Background: The aim is to investigate induced higher-order aberrations (HOA)s and astigmatism as a result of non-toric ortho-k lens decentration and utilise artificial intelligence (AI) to predict its magnitude and direction. Methods: Medmont E300 Video topographer was used to scan 249 corneas before and after ortho-k wear. Custom-built MATLAB codes extracted topography data and determined lens decentration from the boundary and midpoint of the central flattened treatment zone (TZ). An evaluation was carried out by conducting Zernike polynomial fittings via a computer-coded digital signal processing procedure. Finally, an AI-based machine learning neural network algorithm was developed to predict the direction and magnitude of TZ decentration. Results: Analysis of the first 21 Zernike polynomial coefficients indicate that the four low-order and four higher-order aberration terms were changed significantly by ortho-k wear. While baseline astigmatism was not correlated with lens decentration (R = 0.09), post-ortho-k astigmatism was moderately correlated with decentration (R = 0.38) and the difference in astigmatism (R = 0.3). Decentration was classified into three groups: ≤0.50 mm, reduced astigmatism by −0.9 ± 1 D; 0.5~1 mm, increased astigmatism by 0.8 ± 0.1 D; >1 mm, increased astigmatism by 2.7 ± 1.6 D and over 50% of lenses were decentred >0.5 mm. For lenses decentred >1 mm, 29.8% of right and 42.7% of left lenses decentred temporal-inferiorly and 13.7% of right and 9.4% of left lenses decentred temporal-superiorly. AI-based prediction successfully identified the decentration direction with accuracies of 70.2% for right and 71.8% for left lenses and predicted the magnitude of decentration with root-mean-square (RMS) of 0.31 mm and 0.25 mm for right and left eyes, respectively. Conclusions: Ortho-k lens decentration is common when fitting non-toric ortho-k lenses, resulting in induced HOAs and astigmatism, with the magnitude being related to the amount of decentration. AI-based algorithms can effectively predict decentration, potentially allowing for better control over ortho-k fitting and, thus, preferred clinical outcomes.
