Diagnosis and Management of Keratoconus by Eye Care Practitioners in Kenya

Abstract

Abstract Background: To explore current eye care practice in keratoconus diagnosis and management in Kenya. Methods: An online questionnaire was distributed to ophthalmic clinical officers (OCO) and optometrists. Results: A total of 203 responses were received from 52 OCOs and 151 optometrists with a response rate of 24.4% and 53.5% respectively. The majority reported having access to retinoscopes (88.5%; p=0.48) and slit lamps (76.7; p=0.14). Few practitioners did not have access to a corneal topographer (13.5%; p=0.08) and rigid contact lens (CL) fitting sets (OCOs 5.8%, optometrists 33.8%; p<0.01). One-third did not feel that retinoscopy (38.7%; p=0.21), slit lamp findings (30.3%; p=0.10) and corneal topography (36.6%; p= 0.39) are important investigations in keratoconus diagnosis. Corneal topography was not recommended in two-thirds of patients (59.0%; p=0.33) with vernal keratoconjunctivitis (VKC). The majority counselled against eye rubbing in mild (73.6%; p=0.90) VKC, 52.9% in moderate (p=0.40) and 43.6% in severe (p=0.24) cases. The majority prescribed spectacles in mild (90.2%; p=0.95), 29% (p=0.97) in moderate and 1.9% (p=0.05) in severe cases. When the binocular best corrected visual acuity (BCVA) with spectacles was ≤ 6/18, 76.9% of OCOs and 58.9% of optometrists referred for CLs (p=0.02). When binocular BCVA with CLs dropped to ≤6/18, 83.7% (p=0.18) referred to the ophthalmologist for surgical intervention. Few OCOs fitted rigid CLs (15.4% OCOs, 51.0% optometrists; p=0.01), majority referred to optometrists (82.7% OCOs, 43.7% optometrists; p<0.01). Progression was monitored in 70.1% (p=0.11) of mild, 50.9% (p=0.54) moderate and 25.3% (p=0.31) advanced cases. Few OCOs (15.4%) performed corneal cross-linking (CXL). Keratoconus patients were referred to an ophthalmologist when BCVA dropped (50.4%; p=0.35) and on signs of progression (59.8%; p=0.37). About one-quarter (26.1%; p=0.10) referred for CXL regardless of age and progression, two-thirds (68.5%; p=0.46) when keratoconus was progressing and a few (5.4%; p=0.13) did not know when to refer. Co-management with ophthalmologists was reported by 58.0% (p=0.06) of respondents. Conclusion: The results of this study highlight the need to map services for keratoconus patients, review current curricula and continuous education priorities for mid-level ophthalmic workers, develop guidelines for the diagnosis and management of keratoconus and improve interdisciplinary collaboration.