In 1983 I had the privilege of co-authoring my first paper on keratoconus, “Does the Boston II Contact Lens correct keratoconus?” (Shovlin et al.). This began a career during which I’ve seen my share of patients, continued to publish and participated in clinical trials involving all aspects of keratoconus management.
However, it’s hard to profess expertise about a condition whose etiology you don’t fully understand and when the contact lenses you prescribe provide adequate visual acuity, but not necessarily quality of life. For sure, it’s hard to view oneself as an expert when not entirely certain who will progress to surgical intervention. These uncertainties hold true for many medical conditions, but there’s something humbling about keratoconus, perhaps because it involves sight.
Sight is truly a marvel of natural engineering, and the cornea plays no small role. A mere 0.5 mm thick and 11.5 mm wide, optically clear and metabolically active, it’s utterly amazing what the cornea does. It’s equally devastating, however, when this delicate structure goes awry. Biomechanical instability, increased optical aberration and eventual loss of transparency pretty much summarize the cornea’s demise in keratoconus. It’s unsettling that we’ve largely managed keratoconus’ unabated change with contact lenses, while accepting its progression and attending negative impact on quality of life. Even more frightening is that keratoconus management has not changed much over the past 30 years. That is, until now.
Arguably, we’re witnessing a keratoconus renaissance of sorts. Genetic mapping provides a better understanding of the complexities of keratoconus inheritability ... not to mention the huge role environment plays. Corneal biomechanics and full thickness imaging allow us to assess risk and diagnose earlier. Newer contact lens platforms are improving vision correction and comfort (think quality of life). And corneal collagen cross-linking (CXL) has finally given us a means by which to alter the course of disease. Partnering CXL with intracorneal ring segments and/or topography-guided PRK offers a potential path to contact lens-free vision – at least part of the day. Perhaps most importantly, these collective strategies reduce the likelihood of more aggressive surgical intervention. With procedures such as Bowman’s layer transplantation and deep anterior lamellar keratoplasty, we might ultimately relegate penetrating keratoplasty to a historical footnote.
In this month’s Primary Care Optometry News, our feature article, “Keratoconus care benefits from new diagnosis, treatment strategies,” offers an overview of the renaissance we’re witnessing. Please enjoy what, I believe, is a very worthy read. And, yes, the Boston II Contact Lens did correct keratoconus. At least by 1983 standards.
- Shovlin J, et al. Contact Lens Forum. 1983:8(7).