Keratoconus Surgery

Do you suffer from or suspect you suffer from keratoconus? Read on to learn more about what it is, its causes, as well as the typical signs and symptoms. Explore your treatment options with Dr Dylan Joseph today.


Dr Dylan Joseph

Cataract and Refractive Surgeon

MBChB(Pret), Dip Ophth(SA), FC Ophth(SA),
MMed Ophth UFS (cum laude)

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Once you understand more about keratoconus and all that it entails, you will be able to make a more informed decision about the way forward. Allow us to walk you through the ins and outs of this condition.

What Is Keratoconus?

Keratoconus is an eye condition that impacts the cornea’s shape. Instead of it being dome-shaped, as is the norm, those afflicted with keratoconus have a rugby ball-shaped cornea. The result of this cone-shaped bulge is poor eyesight.

The collagen – or tiny protein fibres – in your eye help to keep your cornea in position. If the collagen grows weak, it cannot properly retain its shape. This is how your cornea can gradually grow more cone-shaped.

Decreased antioxidant levels in the cornea often lead to the development of keratoconus. Just as a car’s exhaust produces toxic fumes, your corneal cells also produce damaging by-products. An eye with normal antioxidant levels rid the cornea of these harmful materials, protecting the collagen. When these levels drop, the collagen starts to weaken and the cornea begins to bulge.

The onset of keratoconus is usually around puberty, progressing slowly afterwards. The condition can either progress slowly yet continuously over many years before permanently stabilising, or it can actively progress during certain periods and then suddenly appear to stop. It is unusual for keratoconus to progress further after the age of 40. Factors that control the condition’s advancement and stabilisation are currently unknown.

Keratoconus will always affect both of an individual’s eyes, although not equally – i.e. it presents itself in a bilateral, asymmetric way. One eye will usually be impacted by a more severe case of astigmatism than the other. The main symptom is weakened vision – it is the result of the irregular, myopic astigmatism caused by the condition.

What Are the Most Common Causes of Keratoconus?

The causes of keratoconus are currently unknown. Researchers do, however, believe that some individuals are likely to be afflicted since birth. The following factors are believed to link to the condition:

A Familial History

Should you have a family member suffering from keratoconus, you are far likelier of developing it yourself. Those diagnosed with the condition should have their children’s eyes checked around age 10 to catch any signs early on.


As mentioned before, the condition usually begins to manifest during the teenage years, although it may also appear during childhood or not until an individual reaches their 30s. It is extremely uncommon for keratoconus to start affecting individuals aged 40 and up.

Excessive and/or Hard Eye Rubbing

When you rub your eyes frequently or too hard, the cornea may start breaking down over time. Those already suffering from keratoconus can also end up accelerating the condition’s progress.


Atopic eye disease, allergies, asthma and other inflammation-causing health issues can lead to the breakdown of corneal tissue.

Other Medical Disorders

Studies have made a connection between keratoconus and certain systemic conditions, including Ehlers-Danlos syndrome, Down syndrome, retinitis pigmentosa and osteogenesis imperfecta.

Racial Background

A study comprising of over 16 000 participants diagnosed with keratoconus revealed that those who have a Black or Latino heritage are around 50% likelier to develop the condition than Caucasians.

The Signs and Symptoms of Keratoconus

Individuals suffering from keratoconus will notice that their vision changes in two distinct ways. During the process of the cornea changing from a dome to a rugby ball shape, the normally smooth surface grows wavy. It is known as irregular astigmatism.

Individuals will also become more near-sighted as the front of their cornea expands. Up close objects will remain in focus while anything further away will grow blurry.

Should you experience any of the following symptoms, please be sure to notify Dr Joseph during your consultation. These could be some of the tell-tale signs of keratoconus:

  • Blurred vision, making it difficult to drive
  • Both near and far objects seem blurred
  • Double vision, when looking through just one of your eyes
  • Halos that appear around bright lights
  • Light streaks
  • The appearance of triple ghost images in your vision

Keratoconus Diagnosis and Treatment

A keratoconus diagnosis is made by measuring the shape of the cornea. It can be done in different ways, the most common of which is known as corneal topography. An ophthalmologist will take a photograph of the cornea and examine it closely. Again, should you or your partner suffer from keratoconus, it is important to have your children undergo this examination on a yearly basis starting from age 10.

