For practices yet to jump into CXL, changes may warrant a closer look.


	
	Corneal collagen crosslinking (CXL) for the treatment of keratoconus is a procedure that has stood the test of time.
	
	Available in Europe for the past 15 years and nearly 4 years in the United States, it is by now well established as a great option for patients with progressive keratoconus.


	
	Unlike any other treatment for keratoconus, CXL is effective at slowing or halting disease progression,

 while improving vision- and health-related quality of life.

Many cornea practices were early adopters of CXL technology, but the time may be right for comprehensive ophthalmologists to explore this technology, as well. CXL is certainly well within the skill set of any anterior segment surgeon.
	
	

Traversing the CXL pathway: Where do we go from here?


	
	As our practices emerge from the global health and financial crisis caused by the COVID-19 pandemic, CXL is a procedure that can begin sooner than some others, given its minimally invasive nature and younger candidate pool.
	
	Recent data suggest a higher level of patient need for treatment than previously thought.

 And we now have a much clearer reimbursement path and lower barriers to entry than existed in the early years of CXL availability in the United States.
	 

Higher incidence of prevalence of keratoconus

 has generally been accepted to be approximately 1 in 2,000 or 1 in 3,000, making it a relatively rare condition.


	
	More recently, an analysis of 4.4 million patients covered by the Netherlands’ largest health insurer found an annual incidence and estimated prevalence of keratoconus that is 5- to 10-fold higher than historical estimates 


	
	The researchers found that keratoconus affected about 1 in 7,500 people in the 10- to 40-year-old age group each year, for an overall prevalence within the population of 1 in 375 people, or 265 per 100,000.

A number of factors have likely contributed to this jump in prevalence. First, computer-based corneal imaging technologies have improved dramatically, leading to earlier and more accurate diagnoses.

Corneal collagen crosslinking imperative in paediatric keratoconus 


	
	We know that keratoconus has a genetic predisposition, which is often compounded by iatrogenic factors such as eye rubbing, and that it is more common in patients with longer axial length and more highly myopic eyes.


	
	So, with rising rates of myopia/high myopia and obesity, which have been associated with sleep apnea and eye rubbing, it is not surprising that we are seeing more cases of keratoconus.

Given the higher estimates of keratoconus prevalence in the population, we likely do not have enough cornea specialists or current CXL providers to treat everyone who would benefit right now. There is a need for CXL; providing the procedure is a significant service to the community.
	
	

PACK-CXL researchers continue to clear hurdles of topical drugs


	Early on, as with many new ophthalmic procedures, there were problems with reimbursement for CXL that made many practices hesitant to offer it.
	
	Today, the majority of commercial health plans in the United States-representing more than 95% of commercially covered lives-recognize CXL with the FDA-approved drugs and device as a covered service, so the barriers to launching CXL within a practice have been significantly lowered. 

The procedure can be performed in the office or in a surgery center environment.  There is only 1 CXL system approved in the United States: The KXL system, used along with Photrexa Viscous (riboflavin 5’-phosphate in 20% dextran ophthalmic solution) and Photrexa (riboflavin 5’-phosphate ophthalmic solution) (all from Avedro, now part of the Glaukos Corneal Health Division).
	
	

Estimating the total corneal power key in keratoconus patients 


	
	The return on investment is rapid, with most practices able to recoup their investment in a year or less. The company has recently expanded both its reimbursement support and financing options to ease the acquisition process for practices.  

The ophthalmic solutions now have a J code for reimbursement, so there is not as much concern about receiving adequate compensation for needed supplies.
	
	The procedure typically takes a total of 1 to 2 hours, so practices need to allocate appropriate clinical staff time and space in the office for a procedure of that duration.  

CXL is indicated and reimbursed for progressive keratoconus, so it is important to establish procedures for documenting progression. This process does not need to be daunting.
	
	

Keys to assessing true crosslinking outcomes


	Although the ideal would be to have serial topographies demonstrating progression, we also know that the chance of progression in patients younger than 25 years of age is very high, and historical topography may not be available.  

