When I die, my only wish is that my coffin be shaped like a giant spectacle case with my practice name printed on the top. I’d also appreciate an extra large microfiber blanket please.
In reality though, I do have a specific request on my departure. It’s that my corneas only get transplanted to a person with keratoconus if they were given the opportunity to try contact lenses first.
Corneal transplants can be wonderful and there are emerging treatments such as CAIRS which are exciting. In Brisbane, where I practice, we are fortunate to have some amazingly talented and caring surgeons. If I had keratoconus with corneal scarring, or lacked the ability to wear contact lenses, I would happily refer myself and I would be forever grateful to the surgeon, and most importantly to the donor.
But in some states in Australia at least, there are a group of patients who never get the chance to find out whether they actually need surgery or whether they in fact could just wear contact lenses to achieve good vision.
In these states there is no publicly accessible funding for contact lenses. Which means that if you have keratoconus and no money, you are stuck between living a blurry life or seeking publicly funded corneal transplants, and there is no certainty that transplants will lead to clear vision with spectacles. Not only does this go against all evidence-based protocols, but it also puts public hospital ophthalmologists in the difficult position of only being able to offer funded surgery, and nothing else.
Access to clear vision should be equitable. Patients can access means-tested glasses, hearing aids and prosthetics, but not contact lenses. A person with uncorrected keratoconus may not be able to work, drive or see their children’s faces and that apparently is acceptable. For decision-makers to decline to fund vision correction because that person suffers a condition not correctable with glasses can only be considered discriminatory.
In our practice, we fit custom contact lenses all day long. They are an exceptionally effective and low risk form of vision correction. Yes, even though I love contact lenses, and see happy and successful lens wearers every day, I will admit that a small percentage of people can’t wear them.
But that is the exception and not the norm.
The Global Consensus on Keratoconus and Ectatic Diseases describes that “surgery should be considered when patients were not fully satisfied with nonsurgical treatments”. So then why isn’t the option of contact lenses made available to all patients in this category? Because this problem requires a solution at a public health level and cannot be solved at a private practice level.
In our practice we have tried many things to help patients with keratoconus who cannot afford even basic lenses. Following the cessation of the last form of contact lens funding in Queensland, we trialed a program of very heavily discounted lenses and bulk billed appointments for needy patients. This was an abject failure. Unfortunately, most people either have some money for medical expenses or they have none. And for those who have none, a loss-to-the-
practice half price contact lens still isn’t an option.
Patients with vision conditions requiring contact lens correction need our help. They need practitioner and patient associations to make strong representations on their behalf. They need to know that whilst surgery can be great, it isn’t a globally recommended first line form of vision correction for people with keratoconus. And organ donors need to know that the organs they leave will be used judiciously.
At some point in the future, there will be a non-invasive permanent cure for keratoconus. And when that day comes, I will happily pack up my topographer and celebrate with the many patients who will benefit. But until then, all global protocols are clear that spectacles and contact lenses are the best first line forms of vision correction.
If I die and my corneas find their way into eyes which could easily have been wearing contact lenses instead, I will haunt the policy-makers. Not in spooky or scary ways, but in super annoying ways. I will use my supernatural powers to change their wifi passwords. And every time they self-scan an item at Coles I will place an unexpected item in the bagging area. And worst of all I will leave selfies of myself everywhere they go, so that they know what a life with ghost images everywhere is really like.
About the author:
Name: David Foresto
Qualifications: Optometrist specialising in contact lenses
Job title: Principal optometrist
Location: Brisbane CBD and a lecturer at QUT
