.” And that’s very helpful and very reassuring for the patient.
Dr. Jong: Now, how would you teach insertion and removal (I&R) and the whole cleaning process to your patients in OrthoK? Do you have a staff member do it, and is it a big process, or do you have materials such as videos available?
Dr. Aleman: There are videos available. I myself do not use videos. Sometimes I myself will take an OrthoK lens from one of my old trial lens fits and put it on myself. Also, because we are fitting in empirical for 99% of the patients, I give them a sample. I let them test. I let them play around with one of those trial lenses that I have in my office. I let them touch the lens. I let them feel it. I give them a little bit of solution so that they can familiarize themselves. And when the lens comes in, they already know how the lens feels in their hands. They’ve touched it. So it’s not a completely strange new device that they’re going to be testing. So, that makes them feel a little bit more at ease. Also, when I do my insertion and removal, which I do sometimes depending on the patient, that’s another thing that as practitioners, we know that it’s not one fits all. So, if it’s an older child, I see they’re very independent. I might have my assistant do the I&R. If I see there is a child that had a little bit more trouble with the idea of putting something in their eyes, then I like to do the I&R myself, so I can make the process easier for the patient. And they say, “Well, I want to know how the lens is actually going to feel in my eyes.”
Dr. Jong: That’s really wonderful to see you have that conversation with them and involve them in their own care. This is really what it’s about when it’s myopia management, personalized treatment involving the patient in every step. Now, J&J is also coming to support OrthoK practitioners by producing insertion and removal, cleaning, and disinfection videos designed for children with language that is suitable for children and images that are also aimed at engaging children to support the process. So, that’s something we’re very excited about. So, you know this is a completely new area that Johnson & Johnson is entering, and so we are producing the professional education materials and practitioner support materials as we build the Abiliti portfolio over time. That includes the app, the website, and the FitAbiliti software. Now, in terms of OrthoK management, can you take us through the steps of the visits that you do to determine the final lens for your patient?
Dr. Aleman: Yes. So, once we start with OrthoK, after we do the fitting, I want to see the patient ideally the morning after they start OrthoK,3 or if they started on a Saturday, I would see them the following Monday. So, two mornings after they started their OrthoK fitting, depending, of course, on all the factors, parameters, initial prescription. Some cases I have gone to my office on a Sunday morning to see a patient. So, the follow-up schedule is once we do the initial fitting, I see the patient within the first 48 hours. So, either the morning after, or two mornings after they start their OrthoK fit. After that, I want to see them in about a week, and I usually tell the patient that I’m going to see you back in one week.3
And at that visit, I want to learn more about how the lens is doing. I want to measure the progress, but for me more importantly, I want to bring the patient back at that one visit to see if they might need a refresher on their I&R. I revisit their insertion and removal instructions with them. I ask them to always bring the lenses so that we can inspect them and make sure that the lenses are clean and there’s no chips or they haven’t broken. And also I tell them that most likely, and this is very important, I do tell them at the one visit, for your one-week follow-up, most likely I will not be making any changes. It is really important that we allow the OrthoK lens, this amazing technology, we give it enough time to work and give the proper treatment that we want.
So, I refrain from making any changes at the one week. The next visit I’m going to see them is at the third week after they have been wearing their OrthoK lenses.3 That is the visit that I will determine if the lens is giving me the desired results, or if I need to maybe tweak the lens design a little bit, which the beautiful thing with the FitAbiliti software is that once we go and we input all the information at every visit, for the third one it’s going ask if the lens is centered, it’s going to ask you if there’s any corneal staining, are you happy with the refraction that you are getting? Once you answer those questions, the system, it detects that there is a centration problem or that we’re not getting the desired results with a lens.
And you as the physician, of course, get to see the simulation on how the fluorescein pattern is going to look and FitAbiliti does allow for us to manipulate a few parameters where we can customize it even more and add on our own perspective to the fitting. Once we do the third week, the next visit is going to be, if you are ordering a new lens, then you would want to bring that patient back for dispensing. And at that point, you would want to reevaluate that lens fit again in two to three weeks. And once that fit is final, we are happy with the result, the lens is feeling great, now we’re going to follow the traditional schedule, which is going to be, I see the patient back in three months, and then I see them again in six months.3 This schedule usually happens the first year. And usually I see the patients every six months after that.
Dr. Jong: Now, just to finish off, are there any take-home messages to the practitioners out there who have never tried fitting an OrthoK lens that really want to get into it?
Dr. Aleman: My best advice that I would give practitioners is that there has never been an easier time to get started with OrthoK, especially with the new FitAbiliti software. It’s really easy. Johnson & Johnson has so many resources. They have a great team of experts that are there. We are there available to help you through the process. They have great sales consultants, clinical consultants, a whole team that has been assembled and an array of resources available for the providers. I will tell the providers, even if you feel that you’re not ready, just get started. We just have to start, take the next step, set up an implementation date, start looking for your equipment, and reach out to your Johnson & Johnson rep to get started.
Dr. Jong: Thank you so much Dr. Aleman for sharing your extensive OrthoK knowledge with us, and especially speaking about your personal experience with the ACUVUE Abiliti Overnight Therapeutic Lens for Myopia Management.
John Sailer: And thank you both, Dr. Jong and Dr. Aleman, for your OrthoK fitting tips. Thank you for watching, and thank you Johnson & Johnson Vision for sponsoring this video.
References
*Final lens fit is determined by the ECP — software is for decision support only
†OrthoK can be used to correct myopia in adults.
1 JJV Data on File 20 ACUVUE Abiliti Overnight Therapeutic Lenses for Myopia Management – Consolidated, Approved Claims List (United States Only Claims).
2 Vincent SJ, Cho P, Chan KY, et. CLEAR – Orthokeratology. Cont Lens Anterior Eye. 2021;44(2):240-269. doi:10.1016/j.clae.2021.02.003
3 Johnson & Johnson, 2021. Package Insert ACUVUE Abiliti Overnight Therapeutic Lenses for Myopia Management.
PP2022ABL4094
