At what stage should I refer a keratoconus patient for specialty lenses?

When best-corrected spectacle acuity stops being good enough for what the patient needs to do, or when the refraction has become unstable or unreliable. That is usually earlier than most referrals arrive. There is no stage threshold to wait for \u2014 mild keratoconus with a symptomatic patient is a reasonable referral, and severe keratoconus in a patient managing fine in a lens is not urgent.

Should I refer for cross-linking or for lenses first?

They are separate questions and do not have to happen in order. Cross-linking candidacy turns on documented progression, which takes serial imaging to establish. Lens fitting addresses vision now and can proceed in parallel. If you are unsure whether the cornea is progressing, that is something we can establish and send back to you before anyone commits to a procedure.

Do you take the patient over?

No. We fit the lens, send you a report, and return the patient to you for their primary eye care. Co-management is the model \u2014 your patient stays yours.

What imaging do you need from me?

Nothing mandatory. Send your working diagnosis and any topography you already have, which is useful for establishing a timeline, but we repeat corneal topography and Eaglet Eye profilometry ourselves as part of the evaluation.

What if the patient has already failed contact lenses elsewhere?

That is one of the most common referrals we take, and it is usually a fit problem rather than an intolerant patient. Most failed fittings were selected from a standard trial set rather than designed from the patient\u2019s own scleral shape. A previous failure is not a contraindication and should not be treated as one.

How many visits will my patient need?

More than one. An initial specialty evaluation with imaging, a diagnostic fitting, a dispensing visit with handling training, and follow-ups to refine the design once they have worn the lenses in daily life. We tell patients this at the outset so the follow-up schedule does not come as a surprise.

When To Refer A Keratoconus Patient | Michigan Contact Lens

This one is written for colleagues rather than patients — a practical note on when a keratoconus patient is worth sending to a specialty lens practice, and what comes back when you do.

The short version: most referrals arrive later than they needed to, and the reason is usually that everyone is waiting for a stage threshold that does not exist.

The trigger is function, not stage

There is no keratoconus grade at which specialty lens referral switches on. Mild keratoconus in a patient who cannot do their job is a reasonable referral. Advanced keratoconus in a patient comfortable and seeing well in a lens is not urgent.

The practical trigger is simpler than a classification:

When best-corrected spectacle acuity stops being enough for what the patient actually needs to do — or when the refraction stops being reliable — a lens is the next step.

That covers the patient who can technically read 20/30 on the chart but cannot drive at night, and the one whose subjective refraction changes meaningfully between visits and never quite lands.

Waiting rarely helps. The cornea does not become easier to fit later, and the patient spends the interval seeing worse than they need to.

Specific situations worth a referral

Spectacle acuity no longer meets the patient’s needs, whatever the number on the chart says.
The refraction is unstable or unreliable — the endpoint keeps moving, or the two eyes disagree in a way that does not resolve.
Glare, ghosting or monocular diplopia that the refraction does not explain and glasses do not fix.
Soft toric lenses are no longer holding vision — often the first functional sign, and frequently mistaken for a rotation problem.
A prior contact lens fitting failed. Very common, and usually a fit issue rather than intolerance. Worth reading as a referral indication rather than a contraindication.
Post-cross-linking, once the surgeon confirms the cornea has settled. Cross-linking does not smooth the cornea, so the irregularity that was blurring the patient’s vision is still there — and a good number of these patients are never fitted afterwards.
You are not sure whether it is progressing. That question is answerable with serial imaging, and it is a reasonable thing to send to us rather than resolve alone.

Cross-linking and lenses are separate questions

Worth stating plainly, because the sequencing causes more confusion than anything else in keratoconus co-management.

Cross-linking candidacy turns on documented progression, not on the presence of keratoconus. Establishing that needs serial corneal topography over time — a single scan, however abnormal, shows a shape rather than a trajectory. In practice a meaningful number of patients referred as urgent turn out to be stable, and some presenting as routine are not.

Lens fitting addresses vision now and is independent of that. It does not need to wait for the progression question to resolve, and it does not interfere with cross-linking if that follows.

So the two can run in parallel. If you would like the progression question answered before committing your patient to a surgical pathway, we can establish it with serial topography and profilometry and send you the comparison.

