Keratoconus patients can now benefit from cutting-edge treatments, including corneal cross-linking and advanced surgery. Dr. Mitch Eibach shares how early intervention can preserve vision and improve quality of life.
Keratoconus is a vision disorder in which the normally dome‐shaped cornea gradually thins and bulges into a cone shape. This abnormality distorts incoming light, leading to blurred and irregular vision. In the past, patients were limited to monitoring the progression and relying on specialty contact lenses or glasses. Today, however, new treatment options—most notably corneal collagen cross‐linking (CXL) and advanced surgical techniques—are revolutionizing the prognosis for those affected by keratoconus.
In a recent in‐depth discussion, Dr. Mitch Eibach, a South Dakota–based optometrist with extensive experience in both clinical trials and anterior segment care, explained how recent innovations have transformed the management of keratoconus. Throughout the conversation, Dr. Eibach stressed the importance of early detection, patient education, and a proactive approach when it comes to intervening before the disease causes irreversible vision loss.
Under normal conditions, the cornea is smooth, evenly curved, and approximately 550 microns thick. However, in keratoconus the structural integrity of the cornea is compromised because of abnormal collagen arrangements. The collagen fibers lose their interlinking support, making the cornea “floppy” and prone to progressive thinning and bulging. As the cornea deforms, patients typically develop myopia (nearsightedness) accompanied by irregular astigmatism that is difficult to fully correct with standard glasses or soft contact lenses.
Dr. Eibach explained that keratoconus typically presents during the late teens or early twenties, and while many patients still have the opportunity to achieve good vision correction with specialty contact lenses, the disease’s progression in some cases may eventually require surgical intervention. Key symptoms include blurred vision, glare, halos (often described as “ghosting” or tails on vision), and rapidly changing prescriptions.
A major breakthrough discussed by Dr. Eibach was the introduction of corneal collagen cross‐linking (CXL). Approved by the FDA in 2016 for progressive keratoconus, the traditional (“epithelium‐off”) Dresden protocol has fundamentally altered patient management. With CXL, riboflavin (a form of vitamin B2) is applied to the corneal stroma after removing the epithelium (the cornea’s outer layer). Once the cornea is saturated with riboflavin, ultraviolet A (UV-A) light is directed onto the cornea for 30 minutes. This interaction generates free radicals and singlet oxygen that form new covalent bonds between collagen fibers, effectively “stitching” the collagen matrix together and increasing corneal rigidity.
Dr. Eibach emphasizes that the primary goal of CXL is not to improve vision per se but to “freeze” the structural integrity of the cornea and halt further progression of the disease. Studies have shown that patients who undergo cross‐linking can experience not only stabilization, but in some cases even a modest flattening of the cone—improving overall corneal shape.
Although the current FDA-approved protocol requires removal of the epithelium, evolving techniques—such as “epithelium-on” (epi-on) procedures—are under investigation. These non–epithelium removal methods aim to reduce post-operative discomfort and accelerate recovery while still achieving effective cross-linking. However, for now the epithelium-off approach remains the gold standard in the United States.
A crucial part of managing keratoconus is determining the right time for intervention. Dr. Eibach explained that although many insurance companies require evidence of disease progression before approving CXL, from the clinical standpoint waiting for significant worsening may risk irreversible vision loss. For instance, he expressed that in a young patient—especially a child under 10 years of age—it is prudent to perform cross-linking almost immediately upon diagnosis rather than waiting for a full year of progression.
In his view, progression can be defined using key diagnostic measures like changes in the steepest keratometry value (K-max). A change of approximately one diopter (D) over a one-year period is generally viewed as progression. Other red flags include significant, irregular astigmatism (often seen when prescribing glasses or contact lenses) and clinical signs observed via slit-lamp examination. Even basic tools like retinoscopy, which may reveal a distinct “scissoring” reflex, can alert the clinician to an irregular corneal curvature and initiate further diagnostic evaluation.
Early and accurate diagnosis is fundamental. Dr. Eibach highlighted several technological tools that help build a comprehensive picture of corneal integrity and progression:
Together, these tools enable eye care professionals to assemble a “puzzle” that confirms the diagnosis and determines the urgency and type of treatment required.
While cross-linking has become the first-line treatment to halt progression, there remains a subset of keratoconus patients who either do not respond adequately or have advanced disease requiring additional intervention.
