KERATOCONUS SPECIALISTS IN SAN ANTONIO
Focal Point Vision offers the widest range of treatments for keratoconus in South Texas. We have three fellowship-trained doctors who specialize in the treatment of keratoconus. These treatments include INTACS, corneal crosslinking, and corneal transplantation (either partial or full).
We are happy to announce that corneal crosslinking was approved by the FDA last year, and we have then only FDA-approved device in San Antonio! We were involved in three clinical trials that led to the approval of this new treatment and have the most experience in South Texas with this therapy.
Keratoconus is a condition in which the cornea becomes weak and begins to change shape, becoming steeper, like a cone, and causing distorted vision because of high astigmatism.
Most patients are diagnosed with keratoconus in their teens or 20s, and it is a progressive disease, which means that most patients eventually require special rigid contact lenses.
If you have keratoconus, call our office at 210-614-3600 or contact Lisa Navarro to set up an evaluation.
What is keratoconus?
Keratoconus, often referred to as “KC”, is a non-inflammatory eye condition in which the typically round dome-shaped cornea progressively thins and weakens, causing the development of a cone-like bulge and optical irregularity of the cornea. This causes “static” in your vision and can result in significant vision impairment.
Corneal cross-linking is a minimally invasive outpatient procedure that combines the use of Photrexa® Viscous (riboflavin 5’-phosphate in 20% dextran ophthalmic solution), Photrexa (riboflavin 5’-phosphate ophthalmic solution) and the KXL system for the treatment of progressive keratoconus.
The safety and effectiveness of corneal cross-linking has not been established in pregnant women, women who are breastfeeding, patients who are less than 14 years of age and patients 65 years of age or older.
What is corneal crosslinking?
Corneal cross-linking is the latest treatment for keratoconus. It involves the administration of Vitamin B2 drops (riboflavin) to the cornea, and then the cornea is exposed to ultraviolet light for up to 30 minutes. This causes a chemical reaction in which the cornea becomes stiffer and flatter, thus stopping the progression of keratoconus.
The procedure was pioneered in Europe approximately ten years ago, and many thousand patients have undergone crosslinking. Last year, the FDA approved crosslinking in the United States, and you can call our office at 210-614-3600 or contact Lisa Navarro to set up a consultation.
Who is a good candidate for corneal crosslinking?
A good candidate for corneal cross-linking is a patient with mild-to-moderate keratoconus who has good vision in their current glasses or contacts. The goal of corneal crosslinking is to stop progression of the condition, which it does successfully in over 94% of patients. Crosslinking does not eliminate the need for glasses or contacts.
Again, corneal crosslinking can stop progression in the vast majority of patients, but it does not return the cornea its shape before developing keratoconus.
What is riboflavin?
Riboflavin (vitamin B2) is naturally occurring in the body, including the eye. It is a
photosensitizer. Riboflavin is non-toxic and is used as an additive in food and pharmaceuticals.
What is ultra-violet A (UVA) light?
UVA is one of the three types of invisible light rays given off by the sun (together with ultra-violet B and ultra-violet C) and is the weakest of the three.
Does corneal cross-linking require removal of the epithelium?
Yes, your doctor will apply topical anesthesia to numb the eye prior to the removal of the eopthelium. This process helps to prepare your eye so that the drug can penetrate the tissue of the cornea to have an effective cross-linking procedure.
How is the crosslinking procedure performed?
The procedure is performed in our office, and it takes about 60 minutes. First, the patient receives anesthetic drops, then the surgeon gently removes the corneal epithelium (the outer layer of the cornea), riboflavin drops are applied for 30 minutes, and a special UV light is administered for up to thirty minutes. After the procedure, a bandage contact lens is placed, and the patient is seen the next morning. There is mild-moderate pain for the first few days as the epithelium heals. The contact is removed about a week after the procedure, and the vision is blurry during that time. There is some fogginess to the vision for the first month, and then the clarity will return.
We treat one eye at a time, and the interval between procedures can range from 1-3 months.
Is crosslinking covered by insurance?