Dr. Kresch is an optometrist and does not perform cross-linking. We do the imaging beforehand and the fitting afterwards, which is exactly where these patients tend to fall through the gaps.

The patients who most often get missed

Three groups, in our experience:

The patient who was fitted once, years ago, and gave up. They tried rigid lenses, it hurt, they concluded contacts were not for them. Most of those fittings used a standard trial set on an eye whose sclera is asymmetric — the lens landed unevenly and dug in. A design taken from a three-dimensional map of that patient’s own eye is a genuinely different proposition, and they often do not know that.

The post-transplant patient managing at a level they have accepted. Graft surfaces are rarely optically perfect, and a lens over a graft is routine rather than a sign anything failed. Many of these patients were never offered one.

The patient told nothing more can be done. Almost always a statement about what has been tried rather than about the eye.

What happens after you refer

Your patient gets a specialty evaluation: corneal topography, Eaglet Eye scleral profilometry, ocular surface assessment, and a diagnostic fitting. The first consultation is complimentary, so there is no financial barrier to you sending someone for an opinion.

You get a written report, not a note in our file:

The topography and profilometry maps, with the clinically relevant findings called out
Whether the disease appears stable or progressing, and on what evidence
The lens design fitted, its parameters, and why that design over the alternatives
Corrected acuity achieved, and what limits it if anything does
Ocular surface findings, which frequently change the lens decision
Our recommended follow-up interval and what we will be watching

On coding: keratoconus sits in the H18.6 family, and the code turns on whether the disease is stable or unstable as well as on laterality — the same distinction that governs cross-linking candidacy. Our progression assessment supports the documentation as well as the clinical decision. Your billing team should confirm the specific codes for your own claims.

Co-management, not transfer

Your patient comes back to you for their primary eye care. We fit the lens, monitor the fit, and keep you informed. We do not poach patients, and we do not want to — a referral relationship is worth considerably more to this practice than a single patient file.

If you already work with a corneal surgeon, we fit alongside them. If you would like a referral pathway for cross-linking, we can point you to surgeons we work with regularly.

How to send someone

Call (248) 545-2800, fax a referral to (248) 581-4074, or use the form on our referring physicians page. If you would rather talk a case through first, ask for Dr. Kresch directly — a five-minute conversation often settles whether a referral is the right move.

We also co-manage corneal transplant, post-surgical ectasia, pellucid marginal degeneration, corneal dystrophies, ocular GVHD, Sjögren’s and neurotrophic keratitis.

Referral questions we get asked

At what stage should I refer a keratoconus patient for specialty lenses?: When best-corrected spectacle acuity stops being good enough for what the patient needs to do, or when the refraction has become unstable or unreliable. That is usually earlier than most referrals arrive. There is no stage threshold to wait for \u2014 mild keratoconus with a symptomatic patient is a reasonable referral, and severe keratoconus in a patient managing fine in a lens is not urgent.
Should I refer for cross-linking or for lenses first?: They are separate questions and do not have to happen in order. Cross-linking candidacy turns on documented progression, which takes serial imaging to establish. Lens fitting addresses vision now and can proceed in parallel. If you are unsure whether the cornea is progressing, that is something we can establish and send back to you before anyone commits to a procedure.
Do you take the patient over?: No. We fit the lens, send you a report, and return the patient to you for their primary eye care. Co-management is the model \u2014 your patient stays yours.
What imaging do you need from me?: Nothing mandatory. Send your working diagnosis and any topography you already have, which is useful for establishing a timeline, but we repeat corneal topography and Eaglet Eye profilometry ourselves as part of the evaluation.
What if the patient has already failed contact lenses elsewhere?: That is one of the most common referrals we take, and it is usually a fit problem rather than an intolerant patient. Most failed fittings were selected from a standard trial set rather than designed from the patient\u2019s own scleral shape. A previous failure is not a contraindication and should not be treated as one.
How many visits will my patient need?: More than one. An initial specialty evaluation with imaging, a diagnostic fitting, a dispensing visit with handling training, and follow-ups to refine the design once they have worn the lenses in daily life. We tell patients this at the outset so the follow-up schedule does not come as a surprise.

When to Refer a Keratoconus Patient