Which is Best for Keratoconus — Surgery or Contact Lenses?

Which is Best for Keratoconus — Surgery or Contact Lenses?

by Brian Chou, OD, FAAO, FSLS

  • May 15, 2022

If you have keratoconus, is surgery or contact lenses your best option? The answer depends on your individual case of keratoconus. Some keratoconus patients need both surgery and contact lenses. Yet there are situations where neither surgery nor contact lenses is needed. Learn the important considerations that determine what is best for you.

Surgery Can Stabilize Disease Yet It Does Not Fully Restore Vision

The leading surgery for keratoconus today is iLink corneal cross-linking (CXL). This received FDA approval in April of 2016 to slow or halt progressive keratoconus. An important concept is that CXL does not predictably change vision. Often, the vision after CXL is like what you had before. But CXL sometimes improves vision and sometimes it worsens it. The over-whelming majority that has CXL still require rigid surface contact lenses afterward to obtain the utmost clarity of vision. Slowing or halting progressive cornea distortion through CXL can arrest the disease in a milder state, minimizing the risk of corneal transplantation. Thereby, the benefit of CXL is gaining reassurance of knowing that you are doing everything possible to keep the disease in its current state.

Progression of keratoconus is common during the teenage years to early twenties. For most, keratoconus arrests on its own by the third to fourth decade of life. As an example, if you have keratoconus and are in your sixties (when the disease is commonly stable in its own) CXL may not hold value. If it is not obvious whether your keratoconus is progressing, your eye doctor may recommend monitoring every few months.

Contact Lenses Can Optimize Vision and Do Not Stabilize Keratoconus

The gold standard for restoring vision for keratoconus is a rigid-surface contact lens. The rigid surface provides a smooth light-bending surface over the distorted cornea, thereby enabling clear vision. Soft contact lenses drape over the irregular cornea in keratoconus and do not adequately reduce the eye’s complex visual aberrations. Eyeglasses are also ineffective at reducing the asymmetric visual aberrations of keratoconus. Finally, corneal surgery – including corneal cross-linking, Intacs, lens implantation and corneal transplantation – similarly do not provide a light-bending surface as smooth as a rigid-surface contact lens. That is why there is no surgery now that optimizes vision as well as a rigid-surface contact lens, like a scleral contact lens. While it is possible for CXL, Intacs, and corneal transplantation to improve vision of the bare-naked eye, you can realistically expect to still need a rigid-surface contact lens afterwards to enjoy the best possible vision.

Decades ago, some eye doctors believed that hard or rigid contact lenses would retard the progression of keratoconus by holding the shape of the eye in place like a girdle. This notion is now known as false. Keratoconus can still progress if you are wearing contact lenses. In fact, there is evidence that corneal scarring is associated more in keratoconus patients wearing rigid contact lenses that mechanically interact with the apex of the distortion. One of the benefits of scleral contact lenses is that they are designed to avoid touching the sensitive corneal surface, minimizing the potential risk of corneal scarring.

Surgery or Contact Lenses for Keratoconus?

As you can now understand, this article’s titular question is a false choice. Most patients with keratoconus – except for those with the mildest corneal distortion – need custom rigid-surface contact lenses for the best vision. In addition, patients with progressing keratoconus, usually in the teenage and early 20s, benefit from CXL to slow or halt any increasing corneal distortion. A well-educated keratoconus patient should not expect CXL to restore vision.  However, it is reasonable to expect FDA-approved iLink CXL to prevent further deterioration in progressive keratoconus. To regain vision lost to keratoconus, your ticket is almost always a special rigid-surface contact lenses, not surgery nor eyeglasses.

ReVision Optometry in San Diego is a referral-based practice providing medical contact lens services for patients with keratoconus and other complex eye conditions.  Request an appointment online or call 619.299.6064.