It is not covered by most insurance policies; however, we have started to see coverage by some companies. We are happy to apply for a predetermination letter to assess coverage. We charge approximately $4500 for the treatment per eye.
Why is it so expensive?
The Avedro KXL unit is the only FDA-approved machine for cross-linking. The company has recently increased the cost of their riboflavin solution from $300 to $3000.
Am I awake during the procedure?
Yes, typically you will be awake during the treatment. You’ll be given relaxing medication and numbing anesthetic drops.
How long does the treatment take?
The actual procedure takes about an hour, but you will be at the offfice for approximately two hours to allow sufficient time for preparation and recovery before you return to the comfort of your own home.
Does it hurt?
There is some discomfort during immediate recovery but usually not during the treatment. Immediately following treatment, a bandage contact lens is placed on the surface of the eye to protect the newly treated area. After the numbing drops wear off, there is some discomfort, often described as a gritty, burning sensation managed with Tylenol and artificial tears. If pain is severe, oral narcotic medications may be used.
Can anyone tell by my appearance that I have had cross-linking?
No. There is no change in the appearance of your eyes following cross-linking.
How many patients have you treated with corneal cross-linking?
As part of the FDA trials, we treated over 60 patients, and since FDA approval, we have treated over 100.
Will I need to be out of my contact lenses for this process?
Yes. Typically, doctors ask their patients to stop wearing contact lenses prior to surgery for up to a period of several weeks. Once treated, patients may not be allowed back into contact lenses for 1 month.
What is the difference between epithelium-on and epithelium-off cross-linking? How can a doctor use a device not approved by the FDA?
All of the FDA trials involved epithelium-off cross-linking, and all of the data from Europe and South America represent procedures done with epithelium-off cross-linking. The epithelium has to be removed so that the cornea can absorb the riboflavin and enough oxygen can penetrate. However, there are reputable doctors in United States who advocate epithelium-on cross-linking, and their data are becoming available. Time will tell if “epi-on” cross-linking is as efficacious as epithelium-off cross-linking.
There are some doctors who advertise on the Internet about crosslinking, but they’re not using the FDA-approved device manufactured by Avedro. How can they do a procedure that is not FDA-approved?
Good question. Some doctors purchased the UV light source abroad and brought it to United States. They have created their own “studies” and treat patients according to their own rules. It is important to ask them the overall cost of the procedure, the number of patients treated, who is monitoring their “study,” and if the procedure is covered by the doctor’s malpractice insurance.
What are the side effects of corneal cross-linking?
The most common ocular adverse reactions in any corneal cross-linked eye were haze (corneal opacity), inflammation (punctate keratitis), fine white lines (corneal striae), disruption of surface cells (corneal epithelium defect), eye pain, reduced sharpness of vision (visual acuity) and blurred vision.
The risk information provided here is not comprehensive. To learn more, talk about corneal cross-linking with your healthcare provider.
The FDA-approved product labeling can be found at www.Avedro.com. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit MedWatch (/Safety/ MedWatch/default.htm) or call 1-800-FDA-1088.
What are INTACS?
INTACS are thin rings that are inserted into the cornea to improve its shape. Imagine that they are like rods in a tent that give it rigidity and a dome-like shape. The main goal of INTACS is to stop the progression of keratoconus. They do not obviate the need for contacts or glasses, but in the vast majority of cases, they do STOP the progression of keratoconus.
Imagine your keratoconic cornea as a tent with a curved top. If the sides are pushed out, the top is flattened slightly and the dome shape is restored. Placing Intacs in the periphery of the cornea flattens the center by restoring the natural dome shape of the cornea to improve vision.
Who is a good candidate for INTACS?
A good candidate for INTACS is a patient with mild-to-moderate keratoconus who is unhappy with their contacts and glasses. In general, INTACS can reduce one’s astigmatism by half, and more importantly, stop the progression of keratoconus.
How is the INTACS procedure performed?
