The Eye Practice

Keratoconus at The Eye Practice is an extremely common encounter, as we specialise in it.  Even though finding vision solutions is the reason most patients  attend, explanation of the eye condition and giving peace of mind is also a very important component.

Because detailed and individualised explanation is so important a number of years ago Dr Jim Kokkinakis wrote: "The 7 critical issues that you need to know about Keratoconus... but Don't".  From around the world this article has been downloaded nearly 25,000 times to date.

Recently Dr Jim Kokkinakis (Optometrist) in conjunction with Dr Michael Loughnan (Corneal Ophthalmologist), Mr Richard Lindsay (Optometrist) and Professor Gerard Sutton (Corneal Ophthalmologist) have published what they think is a very important piece of literature written in laypersons language.

If you have keratoconus or have a family member or friend with this frustrating condition, this simple text goes through all the issues involved.

Call us on +61 2  9290 1899 or email us HERE to get your copy for $19.95 plus postage.

Keratoconus can be a very frightening diagnosis to get if your vision has recently deteriorated.  What is even scarier is that it can be hard to get some good news. 

Here is the bottom line - you do not go blind from keratoconus.

At The Eye Practice keratoconus is what we do.  After more than 20 years of treating patients with keratoconus we have a pretty good understanding of what to expect and exactly the appropriate treatment options at the appropriate time.

The best time for us to see a patient with keratoconus is usually when no one else has tried any treatment.  This by no way is trying to downgrade other practitioners, but the reality is keratoconus is absolutely unique with every individual. It is only after treating thousands of patients that an eye practitioner  will have a great understanding of what option to choose and at what time.

Our experience at The Eye Practice has revealed the following:

• NO ONE GOES BLIND FROM KERATOCONUS

• If an ophthalmologist or an optometrist has advised you that you cannot wear glasses, there is at least a 30% chance that this is not true.  How can this be?  Like anything, practice makes perfect.  Having seeing thousands of patients with keratoconus we have developed a skill in measuring glasses for keratoconus.  This does not mean everyone we see can wear glasses - it means of those that have been told they cannot wear glasses about 30% of the time we can find a very useful pair of glasses.  In these cases it is like winning the lottery!

• If you have failed in trying contact lenses elsewhere, we can fit you successfully 80% of the time.  Why such a dramatic difference?  Again it is about experience and options.  The average optometrist does not have any contact lens templates to try - At The Eye Practice we have over 50 different trial sets under 6 different categories.  Our specialty is keratoconus therefore we have invested in all possible options to give you every opportunity to succeed. 

• It is imperative to follow a process and not leap frog options. The process involves simple options followed by more complex ones.  Why would you want to try a complex option without having first tried a simple option?

• Referral to an experienced corneal surgeon is critical to a good result when surgical intervention is required.

• Only 5% of patients with keratoconus will require a corneal transplant.  Make sure you have failed in contact lenses before moving on to corneal transplantation.  This is because of two reasons:

1. A significant percentage will require contact lenses to see properly after corneal transplantation.
2. 50% of corneal transplants will fail by 15 years. Another corneal transplant can be done, but the second and third transplants will usually fail at an earlier time.

• Collagen cross-linking is very fashionable at the moment.  If you are over 30 years old and are offered this procedure make sure you have progressed in the disease as after 30 it is likely that keratoconus stabilises in most cases.  Crosslinking on average is better suited to some one under 25 years of age and has been documented as having progressed.

• Intacs or Kera Rings have been disappointing procedures.  Before trying them make sure an expert contact lens specialist has tried a number of options, as trying to fit contact lenses over the top of these devices is more complex - it can be done but maybe we have leapfrogged a simpler procedure in the past.

• Keratoconus is an inconvenience it is NOT A LIFE SENTENCE!

Call us on 9290 1899 or Book an Appointment Online Now.

