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.
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, kp.org/MDO,
or NKCF.org (National Keratoconus Foundation), and nih.gov (U.S. National Institutes of Health).