Panel: Screen all patients for keratoconus

NEW ORLEANS – Experts agreed that measurement of the posterior elevation of the cornea is required to diagnose keratoconus, and all patients at risk should be evaluated.

A panel of optometrists here at the Optometric Council on Refractive Technology meeting, held in conjunction with the American Academy of Optometry, stated that the incidence of keratoconus is one in 700.

“If it’s that common in the population, perhaps we should look at tomography at baseline and periodically run it on patients perhaps under age 30 years,” panelist S. Barry Eiden, OD, FAAO, proposed.

The panelists agreed that the use of tomography should become more commonplace in primary care optometry in the future.

Clark Chang, OD, MSA, MSc, FAAO, said that the epithelium has the ability to mask disease, and “if you just look at the anterior surface, unless a patient is extremely severe in their keratoconus, you have compounding factors and can’t really pick up disease progression without looking at posterior elevation.”

Clark Chang

Eiden said intraocular pressure is commonly evaluated in teenagers, but, “How common is glaucoma in a 15-year-old? Why aren’t we looking at a disease (keratoconus) that is much more concerning in that age group?”

Bill Tullo, OD, FAAO, DiplAAO, noted that corneal thinning and changes in elevation occur differently in all keratoconus patients, underlying the importance of performing tomography. However, it may be cost prohibitive for a small practice to purchase the technology, and “it becomes a problem in developing a screening process like we’re talking about,” he said. “It’s going to be a challenge to get to that point until the technology becomes more affordable. I would love to screen every relative of patients with keratoconus, because I think we’d pick up a ton of disease, but in most offices it’s not practical.”

Eiden noted when instruments such as tomographers become multifunctional, they can be used more commonly.

Moderator Andrew Morgenstern, OD, FAAO, asked the panelists if they believed optometrists would be screening all patients by 2020.

“For this to become commonplace, we need to get FDA approval for corneal cross-linking and we need to get insurance reimbursement for the procedure,” Tullo said. “Once we get a code that’s reimbursable for a technology that’s expensive, people will start using it.

S. Barry Eiden

Andrew Morgenstern

“Right now, we wait for keratoconus to find us,” he continued. “We wait until patients lose best corrected visual acuity in the phoropter and try to fit them with contact lenses, and then when they’re not happy with their vision, we get a topography. The paradigm has begun to change elsewhere around the world in larger centers that can purchase this type of equipment.”

Chang added that portability will also make a difference.

“Medicine is moving towards prevention,” he said. “We need to diagnose everything earlier before it gets out of control. Multifunctionality of instrumentation, modules to look at tear film – hopefully that will bring more practices to see the value of one instrument.” – by Nancy Hemphill, ELS, FAAO

Disclosures: Chang reports no relevant financial disclosures. Eiden, Morgenstern and Tullo are consultants for Oculus.