A Friendly Reminder

Corneal transplants are not the only option for all advanced keratoconus patients

We have encountered these patients many times in our clinics: A 20-something-year-old who has advanced keratoconus (KCN) presents for a second opinion after being told that he needs a corneal transplant. The young patient also divulges that his previous physician informed him and his parents that the condition could have been avoided via corneal cross-linking (CXL), if addressed sooner. At hearing this, fear and guilt overtake the parents, while dread begins to sink in for the patient.

On examination, his uncorrected vision is 20/400 and corrects to 20/70 with refraction. His cornea is very steep, but it remains clear. Is a corneal transplant the only option for this patient and others like him? The answer is “no.”

“Save the Corneas!”

Being that the cornea is still clear, without significant central scarring, if a scleral lens can be fitted, the patient has an excellent chance of attaining outstanding vision. With advances in scleral lens technology, few situations exist where a lens cannot be fitted.

The family is also informed that while scleral lenses may provide tremendous visual improvement, they will not stop the KCN progression. Hence, CXL in conjunction with scleral lenses is recommended, and works!

“Watch the Educational Gap”

As eye care professionals, we are confronted with two educational gaps regarding KCN, and both present in this case:

The first is typically encountered in some gatekeepers (optometrists and general ophthalmologists). Specifically, when young patients presented with early KCN, we previously watched helplessly over the years until they needed a transplant. Now, we know that with early intervention by CXL, progression may be stopped and a transplant may be prevented. Even advancement to the stage of contact lens dependence may be prevented.

The second is often encountered in some corneal surgeons. Specifically, in the past, the advanced KCN patient who had very steep corneas and uncorrectable vision would be doomed to a transplant and, therefore, face a lifetime of maintenance. This includes the risk of infection, trauma, cataracts, glaucoma, graft failure, the need for long-term eye drops, countless doctor visits, and the possibility of one or more repeat surgeries over their lifetime. Even a 23-year-old patient who corrects to 20/25 after surgery may still not be a long-term success when all this is taken into account. Therefore, if these patients can be stabilized with CXL and fitted with a scleral lens, they can potentially avoid all this.

In this issue of Corneal Physician, Dr. W. Barry Lee describes how to avoid a transplant in patients who have advanced KCN — a friendly reminder, and educational gap filler.

Additionally, Drs. Kanika Agarwal and Kathryn M. Hatch discuss how to address patients who have both KCN and cataracts.

“Wait! There’s More!”

Other compelling topics in this issue include the management of both typical and atypical corneal infections, by Drs. Margaret Y. Wang and Zaina N. Al-Mohtaseb, and Sumitra Khandelwal, respectively; and corneal inflammation linked with systemic disease, by Dr. Helen K. Wu. Further, Drs. Darrell E. White, Mark S. Milner, and Himani Goyal skillfully tackle dry eye disease with a look at the latest algorithms and compounded/off-label treatments, respectively. Finally, in a world where we must now adapt to COVID-19, Dr. Alanna Nattis discusses how the vaccination affects keratoplasty. I hope you enjoy this issue of Corneal Physician! CP