Collaborative Case #009: Two Cases of Keratoconus

This Case Report is Interactive!

Challenge your understanding of diagnostic and treatment conventions by entering your answers to the questions below. Follow @collaborativeeye on Instagram for more cases like this.

Case Presentation

Keratoconus is a condition that is often progressive. Young patients are known to be at high risk for progression, and there is evidence that supports performing corneal cross-linking (CXL, Glaukos) in children upon diagnosis rather than waiting for progression. Additionally, patients who have had LASIK and who have been diagnosed with post-LASIK ectasia are also at high risk for progression of keratoconus, which is why the FDA clinical trial for CXL) did not require patients with ectasia to have documented progression before enrolling them in the clinical trial that led to the FDA approval of CXL.

For patients with keratoconus who are older, some believe that the condition is unlikely to progress. However, we have found that the risk for keratoconus progression in patients 40 years of age and older is actually higher than what was believed. In a paper presented at the CXL Experts Meeting in December 2022, we found the 41% of patients with keratoconus who were 40 years of age or older had progression of their disease before undergoing CXL when followed for 6 months or longer.¹

Case #1

Figure 1. This 48-year-old female with mild to early moderate keratoconus OD had a K Max reading of 52.0 D.

The patient was advised that they were eligible to be enrolled in a clinical trial for CXL in 2010, but she opted to wait. A follow-up appointment was scheduled for 6 months later, but the patient did not return for 12 years. Now, at age 60, the patient has repeat corneal mapping and progressive keratoconus. Additionally, her KMax reading worsened from 52.0 D to 58.0D (Figure 2), which means she has been progressing approximately 0.5D per year.

Figure 2. Comparison of KMax scores showing progressive keratoconus for a patient who was lost to follow-up for 12 years.

At this point, the patient opted to move forward with CXL, and we expect that she will do quite well with stabilization of the corneal shape, and in many cases, improvement in the corneal shape.

Case #2

In this second case, a 79-year-old male with bilateral keratoconus, more severe OS, and mild cataracts presented for evaluation (Figure 3). The patient wondered whether CXL might help improve the corneal shape prior to undergoing cataract surgery.

Figure 3. Corneal mapping of this 79-year-old patient revealing his bilateral keratoconus and cataracts.

The patient opted to have CXL in both eyes. Although previous corneal maps were not available, the patient had changes in his refraction that qualified them for insurance coverage of the CXL procedure. He returned 11 months later, on September 8th, 2023, and both eyes demonstrated significant improvement in their corneal shape. The difference map in the right eye demonstrates that the steep part of the cornea flattened, while the flat part of the cornea steepened.

Figure 4. The difference map in the right eye shows the 11-month results of CXL in this 79-year-old patient.

Figure 5. The difference map in the left eye shows that there is general flattening of the corneal shape comparing October 2022 to September 2023.

CONCLUSION

These cases demonstrate that older patients with keratoconus can progress and that older patients (ie, those in their 70s and 80s) can benefit from CXL, either before or after cataract surgery (Figures 4 & 5).

William B. Trattler, MD

- Director of Cornea, Center for Excellence in Eye Care, Miami

wtrattler@gmail.com

- Financial disclosures: Consultant (Glaukos, CXL Ophthalmics, Oculus Optikgeräte)

Ready for another case?

View all Collaborative Cases »
Follow @collaborativeeye on Instagram for new cases.

ABOUT THIS SERIES

On the path from initial diagnosis to severe disease management, patients may encounter a number of eye care providers. The Collaborative Care Case Series was developed, with guidance from William Trattler, MD, and Diana Shechtman, OD, FAAO, to challenge clinicians' understanding of diagnostic and treatment conventions and advance knowledge of all eye care providers along the continuum.

Scroll back to top

Ready to Claim Your Credits?

You have attempts to pass this post-test. Take your time and review carefully before submitting.

Good luck!