The Life-Altering Burden of Keratoconus

Early intervention and thoughtful surgical planning can restore functional vision, increase independence, and improve quality of life in patients with keratoconus.

Brooke Messer, OD, FAAO, FSLS

Cataract and Refractive Surgery Today

Key Takeaways Keratoconus management requires an interventional mindset that treats at diagnosis rather than waiting for visual acuity to decline. Early CXL can reduce substantial lifetime out-of-pocket costs and lessen the quality-of-life burden associated with progressive disease. Suspect keratoconus in young patients whose vision cannot be corrected to a crisp 20/20, who report difficulty with nighttime driving, or who show rapid changes in myopia or astigmatism. Inconsistency between autorefraction and manifest refraction is another clue. Corneal tissue addition keratoplasty can serve as a useful midpoint in select patients with keratoconus between contact lens failure and corneal transplantation. Customized donor tissue regularizes the corneal surface, helping normalize corneal shape and reduce irregular astigmatism. Keratoconus is the most common type of primary corneal ectasia. It has a multifactorial etiology, with genetic and environmental factors contributing to weakening of the corneal collagen fibers and the development of a cone-shaped cornea. Keratoconus is associated with a wide range of systemic conditions, including atopy, connective tissue disorders, obstructive sleep apnea, and Down syndrome.1 Eye care providers are well acquainted with the visual consequences of keratoconus, but we typically see these patients only once or twice a year, which makes it easy for us to underestimate the profound effect the disease can have on their lives. THE QUALITY-OF-LIFE BURDEN OF KERATOCONUS A recent study identified seven quality-of-life (QOL) domains affected by keratoconus, including driving, finances, career, and personal relationships (Table).2 The study authors noted that patients with keratoconus often felt guilt or shame about relying on others, which could contribute to those patients’ withdrawal from social activities.

Postoperative Intolerance of Monovision

Surgeons are asked to address a case in two parts.

Brandon D. Ayres, MD; Kara Jones, MD; Clara C. Chan, MD, FRCSC, FACS; Jennifer Loh, MD; and Gregory S.H. Ogawa, MD

Cataract and Refractive Surgery Today

KEY TAKEAWAYS Surgeons consider how to manage a patient’s intolerance of monovision 2 years after bilateral cataract surgery Interventions considered include a refractive enhancement and an IOL exchange The panelists weigh how to proceed when the patient’s visual acuity decreases to no light perception following an IOL exchange CASE PRESENTATION A 63-year-old woman is referred by her ophthalmologist for evaluation for an IOL exchange. Two years ago, the patient underwent bilateral cataract surgery with a Light Adjustable Lens (LAL; RxSight) and a monovision strategy; the right eye was targeted for distance vision and the left eye for near vision. She has been experiencing headache and nausea because her eyes are not working together properly. On examination, the patient’s UCVA is 20/20 OD and 20/20-1 OS. The manifest refraction is -0.50 +1.00 x 019º OD and -0.75 +0.25 x 008º OS. Pupillary motility is full, and no relative afferent pupillary defect (RAPD) is evident. A slit-lamp examination shows a well-positioned LAL and an open posterior capsule in each eye. A posterior examination of each eye is normal. How would you approach the patient’s intolerance of monovision? Biometry is provided in Figure 1 to assist with decision-making.

Candida Endophthalmitis

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