BLOG: What new ophthalmologists will know that we did not
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Standards for care in keratoconus have been changing rapidly. As today’s residents and fellows prepare to enter practice, they will have a completely different perspective on this disease than ophthalmologists who are more experienced.
We now have more advanced diagnostic imaging, better contact lens technology and the ability to halt progression with corneal collagen cross-linking. I hope that residents and fellows across the country are getting good exposure to cross-linking and the latest scientific developments in the management of keratoconus. For those who are not, it is critical to seek out continuing education so they can be equipped with the necessary tools to clearly identify and stop progression of this disease at an early stage.
Like many things in medicine, knowing what to look for is half the battle. The availability of tomography-based systems like the Pentacam (Oculus) that allow us to image the posterior curvature of the cornea have become important for accurate diagnosis. We definitely want our residents and fellows at UC-Irvine to leave with a strong foundation in the interpretation of both topography and tomography. Imaging is always reviewed by a cornea faculty member who can ensure that the resident isn’t missing any subtle changes in the posterior cornea when evaluating the patient with keratoconus.
As we get more sophisticated at looking for keratoconus, we are likely to find more of it. Tomorrow’s ophthalmologists will likely start from the presumption that keratoconus is relatively common. Recent studies suggest that historical assumptions of a prevalence of 1:2,000 are probably grossly underestimated.
The young cornea specialist will also have a completely different decision tree for keratoconus than I did starting out. Rather than watchful waiting and performing a penetrating keratoplasty when needed, they have better options to offer patients. Residents here are given significant exposure to patients with suspected keratoconus. They are encouraged to be the “captain of the ship,” managing patients’ care (with oversight, of course) from the initial consultation through post-treatment follow-up. We want them to understand not only how to evaluate the irregular cornea, but also how to track progression and understand differences among patients in the speed of progression. They also need to know how to manage patient expectations, discuss risks and deal appropriately with discomfort after cross-linking. In fact, learning all of these lessons is probably more important than doing the procedure, which has a relatively quick learning curve.
Not every patient will require cross-linking, but it should always be considered as part of the decision tree. In addition, there have been significant developments in specialty contact lenses that allow more patients to achieve good vision for more years. My hope is that residents who are graduating today will rarely need to perform a PK for keratoconus during their careers. Certainly, they will come out of training with much more advanced knowledge about keratoconus and its treatment than their predecessors.
Reference:
- Godefrooij DA, et al. Am J Ophthalmol. 2017;doi:10.1016/j.ajo.2016.12.015.
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