Keratoconus in kids or teens? What to do?

Hearing the words that your child has keratoconus can be daunting. What does it mean? Will this affect his future? Keratoconus is a progressive corneal thinning condition, making the outer transparent part of the eye look like a cone. The instability of the corneal structure in susceptible patients may lead to the worsening of keratoconus. Keratoconus is usually diagnosed in the 2nd decade of life, but we have also seen an increased number of patients referred to us who are still in their teens. The youngest keratoconus patient recorded in publications was a 4-year-old boy.

When we have kids in our chair, we discuss cross-linking, which stabilizes the keratoconus progression; and contact lenses for vision rehabilitation. We also discuss issues of eye itchiness. An important thing to consider too is to stop your child from eye rubbing. Eye rubbing is associated with keratoconus and its progression. Manage the reason why he rubs his eyes. Is it an allergy? Could it be his hair is irritating his eyes? Is it eyelashes poking his eyes? Is it mannerism? In kids, the advancement of the condition is more aggressive than adults, so we extensively advise controlling the situation and then contact lens wear. Without cross-linking, the rate of the changing of contact lenses will be higher, as the increased curving (steepening) of the cornea will need an alteration of the contact lens fitting.  

Our clinic’s youngest was 9 years old. An ophthalmologist referred him to us for contact lens fitting. His cone was so steep that we cannot fit him with a GP (gas permeable lens) anymore as the lenses pop out. Since he was still young, and the goal is to delay corneal transplant for as long as possible, we fitted him with scleral contact lenses. The scleral lenses allowed him to see well for far and near, which significantly helped his studies. If you think that 9-year-old is too young to wear contact lenses, not really, kids follow instructions well. The safety of contact lens wear is similar to adults, if not better. 

Contact lenses for keratoconus patients can improve their self-esteem. Some keratoconus patients feel down due to their blurred vision, so we encourage parents to explore contact lenses for them to wear. These will help your child reach his potential. 

There are several contact lens options for keratoconus patients; visit our clinic for an evaluation to know which one will work best for you. We will be with you on this journey.

You can reach us via the following:

https://goldheartoptical.com/

https://www.facebook.com/GoldHeartOptical

Email: goldheartoptical@gmail.com

Mobile: 09215452389

Reference:

  1. Kankariya VP, Kymionis GD, Diakonis VF, Yoo SH. Management of pediatric keratoconus – evolving role of corneal collagen cross-linking: an update. Indian J Ophthalmol. 2013;61(8):435-440. doi:10.4103/0301-4738.116070
  2. Sabti S, Tappeiner C, Frueh BE. Corneal Cross-Linking in a 4-Year-Old Child With Keratoconus and Down Syndrome. Cornea. 2015 Sep;34(9):1157-60. doi: 10.1097/ICO.0000000000000491. PMID: 26165788.
  3. Walline JJ, Lorenz KO, Nichols JJ. Long-term contact lens wear of children and teens. Eye Contact Lens. 2013 Jul;39(4):283-9. doi: 10.1097/ICL.0b013e318296792c. PMID: 23771010.
  4. Wu Y, Tan Q, Zhang W, Wang J, Yang B, Ma W, Wang X, Liu L. Rigid gas-permeable contact lens-related life quality in keratoconic patients with different grades of severity. Clin Exp Optom. 2015 Mar;98(2):150-4. doi: 10.1111/cxo.12237. Epub 2014 Dec 29. PMID: 25557946.
  5. Picot C, Gauthier AS, Campolmi N, Delbosc B. Qualité de vie des patients équipés en verres scléraux [Quality of life in patients wearing scleral lenses]. J Fr Ophtalmol. 2015 Sep;38(7):615-9. French. doi: 10.1016/j.jfo.2014.10.018. Epub 2015 May 20. PMID: 26001955.

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What is Keratoconus?

KERATOCONUS 

WHAT IS KERATOCONUS?

 According to the American Optometric Association, KERATOCONUS is a condition that occurs when the normally round cornea (outer, transparent part of the eye) becomes thin and cone-shaped.  This irregularity prevents the light entering the eye from being focused correctly on the retina which then causes distortion and blurring of vision.

Growing up, parents would notice that there was a need to change the prescription of their child more frequently.  It seemed that the prescription was always taken incorrectly, and your child’s astigmatism and nearsightedness got higher with each vision examination. Then eventually, the prescription was not enough to provide the patient with the usual coveted 20/20 perfect vision with their glasses or conventional contact lenses.  And it is because a person with keratoconus would usually not achieve the 20/20 vision, many would mistake the condition as a simple amblyopia or lazy eyes. A keratoconic cornea becomes irregular thus the astigmatism created is also irregular, causing conventional glasses or contact lenses to be unsuitable for correction.

Originally, keratoconus was deemed rare, having an incidence of 1:2000 during a published study in 1986. However, recently, a study involving the population in the Netherlands resulted in a prevalence of  1:375 of keratoconus in the general population.  Over the years, we have seen a greater amount of keratoconus referrals and realized that indeed this condition is not at all rare, with a pool of patients being detected during the screening for refractive surgery consults.

How keratoconus can be managed?

