Diagnose and Manage Keratoconus Early for Best Results

Keratoconus is a common and manageable ophthalmic condition. But even with an abundance of eye care technologies, diagnosing keratoconus early continues to present challenges. Part of that may be because the equipment available at optometric and ophthalmic practices does not necessarily offer metrics on how keratoconus develops. 

In his, “Comprehensive Management of the Patient with Keratoconus,” at the Southeastern Educational Congress of Optometry (SECO) 2021 meeting, Jason Jedlicka, OD, FAAO, demonstrates how to properly use imaging technologies in the management of the condition. He also offers an explanation of the disease’s development and the management options clinicians have at their disposal. 

“Keratoconus is a disease of thinning,” Dr Jedlicka’s presentation slides emphasize. Because this is the most important metric for early detection, corneal topographers cannot be relied upon as the sole technique for identification. These machines do not inform you on  the posterior corneal shape, nor do they offer any information regarding the thinning or thickness profile of the cornea, the presentation explains. Clinical findings, such as those evident during a slit lamp exam, are also insufficient for keratoconus detection as these presentations are often not evident until later in the disease process. 

While initial suspicion of keratoconus may arise from reduced acuity with increased astigmatism, Dr Jedlicka recommends 2 specific testing protocols for patients who may have this condition. First, retinoscopic reflex should demonstrate scissoring. Second, corneal tomography and pachymetry should be considered the definitive diagnostic tests. Corneal tomography, in particular, provides the truest elevation of the anterior and posterior cornea and is the best tool available for early detection of the disease since it can provide all data that is relevant for diagnosis.

The presentation guides attendees through the specifics of testing patients for keratoconus and details a variety of treatment methods, such as corneal collagen crosslinking (CXL), a procedure that can halt disease progression. Dr Jedlicka explains that this technique — while still relatively new — is absolutely necessary and “should almost be mandatory” for patients younger than 30 years of age. Patients 30 to 45 years old may require an evaluation of the state of their disease as well as, and any recent progression, but it’s likely still a good idea for many of those patients, too, according to the presenter. 

In his presentation, Dr Jedlicka shares 4 ways to identify the candidates who are most likely to respond to this technique. The best candidates will present evidence of progression of ectasia, display an absence of significant or full-thickness scarring, have a minimum corneal thickness of 300 µm pre-procedure, and have visual functioning worth saving. The procedure is not ideal for patients with severe disease.

Other treatments offered include the use of scleral, gas permeable, and other specialty contact lenses. The presentation informs clinicians which options are appropriate for correcting visual acuity vs which directly assist with managing the disease.

When all else fails, corneal transplantation via a procedure such as deep anterior lamellar keratoplasty or penetrating keratoplasty is an option that can involve comanagement with a surgeon. 

Reference

Jedlicka J. Comprehensive management of the patient with keratoconus. Presented at: Southeastern Educational Congress of Optometry (SECO) 2021 Annual Meeting; April 28-May 2, 2021; Atlanta, GA. Course 130.