Patient Presentation
A 22-year-old male presents with a chief complaint of progressively worsening vision in his left eye over the past 12 months. He reports increasing glare and halos around lights, making night driving difficult. He has a history of seasonal allergies and admits to frequent eye rubbing.
Examination Findings
- Visual Acuity (OD): 20/20
- Visual Acuity (OS): 20/60, improving to 20/40 with glasses (-2.00 / -3.50 x 095)
- Slit Lamp (OS): Prominent corneal nerves, mild Vogt's striae, and a faint Fleischer ring at the base of the cone.
- Corneal Topography (OS): Shows significant inferior steepening with a maximum keratometry (Kmax) reading of 54.5 D, an increase from 52.0 D recorded 6 months prior.
- Pachymetry (OS): Thinnest point is 450 microns inferiorly.
Diagnosis
Progressive keratoconus in the left eye.
Clinical Discussion
Given the patient's age, documented progression of ectasia (increase in Kmax), and subjective worsening of symptoms, he is a clear candidate for treatment. The primary management goal is to halt the progression of the disease.
Proposed Plan:
- Corneal Collagen Cross-Linking (CXL): Epi-off CXL is recommended for the left eye to stiffen the cornea and prevent further steepening.
- Refractive Management: Following CXL (typically 3-6 months post-op), the patient will be refit with a rigid gas permeable (RGP) or scleral contact lens to achieve optimal visual acuity.
- Patient Education: Advise the patient to cease all eye rubbing, as this is a significant risk factor for progression. Manage ocular allergies with appropriate topical mast cell stabilizers or antihistamines.
This case highlights the importance of early detection and intervention in managing keratoconus. Timely CXL can prevent the need for more invasive procedures like corneal transplantation in the future. What are your standard protocols for CXL in similar cases?
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Attached Media
Baseline Corneal Topography (OS)
Anterior Segment OCT showing corneal thinning