Varun (name changed) came to my clinic with a history of blurred vision. He faced glare at night while coming home from tuition on his cycle; he faced severe eye strain, and his spectacle power values kept changing every three months, which was unusual.

He had been wearing eyeglasses and checking his vision every six months, but the numbers kept changing lately. He realised that the clarity became better when he rubbed his eyes, and it became a habit.

He tried every possible solution, from getting blue-cut lenses to anti-reflective coating lenses to photochromatic lenses. Nothing worked. Eventually, the optician sent him to me.

I performed a visual acuity test with a dilated refraction in a dark room. I observed that his cylindrical power was way high, indicating astigmatism. Astigmatism is a condition that causes blurred vision due to the steep corneal surface.

His astigmatism worsened rapidly when I compared his previous glass prescriptions. He was in his final year of school. He spent long hours staying awake and peered at his tablet, which contained most of the worksheets and homework. Back in school, his teachers used a smart board to teach, and the classroom lights were permanently switched off.

His cylinder values were over minus 2. And there was a 50-diopter bump from his older prescription. This can be common for most astigmatic children, teens, and young adults. You see their growth hormone levels peak at this age. But what caught my eye was his Keratometry readings.

Keratometry is the value of the corneal curvature, which is routinely assessed by the auto refractometer. Almost all optical shops and clinics have an auto refractometer. They come out as K1 and K2 values.

For example, a K1 value of 45 and a K2 value of 47 are acceptable. But in Varun’s case, K1 was 48, and K2 was 51. This keratometry reading had a very high and wide value. So, I ordered a corneal topography and pachymetry to map his cornea.

Corneal topography is a corneal scan that uses concentric rings of light to map the oval surface of your cornea. Advanced machines use AI to give you a near-perfect diagnosis.

Pachymetry measures the thickness of the corneal tissue layers. His result showed a 90% probability of a condition called Keratoconus.

What is Keratoconus?
Spelt as Ker-Uh-toe-koh-nus, it is a progressive eye condition that causes vision impairment due to an irregularly shaped cornea, which is thin in a particular plane and bulges outward. It belongs to a bunch of diseases that come under corneal dystrophy.

Symptoms
Varun’s complaints were blurred vision, photophobia or sensitivity to light due to glare, frequent spectacle changes and rapid clouding of vision. Typically, the complaints will be observed in late teenagers between 15 – 19 years to 20- 30 years of age.

The world’s incidence of the disease was 1 in 2000. However, with the increase in screen time, this data is increasing at an alarming rate. There is no cause for it. Something which sometimes doctors call an “idiopathic cause” wherein the doctor is an idiot, and the patient is pathetic. But, studies have shown that 1 in 10 have a parent who has had Keratoconus.

However, genetic and environmental factors do play a role.

Who stands at risk?
It’s an autosomal dominant disease. So, you can get it if either of your parents have it and it can also be induced when you rub your eyes as a habit.

Some diseases, like bronchial asthma, share the same gene expression as Keratoconus and can be found in asthmatic individuals. However, the chance is 1%, which is almost negligible.
Another study shows that the occurrence of Keratoconus is as high as 70% in individuals suffering from Down syndrome. These individuals have bodily developmental issues that can cause Keratoconus.

Varun’s parents didn’t have Keratoconus. He mainly acquired it from rubbing his eyes due to extensive, overwhelming screen time.

Complications
Keratoconus may progress fast and cause the cornea to cone rapidly, thinning the outer surface of the cornea called epithelium. In addition to quickly decreasing vision, it can cause scarring of the epithelium.

This condition is called Hydrops. Hydrops needs to be treated immediately, and scarring can be so bad that a corneal transplant might be required.

Diagnosing Keratoconus
It has to be done in an ophthalmology clinic as it requires dilation. The optometrist will do a dilation refraction. The doctor examines the eye for any scarring under a slit lamp biomicroscope.
A corneal topography scan will clinch the diagnosis. Modern topo machines have built-in pachymetry to help the surgeon read further data to evaluate the severity. Normal corneal tissue pachy values range from 530-570 micrometers.

Treating Keratoconus
Treating Keratoconus, or KC as it is known the world over, is to slow down the progression and provide rapid, immediate intervention. Slowing it down involves reinforcing the weak, thin surface of the cornea.

Imagine tissue paper. To make it thicker, you can add layers of tissue to strengthen it. Ophthalmologists perform a procedure called C3R, or corneal collagen cross-linking with riboflavin. This is a non-interventional surgical daycare procedure done under local anaesthesia in an operation theatre. It’s completely painless, and recovery is fast. Visible improvement in visual acuity is noticeable.

Treatment is based on its severity
Mild to moderate Keratoconus individuals are advised to use glasses and contact lenses. Various types of contact lenses are available, like the Ortho K, which are supplied only to eye clinics. Because they require a precise fitting technique that has to be done under slit lamp microscope examination, an ill-fitting contact lens can worsen the Keratoconus.

Individuals must visit the clinic every six months; a complete reevaluation is mandatory.

In cases that don’t improve with C3r or if there is rapid scarring, a corneal transplant is advised; this is why we ophthalmologists insist on donating your eyes. After removing the scarred cornea, the corneal button or of the donor’s eye is sutured onto the recipient’s eye as a corneal graft. This procedure is called penetrating keratoplasty or PKP.

It is a complex process; sometimes, the eyes reject the corneal graft. Individual corneas can become completely opaque, and they can become blind permanently. Treatment options include invasive and non-invasive methods.

Contact lenses
These are speciality lenses, which, as said before, can only be prescribed by an ophthalmologist.There are soft lenses, but these lenses must be changed frequently as the corneal surface adapts and changes.

Next is a customisable hard contact gas permeable lens (RGP lens). They give excellent vision clarity but are initially uncomfortable but adaptable as time passes. Sometimes, when the hard lenses are uncomfortable, they can be stacked over a soft lens.

Other options are hybrid lenses, which have a soft outer curvature and hard centre for those who cannot tolerate hard contact lenses.

Finally, scleral contact lenses, wherein the lens’s outer curvature rests on the white part of the eye called the sclera to cover the cornea instead of applying pressure on the corneal-scleral margin called the limbus.

Surgeries for Keratoconus
INTACS is a procedure in which the surgeon inserts a crescent-shaped silica ring into the cornea via a microscopic cut under local anaesthesia. The ring is then sutured. INTACS only works for mild to moderate Keratoconus. In advanced stages, a corneal transplant is done, but again a very complex process and risks include graft rejection.

Catch it early
It reinforces early diagnosis and intervention. If you suffer from Keratoconus, join a Keratoconus community to discuss how everyone deals with contact lenses or the grafting procedure.

Don’t think of it as an impediment. Basketball stars like Stephen Curry of the Golden State Warriors Team are still dunking basketballs while wearing contact lenses. If you loved the TV series Homeland and the movie Princess Bride, actor Mandy Patinkin managed to act in all the blinding studio lights to give a performance of a lifetime. If they can do it, you can do it too. Just don’t rub your eyes.