In these younger patients, a significant increase in the manifest refraction (myopia or cylinder) over the course of 1 to 2 years with a keratoconus topography map may be sufficient evidence of progression. In the absence of patient records, prior spectacles may be useful in evaluating changes in refraction.
	
	Although keratoconus progression slows or stops, on average, by age 40, there are certainly individuals who progress well beyond the typical range, into their 60s.

Microscopy study suggests stem cell success in keratoconus 


	
	In my experience, these patients are most likely to be significant eye rubbers, particularly with floppy eyelid syndrome

With a clear reimbursement pathway and fewer hurdles to beginning CXL, ophthalmologists can now viably perform the procedure, meeting a significant patient need.

This, of course, also requires a redoubling of efforts to educate local physicians and optometrists about keratoconus and CXL. I believe we are moving rapidly toward a new paradigm in which any young patient who develops myopia and astigmatism should undergo corneal topography.
	
	We need low-cost, accessible topographers so that more optometrists can routinely perform this diagnostic test as part of their exam. Making the diagnosis and undergoing CXL even a year or 2 earlier can mean the difference between a lifetime of quality vision with glasses and the need to wear specialty rigid gas permeable or scleral contact lenses.
	
	Patients who are able to successfully remain in contact lenses have a reduced risk of requiring a corneal transplant in the future.

 We owe it to our patients to give them the opportunity to achieve the best possible outcomes.
	
	

Dr. Donnefeld is in private practice with Ophthalmic Consultants of Long Island in Garden City, New York. He is a trustee of Dartmouth Medical School and a clinical professor of ophthalmology at New York University Medical Center. He is a consultant for many ophthalmic companies, including Glaukos. 

Gomes JAP, Tan D, Rapuano CJ, et al; Group of Panelists for the Global Delphi Panel of Keratoconus and Ectatic Diseases. Global consensus on keratoconus and ectactic diseases. 

Hersh PS, Stulting RD, Muller D, et al; United States Crosslinking Study Group. United States Multicenter Clinical Trial of Corneal Collagen Crosslinking for Keratoconus Treatment. 

Shetty R, Pahuja NK, Nuijts RM, et al. Current protocols of corneal collagen cross-linking: visual, refractive, and tomographic outcomes. 

Raiskup F, Theuring A, Pillunat LE, Spoerl E. Corneal collagen crosslinking with riboflavin and ultraviolet-A light in progressive keratoconus: ten-year results. 

Cingu AK, Bez Y, Cinar Y, et al. Impact of collagen cross-linking on psychological distress and vision and health-related quality of life in patients with keratoconus. 

Brooks NO, Greenstein S, Fry K, Hersh PS. Patient subjective visual function after corneal collagen crosslinking for keratoconus and corneal ectasia. 

Godefrooij DA, de Wit GA, Uiterwaal CS, et al. Age-specific incidence and prevalence of keratoconus: a nationwide registration study. 

Kennedy RH, Bourne WM, Dyer JA. A 48-year clinical and epidemiologic study of keratoconus. 

Masiwa LE, Moodley V. A review of corneal imaging methods for the early diagnosis of pre-clinical keratoconus. 

. pii: S1888-4296(19)30104-9. doi: 10.1016/j.optom.2019.11.001

Mas Tur V, MacGregor C, Jayaswal R, et al. A review of keratoconus: diagnosis, pathophysiology, and genetics. 

Gokul A, Patel DV, Watters GA, McGhee CNJ. The natural history of corneal topographic progression of keratoconus after age 30âyears in non-contact lens wearers. 

Donnenfeld ED, Perry HD, Gibralter RP, et al. Keratoconus associated with floppy eyelid syndrome. 

Naderan M, Rezagholizadeh F, Zolfaghari M, et al. Association between the prevalence of obstructive sleep apnoea and the severity of keratoconus. 

Dana MR, Putz JL, Viana MA, et al. Contact lens failure in keratoconus management. 

Articles

Is the time right for crosslinking?

For many ophthalmology practices, special times deserve special actions.

In normal times, the physician sets the tone in developing and leading the professional culture of the practice organization. Collaborative partnering approaches between the physician team and the patient help foster efficient and effective patient care. Of equal importance are patient satisfaction and patient retention, which are fundamental to the financial success and sustainability of a practice, according to Suber Huang, MD, MBA.

