BLOG: Choose the transplant-saving path
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Key takeaways:
- Ophthalmologists should look for alternatives to corneal transplants whenever possible.
- Cross-linking and scleral lenses are available to treat keratoconus.
We are still performing too many corneal transplants for keratoconus — and I say that as a cornea transplant surgeon.
With today’s cross-linking and scleral lens technology, I believe that we do patients a disservice in performing a corneal transplant unless the cornea is opacified with a true vision-limiting scar. Consider that even a successful corneal transplant still entails months of recovery postop and a lifetime of regular doctor visits, medications and precautions. I saw a patient who underwent his first corneal transplant a decade ago at age 18 years, before the availability of cross-linking. He had a great outcome: 20/20 uncorrected vision. But he was roughhousing with a friend in school one day and popped his graft open. We took him back to the operating room and were able to get him to 20/20 again following that second surgery. After that, he was lost to follow-up for a few years, became medically noncompliant and experienced a graft rejection. With steroid treatment, he is back to 20/20 again, but he’s still at risk for glaucoma and early cataract formation. There’s also a high likelihood he’ll need another graft in his lifetime even if he is perfectly compliant. Is this truly a success?
The availability of corneal cross-linking with iLink (Glaukos), the only FDA-approved cross-linking system, is certainly helping to reduce the number of transplants that cornea surgeons perform because cross-linking has the potential to halt further progression of the disease. Researchers in Norway recently demonstrated that the number of penetrating keratoplasty procedures for keratoconus dropped by about 50% within 8 years of the approval of cross-linking in that country and by 80% within 15 years of the approval of cross-linking. Cross-linking should be the first priority for any patient who is still progressing or is young and has a high chance of progression.
Even after cross-linking or stability of the cornea with age, I will no longer perform a transplant on a clear cornea just because it is steep or just because the visual acuity is poor until we have proven that better vision with specialty contact lenses is not possible. Here are three myths I have heard used as justifications for transplanting an unscarred cornea.
Myth 1: They have terrible vision with glasses and meet the criteria for a PK.
I have seen many patients with advanced keratoconus who are completely dysfunctional (20/80 to 20/200 or worse) in glasses, but they have never really tried a contact lens. Such patients are often told the next step is a corneal transplant. But, as with the example I shared above, a transplant is a big deal, especially for a young person. I would always recommend trying a scleral lens first to see if the vision can be improved before proceeding to a PK. I have seen many patients who were 20/400 in glasses and had very steep keratometry readings, in the 70s and higher, achieve 20/20 vision in scleral lenses. It is worth a try.
Myth 2: They are contact lens intolerant so a transplant is the only option.
A claim of “intolerance” is often based on experience with soft or gas-permeable (GP) contact lenses years ago. A well-fitting hybrid or scleral lens is completely different from a soft or GP lens, and in my experience, most people are able to tolerate these more specialized lenses. Additionally, if their prior contact lens experience was before cross-linking, tolerance may improve after cross-linking, when the cornea has gone through the remodeling and reshaping process. Anyone who treats keratoconus patients should have a good referral relationship with a local scleral lens specialist if you don’t offer that service in your practice. I feel so strongly about the benefits of these lenses that I would say if you can’t find a local optometrist who fits them, you should hire one, refer to a wider radius or even learn to do it yourself — it’s that important.
Myth 3: The patient will probably be noncompliant, so contact lenses aren’t a good idea.
Teens or young adults are at high risk for life getting in the way of good compliance, but that is the case both with contact lenses and with post-graft medications and follow-up. These patients are often at an age where they move frequently, are uninsured or underinsured, and have active lifestyles, putting their grafts at risk. I’d rather test their compliance with a contact lens than with a transplant.
Ultimately, we must consider not just the patient’s visual acuity but their lifetime risks in deciding on how to manage their keratoconus. I know that for myself or a family member, I would always prefer to avoid or postpone a transplant as long as possible. Cross-linking and scleral lenses can be transplant-saving and life-changing.
Reference:
For more information:
Kenneth A. Beckman, MD, FACS, of Corneal Surgery at Comprehensive Eyecare of Central Ohio, can be reached at kenbeckman22@aol.com.
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