Keratoconus Treatment & Management

  • Author: Barry A Weissman, OD, PhD, FAAO; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Nov 23, 2011
 

Medical Care

Rigid contact lenses (CLs) are the mainstay of keratoconus (KC) treatment.

Patients with early keratoconus may successfully use spectacles or spherical/toric soft contact lenses. They may even rarely find that spectacle vision is superior to rigid contact lenses.

Patients with modest-to-advanced keratoconus almost always require rigid contact lenses. When rigid contact lenses are no longer tolerated, some patients can maintain contact lens wear and usable visions with hydrogel contact lenses, piggyback contact lenses, or scleral (haptic) contact lenses but usually at a physiological or visual cost.

Contact lens wear is often complicated by episodes of intolerance, allergic reactions (eg, giant papillary conjunctivitis), corneal abrasions,[30] neovascularization, and other problems, sometimes leading to total intolerance.

Though not FDA approved in the United States, corneal collagen cross-linking (CXL) is a procedure used to increase the rigidity of the cornea by inducing additional cross-links within or between collagen fibers using UVA light and a photomediator, riboflavin, with the goal of slowing down, possibly stabilizing, and even perhaps reversing, the progression of corneal ectasia in patients with keratoconus.[31, 32]

Long-term studies are still needed to determine the success and adverse effects of the procedure, as well as the long-term biomechanical effect of CXL. Currently, there is no effective way to measure collagen turnover and, hence, the stability of the collagen cross-links remains a concern.[33] More studies are also needed to identify high-risk patients perhaps related to their age, diagnosis, corneal shape, and/or stages of ectasia.

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Surgical Care

Surgically removing central nodular scars by shaving the corneal surface (superficial keratectomy with a blade or excimer laser phototherapeutic keratectomy) may improve contact lens tolerance, decrease the rate of associated corneal abrasions, and preclude the need for corneal transplant.

Intrastromal corneal rings (Intacs) have been implanted for patients who have become intolerant to contact lenses, but these have been found to be more successful in modest than advanced disease.[18, 19]

Lamellar keratoplasty, or various types, especially deep anterior lamellar keratoplasty (DLAK) with "big bubble" technique, is being reconsidered as a surgical treatment for keratoconus.[16, 17]

More traditionally, these patients, including those whose vision is not correctable to better than 20/40, are referred for corneal transplants penetrating keratoplasty (PKP). PKP is very successful in keratoconus, resulting in clear visual axes in greater than 90% of all cases. PKP for KC exhibits excellent visual and survival results, but young patients may require 1 or more grafts during their lifetime.[34] Contact lenses are often still required post graft for optimum vision.

PKP requires continuing professional care to watch for rejection, suture-related problems, wound dehiscence, and other difficulties.

Although extremely rare, keratoconus can recur in a graft.

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Consultations

Consult with a cornea specialist (a graduate of a cornea fellowship program) and/or contact lens specialist who provides appropriate (primarily rigid gas permeable [GP]) contact lens care.

An ophthalmologist who is a cornea specialist assists in identifying appropriate clinical conditions and timing for surgical intervention, such as superficial keratectomy, PKP, implantation of plastic corneal ring segments, or collagen crosslinking. Alternatively, topography-guided conductive keratoplasty has been shown to be modestly effective in reshaping the cornea in keratoconus eyes, at least temporarily.[35]

A specialty contact lens practitioner (usually an optometrist but can be an optician or ophthalmologist) monitors contact lens care to optimize vision while minimizing complications of contact lens wear. The practitioner also helps to establish the appropriate clinical conditions and timing of surgical intervention, should this become necessary.

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Activity

Patients should avoid (vigorous) eye rubbing.

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Contributor Information and Disclosures
Author

Barry A Weissman, OD, PhD, FAAO  Chief of Contact Lens Service, Professor, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine; Adjunct Professor of Optometry, Southern California College of Optometry

Barry A Weissman, OD, PhD, FAAO is a member of the following medical societies: American Academy of Optometry, American Optometric Association, California Optometric Society, and International Society for Contact Lens Research

Disclosure: VSP None Speaking and teaching; Alcon None Speaking and teaching; Vistakon/The Vision Care Institute Grant/research funds support of Fellowship program

Coauthor(s)

Karen K Yeung, OD, FAAO  Director of Optometry, Arthur Ashe Student Health and Wellness Center, University of California, Los Angeles, David Geffen School of Medicine

Karen K Yeung, OD, FAAO is a member of the following medical societies: American Academy of Optometry

Disclosure: Nothing to disclose.

Specialty Editor Board

Fernando H Murillo-Lopez, MD  Senior Surgeon, Unidad Privada de Oftalmologia CEMES

Fernando H Murillo-Lopez, MD is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Christopher J Rapuano, MD  Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Institute

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology

Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; RPS Ownership interest Other; EyeGate Pharma Consulting fee Consulting; Bausch & Lomb Honoraria Speaking and teaching; Bausch & Lomb Consulting; Merck Honoraria Speaking and teaching

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

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An optic section of a keratoconic cornea shows corneal thinning. Vogt striae and some scarring can also be seen centrally; superiorly, a small (brown) section of the Fleischer ring is noted.
The fluorescein pattern of a rather flat-fitted rigid contact lens on an advanced keratoconic cornea.
 
 
 
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