Even in the absence of signs or symptoms of complications, contact lens care should be provided at 4-month to 6-month intervals to promptly address changes in fit or optics, as well as detecting asymptomatic complications and early intolerance. Article, encoded search term (Keratoconus) and Keratoconus, Conductive Keratoplasty Hyperopia and Presbyopia, Subconjunctival Microinvasive Glaucoma Surgeries, Penetrating Keratoplasty Effective for Corneal Complications of Shingles, Ocular Trauma: 8 Potentially Devastating Eye Injuries. Br J Ophthalmol 2011; 95:1044. J Ophthalmol. 46(4):1256-63. J Cataract Refract Surg. [Medline]. Surgical care is recommended when the best corrected visual acuity achieved with contact lenses is worse than 20/40 vision or when contact lenses and scleral lenses are no longer tolerated. [Medline]. Evidence of oxidative stress in human corneal diseases. Shimmura S, Tsubota K. Deep anterior lamellar keratoplasty. [54, 55, 56] Most patients will require spectacles and/or contact lenses following surgery. Keratoconus is not fully understood, and its progression is unpredictable. Kymionis GD, Grentzelos MA, Karavitaki AE, Zotta P, Yoo SH, Pallikaris IG. 2007 Dec. 33 (12):2135-7. To do the opposite (UV-CXL, then later ICRS) limits the flattening effect of the segments since the cornea has been already fixed into a sub-optimal configuration. Maharaja Ranjit Singh Marg, New Delhi, Received:
Other investigators have also reported on combining a customized partial refraction surface ablation and CXL in the management of keratoconus and ectasia.16–19. Efficacy of single or paired intrastromal corneal ring segment implantation combined with collagen crosslinking in keratoconus.  PKP requires continuing professional care to monitor for rejection, suture-related problems, wound dehiscence, and other difficulties. In a healthy eye, the cornea is clear and dome-shaped. J Cataract Refract Surg 2012; 38:1559-67. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTE5NDY5My10cmVhdG1lbnQ=. Part II. Fernando H Murillo-Lopez, MD is a member of the following medical societies: American Academy of OphthalmologyDisclosure: Nothing to disclose. Am J Ophthalmol. Han DC, Mehta JS, Por YM, Htoon HM, Tan DT. Cornea. Results of photorefractive keratectomy in keratoconus suspects at 4 years. Eye (Lond). Development of keratoconus after contact lens wear. Eye Vis (Lond). Hypo-osmolar riboflavin formulated with Dextran or Hydroxypropyl Methyl Cellulose has a low colloidal osmotic pressure (310mOsmol/L as compared to 402.7 mOsmol/L in isotonic riboflavin) and has been used to cause stromal swelling where stromal bed is less than 400µm thick. The cornea assumes a conical shape because of thinning and protrusion causing a variable degree of irregular astigmatism and myopia resulting in mild to marked impairment of visual function. Tuwairqi WS, Sinjab MM. Diffuse lamellar keratitis after corneal crosslinking in a patient with post-laser in situ keratomileusis corneal ectasia. Riboflavin 5´-phosphate topical ophthalmic (Photrexa, Photrexa Viscous) was approved by the US Food and Drug Administration (FDA) in April 2016 for use in corneal collagen cross-linking (CXL) in combination with the KXL System for the treatment of progressive keratoconus. Wagner H, Barr JT, Zadnik K. Collaborative Longitudinal Evaluation of Keratoconus (CLEK) Study: methods and findings to date. Acta Ophthalmol. Duddell in 1729, described a … Alnawaiseh M, Rosentreter A, Eveslage M, Eter N, Zumhagen L. Changes in Corneal Transparency After Cross-linking for Progressive Keratoconus: Long-term Follow-up. J Refract Surg 2014; 30: 22–6. Int Cont Lens Clin. Contemporary advances in contact lens designs and materials have significantly expanded the available fitting options for patients with corneal ectasia. . Although not often fully successful, they are an option for patients who (1) are intolerant to contact lenses, (2) have clear central corneas, (3) have corneas with a thickness of at least 400 µm, and (4) retain penetrating keratoplasty as a remaining option. 7 (3):517-21. J Refract Surg 2011; 27:189-94. 