This case report discusses the management of keratoconus in a 24-year-old male. He was referred for contact lens fitting for keratoconus diagnosed 5 years prior in his right eye, which had previously undergone C3R procedure. Topography showed inferior thinning in the right eye. Rose K2 and soft toric lens trials produced good centration and vision. The lenses were ordered and the patient was asked to return for collection. The conclusion discusses recent advances in keratoconus treatment including collagen cross-linking, excimer laser, phakic IOLs, and intrastromal corneal ring segments.

1. Case report on
Keratoconus management
MEENAKSHI
MOPTOM PR 003

2. Introduction
• Keratoconus is a benign, usually bilateral, non-
inflammatory, progressive thinning, weakening
and ectasia (protrusion) of the cornea,
resulting in corneal surface distortion. This
leads to visual loss primarily due to a high
degree of irregular myopic astigmatism and
corneal scarring.
• The protrusion usually develops in the infero-
central zone of the cornea that results in a
cone-like anterior protrusion. While the early
stages of the disease usually involve irregular
corneal astigmatism with inferior corneal
steepening, later stages may involve a cornea
that is relatively flat centrally but very steep
inferiorly. This can result in hyperopic rather
than myopic astigmatism.

3. • Although KC usually occurs bilaterally, the onset of the disease may occur at different times
in each eye.
• Due to the advent of videokeratoscopes, the detection of keratoconus in its nascent form
has increased dramatically thereby increasing the apparent incidence of the condition.
• This early form of undeveloped disease with inferior corneal steepening as its hallmark, is
also called as forme- fruste KC.
• Although the etiology of KC is not fully understood, it is probably multifactorial.
• While heredity is believed to be a factor , associations with collagen abnormalities & other
atopic diseases have been suggested as additional possible factors .
• The evidence implicates an abnormality of stromal collagen tissue.

4. Case Discussion
• A 24-year-old male was referred for CL Trial
• He had history of right eye keratoconus diagnosed 5 years ago.
• C3R was done in RE eye 5 years ago.
• Rest other history was not contributory.
• H/0 using RGP lens on and off in RE and soft toric in LE
• Was not aware of the brand name and had last pair of lens with him , for RE he was not
comfortable with RGP so was referred for Rose K trial.

5. Investigations
• Current glass prescription
• OD -4.75
• OS -4.00DS/-0.75DC X 65
• Subjective Refraction
• OD -2.75DS/-2.25DC X 90 6/12,N6
• OS -4.00DS/-0.75DC X 90 6/6,N6
• Keratometry
• OD K1 6.90mmavg k 6.8 mm K2 6.70mm
• OS K1 7.35mm avg k 7.30 mm K2 7.25mm

6. • UCVA 6/18 in the right eye and 6/60 in the left eye for distance.
• VA with present glasses 6/12 RE and 6/9 LE &
• PH visual acuity 6/9 RE and 6/6 LE.
• Pupillary examination revealed round pupils which reacted well to light, and RAPD was
absent.
• Slit Lamp Examination revealed normal lids and conjunctiva, inferior thinning right
eye, RRR pupil in both eyes and normal clear lens in the both eyes.
• Fundus examination was found within normal limits and optic disc CDR 0.3:1 in both
eyes.

7. OD TOPORAPHY

8. OS TOPOGRAPHY

9. CL Trial
• OD 6.50mm/-8.00DS/8.50mm/STD/ROSE
K2 NC
• OS 8.6mm/-3.75DS/-0.75DC X 90
/14.20mm/Purevision 2 toric

10. Lens fit assessment
Rose K2 NC
• Centration – Well centered
• Movement with blink = 1.5mm
• Movement type= smooth
• Speed of movement= average
• Stability= yes
• With lenses on
• VA 6/6p ,n6
• Over refraction plano

11. Lens fit assessment
soft toric
• Centration- Good in all gazes
• Movement with blink primary gaze= 0.3mm
• Movement with blink upgaze gaze= 0.5mm
• Upgaze lag = 1mm
• Horizonatal lag = 1mm
• Push up test = 50%
• Fit classification= optimal
• Patient comfort = 5
• Vision with blank and after blink = 6/6,n6

12. • Final Lens order
• OD 6.50mm/-8.00DS/8.50mm/STD/ROSE K2 NC / FL 90/ GREY
• OS 8.6mm/-3.75DS/-0.75DC X 90 /14.20mm/Purevision 2 toric
• Both eye lenses were ordered and patient was asked to come for lens collection.

13. Conclusion
• In the early stages, patients with keratoconus can usually achieve adequate visual
correction with spectacles. The primary treatment mode initially was the usage of rigid
contact lenses and spectacles, while for advance cases keratoplasty was the preferred
choice of treatment. However, after the advanced development in the past decade,
there have been various therapeutic options now available that have revolutionized
the treatment approach for this disease.

14. • There has been a paradigm shift from the preferred Keratoconus treatment option from
fitting of contact lens, followed by Deep Anterior Lamellar Keratoplasty (DALK) or
Penetrating Keratoplasty (PK) to Ultraviolet-A (UV-A induced collagen cross-linking (CXL) for
stabilizing the corneal ectasia for long term.
• The recent advances in Keratoconus treatment has introduced the usage of excimer laser
application, Phakic IOLs, Intrastromal Corneal Ring Segments (ICRS), as well as the
utilization of combination techniques which have resulted in a major contribution to offer
effective management options for Keratoconus at different stages of its progression .
• The newest technique is the Bowman layer (BL) transplantation which has been introduced
recently as a substitute to PK/ DALK for Keratoconus at advance stage, unsuitable for ICRS
or UV-CXL.