A plea for universal keratoconus screening for all pediatric patients
Click Here to Manage Email Alerts
The earlier we detect keratoconus, the better our chances of preserving functional vision by stabilizing the cornea with cross-linking treatment.
The initial signs of keratoconus are invisible during a traditional comprehensive eye exam, making early diagnosis challenging. By the time biomicroscopy reveals lagging indicators of keratoconus like apical scarring, Vogt’s striae or a Fleischer ring, there is usually already accompanying loss of best-spectacle corrected visual acuity. To effectively catch keratoconus at first detectable onset, prior to visual impact, it is necessary to screen all pediatric patients using corneal imaging capable of identifying subclinical keratoconus.
Unlike other eye diseases, where the signs are visible during standard examination or codes exist for suspicion, keratoconus has neither. Without a definitive keratoconus diagnosis, billing and coding for such testing is typically not possible. Without a reimbursable code for screening or suspicion, adoption of the necessary devices may not be widespread.
The misconceptions
Many vision plans require keratometry as part of the comprehensive eye exam but auto-keratometry is inadequate for detecting keratoconus, especially at its earliest manifestation. Autokeratometers typically capture only the central 2 mm to 3 mm of the cornea, while the keratoconic “cone” often presents outside of this central area. Simulated keratometry values are poorly correlated with tomographic metrics, frequently underestimating the severity of keratoconus (Greenstein SA, et al).
By comparison, corneal topography provides up to 10 mm of anterior corneal shape data. Tomography goes a step further by measuring the posterior cornea and global pachymetry, allowing earlier detection.
Some may question whether pediatric patients are even able to sit for topography or tomography. A study conducted in a Chicago-based pediatric population included children as young as 3 years, showing that even young pediatric patients could be successfully imaged with tomography (Block SS, et al). This study also demonstrated that with use of tomography in this cohort, keratoconus was significantly more common than previously reported.
The solution, the barriers
Proactive, widespread screening of young patients with corneal topography and tomography is essential, but several barriers must be overcome to achieve this goal.
If screening is not covered by insurance, the practitioner either donates the service or needs to charge the patient for an out-of-pocket service, as we do with ultra-widefield retinal imaging. Unlike widefield retina photos, which have an immediate patient benefit of reducing the need for dilation, topography and tomography provide less of immediate benefit. Accepting an à la carte charge for topography and tomography is a difficult pill for most patients to swallow when keratoconus is not even in the public vocabulary.
Reimbursement — or lack thereof — remains a significant obstacle to routine keratoconus screening. Topography and tomography can be billed once a keratoconus diagnosis is made or, in the case of VSP insurance, annual evaluation of irregular astigmatism may be able to be billed. However, there is no diagnosis code for “keratoconus suspect” when patients have personal or family risk factors or exhibit warning signs such as poor BCVA.
The ask, the argument, the alternative
We need a reimbursed general screening that allows for topography and tomography on an annual basis for patients younger than 18 years. There is an argument to be made for expanding that screening time frame to age 30 years; however, the pediatric population is most critical. Clinicians and professional advocacy associations should fight for insurance coverage for universal adoption. Additionally, “keratoconus suspect” should be adopted into the next revision of ICD codes.
For insurance companies, it comes down to the numbers, so this section is dedicated to the bean counters and how this benefits your company’s wallet. Without advanced diagnostics, keratoconus is often not detected until vision is already lost or overt signs are visible on slit-lamp examination. By that time, expensive interventions such as scleral lenses or corneal transplants may be required, as well as additional follow-up care, complication management, pharmaceuticals and replacement costs, so it just makes financial sense to implement better screening.
Instituting universal annual keratoconus screening would offer significant value. For insurance companies, annual screening enables early intervention, potentially reducing lifelong costs. For patients, it could translate into a higher quality of life. For practitioners, it means the ability to invest in the necessary equipment to perform these tests.
It is possible a judicial ruling could force the adoption of topography or tomography as part of the comprehensive eye examination. For example, in 1974 the Washington Supreme Court ruling in Helling v. Carey triggered the requirement of routine tonometry on persons younger than 40 years, despite the low incidence of glaucoma (one out of 25,000) in this age demographic. The court reasoned that tonometry was required in these cases for patient safety due to the simplicity, low cost and noninvasiveness of this measurement.
Currently, there seems to be an uptick in civil medicolegal claims by keratoconus patients claiming their disease was not diagnosed on a timely basis and that they sustained damages because they did not have corneal cross-linking done in a timely manner. Rather than waiting for a court to determine what health care practitioners should do, eye care practitioners can proactively mitigate their risk in missing subclinical keratoconus by acquiring topographers and tomographers and using them widely for pediatric keratoconus screening.
References:
- Block SS, et al. Invest Ophthalmol Vis Sci. 2022;63:2415-A0218.
- Greenstein SA, et al. Eye Contact Lens. 2023;doi:10.1097/ICL.0000000000001024.
For more information:
John D. Gelles, OD, FAAO, FIAOMC, FCLSA, FSLS, FBCLA, is director of the specialty contact lens division at the Cornea and Laser Eye Institute in Teaneck, New Jersey, and clinical assistant professor in the department of ophthalmology at Rutgers New Jersey Medical School. He can be reached at johngellesod@gmail.com.
Brian Chou, OD, FAAO, FSLS, is the owner of ReVision Optometry in San Diego. He can be reached at bchou@revisionoptometry.com.
Collapse
Read more about
Click Here to Manage Email Alerts