Various experts in the field of keratoconus share clinical pearls for managing and comanaging the condition as well as the latest diagnostic and treatment options, including corneal cross-linking. Image: John D. Gelles, OD, FIAO, FCLSA, FSLS, and CLEI Center for Keratoconus

BLOG: Make that cross-linking referral

Katie Greiner

by Katie Greiner, OD, MS, MBA, FAAO

Cross-linking is the standard of care for patients with progressive keratoconus. It is my belief that we are doing the patient a disservice to not offer it as an option in the repertoire of care for this disease.

Treating these patients when they are young, just starting to show early corneal changes and still correctable to 20/20 in glasses or contacts makes all the difference in their future quality of life.

The population most afflicted by this disease are those in their budding years of higher education or early establishment of their careers and family life – all crucial life events that require good vision.

When the disease progresses with further corneal steepening and thinning, striae and corneal haze can also appear, causing loss of best corrected visual acuity. At this point the patient is fully reliant on complicated contact lenses and, if the disease is too progressive, it may lead to a deep anterior lamellar or penetrating keratoplasty. CXL no longer becomes an option at this point, and the patient is left asking, “What if?”

I work in a busy OD-MD referral center that does not yet offer corneal collagen CXL simply because the larger hospital systems around us do and are very willing to accept new patients. With this partnership, we can comanage the procedure with our patients shortly after it occurs.

Topography shows inferior steepening, indicating keratoconus more in the right eye than the left.
Source: Katie Greiner, OD, MS, MBA, FAAO

To help other eye care practitioners understand the right time for a referral, meet RW, a 22-year-old African American male who presented to the clinic with complaints of a fluctuating spectacle prescription for the past 6 months in his right eye more so than his left. He stated that his vision never seemed to be corrected clearly despite multiple new glasses prescription attempts. RW also reported that his older brother was diagnosed with keratoconus 10 years prior. RW wore daily disposable soft contact lenses and had no prior concerning ocular history nor did he take any medications for any systemic issues. He did report occasional eye rubbing that was not severe.

His current glasses and contact lenses were -2.00 D OU, with visual acuity of 20/40 “blurry” OD and 20/20- OS. With a manifest refraction of -2.75 D +2.75 D x 180 he was correctable to 20/20 OD (but still blurry), and with a -2.25 D sphere he was 20/20 OS. A slit lamp exam revealed mild thinning of the right cornea but no striae or scarring. The left eye showed trace thinning and was otherwise clear. The rest of the slit lamp, IOP and dilated fundus exams were deemed normal. Topography was performed, and the accompanying images showed inferior steepening, indicating keratoconus more in the right eye than the left.

It was clear cut from RW’s case that his right eye was showing progression in the cylindrical component of his spectacle Rx as well as his corneal astigmatism. His symptoms of fluctuating and blurring vision were worsening, and his brother had a 10-year history of keratoconus. The conversation easily flowed into making the impending diagnosis and referring out for the corneal collagen CXL procedure even before pursuing the option of specialty contact lenses. His mother was a huge advocate for the procedure after further researching it, and he was evaluated just a few short weeks after our initial exam.

I am happy to report that RW has successfully undergone CXL in his right eye and was fit in a scleral lens with BCVA of 20/20 (clear), and his left eye will be undergoing CXL in the very near future. This 22-year-old Master’s student has a whole life ahead of him that will not bear the burden of keratoconus – but could have if the disease kept progressing at the rate it had in just 6 months.

I urge you to do what is best for your patients and make that CXL referral!

For more information:

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:

Disclosure: Greiner reports she is a consultant for Acculens and Avedro.