Excerpted from page 44 of the May 2017 edition of AOA Focus.
Today there are more options for keratoconus management at doctors' disposal than ever before, but has optometry made the most of these?
In the past decade alone, care of the keratoconic patient has progressed by leaps and bounds with advances in technology bolstering an array of management options, ranging from spectacles and contact lenses to surgery. But familiarity with these emerging opportunities hasn't necessarily advanced at the same speed, leaving many practitioners confused about how to proceed.
"Optometrists understand what to look for in making a diagnosis, but the understanding of how best to treat the patient with keratoconus still needs a lot of work," says Jeffrey Sonsino, O.D., AOA Contact Lens & Cornea Section chair.
That's why he, along with Ed Bennett, O.D., University of Missouri-St. Louis (UMSL) College of Optometry professor and assistant dean, and Barry Eiden, O.D., president and co-founder of the International Keratoconus Academy of Eye Care Professionals, look to set out a basic framework—a recommended model of care for keratoconus that doctors can implement in their own practices—during a continuing education (CE) lecture on June 22 during Optometry's Meeting ® in Washington, D.C.
"Right now, there is no standard of care for recommendations about different contact lenses at different stages of keratoconus, and that's what we're trying to establish," Dr. Sonsino says.
It wasn't all too long ago that keratoconus options were few and simplistic: Corneal gas permeable (GP) contact lenses were virtually the sole treatment of choice for decades, ordering greater visual acuity than spectacles, but often at the cost of comfort. That said, no two keratoconus patients are alike.
Today, in addition to corneal GPs, practitioners can tailor their care using scleral or hybrid contact lenses, custom soft contact lenses, or "piggyback-fit" contact lenses before considering surgical interventions.
These advances in management options go hand in hand with the proliferation of new technologies. Dr. Bennett points to more sophisticated corneal topographers in recent years that clearly define options. Optical coherence tomography also plays a role in visualizing how the lens lands, influencing scleral fitting.
"Instrumentation has really helped us tremendously," Dr. Bennett says. "When I look back at yesterday, I think of not only the limited tools, but also the limited knowledge of corneal shape. But today, we can map the cornea and know what we're working with. We also can take photos and videos with our cell phone and this—in combination with our lab consultant—often results in success."
However, it extends beyond contact lenses. Optometry plays a central role in keratoconus diagnosis, management and patient counseling. Therefore, it also is important to understand when treatment options, such as corneal crosslinking or transplantation, should be considered.
As clinical understanding of keratoconus undergoes tremendous change, it's vital to know how important early diagnosis and management options can be in dramatically impacting patients' visual function, Dr. Eiden says. Alongside case-based examples, discussion among CE attendees and the three presenters—who share a combined 75 years' worth of clinical expertise, and thousands of keratoconic patients—will foster a model for state-of-the-art care to keratoconic patients.
"It's our goal that this course will address all of these factors and lay a framework for better understanding of the disease, technologies to make early diagnosis, and management in terms of disease progression control and improvement in vision," Dr. Eiden says.
Currently, licensed doctors of optometry in 10 states perform YAG laser capsulotomy and a new study provides further evidence to support its use in optometric practice.
Significant clinical studies on atropine for myopia control show conflicting results for doctors of optometry seeking a solution to myopia progression. More research is needed on atropine dosage and why results were different among children living in the U.S. and Asia.
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