Collaborative care needed for patients with keratoconus
At Bascom Palmer Eye Institute, we are fortunate to have a large network of clinicians who refer patients to our cornea service.
In many cases, these patients have already been diagnosed with progressive keratoconus and are being sent for an evaluation for cross-linking. As awareness of cross-linking has grown, I am increasingly seeing patients early in the course of keratoconus, which is great news.
But every week, I also see patients who I wish had been sent to me 10 years earlier. As cornea specialists, we have the capacity to preserve patients’ corneal stability and vision with cross-linking, but that ability is dependent on timely referrals, which are in turn dependent on a strong referral network and collaborative relationships in the local community. Here are seven steps for improving both:
- Proactively reach out to local referral sources to share that you perform cross-linking and explain the types of patients to refer and when they should be referred. Many people assume that medically-oriented private practice optometrists and scleral lens specialists who enjoy managing keratoconus will be the ideal referral sources. They may be, but don’t forget about optometrists who practice inside “big box” stores like Costco and Target. These ODs serve many families, and I find that they are willing to refer children and teens who raise red flags, such as those who have high astigmatism or are not correctable to 20/20. Pediatric ophthalmologists, refractive surgeons who do not do cross-linking and allergists can also be good sources for referrals of patients with keratoconus.
- Once a connection is made, try to get to know each referring doctor a little bit better, whether that be through continuing education seminars, personal visits or phone calls or by hosting them to observe surgery. A closer connection builds trust and helps to ensure that transfers of information can happen more smoothly in both directions.
- Find out who has topography capabilities and make sure they know to send the last several topography exams with the patient. With topography becoming less expensive, more mobile and more integrated into multiuse autorefractors, I recommend that my referral partners consider getting one. Built-in AI algorithms in these devices can quickly identify suspicious topographical findings and prompt a referral, as well as make keratoconus easier to follow over time.
- Emphasize to referring doctors that they do not have to spend a lot of time educating their patient about keratoconus treatment, but they do need to be clear about the urgency of the referral. If a patient or parent is just handed a sheet of paper with a cornea specialist’s contact information, they may wait months or even years to make the appointment, not realizing that keratoconus can continue to progress.
- Send a letter to the referring doctor after cross-linking or a corneal transplant, detailing what procedure was performed, when the patient should return to me and when they can return to contact lens wear.
- Empower patients to access and save their own information. We have an internal portal that patients can access, including from a mobile phone, to share exam notes and topography images with their other doctors. I also encourage any patient with a lifelong disease like keratoconus to maintain a file of their own health information.
- Always send the patient back to the referring doctor once they are stable to optimize their vision correction. Although we do have a large optometry and scleral lens service at Bascom Palmer, we also collaborate well with optometrists in the surrounding counties, and we refer back and forth with these providers all the time.
I am encouraged by the changes we have seen in keratoconus management in the past decade. The availability of cross-linking has changed many lives for the better by preventing vision loss and halting progression of the disease. The International Keratoconus Academy of Eye Care Professionals is a great example of ophthalmologists and optometrists working together to improve the care of patients with keratoconus over their entire lifetime. As awareness and collaboration continue to grow, it can only be to the benefit of our patients.
- For more information:
- Kendall E. Donaldson, MD, MS, Healio | OSN Technology Section Editor, professor and the Rodgers Clark Endowed Chair in Ophthalmology at the University of Miami Bascom Palmer Eye Institute, and medical director of the institute’s office in Plantation, Florida, can be reached at kdonaldson@med.miami.edu.
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