Keratoconus Treatment

Keratoconus is a progressive corneal condition that typically affects young patients’ vision, although a less common variant, Pellucid Marginal Degeneration (PMD), occurs in older patients.

Keratoconus Treatments

Keratoconus is a progressive corneal condition that typically affects young patients’ vision, although a less common variant, Pellucid Marginal Degeneration (PMD), occurs in older patients.
Often with onset in teenage years, it results in a progressive bulging forward of the cornea into a cone-like shape. With an incidence of 1: 2000 people, until recently progression of the disease could not be prevented or stabilized. In recent years Corneal Cross-Linking (CXL) has become available which offers stabilization of the disease.

Untreated, the natural history of Keratoconus is to progress. Eventually, the disease stabilises but frequently only after significant visual distortion results. This can make wearing glasses very difficult and result in an unsatisfactory quality of vision. When vision is poor with glasses, rigid contact lenses are the mainstay of treatment. This too may not provide sufficient clarity and these type of lenses can have their own issues in terms of comfort and safety.

Corneal Cross-Linking (CXL) utilises principles derived from dentistry where light can be used to strengthen polymers used for fillings and tooth restoration.

Things to Know About Corneal Cross-Linking (CXL)

About the process

In the treatment of Keratoconus or Pellucid Marginal Degeneration (PMD) the aim is to strengthen the corneal collagen by exposing it to UV light. This is achieved by soaking the corneal collagen with a green dye in the form of Riboflavin. Riboflavin specifically absorbs UV light releasing a reactive oxygen particle. This particle binds together the side chains of the collagen leading to an immediate and generally permanent increase in the structural strength of the cornea. This increase is approximately three times that of the untreated cornea enabling it to withstand the deformation forces in the eye that leads to the cone shape distortion seen in Keratoconus.

Success expectations

In mild to moderate Keratoconus, CXL can stop disease progression in virtually all eyes. It is, therefore, preferable to treat eyes before the disease produces marked difficulties with vision. When to treat remains a matter of judgement but can be assisted by the use of diagnostic devices (such as the Pentacam, as used by AE&LC) that can document progressive steepening of the cornea and therefore of the disease.

As Keratoconus frequently runs in families, siblings and children of Keratoconus sufferers can be screened for the disease early and monitored for progression. In the future, there exists the potential to intervene early in the disease and prevent many of its consequences.

Procedure

In order to deliver sufficient Riboflavin into the cornea, the epithelium (a layer of tissue that covers the front of the cornea and acts as a protective barrier for it) must be bypassed since Riboflavin is too large a molecule to passively pass through it. Classically this means removing a large central area of the epithelium, about 9mm round, under topical anaesthetic drops and then applying the riboflavin for 20-30 minutes.

Because epithelial removal results in more discomfort and slower recovery, attempts are being made to deliver the Riboflavin with the epithelium intact. So far this approach has been controversial, as it may not provide full strengthening of the cornea. Currently, we employ an epithelium off approach to guarantee the full effect and highest success rate of the procedure, however, this may change in the future depending on technology and research advancements in this surgical field.

Once there is sufficient Riboflavin in the cornea, 10 minutes of UV light is delivered to the cornea. This requires the eye to be open for the duration of the treatment and an eye speculum is used for this purpose. Sensitive cells at the edge of the cornea are protected and after completion of the treatment drops are instilled and a bandage contact lens is inserted to protect the regenerating epithelium.

In some eyes that have mild Keratoconus and sufficient corneal thickness, it is possible to perform a therapeutic laser treatment to treat irregular astigmatism induced by the condition. This is designed to improve the best-corrected vision of the eye and may even eliminate the need for spectacles or contact lenses. This treatment is performed using an Excimer laser and based on the pre-operative Pentacam and customised topography maps that are used to direct the laser pulses onto the cornea. Cross-linking is then performed in a routine manner immediately after.

Regarding all of the above, you will have the opportunity to ask any questions to your surgeon to ensure you understand the procedure and your treatment program.

Recovery

It takes 4-5 days for the epithelium to regenerate and a further 2-4 weeks before the vision in the eye approaches pre-operative levels. Thereafter, stabilisation and in many cases improvement is seen. Drops are required for 6-8 weeks and appointments with our clinicians are necessary at one, three, and nine months.

It is normal to see a reaction within the corneal collagen over the first few months characterised by a hazy appearance to the cornea of a mild degree. This is not normally noticed by the patient but a slight loss of contrast to lights may be experienced for up to three months.

It is usually necessary to be away from work for 7-10 days. Once the epithelium has healed, normal activities can commence only being limited by the rate of visual recovery. Contact lenses can be worn again after two weeks but it may be four weeks before this can be done comfortably.

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    Copyright 2021 by NHSTR. All rights reserved.