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Myopia Management Therapy:

The general length of your treatment will be primarily determined by your prescription and your compliance with the prescribed Ortho-K wearing schedule. Ortho-K lenses are to be refitted annually like a soft contact lens. Typically, we expect to see 90% of the vision changes within the first week of treatment and full treatment within the first 30 days. Some eyes will require a longer period to complete the process. Thereafter, the lenses will have to be worn routinely to maintain treatment vision.
What is included:
  • All check in appointments throughout the therapy include a 30min wellness check which include testing Visual Accuity, Overall health of the surface of the eye, and Topography testing which maps the surface of eye.
  • Specialty Contact lens fitting
  • Specialty refitting’s (Ortho-K fits are not the same as a soft contact lens fitting, however they are to be done annually to maintain the therapeutic results.)
  • Lens training (insert and removal)
  • Medical visits pertaining only to the Ortho-K therapy program
(If patient in not complaint with the care and wear schedule then this will not be covered and will be considered an out-of-pocket cost.) ,

Check In Schedule:

Therapy follow-up visits will occur in the order of:

1 Day,1 Week (7th day), 1 Month (30th day), 2 Month (60th day), 6th Month, 8th month (if needed)

Follow-up schedule will restart in year two from the date of Comprehensive exam.

Any additional follow-ups may be requested should there be any complication with the patients wearing schedule. Therapy follow-ups are crucial to treatment. We are mapping the surface of your eye as you are being treated. Constant monitoring is important for the first 60days of the therapy.

Patient Responsibility Acknowledgement

1. I understand that the success of the Corneal Refractive Therapy Program is directly dependent on my compliance with the program; I must wear the Ortho- K lenses no less than 6 hours every night and abide by the proper ocular hygiene for best results.
2. I understand that certain personal, physiological, and environmental factors may adversely affect the successful use of the Ortho-K contact lenses and may necessitate:
  • A change in the prescribed wearing schedule
  • Switch to a myopia control program (Atropine)
  • Termination of lens wear due to:
  • Inability or unwillingness to return to follow-up visits.
  • Poor lens hygiene or Continual breakage due to handling
  • Allergic reaction o Manual dexterity problems which would prevent lens removal, and cleaning.
  • Poor concentration of lenses due to changes in the cornea, astigmatism, asymmetry of cornea, excessive or uneven lid pressure or other factors.
3. I understand that in case Ortho-K contact lenses are not suitable for my eyes, the doctor may choose to switch to myopia control Atropine Program, which also uses therapeutic application in the form of eye drops to help reduce and control myopia.

4. I understand the risk of using contact lenses and complications associated with contact lens usage which also applies to orthokeratology lenses, commonly known as Ortho- K.

5. I understand that this agreement is only for Ortho- K follow-ups visits. I understand that any services that I may need rendered during this therapy treatment caused by poor hygiene will not be covered under the corneal refractive therapy package. I understand that there may be additional medical visit costs if I fail to recognize and abide by the Patient Responsibilities’.

6. I understand that medical conditions are not part of the corneal refractive therapy package and will not be covered under said contracted services.

7. I understand that my Ortho- K lenses should be worn according to the prescribed schedule alter the corneal refractive therapy program to maintain maximum results.

8. I understand that if my child/ ward is under the age of 10, has ASD, or any other debility, and is having trouble inserting or extracting the ortho k lens that it is my responsibility to help them.

9. I understand that this procedure is designed to change my own / Child’s/ Ward’s vision through the process of corneal reshaping.

10. I understand that altered vision through my current eyeglasses and or contact lens prescription lenses is due to the change of corneal curvature results of the corneal refractive therapy. I understand there is no guarantee that my uncorrected vision will improve.

11. I understand that during the program, my doctor has recommended that I keep my backup pair of glasses for emergency use.

12. I understand that I should report all emergencies related to treatment immediately by calling Pupila Family Eyecare or emailing Support@pupilaeyecare.com

13. I understand that if I started the program with a certain case level and within 1 year there should be an increase in my prescription that falls into a different case RX range level, that I am responsible for the price difference.

14. I understand that it is imperative that I schedule my follow-up examinations and agree to keep these appointments scheduled for myself and to follow instructions for contact lens wear and care.

15. I understand that this program does not include any contact lens solution or eye drops and that it is my responsibility to obtain these to maintain the quality of my prescribed Ortho-K lenses.

16.I understand that my doctor has instructed that I use Boston Simplus for the cleaning of my Ortho- K lenses, and that I will use this solution and follow treatment plan for proper cleaning of my lenses.
The following signed by the patient, parent, or guardian for the patient, child, or ward that is participating in the Orthou0002K treatment. The following signed, agrees to the terms of Patient Responsibility and Acknowledgement.
Printed Name:(Required)
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