Q&A on Keratoconus

Questions were answered by Burt Dubow, OD, and Charles Slonim, MD

Q: I have been diagnosed with the beginning stage of keratoconus and was prescribed rigid gas permeable lenses to treat the condition. However, I could not tolerate wearing these lenses. What are any other treatment options relating to this condition? — M.C., Wisconsin

A: Keratoconus is an eye condition where the clear front of the eye, the cornea, gets thin and bulges outward into a cone shape. This usually begins in the teens or early twenties and affects mostly males. And one eye is usually worse than the other eye. It is also oftentimes familial, so alert other family members to get their eyes checked.

As the cornea thins and bulges, it becomes distorted and even droopy, creating blurred vision that is not very correctable with glasses. Contact lenses can kind of give the eye a new, smoother front that focuses light properly. Rigid gas permeable lenses are my first choice, and they usually can be prescribed successfully.

There are a number of fitting designs that can be tried before turning to other options. Before you give up on RGPs, ask your practitioner if he or she can prescribe specially made rigid lenses such as the Rose K, large diameter corneal lenses or mini-scleral lenses that may work better than smaller, standard RGP lenses.

If RGPs simply will not work, there is another lens called SynergEyes that is a combination RGP and soft lens (also called a hybrid contact lens). This lens may work well for keratoconus, and can be much more tolerable than a straight RGP fit. Soft lenses also are made for people with keratoconus, but these would be my last choice, because they are not rigid enough to help keep the cornea from bulging over time. But they can offer better vision than glasses.

Your eye care practitioner also can consider a technique that we call piggybacking, which is an RGP lens fitted over a soft lens. This combination can make RGP lenses much more comfortable and give you excellent vision as well.

Please keep in mind that people with keratoconus usually have a harder time with contact lens comfort and vision — their eyes are not normal, their tears are not normal, etc. Give your practitioner plenty of time to get you up and running, and expect more frequent tune-ups than a regular patient. Most importantly, look at the good side... keratoconus is not a fatal disease and does not cause blindness. Hang in there! — Dr. Dubow

Q: My new eye doctor told me that I have keratoconus and recommended that I switch from soft contacts to RGPs. Previous doctors told me that I had to wear glasses over my soft contacts, but didn't say that I had keratoconus. What is keratoconus, and what should I do? — D.O., Missouri

A normal eye vs. an eye with a slight amount of keratoconus. The keratoconic cornea bulges slightly, for a more cone-shaped surface. (Artist's re-creation of keratometry images.)

A: Keratoconus is an eye condition where the cornea, the clear front covering of the eyes, becomes thinner and starts to protrude — like a cone in shape. This cone can grow larger and larger until it actually starts to droop due to gravity. This distortion on the front of the eye causes one's vision to be unclear. It is believed that keratoconus is a familial problem, so you should pass the word for others in your family to be on the alert.

Rigid gas permeable (RGP) contact lenses are the standard of care for keratoconus because they provide a round and non-distorted front surface for the eye, improving vision, while hopefully slowing down the progression of the cone shape. There are many good RGP designs that work very well. Other options include hybrid contact lenses and certain custom soft lenses. In some cases, wearing an RGP lens over a soft lens — this is called piggybacking — may be the best solution. — Dr. Dubow

Q: A doctor recently diagnosed me with keratoconus. He prescribed soft permeable contact lenses, and my vision is back to 100 percent, but I was wondering if there are any other treatments for this condition. — Eric, Florida

A: Keratoconus is a condition where the front of the eye (cornea) bulges outward into a cone shape, distorting the vision. It is very often hereditary.

Soft contact lenses would be my last choice because they are not rigid enough to keep the cornea from bulging. Standard rigid gas permeable (RGP) lenses may work for you. If not, ask your practitioner if he or she can prescribe specially made rigid lenses such as the Rose K, large diameter corneal lenses or mini-scleral lenses that may work better than smaller, standard RGP lenses. Other options also are available, such as a combination of RGP and soft lens (SynergEyes). (See first answer for more details about options.)

If contact lenses don't work, there are other new and interesting options available. Intacs corneal inserts received FDA approval for correction of nearsightedness and astigmatism in people with keratoconus. They are easily implanted in the peripheral cornea by an eye surgeon.

Intacs can flatten the cornea and reduce irregularities, helping people with keratoconus see much better.

Also, corneal cross linking procedures such as C3-R (Advanced Vision Education, Los Angeles) have produced promising results by strengthening connective tissue within the cornea, making the front of the eye harder and less flexible so it can maintain the proper shape for good vision.

Some people also may be candidates for a cornea transplant, where the center of the cornea is removed and a donor cornea is put in its place. Follow your eye doctor's advice — he or she will advise you of your options. — Dr. Dubow

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[Page updated March 2010]