The treatment options for newly diagnosed keratoconus patients have changed dramatically over the past decade. This is great news for patients who suffer from this disease, because they are usually diagnosed at a young age and it is a lifetime concern for them. For practitioners, it can muddy the waters with respect to our approach to initial steps.
With so many factors playing a role, it can be hard to navigate the next steps for our patients. The first step in keratoconus is diagnosis. Practitioners hope to catch this as early as possible by looking for typical signs such as a refraction that changes annually, increasing astigmatism that is usually not in the principal meridian, and vision that cannot be fully corrected with glasses. Sadly, some patients slip through the cracks due to lack of access to care, socioeconomic barriers, or simply lack of awareness of the need for routine exams.
Create a Care Map
During the 2021 Global Specialty Lens Symposium (GSLS), Christine Sindt, OD, noted that it is important to develop a care map between practitioner and patient. This step includes a long discussion with patients with a description of their diagnosis, long-term care, and eyecare options. It’s here that physicians can begin to develop a game plan.
Define and discuss lens options, if indicated. Clearly, the severity of the keratoconus will direct practitioners to select a specific lens or perhaps even a new spectacle prescription.
Practitioners may also discuss surgical options and their indications such as corneal cross-linking (CXL) for arresting progression (not elimination of the disease). Practitioners can also discuss corneal transplants. Let patients know that transplants are more indicated when all lens options fail or when vision cannot be adequately achieved due to limiting factors such as scars. At the 2021 GSLS, Carina Koppen, MD, PhD, discussed several papers demonstrating that scleral lens design advances have had a significant impact on patients’ need for corneal transplants and that transplant rates for keratoconus are falling.
A key step when discussing the keratoconus care map is to give patients resources. This helps develop a relationship between practitioners and patients and gives patients reliable resources.
For CXL, reiterate that it is indicated early on in diagnosis to halt the progression of the disease. Specific criteria include change in corneal curvature, either by mean keratometry readings or comparison of corneal topography and tomography. Corneal thickness changes may also be a valuable tool with respect to referral. While not completely reliable, a change in refractive error can be taken into account.
Care Over Time
The next step is the longest—care over time. These patients can be with you for decades. At the GSLS, S. Barry Eiden, OD, discussed criteria of progression. Patients need at least two or more of steepening of the anterior corneal surface, steepening of the posterior corneal surface and/or progressive thinning of the cornea (Gomes, 2015). Evaluate patients annually, capture corneal imaging if feasible, and continue to monitor their case. For patients who are wearing lenses, vision, lens fitting relationship, and the condition of the lens are integral parts of their care. I always talk to patients about new updates or developments for keratoconus. Most of these patients are well read, so they may beat you to the punch; but talking with them during their visit helps further cement the relationship. CLS
For references, please visit www.clspectrum.com/references and click on document #305.