corneal refractive therapy
Managing the Young CRT Patient
Learn how to integrate Corneal Refractive Therapy into your practice with a focus on children and teens.
BY RICHARD KIMMICH, O.D., M.S., F.A.A.O., F.C.O.V.D., Athens, Ga.

In 2002, the Food and Drug Administration (FDA) approved corneal refractive therapy (CRT) as a nonsurgical means of decreasing the progression of myopia. CRT uses special gas permeable contact lenses to reshape the cornea at night so we can offer patients uncorrected, clear vision during the daytime.

I believe CRT is an excellent choice for children and adolescents (see "Success Stories"). I'll discuss what I feel are the easiest, least expensive and most successful steps in developing a CRT specialty for these younger patients.

We make all of our parents and patients aware of CRT through posters, informational videos and pamphlets. We screen family members to make parents aware of the benefits of CRT to their children. This has become an excellent method of identifying candidates. We give pamphlets to all good candidates, including those interested in athletics and those who have children who may become nearsighted. Paragon Vision Sciences, the only company that manufactures CRT lenses, provided all of these educational materials.

CRT in your office

You should have at least one staff member who is a successful CRT patient who can communicate information and manage patient expectations and anxieties. Focus on easier candidates first -- patients above 10 years of age and with powers of -2.50 and below without any significant astigmatism or anterior corneal complications, such as dry eye.

Have a technician take the patient's history, ask how he found out about CRT and gather data including topography and an autorefraction. The patient then views the CRT video. After the tech establishes the patient's acceptability as a candidate, the patient and/or his parents decide whether to proceed.

Starting out

When a patient elects CRT, we schedule a five-minute consultation in which I gather supplemental information, including a slit lamp evaluation of the cornea and K readings using a keratometer. We've appointed a staff member to act as CRT coordinator. She phones the patient to answer questions and to schedule appointments for fitting, insertion/removal, first overnight, first week and first month. The coordinator also arranges payments.

In the first two months of 2003, my practice fit 27 new CRT patients. The average number of visits per patient was five.

Seeing the results

During this time, acuities of the 10 children and adolescents who were treated were:

• K.B. (age 10). Initial power -3.00 -1.00 x 90. Happy with his acuity of 20/30 but still waiting for his second pair of lenses.
• N.A. (age 9). Initial power -4.50 - 0.50 x 100. Released for three months at 20/20.
• E.F. (age 13). Initial power -3.00, 20/25+. Released for one month.
• I.H. (age 15). Initial power -3.00. First overnight acuity at this point 20/25-.
• A.B. (age 15). Initial power -6.00, still in progress with best visual acuity 20/40. This is at a two-week visit and I've ordered new lenses. I expect this case to take longer because of the high initial power and the K numbers are steep at 4750 x 4887 OU.
• J.D. (age 18). Initial power -2.00, completed and released for 3 months at 20/15 visual acuity.
• D.B. (age 12). Initial power -2.00 OU. Current powers: 20/30 OU. Will return for one-week evaluation. Happy with progress.
• S.K. (age 15). Initial power -2.00 OU at the first week's visit. Current power are 20/20 OD, 20/20 OS, 20/15 OU. Patient will return in one month.
• R.H. (age 9). Initial powers -3.75 OU. Current powers: 20/30 OD, 20/25 OS. Patient is in progress with first pair of lenses and is happy with vision. Will return for one-month evaluation.
• J.S. (age 18). Initial powers: ­4.75 OD, -4.25 OS, 20/40 OD, 20/40 OS, 20/30 OU at 10 days. Will return for one-month evaluation. I will change lenses on follow up as needed.

At two weeks, most patients in the -3.00 and under category are where we'd like them to be and we've made additional lens changes for those who aren't completely treated yet. Several of these patients have been a challenge because of previous contact lens failure or dry eyes but lubrication enables many previous dry eye failures to find success with CRT. Unless otherwise stated, the patients listed are seeing clearly through all waking hours.

Reviewing final facts

The FDA requires certification before you become a CRT fitter and I strongly suggest you purchase a fitting set. Some practitioners feel that CRT is best performed with the use of topography, which enhances the safety of the patient and the confidence and competence of the fitter. The topographer will pay for itself in reduced chair time and in providing billable code coverage.

CRT has been the most exciting thing to enter my practice. I hope this approach will be a positive tool for your practice too.

Dr. Kimmich practices at Five Points Eye Care Center in Athens, Georgia. Contact him via e-mail at rkimmich@negia.net