Keratoconus treatment has had a number of significant options that have been developed in the last few years.  This has been both from a contact lens perspective and from a surgical perspective.

Every valid treatment option that is developed ultimately means that less patients require to have a corneal transplant.  Even though corneal transplantation is a good procedure, it is not without potential problems.

In a previous post we discussed Collagen Crosslinking.  This procedure strengthens the cornea, which hopefully will stop or slow down any further progression.  This procedure was first developed in Germany over 10 years ago.  It is now fairly main stream in Australia.  Its limitation is that it normally does not improve the vision.

A new procedure called "KeraFlex" hopes to improve the vision, without having to resort to a corneal transplant. To understand Keraflex see the video below:

KeraFlex involves heating the cornea with microwaves around the conical portion that is causing the visual problem, to 65º Celsius.  This contracts the cornea so that it flattens out and hence the vision is improved.  To maximise the effect and hopefully protect the result Keraflex will probably be offered with Collagen Crosslinking.

What is really important to understand at the moment is where this procedure fits into the keratoconus treatment paradigm.  It is still in investigational stages, therefore will not be offered unless contact lenses have failed; usually because of intolerance.

Dr Jim Kokkinakis specialises in keratoconus management.  Patients are referred from around the country and internationally to be fitted with specialised contact lenses for keratoconus.  He has investigated this new technology, and feels it has great potential.

If you would like to find out more about KeraFlex, he can assess you and make sure that you fall into the group of patients that are currently being offered the procedure.  It is important to understand that if the procedure fails it is likely that the next step will be corneal transplantation.  Having said that; if the cornea is not scarred across the vision it will be possible to fit contact lenses on a cornea that has had the Keraflex procedure.

An older procedure called Intacs (or Kera-Rings) was a little disappointing and when contact lenses needed to be fitted after this procedure it was quite complex.  It is likely that after KeraFlex this complication will not occur, so it is quite possible that if Keraflex proves to be successful in the long term it will replace the Intacs / Kera-Ring procedure.

Make an appointment to see Dr Jim Kokkinakis so he can assess your current contact lenses and make sure you are a suitable candidate for the KeraFlex procedure.  Call on 9290 1899 or BOOK AN APPOINTMENT ONLINE NOW.

Keratoconus in the last 40 years or so has been principally managed with rigid contact lenses.  The category of rigid contact lenses is very vague, as within this, there are half a dozen possibilities that can work very well - So which is the best visual option when correcting blurry vision caused by Keratoconus?

Possibly what the average patient with Keratoconus does not realise is that in a country the size of Australia, there are probably around 10 contact lens specialists that have adequate experience in fitting all keratoconus contact lens designs.

What is normal to find, is the average optometrist will not have any contact lens templates designed specifically for keratoconus.  This is because at most they might run into one keratoconus patient per year, therefore investing in contact lens designs and high tech equipment for keratoconus is a waste of time and money. 

To try and fit a patient with keratoconus, the average optometrist will either refer the patient to a specialist (usually the best option) or borrow a trial set from one of the contact lens laboratories and take on the challenge.

At The Eye Practice one of our specialisations is fitting contact lenses to eyes that cannot wear glasses due to irregular corneal topography.  The conditions include:

• Keratoconus
• Failed Laser Eye Surgery
• Corneal Grafts
• Failed Radial Keratotomy (this was the old Russian technique)
• Pellucid Marginal Degeneration
• Traumatised Eyes
• Other conditions that cause irregular corneal topography.

 Every person that has any of these eye conditions tends to be unique, therefore having all options available in template format is critical to success.

At The Eye Practice, Dr Jim Kokkinakis has over the years traveled around the world to not only extend his knowledge in Keratoconus and all other irregular corneal conditions, but to also source as many different contact lens templates to try and maximise successful outcomes for patients. These people would otherwise not be able to visually function.

Often patients and other practitioners ask: "What are the BEST contact lenses for these irregular corneal conditions?"

