20 Pearls for Managing Post-PK Patients With GP Lenses, Part 3
BY EDWARD S. BENNETT, OD, MSED, MARLANE BROWN, OD, DEREK LOUIE, OD, & BRUCE ANDERSON, OD
This is the third in a three-column series pertaining to GP management of a challenging and variable condition: post-penetrating keratoplasty (PK). This article focuses on problem-solving, patient management, and resources available to help with these patients.
Step 14. A problem we sometimes experience with this type of lens is adherence or lens binding. This is particularly problematic with a large-diameter lens on an irregular cornea. Reducing the optical zone diameter should result in better corneal alignment while facilitating tear flow and venting.
Step 15. It is important to use caution when considering soft lenses for these patients. Although some of the new custom soft lenses exhibit success in these cases and custom silicone hydrogel toric lens designs are indicated when GP lenses are unsuccessful, there are risks as well. A tight-fitting lens and/or overwear could lead to neovascularization and ultimately to a rejection episode.
Step 16. Many of these patients are taking some form of corticosteroid drops once or twice a day to reduce the risk of rejection. It is important to reassure patients that it is acceptable to apply the steroid drops prior to lens application and/or after contact lens removal.
Step 17. It is important to bill these patients appropriately. There are many columns in Contact Lens Spectrum as well as resources on the National Keratoconus Foundation Web site (www.nkcf.org) on how to code, bill, and obtain reimbursement for irregular cornea patients.
When performed correctly, this is a practice builder and will be rewarding for both you and your patients. You will likely gain loyal patients for life.
Step 18. Numerous contact lens designs are available for managing these patients including intralimbal, reverse geometry, and hybrid designs. The ultimate success of these patients often depends upon your willingness to trial and error. If one lens design is not successful, it is certainly possible that another design will demonstrate an improved performance.
Step 19. It is essential to order all contact lenses with a laboratory warranty to allow lens changes at a set cost. This may cost more up front, but will save money in the long run as changes in the contact lens design or power are quite common. Likewise it is important to understand the warranty policies of the laboratory you use. Two exchanges are usually allowed under the warranty. Base all follow-up care on the time period of the warranty. Timely follow up and contact lens readjustments are key to reducing costs and optimizing both your bottom line and patient satisfaction with the services you provide.
Step 20. Remember that there are many resources available to help you manage these patients. The most important resources are your laboratory consultants. They can assist with diagnostic lens sets, fit consultation, and troubleshooting.
The GP Lens Institute (www.gpli.info) has many resources available including a case grand rounds online text and a keratoconus management module. In addition, all Contact Lens Manufacturers Association member laboratories and their designs are provided, including the ability to search the categories of keratoconus designs and reverse geometry designs. CLS
Dr. Bennett is an associate professor of optometry at the University of Missouri-St. Louis and is executive director of the GP Lens Institute. Dr. Brown is an optometrist at Minnesota Eye Consultants in Minneapolis, Minn. Dr. Louie is an assistant professor of Ophthalmology at the Oregon Health & Science University in Portland, Oregon, with a practice emphasis on medically necessary contact lenses. Dr. Anderson has a private practice in Tampa, Fla., and is the director of the Contact Lens Clinics at the University of South Florida, College of Medicine Department of Ophthalmology.