In everyday optometric practice, a corneal finding of mild superficial punctate keratitis (SPK) is somewhat common, and its mitigation can begin with a discussion with patients about ocular lubricants, lid margin hygiene, or alteration in cosmetics and skin care products. Personally, I don’t lose much sleep over mild SPK in most patients. However, my apprehension certainly increases when I see mild corneal staining in patients using orthokeratology (ortho-k) lenses, especially pediatric patients.

When I first began prescribing ortho-k lenses, any corneal findings would have me adjusting the lens parameters to correct the issue. This led to numerous office visits and unnecessary lens remakes. Now, almost 15 years later, my level of concern is no different, but I assess the situation with a more thoughtful approach.  

When I see corneal staining during the initial visits of the prescribing process, I zero in on the cornea–lens relationship and the application and removal process. Central corneal staining or circular patterns that match the peripheral curves clue me into lens binding during overnight wear, and I would be more likely to change lens parameters. I would also reassess the patient’s techniques for applying the lens to ensure that they are not pushing the lens too hard onto the eye, creating a seal-off from tear exchange. Errors in lens placement, such as a tilted lens or decentered application, could lead to nonspecific patches of corneal staining that do match the lens diameter or curvatures.

After a successful fitting process, periodic corneal health assessments are part of my routine ortho-k program. If corneal staining is noted after a successful fitting, my troubleshooting process does not typically involve lens changes. I would start with a change in lens care systems, usually from a multipurpose disinfection system to hydrogen peroxide. I would also evaluate the lens itself under the slit lamp to look for biofilms, especially on the back surface. Even mild deposits on the lens can affect the corneal surface, which can impact the cornea–lens relationship, vision, and lens comfort.

I also ask the patient to dispose of their current lens case and recommend a strong deep clean with a protein-removing solution. Many patients prefer to fill the lens with a viscous solution for comfort upon application and, over time, that filling solution often becomes their multipurpose solution. Educating the patient on the importance of switching that habit to the use of a preservative-free lubricant rather than overexposing the cornea to disinfection agents can increase the likelihood of successful lens wear.

The benefits of ortho-k outweigh the risks associated with overnight lens wear in most cases. As providers, we need to hold ourselves to the highest standards when corneal staining is observed to ensure that ortho-k can be safely provided to anyone who might benefit from it.

BROOKE MESSER, OD, FAAO, FSLS practices at Vance Thompson Vision in West Fargo, ND. She is also a fellow of the American Academy of Optometry. She has received remuneration from Bausch + Lomb SVP, Glaukos, and Heidelberg.

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