The honest answer is - it depends!  The trick seems to be to try and follow a process that will begin with the simplest contact lens options first followed by more complex ones if the simpler ones fail. 

The following is a series of lens fittings that occurred for a complicated keratoconus patient:

1. Left Eye: 9.0mm diameter rigid gas permeable keratoconus design - even after adjustment lens was unsuccessful due to being unstable and uncomfortable.
2. Changed to a larger diameter 10.2mm rigid gas permeable keratoconus design - one change was required to loosen the lens and success was achieved for the left eye with 6/7.5 vision. Patient could wear the lens all day with minimal discomfort.
3. After 6 months patient returned and wanted a lens that she could play high level soccer in. We fitted her with a Synergeyes ClearKone. This lens is much more stable, but tended to dry out in air conditioned environments for this particular patient. She therefore wears the ClearKone for sport and the rigid gas permeable for work and other activity. She was delighted with this outcome.

1. Right Eye: Required a corneal transplant as previous lens fitted by inexperienced practitioner had caused scarring and therefore reasonable vision was impossible.
2. The right eye was followed over the rehabilitation process, which took over 12 months for the sutures to be removed. During this period glasses could not be prescribed as the surface of the cornea was too irregular for reasonable vision. Luckily she was doing very well with the left eye.
3. Sutures were finally removed and a contact lens had to be fitted over the corneal transplant to achieve reasonable vision.
4. Corneal topography and observation revealed that the junction between the host cornea and the graft cornea had a deep ridge. Fitting with a smaller rigid lens was impossible.
5. The eye was therefore fitted with a 15mm miniscleral design, which could achieve great vision of 6/6 or 20/20 but was still rubbing on the ridge.
6. The miniscleral was changed to a 18.5mm scleral imported from the US and after one adjustment to tighten the lens we finally had a great result.

This is not a common case but without having the ability to use over 30 different lens designs, fitting this patient successfully wold have been impossible.  The following points are worth mentioning:

• A successful outcome can be very inconvenient and expensive on both the patient and the practitioner.
• Occasionally many options need to be worked through to achieve what is perceived as a successful result. This really only can be achieved by a specialist contact lens practitioner, who has available a plethora of different lens designs.
• What price can you put on getting your vision and life back?

Keratoconus is documented in the medical literature as affecting 1/2000 of the population. Even though this might sound rare, it isn't really.  There are many diseases that have a far lower prevalence.

There is plenty of evidence to show that keratoconus is transmitted genetically even though many people with keratoconus will tell you they do not know anyone else in their family with the eye condition - they have somehow drawn the short-straw!

The reality is if a patient has clinically diagnosed keratoconus there is about an 8% chance that they will have another member in their family with the condition.  On these statistics alone one must conclude that  keratoconus has some sort of genetic basis, as it is significantly more prevalent than the 1/2000 that occurs in the general population.

Some of the best studies in genetics related to keratoconus have been done by an American ophthalmologist called Dr Yaron Rabinowitz.  In one of his studies he examined the family members of a number of his keratoconic patients.  Amazingly he discovered that up to 50% of the family members had at least a very low level of keratoconus, which had not been clinically diagnosed previously.

A very low level of keratoconus is called Forme Fruste Keratoconus and typically is so mild that if there is any vision problem, the vision can be corrected easily with normal glasses.

Forme Fruste Keratoconus really only can be diagnosed using sophisticated equipment called corneal topography and global pachymetry.  The Eye Practice is only one of a few optometry practices in the country that has invested in this advanced technology.  This is to make sure that no patient can be missed with keratoconus.

A very common question that we are asked at The Eye Practice is:

"I have keratoconus and I am scared of having children, just in case they get it.  What should I do?"

The reality is that having keratoconus is not something that should stop you from having children, in case they develop it.  Chances are that they will be one of the 92% that do not develop it anyway.

