BLOG: A smooth handoff to the referring doctor after cross-linking
Key takeaways:
- Ophthalmologists must know how to transition patients back to their referring doctor.
- Communication with both the patient and the referring doctor is key.
As cornea specialists, we talk a lot about how to get timely referrals of keratoconus patients from optometrists and ophthalmologists who don’t perform cross-linking.
But it is also important to recognize our role in transitioning the patient back to the referring doctor. To me, there are three key elements of a successful handoff.
Setting expectations with the patient
First, it is important to educate the patient about what to expect. They don’t necessarily understand the distinctions among different types of eye care providers and who does what. I explain that, because I don’t see a lot of patients for long-term general eye care, I’m going to send them back to their doctor, who is more than capable of continuing to care for their eyes, as soon as the eye is healed, around the 1-month mark. We want the patient to understand that, just because they underwent cross-linking, they aren’t “done.” The underlying disease, keratoconus, is one that requires monitoring over time (initially by me and later by their regular eye care provider). It is important that they return for follow-up appointments so that we can make sure there aren’t complications or continued progression. I also try to set expectations for changes in their vision, return to contact lens wear and the timing of cross-linking the second eye.
Exchanging information with the referring doctor
Secondly, it is important to communicate effectively with the referring doctor. I send a letter explaining what was done, any future plans (for the fellow eye, for example) and necessary follow-up. I ask them to keep me informed about their findings and any concerns that arise after cross-linking. Issues that would warrant a call or referral back to me include significant pain or discomfort, a significant drop in vision that is not correctable and any signs of infectious keratitis. In talking to referring doctors, I educate them that fluctuating vision and some foreign body sensation are normal and that some postoperative haze — which I am careful to distinguish from a corneal infiltrate — is to be expected.
I typically see cross-linked patients and review their topography/tomography 3 to 4 months after cross-linking and then at 6-month intervals during the first year or two to make sure they are stable. During that time, they may also see the optometrist for vision correction. Timing of the return to the referring OD can vary but may be as soon as 1 month after cross-linking, at the discretion of the referral partners.
Interpreting topography/tomography after cross-linking can be tricky; it is easy to mistake normal corneal remodeling for progression if one is looking at only the keratometry values on topography/tomography, without visual changes and difference mapping for context. Once the eye is stable, they can be followed annually by the referring doctor.
Addressing vision correction
Vision correction can be the easiest or the most complicated part of the transition back to the referring doctor. The easy part is that correction with contact lenses is very much in the wheelhouse of a referring optometrist. I understand that there is as much nuance with contact lenses as there is with IOLs, and I am happy to leave the specific lens recommendations and fitting to the experts. One challenging aspect is that patients are often disappointed not to immediately have clear vision after cross-linking. We explain that they may still want to use their habitual lenses or glasses for a few months until the cornea has stabilized to a degree, after which they can invest in a new prescription, but I encourage them to discuss the timing of that with their optometrist. For those who were already wearing scleral lenses, lens wear can be resumed as soon as 1 to 2 weeks after the initial healing after cross-linking because the lens vaults over the cornea and rests on the sclera. Again, the referring optometrist can help to figure out the exact timing and type of lenses if a change is warranted.
The bigger challenge is when I know the patient would benefit from scleral or other types of advanced lenses, but their referring doctor doesn’t fit specialty lenses at all. I tell the patient I can make a referral to a contact lens specialist, but I also suggest they ask their regular eye care provider for recommendations, as well.
Ultimately, a commitment to respect and good communication by both parties is helpful in ensuring a smooth handoff and successful collaborative care that is always in the patient’s best interest.
For more information:
Sumit “Sam” Garg, MD, a professor of ophthalmology, vice chair of clinical ophthalmology and medical director at the Gavin Herbert Eye Institute at the University of California-Irvine, can be reached at gargs@hs.uci.edu.
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