International Journal of Keratoconus and Ectatic Corneal Diseases

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VOLUME 9 , ISSUE 1 ( January-June, 2020 ) > List of Articles


Very Asymmetric Keratoconus: A Case Report of Long-term Follow-up

Pedro Manuel Baptista, Rui C Freitas, Nelson Sena Jr, Fernando F Correia, Renato Ambrosio Jr

Keywords : Corneal cross-linking, Eye rubbing, Keratoconus, Very asymmetric disease, Violet June

Citation Information : Baptista PM, Freitas RC, Sena Jr N, Correia FF, Ambrosio Jr R. Very Asymmetric Keratoconus: A Case Report of Long-term Follow-up. Int J Kerat Ect Cor Dis 2020; 9 (1):13-19.

DOI: 10.5005/jp-journals-10025-1190

License: CC BY-NC 4.0

Published Online: 13-04-2022

Copyright Statement:  Copyright © 2020; The Author(s).


Background: Although classically described as a noninflammatory disease, recent evidence suggests that chronic inflammation may play a role in keratoconus pathophysiology. Continued eye rubbing is well established on ectasia development, taking part in the “two-hit” hypothesis, which combines the concept of intrinsic biomechanical susceptibility and external stimuli decompensating the structural integrity of the cornea. Aim and objective: To describe a case of very asymmetric bilateral keratoconus requiring different approaches on both eyes. Case description: A 14-year-old patient with a history of atopy and intense eye rubbing was referred for a cornea consultation because of low vision accompanied with pruritus on both eyes and pain on the left eye. Corneal hydrops was present on the left eye. A diagnosis of grade II keratoconus was established for the right eye. Distance-corrected visual acuity (DCVA) was 20/70 in the right eye and count fingers at 1 meter in the left eye. After 1 month of avoiding eye rubbing, topical mild steroids, and anti-allergic prescription, the patient referred significant improvement in both eyes. DCVA was 20/30, and flattening of 2.5D in the anterior curvature was noted in the right eye. Three months later, ectasia progression was detected in the right eye, and transepithelial cross-linking was performed. More than 6 years after the procedure, the right eye maintained visual and tomographic stability and the left eye had resolution of edema with residual stromal scar. DCVA was 20/30 in the right eye and 20/40 in the left eye. Anterior corneal curvature maintained stable, with a overall decrease of 2.1D in the right eye and 40.9D in the left eye. Conclusion: In the presented clinical case, avoidance of eye rubbing and topical anti-inflammatory drugs were followed by spontaneous partial regression of the ectasia, delaying the necessity for a more invasive treatment. When progression was documented, transepithelial corneal cross-linking was effective in halting disease progression, with topographic stability for more than 6.5 years follow-up period. Clinical significance: Avoidance of deleterious factors like eye rubbing in keratoconic eyes is crucial for clinical stabilization or even improvement. Anti-inflammatory therapy may play a role in ectasia stability.

  1. Gomes JA, Rapuano CJ, Belin MW, et al. Global consensus on keratoconus diagnosis. Cornea 2015;34(12):e38–e39. DOI: 10.1097/ICO.0000000000000623.
  2. Belin MW MJ, Duncan JK, Gelman R, et al. Assessing progression of keratoconus and cross-linking efficacy: the Belin ABCD progression display. Int J Kerat Ect Cor Dis 2017;6(1):1–10. DOI: 10.5005/jp-journals-10025-1135.
  3. McGhee CN, Kim BZ, Wilson PJ. Contemporary treatment paradigms in keratoconus. Cornea 2015;34 (Suppl. 10):S16–S23. DOI: 10.1097/ICO.0000000000000504.
  4. Faria-Correia F, Luz A, Ambrósio R. Managing corneal ectasia prior to keratoplasty. Expert Rev Ophthalmol 2015;10(1):33–48. DOI: 10.1586/17469899.2015.991390.
  5. Roberts CJ, Dupps WJ Jr. Biomechanics of corneal ectasia and biomechanical treatments. J Cataract Refract Surg 2014;40(6): 991–998. DOI: 10.1016/j.jcrs.2014.04.013.
  6. McMonnies CW. Mechanisms of rubbing-related corneal trauma in keratoconus. Cornea 2009;28(6):607–615. DOI: 10.1097/ICO.0b013e318198384f.
  7. Rabinowitz YS. Keratoconus. Surv Ophthalmol 1998;42(4):297–319. DOI: 10.1016/s0039-6257(97)00119-7.
  8. Galvis V, Sherwin T, Tello A. Keratoconus: an inflammatory disorder? Eye 2015;29(7):843–859. DOI: 10.1038/eye.2015.63.
  9. Shetty R, Ghosh A, Lim RR, et al. Elevated expression of matrix metalloproteinase-9 and inflammatory cytokines in keratoconus patients is inhibited by cyclosporine A. Invest Ophthalmol Vis Sci 2015;56(2):738–750. DOI: 10.1167/iovs.14-14831.
  10. Wollensak G, Spoerl E, Seiler T. Riboflavin/ultraviolet-a-induced collagen crosslinking for the treatment of keratoconus. Am J Ophthalmol 2003;135(5):620–627. DOI: 10.1016/s0002-9394(02)02220-1.
  11. Salman AG. Transepithelial corneal collagen crosslinking for progressive keratoconus in a pediatric age group. J Cataract Refract Surg 2013;39(8):1164–1170. DOI: 10.1016/j.jcrs.2013.03.017.
  12. Fan Gaskin JC, Patel DV, McGhee CN. Acute corneal hydrops in keratoconus – new perspectives. Am J Ophthalmol 2014;157(5): 921–928. DOI: 10.1016/j.ajo.2014.01.017.
  13. Maharana PK, Nagpal R, Sharma N. Corneal hydrops in keratoconus. Int J Kerat Ect Cor Dis 2015;4(2):52–55. DOI: 10.5005/jp-journals- 10025-1098.
  14. Ambrosio R Jr, Belin MW. Imaging of the cornea: topography vs tomography. J Refract Surg (Thorofare, NJ: 1995) 2010;26(11):847–849. DOI: 10.3928/1081597X-20101006-01.
  15. Ambrósio R Jr. Violet June: the global keratoconus awareness campaign. Ophthalmol Ther 2020;9(3):685–688. DOI: 10.1007/s40123-020-00283-5.
  16. Rush SW, Rush RB. Epithelium-off versus transepithelial corneal collagen crosslinking for progressive corneal ectasia: a randomised and controlled trial. Br J Ophthalmol 2017;101(4):503–508. DOI: 10.1136/bjophthalmol-2016-308914.
  17. Shalchi Z, Wang X, Nanavaty MA. Safety and efficacy of epithelium removal and transepithelial corneal collagen crosslinking for keratoconus. Eye (London, England) 2015;29(1):15–29. DOI: 10.1038/eye.2014.230.
  18. Tu EY. Descemet membrane endothelial keratoplasty patch for persistent corneal hydrops. Cornea 2017;36(12):1559–1561. DOI: 10.1097/ICO.0000000000001351.
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