1. 1 Corneal MoldStarter Kit | [Type the companyname]
Meet the Doctor
PeterE. Wilcox,O.D.
Dr. Wilcox grew up on the Peninsula with
eleven brothers and sisters.Dr.Wilcox and
his wife, Robin, livein Williamsburgwith their
children,Jacob,Max and Matthew. He
understands the importanceof family.As a
patient of the Wilcox Eye Center, you can
expect to be treated as a member of our eye
carefamily.
Dr. Wilcox earned his Bachelor of Science
degree from the College of William& Mary.
He was awarded his Doctorate of Optometry
from The University of Alabama at
Birminghamand completed a residency in
ocular diseaseatThe Eye Institute in
Philadelphia,Pennsylvania.Becauseresearch
continues to alter the world of eye care,Dr.
Wilcox is committed to continuous study. He
has extensive trainingand experience in
glaucoma treatment, cataractand refractive
surgery co-management and specialty
contact lenses,includingcorneal molding
Tyndall Square, Ste. 1
2652 Geo. Wash. Memorial Hwy
Hayes, Virginia 23072
Phone: 804-642-9800
Fax: 804-642-0334
www.wilcoxeye.com
Orthokeratology
Ortho-k is the scienceof altering the curvature or shape of the cornea to
change how lightis focused on the retina.The cornea separates the eye from
the outside world.It also has a curvaturethat bends lighttowards the back of
the eye; it is responsiblefor most of the eye's corrective power.
One key procedure to designingthe mold is the mappingof your cornea. To
do this an instrument called a Topographer is used.Just likea topographical
map of a campingarea showinghills,plains,and valleys;topography of the
eye shows the doctor exactly how your cornea is shaped.The information
from your corneal mappingplus your prescription is needed to design the
retainer lenses (corneal molds).
On the day you pick up your Ortho-k retainer lenses you will beinstructed in
how to insert, remove, and carefor your vision retainers.
Welcome to Corneal Molding

2. 2 Corneal MoldStarter Kit | [Type the companyname]
EveningInstructions:
 Prior to handlingthe molds,wash your hands with a mild non scented soap.
 Never squeeze the molds between your fingers.This can snap the lens in half.
 To insertthe molds,remove molds from their case,rinsewith salinesolution if needed, and placea mirror face up on
counter (do not use the wall mirror).Placeone drop of a salinesolution or rewetting drop in the bowl of your mold.
Tiltyour head downward as you bringthe mold upward (this prevents dumping solution outof the bowl during
insertion).
 If you wake in the middle of the night, instill onedrop of Refresh on top of molds before you go back to sleep.
 Prior to handlingthe molds,wash your hands with a mild soap
 When you wake up in the morning, put one drop of Refresh Tears or similardrop in both eyes, closeeyes and roll them
around.Wear your molds for a few minutes prior to removal.
 Remove the molds by plunger method or pinchingmethod.
 Rub both surfaces of the molds with Sauflon solution and CleaningSponge in palmof hand.
 Once a week rub surfaces with Optima Extra Strength Cleaner or Boston Cleaner with CleaningSponge.
 Store them in proper basket and store in Sauflon solution.Your lens must soak for a minimum of 6 hours.
Whenindoubt,remove the moldsandcall the office!
Phone: 804-642-9800
Morning Instructions:
Care Regimen

3. 3 Corneal MoldStarter Kit | [Type the companyname]
Figure 1
Figure 2
Figure 1: Sauflon One StepHydrogenPeroxide
Cleaner.Thisisusedtodisinfectandstore CM
duringthe day.Rub lenswithSaufloninpalmof
handprior to placingCMin basketforsoaking
Figure 2: Bausch&LombSensitive EyesSaline.
Moldsmay be rinsedwiththis,if desired,after
removal fromSauflon.Mayalsobe usedto rinse CM
if droppedonany surface before insertion
Starter Kit

4. 4 Corneal MoldStarter Kit | [Type the companyname]
Figure 3
Figure 4
Figure 5
Figure 3: RefreshLiquigelrewettingeye drop.Priorto
insertiondispense2dropsin "bowl"of CM. Insertone drop
each eye duringthe nightif youwake.Insertone dropinthe
morningafterremoval of molds.
Figure 4: OptimumExtraStrengthCleaner.Use withsponge
to cleanCM, prior to peroxide(Sauflon)soaking.Removed
depositsof oils,lipids,salts,andcosmeticresidue.Use as
oftenas desiredbutaminimumof once a week.
Figure 5: Bausch&LombBostonAdvance Cleaner.Most
commonlyfoundcleaneravailableinstores.Same directions
as Optimum

