Keratoconus and Corneal Cross-Linking Treatment

Author: My Doctor - Kaiser Permanente

Hello, I am Dr. Naveen Chandra I am an Ophthalmologist at Kaiser Permanente. You have probably been asked to view this video because your Optometrist suspects that you have a condition called Keratoconus in one or both of your eyes. We have created this video to give you information about Keratoconus, and to describe the kinds of treatments available to treat this condition.

The treatments best suited for you will be determined by your personal circumstances in discussion with your doctor. Please have a pencil and paper ready while you watch this video so that you can write down questions. You may pause this video at any time and return to a previous section by using the control buttons on the screen. In this presentation we will discuss: The cornea, the clear front window of the eye Keratoconus and its effects on vision and the cornea Symptoms and tests used to diagnose and assess Keratoconus Treatments for Keratoconus, and Detailed information about the procedure called, Corneal Cross-Linking Keratoconus is a disorder of the cornea. The cornea is the clear front window of the eye that covers the pupil and the lens.

The cornea focuses light entering the eye. The shape of the cornea is curved, like the surface of a ball. Over time, in Keratoconus, the cornea distorts and thins. This causes the cornea to bulge out, like a cone, causing problems with vision.

The condition can worsen and cause significant vision loss. Keratoconus is typically first identified when people are in their late teens or early twenties, but it can develop at any age. About 1 in 2000 people experience this condition. The cause of the condition is not clear, though there may be some relation to rubbing the eye, sleep apnea, and a possible influence of family history. Some other medical conditions of the eye may contribute to this problem. If Keratoconus progresses in severity it can lead to seriously damaged eye sight, and in severe cases a person might need a corneal transplant. Keratoconus is usually first identified by your optometrist, either during a routine eye exam or perhaps you were experiencing problems with your vision. You may have noticed blurry vision or glare.

Keratoconus and Corneal Cross-Linking Treatment

You might have found that new prescriptions of eye wear still did not correct your vision problems. Other common symptoms include seeing streaks of light, halos or ghosting, especially at night. You might have felt uncomfortable eye strain with associated headaches or pain in your eye.

One reaction can be to rub your eyes more than normally, which unfortunately worsens the disease. The condition can worsen over time and create problems ranging from mild astigmatism to severe distortion, corneal thinning, protrusion, and scarring. The rate of progression varies, but typically occurs over 10 � 20 years. Numerous tests are performed to assess your corneas for Keratoconus.

Regardless of whether you�ve ever worn glasses, you will have an eye exam conducted by an optometrist or an ophthalmologist. It is the same type of exam as assessing a person�s need for prescription eye glasses. Images will be taken of your cornea with a mapping device called tomography, a common brand is the Pentacam. The camera takes images of your cornea with a spinning slit beam of light. This mapping will show the shape and thickness of the cornea. There are numerous treatments for Keratoconus. The choice of treatment methods are often determined by the physical condition of the cornea, the rate of disease progression, as well as a person�s age and other eye-related medical conditions.

Treatments for early mild Keratoconus may include use of eye drops, avoiding eye rubbing, treating any associated eye allergies and prescription eye glasses or soft contact lenses. Other types of treatment include: Contact lenses of various kinds and materials, including gas-permeable lenses, a combination or �piggy back� of more than one type of lens, hybrid contact lenses, scleral or semi-scleral lenses that cover a larger part of the eye surface. Surgical treatments, include eye implants, called �Intacs,� surgical corneal transplants, and a new treatment called �corneal cross-linking.� If a type of contact lens or combination of lenses is recommended for your treatment, your doctor will explain the lenses in detail. When all forms of contact lenses are no longer effective or comfortable to maintaining useful vision, Intacs may be surgically placed into the layers the cornea to change the corneal shape. The tiny plastic inserts are used in attempt to re-shape the lopsided distorted cone-shaped cornea for clearer vision. Intacs are not a cure and will not delay nor slow the progression of Keratoconus, but for the right moderate stage disease, the implants may turn back the clock a couple of years in the natural progression of Keratoconus. And help achieve useful vision in contacts or glasses again. Surgery- Corneal Transplants If corrective lenses no longer achieve clear vision and Intac inserts are not appropriate or have failed to sufficiently to restore vision, a surgical corneal transplant may be considered.

In cornea transplantation, donor cornea tissue from a recently deceased human is used to replace the central 80% of your distorted Keratoconic cornea. They are performed for about 1 in 10 Keratoconus patients. Some corneal transplant techniques replace the front majority of the cornea (preserving the inner lining Descemet�s membrane) and other techniques replace the entire central cornea. Success with corneal transplants is high, though glasses or contact lenses are most likely to be necessary. Cornea transplants require a lifetime of follow-up with a cornea specialist, often require a lifetime of eyedrops to control your body's immune system from rejecting the donated tissue and require strict eye protection and activity restrictions to protect the delicate surgical wound. Surgery- Corneal Cross-Linking In 2016, the FDA approved a new surgical procedure available at Kaiser Permanente called �Corneal Cross-Linking,� also referred to as �CXL.� Successful cross-linking has been performed since 2006 across the globe. Corneal cross-linking strengthens and stiffens the cornea to prevent further distortion, maintain current vision quality, and avoid the need for corneal transplant. The benefits of CXL are best achieved during the early stages of Keratoconus, when the distortion is still mild.

