Is This the New Norm?

Is Keratoconus Surgery the New Normal?

BY MILE BRUJIC, OD, FAAO, & DAVID L. KADING, OD, FAAO

We live in an age of quick fixes. Those who are overweight are looking for a magic weight loss pill, and individuals who are in pain want a painkiller to solve their ailments rather than looking for a more permanent solution to their problems.

We are fortunate enough to have specialty-based anterior segment, dry eye, and contact lens practices. When new keratoconus patients come to us for a consult or a second opinion, we are surprised to hear the things that they tell us regarding their vision and projected future.

Many patients come in with far less than ideal vision and with uncomfortable contact lenses. Or, they explain that they have been referred for surgery having been told that surgery is their only option because of how bad their eyes are.

We have even seen patients who have 20/25 spectacle vision in our offices who were told that they have a disease called keratoconus and that they need a corneal transplant (Figure 1). Others have come who have undergone intrastromal ring implantation surgery, but they haven’t noticed any difference in their vision or lens comfort.

Figure 1. An eye that has undergone a corneal transplant for keratoconus.

To Cut or Not to Cut

As with any surgical procedure, we are major fans of the advancements that have made their way into corneal surgery. When all contact lens options have been exhausted or the cornea is clouded over from scarring, we too refer our patients for corneal surgery. But, we are dismayed by the eagerness that some colleagues show by referring their patients for a complex corneal surgery in an attempt at a quick fix.

The vast majority of the patients whom we see are gladdened by the opportunity to give another contact lens a try. With all of the possible hybrid, custom soft, corneal, and scleral options, surely there is another option that has not been tried on these patients prior to surgery.

In our 20 years of combined specialty contact lens fitting, we have (combined) sent less than 20 patients in for corneal surgery due to contact lenses not being able to correct their vision.

If you personally have tried all contact lens options, consider getting a second opinion from a fellow contact lens-fitting colleague within your practice or a nearby specialty contact lens center. Only then, when you and at least one other colleague have exhausted all options, should you consider surgery.

The Verdict

Although surgery can always be performed, the potential negative outcomes that rarely (but sometimes) occur following surgery cannot always be fixed. It is our opinion that all contact lens options should be exhausted—and exhausted again—prior to a permanent transplantation surgery. If keratoconus surgery is the new normal, then we don’t want to be in that camp. CLS

Dr. Brujic is a partner of Premier Vision Group, a three-location optometric practice in northwest Ohio. He has received honoraria in the past two years for speaking, writing, participating in an advisory capacity, or research from Alcon Laboratories, Allergan, B+L, Optovue, Nicox, Paragon, SpecialEyes, TelScreen, Transitions, Valeant Pharmaceuticals, Valley Contax, VMax Vision, VSP, and ZeaVision. Dr. Kading owns the Specialty Dry Eye and Contact Lens Center in Seattle. He is the co-owner of Optometric Insights with Dr. Brujic. He has received honoraria for consulting, performing research, speaking, and/or writing from Alcon Laboratories, Allergan, Bausch + Lomb, CooperVision, Ocularis Pharma, Oculus, RPS, TearScience, Valley Contax, Zeiss, and ZeaVision. Follow him on Twitter @davekading.