Treatment for Keratoconus Helps Avoid Corneal Transplant: Condition often appears in early teen years

By Amy Geiszler-Jones
Tuesday, August 20, 2019

When Wichitan Mike Ellis was diagnosed 25 years ago with keratoconus, a condition in which the cornea becomes misshapen, his treatment options were to monitor its progression and get stronger corrective lenses until the severity of his vision loss would require a corneal transplant.

Wichitans Mike Ellis and his daughter, Zoey, both had corneal cross-linking performed by Dasa V. Gangadhar, MD, Grene Vision Group ophthalmologist

When his daughter, Zoey, was diagnosed with the condition in 2017, a new treatment option that can halt the progression of the disease, preserve one’s vision and avoid a corneal transplant had become available.

The Ellises underwent the treatment, called corneal cross-linking, on the same day in February 2018. Dasa V. Gangadhar, MD, of Grene Vision Group, who had been monitoring Mike’s condition since it was first diagnosed and then became Zoey’s ophthalmologist, performed the procedures.

Based in Wichita, Kansas, Grene Vision Group is the only practice in Kansas, outside of the Kansas City area, that performs the procedure that uses a combination of riboflavin and ultraviolet light to treat keratoconus patients, Dr. Gangadhar notes.

“It’s a relief to me to know that we will likely not need a corneal transplant,” says Mike Ellis, the Chief Financial Officer with Delta Dental of Kansas. “Thanks to this treatment, my eyes are stable and my daughter’s eyes are stable.”

What Is Keratoconus?

Dr. Gangadhar calls keratoconus “a disease of the young.” That’s because symptoms, which include blurred, distorted or double vision and light sensitivity, tend to appear around puberty or one’s teenage years. For Mike, symptoms appeared when he was 19; his daughter’s symptoms appeared when she was 13.

Dasa V. Gangadhar, MD, is a fellowship-trained corneal surgeon at Grene Vision Group. His areas of expertise include corneal cross-linking, corneal transplantation, and cataract and implant surgery. He has regularly handled the most complex medical and surgical cases from all over Kansas.

With keratoconus, the normally dome-shaped cornea — the clear tissue at the very front of the eye that allows light to pass through to the retina — begins to thin out and bulge forward in a cone shape. Because the cornea is misshapen, the light rays are out of focus, affecting one’s vision.

Its cause hasn’t been determined, but genetics do play a part, Dr. Gangadhar says.

“It occurs in family more commonly than by chance alone,” he says. “The exact genetics have yet to be elucidated, but unquestionably, there’s a genetic linkage.”

According to the American Academy of Ophthalmology (AAO), about one of every 10 patients with keratoconus has a parent with it. It’s also associated with excessive eye rubbing, according to Dr. Gangadhar and the AAO.

Mike says knowing there’s a genetic link and that it manifests in teen years has him and his wife on the lookout for any changes in their son’s vision, as he’s now 13. Zoey had to wait until she was 14 to have the procedure, which is FDA-approved for patients ages 14 to 65.

Generally, patients with keratoconus tend to have worsening vision over the next decade or so after diagnosis that requires changes in corrective lens prescriptions until a corneal transplant is needed.

“Typically, a 14-year old would get a transplant at age 22,” Dr. Gangadhar says.

In 44-year-old Mike’s case, the condition was more stable in one eye, but continued to progress in the other eye into his 40s. Left untreated, the progression could have led to a corneal transplant, which is something he wanted to avoid.

What Is Corneal Cross-Linking?

In April 2016, the FDA approved the corneal cross-linking procedure, which Dr. Gangadhar calls “one of the biggest advances in ophthalmology in a decade, maybe even longer.”

The minimally invasive procedure takes about 60–90 minutes and is done on an outpatient basis. In the procedure, the cornea’s epithelium is removed and corneal tissue is soaked with riboflavin (vitamin B2) drops for 30 minutes. The corneal thickness is measured and then, for the remainder of the procedure, a UV light is shone onto the eye. The light treatment helps stiffen and strengthen the collagen fibers in the cornea.

“With cross-linking, you’re essentially creating molecular bonds, or cross-links, between those fibers and gluing them together. The procedure strengthens, stiffens and stabilizes the fibers,” Dr. Gangadhar explains.

If a patient requires the procedure in both eyes, as Zoey did, the second procedure is performed at least three months later.

Most patients won’t see an improvement in vision, but that’s not the purpose of the procedure.

“The main goal of this is to save vision and avoid the need for a future corneal transplant,” Dr. Gangadhar says.

FDA trial outcomes showed the procedure stops the progression of the condition for 92–95% of patients, and Grene Vision Group has had similar outcomes since it started offering the procedure in December 2016, Dr. Gangadhar says.

Dr. Gangadhar has performed about 200 corneal cross-linking procedures, with more patients opting for the procedure as insurance reimbursement becomes more accessible, he says.

In Europe, where the procedure was available for almost 10 years before FDA approval, studies indicate the rate of corneal transplant has dropped substantially in the past decade. Because the procedure is still new in the U.S., there is no similar data for U.S. patients.

Patients Should Have Annual Eye Exams and Report Vision Changes

Patients with changes in vision should always seek medical attention. With annual eye exams that include measuring the cornea and computerized mapping of the eye’s topography, a condition like keratoconus can be diagnosed early.

“If a child has problems on a school screening exam or if a patient reports eye problems to their family doctor, the patient should be sent to an optometrist or ophthalmologist,” says Dasa Gangadhar, MD, an experienced ophthalmologist with Wichita-based Grene Vision Group. “Maybe it’s a normal refractive error like nearsightedness or farsightedness that can be corrected by lenses. But if vision isn’t being corrected with that treatment, we have to look at other reasons for vision problems. One possibility can be keratoconus [when the cornea becomes misshapen]. There are subtle clues that the screening physician, whether it’s an optometrist or ophthalmologist, can look for, such as if the patient is not correctable to 20/20 vision or the patient has progressive nearsightedness with progressive astigmatism.”

The exact cause of keratoconus isn’t known, but there is a genetic link, so it’s important that patients know their family’s eye health history. Also, keratoconus has been associated with eye allergies and eye rubbing, according to the American Academy of Ophthalmology.