Keratoconus

Definition
A condition characterized by a conical protuberance of the cornea with progressive thinning
on protrusion and irregular astigmatism. (Brunner & Suddarth)
Occurs when your cornea — the clear, dome-shaped front surface of your eye — thins and
gradually bulges outward into a cone shape. (Mayo Clinic)
Clinical Manifestations
o Glare and halos around light
o Difficulty seeing at night
o Eye irritation/headache associated with eye pain
o Increased sensitivity to bright light
o Sudden worsening/clouding of vision
Precipitating Factors
o Heredity. One in 10 keratoconus sufferers has a close family relative with the
disorder.
o Women. Higher incidence in women than men.
o Chronic eye inflammation. Constant inflammation from allergies or irritants can
contribute to the destruction of corneal tissue that may result in developing
keratoconus.
o Age. Keratoconus is often discovered in the teenage years. Generally, young patients
with advanced keratoconus are more likely to need some form of surgical intervention
as the disease progresses.
Predisposing Factors
o Frequent eye rubbing. Chronic eye rubbing is associated with developing keratoconus.
It may also be a risk factor for disease progression.
o Having a history of asthma, allergies, Ehlos Danlers syndrome, Down’s syndrome, or
retinitis pigmentosa.
Pathophysiology
Normally in response to UVB and mechanical stress (eye rubbing), there is a
formation of reactive oxygen and nitrogen species (ROS/RNS). In normal tissues, there are
antioxidant enzymes that remove them and eliminate the reactive oxygen species. However,
if the antioxidant enzymes are overwhelmed or do not function properly then buildup of
ROS/RNS happens. When this happen, the ROS/RNS can then be processed in two different
pathways; one is the lipid peroxidation pathway that results in increased cytotoxic aldehydes,
second is the nitric oxide pathway which results in increased peroxynitrites. Both cytotoxic
aldehyde and peroxynitrites can damage tissue and this leads to oxidative damage thus
increasing the level of activity of the degradative enzymes and decreasing the collagen/matrix
production. This results to loss of the Bowman’s layer, which is a smooth, acellular,
nonregenerating layer, located between the superficial epithelium and the stroma in the
cornea of the eye. The epithelium becomes irregular in thickness. The anterior part of the
stoma contains cells that undergoes apoptosis, programmed cell death, that is found in
various pathologic condition. The main stroma of the cornea is much thinner (200-300
microns thick) than normal (500-540 microns thick) cornea.
Diagnostic Studies
o Corneal topography. This is the most accurate way to diagnose early keratoconus and
follow its progression. A computerized image is taken that creates a map of the curve
of the cornea.
o Slit-lamp exam. This examination of the cornea can help detect abnormalities in the
outer and middle layers of the cornea.
o Pachymetry. This test is used to measure the thinnest areas of the cornea.

Nursing Management
o Reinforces surgeon's recommendations and instructions regarding visual rehabilitation
and improvement.
o Encourage client to avoid rubbing their eyes to prevent worsening the condition.
o Assess client’s allergies to help decrease chances of eye irritation therefore decreasing
eye rubbing.
o Remind client of follow-up on a 6-month to yearly basis to monitor the progression of
the corneal thinning, steepening, resultant visual changes, and re-evaluate contact lens
fit and care.
o Educate client on how to administer flurometholone and artificial tears during post-
operative cross-linking period which he/she will do for a period of one month.
Medical Management
Early Stages
Current treatment for keratoconus includes glasses in the earliest stages to treat
nearsightedness and astigmatism. As keratoconus progresses and worsens, glasses are no
longer capable of providing clear vision, and patients need to wear a contact lens, usually a
hard contact lens.
Intermediate Stages
Progressive keratoconus can be treated by corneal collagen cross-linking. This one-time, in-
office procedure involves the application of a vitamin B solution to the eye, which is then
activated by ultraviolet light for about 30 minutes or less. The solution causes new collagen
bonds to form, recovering and preserving some of the cornea’s strength and shape.
While the treatment cannot make the cornea entirely normal again, it can keep vision from
getting worse and, in some cases, may improve vision. The procedure may require the
removal of the thin outer layer of the cornea (epithelium) to allow the riboflavin to more
easily penetrate the corneal tissue.
Cross-linking was approved as a treatment for keratoconus by the FDA in April 2016, after
clinical trials showed that it stopped or produced a mild reversal in bulging of the cornea
within three to 12 months after the procedure.
Advanced Stages
Corneal ring. With severe keratoconus, a standard contact lens may become too
uncomfortable to wear. Intacs are implantable, plastic, C-shaped rings that are used to flatten
the surface of the cornea, allowing improved vision. They may also allow a better contact
lens fit. The procedure takes about 15 minutes.
Corneal transplant. In a corneal transplant, a donor cornea replaces the patient’s damaged
cornea. Corneal transplants are often performed on an outpatient basis and take about an hour
to complete. Vision usually remain blurry for about three to six months after the transplant,
and medication must be taken to avoid transplant rejection. In almost all cases, glasses or a
contact lens are necessary to provide the clearest vision after transplant surgery.
Penetrating keratoplasty (PKP; corneal transplantation or corneal grafting). Involves
replacing abnormal host tissue with healthy donor (cadaver) corneal tissue. Common
indications are keratoconus, corneal dystrophy, corneal scarring from herpes simplex
keratitis, and chemical burns.
Phototherapeutic keratectomy (PTK). A laser procedure that is used to treat diseased corneal
tissue by removing or reducing corneal opacities and smoothing the anterior corneal surface
to improve functional vision.