The Future of Interventional Keratoconus Management: Perspectives on Integrating Epithelium-on Oxygen-Enriched Cross-Linking into Comprehensive Care Pathways

This perspective presents a new conceptual framework for the comprehensive care of patients with keratoconus. Keratoconus is an ectatic degeneration of the cornea associated with progressive vision loss and diminished quality of life. Until recently, treatment consisted of optical correction in early stages and corneal transplantation in later stages, neither of which impacted the progressive nature of the disease. The development of corneal cross-linking-a minimally-invasive procedure that stabilizes the disease process and prevents progressive ectasia and vision loss-has significantly altered the therapeutic approach to keratoconus. Until recently, the procedure required removal of the corneal epithelium, but a newly FDA-approved epithelium-on oxygen-enriched option may simplify the process with a favorable benefit-to-risk balance. The FDA indication for this new epithelium-on treatment option also does not require disease progression, further facilitating earlier intervention. Interventional keratoconus management is a novel paradigm characterized by early diagnosis enhanced by new and emerging technology, and early proactive intervention to prevent vision loss and quality of life. Some technologies like epithelium-on oxygen-enriched cross-linking are FDA-approved, while others such as pharmaceutical treatments and customized cross-linking are in development. A decentralized coordinated effort from all eyecare providers, including optometrists, comprehensive ophthalmologists, and corneal surgeons may be necessary for identification of early cases and timely referral for early interventional cross-linking treatment. This approach facilitates preservation of vision and quality of life for patients with keratoconus; it also may reduce the economic burden of keratoconus for health systems and society by reducing the long-term costs of care as well as lost productivity and disability. Development and implementation of a viable community-based, patient-centered, interventional keratoconus care pathway will likely require expanded awareness and education regarding keratoconus and its treatment, as well as creating recommendations and guidelines for healthcare systems and providers to streamline screening, referral, and treatment processes. Given that evidence is emerging and clinical practices are evolving for this novel technology, the paper represents a modern perspective based on a synthesis of available evidence, rather than a traditional consensus guideline.