John D. Gelles
by John D. Gelles, OD, FIAO, FCLSA, FSLS
Cornea collagen cross-linking has forever changed the management of keratoconus, representing the single most significant advancement in its treatment since the rigid contact lens and the corneal transplant.
Since the FDA approval of corneal collagen cross-linking (CXL) with Avedro’s Photrexa viscous (riboflavin 5’-phosphate in 20% dextran ophthalmic solution), Photrexa (riboflavin 5’-phosphate ophthalmic solution) and KXL System in 2016, it has become the standard of care for progressive keratoconus.
CXL is designed to stabilize the cornea and prevent progression of keratoconus. Therefore, early diagnosis and treatment is critical in the management of keratoconus, especially in the pediatric population who is at the greatest risk for progression. Primary care optometry is at the front line for early diagnosis in most patients. It is incumbent on our profession to adopt practices and technology to properly diagnose patients with keratoconus and monitor for related progression. Any patient, particularly a pediatric patient, with reduced vision or a difficult refraction should be suspected and worked up to rule out this disease.
The management of keratoconus has always been a collaborative care model, with optometry utilizing nonsurgical options in the form of specialty contact lenses and with ophthalmology performing surgical procedures such as intracorneal ring segments and various forms of corneal transplantation when contact lenses do not provide adequate vision or comfort. With CXL, the relationship between optometry and our ophthalmology colleagues must be even closer, as ideally CXL should be performed before adverse visual sequelae occur.
The care of these patients has changed from a model where practitioners could only stand by and observe as keratoconus progressed to now taking action when progression is identified. This new model is similar to the management of glaucoma. Based on risk factors, such as age, family history, level of disease and visual acuity, patients are monitored more closely, and early intervention with CXL can be implemented to prevent progression. This will prevent advanced disease states and the need for corneal transplant in the future.
It is important to note that although CXL is more than 90% successful at stopping progression of keratoconus, a small percentage of patients will still progress and may require retreatment. Therefore, it is essential to continue to monitor these patients for progression postoperatively.
CXL has also provided renewed interest in visual correction with surgical procedures such as topography-guided PRK. In our clinic we have seen encouraging results utilizing this technique, as well as other vision correcting procedures for patients with keratoconus. Future blogs will delve further into these promising procedures.
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John D. Gelles, OD, FIAO, FCLSA, FSLS , is the director of the specialty contact lens division at the Cornea and Laser Eye Institute-Hersh Vision Group and the CLEI Center for Keratoconus, a subspecialty clinic dedicated to research and treatment of keratoconus, in Teaneck, N.J. His clinical work is dedicated exclusively to specialty contact lenses and surgical comanagement for keratoconus, corneal disorders, ocular surface disease and postsurgical corneal conditions. He is a subinvestigator for multiple keratoconus-specific clinical trials.
Disclosures: Gelles reports he is a consultant and speaker for Avedro, BostonSight, SynergEyes and Visionix; an advisor to and speaker for Gas Permeable Lens Institute; and an executive board member and speaker for the International Keratoconus Academy.