AOA 2024: Building out your keratoconus toolbox

At Optometry's Meeting 2024, Susan Gromacki, OD, MS, FAAO, FSLS, presented alongside Clark Chang, OD, MSA, MS, on the value for clinicians to expand the tools they have in their practice to help patients with keratoconus. The duo discusses tips and tricks for fitting scleral lenses, but they also dive into what to do when scleral lenses fail—and where to begin for those just beginning to help patients with keratoconus.

Video transcript

Editor's note: This transcript has been lightly edited for clarity.

Emily Kaiser Maharjan:
Hi everyone. I'm here today to chat with Dr. Susan Gromacki, who is here to talk about her presentation, "Growing your keratoconus contact lens toolbox," which she is presenting alongside Dr. Clark Chang at AOA. Thanks for taking the time to chat today, Dr. Gromacki.

Susan Gromacki, OD, MS, FAAO, FSLS:
Thank you for having me. It's a pleasure.

Kaiser Maharjan:
Of course. So first, can you tell me a little bit about the presentation and how this topic came to you? What the evolution of the topic has been over the past few years; just give me a little bit of background.

Gromacki:
So Dr. Clark Chang and I both specialize in keratoconus. It's something that both of us in our practices, see and do all day every day. I wrote my master's thesis on keratoconus back in 1993, over 200 pages long, and ever since then, I've specialized in the condition and it's a challenge, but it's also a pleasure to see how much we can help our patients.

Kaiser Maharjan:
So you've been specializing in keratoconus for 30 years. Can you tell me a little bit about how the the practice and the diagnosis has changed over that time?

Gromacki:
Absolutely. So when I wrote my master's thesis on keratoconus, obviously, it was comprehensive. It was over 200 pages long. And then for probably 15 years after that, when my patients would say, is there anything new in keratoconus? I would say, no, not really very much. This is kind of what we have right now.

But about 15 years ago, we had a couple of things come about that really impacted and changed our practices for the better. And one was corneal collagen cross-linking, which actually started back in Europe long before it came to the US. But generally, about 2008-2009, we started to kind of see the beginnings in the US. And fortunately, when I moved to the DMV area, the practice I joined in 2012 had already been doing cross-linking. It was one of the first in the country to do corneal collagen cross-linking. So I got in on it, even prior to the FDA approval in 2016. And I saw the impact it was having on my patients, which was to arrest the development of keratoconus. And that was really exciting.

The second thing, of course, that we all know about that came about 15 years ago, again commercially, it was certainly available before then but on a very limited basis, was scleral lenses. And scleral lenses have changed everything. They have brought vision back to patients who never thought they had that. They've brought comfort, better retention than this little small GPs [gas permeable lenses] that I started fitting early in my career; they've really changed everything in a positive way for my patients.

Kaiser Maharjan:
So your talk is about the growing a toolkit for keratoconus. Could you tell me a little bit about some of the tools that you keep in your toolkit?

Gromacki:
Absolutely. So Clark and I go through case by case, actual cases that he and I have seen and helped patients with, and part of the impetus was that I think a lot of the younger optometrists come out of optometry school pretty confident now fitting scleral lenses. Obviously, you know, 10-15 years ago, that wasn't the case because they were so new, and it was the opposite. People came out of optometry school, knowing how to fit the small GP lenses pretty well. And now it's almost reversed. I think, you know, the younger docs aren't fitting corneal GPs as much as they used to obviously now that we have scleral lenses with all their benefits.

So if you have a practice like mine and Clark's, you have to have everything in your toolbox to solve each and every issue that patients might have. And some patients might need a corneal GP lens. Some patients might need a soft contact lens for keratoconus. Some patients might need piggyback or hybrid or a lot of different other things other than scleral. So it's going to be kind of fun to give this lecture and sort of bring out some things for certain patients and patient types that might be a little outside the box, that aren't just okay, we're going to fit a scleral lens for everybody. Because, honestly, not everybody needs a scleral lens, and there are certain little issues that benefit from other things too.

Kaiser Maharjan:
Yeah, absolutely. Do you have a favorite tool that you use when treating patients with keratoconus?

Gromacki:
Well, scleral lenses have so many benefits that they really are probably the number one new fit, but sometimes scleral lenses fail. And, you know, early on in the process, when scleral lenses were in their infancy, I was so excited to introduce them to patients. Now that they've been out for a while, I tend to get patients who have failed with scleral lenses for one reason or another, and they find me. Somehow these patients find me, which is great, because this is what I love to do. And I find that, well, maybe there was something off there. Maybe the patient wasn't caring for their lens properly, maybe they weren't using the right solutions, or filling the bowl of the lens in the morning with the right thing. And they just weren't instructed properly, or it was a few years since they saw an eye doctor and they morphed into some bad behavior. So sometimes it's a matter of refitting with a scleral lens. But sometimes as you'll see in the lecture, sometimes you have to think outside the box, and grab everything else in your toolbox to help these patients succeed.

Kaiser Maharjan:
So for clinicians who are maybe just starting to implement some keratoconus care into their practices, or are just kind of starting on that journey, do you have kind of a beginner's toolkit that you would recommend for people who just need the basics to get started before they start growing the toolkit?

Gromacki:
I think the number one item that new fitters should have in their toolbox is passion. I think they, if you don't have a passion for helping these patients, you're probably not going to succeed in practice because our patients are smart. They can see through this, they know who does this for a living all day, every day. And they can tell if they visit somebody who just dabbles in it. Fortunately, so many of my colleagues who who dabble in it refer to me because they know that they might specialize in something else other than keratoconus; they don't pretend. So that's how I do get a lot of my patients. But you know, the patients have been suffering with this condition for a while, many of them, and they can tell the difference between somebody who is genuinely invested in it, and cares about their eyes and cares about learning the new technology, and someone who might just be doing it to do it or just hasn't invested their entire practice into treating and fulfilling the needs of keratoconus patients. And it's a practice-wide commitment. You know, the front desk needs to know that when these patients call in because they broke a lens, that they can't see with glasses, it's not like our soft spherical patients, you know, wearing a daily disposable where they can just wear their glasses for a day or two while they're waiting for their contacts to come in. They literally cannot see with glasses. Many of them refuse refractions. And so the staff needs to know that they need to order that lens immediately because this patient can't see. Little things like that.

Hiring a good technician to help you with the insertion or removal process, the instruction process, and having that technician on the same page as yourself so that no matter who they're seeing in the practice, they get constant messaging, constant communication, that's going to be the same as what you would do if you were doing it yourself. So it does need to be a practice-wide commitment as well.

Kaiser Maharjan:
Do you have any key takeaways that you really want to drive home?

Gromacki:
I think that is that if you truly want to specialize in this, you need to have lots of tools in your toolbox, not just scleral lenses, but other tips and tricks that will help you help your patients succeed and ultimately see their best and do their best in life.

Kaiser Maharjan:
Thank you so much for taking the time to chat today, Dr. Gromacki.

Gromacki:
Thank you so much.

Kaiser Maharjan:
I've learned so much about the tools needed to fit contact lenses for patients with keratoconus, and I really appreciate you sharing your wisdom.