7 Vital Facts You Should Know about Keratoconus…but don’t.

by Jim Kokkinakis
BOptom FAAO ISCLS www.theeyepractice.com.au

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The Seven Vital Facts you need to know about Keratoconus…but don’t.

Keratoconus is a disease of the front surface of the eye that often is visually
debilitating. It affects only 1/2000 of the population, so in Australia it is estimated that at least 10,000 people suffer with this condition. Many struggle to function in every day life due to inappropriate treatment options or advice. An important point is that most eye-care practitioners see about 2,000 eye patients per year, so on average they will only see one keratoconic patient per year. It does not matter how smart you are; if you do not involve yourself frequently with an activity you will never develop the skill to deal with it effectively and efficiently. Because there is a lack of experience in the keratoconus area often a person that has keratoconus will accidentally be steered in a totally incorrect direction. Fortunately, you can be different! This report covers the seven vital issues in keratoconus that if not understood can lead to significant problems, inconvenience, grief and emotional distress. When you understand and apply these important principles you can be at ease with this frustrating condition.

1. Keratoconus is not a blinding condition
It amazes me that most of the patients I see at some stage fear that they will eventually go blind. This occurs simply because they have seen their vision get worse and worse so they believe that the eye condition will continue to degrade to the point that nothing can be done to recover the vision. Some people have seen a number of eye care practitioners over time and no one has been able to fit them with contact lenses or glasses and they are too scared to pursue corneal transplant surgery. They then try to function with poor vision and believe it is only a matter of time before they will see nothing at all. The reality is that no one goes blind from keratoconus. There are currently umpteen options before corneal transplantation might be required from: a. Glasses b. Soft contact lenses c. Rigid gas permeable contact lenses (when fitted properly this is the most successful option). d. Rigid gas permeable lenses piggybacked on soft disposable contact lenses e. Mini-scleral contact lenses f. Intacs with Riboflavin drops g. Re-prescribing glasses, soft contact lenses or rigid gas permeable contact lenses after Intacs.

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The Seven Vital Facts you need to know about Keratoconus…but don’t.

If corneal transplantation is finally required its success rate is greater than 95%, when done by an expert corneal surgeon. Please note that glasses or contact lenses are normally required after surgery, but visual quality is normally very good. It is important to understand vision correction is still required in most cases. Somewhere along the line we always get reasonable vision.

2. Keratoconus does not progress forever
Typically when I see a patient with keratoconus for the first time, they have been referred by another optometrist or ophthalmologist (eye surgeon). They are usually in their teens and they are accompanied by their parents. Keratoconus usually begins slowly or aggressively as a teenager during puberty. The front window of the eye in keratoconus (the cornea) becomes thinner and eventually destabilizes and becomes irregular in shape, which also then deteriorates the vision. The typical patient that is affected by keratoconus assumes that the condition will continue to progress forever. When I see a teenager accompanied by their parents I normally have a long and careful discussion, as everyone is stressed and upset. The good news for most people is that keratoconus usually stabilizes quite nicely after twenty-five years of age except when: 1. 2. Poorly fitted contact lenses are used The affected person regularly and aggressively rubs their eyes.

Having read many articles on keratoconus in the literature and on the internet it is common to read that keratoconus progresses through to forty years of age. This has not been my experience when lenses are fitted properly and the affected person and his/her family have careful counseling about the potential damage that is done by eye rubbing. The moral to the story then: “I promise to fit the lenses properly as long as you significantly decrease eye rubbing.”

3. Significantly decreasing eye rubbing is essential!
People that have keratoconus often also have allergies. Hayfever, skin allergies, and asthma are common. With these conditions come itchy eyes. Another group of people that has keratoconus does not seem to have allergies but have a habit of eye rubbing. Aggressively rubbing eyes can cause or progress keratoconus. Therefore it is very important to have strategies to decrease the urge to rub.

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The Seven Vital Facts you need to know about Keratoconus…but don’t.