Today we are in a position to diagnose keratoconus very early and in doing so can choose to have a procedure called collagen cross-linking.  This procedure when done early enough is likely to significantly suppress the progression of keratoconus.  CLICK HERE for further information about Collagen Cross Linking for keratoconus.

In future posts about Keratoconus we will discuss; things that seem to be associated with keratoconus and things that a person with keratoconus can do to not contribute to further progression of the condition.

Keratoconus management has many options.  Choosing the correct option requires assessment of many parameters / issues and as we have said time and time again - this is best done by experts that have seen thousands of keratoconus patients through all the options and have experienced the gamut of possible outcomes.

The definitive surgical intervention is a corneal transplant.  This can take two basic forms:

1. Full thickness penetrating corneal transplant OR
2. Partial thickness corneal transplant.

              

The procedure that has had the longest history of successful outcomes is the full thickness version.  In the last 5 years or so many corneal surgeons have given their patients (where possible) the option of the partial thickness corneal transplant.  It is thought that rejection will be less and that if required they can then move on to full thickness penetrating transplantation later if required.  It is also more durable to a traumatic injury.

The partial thickness transplant has two disadvantages:

1. It is a more complex surgery, so only the best corneal trained surgeons should attempt this.
2. Vision outcomes are possibly not quite as good.

At The Eye Practice, Keratoconus is our specialty.  Not a day will go by that we do not see at least 5 or 6 patients with the condition.  What is clear is that corneal transplantation (or corneal graft) should not be done unless a number of different contact lens options have been tried.  In the hands of specialist contact lens fitters, 95% of patients with keratoconus can avert the invasive procedure called a corneal transplant.

An obvious question that often arises if fitting contact lenses to patients with keratoconus is such a specialty, why not just leap frog the contact lenses all together.

Jumping straight to a corneal transplant is inappropriate because:

• 50% of corneal transplants will fail within 15 years (Australian Corneal Graft Registry)
• Between 10% and 50% of corneal grafts will eventually require contact lenses to see well
• Each subsequent time a corneal graft is done to the same patient the time to failure is likely to be less than the previous graft.

That's the bad news, so is there any good news about corneal grafts (corneal transplants).  Sure there is!  Of all organ transplants that are done on the human body, the corneal transplant is in fact the most successful.  When performed by corneal transplant surgeons at the proper time it can be a life changing event.

If you think you would like to know more about corneal transplants call us at The Eye Practice and make an appointment on (02) 92901 1899 or BOOK ONLINE HERE.

There is a lot to keratoconus isn't there? Together with three other keratoconus specialists in Australia, Dr Jim Kokkinakis will soon publish a book detailing all there is to know currently on this confusing topic.  Stay tuned for this.

 In the mean time let's move on to,

Other facts #2: Intacs or Kera Rings are reasonable options but when?

 Firstly what are these devices? 

Before we answer this let's talk a bit about their history.  These devices were originally implanted in normal corneas to try and correct or reduce myopia by flattening the cornea. Unfortunately for the investors in this technology Laser Vision Correction was far superior and they went into receivership.

For keratoconus though accuracy does not have to be perfect. Even if vision can be improved slightly so that a corneal graft can be avoided, this is now seen as successful.

A recent advance in Intacs / Kera Rings surgery has been the introduction of the femtosecond laser to create a channel in the cornea. The channel was originally made with a manual metal device.

Secondly when are these implants used?

Intacs / Kera Rings should be considered only after most contact lens options are exhausted. We have seen many cases of failed procedures sent for contact lens fitting. Even though it can be successul, we much prefer to fit keratoconus eyes before Intacs as they add another layer of complexity.

That will do for today. We will move on to Fact #3 in the next few days.

What a year we have endured! It's been a long miserable winter and spring is finally upon us. For most Australians, the start of spring makes us get excited about warm sunny days, bright colours, flowers, picnics and generally fun outdoor activities.

