BLOG: I made that cross-linking referral ... now what?
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by Katie Greiner, OD, MS, MBA, FAAO
If you read my post a few months back titled, “Make that cross-linking referral,” we are going to follow up on my patient, RW, a 23-year-old man at the start of his career and postgraduate school with progressing keratoconus in the right eye more so than the left.
RW underwent corneal collagen cross-linking in his right eye in May 2019. The image shows his Oculus Pentacam reading for that eye 2 months after the procedure.
It is imperative to remind patients that cross-linking will not improve their condition or their vision, but it will halt the progression of the disease. For a busy 23-year-old man, this was essential. With the development of his career and family life ahead of him, stopping this debilitating disease from causing his vision to worsen was the only option in his mind. To achieve his best vision, however, RW also understood he would need to be fitted with specialty contact lenses after the procedure.
Practitioners may vary the time before fitting the patient for a contact lens after cross-linking, and they should always wait longer if it is going to be a gas-permeable lens resting on the cornea. I will typically initiate a scleral lens fit beginning at about 1 month postoperatively if the patient’s corneal surface is healed and they have been weaning off their postoperative medications appropriately. If they wore a scleral lens before cross-linking, I encourage them to bring it to their 1-month visit and try it on for me to evaluate. There are many times it still works very well, and I do not need to refit. Other practitioners like to wait up to 3 months for any type of contact lens fit to ensure the Ks have stabilized.
Because scleral lenses have some forgiveness due to the post-lens tear film, and because these patients rely heavily on the sight that these contact lenses provide, I felt comfortable fitting RW at 1 month. He was anxious to get into scleral lenses for the first time and to use the vision in his right eye again. His cornea was free of haze, his postoperative Ks were 42.20/45.30 at 100, and he was still using steroid eye drops twice daily. I informed him that he could use the drops 5 minutes to 10 minutes before lens insertion and again after removal so it would not interfere with his lens wear. I also encouraged him to liberally use wetting drops over the contact lens for comfort and continued healing.
I started him in a scleral lens with a diameter of 16.4 mm, a base curve of 7.67 and a sagittal height of 4.90 with a front toric power of –4.00 D -2.00 D x 075, correcting him to 20/20. The first lens dispensed needed a slight modification due to some slightly excessive movement of the lens and the patient reporting feeling the lens when he blinked. By steepening the furthest peripheral curve by one step 360°, the next lens was the final lens for him.
He struggled with insertion and removal training, seemingly apprehensive to cause harm to his newly cross-linked eye. I reassured him that this would not happen, and it helped when he realized the lens did not touch the cornea itself. By explaining that the bowl of the lens was filled with a preservative-free saline that bathes the eye in moisture all day, his fear of scleral lenses started to fade.
At this point, the keratoconus in his left eye is stable and, although he is at an age where progression is very common, the corneal surgeon does not feel surgery is currently necessary. He is monitored every 6 months due to the likelihood he will eventually need surgery. His insurance plan did not allow coverage for the right eye, so he hopes his plan will be onboard when the next eye is ready. With the rate at which insurance plans are now covering this procedure, chances are good. For now, he is 20/20 best corrected in a well-fitting scleral lens for the right eye. I saw him 3 months after dispensing, and he reported no concerns, and the cornea looked clear. I plan to see him every 6 months to monitor the fit of the lens and for any progression in either eye.
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Katie Greiner, OD, MS, MBA, FAAO, is chief operating officer and a practicing optometrist at Northeast Ohio Eye Surgeons, located in Stow, Kent and Akron. She completed a surgical comanagement and contact lens residency at Davis Duehr Dean in Madison, Wis. She can be reached at: kgreiner@neohioeyes.com.
Disclosure: Greiner reports she is a consultant for Acculens and Avedro.