One of our patients, a 17-year-old high school football player with hopes to play in college, has obvious keratoconus (KCN). (For topographies, see Figure.) His vision with scleral contact lenses was 20/20 OU. The problem, however, was that his keratometry readings were progressing. His potential need for a keratoplasty was a real concern from both a health perspective as well as for his goal of playing football. Thankfully he was able to undergo corneal crosslinking (CXL), healed quickly and was back in his scleral contact lenses seeing well and playing well, with his football dreams intact.

As surgeons, we derive gratification from the joy patients reflect to us after treating their cataracts, painful eyes and infections. CXL, like treating glaucoma, unfortunately doesn’t provide that same instantaneous positive feedback. However, all it takes is seeing a patient with a full thickness corneal transplant with the associated possible complications (graft rejection, need for glaucoma surgery, graft failure, etc) to feel equally as great about performing CXL.

From a corneal surgeon’s view, the goal is for everyone who has KCN or post-refractive ectasia to be given the option of crosslinking treatment. How do we reach this goal? Here, I will discuss the three steps:

1. Screen for KCN and corneal ectasia
2. Avoid the myths
3. Consider providing CXL (when appropriate)

SCREEN FOR KERATOCONUS AND CORNEAL ECTASIA

Early detection and treatment of KCN and corneal ectasia are crucial for preserving vision and preventing the need for more invasive surgeries down the line. Risk factors for KCN include family history of KCN, frequent eye rubbing and a history of certain eye conditions such as atopic dermatitis and vernal keratoconjunctivitis. Risk factors for corneal ectasia include prior corneal refractive surgery, especially in those with higher corrections and/or thin baseline corneal thickness.

Topography or tomography are a must-have for a modern general ophthalmology practice. Along with being essential for modern cataract surgery, they are the mainstays for the diagnosis of KCN and corneal ectasia. If you already have topography or tomography, consider confirming that your referring MDs and ODs do as well. You might be surprised by how many don’t. A nudge to them to acquire this technology due to its role in screening for KCN and corneal ectasia will help patients make it to your door before it is too late.

Genetic testing (AvaGen, Avellino) also may help screening for refractive patients who may be at risk for future ectasia. The AvaGen test is collected in-office via a cheek swab and sent to the company for processing. A KCN risk score is reported back, which can help doctors counsel patients on the safety of laser refractive surgery in their case.

AVOID THE MYTHS

Some “myths” or misconceptions are preventing patients from receiving proper screening and treatment for KCN and corneal ectasia. Here are three common myths that need to be addressed:

1. KCN only progresses in young people. Traditional teaching is that KCN begins at puberty and progresses through a patient’s 30s but stops progressing by age 40. While this may be true for most patients, some don’t fit the mold. My colleagues and I have all seen progression in patients after 40. Keep this in mind when deciding to screen.
2. There is no need to treat KCN if a scleral contact lens is giving good vision. While scleral contact lenses can provide excellent vision for people with KCN, they do not treat or stop the underlying condition. KCN is a progressive disease that can worsen over time if left untreated. By undergoing proper treatment, such as CXL, patients can halt the progression of the disease and preserve their vision.
3. Referring optometrists will lose valuable contact lens patients if they refer for CXL. Referring a patient for CXL or other treatment options for KCN is not about losing patients, but rather providing them with the best care possible. By referring patients for appropriate treatment, optometrists can improve the patient’s vision, prevent the progression of the disease and ultimately strengthen their relationship with the patient. Also, these patients will still need expert contact lens fitting after crosslinking and often like having an existing relationship with an optometrist to pursue fittings.

CONSIDER TREATING KCN

If you are considering incorporating CXL into your practice, here are some steps you can take:

1. Educate yourself. Familiarize yourself with the CXL procedure, its indications, contraindications, and potential complications. Attend webinars and training sessions to expand your knowledge and expertise.
2. Evaluate patient demand. Determine whether there is a demand for CXL in your area. Consider the prevalence of KCN and corneal ectasia in your patient population and the availability of other treatment options in your area. Before deciding that there aren’t any patients who would need this in your area, consider the experience of buying a new car only to see that same car all over the place afterwards. Look again.
3. Invest in equipment. Purchase the necessary equipment for performing CXL, including an ultraviolet A (UVA) light source, a riboflavin solution and protective equipment for the patient and provider. iLink (Glaukos) is currently the only FDA-approved CXL treatment. While I’m not opposed to off-label treatments, patients need to understand the difference between an on-label approved treatment vs an off-label treatment. I have seen multiple patients who had non-FDA approved treatment who ended up needing retreatment due to progression.
4. Train staff. Ensure that your staff is trained on the CXL procedure, patient preparation and post-operative care.
5. Promote the service. Market your CXL services to patients, optometrists and other health-care providers in your area. Emphasize the benefits of early detection and treatment of KCN and corneal ectasia and the potential for improved outcomes with CXL.

CXL FREQUENTLY ASKED QUESTIONS

What are the benefits to the practice?

Benefits of offering CXL in your practice include:

1. Increased access to care as well as improved patient outcomes and quality of life. Staff and physicians may also feel motivated from providing this sight-saving care in-house.
2. Competitive advantage. Offering CXL can help differentiate your practice from others in the area and attract patients seeking advanced treatment options for their eye conditions.
3. Increased revenue. CXL can be a profitable procedure for eye-care practices. In addition to the fees charged for the procedure itself, practices may also see increased revenue from follow-up visits and the potential for increased referrals from satisfied patients. Follow-up visits are often at 1 day, 1 week, 1 month, 3 months, 6 months and annually.
4. Improved patient relationships. Providing advanced treatment options like CXL can help build trust with patients and improve patient satisfaction. Patients who receive effective treatment are more likely to recommend your practice to friends and family members who may be seeking eye-care services.

