Treating Keratoconus & Benefits of Corneal Topography Conversations with Nick Howard
Hello again, welcome to another Contacts with Conway.
In this weeks conversation, I’m in conversation with Nick Howard
a fellow practitioner from the UK. Because of the vagaries of the
system here in the UK for treating keratoconus,
I thought it would be interesting if Nick explained how the system works for those
of you that are resident outside of the UK. He later
goes on to discuss his feelings on the use of topography in
general practice in the UK and elsewhere.
Martin: I think most of our audience is probably
outside of the UK, so perhaps it would be a good idea to explain how you work and
the balance between hospital work over here and how the
Health Service works for keratoconics and things like that.
Nick: Yeah, hi Martin, well my work is fairly varied and
I work typically 3 days per week for the
National Health Service in a hospital environment
and I spend the rest of my time in a private independent
high street clinic and I do a little bit of time as well
doing lectures and presentations both in the UK
and overseas. I think the UK situation with keratoconus is
fairly unique in that a high street practice
or an independent practice will refer to a hospital ophthalmologist who will then
send on to me on the suspicion of early stage
keratoconus and then it will be typically looked after
in either a hospital clinic by somebody like myself
or possibly sent back out to the community for
management in a high street practice.
Martin: But the main cost of that treatment whether it be contact lenses or
whichever route - even cross linking would be borne by the
the state, by the Health Service in fact.
Nick: Yeah, that's right. Patients can elect to pay privately if they wish, but the majority will stay
under the under the banner of the National Health Service yeah.
Martin: And why would they elect to pay privately? Just for speed of access?
Nick: Their choice: speed, access, freedom of choice,
that type of thing. You know, there can be a little bit of a waiting time through the NHS
and if patients choose - it is their choice. But I would say that the majority stay under the NHS umbrella
Martin: What 90 percent plus or?
Nick: I’d guess so.
Martin: And there's a maximum charge that they can be asked to pay as well,
the patients?
Nick: That's right yeah, there's a fixed - what's called an NHS contributory charge
towards contact lenses and at this moment in time it's
£57 per eye per year. So a patient will pay a maximum of £114.
Martin: Converting that in dollars at the top of my head would be $135-140 maybe
which will surprise many of our viewers in the United States and elsewhere as to
what the cost is. Is your choice limited as a fitter?
Can you supply whatever product you feel is
or are there constraints on what you can spend?
Nick: There are no constraints for me personally,
but I know there are limitations.
My constraint really is to get to an end point as quickly and efficiently as is possible
and if that means using a slightly more expensive product then I'll do that.
But yeah, the pressure, if that's the right word to use, is to
reach that end point quickly and efficiently.
Martin: To save chair time, so you can deal with the backlog of patients building up.
Nick: That's right.
Martin: Another thing that I've been asked several times by, particularly lecturers
in universities in the UK,
is how are guys like you and I get into the positions that we find ourselves?
You know, what's the route of career because a lot of students watch this and
they're coming up to their last year and they're thinking how do we get into
those kind of jobs? So perhaps you just enlighten us
us on your career to date: what brought you to where you are now?
Nick: Oh goodness me - it's a great question
actually that Martin. Not specifically by design, I don't think.
I worked for a long time doing hospital work within community practices and built up
a reasonable wealth of experience but made a conscious effort one day to
say right I'm going go out there and
distribute a little bit of this knowledge and experience. And it was
the Practice Academy the CIBAVision Practice Academy - I think that's when we first met wasn't it?
Martin: I remember it well, yeah. I think that was a launch pad for
quite a few careers in professional services.
Nick: It was indeed, and I remember doing lectures across the Northwest of the UK fairly extensively
actually, you know, it's quite a large program and before I knew
what was happening I was going around UK universities and overseas as well.
So it sort of snowballed very, very quickly. But it definitely needed
that launch pad - I think launch pad is that is the right word.
Martin: Yeah it doesn't come knocking on your door, I'll agree.
You do have to decide I want to move and look and then when those opportunities come up you have to
not be shy, you just take them and see where it leads you.
You're also quite active with the BCLA as well, which for those viewers outside
of the UK is the British Contact Lens Association.
Nick: That's right, yeah. I'm a BCLA council member at this moment in time.
The BCLA has been very much the backbone of my learning set I guess for the last 20-25 years.
I'm not quite sure I could have achieved what you know we collectively have achieved without them.
Fabulous organisation, and great to have the benefits of membership in a
very, very small industry, in a very small profession.
Martin: I think for those students looking at this now I think the benefit of putting effort into those sorts of
organisations are A) the contacts that you make,
but we tend to work – we’re solitary workers - we tend to be working
on our own most at the time. And it's handy also if you do have a
particularly dodgy patient or something you're not quite sure of, you can always
pick up the phone find someone, somewhere you know within
your contacts that can reassure that the decisions right or point you in a different direction.
Okay, Nick, moving on with the main topic really
I know a bugbear of yours is the use of keratometers instead of topographers.
