eMedicine Specialties > Ophthalmology > Cornea

Keratoconus: Treatment & Medication

Author: Barry A Weissman, OD, PhD, FAAO, Chief of Contact Lens Service, Professor, Department of Ophthalmology, Jules Stein Eye Institute, University of California at Los Angeles
Coauthor(s): Karen K Yeung, OD, FAAO, Director of Optometry, Arthur Ashe Student Health and Wellness Center, University of California at Los Angeles
Contributor Information and Disclosures

Updated: Jan 8, 2007

Treatment

Medical Care

• Rigid CLs are the mainstay of treatment.
  • Patients with early KC successfully may use spectacles or spherical/toric soft contact lenses. They may even rarely find that spectacle vision is superior to rigid CLs.
  • Patients with modest-to-advanced KC almost always require rigid CLs. When rigid CLs are no longer tolerated, some patients can maintain CL wear and usable visions with hydrogel CLs, piggyback CLs, or scleral (haptic) CLs but usually at a physiological or visual cost.
  • CL wear often is complicated by episodes of intolerance, allergic reactions (eg, giant papillary conjunctivitis), corneal abrasions, neovascularization, and other problems, sometimes leading to total intolerance.

Surgical Care

• Surgically removing central nodular scars by shaving the corneal surface (superficial keratectomy with a blade or excimer laser phototherapeutic keratectomy) may improve CL tolerance, decrease the rate of associated corneal abrasions, and preclude the need for corneal transplant.
• Although still controversial, intrastromal corneal rings (Intacs) have been implanted in the eyes of patients who have become intolerant to contact lenses. More traditionally, these patients, including those whose vision is not correctable to better than 20/40, are referred for corneal transplants (or PKPs).
  • PKPs are very successful in the treatment of KC, resulting in clear visual axes in greater than 90% of all cases.
  • Contact lenses are often still required postgraft for optimum vision.
  • PKPs require continuing professional care to watch for rejection, suture-related problems, wound dehiscence, and other difficulties.
  • Although extremely rare, KC can recur in a graft.
• A surgical treatment involving riboflavin and UV light has been proposed. With this treatment, the corneal epithelium is first removed, and the corneal stroma is subjected to riboflavin and exposed to UV light. The cornea is then allowed to reepithelialize. This treatment is an effort to induce increased collagen cross-linking to enhance corneal rigidity and to decrease keratoconic corneal steepening. While some act as advocates for this treatment, others have significant concerns that it may be harmful rather than beneficial. Additional human and animal studies are in progress.

Consultations

• Consult with a cornea specialist (a graduate of a cornea fellowship program) and/or CL specialist who provide rigid CL care.
  • An ophthalmologist who is a cornea specialist assists in identifying appropriate clinical conditions and timing for surgical intervention, such as superficial keratectomy, PKP, or implantation of plastic corneal ring segments.
  • A specialty contact lens practitioner monitors CL care to optimize vision while minimizing complications of CL wear. The practitioner also helps to establish the appropriate clinical conditions and timing of surgical intervention, should this become necessary.

Activity

Patients should avoid (vigorous) eye rubbing.

Medication

No direct pharmacological management of KC is available, although nonsteroidal anti-inflammatory (NSAID), antihistamine, or mast cell stabilizing topical medications are occasionally helpful in controlling the often concomitant signs of ocular allergies, especially pruritus, that can lead to eye rubbing.

Episodes of hydrops may require treatment with hyperosmotics to reduce corneal swelling or topical steroid drops to reduce inflammation. Topical antibiotics are used for suspected infection.

Mast cell stabilizers

Used to manage signs and symptoms of long-term ocular allergies, which can lead to patient discomfort and increased vigorous eye rubbing.

Alamast (Pemirolast) or alocril (Nedocromil)

Mast cell stabilizers are effective to treat long-term ocular allergies, specifically giant papillary conjunctivitis, which can accompany contact lens wear (especially in keratoconus). This is not effective for acute allergies.

Olopatadine hydrochloride (Patanol), epinastine (Elestat), azelastine (Optivar)

Inhibitor of histamine release from mast cell and devoid of effects on serotonin, alpha-adrenergic, muscarinic, and dopamine receptors.

Corticosteroids

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli.

Loteprednol (Lotemax)

Site-specific steroid for acute severe allergic reactions.

Antihistamines

Reduce symptoms of itching that can lead to eye rubbing, thereby decreasing eye rubbing both in duration and intensity.

Emastadine (Emadine)

Relatively selective H1-receptor antagonist.

Hyperosmolar diuretics

May reduce inflammation in cornea by creating an osmotic gradient across an intact blood barrier.

Sodium chloride 2% and 5% (Muro 128, Adsorbonac, Afrin Saline Mist)

Used for temporary relief of corneal edema.

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