Most patients eligible for CXL will be under the age of 25, or over age 25 with documented disease progression within the prior year. The procedure does not return the cornea to normal shape. The goal is to prevent further corneal deterioration. Use of corrective glasses or contact lenses after the procedure may be enough to maintain normal function. The Corneal Cross-Linking procedure CXL involves the application of vitamin eye-drops soaked into the cornea plus exposure to a specified ultra violet light. This process triggers a reaction in the cornea to form tiny cross-links, or �cross beams� in the corneal tissue. The cross-links add strength to the cornea to prevent its shape from further distorting. The very outer layer of the cornea (called the epithelium) is removed and the eye drops are placed on the cornea for 30 minutes at frequent intervals.

The cornea is then exposed to ultra violet light for an additional 30 minutes with continued frequent interval eye drop application. In some cases a combination of CXL and Intac implants may complementary results. These are usually performed separately: CXL to stiffen the cornea and prevent future distortion, and Intacs to reshape the existing corneal distortion. Risks Associated with CXL There are risks associated with any surgery. Risks with CXL can include infection or poor healing. Also, the procedure is not a guarantee to stop progression of Keratoconus. It is possible that there could be damage to other parts of the eye caused by use of UV light. Corneal haze causing hazy vision may occur following surgery, but this usually resolves to clearer vision as the cornea heals over the following months.

There is a low risk of losing the quality vision in the eye, especially in an eye with extremely mild disease. There is always a risk of blindness, though this is exceedingly rare. Preparing for Cross-link surgery If you decide to undergo the corneal cross-linking procedure, If not already performed, you will have an eye exam to assess your vision for eye glasses or contact lenses. You will have a preoperative evaluation with a cross-linking specialist.

This can be done either in person or sometimes over the phone or videochat. Your surgery day will be scheduled. If surgery is needed on the second eye, this will not be done any sooner than 3 months after the first surgery, to allow the first eye to recover fully. Detailed medication and eye care instructions to prepare for surgery, including use of eye drops, will be provided at your evaluation with the cross-linking specialist. Your surgery will be done at our Medical Center.

Please arrive on time. Plan extra travel time for traffic and parking. You will sign a consent form on the day of surgery. Most people will take a relaxing prescription medication by mouth after arrival and before the surgery, to help with boredom. Please bring music and headphones to help you stay relaxed during the procedure. You will meet the members of your surgery team and you will be asked questions, sometimes more than once. This is part of our safety protocol, so please be patient with us. Some final examinations and tests may be performed by staff and the doctor.

Your visit on the procedure day will be 2-3 hours long. The actual surgery will last over an hour. Eye drops will numb your eye. So you don't have to worry about blinking, a device will be placed to hold your eye lids open during the procedure. The epithelium, or surface layer of the cornea, is removed, often with a brush. Then medicated vitamin eye drops are placed into the cornea at frequent intervals. This will continue for 30 minutes. Then, The surgeon will evaluate the cornea and make adjustments accordingly.

Then, a specialized UV light will then be applied for another 30 minutes along with continued frequent application of the medicated vitamin eyedrops. At the end of the procedure a soft contact lens will be placed over your cornea to that acts like a bandage to reduce discomfort over the following days. Following the procedure, a shield will be placed over your eye and taped into place to protect your eye from rubbing and injury. When you are ready, you can go home with a responsible adult. You will not be able to drive yourself and you will not be allowed to take a taxi without a responsible attendant. When you leave the Medical Center you may want someone to stay with you for the rest of the day.

Be sure not to rub your eye for the first five days after surgery. You will feel significant pain at first and you can use ibuprofen or pain medication that will be prescribed before you leave the Surgery Center. You will experience light sensitivity and tearing for a few days. Because the skin layer of the cornea has to heal over a few days, to prevent infection, avoid getting the eye wet and do not expose the eye to showers, ocean, or swimming pool water until you have permission from your doctor.

You may leave the eye shield over your eye for protection or you can protect your eye by wearing eye glasses or sun glasses. If your �bandage� contact lens falls out or moves on the surface of the eye do not try to replace it yourself. Call the office during office hours to arrange an appointment for a new lens to be placed. If you experience sudden loss of vision or severe pain, contact your doctor or the Kaiser Permanente Call Center. You will begin using eye drops the day after surgery and continue using them for the next few months.

A visit with your doctor will be scheduled for 1 day after surgery and again within a week after surgery for the doctor to remove the bandage contact lens and confirm appropriate healing. More doctor visits will be scheduled during the first year after the surgery. You can expect some further tests to be done during these visits. I hope this information has helped you to better understand the condition of Keratoconus and treatments to maintain the quality of your eye sight. Keratoconus will likely cause increasing cornea and vision damage if left untreated. It is best to treat Keratoconus as early as possible to prevent further cornea damage. Eye glasses or contact lenses will likely be needed after treatment. Corneal cross-linking surgery is very promising to keep your eyes and vision from becoming worse but it does not reverse distortion that has already occurred.

The various treatment options for your particular stage of disease will be assessed and offered to you before considering a cornea transplant. Questions and further information Thank you for taking this time to learn more about Keratoconus and available remedies. If you have thought of questions during this presentation, please bring them with you to your next eye care appointment.

We are happy to answer your questions and we look forward to working with you to keep your vision clear and your eyes healthy. For more information about the cornea, Keratonocus, medical and surgical treatments, including corneal cross-linking you can go online to Kaiser Permanente�s website,, or (National Keratoconus Foundation), and (U.S. National Institutes of Health).

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