How Have Advances in Corneal & External Disease Altered the Management of Keratoconus

Professor John Dart

Meeting:  2011 RANZCO


Date: 21 Nov 2011


Session Time: 11:05 am - 11:30 am

Recent advances in Corneal & External Disease that have altered my practice include the use of topical ciclosporin, the identification of cytomegalovirus as a cause of acute endotheliitis, corneal collagen cross-linking, toric phakic & pseudophakic piggy back intraocular lens implants, lamellar corneal surgery, both deep anterior lamellar keratoplasty (DALK) and Descemet’s stripping automated endothelial keratoplasty (DSAEK) and the recent success of the Boston keratoprothesis (Kpro).

Of these many have a role in the modern management of keratoconus (KC) and this presentation outlines the role of some of these advances for this condition. Contact lenses (CL) remain the cor-nerstone of the management of moderate and advanced KC. The advent of soft CL’s designed for KC have extended their use in less severe KC, whereas the introduction of silicone hydrogel CL’s has encouraged a return to the use of piggy-back CL systems. Many patients with KC have allergic conjunctivitis and control of this is essential for successful CL wear and maintenance of CL toler-ance. The use of topical ciclosporin has an important role in the management of severe allergic eye disease in this patient group. However in early KC the use of corneal collagen cross-linking (CXL), with a complication rate of 1–2%, promises stabilization of disease and continued use of spectacles and CL’s in most patients for at least a few years. The role of CXL with laser ablation, intracorneal ring segments and pre-keratoplasty is unproven. DALK has become the treatment of choice in Europe for severe KC cases requiring transplant surgery whereas, for less severe contact lens intolerant cases, corneal ring segments may delay the requirement for keratoplasty. Toric phakic, and piggy back pseudophakic, intraocular lens implants have been useful in a few contact lens intolerant patients with moderate astigmatism and anisometropia after keratoplasty, as well as in some older patients with forme fruste keratoconus. DSAEK has become the treatment of choice for restoring vision in patients with failed penetrating keratoplasties in whom pre-failure contact lens or spectacle vision was adequate. Lastly the Boston KPro has now become a reasonably safe option for the management of persistent corneal transplant rejection in patients who have had penetrating keratop-lasty for KC. Within the last decade these new techniques have revolutionized KC management.