However, the current times are not normal, and management during the coronavirus disease 2019 requires dealing with a different set of demands. 
	
	

Pearls for clinic flow in the age of COVID-19

“Office management in the time of a crisis is fundamentally a challenge of leadership,” Huang said and outlined 5 ingredients in the recipe for managing the office climate.


	Whether practicing in a solo or group practice, the managing physicians and/or senior administrative staff must set the tone regarding knowledgeable reassurance on handling all aspects of the crisis. 


	“Practice leadership must think carefully about all priorities over time, that is, what is immediately important, what is important in the medium term, and potentially what is important in the long term, with the recognition that the long-term outcomes are not at all clear,” said Huang, president and CEO, Retina Center of Ohio, and voluntary assistant clinical professor, University of Miami, Bascom Palmer Eye Institute.

 Developing flexible strategies for the office is necessary to educate patients, staff, and community as part of a larger public health perspective.


	Problems, then, must be prioritized and solved as they arise. “The goal is not to live in the past, not worry about the future, but do what can be done in the present,” he advised. 

The desire to assign blame is rarely productive. Understanding root causes, adapting to challenges, and making actionable plans is a much-preferred approach.


	When a physician is anxious, the anxiety will be communicated to the staff and diminish his or her effectiveness. 

“This is the most important factor in leadership,” Huang said. 

Huang offered the following steps to aid employees and patients in an unsettled environment: (1) normalize anxiety by channeling energy into learning and action steps; (2) offer perspective by not over- or underestimating the dangers; (3) shift the spotlight, which has the effect of minimizing anxiety when attention is turned to helping others; (4) encourage distraction by taking a break from information seeking and giving your mind a rest; and (5) manage your own anxiety with the goal of reducing staff and patient anxiety.

COVID-19: Companies offering new technology to connect physicians with patients


	Teamwork is important in a crisis. Take the time to understand your staff members’ concerns and explore potential contributions.  

Huang offered these practical strategies to keep staff engaged and productive by sending letters to patients, rescheduling all nonemergent and urgent patient appointments, developing telescripts for use during patient reminder calls, deep cleaning of the office, updating the procedural manual, and adding hygiene protocols-all things that may not receive sufficient attention in a normal environment.

“Managing during a crisis depends on developing a working plan of action that everyone in the practice can embrace and execute,” he said.

This approach creates work for staff even when the practice income is in limbo. Projects also help alleviate anxiety regarding loss of patient volume.
	
	

COVID-19: Survey finds Americans are embracing telehealth services


	Huang chooses to focus first on his employees when faced with such an all-encompassing problem such as the coronavirus disease 2019.

He pointed out that it is important to first address the largest looming concern for staffers, which, in this case, is their own health. The second issue is the worry that employees will infect their family members or friends, followed closely by the fear of infecting patients, and last but certainly not least, the effect of the crisis on the practice’s livelihood. 

During this time, staff members can work from home to minimize their exposure to the virus while they are engaged in contacting patients by mail or phone to reschedule appointments or answer health-related questions. 

If the staff alternates between time in the office and time at home, this schedule may provide more of a feeling of control over their health and that of their families and give them a greater chance to socially distance from others outside of their families. Working from home also alleviates anxieties about maintaining their jobs and income by performing tasks that are meaningful to the functioning of the practice. 


	Flexibility can differ in a solo practice compared with a larger practice that has satellite offices and larger staffs. In the former, decisions can be made and implemented instantly. 

“In my practice, we huddle once or twice a day and we can change practices on the fly. In larger offices, there is flexibility but it is harder to move quickly,” Huang pointed out.

In a 2-person group with 2 offices, the principles could consider alternating schedules. 

“In this scenario, the staff members can isolate during the off-week and if no symptoms develop during that time, they can continue on with the alternating schedule,” Huang suggested.

In a practice with 3 or more offices, a pod design is a possibility, in which each doctor would have 1 set of staff members and use 1 office. In this case, if the virus developed in 1 office in a clinician or patient, that office can be closed, quarantined, and the other offices can remain in practice and be unaffected.

