Keratoconus is a progressive condition, therefore, early detection is critical. Patients can progress at any age, but younger patients from their pre-teens to their 20s have the highest risk, because their tissues are very elastic. Screening is essential, as is early intervention using corneal cross-linking to slow or prevent progression of keratoconus.
In 2016, Avedro received FDA approval for corneal cross-linking for the treatment of progressive keratoconus and corneal ectasia following refractive surgery. Cross-linking is the only approved therapeutic treatment for progressive keratoconus. Based on my experience in the last few years, I can share the following tips on how to implement this treatment into your practice.
Education and Expectations
Implementing cross-linking is a whole office effort, from the staff answering the phone, to the technicians, coordinators, and physicians. I have a staff member who is a dedicated cross-linking coordinator. Her primary role is to meet with patients, answer inquires, schedule the procedure, and obtain insurance prior authorization. The coordinator also reviews what patients should expect, from the eye drops to the procedure itself, including how long they’ll spend in the office, and any post-op prescriptions.
I ensure patients understand that managing keratoconus is a team effort. Patients occasionally ask if I personally perform the procedure. I explain that I am in charge of the procedure, but I have technicians who help by handling specific steps and who will be with them throughout the procedure. While I’m explaining this approach, I introduce one of my cross-linking champion technicians, all of whom have a very calming effect on patients and are pros as setting expectations for a variety of patient types.
For example, I see many teenage keratoconus patients, and I tell them they’re welcome to listen to their music during the procedure. If someone seems nervous, we might give a tour of the laser suite where the procedure will take place. Many keratoconus patients with special needs come to our offices, and a tour with staff introductions can be particularly helpful for them to prepare. The mother of one patient with Down syndrome put together a book to help patients with special needs understand what’s ahead. It includes pictures of the laser suite, staff, and physicians. We spend a great deal of time communicating because we think it’s important to make everyone feel confident in our team and comfortable with the process.
Cross-linking and Monitoring
The cross-linking procedure itself can be a difficult concept for some patients. Many still ask me the day after surgery, “Am I going to see better?” We must keep reiterating to patients that cross-linking is not a refractive procedure. The purpose is to stabilize the cornea and prevent future progression. This point is especially important to emphasize to patients whose keratoconus was detected when they presented seeking LASIK or other vision enhancement. Avedro offers many resources for patients on their educational website, LivingWithKC.com .
On treatment day, I start by giving patients a bit of benzodiazepine. I then see patients several times during their procedure, but I’m not with them every moment. I explain to them, “I’m going to see you after we load the cornea, again before the light treatment, and then at discharge.” The technicians guide the patient through each step of the cross-linking procedure while I’m seeing patients in the clinic. We can treat up to four or five eyes a day in our clinic with this approach.
After cross-linking, it’s important that patients are monitored. We usually see them day 1 and frequently — sometimes daily — until the epithelium is fully healed. At that point, we remove the bandage contact lens, and patients typically return to their referring providers. I start to assess the results of cross-linking around 3 to 4 months and again at 6 to 9 months. One month is too early because the cornea can actually get steeper as a result of epithelial hypertrophy.
Referrals and Reimbursement
It’s essential to work with optometrists and other ophthalmologists in the community to reinforce the importance of early diagnosis for keratoconus and to emphasize that cross-linking is the standard of care and is FDA approved to slow or halt progression. It is crucial that they tell keratoconus patients about cross-linking and refer them for consultation.
In my practice, we share these messages with eyecare professionals in the community, referring optometrists and ophthalmologists, and through continuing education programs. These programs help to build these essential relationships and educate our partners on the process of referring patients to us for treatment, after which we return patients to their primary eyecare providers. After the procedure, most patients will need a new contact lens fitting and possibly a new prescription, which is reassuring to their optometrists.
These programs are also a great opportunity to educate our network on insurance progress, which is essential to making this procedure accessible for their patients. We’ve had great success with commercial insurance coverage of corneal cross-linking. Two years ago, it was exclusively self-pay, but that’s no longer the case.
On the rare occasion that I see a patient who is not covered by insurance, we work with the Avedro Reimbursement Customer Hub (ARCH), a patient assistance program that reaches out to insurers. We need this less and less as corneal cross-linking has become the standard of care for progressive keratoconus, making the procedure simple to manage from a billing perspective. ❖
DISCUSSION
DR. RAJPAL: Insurance coverage and the reimbursement process have gotten dramatically better at our practice, but occasionally, patients try to obtain pre-authorization, which takes time, especially for younger patients. How do you counsel those patients about progression?
DR. HATCH: Ideally, we don’t want to wait long periods of time for prior authorization to perform treatment, especially in a pediatric population (< 18), who are at a high risk for rapid progression. I aim to treat patients as soon as possible, usually within several weeks or a month. When I explain the sight-preserving importance of the procedure to young patients and their parents, they understand.
DR. FRAM: Avedro has done a very good job of advocating for patients and physicians. They’ve also helped to educate our practice administrators and billing department.
DR. RAJPAL: How do you document progression? Have insurance companies put any requirements in place?
DR. PARIKH: Once we diagnose keratoconus, we create a standard document that goes to the insurance company. It includes a clinical vignette of the patient showing progressive keratoconus and the need for cross-linking. We usually get a response for pre-determination in 4 to 6 weeks. If a patient doesn’t need or want cross-linking, we bring them back every 6 months. We see younger patients at much more frequent intervals because their condition can deteriorate very quickly.
DR. HATCH: Some insurers have specific guidelines for defining progression, whether it’s an increase in Kmax, a change in refraction, or failure of the contact lens. Sometimes, we don’t have this information available, but I know the patient is progressing based on the history and the refraction. Often, young patients aren’t wearing vision corrective visual aids, aren’t complaining, and they can't tell they’re getting worse. I try to always clearly document the subjective decline. This way, if I am challenged by an insurance company, I can demonstrate that the condition is progressive.
DR. RAJPAL: Whenever possible, we document progression using topography, but otherwise we use refraction to demonstrate increasing myopia or cylinder. We augment that with prior documentation from the referring provider, as well as old prescriptions.
For more information on corneal cross-linking, visit www.avedro.com
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