1997 May. 2011 Feb 17. The combination of PRK with crosslinking has been a widely utilized strategy and, in these cases, the criteria for its application has to do with the residual stromal bed posterior to ablation, which ideally should be greater than 400-450µm. Patients with keratoconus who use contact lenses often have corneal abrasions, [Medline]. 2018. Cont Lens Anterior Eye. Ophthalmology. Iontophoretic delivery of riboflavin and future applications with corneal CXL with UV-A for keratoconus treatment. Contact lens wear is often complicated by episodes of intolerance, allergic reactions (eg, giant papillary conjunctivitis), corneal abrasions, neovascularization, and other problems, sometimes leading to total intolerance. /viewarticle/909386
Management of KC has advanced during the last few years and still in progress. Am J Ophthalmol. If you have this type, you likely won't experience severe vision problems or require further treatment.In some people with keratoconus, the cornea becomes scarred or wearing contact lenses becomes difficult. 1998 Jan-Feb. 42(4):297-319. Open Ophthalmol J. 2012 Jan. 153 (1):24-8. 2000 Aug. 14 ( Pt 4):625-8. 1989 Oct. 107(10):1507-10. Dr. Stark explained that the cause of the condition is multifactorial. These segments may be implanted symmetrically if the keratoconic cone is located centrally, or asymmetrically if the cone is decentred. . [Medline]. [Medline]. Corneal Sensitivity and Dry Eye Symptoms in Patients with Keratoconus. These bridge the amino groups of collagen fibrils, increasing the rigidity of corneal tissue. 2014 May. Keratoconus is a bilateral, progressive disease characterised by corneal thinning, ectasia, variable degree of irregular astigmatism and resultant mild to severe reduction in visual acuity. 0.02% Mitomycin C was applied for 20 seconds and then the exposed stroma was soaked with 0.1% riboflavin solution for 5 minutes. Acta Ophthalmol. New Delhi 110029, © 2010 - 2019 Delhi Ophthalmological Society. Outcomes: Following BL transplantation, BSCVA typically improves by 1-2 lines, although BCVA usually remains unchanged. Karen K Yeung, OD, FAAO is a member of the following medical societies: American Academy of OptometryDisclosure: Nothing to disclose. In the clinical setting, various transepithelial riboflavin formulations using permeability enhancers show some penetration but not equal to standard protocol in comparative studies. Once the cylindrical power increases beyond 4.0 diopters, patients find it difficult to tolerate such high power in glasses. [Medline]. It is characterised by para-central corneal thinning and ectasia so that the cornea takes the shape of a cone. Compañ V, Aguilella-Arzo M, Edrington TB, Weissman BA. Moschos MM, Gouliopoulos NS, Kalogeropoulos C, Androudi S, Kitsos G, Ladas D, et al. By means of this article, we aim to provide a summary of these recent trends in therapeutic options for the optimal management of keratoconus. Krachmer JH, Feder RS, Belin MW. Traditionally, use of spectacles and rigid contact lenses has been the primary mode of treatment in early KC while keratoplasty has been the treatment of choice in advanced cases. Request PDF | On Apr 1, 2015, Fernando Faria-Correia published MANAGEMENT OF KERATOCONUS | Find, read and cite all the research you need on ResearchGate 2014 Aug. 92 (5):473-7. Itoi M. (1979) Management of Keratoconus. 2013 Apr. Recently, use of Intrastromal Corneal Ring Segments, Phakic IOLs, application of excimer laser and use of combination techniques have all made significant contribution in providing options for effective management of different stages of this disease. Patient characteristics. Keratoconus is the most common primary cornea ectasia, where the cornea undergoes structural changes, leading to loss of tissue integrity and vision loss. [Medline]. [Medline]. [Medline]. Choi JA, Lee MA, Kim MS. Int Ophthalmol Clin 2013;53:91-101. With asymmetrical placement, a thicker segment is implanted in the axis of greatest steepening. Raiskup F, Spoerl E. Corneal cross-linking with hypo-osmolar riboflavin solution in thin keratoconic corneas. 2008 Apr. 2001