Usually, the protocol in managing keratoconus patients would include a discussion about corneal collagen cross-linking that aims in controlling the worsening of the disease. If there is an indication that the keratoconus of the patient is progressing, collagen cross-linking may be performed. In collagen cross-linking, riboflavin (vitamin B2) is administered in conjunction with ultraviolet A which leads to biomechanical stiffening of the cornea.   It was shown that this procedure flattens the cornea by about 2 Diopters and may improve vision to about 2 lines or 10 letters.  Some patients would delay this procedure, but note that there is a minimum cut-off corneal thickness for the surgeon to still allow to do the procedure for safety purposes.

Intrastromal corneal ring segments are small, crescent-shaped plastic rings that are placed in the deep, peripheral corneal stroma in order to flatten the cornea. They are made of polymethylmethacrylate (PMMA).   This too may flatten the cornea to about 2 Diopters, and may improve uncorrected vision to about 2 – 4 lines as noted in different studies. This is not a must in the keratoconus management, however, it may be indicated if contact lenses cannot be fitted due to the very steep cornea.

In the worst cases, corneal transplantations are considered. Only about 10-28% of keratoconus patients would need corneal transplantation to improve their vision.   Corneal transplant is only indicated if vision cannot be improved anymore with contact lenses and if lenses are intolerable already.  The average long-term graft survival is nearly 20 years.  This means that a young patient can have more than one corneal transplant in a lifetime. Vision with correction will definitely be improved however note that uncorrected, patient may still have astigmatism. If your keratoconus was severe before the transplantation, it is possible for you to see a dramatic change in your uncorrected vision. Some patients may be happy with their uncorrected vision post the transplant, but most would still need contact lenses to achieve good vision.

In general, to attain good vision, specially designed contact lenses would still be needed after the collagen cross-linking, intrastromal ring implantation and corneal transplant.  This is why, before considering corneal transplants, all contact lens options should be exhausted to see if vision can still be satisfactory with them.    Most often than not, one can achieve good vision with contact lenses.  Attaining a 20/20 vision is not impossible but it is also not the default. It all depends on the severity of the condition and if the cornea does not have scars.   Special contact lenses include small GP (gas permeable) lenses, large GP lenses (scleral lens), soft customized contact lenses and hybrid contact lenses.

References:  

  1. Javadi M. A., Motlagh B. F., Jafarinasab M. R., et al. Outcomes of penetrating keratoplasty in keratoconus. Cornea. 2005;24(8):941–946. doi: 10.1097/01.ico.0000159730.45177.cd.
  2.    Sykakis E et al.Corneal Collagen Cross-linking for treating keratoconus.  Cochrane Database Syst Rev. 2015 Mar 24;93): CD010621.
  1. Wollensak G, Spoerl E, Seiler T. Stress-strain measurements of human and porcine corneas after riboflavin-ultraviolet-A induced cross-linking.Journal of Cataract and Refractive Surgery.  2003;29(9):1780-1785.
  1. Zadnik K, Money S, Lindsley K.Intrastromal corneal ring segments for treating keratoconus. Cochrane Database Sys Rev. 2019 May 14.
  1. Kelly T, Williams KA, Coster DJ, Australian Corneal Graft Registry. Corneal Transplantation for Keratoconus: A Registry Study. Arch Ophthalmol.2011;129(6):691–697. doi:10.1001/archophthalmol.2011.7
  1.     Kennedy RH, Bourne WM, Dyer JA, 1986. A 48-year clinical and epidemiologic study of keratoconus. Am. J. Ophthalmol101, 267–273.
  1. Godefrooij DA et al.Age-specific Incidence and Prevalence of Keratoconus:  A Nationwide Registration Study. Am J Ophthalmol. 2017 Mar; 175:169-172.
  1. Grentzelos MA, Kounis GA, Diakonis VF, Siganos CS, Tsilimbaris MK, Pallikaris IG, Kymionis GD, 2017. Combined transepithelial phototherapeutic keratectomy and conventional photorefractive keratectomy followed simultaneously by corneal crosslinking for keratoconus: cretan protocol plus. J. Cataract Refract. Surg43, 1257–1262

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Scleral Contact Lens Fitting in the Philippines

Scleral contact lens fitting is available in the Philippines.  It was not available though in the earlier years.  I have come across one foreign keratoconus blog with a Filipino with keratoconus asking where to get scleral lenses in the Philippines.  He seemed desperate, I tried to reach out but the blog was no longer active.  That was where the idea started.  I used to think that small rigid gas permeable lens is  the answer for all corneal irregularities, now I know I am wrong.

As more literatures are coming out, I realised that scleral lenses are invaluable in managing complicated corneas such as keratoconus, post surgical corneas such as in post LASIK and other post refractive surgery complications and corneal transplants.   These lenses act as band-aids with cushions, vaulting the entire injured or compromised area.  And since the lenses are filled with  saline, these are great too for patients with ocular surface diseases such as dry eyes.  The skirt of the scleral lens lands on the least sensitive part of the eye which is the sclera, that is why patients tolerate scleral lenses more than small rigid gas permeable lenses.  As to the cost, it may be more than what conventional rgp’s would cost, but the outstanding vision and comfort that these lenses provide make it all worth it. When we do scleral contact lens fitting, we do series of tests and fittings before finalising the best fit for you.

How long does a scleral contact lens last?  Well, depends on the progression of the condition as well as how well you clean them.  A safe estimation will be  2 years or so.

We welcome inquiries on scleral contact lens fittings.

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