So perhaps you'd like to share us your views on the use of topography versus keratometry.
Nick: Yeah thanks Martin, I don't think it would be fair and proper if I ever talked about anything else but
keratometers and topographers. Keratometers for me belong in a previous life, they
belong in a previous century. I was trained on keratometers,
but the minute I actually saw the benefit of using corneal topography, it changed my
entire outlook on the work I was doing. It changed the choice of
lens that I was using and the ease of fitting as well and the amount of information that we can
get from, not even from their high-end machines
but the very, very basic topographers; they put keratometers where they jolly
well belong - back in the 19th century. You know we're in 2020 now,
and we really should be using an instrumentation that marries the era that we're in today.
Martin: And it's not just the fitting of lenses, the fitting of corneal lenses, that you're talking about as well.
You actively use them in the treatment of dry eye and even on dubious refractions as well.
Nick: That's right yeah. The osmolarity tests that I use combined with corneal topographer
is really the backbone of my specialty dry eye clinic because I can tell so much from a topography map.
It directs me where I'm going and of course we can we can assess the impact of dry eye management
or dry eye treatment on the integrity of the surface. It's very visual, patients
understand it, it's not a difficult science. So yeah, I can't live without one now.
Martin: Also, I think you've got a couple of slides you want to share with us as well.
Nick: Yeah, I have indeed. These were a couple of interesting slides which I've used on a few occasions
before and I've cherry-picked these ones really not from the contact lens fitting aspect but
really from the aspect of patient screening. The first one I'm looking at is
at is a corneal topography I took of a young lady I was working with, and I was assessing tear film variability
and what I discovered was that this patient had a very, very early stage keratoconus.
And I made all sorts of additional diagnostic tests in terms of checking visual acuity,
I checked it with the retina scope and checked it with a keratometer even,
and there was no sign of this whatsoever. But you can see just down in the lower third of this particular cornea,
there's a very, very slight protrusion there and this was actually very slightly progressive.
So we were able to intervene with this one: apply a sensible
management plan and not allow this to progress any further. The patient got 6/6 vision
uncorrected - there was no reason whatsoever to suspect anything
and yet we've managed to pick out a problem which stayed very, very low-key for as long as the patient
stayed under management and there was no other instrument which would have picked this
Yeah and the additional slide I've got here: it was another fascinating one.
It was in a similar environment, it was a patient who had 6/6 vision in one eye and was getting sort of 6/7.5-
in the other eye, and had never ever had topographies taken before.
We can see on this one we've got two topographies on the on the left-hand side, and of course,
these look pretty identical, it's a fairly obvious low-grade keratoconus. But the two images were taken actually
12 months apart and the image you see on the right-hand side is what we call a difference map it's
actually, the computer has subtracted one image from the other and the net difference between
the two eyes is zero - it's nil. Which means there was absolutely no progression
of the condition whatsoever. Again the patient was
unaware of the condition but we were able to manage this
on an ongoing basis without the use of any form of contact lens without any
necessity for referral and this is the sort of thing that in
the hospitals we want to see community practices
managing these types of cases in the community.
Fair enough if it is progressive or it needs contact lenses, by all means, send it in.
But this was a very, very easy management and a very loyal patient, as well given that he had
no idea of the reason behind his very slightly reduced visual acuity.
Martin: Yeah I think I think we're now realizing that it's oft-quoted that 1 in 2,000 patients have keratoconus.
But I don't know where that number came - it's then it seems a bit of a convenient number,
but I'm yet to find any serious data to support it, however there is data coming out of Holland more
recently to show that number - and it's probably because in Holland the use
of keratometers - it just doesn't exist.
Most people have got topography and so they're picking up keratoconus
much more frequently than perhaps we do here in the UK. And I think the frequency
now is more like 1 in 400 - that's a six-fold difference in what we first estimated
most practitioners will be coming across keratoconic patients in
the course of their normal practice. Before we finish, obviously the growth in
the use of sclerals has escalated over the past ten years,
shall we say, but currently what's the percentage usage of sclerals in your practice at the moment?
Nick: In the hospital practices it's probably 20%
of the patients we’re of seeing, we're doing scleral lenses. Sclerals, as
probably most of us are aware have become hugely more popular over the last,
certainly over the last decade. I think 2010-2011 we started using sclerals
with a far greater frequency and of course one of the benefits of scleral
lenses and corneal lenses for that matter is we can actually fit the things virtually now
on the corneal topographer. So it cuts down on the
use of diagnostic lenses, it cuts down on the amount of time we
spend in close proximity and of course the amount of time we spend on lengthy
disinfection programs with too diagnostics.
Martin: So the other 80% percent then, you would be fitting with either soft lenses or GPs?
Nick: Soft, GPs, hybrids, piggybacks, yeah
you name it, if it exists, we do it. But there's a lot of the early stage
keratoconus that we’ll fit with a fairly straightforward soft toric lens until
such time as the condition progresses to the necessity of something a little bit more advanced yeah.
Thank you for watching
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