5. 5 Corneal MoldStarter Kit | [Type the companyname]
Figure 6
Figure 7
Figure 8
Figure 6: Easy EyesCleaningSponge.Use withcleaning
agentsto remove stubbornbuild-up.Wetsponge, apply
sufficientamountof cleaner,andrubfor 20 secondson
eitherside.Rinse thoroughlywithsaline solution.
Figure 7: RGP/CMPlunger.Assistsinremoval of lens.
Wet endof plungerandplace directlyoncenterof CM.
Figure 8: Drain Stopper/Strainer:Notincludedinstarterkit.
Recommendedforbathroomwhere CMwill be primarily
insertedtopreventCMfor goingdownthe drain.Can be
foundat any local hardware store.

6. 6 Corneal MoldStarter Kit | [Type the companyname]
_______Applicable to minors only: By lawwe may not fit minors without parental or guardian consent.Initialinggrants us
permission to fit your child with corneal molds.This also confirms your responsibility to ensure your child understands CM
FittingPacket and will comply with the regiment.
_______Use of CM has been approved by the FDA for daily wear but not for overnight wear. Initialingconfirms you been
informed the molds fitted for you are being used in an off-label manner.
_______Statements and prices listed on Corneal Molding Agreement have been explained thoroughly and to my understanding.
_______I am aware RED LENS = RIGHT EYE/ YELLOW LENS = LEFT EYE.
_______Each solution and cleaningagenthas been explained thoroughly and I am aware of their use and purpose.
_______I am aware any bottles with a RED cap are potentially damagingto my eye if inserted directly before solution is
neutralized.
_______I have been explained and taught how to remove my CM with use of a lens plunger or a pinchingtechnique.
_______I have been informed to put Refresh Liquigel or other recommended lubricantsin the bowl of my lens prior to insertion.
_______I have been informed anti-bacterial non-scented soap is recommended by Dr. Wilcox prior to handlingmy molds.
_______I have been informed to contact the Wilcox EyeCenter immediately if my eye becomes irritated and/or decreased
vision is experienced (804-642-9800).
Patient’s Signature Date _______________________
Parent/Guardian Date ____________________ __
Technician’ Initials Date _______________________
Initials required by guardian next to the following statements
Corneal Molding Training & Consent

7. 7 Corneal MoldStarter Kit | [Type the companyname]
 Customcomputer based Corneal Mold designs.
 Dispensing office visit with insertion and removal training along with product care training.
 Initial products for care of your Corneal Molds.
 Follow-up office visits for the first six months
 Topography imaging at each appointment for thefirst 6 months
 Up to 2 molds per eyewithin the first 6 months, as determined by the doctor.
Guarantee: If circumstances prevent you from continuing your treatment during the first three months of care, the Wilcox Eye
Center will gladly refund 50% of the Corneal Mold fees.
Continued Care Maintenance Program: Cost: $000.00
 12 month annual comprehensive eye exam. This includes refraction, topography imaging, and an evaluation of your
eye health (neurological assessments, measurement of internal eye pressure, and a thorough examination of the
internal and external structures of the eye).
 Corneal mold evaluation and Progent cleaning of lenses.
 18 month - Corneal Mold evaluation and a Progent cleaning of theMolds. (Progent is a protein remover, disinfectant,
and intensive cleaner that treats against all organisms likely to contaminate lenses, including bacteria, molds, yeasts,
and viruses).
Continued Care Fee for Service: Cost: $000.00
 Annual comprehensive eye exam (recommended once a year): $000.00
 Corneal mold follow-up office visit (recommended every 6 months): $00.00
 Progent cleaning of the CM (recommended every 6 months): $00.00
The statements and prices on this document have been explained to me thoroughly and to the best of my understanding.
In agreement with Dr. Wilcox my child is/I am being fit with a level _______ corneal mold regimen. Furthermore I am
selecting the_____ month for continued care.
_____________________________________ ________________
Patient Signature (parent if under 18) Date
Included Services with Selected Level
Interest-Free Financing
by Citi Health Services
Payment in Full
10% payment in full discount applied
Level 1 $0000* $000*
Level 2 $0000* $0000*
Level 3 $0000* $0000*
Level 4 $0000* $0000*
Level 5 $0000* $0000*
Level 6 $0000* $0000*
Level 7 $0000* $0000*
*prices subject to change without notice*