The procedure is performed in our Medical Center office, with mild sedation and topical anesthesia. We can also numb the eye with a block if the patient desires. The procedure lasts about 15 minutes, and we perform them on Thursday mornings. Generally, the patient can return to work on Monday, and they have only 1 to 2 days of a mild scratchy feeling and some soreness that can be relieved with ibuprofen or Tylenol.
Is INTACS covered by insurance?
Most insurers cover the INTACS procedure; however, there can be a lengthy process to obtain insurance approval. INTACS is an FDA-approved procedure for the treatment of keratoconus.
How many patients have you treated with INTACS?
Drs. Maverick and Lehmann have been performing the procedure since it was approved over ten years ago. We average 2-3 procedures a month.
Can you get keratoconus from LASIK?
Preoperatively, we check all LASIK patients for signs of keratoconus, and we would not perform LASIK on a patient with keratoconus. Simply put, LASIK can worsen an eye with keratoconus.
What is a corneal transplant?
In the setting of keratoconus, a corneal transplant involves replacing the patient’s scarred, disfigured cornea, with a new, clear cornea.
Where does the new cornea come from?
Just like other organs, the cornea is donated after somebody passes away. The decedent’s family is consulted, and they give approval for the donation. Technicians from the San Antonio Eye Bank harvest the cornea, and they carefully check it for any structural problems or infectious diseases. Only after passing rigorous inspection, is it deemed suitable for use.
When is a corneal transplant needed?
Every situation is unique, but generally speaking, if the patient can no longer wear their contact lens due to discomfort or does not have good vision in their glasses, then a corneal transplant is indicated.
What kind of corneal transplants exist?
In terms of corneal transplants for keratoconus, there are two types. The first type is called a PK, or penetrating keratoplasty, and this is a full-thickness corneal transplant in which the patient’s cornea is removed, and a new cornea is sutured in place. Another type of corneal transplant is called a DALK, or deep anterior lamellar keratoplasty. This is a transplant that involves only the front 99% of the recipient’s cornea, preserving the posterior aspect of the cornea. Our surgeons will help you decide which type of transplant is best for you.
How is a corneal transplant performed?
Corneal transplants are performed in a sterile operating room with a local anesthesia and IV sedation. That means that the patient is breathing on their own, but they can receive medicine in their IV to relieve anxiety and make them drowsy. The eye is numb and cannot move or see. At all times, an anesthesiologist is monitoring the patient, keeping their blood pressure under control, and most importantly, keeping them free from pain. The surgery takes about an hour, and afterwards a patch is placed. We check the patient the next morning, and patients have moderate pain for the first 2 to 3 days. We can prescribe Vicodin, or the patient can use Ibuprofen or Tylenol, for pain relief.
What is the recovery like?
Patients have moderate discomfort for the first few days, and most patients take off 1 to 2 weeks from work. The visual rehabilitation can take many months. The cornea has no blood vessels, so it takes a long time for the graft to “scar in,” and we often have to adjust the shape of the graft through suture removal. Generally speaking, by 6 to 12 months, we are able to get patients into a pair of glasses or contacts so that they see well.
Can my body reject the new cornea?
Yes, but it is not common. To be safe, we keep the patient on a drop of a topical anti-inflammatory, also called a “steroid,” for life. There is not a need to take oral immunosuppression to prevent rejection as there is with solid organ donation such as a heart or kidney transplant. This is very important, so I will mention it again – the vast majority of patients do not have to take oral immunosuppression after corneal transplants.
How many corneal transplants do your doctors perform each year?
Drs. Maverick and Lehmann perform close to 200 transplants each year. Dr. Maverick is the medical director of the San Antonio Eye Bank, which means that he is responsible for the quality of the corneas exported from our bank. He is not compensated for this extra work and attends meetings twice a year to maintain quality and efficiency at the SA Eye Bank. Dr. Lehmann is the only corneal surgeon in South Texas who performs DALK transplants, and he has carried corneas from the San Antonio to India, China, and Israel to treat indigent patients and teach local doctors about advanced techniques in corneal transplants.
To learn more about Focal Point Vision, or to schedule an appointment, please call us at (210) 614-3600.