This presentation describes all the clinical aspects of keratoconus management You can watch the illustrated presentation in this link : https://www.youtube.com/watch?v=pYxwZPGm7e4&list=PLZ_mM13I_TrhWavjTmE9NjW1O5bGxkONO&index=13

1. BY
Dr. Amr Mounir, MD, PhD
Lecturer of Ophthalmology
Sohag university

2. Keratoconus is a progressive,
noninflammatory, bilateral
(but usually asymmetric)
ectatic corneal disease,
characterized by paraxial
stromal thinning and
weakening that leads to
corneal surface distortion.

3. - History of trauma that causes
corneal weakness
- Recurrent trauma due to rubbing from
Blepharitis, Vernal keratoconjuctivitis

4. -- Epithelial basement
membrane fragmentation
and scarring
-- Axial stromal thinning
and scarring
- Breaks in and folds
close to the Descemet's
membrane result in acute
hydrops

5. Patients with keratoconus (KC) often report
decreasing vision (distortions, glare/flare,
and monocular diplopia or ghost images),
with multiple unsatisfactory attempts in
obtaining optimum spectacle correction

6. - Decrease in visual acuity
- Progressive myopia ,irregular
astigmatism
Oil droplet sign by direct ophthalmoscope
Irregular scissoring by retinoscopy

7. FLEISCHER RING abrupt change in curvature
VOGT’S STRIAE 1st Sign
STROMAL THINNING
STROMAL SCARS
ENLARGED CORNEAL NERVES
ACUTE HYDROPS

10. 1- Old methods :
A- Placido Disc
B- Retinoscopy
2- New Methods :
A- Corneal topography
B- Pentacam

11. 1- Pachymetry map
2- Keratometry map ( K1,K2,Kmax)
3- Cone site and shape
4- Elevation map
5- Provisional diagnosis: Keratoconus Summary
( Sirus device)
6- Aberration map
7- Scheimpflug imaging

14. Several classifications of keratoconus based
on:
1- Morphological Patterns
2- Topographical Patterns

16. Nipple cone

17. Oval cone

19. Krumeich Classification of Keratoconus:
Severity of KC is also classified by amsler krumeich
classification.
This classification depends on mean K-readings on the
anterior curvature sagittal map, thickness at the
thinnest location, and the refractive error of the
patient .

21. It is a new keratoconus staging system that uses
current tomographic data and better describes the
anatomical and functional changes seen in
keratoconus.
It includes anterior and posterior curvature,
thinnest pachymetric values, and distant visual
acuity (reported clinically by the physician) and
consists of stages 0–4 (5 stages).

23. is a subclinical disease and is not a variant
of KC.
Although clinicians use many other terms
such as mild KC, early KC, and subclinical
KC

24. .1FFKC is a completely normal cornea with
neither clinical nor topographical risk factors,
but this cornea is able to develop KC when
treated by laser.
.2The fellow eye may be keratoconic or there
may be a family history of KC

25. 2. FFKC is an abnormal cornea.
Corneal topography or corneal hysteresis or both
are abnormal; i.e., there are risk factors but the
case is still not a clinically obvious KC

30. -PMD is a bilateral, non-inflammatory, peripheral
corneal thinning disorder characterized by a
peripheral band of thinning of the inferior
cornea.
-The cornea in and adjacent to the thinned area is
ectatic.
- Patients usually are aged 20–40 years at the time
of clinical presentation.

34. Depend on :
1- Age
2- Refraction
3- Pachymetry
4- Keratometry
5- Cone Position
6- Corneal Opacifications.

35. 1- Glasses and follow up.
2- Hard Contact Lens.
3- CXL ( Transepithelial – Epi-off).
4- Rings ( Kerarings- Myoring).
5- Keratoplasty(Lamellar – penetrating )

36. 1- Non of treatment options is satisfactory for the patient.
2- The disease is progressive by its nature.
3- Follow up is mandatory.
4- Combination of treatment options can be done.
5- Keratoplasty can be a final destiny even with treatment.
6- Rings mostly will be followed by glasses.
7- Don't judge on improvement of VA without correction.
6- Financial aspect should be taken into consideration.

37. When ?????
1- Age > 28 ys old.
2- Stable and low refraction with BCVA
>6/24
3- Clear cornea
4- Favorable Pentacam:
1) Average Keratometry <46 Ds
2) Thinnest Pachymetry > 480 um

38. -- GP lenses are not the same as the old hard
lenses. For one thing, GP lens materials allow
oxygen to pass through the lens and reach
the cornea.
- With advances in manufacturing, GP lenses
are made in thinner designs, larger
diameters, and with more consistently smooth
edges than ever before.

39. - GP contact lenses are custom made for
each individual.
- Parameters which are needed for GP
contact lens request.
1) Keratometry: for initial fitting
2) Refraction.

41. - Soft lenses do provide better initial comfort, while GP
lenses require a brief adaptation period. But this is
due to the size of the lens — not the lens material.
- Soft lenses are larger in diameter than GP lenses
and "tuck under" the eyelids. As a result, you don't
feel the lens edges when you blink. But since GP
lenses are smaller, during blinking your eyelids will
experience initial "lens awareness.

42. This is a lens design combination that has an RGP
center surrounded by a soft peripheral “skirt”.
Hybrid contact can provide the crisp optics of a GP
lens and wearing comfort of soft contact lenses.
They are available in a wide variety of parameters to
provide a fit that conforms well to the irregular
shape of a keratoconic eye.

45. - The only actual therapy for keratoconus.
- Main effect is stiffening and flattening.
- Long term effect.
- Minimal optical effect.

46. Important hints:
- Less effective than Epi-off.( Less flattening
effect)
- Less complications rate.
- More comfortable for the patient.

47. - Early Keratoconus. 46 Ds<Mean K < 48 Ds
- Middle aged patients.
- Very thin corneas.
- After ICRS.
- Inadequate follow up.

49. When to do???
- In moderate and advanced cases.
- In young patients < 25 ys old.

54. - High errors.
- Mean Keratometry > 48 Ds
- K Max > 50 Ds
- BCVA < 6/30
- High patient motivation

56. - Non central cones.
- High cylinder.
- High difference between K1, K2.
- Thickness at insertion site >400 um

58. - Central cones ( Nipple ,Oval , Globus)
- High K readings K1, K2 with low difference.
- High errors with high sphere.
- Thinnest location > 400 um.
- Epi-off like CXL.
- Eye without refraction.

60. Central cone - Refraction : -8 Ds -7 Dc
- Very high K readings For Myoring implantation

61. -Shifted cone , Refraction : -9Ds -4.5 Dc
-K2 @ 68 For Kerarings implantation

63. With Myoring:
-It should be done in the same session
( intrapocket CXL).
- Epi-off like effect as it crosses the epithelium
With Kerarings:
-It should be done in the same session or after ring
implantation not before.

65. Young age < 25 ys ---------- be more
aggressive
Early Keratoconus: Epi-off CXL stabilization
and follow up
Moderate and severe Keratoconus: CXL 
stabilization + Rings  Regularization and
Flattening
Advanced opacified cornea: Keratoplasty

66. Middle age > 25 ys ---------- be less aggressive
Early Keratoconus: Epi-on CXL or follow up
Moderate and severe Keratoconus: Rings
 Regularization and Flattening with follow up if
progression  Stabilization by CXL
Advanced opacified cornea : Keratoplasty

67. - Many guidelines affect our decision in keratoconus
management.
- Pentacam is an important tool in evaluation of
Keratoconus patient.
- Age is a guiding factor in treatment with aggressive
attitude in young age.
- Customization should be done for every patient in
keratoconus management.