Article Date: 6/1/2001

Keratoconus Management
A structured approach to treating and billing.
By Deepak Gupta, O.D., Stamford, Conn.

Optometrists are often the first to see keratoconic patients, and we're the best qualified to serve their primary eyecare needs. We can fit them with glasses or contact lenses, or refer them for surgery.

Although many of us are fully capable of managing this condition, a lot of us are frustrated by the resistance of insurance companies to reimbursing us for our services. This article highlights a structured approach to managing and billing for keratoconus, which will benefit both you and your patients.

Keratoconus protocol

Corneal topography on this patient revealed the inferior steepening, which helped to confirm the diagnosis of keratoconus.

The following is my plan of action for keratoconic patients.

The role of contact lenses

Managing keratoconus isn't limited to fitting contact lenses. In addition to regularly scheduled topography to monitor corneal changes, intermediate exams monitor the progression of the disease as well. This mode of treatment can add substantial income to your practice while you help your patients manage this condition.


Treatment for the Future


ISTA Pharmaceuticals is working on a product with great potential for keratoconic patients. This product, called Keraform, uses hyaluronidease in a three-part system that:

  • softens the cornea uniformly

  • works with rigid contact lenses to reshape the cornea to a more normal shape

  • stabilizes the corneal surface via topical drops.

The company says that this process provides improved visual acuity and slows the progression of keratoconus so that patients may avoid a corneal transplant.

ISTA completed a Phase I study in blind eyes and is in the process of initiating a Phase IIa trial to begin before the end of this year.

-- By Karen Rodemich
Senior Associate Editor

In many cases, a patient's medical insurance will cover keratoconus contact lens fitting if you send the letter of medical necessity or call for pre-authorization. If it won't, don't prejudge your patient's willingness to pay for it. He'll accept a contact lens fit for keratoconus if you successfully convey the value he'll get. Plus, he'll be grateful for your help in managing his condition.

Not every keratoconic patient will require a contact lens fitting. In fact, I don't always rush early keratoconic patients into RGP lenses because of the long adaptation period. The vision for a patient should be decreased to 20/40 or 20/50 and improvable with RGPs. If a patient knows he'll get better vision with the lenses, he'll be more willing to put up with the initial adaptation period. If a 

patient hasn't been fit with RGPs and there's no significant corneal scarring, we have a pretty good idea of how much we can improve his vision.

In my practice, I find that roughly one-third of keratoconic patients are against RGPs. A handful opt for soft lenses, and the rest make do with what vision they get from their glasses.

In either case, these patients are valuable to my practice. Because I'm following these patients for a medical condition, they tend to be more loyal to my practice. In terms of dollar amount, I find that each keratoconic patient I have the satisfaction of helping in turn provides about $250 of additional revenue to my practice. And that's not even counting the contact lens fitting portion, which is about another $800.

Added value

Remember, you're the expert in this field, so patients are going to be more open to treatment options. After all, if their best corrected vision with eyeglasses is 20/80 and you get them to 20/30 with contact lenses, they'll be much happier with their lives, more productive at work and they'll feel much safer while driving.

If patients are willing to pay $4,000 for refractive surgery, then why wouldn't they pay $1,150 to enable them to see better than before? 

Dr. Gupta works for Stamford Ophthalmology in Conn. He has no financial interest in any of the products or companies mentioned in the article. You can reach Dr. Gupta at


RE: Patient Name
DOB: 01/01/2001
Stamford Chart No. :12345

Dear Sir:

I wish to request authorization for treatment of my patient,______________________, who has been diagnosed with the eye condition of keratoconus [ICD-9 code: 371.60]. I examined him in my office on June 20, 2001. Historical and testing information, which led to the diagnosis of keratoconus included the following:

_______ Blurred vision [ 368.8 ]                                       _______ Corneal striae [ 371.32 ]
_______ Monocular diplopia [ 368.15 ]                             _______ Corneal Fleischer's ring
_______ irregular astigmatism [ 367.22 ]                          _______ Corneal thinning
_______ Photophobia [ 368.13 ]                                      _______ Distorted keratometry mires
_______ Corneal scarring [ 371.00 ]                                 _______ Cone-like corneal steepening
_______ Scissors motion on retinoscopy on topography