Epi-on or epi-off?

Epithelium-off CXL, or epi-off, is the only version that is FDA approved. However, there are distinct advantages to not removing the epithelium, known as epi-on treatment, including shorter treatment and recovery times, less discomfort, and a potential for same-day bilateral treatment. Adjuvants such as increased oxygen and methods of allowing for more absorption of riboflavin through the epithelium are being assessed. While it is unclear if epi-on CXL will be as effective as epi-off, depending on your patient and their individual characteristics/risk, the advantages will likely outweigh the smaller risk of needing retreatment.

How much space is required?

The iLink is a small form factor UVA device. I typically perform CXL treatments in the refractive suite, using the microscope for epithelium removal. Epithelium can also be removed at the slit lamp. However, if needed, this can easily be performed in the operating room setting.

How much time does a treatment take?

The CXL procedure can be time-consuming, which may be a concern for busy practices. The entire treatment of the-FDA approved epi-off CXL takes roughly 1.5 hours (30 minutes of riboflavin saturation, 30 minutes of UVA irradiation and another 30 minutes for set-up, post-procedure, etc). I typically perform the epithelium removal, pachymetry and initial setup of the UVA device. For the other steps (riboflavin loading and UVA treatment), I utilize a trained medical assistant. Treatments can be performed on dedicated procedure days or during clinic sessions; it is important to assess what will work best with your office workflow and infrastructure.

What about referrals?

We see only what we look for. Some referring providers may benefit from a review of the importance of screening for corneal ectasia and the benefits of CXL. A visit or call letting them know you are providing CXL is an ideal time to discuss these benefits and bring to their attention KCN screenings.

Should I buy now?

While the current FDA-approved epi-off CXL is the gold standard in terms of effectiveness, there are real downsides to removing the epithelium, including pain, longer healing time and corneal haze. As noted above, work is being done on protocols for epi-on CXL, but currently nothing is FDA approved.

Approval for epi-on crosslinking is at least 1-2 years away. Given the timeline and the fact that most of the cost of the FDA-approved CXL procedure is in the drug itself, purchasing the technology is likely to pencil out (of course, apply the specifics of your practice to this decision).

How hard is it to get reimbursement?

Most insurances that I work with cover CXL, though insurance coverage can vary and may not always cover the full cost of the procedure. Practices should be aware of the potential reimbursement rates and coverage restrictions in their area. On occasion, I receive a denial for service even with evidence of progression. In the vast majority of these cases, a peer-to-peer discussion has led to approval.

Our practice has a dedicated prior authorization/billing coordinator who helps shepherd patients through the process. With some insurances, the appeals process can be a lot of work.

For coding details, see the AAO’s CXL page (bit.ly/3KRLM0B ).

Are all patients with KCN or ectasia candidates?

While I see benefits in treating even stable KCN in patients at high risk for progression, most insurances will require evidence of progression. Anthem Blue Cross (bit.ly/3opQV8A ) has the following guidelines:

Corneal collagen cross-linking (CXL) is considered medically necessary as a treatment for progressive keratoconus when all of the following conditions are met:

1. Diagnosis of keratoconus based on keratometry and corneal mapping; and
2. Any of the following changes have occurred within 24 months:
   1. increase of 1.00 diopters (D) or more in the steepest keratometry measurement; or
   2. increase of 1.00 D or more in manifest cylinder; or
   3. increase of 0.50 D or more in manifest refraction spherical equivalent (MRSE); and
3. Age 14 years or older; and
4. Corrected distance visual acuity (CDVA) worse than 20/20 with properly fitted spectacles or contact lenses; and
5. Corneal thickness 300 microns or more; and
6. No history of corneal or systemic disease that would interfere with healing after the procedure such as chemical injury or delayed epithelial healing in the past.

Corneal collagen cross-linking (CXL) is considered medically necessary as a treatment for corneal ectasia resulting from refractive surgery (e.g. LASIK) when all of the following conditions are met:

1. Age 14 years of age or older; and
2. Axial topography pattern consistent with corneal ectasia; and
3. Corrected distance visual acuity (CDVA) worse than 20/20; and
4. Corneal thickness of at least 300 microns at the thinnest area; and
5. No history of corneal or systemic disease that would interfere with healing after the procedure such as chemical injury or delayed epithelial healing in the past.

It is important to stay up-to-date on the latest reimbursement guidelines and coding requirements for CXL to ensure proper reimbursement and avoid any potential billing issues. Working with a billing and coding specialist or a medical billing service can also help streamline the reimbursement process and ensure accurate coding and billing.

SUMMARY

If you are considering adding CXL to your practice, now is a good time. KCN is very common, and CXL treatment can help patients with progressive disease avoid more invasive procedures down the road. It is a practice-building procedure that provides value to patients and referring optometrists. Get started initially by screening with corneal topography or tomography, avoiding the common myths and, after consideration of your patient population and local availability of the procedure, move on to providing this sight-saving procedure. OM

Matthew W. Wade, MD, is a board-certified eye surgeon at UCI Health in Irvine, Calif. He specializes in complex cataract surgery, cornea disease and transplantation, as well as LASIK vision correction. Disclosures: Dr. Wade is a consultant for Centricity Vision, Glaukos, Johnson & Johnson Vision, Tarsus and Vialase