It is felt that rubbing eyes that are predisposed to keratoconus traumatizes the cornea causing it to thin and become distorted in shape. As discussed before, this distortion in shape then causes distortion in vision that often cannot be corrected with glasses. One thing is to know that eye rubbing is a problem and another is putting a halt to it. People that get itchy eyes will tell you that it drives them mad and once they start they cannot stop until their eyes are red raw. It is this vicious cycle that can progress keratoconus. Over the years I have come up with three strategies: 1. Because allergies contribute significantly to the urge to rub, it is a good idea to use anti-allergy drops, especially in allergy season. There are two drops which I have found to work very well: a. Zaditen (twice a day) – this drop is now over the counter b. Patanol (twice a day) – this drop requires a prescription. Even though this requires prescription it is no better than the one above. Cold compresses should be used when you feel like you need to rub. The most convenient form of cold compresses is to purchase a cold pack from the chemist (which is a blue gel in a plastic bag), freeze it and have it ready. When you need to use it wrap it once in a tea towel and then mould it into your eye sockets. You will find relief very quickly this way. If you are wearing contact lenses, the solutions that they are stored in are loaded with preservatives which can cause itchiness. Rinsing the lenses with unpreserved saline before inserting them into your eyes will contribute to rubbing your eyes less.

2.

3.

Decreasing eye rubbing cannot be overstated. You need to stop and you need to stop now.

4. Not all contact lens solutions are the same
Contact lens hygiene is critical to the ongoing success of contact lens wear and consequently good vision. It is obvious that keeping the contact lenses clean is important to maintain good eye health, but did you know that the solutions themselves often cause toxic or allergic reactions, which can make contact lens wear from uncomfortable to unbearable. Contact lens solutions are preserved so that they remain sterile. Preservatives kill bacterial cells but the eye is also made up of cells, which can be affected by these same preservatives. Preservatives in contact lens solutions can make eyes go red, feel gritty and itchy. In cases like this I recommend a quick rinse with an unpreserved lubricant before inserting

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The Seven Vital Facts you need to know about Keratoconus…but don’t.

the lens in the eye. By rinsing the lens with an unpreserved solution before insertion, this dilutes most of the preservatives off the lens after the overnight disinfection process and therefore they do not then have the opportunity to cause an adverse reaction. Remember what we said before. Many patients with keratoconus suffer with allergies and are therefore more sensitive to irritants. Unfortunately the very solutions that are keeping away infections from our eyes can also cause an allergic or toxic reaction. The procedure as described before though is not too difficult and often creates significant improvement in comfort, leading to successful contact lens wear.

5. One step cleaning solutions are not a good idea
When I start a contact lens patient on a cleaning system I try to keep it simple, but not too simple! Many solutions today are promoted as “one step” and “no rub”. For rigid gas permeable lenses I believe these types of solutions just do not make any sense. These types of lenses normally have a life expectancy of at least twelve months. It is important to rub them with a detergent based cleaner. The cleaner then needs to be rinsed off with saline and then the lenses need to be soaked in a preserved conditioning solution overnight. Often a protein cleaning drop also needs to be added to the conditioning solution to keep the lenses squeaky clean. Unfortunately many patients are lured into the easier “one step” “no rub” solutions, innocently thinking that their lenses will be cleaned properly. This is not the case and significantly will shorten lens life and cause eye irritations in many patients. It is a bit like saying to wash your hair only with conditioner and never use a shampoo. You will look like a drowned rat in no time.

6. Your optometrist should professionally polish your contact lenses
This is very important when keratoconic contact lenses are involved. Your practitioner should be pre-booking you at least every six to twelve months. Remember this: most people that have keratoconus are nearly 100% reliant on their rigid gas permeable contact lenses. Often glasses do not work very well and consequently contact lenses are worn during all waking hours, seven days per week. Professionally polishing rigid gas permeable lenses using aluminium oxide is an often forgotten but extremely effective troubleshooter. Despite your best efforts in cleaning, rigid gas permeable contact lenses can either deposit with natural tear secretions or lose their wet-ability. Both of these circumstances can cause significant discomfort and fluctuating visual quality.