Keratoconus is one of the few eye conditions that makes contact lenses a medical necessity. It is an ocular disease in which progressive, degenerative thinning of the cornea (the main refractive surface of the eye) results in a complex, irregular steepening of the corneal surface. Vision is affected by progressively reduced and distorted visual acuity that is not fully correctable with spectacles because of the irregular corneal surface. The primary accepted management to aid vision is with rigid gas permeable (RGP) contact lenses. By physically resting on the eye, the complex contact lens designs help create a regular optical surface in place of the irregular keratoconic cornea. Often times, this will restore vision to the point where the patient can legally drive a car and perform many job-related activities.

Therefore, I recommend that this patient be fit with RGP contact lenses to achieve the best vision possible. Based on the information provided above supporting a definitive diagnosis of keratoconus, these devices and associated services are not only the standard of care, but also a medical necessity for this patient.

I am requesting authorization for the following services:

Contact lens fitting and instruction        [ 92070 ]        $ 750.00
Contact lens OD                                 [ V2510 ]        $ 500.00
Contact lens OS                                 [ V2510 ]        $ 500.00

Your time and effort on behalf of my patient is sincerely appreciated. If you require further information, please feel free to call me at (203) 327-5808.

Warmest regards,

Deepak Gupta, O.D.


Contact Lens Choices for Keratoconus Management
By Ken Daniels, O.D., F.A.A.O., Hopewell, N.J.

Several lenses are available to help us manage keratoconus. Until recently, rigid gas permeable (RGP) lenses were the most viable option for managing keratoconus because the shape of the distorted cone requires a lens rigid enough to compensate for the uneven corneal surface.

When fitting RGPs, I'll traditionally use the first definite apical clearance (FDACL) technique derived from the Collaborative Longitudinal Evaluation of Keratoconus (CLEK) study. Start with a steep K, work backward to a flatter K until you achieve a minimal apical touch complemented by a small-to-moderate lens diameter.

Soft lenses are generally inappropriate simply because they drape over the cone and don't compensate for the irregular shape of the corneal surface. However, if an early keratoconic patient has reasonably good visual acuity, consider a soft toric lens, although the patient will have a limited time span in using the lens.

  • Of the many new lens designs for keratoconus, Specialty UltraVision's Epicon may be the most promising because it yields a nice balance of comfort and optimal achievable visual acuity. The lens is made from a unique material called carbosilfocon, originally designed to oxygenate blood during heart and lung surgery.
    This material has a high Dk and can cover a larger portion of the corneal surface without risk of edema. It provides comfort close to that of a soft lens, yet provides optics equal to, or superior to, those of an RGP.
    Even for the more severe cones, the Epicon lens has become a first choice in my practice because of its great comfort, excellent stability and the economical replacement schedule for the patient.
  • The SoftPerm by CIBA Vision (Novartis -- Wesley Jessen) is made from t-butylstyrene silicone acrylate with a HEMA skirt. I use this lens for patients who've never worn a lens before to facilitate comfort and visual acuity. The advantage of the SoftPerm is that it's a soft contact lens for keratoconus patients who don't want surgery and can't tolerate RGPs. On the other hand, it allows very little oxygen to the cornea.
  • The Rose K by Lens Dynamics is more difficult to fit, but because of its computer generated technology, you can customize it to fit the cone. You can use it for severe cones, but it performs much better on early to moderate cones.
  • Finally, for patients who require an RGP, but simply can't tolerate the discomfort, you might try piggybacking. I generally start with a soft lens such as Vistakon's Acuvue Single-Use Lens or CIBA Vision's Dailies, using a -0.50D steep curve that acts as the carrier lens. The RGP, which is carried on the soft lens, is then designed in the same manner as the FDACL, yet you can fit it slightly flatter. This helps the patient tolerate the RGP yielding comfort and lens stability.

Dr. Daniels is in private practice in N.J. He's an assistant clinical professor and CLEK investigator at the Pennsylvania College of Optometry.

Optometric Management, Issue: June 2001