But for many of us, spring also reminds us of the sneezing, sniffling and red eye irritations from allergies like hay fever, conjunctivitis, also known as pink eye, and sinusitis. This is due to the increased amount of pollens in the air. 1 in 5 Australians suffer.

Hay fever symptoms include:

• Red eyes, swollen or itchy eyes
• Runny nose
• Itchy mouth, nose or throat
• Sneezing
• Headaches
• Eczema and Dermatitis

Red Eye allergies can affect many of us, however spring is particularly difficult on those who wear contact lenses and those who suffer from asthma.

To treat and relieve symptoms, contact lens wearers should speak to their optometrist about possibly changing cleaning methods,or using daily disposable contact lenses. In most cases, symptoms can be relieved with prescription or over the counter drops, such as antihistamines.

The question is which drops?

That's where a therapeutically qualified optometrist comes in. They have been fully trained in the proper treatment of allergies and other eye issues like glaucoma. Going to the chemist is a minefield. There is a whole wall of eye drops to choose from. You could ask the pharmacist but you are relying on them to try and diagnose your problem across the counter. Is that what you want for your eyes? Did you know that red itchy eyes could be caused by a whole host of things that is generalized as conjunctivitis? Before starting any eye treatment it is imperative to diagnose the type of conjunctivitis you have. In a future article we will go into other types of conjunctivitis and their possible treatments.

At The Eye Practice giving Peace of Mind about your most important sense – Your Vision, is what we are all about. Being therapeutically qualified and using the latest eye examination technology, gives you that Peace of Mind, that you are at the right place!

Asthma sufferers should try and avoid going outdoors on very windy days particularly in the mornings and late afternoons, when pollen count is highest.

Other important tips to avoid eye allergies such as conjunctivitis, pink eye, hay fever and eczema / dermatitis around the eye include:

• Avoid rubbing or touching your eyes
• Never share contact lenses
• Never share eye makeup
• Avoid wearing eye makeup where possible
• Wear protective wraparound sunglasses when outdoors
• Clean surfaces regularly to avoid dust build up
• Avoid mowing lawns

Just remember that relief is at hand. Call and make an appointment with your optometrist and discuss what options are available to suit your needs.

If you are reading this blog it is likely that you either have this eye condition or know someone that is close to you with it… and you are concerned.  We are talking about our most precious sense: Vision, so of course you are concerned.

There is a plethora of information on the Internet and even though a lot of it is accurate, it is often taken out of context. That’s where this blog fits in.  A number of years ago I set up a website called: www.keratoconus.com.au

On which I have also written a document called “7 Vital Facts you need to know about Keratoconus… but Don’t”.

It has been around for a number of years and from there I have had many, many enquiries. Most of these have come from people that are distressed and do not know where to turn.

My name is Dr Jim Kokkinakis and over the past 20 years I have developed an expertise in this area from many sources. If you are interested go to my profile page for more information.

Keratoconus is a huge area and the information is overwhelming. The first thing we need to know is that Keratoconus will not make you go blind. Secondly that being guided by an expert will always give you the best outcome. If you download the above document, I go into this in detail.

The purpose of this blog is to update on what is the latest in this large and very confusing area, so we will start with 7 other facts. Today we will start at number 1 and over the course of another 6 posts we will develop further understanding. I highly encourage you to read the first document so that you have a good grounding and therefore following 7 points will make more sense:

Other facts # 1: Collagen Crosslinking is a viable treatment

In my previous document I mentioned that the main years for Keratoconus to progress is between 15 and 25 years of age. It can also sometimes start earlier and there are documented cases of progression even up to 45 years of age.

When I wrote my original 7 facts there was a procedure called collagen crosslinking (CCL) that was in a trial phase in Australia. The studies now have been finished and it is clear that if a Keratoconus specialist is monitoring a patient with Keratoconus and they are definitely getting worse, then this procedure is something that should seriously be considered. Commonly asked questions about this procedure are: