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Top 5 Treatment Options for Keratoconus

Written by Andrew Le, MD

UpdatedFebruary 29, 2024

Keratoconus is a progressive eye condition characterized by thinning and bulging of the cornea, leading to vision distortion and impairment. As the disease advances, the cornea takes on a cone-like shape, resulting in substantial visual defects.

Keratoconus often starts during puberty and progresses until the third or fourth decade of life, when it usually stabilizes. While glasses and contact lenses can correct early-stage keratoconus, patients require specialized treatment options to stop disease progression and restore sight as vision worsens.

This article outlines the top 5 treatment approaches for managing keratoconus - corneal collagen cross-linking, custom soft contact lenses, gas-permeable rigid contact lenses, hybrid contact lenses, and scleral lenses.

Prevalence, Pathogenesis, and Genetic Insights

The condition is the most common corneal ectatic disorder (a group of conditions that cause your cornea to thin and bulge outward), affecting about 1 in 375 to 1 in 2,000 individuals globally, and is more prevalent among younger populations.

The pathogenesis of keratoconus involves both genetic and environmental factors. Recent genetic studies, including large-scale genome-wide association studies (GWAS), have identified numerous keratoconus-related genomic loci. These findings suggest the disease is linked to corneal collagen matrix integrity dysregulation and cell differentiation pathways. About 12.5% of the genetic variance in keratoconus is explained by common genetic variants, pointing to a strong genetic component in its development.

Moreover, the disease has higher prevalence rates in certain ethnic groups, such as Europeans, Maoris, and Iranians.

Top 5 Treatment Options for Keratoconus

We understand the challenges faced by individuals seeking effective treatments for Keratoconus. To assist in this journey, we have compiled a list of the Top 5 Treatment Options for Keratoconus.

This carefully curated selection is designed to provide valuable insights into the most effective and current treatment methods available, offering a comprehensive guide to help you navigate the various options and make informed decisions for managing this condition.

1. Corneal Collagen Cross-Linking (CXL)

Corneal Collagen Cross-Linking (CXL) is a medical procedure primarily used to treat corneal ectasia, such as keratoconus, where the cornea thins or bulges due to a breakdown in collagen fibers. It was first described over a decade ago and has become a significant surgical innovation in modern ophthalmology. Before its introduction, the primary treatment for ectatic disease was corneal transplantation.

CXL involves using riboflavin drops and ultra-violet light to form strong chemical bonds between collagen fibers, thus strengthening the cornea. This minimally invasive surgery is done outpatient, allowing patients to return home the same day.

The cost of corneal cross-linking in the US ranges between $2,500 and $4,000 per eye. Insurance coverage for this procedure varies and depends on the type of surgery performed.

Pros

  • CXL prevents the progression of corneal damage and stabilizes vision, which is particularly beneficial for people with keratoconus.
  • Some patients experience improved vision post-surgery. Studies have shown that around half of the patients who underwent CXL saw an improvement in visual acuity.
  • CXL is known to stop the progression of keratoconus. In a study, 86.7% of patients who underwent CXL showed improvement compared to those who didn't receive the treatment.
  • A minimally invasive procedure involves less risk than more invasive surgical options.
  • The surgery is performed outpatient, allowing patients to go home the same day.
  • In some cases, insurance companies cover the cost of the surgery, especially if conservative treatments have failed.

Cons

  • Patients with thin corneas, infections, scars, dry eyes, or autoimmune diseases may not be suitable candidates.
  • The recovery from CXL can be lengthy, stretching for weeks or months.
  • Patients may experience discomfort, such as a hot, gritty, dry, or painful eye sensation after the surgery.
  • Vision may fluctuate during the first three months post-surgery and may continue to change afterward.
  • Some insurance plans might not cover the procedure, especially certain CXL surgeries like the epi-on method.
  • Being a relatively new procedure, there are still aspects that researchers are learning about, and not all methods are approved or covered by insurance.

2. Custom Soft Contact Lenses

Custom soft contact lenses for keratoconus offer a specialized solution for vision correction in individuals diagnosed with keratoconus.

Unlike rigid gas-permeable (RGP) lenses typically prescribed for keratoconus, custom soft lenses are more flexible and conform better to the eye's shape. They are particularly effective in the earlier stages of keratoconus. Brands like NovaKone utilize thick plastic to compensate for corneal irregularities, enhancing visual clarity​​​​​​.

In terms of price, custom soft contact lenses for keratoconus are more expensive than other keratoconus lenses. In the US, brands like Bausch + Lomb offer KeraSoft lenses (made of silicon hydrogel) and NovoKone lenses (hydrogel lenses). The exact price may vary and could be influenced by insurance coverage and specific patient requirements.

Pros

  • Tailor-made to match the patient's corneal shape, ensuring comfort and vision correction.
  • Softer and more flexible material enhances comfort for extended wear.
  • Thicker plastic helps maintain a spherical shape and corrects irregularities of the keratoconic cornea.
  • More comfortable for daily wear compared to RGP lenses.
  • There is a higher likelihood of staying in place on the irregular corneal surface.
  • Silicone hydrogel materials provide good functional vision and physiological responses​​​​.

3. Gas Permeable (GP) Contact Lenses

Gas Permeable (GP) contact lenses are a type of hard contact lens made from durable plastics that allow oxygen to flow through to the eye. They are particularly beneficial for individuals with astigmatism and conditions like keratoconus, where the cornea is unevenly curved, as they provide sharper vision than soft lenses. These lenses are distinct from old-fashioned hard contact lenses made from polymethyl methacrylate (PMMA), which are now obsolete.

