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Corneal collagen cross-linking: A paradigm shift in keratoconus
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The French philosopher Voltaire once quipped, “The art of medicine consists in amusing the patient until nature cures the disease.” Ouch. As someone who toils daily at enhancing vision and eradicating ocular disease, I find Voltaire’s assertion a bit offensive. However, bruised ego aside, there is some truth in his words. Take keratoconus, for instance.
Since my early days with Drs. Robert Morrison and James Aquavella, I have been immersed in keratoconus. I learned quickly that the complexity and demands of keratoconus patients are diametrically opposed to running a busy, efficient practice. In other words, if you are seeing 25 to 30 patients daily, you do not want all of them to have keratoconus.
For this reason, I have taken to reserving a fixed number of daily appointments for keratoconus. Even so, between my office and the University of Rochester resident’s clinic, I still see more than 700 keratoconus visits per year. Some are young, emerging keratoconus patients, while others have been with me for 3 decades. Just what has this diverse demographic taught me through the years? Voltaire may very well have been correct.
For those who see their share of keratoconus patients, you know exactly what I mean. A primary, idiopathic keratoconus patient may initially present in their late teens or early 20s and, over the ensuing 10 to 20 years, progress. Rapidly.
During that time, we frantically manage the course of disease with a variety of contact lenses, running the gamut from specialty design soft lenses to complex scleral designs. We caution patients against eye rubbing, discuss complementary alternative medicine strategies and employ topical antihistamines, mast-cell stabilizers and corticosteroids ... all in the name of quelling ocular surface inflammation and mitigating keratocyte apoptosis.
Despite our best efforts, some ultimately require Intacs (AJL Ophthalmic), deep anterior lamellar keratoplasty or even penetrating keratoplasty. Fortunately, if we (collectively) weather the storm, something magical happens. Patients return less frequently, require fewer prescription changes and seem pretty content. In essence, as Voltaire would say, nature cures the disease. Maybe, but not entirely.
Clearly, keratoconus does not disappear. However, after many tumultuous years it does seem to plateau. Much like other connective tissues, corneal collagen seems to naturally stiffen as we age. While it’s not clear whether this protein oxidation is brought about by UV exposure, aging or other etiologies, it is clear the cornea naturally cross-links, and with cross-linking comes keratoconus stabilization.
Over the past decade, the eye care community has done much more than merely amuse our keratoconus patients. Rather, we have taken an aggressive approach to simulating nature’s corneal cross-linking ways ... but in a more controlled and timely fashion. We are embracing newer technologies for quicker differential diagnosis and employing cross-linking in an effort to arrest the disease in its earliest stages – all in an effort to ensure patients a better life than if we allowed nature to cure the disease.
In this month’s Primary Care Optometry News, our feature article, “ODs recognize benefits of corneal collagen cross-linking” details the latest advances in this technology as it relates to keratoconus and other ectasias. I am sure you will agree corneal cross-linking represents a paradigm shift in the way in which we will care for future generations of keratoconus patients – a paradigm shift I am sure even Voltaire himself would find more than amusing.
Disclosure: DePaolis reports no relevant financial disclosures.