BLOG: What every OD should know about keratoconus
In this blog post, we’d like to discuss what we wish everyone knew about keratoconus, its diagnosis and management.
During the coming year, we’ll be blogging individually about several of these topics in more detail, so consider this an overview of what’s to come in this “Mastering Keratoconus” blog.
John D. Gelles, OD, FAAO, FIAOMC, FCLSA, FSLS, FBCLA: I wish everyone knew how important it is to make an early diagnosis. By catching keratoconus early, it can be treated with cross-linking, preventing disease progression and limiting visual and social impact.
The iLink (Glaukos) cross-linking procedure has been FDA approved for nearly 6 years and is the standard-of-care treatment for progressive keratoconus, as well as post-corneal refractive ectasia. Recent modeling shows that early intervention with cross-linking can maximize patient productivity and quality of life, as well as provide cost savings for the patient and the nation’s health care system overall.
Of course, patients can’t get treatment until they have been diagnosed; thus, it is incumbent on the practitioner to find it. Early diagnosis can be tricky and requires the use of advanced diagnostic equipment; however, simple clinical signs can be used to infer the need for further testing. We’ll be talking more in a future blog about red flags that can help speed diagnosis.
Katie Greiner, OD, MS, MBA, FAAO: I wish everyone knew how much advanced keratoconus truly affects quality of life and mental health. Historically, patients were managed in an optometric practice until they could no longer see well in gas-permeable or other specialty contact lenses, then referred to a corneal specialist, so primary care optometrists may not have had much opportunity to observe the symptoms and lifestyle impacts of advanced keratoconus.
It affects just about every aspect of patient life — education, career, family, relationships — and at such a young age. Some of that impact comes from vision loss or treatments to address it (ie, corneal transplantation, managing complicated lenses), but there are also more nebulous effects from young patients simply knowing they have a degenerative disease that causes progressive vision loss.
Next time, I’ll review some of the key evidence on the connection between keratoconus and quality of life. The earlier we can intervene with cross-linking so this condition does not have to become advanced, the better their quality of life will be.
Gloria Chiu, OD, FAAO, FSLS: I wish more people knew when to refer for cross-linking. Cross-linking is indicated for progressive keratoconus or postoperative ectasia, and there is a lot of confusion about how to define the “progressive” part. Contrary to conventional wisdom, it does not mean that the patient must have reduced best-corrected acuity, although that is certainly indicative of progression.
Clinical progression can also be defined by at least 1.0 D change in maximum keratometry (Kmax) over 24 months; a myopic shift of at least 0.5 D or an increase in cylinder of at least 1.0 D within 12 months (even if the patient can still see well with correction); new subjective complaints of glare, halo or other changes in quality of vision that can’t be attributed to conditions such as an aging lens or dry eye; or algorithmic changes on advanced topographic/tomographic diagnostics.
Bottom line: If you think the patient may have keratoconus and is even at risk for progression, refer for a cross-linking evaluation as soon as possible. In particular, closer follow-up and a lower threshold for cross-linking should be adopted in patients younger than 17 years and with a Kmax steeper than 55 D (Ferdi et al).
Christina M. Twardowski, OD: I wish that more people knew about the resources available to help patients with keratoconus understand their disease, connect with others who are on the same journey, and find helpful products and access to doctors.
Two great resources are the National Keratoconus Foundation and the Glaukos-supported Living with Keratoconus websites. There are also some inter-related resources, including the Dry Eye Foundation website and its well-moderated support group, My Big Fat Scleral Lens, that provide support and information for patients who wear scleral lenses. Directing patients to these resources when you first diagnose them with keratoconus or recommend scleral lenses is a great supplement to your in-office education efforts.
Mitch Ibach, OD, FAAO: I wish that more people — doctors, patients and parents — knew that eye rubbing is the No. 1 modifiable risk factor for keratoconus. I’d really like to see this emerge as a key talking point in annual exams with young patients and their parents.
The very first question I ask a patient who is coming to me as a suspect keratoconus patient — or a refractive surgery consult, for that matter — is, “Do you rub your eyes?” It’s very important to educate patients with keratoconus or suspicious topography that they need to stop rubbing their eyes. To help with that, we can treat any underlying conditions, such as dry eye, blepharitis or allergic conjunctivitis, to relieve the itch and discomfort that provoke eye-rubbing.
References:
- Ferdi AC, et al. Ophthalmology. 2019;doi:10.1016/j.ophtha.2019.02.029.
- Lindstrom RL, et al. J Med Econ. 2021;doi:10.1080/13696998.2020.1851556.
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