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A primary focus of our practice is the care of the keratoconus
patient. As evidence of that commitment, Dr. Epstein serves as Vice President
for the Center for Keratoconus and on the Medical Advisory Board for the
National Keratoconus Foundation. Dr. Epstein also writes Ask the Doctor,
a regular column for the NKCF Newsletter.
Our strong focus and success in managing keratoconus draws patients from as
far away as Europe, Africa, Asia and South America. However the majority our
keratoconus patients come from the NY Metropolitan area. We have extensive
experience in treating keratoconus and one of the largest keratoconus
practices in the United States. Feel free to contact us if you require
information beyond what you find here or in the
Keratoconus Links offered at the bottom of this
page. For detailed information about keratoconus read Dr. Epstein's text
in PDF format: Keratoconus & Related Disorders.
 What is Keratoconus?
Keratoconus is a disorder that causes progressive thinning and distortion of
the cornea - the clear dome at the front of the eye. The cornea normally has a
rounded shape, but in keratoconus the thinned area bulges forward to
produce a cone like protrusion. This results in progressive distortion and reduced
vision. Many keratoconus patients experience blurred distance vision, glare, light
sensitivity, disturbed night vision, headaches and reading problems, Keratoconus
may affect only one eye but more commonly occurs in both eyes. It affects
people of all races and both sexes. Most patients develop keratoconus in their
late teens to early twenties although it can begin at any age. Pellucid
marginal degeneration (PMD) is a corneal thinning disorder related to
keratoconus that primarily affects the inferior cornea.
Establishing the Diagnosis
Patients who develop keratoconus often experience reduced vision as a first
symptom. Nearsightedness and astigmatism (irregular curvature of the eye)
are often the first signs of the disorder. Frequent prescription changes
are another common sign of keratoconus. Before computerized corneal topography
became available, it was sometimes difficult to establish a diagnosis of
keratoconus, especially if the practitioner was not familiar with the early-stage symptoms
of the disease. The classic signs of keratoconus include:
Fleischer's ring (an iron colored ring surrounding the cone), Vogt's striae
(stress lines caused by corneal thinning) and apical scarring (scarring at the
apex of the cone).
 
Corneal topography has facilitated the diagnosis of keratoconus, helping
establish the diagnosis earlier, follow progression more accurately and
differentiate keratoconus from other conditions.
 
Typical Keratoconus Topography Pellucid Marginal Degeneration
What Causes
Keratoconus?
No one really knows what causes keratoconus. We do know that
keratoconus runs in families and that many patients who have keratoconus report
vigorous eye rubbing. Many patients with keratoconus also have allergies,
but the link to allergic disease also remains unclear. Two theories for
keratoconus have been proposed:
- Keratoconus corneas are more easily damaged by minor trauma such as eye
rubbing.
- Keratoconus corneas lack the ability to self-repair routine damage easily
repaired by normal corneas.
Although contact lenses have been suggested as a possible cause of
keratoconus, this has not been proven and remains questionable. We advise
patients with keratoconus to avoid eye rubbing as much as possible. Cold
compresses applied to the eyes are helpful. Newer anti-allergy medications
such as Patanol or Zaditor are also useful in managing itch and eye rubbing.
Treatment Options
We are great believers in conservative treatment. In the mildest form of keratoconus,
eyeglasses or soft contact lenses often provide adequate vision. As the disorder progresses and the cornea
becomes increasingly distorted, specially designed soft lenses, hybrid
rigid-soft (Softperm) lenses or the recently introduced Epicon lens will often
work well.
In more advanced keratoconus, rigid gas permeable contact lenses are usually
the best choice for visual rehabilitation. There are numerous contact lens
designs used to treat keratoconus and pellucid marginal degeneration. The
Rose-K is an
example of an exceptional and flexible lens design originally introduced by New
Zealand Optometrist, Dr. Paul Rose. However, the key to a successful
contact lens fitting isn't as much the lens as it is the skill and
experience of the contact lens fitter. Fitting contact lenses on a keratoconic cornea is delicate
and time-consuming. You can expect frequent return visits to fine-tune the fit
and prescription. In some cases the process can take many months. For many
patients it is also a continuing process which begins all over again as the
condition progresses.
Fitting patients with PMD can be challenging. In the early stages, the
central cornea is regular although highly astigmatic. Custom soft toric contact
lenses will often provide adequate performance and safety. As the
condition advances, specialized rigid lenses provide viable options.
Improperly fitted contact lenses can cause extensive damage to the cornea and
can ultimately lead to a corneal transplant. Contact lens fitters should be
selected on the basis of experience and commitment to aiding keratoconus
patients. Having a corneal topographer and several keratoconus contact lens
trial sets available in the office are a positive sign.
  
If your cornea can't tolerate a rigid contact lens, or contact lenses no
longer provide acceptable vision, the next step is surgery; either newer INTACS®
ring segment inserts or a traditional cornea transplant, also
called a penetrating keratoplasty. We work closely with several leading corneal
surgeons if the need arises. However, even after a transplant, you most likely will
need eyeglasses or contact lenses for clear vision.
Insurance Information
Keratoconus and PMD are medical conditions for which contact lenses are a
medically appropriate and necessary treatment. Although we are unable to accept
direct assignment of your insurance, we will assist you in obtaining coverage as
much as possible. You should be aware that many managed care plans specifically
exclude coverage for contact lenses regardless of necessity.
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