Should I Have Crosslinking or Scleral Lenses First?
September 18, 2024
If you have the eye disease keratoconus, you probably know there are two revolutionary and now standard treatments: corneal crosslinking (CXL) and scleral contact lenses. CXL is a surgery that prevents further progression of keratoconus, but it does not restore vision. Scleral contact lenses are regularly prescribed to restore vision for keratoconus.
Which should you undergo first? An experienced eye doctor can guide you to what is best for your individual situation. That said, the information below can help you understand the rationale.
Scleral Contact Lenses Are the Usual First Priority
If you have keratoconus, there is a high likelihood that you are struggling with your vision. Traditional eyeglasses and disposable contact lenses usually do not sufficiently restore vision. Instead, rigid surface contact lenses – including scleral contacts – are a mainstay for vision rehabilitation. Regaining vision is an immediate priority so that you can regain the ability to do your activities of daily living. That way, you are not at a disadvantage whether in school, work, driving, or the sports field. Do not delay in undergoing contact lens prescribing if you have keratoconus!
It is particularly desirable to start scleral lens prescribing if you qualify for a vision plan’s necessary contact lens authorization for keratoconus. This can save you thousands of dollars in prescribing services and the cost of expensive scleral lenses. With one major vision plan, having CXL first might cause you to lose qualification for necessary contact lens authorization for keratoconus by reducing the curvature of the cornea below their eligibility criteria.
Corneal Crosslinking (CXL) Is Important for Progressive Keratoconus
For most with keratoconus, the disease stops on its own by the third to fourth decade of life. This means that there is limited value for undergoing CXL if the disease has already self-arrested. If you are in your 40’s and newly diagnosed with keratoconus, your keratoconus may already have stabilized unbeknownst to you. With stable keratoconus there is no need for CXL. But if your keratoconus is progressing, CXL can reduce the risk of undergoing corneal transplant surgery and provide you with peace of mind.
Today, over 95% of commercial medical insurances provide at least some coverage for undergoing FDA-approved iLink CXL for those with demonstrated disease progression. Particularly if you are newly diagnosed in your teenage years to early twenties, your eye doctor will direct you to a corneal specialist that performs FDA-approved Glaukos iLINK CXL as they have special instrumentation to monitor for the most subtle disease progression required for medical insurance coverage of this surgery.
With Progressive Keratoconus, Pursue Scleral Lens Prescribing and CXL Simultaneously
Medical insurance authorization for CXL can sometimes take over a year or longer. Even after a year, the insurance may deny coverage if there is no evidence of progression. This is why it is advisable for most newly diagnosed keratoconus patients in their teenage to early twenties to pursue scleral contact lens prescribing at the same time they pursue a CXL consultation. That way, they are not denied the ability to regain sight having to unnecessarily wait.
For our patients with progressive keratoconus that pursued CXL first, they have in some cases delayed themselves the opportunity to gain restored functional vision with scleral contact lenses by more than a year. This is a travesty particularly for patients in their teenage to early twenties when academic success is frequently dictated by the ability to see in the classroom.
What happens if you undergo CXL surgery amid scleral contact lens prescribing? Each CXL surgeon is different, but most will have you temporarily have you stop wearing your contact lens in the operated eye for about a month. This simply means that completion of your scleral lens prescribing may be delayed by a month. In most cases, the scleral lens prescriber can readily extend the prescribing period of the scleral lenses by that same duration. Whereas scleral lens prescribing usually is completed in a 60-day period at ReVision Optometry, in these select cases, the prescribing period is extended to 90 days.
Will CXL Require Re-Prescribing of Scleral Contact Lenses?
Most of our scleral contact lenses wearers that undergo CXL to halt progressive keratoconus can wear the exact same lenses after their surgical recovery. Bear in mind, CXL stiffens and alters the shape of the cornea, not the scleral or white part of the eye. Scleral contact lenses do not interact with the cornea and instead gently rest on the sclera. This is why re-prescribing of scleral lenses is generally unnecessary after the immediate recovery from CXL. Note that corneal surgeons often do not know this, because they typically do not prescribe scleral contact lenses.
CXL Does Not Improve Contact Lens Wearing Success
A handful of surgeons performing CXL claim that the procedure improves success of subsequent contact lens wear. However, a review of the evidence-based literature does not support CXL improving contact lens success. The purpose of CXL for those with progressive keratoconus is to stabilize the disease to prevent undesirable corneal transplantation. CXL does not improve the success of scleral lens wear and nor is such a claim permitted under the FDA approval.
Scleral Lenses Do Not Halt Progressive Keratoconus
If you completed initial scleral lens prescribing and your corneal surgeon is monitoring for disease progression, it is important to continue those visits. Even though scleral lenses may have restored your vision, keratoconus can progress underneath the scleral lens without you knowing. Some patients after receiving their final scleral lenses mistakenly believe that their treatment is complete. If your scleral lens prescriber recommends you undergo a CXL consultation, it really means it!
ReVision Optometry is a referral-based practice in San Diego providing contact lens services for patients with keratoconus. To schedule an appointment, request your appointment online, or call our office at 619.299.6064.