Keratoconus in the U.S. was classically a “wait and see” corneal disease.

Though improvements in vision could be obtained, traditionally with rigid gas permeable lenses, we as practitioners could do nothing to intervene and stop the progressive nature of the disease.

On a yearly basis, we would monitor our patients with keratoconus and watch keratoconic changes hoping “this will be the year we will see stability and the end of the progressive lifecycle”. We watched these keratoconic corneas progressively thin, steepen and scar as our patient’s vision, and more importantly, quality of life deteriorated.

The only solace we could offer our progressive patients was to stop rubbing their eyes to prevent shear forces which could contribute to the progression. When patients would ask “Doc, how bad will this get?” we could only respond, “We will have to wait and see”. Once vision could no longer be adequately corrected or advanced corneal scarring had formed, our only recourse was corneal transplantation.

However, the times they are-a-changing.

Theo Seiler’s group at the University of Dresden showed us that an oxygen-limited photochemical reaction between corneal collagen and riboflavin activated by UV-A can strengthen the collagen of the cornea preventing further progression of the disease. Quickly this became the international standard of care for progressive keratoconus and other progressive ectatic disease. It has been reported that crosslinking is anywhere from 92-98% effective in stopping progression and carries minimal risks in the classic Dresden protocol procedure.

The U.S. FDA approval of crosslinking came in spring of 2016, nearly 18 years after Seiler’s group’s publication. With the approval came an immediate evolution in the care we as practitioners must provide as well as the diagnostic technology we must utilize.

The new mantra of keratoconic care is: Diagnose early, Stop progression, Rehabilitate vision.

This is a collaborative care model. It is incumbent on Optometry, as ocular primary care, to employ these advanced diagnostic technologies to detect keratoconus in its early stages. This is especially important in the pediatric population as this is when the first signs of keratoconus can be detected.

Once detected, we must utilize our cornea specialist ophthalmology colleagues to perform this vital procedure before advanced disease sets in. Following the procedure, the patient will need visual correction, whether by spectacles or an ever-growing variety of specialty contact lenses.

Out with the old, in with the new (standard of care), oh the times they are-a-changing.
In upcoming articles, we will delve further into diagnostic technologies, refractive surgeries for keratoconus, who gets crosslinking, various forms of crosslinking, what defines progressive keratoconus, and what the future may hold for our patients.