CRU 2025: Updates in keratoconus management with Dr. John Gelles

John D. Gelles, OD, FIAO, FCLSA, FSLS, FBCLA Image credit: Intrepid Eye Society

John D. Gelles, OD, FIAO, FCLSA, FSLS, FBCLA, and Melissa Barnett, OD, FAAO, FSLS, FBCLA, discussed keratoconus, highlighting its progression during pregnancy and the importance of advanced diagnostics like tomography during the CRU 2025 in Napa, California. They emphasized practical management strategies, including scleral lenses and cross-linking. Future advancements in biomechanics, genetics, and CTAK procedures were also discussed, aiming to improve keratoconus management and patient quality of life.

Gelles sat down with Optometry Times to provide tips to eye care providers about providing the best care for patients with keratoconus.

Transcript:

Editor's note: The below transcript has been lightly edited for clarity.

Jordana Joy:

Could you give a general overview of your presentations and then a couple of pearls that you can take away?

John D. Gelles, OD, FIAO, FCLSA, FSLS, FBCLA:

Yeah, so for the keratoconus talk, me and Dr Barnett put together essentially just common questions that we're asked about keratoconus. So everything from myth-busting to practical advice. Like one of the the common ones is, do patients who have keratoconus and are pregnant, do they actually progress? And the answer to that is yes, actually they do. There was a very good study that actually looked at a control group versus a keratoconic group who were both pregnant, following them over time. And what they found was 100% actually of the keratoconic group got worse during pregnancy. So, keratoconus, because of the changes in the various different hormones that are released during pregnancy, do change the the corneal composition, and then thus allow for progression to happen. So a very interesting lecture, and the nice thing about that lecture is we keep it very conversational. It's not just us sitting there, peppering everybody with facts and just background information. This is really focusing on being practical.

So one of the things that comes out of this too is looking at the pediatric population, right? There was a study that [the International Council of Ophthalmology, or] ICO and the International Keratoconus Academy did, looking at pediatric patients that came in for eye exams and screening them with a tomography device, the Oculus Pentacam, and basically using a multi metric analysis on there to be able to determine a patient with a normal cornea, a patient with a suspicious for keratoconus cornea, and somebody who just has flat out keratoconus. And what we found in that study was there was a prevalence of 1 in 330 or so individuals in that. So that's significantly more prevalent than what has previously been stated, but that really comes down to having advanced diagnostic equipment, but that that is where the pearls are in this right? Like, we have cross linking available now, which can stop the progression of this disease. So it's now extremely important to find this disease before it really starts stealing vision from these individuals. So the way that we do that is by employing advanced diagnostic instruments to be able to catch this at its earliest point, and then being able to make it actionable with cross linking. And so these are the little pearls and tidbits there.

And then looking at patient quality of life, we know that keratoconus, depending on severity, does drastically affect their quality of life. And when you look at patients who have more severe keratoconus, it impacts them even more. But there are some good studies that look at various types of intervention and how that improves quality of life. And one of those happens to be that we focused on in the lecture isscleral lenses. These patients see a vast improvement in their quality of life. And that's also, you see an improvement in their quality of vision, they also have a correlated improvement in their quality of life. Multiple studies kind of go over the advantages of giving these patients contact lenses, but there are some that even look at what quality of life improvements you get from cross linking, or other sorts of surgical intervention. So very, very practical, in the same sort of vein, current, relevant, useful, giving these practical tips on how to manage care, right?

Joy:

So you had mentioned the advanced diagnostic equipment. For a practice that may not have that equipment, what tips would you have to at least still be able to help the patient to the best of their ability?

Gelles:

So, the thing is is that there are certain things in the workup, in the exam that should give you a suspicion that maybe this patient may have keratoconus. You know, obviously the big one is if they have a history of keratoconus, we know that's the largest risk factor for it. The second one on that is obviously eye rubbing, but then you're looking at the other associated diseases, which are the, for lack of a better term, the itchy, wheezy diseases. So things like, eczema, atopic dermatitis, asthma, apnea, those sorts of things are highly correlated with it. So, you know, keep that in the back of your head. The other ones that we're looking at are going to be genetic diseases, right? So, ... keratoconus has a ... larger prevalence in patients with Down syndrome. So, there are certain conditions that we should really go, "Oh, okay, well, this is something that I should definitely screen."

