Keratoconus and Corneal Cross-Linking Treatment

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,, or (National Keratoconus Foundation),
and (U.S. National Institutes of Health).

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