It has been well-established that orthokeratology (ortho-k) is effective in slowing axial elongation and, thus, significantly improving quality of life in pediatric myopia patients. As is the case with all contact lens wear, it’s important for prescribers to be aware of contact lens-related dry eye (CLDE), so patients can maintain wear.

Here, I discuss how CLDE occurs from ortho-k lenses and how, specifically, to manage it. 

How CLDE Occurs

Corneal epithelial integrity is a key factor in tear film stability. Epithelial staining is one of the most commonly identified clinical signs of lens-induced corneal epithelial defects among ortho-k patients, especially in the early stages of treatment.¹ Compromised corneal surface integrity induces dry eye through the following mechanisms:

• Lens-caused mechanical trauma. Ortho-k lenses work by applying controlled pressure on the central cornea, inducing temporary epithelial redistribution.² Overnight wear in a closed-eye environment further reduces tear exchange, delaying epithelial recovery. Due to the unique overnight wear modality, the 1-day follow-up is preferably scheduled in the early morning to maximize the likelihood of detecting subtle epithelial defects, which may rapidly heal within a few hours after lens removal.

• Tear film instability. A healthy corneal epithelium plays a crucial role in maintaining tear film integrity by anchoring the tear’s mucin layer. Epithelial damage disrupts this interface, reducing mucin secretion, impairing tear film adhesion, and leading to patchy tear coverage and persistent dryness.³

• Reflex tear dysfunction. Epithelial defects expose underlying corneal nerves, triggering discomfort and reflex tearing.^4,5 If the underlying cause of these epithelial defects is not addressed in a timely manner, persistent corneal surface damage can lead to nerve desensitization, reducing the normal neural feedback loop that stimulates basal tear production, worsening dry eye symptoms.

• Activation of the inflammatory cascade. It is well documented that epithelial injury stimulates the release of inflammatory cytokines such as IL-1, IL-6, and TNF-α, which further destabilize the tear film, causing additional ocular surface damage, increased tear osmolarity, and chronic irritation.^6,7 In severe cases of persistent epithelial damage, chronic inflammation can lead to corneal thinning, scarring, and further epithelial compromise.

Management Strategies

Because suboptimal lens fit is the primary cause of ocular dryness from ortho-k lens wear among children, ensuring proper lens fit should be the primary focus of dry eye management, particularly in the early stages of treatment.

Specifically, lens centration and movement should be carefully assessed to ensure uniform weight distribution of the lens, and persistent corneal staining—especially when dense and coalesced— should be addressed promptly.

For mild, chronic dry eye symptoms not associated with corneal epithelial defects, pre-servative-free artificial tears before and after lens wear may be beneficial. For children who have pre-existing lid conditions, rigorous lid hygiene and warm compresses should be emphasized to optimize meibomian gland function. Finally, routine follow-up visits are essential to identify subtle changes in lens fitting and mild corneal defects, allowing for timely adjustments to prevent worsening symptoms. OM

References

1. Liu YM, Xie P. The Safety of Orthokeratology--A Systematic Review. Eye Contact Lens. 2016;42(1):35-42. doi:10.1097/ICL.0000000000000219

2. Zhang J, Li J, Li X, Li F, Wang T. Redistribution of the corneal epithelium after overnight wear of orthokeratology contact lenses for myopia reduction. Cont Lens Anterior Eye. 2020;43(3):232-237. doi:10.1016/j.clae.2020.02.015

3. Berry M, Pult H, Purslow C, Murphy PJ. Mucins and ocular signs in symptomatic and asymptomatic contact lens wear. Optom Vis Sci. 2008;85(10):E930-E938. doi:10.1097/OPX.0b013e318188896b

4. Pattan HF, Liu X, Tankam P. In vivo assessment of human corneal epithelial cells in orthokeratology lens wearers: A pilot study. Optom Vis Sci. 2024;101(5):263-271. doi:10.1097/OPX.0000000000002130

5. Cho WH, Fang PC, Yu HJ, Lin PW, Huang HM, Kuo MT. Analysis of tear film spatial instability for pediatric myopia under treatment. Sci Rep. 2020;10(1):14789. Published 2020 Sep 8. doi:10.1038/s41598-020-71710-7

6. Carracedo G, González-Méijome JM, Pintor J. Changes in diadenosine polyphosphates during alignment-fit and orthokeratology rigid gas permeable lens wear. Invest Ophthalmol Vis Sci. 2012;53(8):4426-4432. Published 2012 Jul 3. doi:10.1167/iovs.11-9342.

7. González-Pérez J, Villa-Collar C, González-Méijome JM, Porta NG, Parafita MÁ. Long-term changes in corneal structure and tear inflammatory mediators after orthokeratology and LASIK. Invest Ophthalmol Vis Sci. 2012;53(9):5301-5311. Published 2012 Aug 7. doi:10.1167/iovs.11-9155.

Maria Liu, OD, is an associate professor at Herbert Wertheim School of Optometry and Vision Science, University of California Berkeley. She is also the founder of the Myopia Control Clinic, UC Berkeley Eye Center. She received her bachelor’s degree in clinical medicine from Peking University, her OD from Pacific University, and her PhD and MPH from UC Berkeley. She is a world-recognized clinical researcher in myopia. Dr. Liu is a consultant for Coopervision, Essilor, Treehouse Eyes, and Zeiss Vision China.