Eyeworld

79 EW FEATURE thinks that insurance companies will eventually approve it. "The question is when and what are they going to pay for," he said, adding that if they set the price point too low, the procedure is unsustainable since the cost for the machine and the drops is sizable. There would need to be a decent reimbursement to make it profitable. For those incorporating cross- linking into their practices, Dr. Price advised them not to use the tech- nology on everyone. "Whenever we get a new technology, we want to use it on everyone," he said. But it's important to know that this isn't for everyone. "If you have someone who doesn't have satisfactory vision with contact lenses and a really thin cornea, you shouldn't do crosslink- ing because the patient is going to need a transplant anyway," he said. If the patient is too far progressed to where he or she already needs a transplant, there's no point in doing crosslinking, he continued. It may be more difficult later to do the needed corneal transplant since crosslinking can make it hard to get good separation of Descemet's mem- brane for deep lamellar grafts. Overall, Dr. Trattler is hopeful that if crosslinking is incorporated into more offices, physicians will be looking harder to identify patients with early keratoconus. "The earlier we catch this disease, the more likely we are to have patients who retain their vision. To me, that's really im- portant," he said. "I'm hopeful that will happen." EW Editors' note: Dr. Price has no financial interests related to his comments. Dr. Trattler has financial interests with CXLO (Bethesda, Maryland). Contact information Price: fprice@pricevisiongroup.net Trattler: wtrattler@gmail.com said. "But then there will be tech- nicians who are trained to do the drops and to keep the patient under the light source." Dr. Price noted that outside the U.S., this may be handled differ- ently because there are accelerated treatments. "Obviously if we get the accelerated treatments that are 10 minutes, it's going to be easier to do that than the 30-minute treatments that we have approval for," Dr. Price said. Dr. Trattler pointed out that there are a number of steps in the crosslinking procedure. He con- firmed placement of the riboflavin drops can be done by a technician or a nurse after the physician removes the epithelium. However, it is im- portant for the surgeon to evaluate the cornea to confirm that there is sufficient riboflavin in the cornea and to be present when measuring the corneal thickness to decide whether or not hypotonic riboflavin is needed. "Then, once the light is turned on, the technician can monitor the patient and make sure that he or she is looking at the light properly," Dr. Trattler said. Determining when to schedule the crosslinking procedures will depend upon the practice. For those in a busy practice, this is something that can be done as an in-office procedure that doesn't have to go to a surgery center, Dr. Price noted. Deciding when to bring in the cross- linking patients will be up to the practitioners. "In our practice, we have a few days a week when we do our office procedures," Dr. Price said. "We put it on the days that we're doing the minor procedures that we do in the in-office procedure area." Dr. Trattler performs crosslink- ing cases on clinic days, but only after the process is running smooth- ly at the center, and everyone feels comfortable with each of the steps. "Typically, we initiate the CXL procedure. During the 30 minutes of riboflavin loading, the surgeon can see a patient or two in the clinic. However, the priority needs to be on the patient undergoing the proce- dure. In some situations, it is best for the surgeon to be available through- out the entire procedure," he said. In deciding how much to charge patients for crosslinking cases, Dr. Trattler thinks it's important to consider the amount of time re- quired for the case as well as many other costs. "The procedure is about 1.5 hours. The patient is brought into the OR, the patient is situated, the corneal thickness is measured, and then the eye is prepped. The epithelium is removed, and the corneal thickness is remeasured. The patient is positioned so that he or she can receive the drops for 30 minutes, and then brought out to the slit lamp area to evaluate the cornea. There is an additional 40 to 45 minutes during which the patient is situated under the UV light, and the corneal thickness is measured again. If the thickness is above 400 microns, the light is initiated for 30 minutes. However, if the corneal thickness is less than 400 microns, then the cornea has to be loaded with hypotonic riboflavin until the cornea reaches 400 microns, and this can take 10 to 20 minutes or longer. "Following the UV light treat- ment, a bandage contact lens is placed, and the patient is typically evaluated again at the slit lamp to ensure that the contact lens is fitting properly. Patients will then need to be seen at postop day 1, and again at postop day 5 to 6 for bandage contact lens removal. A percent- age of patients will not have their epithelium healed at this visit, so an additional visit will be required to ensure the epithelium has healed. Then patients will be seen for addi- tional postop visits to evaluate the impact of the CXL procedure on the vision and corneal shape. Since 3% of patients will require a second procedure, we include this in the cost of the second procedure and the overall price. "The equipment itself has a sig- nificant cost, including the UV light source, which can cost $75,000 or more, as well as the riboflavin drops, which cost in the $400 range. It is important to understand that this is an expensive procedure to perform," he said. While insurance does not cover this, Dr. Price pointed out that now that crosslinking has been FDA approved, the question is wheth- er or not insurance companies will approve it. "There is no other treatment to stop keratoconus," Dr. Price said. "It's the only thing that can stop it, and it can potentially eliminate the need for transplant surgery." Based on this, Dr. Price September 2016 • Corneal collagen crosslinking " I think that every doctor comes across patients throughout the year who have keratoconus, and there are probably more patients with keratoconus than physicians realize. " –William Trattler, MD

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