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Reproduced with permission, Australian Optometry, May 2005.

Dabbling in Keratoconus: fair or foul?

By John Mountford

In the March 2005 issue of Australian Optometry, Larry Kornhauser of Keratoconus Australia outlined some of the difficulties his association was having in trying to get a fairer deal for his members.

As we all know, keratoconus is an expensive condition to have, with regular replacement of contact lenses due to loss or changes to corneal shape, so a more realistic refund from the private health insurance funds seems like a relatively simple and straightforward approach to the problem.

Similarly, an increased Medicare benefit that reflects the amount of time involved would help offset the price of the lenses, which are commonly used to fill the shortfall of the consultation fee.

The health funds have raised one very important point: an increased benefit would simply lead to unqualified practitioners ‘dabbling’ in keratoconus fitting as a means of improving income. The same scenario would apply if a higher Medicare rebate were to be forthcoming.

Maybe it is time to take a good, hard, long look at where we stand with regard to these issues.

Optometrists Association has a long history of apathy and some would say hostility to the concept of optometric subspecialities; it appears to cling to the outmoded socialist concept that ‘all are created equal’.

This has lead to the formation of the Australasian College of Behavioural Optometrists and the Contact Lens Society of Australia fellowship programs as a means for practitioners to increase their skills and knowledge in areas of specific interest.

I have a lot of contact with Larry Kornhauser and he has passed on to me a list of complaints that his members have with our profession or elements in it. The complaints are:

• Patients are being made to pay for expensive lenses that are ‘fitted’ by ‘dabblers’ who do not have the knowledge and skills to do it.

• Patients have no recourse to refunds when the fitting is unsuccessful.

• Patients are not referred to those who are qualified to do the fitting.

As a practitioner, I see more than my fair share of these outcomes. The patients eventually find their way to the practice, and I get left with a 10930 because someone else has done the 10924.

Even more disturbing are the cases where the 10924 has been charged and no lenses fitted or dispensed. Discussions with other keratoconus practitioners show that this is a not an uncommon occurrence.

The solution appears to be that keratoconus fitting be restricted to those practitioners who can prove expertise in the area.

I am undergoing the rigours of therapeutic training, where there are no grey areas.

You are either qualified to treat eye disease and prescribe drugs, or you are not and are simply not allowed access to the medicines. The same should apply to lenses for keratoconus.

The problem then arises: how is it determined that a practitioner has the skills and knowledge to treat keratoconus?

Larry Kornhauser has a simple but straightforward approach: get the Medicare statistics and see how many 10924 consultation fees each practitioner generates. A cut-off of 25 patients a year could be used to delineate those practitioners who could access the benefit.

This approach has some disadvantages such as availability of practitioners to keratoconus patients who do not live in high population areas, and an imposed exclusion for those practitioners who are keen and interested in becoming more involved in looking after keratoconus patients.

A second option would be to limit access to those practitioners who have a post-graduate qualification in advanced contact lens practice.

At present, that means those who are fellows of the Contact Lens Society of Australia or who hold the Master of Optometry degree from the University of New South Wales in advanced contact lens practice.

This approach would open the door to practitioners from all areas of the country and is not as exclusive as the Medicare numbers approach. Access to these courses is open to any qualified optometrist and requires only some dedication and study.

The FCLSA is desperate for members to take up the challenge and apply for fellowship but is faced by a wall of apathy towards contact lens practice.

Australia has one of the lowest rates of contact lens utilisation in the world and many studies have been conducted to try and find out the reason. Is it that fitting soft lenses is seen as dull and boring, which it is, or that there is simply no real profit in them, which is wrong?

As I said in my first article on keratoconus, it is time for all good men and women to come to the aid of the party. I suggest that for our keratoconus patients to get ethical help from the profession, we have to take the steps to bury the old socialist concepts on equality of all with a degree.

We should start limiting the availability of the 10924 to those who have shown by study to be proficient at fitting keratoconus.

My next article on this subject will be a report on the types of keratoconus lens designs that are available in Australia and from overseas, and the warranties that apply to them.

I find it strange that I can exchange as many soft torics as I like over six months but have limits arbitrarily placed on the number of exchanges I can have for my keratoconus patients.

I may also allow myself a big harangue on the non-use of corneal topography.