Correcting keratoconus can be achieved in a variety of ways, depending on the severity. Should the condition be in its early stages, wearing soft contact lenses or even glasses may still be sufficient in correcting the refractive issue. Once the condition progresses, a more severe degree of irregular astigmatism is achieved, glasses will be of little use. During this stage, hybrid or hard contact lenses have a greater effect on improving your vision.

Once keratoconus has developed to an advanced stage, even contact lenses might not be sufficient enough to make a difference in vision or it may become intolerable to wear them. This can be caused by stromal scarring or some other pathological change. Surgery then becomes a viable option. Those with especially severe cases of corneal irregularity may have to undergo a corneal transplant.

Treating Keratoconus With Corneal Cross-Linking Using Riboflavin

Clinical studies have shown that corneal cross-linking can stabilise both iatrogenic ectasia and keratoconus. Using riboflavin in combination with UV radiation brings about molecular cross-linking of the cornea’s collagen. This procedure slows down and may even stop thinning of the cornea entirely. It also improves the biomechanical strength of the cornea’s tissue.

Ophthalmologists can make an intra-stromal pocket inside an individual’s cornea through the use of femtosecond laser technology. The riboflavin is then administered into the pocket safely and efficiently. This specific treatment option is not used to improve vision but to stabilise it, thus preventing further corneal deterioration. After undergoing cross-linking, plenty of patients enjoy improved vision with the aid of glasses and/or soft contact lenses.

A variation of this procedure is trans-epithelial corneal cross-linking using ricrolin and without de-epithelisation. This variation of the treatment is suitable for young patients under 10, as well as those who have thin corneas.

Treating Keratoconus With Kera/Ferrara Rings

When undergoing Kera/Ferrara ring surgery, a patient has small, semi-circular rings implanted into their cornea. These rings help to flatten the surface of the cornea, thus improving vision in individuals diagnosed with keratoconus. The intra-corneal tunnel into which these rings are slid is created using femtosecond laser technology.

Implanting a Kera/Ferrara ring does not affect an individual’s central optic zone whatsoever. The procedure also does not necessitate any tissue removal and can be undone if any vision changes occur. Due to the nature of the surgery, other vision adjustments and corrective treatments remain viable options in future.

The majority of patients enjoy a noticeable difference when wearing soft contact lenses after surgery.

Treating Keratoconus With ALK or Anterior Lamellar Keratoplasty

Most individuals diagnosed with keratoconus still have a healthy endothelium – i.e. the cornea’s innermost layer. When undergoing traditional corneal grafting surgery (full-thickness corneal transplantation), the healthy layer also has to be removed and replaced with the donor’s tissue. Your body’s immune system will sense this foreign layer and attempt to reject it – this is why post-operative steroid medicine is necessary for such a long period after surgery.

DALK or deep anterior lamellar keratoplasty is a far more modern corneal surgery procedure. As the surgery is known as a partial thickness graph, only select, diseased anterior corneal layers are removed. The cornea’s two healthy, deepest layers, called the endothelium and Descemet’s membrane, remain. Because these two crucial, innermost layers remain in place, your immune system will not recognise any donor tissue, decreasing the chances of rejection. Steroid medicine also does not have to be taken for an extensive period.

Treating Keratoconus by Undergoing Penetrating Keratoplasty

Penetrating keratoplasty or a corneal transplant can be seen as the most extreme form of treatment for keratoconus. The surgical replacement of the conical cornea is only considered when a patient is not a good candidate for any of the other treatment options or contact lenses cannot be fitted properly despite all efforts.

Penetrating keratoplasty, also referred to as corneal grafting or transplantation, is when a patient undergoes surgery to remove all abnormal host tissue and replace it with a donor’s corneal tissue. Femtosecond laser technology makes it possible for both recipient and donor corneal tissue to be cut with precision at specific depths, as well as in numerous patterns.

The customisable nature of the technology improves not only the outcomes of surgery but the wound healing period. Individuals enjoy faster visual recovery, as well as slower progression in their astigmatism when compared to more traditional methods.

Be sure to schedule your appointment with Dr Dylan Joseph at 044 150 0085 to learn which keratoconus treatment option is best for you. Please forward your enquiries to

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