The other side is looking at the clinical symptoms and what they're telling you from their general experience, right? "Oh, I've seen a lot of doctors. Nobody's been able to give me good vision." That right away should give you a flag like, right? Our colleagues are very talented. They're all very good at this. If they're not able to give them good vision, it's because we haven't quite dug deep enough into why they're not getting good vision. So, lots of remakes on glasses, if they're telling you that, "Hey, my nighttime vision seems to be poor." And alsocorrelating age to visual acuity, right? Anybody, I would say, under the age of 45 should be able to rattle off a crisp 20/20, very, very quick and easy. If you have a patient who's doing a lot of pausing, a lot of, "It could be a B, could be an S, could be," those are the sorts of patients that you should start thinking, "Oh, there may be something else going on here," especially in the absence of other obvious disease. Those patients should have corneal topography or tomography done. And if you don't own that technology, you should refer to one of your colleagues who does.

The other things clinically that are very important is looking at their manifest refraction. One of the things that we found in one of our studies was 2 very important things, which was that k values were not actually associated with the severity of keratoconus until the severity was very severe, like greater than 60 diopters. The other side of this was also looking at manifest refraction. Were there any patterns that we saw? And we saw in any level of keratoconus, against the rule, an oblique astigmatism over 2 diopters were associated with keratoconus at any level, so mild, moderate, or severe. So this was really impactful. So again, just keep these tips in the back of your head, that this should be raising red flags for you to say, "Oh, I should probably get a topography on this individual," right, And the big thing on this is comanage these patients, if you're not willing to make the investment into these technologies. And if we look at gold standards, tomography being the gold standard, topography being very good as well,tomography, you're going to be able to find it even sooner.

Joy:

So in the next, say, 5 or 10 years, what would you like to see in terms of development, movement, growth in keratoconus management?

Gelles:

So that's going to be an interesting one. I think you're going to see a lot in development of biomechanics. Outside of the US, biomechanics have been used quite a bit for determining a weak corneal structure, right? Like we know patients that have normal corneal structure – shape, rather – doesn't necessarily mean that they have normal corneal strength, right? So our ability to determine that somebody has a weak cornea before they start showing signs to or changes to their corneal structure or shape, that's going to be very important in the future, because it's going to help us manage these patients better. It will also help us select refractive surgery patients more appropriately as well. But we're going to see newer technologies come in in the US, specifically Brillouin microscopy, which has just been approved, something that we're working with in our center as well.

And then the other side of this will be to see what happens with genetics. The genetic component of this, we know it exists, we know it's poly genetic. We know that these are a condition that is not straightforward in the genetics. But I think if we can come up with a better use case, there may even be some level of, at some point, a genetic-based treatment, once we totally understand the genetics around this, and maybe even a recommendation. There may be more than, "Oh, this patient may have keratoconus." There may be a genetic risk factor that we identify that says these patients are more likely to progress or progress faster, or to develop more severe keratoconus or those sorts of things that may make application of cross linking at earlier times, things more more actionable.

The other thing that we see is a newer technology in this, is CTAK, which is a corneal tissue addition keratoplasty, where you're adding corneal tissue to the keratoconic cornea to be able to reshape it. I think what you're going to start seeing is that this gets more adopted, and this addresses not just the corneal shape, but in turn, the visual correction of the individual. So you'll have cross linking for progression, you'll have CTAK for vision Improvement, and contact lenses for best corrected vision.

And when we look at this, I think one of the things, if I could leave anybody with a tip on this, is that we need to look at our patients with keratoconus is having 3 distinct types of vision. They have their uncorrected vision, their spectacle-corrected vision, and then their contact lens-corrected vision. And their contact lens corrected vision can be wonderful. You know, you may be able to correct an individual the 20/20 but if they take their lenses out and they put their glasses on and they're only 20/200, that individual doesn't live a functional lifestyle with those glasses. So imagine being a -6 myope, taking your contact lenses out and then putting your glasses on and still not being able to see, right? So, this is something where you need these other techniques, like CTAK, to be able to improve their vision in their glasses, improve their uncorrected vision, and you'll still get the best corrected vision out of the contact lenses. But if you can improve their visual acuity uncorrected and with their glasses, this now allows them to lead a functional lifestyle without having to rely on the contact lenses. And then, reshaping cornea really opens up the options for "refractive surgery" for these individuals. What I mean by that is now you can do a lens-based procedure to improve their vision. So let's say, we do a CTAK procedure, it gives us much better keratometry values. It gives much better refractive values to work with. Then, if we do, you know, an ICL or an IOL for this individual, we're going to get much better results with that, which then may be able to eliminate the need for glasses. They may still need the contact lens to give them the absolute crispest vision, but it would be something that would be able to give them more functional vision without anything, and really showing an improvement in quality of life. So this is, this is really impressive.