Once the lenses have reached this state there are really only two options: 1. Throw the lenses away and buy a new pair

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The Seven Vital Facts you need to know about Keratoconus…but don’t.

2.

Professionally polish the lenses and resurrect them.

By polishing the lenses, their surfaces are returned to their original pristine condition and you can once again wear the lenses comfortably. Polishing rigid gas permeable contact lenses is a specialized activity. If not done properly the surface of the contact lenses can be burnt and the lenses are then ruined. I also do not recommend polishing the lenses more than twice, as the lenses slowly lose their durability and can split in the process. It is therefore imperative that you have a spare pair of lenses before offering your current lenses for polishing. Remember it can take up to ten days to manufacture another set of lenses, so having a spare pair is always a great insurance policy.

7. Keratoconus specialists are far and few between
At the beginning of this report I mentioned the prevalence of keratoconus in the general population is only 1/2000. In a country the size of Australia there are therefore only about 10,000 people that have clinically significant keratoconus. There are approximately 3,000 optometrists in Australia so if patients with keratoconus were even distributed every optometrist would only have 3 keratoconic patients to look after. No optometrist in the country could possibly develop any expertise in this area. The good news is that there are approximately twelve to fifteen optometrists around the country that look after many keratoconus patients. The bad news is that they are all in the capital cities of Australia, so if you live in a rural area there is a good chance you have to travel to get expert attention. If you read this report and have or know someone with keratoconus that is having a difficult time, I invite you to contact me via email at: jim@theeyepractice.com.au If it is too difficult to see me in Sydney, I will direct you to your nearest keratoconus specialist quick smart. With the appropriate care you will get an action plan into place quickly and efficiently. In no time at all you will wonder what all the trouble was about.

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The Seven Vital Facts you need to know about Keratoconus…but don’t.

About the Author:
Jim Kokkinakis is well known amongst his peers as an expert in contact lens fitting and troubleshooting. Many colleagues refer their patients to Jim’s practice in the Sydney CBD. Over the years he was worked alongside world famous contact lens fitters and excellent ophthalmic surgeons. In 1986 Jim developed a special interest in complicated contact lens fitting and slowly but surely it became a hobby and passion. Over the years Jim made it his mission to investigate all there is to know about the idiosyncrasies of contact lenses – what makes them work and what makes them not work. It became apparent that to succeed in contact lenses one must have a good medical knowledge of the eye, a good understanding of the patient’s lifestyle, environment and expectations, an up do date approach in contact lens materials and cleaning systems and last but not least, invest in the latest technological instruments so that even the most subtle changes can be measured in visual function and eye health. The mainstay of keratoconic treatment is rigid gas permeable contacts. Because of this Jim has seen many hundreds of keratoconus patients and, over time, has kept up to date with the latest research and thoughts in this area. You’re welcome to visit his blog at: http://conicalcornea.blogspot.com/ where he discusses issues about keratoconus. In 2007 Jim Kokkinakis and an eye surgeon will begin writing a text book called “Keratoconus” which they hope will raise the awareness of the eye-care practitioner to a higher level and therefore translate into better care for people that have the condition. Currently he is a member of a number of optometrical associations, lectures at both an undergraduate and post graduate level at the University of NSW and since 2000, has been elected as one of only 40 full members of The International Society of Contact Lens Specialists. As you can see Jim has been around the block a few times. This report is his way to share his experiences with you and help you continue to enjoy and participate in life. Keratoconus is an inconvenience not a life sentence.

Jim Kokkinakis The Eye Practice Mezzanine Level 44 Market Street Sydney NSW 2000 Phone: 02 9290 1899 Email: jim@theeyepractice.com.au Web: www.theeyepractice.com.au

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