BLOG: More patients may benefit from cross-linking under anesthesia
Click Here to Manage Email Alerts
Key takeaways:
- Young patients with keratoconus must be treated with cross-linking as quickly as possible.
- These patients may benefit from cross-linking under general anesthesia.
When children and teens present with early onset of keratoconus, we often see severe disease and rapid progression.
As a pediatric ophthalmologist, I have unfortunately seen many cases in which a young patient already has hydrops, corneal scarring or a significant loss of vision. It is not uncommon for me to make a keratoconus diagnosis in a young patient who is not only not vision corrected but has never even had an eye exam. We know that the disease often presents asymmetrically, and so kids will naturally rely on the “good” eye without even realizing they are doing so. School vision screenings that don’t test uniocular vision can easily miss frank keratoconus.
Kids are poor candidates for corneal transplants because there is a high rate of rejection and a high likelihood of needing multiple transplants over their lifetime, along with additional risks from the potential development of glaucoma or cataract. So, it is very important to treat young patients with FDA-approved iLink (Glaukos) cross-linking as quickly as possible to prevent further progression.
However, there are barriers to cross-linking children (and adults with neurocognitive disabilities like Down syndrome or autism). Young patients may be anxious or developmentally unable to sit still for the duration of the procedure. Being able to offer cross-linking under general anesthesia, as we do at the University of California San Francisco, is a major benefit for vulnerable populations who are most in need of treatment.
We have shown that cross-linking under general anesthesia is just as successful as cross-linking performed in the clinic, with no anesthesia-related complications. However, it is also more resource-intensive and more expensive to perform cross-linking in an operating room. Many private practice clinicians don’t have the infrastructure to be able to perform the procedure under anesthesia, so it often makes more sense to refer out to a university or other tertiary care center that is experienced and comfortable with cross-linking in the OR setting.
Who qualifies?
I don’t think an age cutoff for general anesthesia makes sense. I have seen very stoic and mature 12-year-olds who handle the procedure beautifully under local anesthetic, while some 17-year-olds are extremely anxious about cross-linking and would benefit from general anesthesia.
I explain the procedure and both options — local and general anesthesia — with the patient and parents in the room. Teens and pre-teens are old enough to assent to the procedure even if they can’t provide legal consent. I want everyone to understand what the experience will be like and what options they have. I can determine a lot just from that conversation. We also purposefully perform applanation tonometry to check IOP. If the patient can’t even handle us touching their eye with numbing drops, I would more strongly suggest general anesthesia.
It is important to disclose that there could be a higher cost to the patient if they are cross-linked under general anesthesia. However, I have not had problems getting anesthesia approved by insurance companies if they are otherwise covering the procedure. Many pediatric procedures, including routine dental care, are performed under general anesthesia when that is the best way to perform a needed service safely.
I encourage colleagues who perform cross-linking to consider offering it under general anesthesia. If access to an OR-based iLink device is not available, find out whom you can refer to in your region. One source to check is the doctor locator on https://kcfinder.glaukos.com/ and search for providers offering “special needs procedural accommodations.” It could be the only way to save the vision of your young and developmentally disabled patients with keratoconus.
Reference:
For more information:
Maanasa Indaram, MD, can be reached at maanasa.indaram@ucsf.edu.
Collapse