Seeing the Cornea Clearly

Of all the conditions we screen for in comprehensive optometric care, keratoconus may be the one we most consistently underestimate. It is not as rare as many of us were taught, not always dramatic in its early presentation, and not always going to announce itself with a symptom profile that makes diagnosis easy. What it does do, if we look carefully, is leave clues: a changing prescription, a cylinder that doesn’t fit the rule, a patient who has seen four doctors and still can’t see well in glasses.

Part four of the EMPOWER: Business + Specialty Care Optometric Series takes on specialty cornea, anchored by two clinicians who have built their practices around this work. Melissa Barnett, OD, FAAO, FSLS, FBCLA, ACC, brings a comprehensive view of how to recognize keratoconus, when to recommend cross-linking, and how scleral lens technology has evolved to serve these patients. John D. Gelles, OD, FAAO, FIAOMC, FCLSA, FSLS, FBCLA, approaches the same condition from the imaging side, unpacking what topography, tomography, OCT, and wavefront aberrometry each contribute to diagnosis, and making a clear case for why corneal topography belongs in every optometric workflow, not just specialty practices.

Both clinicians share something in common: they see patients who have been passed around the system, told their vision can’t be corrected, or nearly cleared for LASIK before a thorough corneal evaluation revealed keratoconus. The cost of a missed diagnosis is not abstract. It is measurable in years of uncorrected vision and, in some cases, in disease progression that did not need to happen.

The imaging tools and lens designs discussed here are not exotic. They are increasingly accessible, and the argument for their broad use is compelling. As Dr. Gelles puts it: anything is better than nothing, but at a minimum, you must own a corneal topographer and use it. That is a reasonable standard of care. This issue makes the case for why.