BLOG: Pursue both cross-linking, contact lenses for newly diagnosed keratoconus patients (2024)

In a previous blog post, I wrote about how soon after cross-linking different types of contact lenses — soft, gas permeable and scleral — can be fit for both new and established wearers.

But what do you do with a newly diagnosed keratoconus patient who needs both cross-linking and new contact lenses? Will it benefit the patient more to start with stabilizing the cornea or correcting their vision?

The answer is: It depends. Optimally, both would be pursued in tandem.

Cross-linking is absolutely necessary for patients who have signs of progression. Just because we have contact lens options that offer excellent comfort and vision for these patients doesn’t mean they don’t need to undergo cross-linking. In fact, the most recent scientific literature continues to reinforce the growing rate of cross-linking (Deshmukh et al) and its role in stopping progression (Cehelyk et al; Cortina et al).

For example, a recent review paper found that the standard Dresden protocol — the style of epi-off cross-linking preformed in the U.S. with the FDA-approved iLink system (Glaukos) — halts disease progression and improves various visual and topographic indices, including UDVA, CDVA, Kmax, K1 and K2, for up to 13 years postoperatively (Cehelyk et al). The American Academy of Ophthalmology also reported that epi-off cross-linking is effective at reducing progression and that complications are rare (Cortina et al).

But of course, patients also need to see well and may prioritize correcting vision if they are struggling to function due to poor vision. It is important to educate patients that we need to pursue both paths, more or less in parallel.

Here are four main factors I consider when determining the exact timing of disease treatment vs. vision correction:

1. Life circumstances. Cross-linking may require the patient (or a parent) to take time off because they will have several days of discomfort and at least 1 week — perhaps longer — during which they can’t wear their normal vision correction. Scheduling around work or school commitments is often the biggest barrier for patients to undergo cross-linking. However, it is important to make sure patients understand the urgency of treatment and do not delay too long. It is recommended that patients younger than aged 18 years wait no more than 6 weeks from initial progression detection, and those older than 18 years no more than 12 weeks (Romano et al).
2. Insurance approval. FDA-approved cross-linking is typically covered by medical and/or prescription drug insurance. However, it can take time to document progression, complete prior-authorizations, conduct peer-to-peer reviews if necessary with the insurance’s medical director and receive the drugs needed for the procedure. I like to get that process started as soon as possible. And while waiting for insurance approval, the patient can also start their contact lens fitting. If the patient is a new lens wearer, application and removal training prior to cross-linking is helpful so that they can resume lens wear more quickly, with confidence and with less risk for micro-trauma to the eye from poor lens handling once the cornea has healed.
3. Provider availability. In some cities, there are multiple eye care providers who can perform iLink cross-linking and many choices of days and times for the procedure. In other areas, there may be only one doctor who performs cross-linking, one day per week. In the latter case, it can be harder to find a time that works for both provider and patient. Again, I would not hesitate to move forward with contact lens fitting while the cross-linking scheduling is getting worked out.
4. Fellow eye status. If both eyes have decreased vision, we may need to correct the vision first so that the patient has improved visual function and can see better in the weeks and months after their first eye is cross-linked. Correcting vision quickly will help the patient tolerate the short-term disruption in vision after the cross-linking procedure. If the fellow eye already sees well, cross-linking should be pursued first.

Every situation is different, which is why we need to individualize choices and planning for each patient, working with their scheduling preferences while also conveying an appropriate sense of urgency to arrest the underlying disease process. In most cases, pursuing both cross-linking and contact lens fitting in parallel will best serve patients newly diagnosed with progressive keratoconus.

References:

• Cehelyk EK, et al. Curr Opin Ophthalmol. 2024;doi:10.1097/ICU.0000000000001054.
• Cortina MS, et al. Ophthalmology. 2024;doi:10.1016/j.ophtha.2024.05.006.
• Deshmukh RS, et al. Cornea. 2024;doi:10.1097/ICO.0000000000003635.
• Romano V, et al. J Refract Surg. 2018;doi:10.3928/1081597X-20180104-01.

For more information:

Gloria Chiu, OD, FAAO, FSLS, is associate professor of clinical ophthalmology at the USC Roski Eye Institute at Keck Medicine of University of Southern California. She can be reached at gloria.chiu@med.usc.edu.

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