One option discussed by Dr. Eibach is the implantation of intracorneal ring segments (ICRS), commonly known as Intacs. These are small, crescent-shaped rings made of inert plastic (PMMA) implanted into the mid-peripheral cornea. The rings help reshape the cornea by flattening the steepest area, thereby improving refractive error and potentially enhancing uncorrected visual acuity. Although Intacs were once a very popular treatment option, their role has diminished somewhat as techniques for cross-linking and contact lens management have improved. Nevertheless, Intacs remain valuable, especially in patients who are contact lens intolerant or cannot achieve adequate vision correction with spectacles.
In more severe cases—where scarring and advanced deformation are present—a corneal transplant (penetrating keratoplasty) may be necessary. However, corneal transplantation is generally reserved as a last resort since there is a high likelihood that patients will still require corrective lenses after surgery. In many cases, the goal of early intervention with cross-linking is to prevent patients from ever reaching the point where a transplant is the only option.
Looking ahead, one of the most promising areas of research is topography-guided corneal cross-linking. This approach uses detailed corneal maps to “customize” the UV-A treatment. By selectively increasing the cross-linking effect on the more ectatic regions, physicians hope not only to halt disease progression but also to achieve a degree of corneal flattening that can improve the optical quality of the eye. Early studies and pilot trials have shown encouraging results; some patients gain as much as one to three lines of best-corrected visual acuity.
Additional procedures, such as topography-guided photorefractive keratectomy (PRK) performed after cross-linking, are being explored with the aim of simultaneously stabilizing and refractively optimizing the cornea. Although these “combined” approaches are still evolving and require further validation, they represent a fascinating frontier in the management of keratoconus.
Don’t wait until your vision worsens. Schedule a consultation with Dr. Mitch Eibach today to explore advanced treatment options for keratoconus. Find a top optometrist near you through Specialty Vision and take the first step towards better eye health!
Dr. Eibach also touched upon the role of genetic testing and environmental factors. While keratoconus is not strictly a “genetic” disease, a positive family history significantly increases the risk. Companies now offer in-office genetic tests that can screen for multiple keratoconus-associated gene variants. These tests may eventually help ophthalmic practitioners decide on more intensive early intervention for high-risk patients.
Furthermore, factors such as eye rubbing—often exacerbated by allergic conjunctivitis—play a key role in disease progression. Patient education is paramount; advising patients on lifestyle modifications, such as avoiding vigorous eye rubbing and managing allergies, forms an essential component of comprehensive keratoconus care.
On the surgical side, several advanced techniques continue to be refined. For example, deep anterior lamellar keratoplasty (DALK) offers a means of replacing the anterior cornea while preserving the patient’s own endothelium. Although technically more challenging, DALK has the advantage of a lower risk of graft rejection compared to full-thickness penetrating keratoplasty. Even newer procedures such as “contact lens-assisted cross-linking” (CACXL) allow clinicians to safely perform CXL in patients with very thin corneas by temporarily swelling the cornea to reach safe thickness thresholds.
What emerges from Dr. Eibach’s discussion is a strong message of collaboration and early, proactive intervention. He remarked, “If your house is on fire, you don’t wait for half of it to burn down before calling the fire department.” Similarly, he advocates for early diagnosis and immediate treatment—especially for young patients—so that irreversible vision loss can be prevented.
The vision care community now has a wealth of diagnostic and therapeutic tools to address keratoconus at every stage. From state-of-the-art corneal topography and tomography to more refined surgical techniques and evolving contact lens technologies (including scleral and hybrid lenses), physicians are well-equipped to tailor treatment plans to individual patient needs. As research continues and new methods become available (such as epi-on cross-linking and customized, topography-guided procedures), the future for keratoconus management looks increasingly bright.
In summary, keratoconus is now managed more effectively through early detection and innovative treatments. Patients experiencing vision changes should seek a comprehensive evaluation, as a tailored, multidisciplinary approach can preserve sight. Ongoing research continues to refine these strategies, offering renewed hope for an improved quality of life.
Don’t wait until your vision worsens. Schedule a consultation with Dr. Mitch Eibach today to explore advanced treatment options for keratoconus. Find a top optometrist near you through Specialty Vision and take the first step towards better eye health!
Explore cutting-edge treatments for keratoconus, including corneal cross-linking and advanced surgical options, with insights from Dr. Mitch Eibach.