A retrospective interventional case series study including a total of 33 keratoconus eyes (age 8 to 17 years) that had undergone ICRS (Keraring segments, Mediphacos) implantation was conducted. Comparative study of riboflavin-UVA cross-linking and “flash-linking” using surface wave elastometry. It is characterised by para-central corneal thinning and ectasia so that the cornea takes the shape of a cone. [Medline]. Although techniques have been developed to treat thinner or steeper corneas. [Medline]. However, it is not recommended for ablations larger than 50µm. [Medline]. [Medline]. Variations of UV-CXL include including accelerated cross-linking Restoring vision in keratoconus has revolved around corneal rigid gas permeable (RGP) contact lenses, with glasses and soft contact lenses serving a smaller number with mild disease. Corneal collagen cross-linking: a review of 1-year outcomes. 2003 Dec. 16 (4):607-20, vii. Vogt striae and some scarring can also be seen centrally; superiorly, a small (brown) section of the Fleischer ring is noted. 52-58. Alternatively, topography-guided conductive keratoplasty has been shown to be modestly effective in reshaping the cornea in keratoconic eyes, at least temporarily. Keratoconus and management 1. Introduction Keratoconus (KC) is a progressive, bilateral, thinning disorder of the cornea in which biomechanical changes in corneal collagen fibers result in progressive increase in corneal curvature and thinning. Outcomes of penetrating keratoplasty in keratoconus. Studies have shown excellent visual outcomes with 96 to 100% of eyes achieving +1.00 D of intended spherical target, post-operative residual cylinder less than 1.00 D in 87% and significant improvements in uncorrected visual acuity. While cross linking stops the progression of the ectasia, ICRS flatten or normalize the corneal shape. With the potential to alter the natural history of KC and possibly even halt disease progression using methods like CXL and BL Transplantation and with the newly developed procedures to provide best possible optical outcomes to these patients, need for corneal transplant in KC may become a thing of the past. 118 (3):492-7. J Cataract Refract Surg. Eur J Ophthalmol 2012; 22 Suppl 7:S81-8. Bykhovskaya Y, Li X, Epifantseva I, Haritunians T, Siscovick D, Aldave A. Kymionis GD, Portaliou DM, Kounis GA, Limnopoulou AN, Kontadakis GA, Grentzelos MA. Georgiou T, Funnell CL, Cassels-Brown A, O'Conor R. Influence of ethnic origin on the incidence of keratoconus and associated atopic disease in Asians and white patients. Ophthalmol Clin North Am. Management Glasses can be prescribed to correct the induced astigmatism in early keratoconus. [Medline]. Gupta PK, Stinnett SS, Carlson AN. [Medline]. Corneal surgery in keratoconus: which type, which technique, which outcomes?. The management of Keratoconus can be a struggle. Buzzonetti L, Laborante A, Petrocelli G. Refractive outcome of keratoconus treated by combined femtosecond laser and big-bubble deep anterior lamellar keratoplasty. 2014 Apr. There are 5 models available, each with variations in their curvature, radius, thickness and arc length, according to the effect to be achieved. Pramanik S, Musch DC, Sutphin JE, Farjo AA. As there are new modalities of treatment, it is better to say that there are traditional modalities and modern... Management of Keratoconus | Springer for Research & Development Can J Ophthalmol 2013; 48: 173–8. [Medline]. Cornea. The short-term safety and efficacy of intracorneal ring segment (ICRS) implantation in keratoconus eyes of children are investigated in this study. . Corneal transplantation for keratoconus: a registry study. World J Ophthalmol 2013; 3:20-31. 112(4):654-9. Clin Experiment Ophthalmol. 2006 Sep. 113 (9):1633-8. The CLAO journal : official publication of the Contact Lens Association of Ophthalmologists, 17(1), pp. Keratoconus diagnosis include a comprehensive eye exam and tests to determine your corneal shape. Int J Ophthalmol. Kenney MC, Nesburn AB, Burgeson RE, Butkowski RJ, Ljubimov AV. [Medline]. J Cataract Refract Surg. Combining both the modalities together has a synergistic action and can be performed simultaneously or sequentially. Cristina Kenney M, Brown DJ. Literature shows that keratoconus is one of the most common indications for PK and the recipients have higher graft survival in keratoconus irrespective of whether the graft was same size or over sized  ,  . Cornea. 20-MAY-2015, Accepted:
JAMA Ophthalmol. 1990 Apr. In a healthy eye, the cornea is clear and dome-shaped. Reddy JC, Hammersmith KM, Nagra PK, Rapuano CJ. Keratoconus: I. Biochemical studies. PKP for keratoconus exhibits excellent visual and survival results, but young patients may require one or more grafts during their lifetime. [Medline]. The techniques that combine these procedures can be sequential or applied in the same sitting. Cornea. [Medline]. Ultrasound pachymetry can also be used to measure the thinnest zone on the cornea. Combined corneal collagen cross-linking and posterior chamber toric implantable collamer lens implantation for keratoconus. UV-CXL is the only procedure that is believed to slow the progression of keratoconus. In Keratoconus there is progressive thinning of the cornea and as a result the cornea develops a cone-like bulge and becomes distorted. [Medline]. Barry A Weissman, OD, PhD, FAAO is a member of the following medical societies: American Academy of Optometry, American Optometric Association, California Optometric Society, International Society for Contact Lens ResearchDisclosure: Nothing to disclose. Rabinowitz YS. Ocul Surf. J Refract Surg 2000; 16:438-43. The genetics of keratoconus. Morphological changes in keratoconus: pathology or pathogenesis. [Medline]. Macsai MS, Varley GA, Krachmer JH. 2008 May. Cornea. Psychiatric care may also be beneficial given that depressive disorders have been associated with the vision impairment caused by keratoconus. One year later, the same authors published a series of 10 keratoconic patients 1-year after Intacs implantation 20 where they support that Intacs reduced the corneal steepening and astigmatism, while visual acuity was improved in almost all … [Medline]. J Refract Surg 2012; 28:341-5. Raiskup F, Spoerl E. Corneal crosslinking with riboflavin and ultraviolet A. [Medline]. A variable degree of stromal swelling ranging from 36 to 105µm over periods ranging from 3 to 20 minutes is noted. Hafezi F, Mrochen M, Iseli HP, Seiler T. Collagen crosslinking with ultraviolet-A and hypoosmolar riboflavin solution in thin corneas. [Full Text]. It is 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, possibly stabilizing, and even perhaps reversing, the progression of corneal ectasia in patients with keratoconus. 46(6):953-63. Dr. Mohd Najmussadiq Khan 2. Lysosomal enzyme abnormalities in keratoconus. [Medline]. 2012 Dec. 154 (6):922-926.e1. Iovieno A, Légaré ME, Rootman DB, Yeung SN, Kim P, Rootman DS. Br J Ophthalmol. Penetrating keratoplasty (PKP) is still the more commonly performed surgery used to treat keratoconus in patients whose vision is not correctable to better than 20/40. 2015. Arnalich-Montiel F, Alió Del Barrio JL, Alió JL. Documenta Ophthalmologica Proceedings Series, vol 20. J Cataract Refract Surg 2013; 39:1146–51. When keratoconus develops, the cornea becomes thin and begins to bulge like a cone. Schlegel Z, Hoang-Xuan T, Gatinel D. Comparison of and correlation between anterior and posterior corneal elevation maps in normal eyes and keratoconus-suspect eyes. PRK has the benefit of leaving a thicker residual stromal bed after surgery than laser in-situ keratomileusis (LASIK) and is a safer option in suspect or thin corneas. Collagen crosslinking with riboflavin and ultraviolet-A light in keratoconus: long-term results. 1984 Jan-Feb. 28 (4):293-322. The sequencing is critical: to achieve maximal flattening, ICRS should be implanted before or simultaneously with UV-CXL. Weissman B, Chun MW, Barnhart LA. J Refract Surg 2006; 22:533-8. 1998 Dec. 39(13):2537-46. Behndig A, Karlsson K, Johansson BO, Brännström T, Marklund SL. JAMA Ophthalmol 2014; 132:495–501.  to improve the corneal integrity prior to surgery on keratoconic eyes. [Medline]. Kymionis GD, Grentzelos MA, Diakonis VF Pallikaris AI, Pallikaris IG. Currently, there is no effective way to measure collagen turnover, so the stability of the collagen cross-links remains a concern.  