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    Keratoconus as refractive surgery: Thinking outside the ‘cone’

    Adapting a planned approach for taming keratoconus presentations to 20/20


    Changing our mindset

    Keratoconus is a word that creates immediate gloom for the patient and a lowered visual set-point for the diagnosing surgeon. It is a diagnosis that when heard by the patient, makes them immediately anxious to get onto Google, find out everything about the diagnosis, and then quickly come to a conclusion of two choices: an interventional transplant surgery or uncomfortable contact lenses, which either way provides less-than-perfect visual endpoints.

    The surgeon in the meanwhile starts to think of all the latest and greatest advances in corneal transplant surgery that they could now use for yet another case and completely misses the point that in many cases of keratoconus, the patient could actually see and see even without glasses or contact lenses-with their own keratoconic cornea!

    To avoid this knee-jerk reaction, I teach my fellows and visiting surgeons to “break down the giant into a smaller, surmountable dwarf” and then confidently create a plan of attack, straight to emmetropia. In breaking down this giant, I help them visualize most keratoconus cases as nothing more than a thin cornea with high keratometry, decentered apex, irregular astigmatism, and associated ammetropia (myopia or hyperopia). By breaking down the disease into its smaller components, it becomes conquerable. Now take this mindset further and actually imagine that these patients should deserve refractive surgery candidate expectations.


    Arun C. Gulani, MD
    Dr. Gulani is director of refractive surgery and chief, cornea & external disease, as well as assistant professor, department of ...

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