GP lenses are more flexible than PMMA hard contacts and allow more oxygen to reach the cornea, making them more comfortable and easier to get used to. They are also designed to move on the eye when the wearer blinks, reducing the risk of discomfort or abrasions​​​​.

Regarding the price, GP lenses are custom-made to the shape of the eye, making them more expensive to replace if lost. Getting a GP lens replaced can take up to a week. Therefore, it's advisable to purchase a spare pair to avoid inconvenience.

Pros

  • Provide clearer images to correct most vision problems.
  • More comfortable than older rigid contacts and sometimes more comfortable than soft lenses for people with dry eyes.
  • Breathable nature reduces the risk of eye infections.
  • Does not contain water, so they are less likely to hold bacteria and collect protein deposits.
  • Strong and less likely to tear
  • Easy to disinfect
  • Some designs can be worn for a week or even 30 days straight​​.

Cons

  • Requires an adjustment period, which can take a few days to weeks.
  • The eyes might need readjustment if they are not worn regularly.
  • May fall out easily, especially during high-contact sports.
  • Require careful maintenance as they are reused for long periods.
  • Can cause discomfort in certain environments or activities​​​​.

4. Hybrid Contact Lenses

Hybrid contact lenses, like SynergEyes, offer a treatment option for patients with mild to moderate keratoconus, combining the benefits of gas-permeable and soft contact lenses. Before hybrid lenses, patients with keratoconus often wore small-diameter GP lenses for good vision but struggled with comfort issues.

Hybrid lenses were developed to provide a more comfortable alternative without sacrificing vision, with the first patent in 1977. These lenses feature a GP lens center for sharp vision and a soft skirt for comfort. However, early generations of hybrid lenses had durability issues, particularly at the junction where the soft skirt and GP lens meet.

The SynergEyes lenses, approved by the FDA in 2005, significantly improved this durability problem. The UltraHealth hybrid contact lens is a newer version in the SynergEyes family, offering higher oxygen permeability with a SiHy soft lens skirt and an ultra-high oxygen central GP lens​​.

Hybrid lenses are typically used for patients requiring medically necessary contact lenses and are best suited for those with mild to moderate keratoconus​​​​.

Practitioners will charge you $400 to $500 for a consultation. Another $300 will be added for case management and evaluation. The cost without insurance can range from $300 to $500, and lenses need to be changed every 6 to 12 months, amounting to an annual cost of $600 to $1,000. Insurance coverage may reduce these costs significantly​​​​.

Pros

  • GP lens can mask most corneal astigmatism.
  • Offers options to reduce dependency on glasses.
  • Precise fitting gives clear vision and good comfort.
  • Not available at discounted suppliers, ensuring quality.
  • Similar pricing to soft multifocals or GP multifocals.
  • Dedicated support lines for patient assistance​​.

Cons

  • Not suitable for significant residual astigmatism.
  • Requires time and consistent wear for adjustment.
  • Insertion, removal, and care training needed.
  • Long-term use might flatten the cornea.
  • Less customizable than scleral or GP lenses.
  • Diagnostic fitting can require more chair time and higher fees​​.

5. Scleral Lenses

Scleral contact lenses have a design that is especially beneficial for those with severe dry eyes, as the space between the lens and the cornea is a fluid reservoir.

Scleral lenses are custom-made, often providing better vision correction than eyeglasses or traditional contact lenses, particularly for individuals with irregular corneas or other eye problems that make wearing regular contact lenses difficult​​.

The cost of scleral contacts is typically three to four times higher than regular contact lenses, ranging from $500 to $4,000 per lens. This higher cost is due to the custom-fitting process, which involves computerized mapping of the cornea's curvature and trying several trial lenses of different sizes and curvatures​​.

Pros

  • These lenses allow significant air to reach the cornea, enhancing comfort over extended periods​​.
  • Despite higher initial costs, scleral lenses don't require frequent replacement​​.
  • The design minimizes water retention, thereby lowering the risk of bacterial infections​​.
  • Each lens is tailored to the wearer's specific vision prescription and cornea shape, maximizing vision correction​​.
  • Scleral lenses are an option for those who cannot wear regular lenses, including individuals with corneal tissue damage, as these lenses don't touch the cornea​​.
  • Ideal for more complex conditions, including advanced keratoconus or severe ocular surface disease​​.

Cons

  • Fitting scleral lenses requires time and a specialist's involvement​​.
  • They are significantly more expensive than traditional contact lenses​​.
  • These lenses demand regular maintenance and may require midday cleaning​​.
  • Transitioning from soft contacts to scleral lenses might require time due to the difference in feel​​.
  • The lenses may slip off the center of the eye several times a day​​.
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Final Words

The top treatment options for managing keratoconus include corneal collagen cross-linking to halt disease progression, various specialized contact lenses to improve vision and comfort, or in advanced cases - corneal transplant surgery.

The choice depends on disease severity, vision correction needs, cost, and insurance coverage. With several advanced options now available, most keratoconus patients can achieve good visual outcomes through personalized management plans.

FAQs on Keratoconus Treatments

What are the symptoms of keratoconus?

Symptoms include progressive nearsightedness and astigmatism, glare and light sensitivity, double vision, and irregular astigmatism that cannot be fully corrected with glasses or contacts.

When is a corneal transplant needed for keratoconus?

If RGP contacts and cross-linking can no longer provide functional vision, a partial or full corneal transplant surgery may be performed.

What is vision typically like after keratoconus treatment?

With early diagnosis and proper management, good vision can often be maintained long-term. But each case needs close monitoring.