and herpetic keratitis. November 28, 2013. J Med Case Rep. 2011 Apr 16. Curr Opin Ophthalmol. Wittig-Silva C, Chan E, Islam FM, Wu T, Whiting M, Snibson GR. 29 (7):843-59. The latest available model of Visian ICL comes with centraFLOW technology that comprises a central KS-Aquaport (a central hole of size 0.36 mm) eliminating the need for peripheral iridectomy that was necessary before. 11 (2):93-108. The outcome of corneal transplantation in infants, children, and adolescents. An ophthalmologist who is a cornea specialist assists in identifying appropriate clinical conditions and timing for surgical intervention, such as superficial keratectomy, PKP, DALK, Bowman layer transplantation, ICRS, or UV-CXL. [Medline]. Addressing such problems may preclude increased scarring, which could necessitate PKP. Shajari M, Eberhardt E, Müller M, Al Khateeb G, Friderich S, Remy M, et al. Karen K Yeung, OD, FAAO Senior Optometrist, Arthur Ashe Student Health and Wellness Center, University of California, Los Angeles [Medline]. 2018 Aug. 44 (8):1003-1011. In: François J., Brown S.I., Itoi M. (eds) Proceedings of the Symposium of the International Society for Corneal Research, Kyoto, May 12–13, 1978. The current paradigm of care for keratoconus has shifted from not only correcting the vision but also slowing the disease process. Management of keratoconus: current scenario. The disease was first described in detail more than 150 years ago by Dr John Nottingham, but the understanding of the disease and its management have undergone significant changes over the last few decades. J Refract Surg 2009; 25:S807–11. Therapies Corneal collagen cross-linking. Rabinowitz YS. 1988 Jun. Krachmer JH, Feder RS, Belin MW. Invest Ophthalmol Vis Sci. Keratoconus and management 1. [Medline]. Long-term outcomes in patients who received a corneal graft for keratoconus between 1980 and 1986. Cornea. [Medline]. J Refract Surg. In order to accelerate the treatment process, which takes more than 1 hour with the standard protocol, variations with the goal to shorten time of treatment have been introduced. J Cataract Refract Surg 2007; 33:484–7. 22(6):539-45. 2015 Jul. For myopia, ICRS work by flattening the cornea to re-focus light rays and improve vision; while in KC patients, ICRS flatten the steep part of the cone and reduce vision distortions. [Medline]. The Bowman layer is removed and replaced by a donor Bowman layer graft. Ophthalmology. 2001 Sep. 42(10):2293-6. Surv Ophthalmol 1984; 28:293-322. Does lamellar surgery for keratoconus experience the popularity it deserves?. [Medline]. 2006 Jun. Br J Ophthalmol 2011; 95:1044. 2007 Jan. 33(1):69-74. 78 (2):76-81. Corneal melting after collagen cross-linking for keratoconus: a case report. Br J Ophthalmol. Keratoconus treatment In the mildest form of keratoconus, eyeglasses or soft contact lenses may help. J Cataract Refract Surg 2014; 40:1013-20. 2012. PLoS One. Georgiou T, Funnell CL, Cassels-Brown A, O'Conor R. Influence of ethnic origin on the incidence of keratoconus and associated atopic disease in Asians and white patients. [Medline]. RGP lenses provide a good level of visual correction, but do not arrest progression of the condition. Intrastromal corneal ring segments implantation in patients with keratoconus: 10-year follow-up. Veerwal V, Jain P, Goyal JL, Arora R, Malhotra AManagement of Keratoconus: Recent Trends.DJO 2015;26:40-45, Veerwal V, Jain P, Goyal JL, Arora R, Malhotra AManagement of Keratoconus: Recent Trends.DJO [serial online] 2015[cited 2021 Jan 9];26:40-45. 34(5):796-801. Cummings AB, McQuaid R, Mrochen M. Newer protocols and future in collagen cross-linking. Computerized videokeratography is also useful in detecting early keratoconus and allows following its progression. Ferrari G, Iuliano L, Viganò M, Rama P. Impending corneal perforation after collagen cross-linking for herpetic keratitis. Open Ophthalmol J 2009; 3: 77–81. Bahar I, Levinger S, Kremer I. Wavefront-supported photorefractive keratectomy with the Bausch & amp; Lomb Zyoptix in patients with myopic astigmatism and suspected keratoconus. More studies are also needed to identify high-risk patients perhaps related to their age, diagnosis, corneal shape, and/or stages of ectasia. Psychological Aspects and Depression in Patients with Symptomatic Keratoconus. 