MANY PATIENTS who have moderate to advanced progressive keratoconus (Figure 1) will need both collagen corneal cross-linking (CXL) to stabilize the cornea and rigid contact lenses to optimally correct vision. The decision of which to offer first depends on many factors, including patient history, lens wear experience, current visual function, and insurance requirements. Below are the options for fitting scleral lenses for patients in 4 common scenarios.
New patient with vision worse than 20/40: The process of cross-linking both eyes, assuming both eyes are progressing, and getting the patient fully back in contact lenses might take as long as 4 to 6 months. If the patient can’t see well enough to drive or function in school, fit them in scleral lenses first while starting the prior authorization process for CXL. My goal is to improve the patient’s vision with contact lenses within 2 to 3 weeks.
Once the patient is no longer struggling with blur or double vision, schedule CXL. Notably, although some patients may be most motivated by vision concerns, it is important to also explain why CXL is necessary to prevent further vision loss.
Current lens wearer with minimal vision loss: This type of patient may have been referred by a colleague as a keratoconus suspect, or may have just begun to progress after a period of stability. This is the ideal stage at which to perform CXL—when the patient’s best vision can still be preserved.
In these cases, my preference is to refer the patient for CXL as soon as possible and then refit them in new contact lenses, if needed. A patient who is already wearing scleral lenses should be able to wear the same lenses after CXL, because CXL doesn’t change the scleral shape or sagittal height of the cornea. Patients in soft lenses may require a change in power post-CXL.
New patient with no prior exams: It is not unusual to see a young adult patient who has not had an eye exam for several years but has recently noticed vision changes. If topography/tomography confirms keratoconus, fit such a patient in scleral lenses first and then schedule a follow-up visit in 3 to 6 months to confirm progression. To authorize CXL, most insurance companies require a documented change in manifest refraction or Max K value over 2 visits within a given period of time.
When I don’t have any baseline data, the initial visit becomes the baseline. Educate patients about keratoconus—how it is affecting their vision and how specialized contact lenses can improve it. Explain that you will monitor the cornea closely to see whether it is still changing and that if it does change, you can move forward with CXL at that time.
Young adult with a high deductible: Some of the toughest cases are young adults who have keratoconus and are working in their first job, no longer on their parents’ insurance, and have an insurance plan with a high deductible. Because these patients are otherwise healthy they might not have met any of their deductible for the year, and the out-of-pocket costs for both scleral lenses and CXL can be a significant financial burden.
If I see such patients late in the year, I consider waiting until January so that they can max out their deductible early in the new year or switch to a lower-deductible plan during open enrollment. A keratoconus diagnosis can be anxiety-provoking for a young person and/or their parents. Even if there is a delay for financial reasons, try to pursue CXL first. Knowing that you have stabilized the cornea and minimized the patient’s risk of future progression and vision loss goes a long way toward resolving their anxiety.
It is fortunate that technologies have advanced so much in the past 10 years. CXL and scleral lenses remain 2 pieces of the same puzzle and should both be offered to patients who have progressive keratoconus. Individualized decision-making can optimize the timing that works best in each patient’s unique situation.