BLOG: Keratoconus provides opportunity to affect the whole person
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We have known for a long time that keratoconus has a negative impact on quality of life.
In fact, the impairment of vision-related quality of life in keratoconus (KC) is similar to that of patients with severe age-related macular degeneration (Kymes S, et al) and may seem disproportionate to the degree of vision loss (Durakovic E, et al).
Unlike AMD, keratoconus develops during the teen and young adult years — a stage in life when the disease itself may affect personality development, coping mechanisms, behavioral patterns and relationships with caregivers, including doctors (Mannis M, et al).
A diagnosis of KC just as individuals are maturing, one major review notes, “may affect job prospects, life aspirations and quality of life, and in turn may potentially have a marked impact on the mental health of those affected” (Durakovic E, et al). These effects likely contribute to what many doctors perceive as patients with KC having a “difficult” personality.
Keratoconus, mental health connection
Several studies published in the past year have looked closely at the relationship between KC and mental health, finding that KC is associated with depression, anxiety and other psychiatric comorbidities (Durakovic E, et al; Alfardan F, et al) and that male patients with KC are more likely than the general population to be diagnosed with ADHD (Safir M, et al).
The ADHD connection, identified in a population of nearly 1 million Israeli adolescents and adults, seems odd at first. What could be the connection between KC and ADHD? An accompanying editorial suggested that perhaps people with ADHD are more likely to engage in repetitive eye rubbing, which is strongly associated with KC, as a chronic stress response, because they are more sensitive to itch sensation or are less able to control their response to itch (Woodward MA, et al).
Interestingly, I have a couple of male keratoconus patients who have been treated for ADHD and other behavioral disorders. Once these patients underwent iLink cross-linking (Glaukos) to stabilize their corneas and I was able to improve their vision and depth perception with scleral lenses, they were able to go off medications for ADHD or other therapies for mental health and even saw improved outcomes in school, sports and other activities of daily living.
So it is also possible the association runs in the other direction — that poor vision is contributing to behavioral problems, which can compound or be misdiagnosed as ADHD.
ODs can make a difference
As optometrists, we have a chance to make a positive impact on our patients who have KC, in a number of ways. First, remember that seeing 20/20 best-corrected in the office doesn’t necessarily correspond to full visual function. Patients’ vision may be much worse with poor lighting or contrast; they may not be able to wear contact lenses for significant portions of time; and good visual acuity doesn’t reflect the cost, time and anxiety involved in managing specialty lens wear.
Consider incorporating questionnaires that evaluate KC patients’ mental health, not just their vision. Durakovic and colleagues provide a list of such resources, which include the National Eye Institute-Visual Function Questionnaire-25, Beck Anxiety Inventory and Zung Self-Rating Depression Scale. Eye care providers should consider asking patients about their mental and emotional well-being and provide a referral for therapy if necessary.
Most importantly, as eye care providers, we have a duty to detect progressive KC at its earliest stage, recommend FDA-approved iLink CXL and optimize vision with all the specialty lens products available to us. If we can be better detectives, we have the opportunity to potentially intervene before KC can create significant mental health challenges.
References:
- Alfardan F, et al. Cureus. 2023; doi:10.7759/cureus.42141.
- Durakovic E, et al. Cornea. 2023;doi:10.1097/ICO.0000000000003263.
- Kymes S, et al. Am J Ophthalmol. 2004;doi:10.1016/j.ajo.2004.04.031.
- Mannis M, et al. Cornea. 2018; doi:10.1097/ICO.0000000000001479.
- Safir M, et al. JAMA Ophthalmol. 2023;doi:10.1001/jamaophthalmol.2023.5176.
- Woodward MA, et al. JAMA Ophthalmol. 2023;doi:10.1001/jamaophthalmol.2023.5283.
For more information:
Gloria Chiu, OD, FAAO, FSLS, is an associate professor of clinical ophthalmology at Keck School of Medicine of University of Southern California. She can be reached at gloria.chiu@med.usc.edu.
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