52-58. The primary visual benefits, then, of BL transplantation may be: 1) to enable more comfortable CL wear by flattening the cornea into a more tolerable configuration; and 2) to permit continued CL wear into the future, by halting disease progression. [Medline]. Share cases and questions with Physicians on Medscape consult. Keratoconus also is associated with overexposure to ultraviolet rays from the sun, excessive eye rubbing, a history of poorly fitted contact lenses and chronic eye irritation. [Medline]. Corneal specialists have adopted new techniques and … Alió JL, Artola A, Ruiz-Moreno JM, Hassanein A, Galal A, Awadalla MA. [Medline]. [Medline]. A 48-year clinical and epidemiologic study of keratoconus. The genetics of keratoconus. 11:241-251. [Medline]. Comparison of outcomes of lamellar keratoplasty and penetrating keratoplasty in keratoconus. Sharma A, Nottage JM, Mirchia K, Sharma R, Mohan K, Nirankari VS. Arch Ophthalmol. Vikas Veerwal, Pooja Jain, J L Goyal, Ritu Arora, Ankit Malhotra
46(6):1948-56. Midstromal transplantation of Bowman layer (also known as anterior limiting lamina [ALL]) is a newer procedure used to flatten and strengthen advanced keratoconic corneas that may be too thin for UV-CXL. If you log out, you will be required to enter your username and password the next time you visit.  and phakic intraocular lens For greater effect, two hemi-spherical segments may be placed instead of one. [2,3] Currently, techniques for the management of KC can be classified into 3 types: Corneal strengthening techniques, Optical optimization techniques and Combined techniques. 31(6):595-9. J Ophthalmol. , Long-term studies are still needed to determine the success and adverse effects of UV-CXL, as well as the long-term biomechanical effect. Kosaki R, Maeda N, Bessho K, Hori Y, Nishida K, Suzaki A. PK has been performed for management of keratoconus for over 7 decades , . Mathew JH, Goosey JD, Söderberg PG, Bergmanson JP. Corneal specialists have adopted new techniques and … [Medline]. Riboflavin acts as a photosensitiser as well as absorbs UV radiation to limit the depth of the treatment effect. Karseras AG, Ruben M. Aetiology of keratoconus. 18(4):279-83. 2018 Mar. When the duration of UV light exposure is reduced, intensity of treatment has to be increased in order to maintain the appropriate fluence. [Medline]. [Medline]. Leccisotti A. Corneal ectasia after photorefractive keratectomy. Refractive and topographic results of benzalkonium chloride-assisted transepithelial crosslinking. With final visual acuities is clear and dome-shaped now being combined with CXL combined with CXL although! End stage, keratoconus gas-permeable contact lenses after surgical correction Permeable lens wear when keratoconus develops the. Their preliminary results regarding the management of keratoconus and prevent further steepening of the ‘ effect! 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Liakopoulos DA, de Wit GA, Uiterwaal CS, Imhof SM, Walline JJ, Kyrillos R Barnett!, controlled trial of corneal transplantation in infants, children, and Sensitivity! Usually improves 1-2 lines of visual correction, but young patients may still require contact lenses can suffice correct... Although corneal RGPs do not arrest progression of the cornea Tan DT could make contact parameters! A task often undermined by limited contact lens on an advanced keratoconic cornea do not retard disease progression, redistribute... Frausto RF, Nguyen CK, Yu F, Raber IM treatment plan can help you. And long-wavelength ultraviolet radiation ( UVA ) having a treatment plan can help in with! Estimated Prevalence of keratoconus -- a retrospective study Science, University of new South Wales, Sydney,.., Zissimopoulos a, Ruiz-Moreno JM, Mirchia K, Kobashi H, M! Surgery with excimer laser: Traditionally, KC or its mild forms with satisfactory visual results Lelij a eyes. 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