Caring for dry eye patients through the coronavirus pandemic


	An unexpected blessing during this crisis is the availability of extra time. 

Huang pointed out that during this period, most retina practices are open for emergencies or continuing care, that is, about 25% of the normal time. During the rest of the time, the staff can continue to engage with patients by calling directly from their homes to allay any patient fears about their care and keep them informed. 

The patients who are contacted should include those engaged in clinical research studies as well as regular patients. Those in trials need to be reassured about the study visit protocol during the crisis, and those not in a trial need reassurance about their continuing care and their need for or rescheduling of an examination.

This slow period provides an opportunity to review office efficiency, drill for potential disasters, role-play regarding patient encounters, and prepare for when patients return to the practice.  

“With planning, a surge of patients returning for care need not be overwhelming, instead, it could be a happy reunion of old friends looking to resume timely, compassionate, expert care, Huang concluded.
	
	

Dr. Huang has no financial interest related to this content.

Damour L. 5 Ways to Help Teens Manage Anxiety About the Coronavirus. New York Times. March 11, 2020. Accessed May 26, 2020. https://nytimes.com/2020/03/11/well/family/coronavirus-teenagers-anxiety.html

Navigating office management during crisis no easy task

Gonioscopy is offering an option in treating patients with glaucoma.

This article was reviewed by Sunita Radhakrishnan, MD


	
	Assessment of the angle is important for managing 

 elevation, such as pigment dispersion and angle recession, and is critical for diagnosis and staging of primary angle closure. 

It is also important for the treatment of 

Genetic variants linked with onset, progression of POAG

“The angle must be visualized in order to perform laser trabeculoplasty, for example, at least when using the devices that are currently available,” said Sunita Radhakrishnan, MD. “A new technology is in the pipeline that enables transscleral laser trabeculoplasty but for now, visualization of the angle is necessary to deliver laser energy to the trabecular meshwork. There are several minimally invasive glaucoma surgeries that also require angle visualization.”

Radhakrishnan is associate, Glaucoma Center of San Francisco and research director, Glaucoma Research and Education Group.

In a clinic setting, physicians often use the van Herick method, which can be performed rapidly, as a substitute for indirectly assessing the width of the angle. However, she questioned if this is the best route to take.

 that evaluated the  diagnostic capability of the van Herick test when performed by observers with different levels of expertise who may all be involved in angle assessment.
	
	The study found that the sensitivity of the van Herick test to detect gonioscopic angle closure ranged from 58% among technicians to 79% among residents. 

“This is low sensitivity when screening patients for angle closure,” she noted. 
	
	

Pharmacologic treatment an option for open-angle glaucoma

 addressed risk factors associated with misdiagnosis when using the van Herick test to detect angle closure.
	
	Indirect assessment using the van Herick test can not only miss angle closure but it also cannot detect angle pathology that could be present in patients with a deep anterior chamber and no obvious glaucoma risk factors.
	
	A classic example, Radhakrishnan said, is angle recession in a patient with an old and forgotten ocular injury. 

These studies underscore the importance of directly viewing the angle structures with gonioscopy. This test provides a 360° assessment of the angle configuration. 

“The observer can perform indentation in angle closure and identify peripheral anterior synechiae as well as plateau configuration. We can also     detect various other causes of elevated pressure,” Radhakrishnan said. 
	
	

Pearls for conducting GATT in open-angle glaucoma


	In her glaucoma practice, Radhakrishnan performs gonioscopy on every patient. However, there is an argument that gonioscopy should be performed even in patients who do not have known risk factors for glaucoma.

“This is a strategy to opportunistically screen for angle-closure,” she pointed out. It is also important to periodically repeat gonioscopy in phakic patients because even those in whom the angle is open at baseline can ultimately develop angle-closure as a result of lens thickening over time.
	
	

Preservative-free tafluprost/timolol lowers IOP well, glaucoma study shows


	When performing gonioscopy, the main landmark and usually the most easily recognized one is the scleral spur, which lies between the pigmented trabecular meshwork and pigmented ciliary body. 

