Expanding Options in Corneal Care

This edition of CRST examines the expanding scope of and barriers to corneal care. Not long ago, the options for managing keratoconus were limited largely to rigid contact lenses for visual rehabilitation and corneal transplantation for patients with advanced disease. CXL allows the cornea to be stabilized before patients reach the point of needing a transplant. In their article, Kendall E. Donaldson, MD, MS, and Elise Kramer, OD, FAAO, FSLS, emphasize the importance of identifying keratoconus early in its course, recognizing its progression, and promptly referring patients for treatment.

Epithelium-off CXL can be an effective treatment for keratoconus and other forms of ectatic disease, but epithelial removal is associated with pain and an extended recovery period. Epithelium-on CXL could improve the patient experience, but I worry that its higher cost could limit patient access, particularly if the lower-cost epithelium-off option becomes unavailable in the United States. This would be especially consequential for children with progressive keratoconus. Delaying treatment because of insurance coverage concerns while the disease progresses would be far from ideal. Payer coverage is always a challenge, but with a much higher cost, the barrier to treatment could be significant. Patient assistance programs can help, but it remains a concern.

Corneal diagnostics help guide refractive surgery screening. In their article, Renato Ambrósio Jr, MD, PhD, FWCRS, and Aydano P. Machado, MD, PhD, discuss how assessing patients' ectasia susceptibility can allow more customized decisions about their refractive surgery candidacy.

This month's cover series also explores different approaches to visual rehabilitation. Steven A. Greenstein, MD, and John D. Gelles, OD, discuss corneal tissue addition keratoplasty, in which biologic tissue is used to reshape the cornea. This procedure raises the possibility of improving patients' vision while avoiding some of the long-term concerns associated with synthetic implants.

Some patients—particularly in settings where early diagnostics, CXL, and donor tissue are difficult to access—present for eye care only after developing significant corneal irregularity or scarring. Priya Narang, MS, and Amar Agarwal, MS, FRCS, FRCOphth, explore how meaningful visual rehabilitation may be possible with a comparatively low-resource surgical approach, pinhole pupilloplasty. Dr. Agarwal has published and presented cases in which this approach dramatically improved patients' vision.

Access is also a major concern when corneal transplantation is required. Esen K. Akpek, MD, and Umut Akova, BS, examine the global shortage of donor corneal tissue and the barriers that prevent many patients from receiving this sight-restoring surgery. Avoiding the need for transplantation through earlier diagnosis and treatment is a part of the solution. Expanding access to transplantation and relying less on donor tissue are another.

Might it one day be possible to replace an abnormal cornea without donor tissue? A well-tolerated alternative with a lower risk of long-term complications could fundamentally change what we surgeons are able to offer patients, particularly in parts of the world where donor tissue is scarce.

The landscape of treatments for corneal disease and ectasia is rapidly evolving. Advances in devices for early diagnosis and treatment, alternatives to corneal tissue, and low-technology solutions for advanced corneal disease are shaping the future and improving options. Options matter. Ensuring that they reach the patients who need them matters just as much.