Radhakrishnan said when she performs gonioscopy, she first locates the scleral spur. If it is not visible in the first quadrant examined, then she looks in another quadrant in which the trabecular meshwork pigmentation may be more prominent.
	
	If the scleral spur still is not visible, Radhakrishnan suggests tilting the gonio lens slightly; if the spur remains undetectable, then she performs indentation gonioscopy to differentiate appositional from synechial angle-closure.

Pale trabecular meshwork may increase the difficulty in visualizing the scleral spur. In such patients, she recommends starting at the Schwalbe’s line (which can be identified with the corneal wedge technique) and working backward from there. 
	
	


	
	Schwalbe’s line often is pigmented, especially in the inferior quadrant, and can be mistaken for the trabecular meshwork so care should be taken in interpreting the angle status to avoid misclassifying a closed angle as open. 

When gonioscopy is performed in the operating room, different steps are necessary from those performed in the clinic. 

Radhakrishnan referred residents, fellows, and novice surgeons to the American Academy of Ophthalmology website (www.aao.org) for tips on gonioscopy in the operating room. 

“The main consideration is that the microscope illumination changes from coaxial for cataract surgery to being directed along the iris plane and onto the angle,” she explained. “The microscope is tilted about 30° toward you and the patient’s head is turned about 30° to 40° away from you. This increases the working distance by several inches, which takes a little time to become accustomed to.”
	
	

Another difference from the examination performed in the clinic is that a surgical (direct) gonio lens is used in contrast to the indirect lens in clinic. A coupling agent is used on the cornea as well as adequate viscoelastic in the anterior chamber.
	
	She prefers Healon GV (Johnson & Johnson Vision), and noted that the product name is now Healon GV Pro to indicate a change in the formulation. Some recommendations that have been suggested for replacing Healon GV are Healon 5 and ProVisc (Alcon), Dr. Radhakrishnan recounted.

Defining alternative therapies for glaucoma


	Despite being the best way to directly evaluate the angle, gonioscopy does have limitations. “It is a subjective procedure, and it needs a slit-lamp as well as a highly trained observer,” she said and noted that angle imaging is an alternative that overcomes some of the limitations of gonioscopy.  

Cross-sectional imaging of the angle can be performed with 

and ultrasound biomicroscopy (UBM). The former is a noncontact technology that facilitates assessment in the dark and the entire anterior chamber is visualized in one scan.
	
	The disadvantage is that visualization of structures behind the iris is not possible.

provides options to image the angle. The dedicated anterior-segment OCT (Visante, Zeiss) is best for visualizing the angle recess, but is not widely available. Angle imaging can also be done with a retinal OCT device, but the scleral penetration is not as good as with the Visante.
	
	

OCT key tool in determining glaucoma progression


	
	She uses a Visante OCT in her practice and also has access to Cirrus OCT (Carl Zeiss Meditec) with an anterior-segment external lens kit that can be attached to the machine to obtain images of the angle. 

UBM provides visualization of the angle structures in front of and behind the iris. However, traditional UBM with an immersion bath is time-consuming. A trained ultrasound technician is needed. The scleral spur is the key landmark to locate. 

Radhakrishnan uses imaging as an adjunct to gonioscopy to identify primary versus secondary angle-closure mechanisms.
	
	However, imaging can also be a substitute for gonioscopy for patients who cannot tolerate a contact procedure or if corneal pathology does not permit visualization of the angle by gonioscopy. 

She also relies on imaging to educate patients about their disease.

“OCT is my first-line imaging device because it is easy to use and comfortable for patients,” Radhakrishnan said. 

Ultrasound biomicroscopy is reserved for viewing structures posterior to the iris and for evaluation of plateau configuration.

“I would like to encourage clinicians to perform gonioscopy more often,” she concluded. “Know the landmarks and use imaging technologies as adjuncts to gonioscopy. Remember that gonioscopy performed in the operating room is different from that in clinic.”
	
	

Dr. Radhakrishnan has no financial interest in this subject matter.

Ophthalmology Times: June 1, 2020

Is the time right for crosslinking?

Navigating office management during crisis no easy task

Assessing the right angle: Surgeons getting back to basics

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