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    Keratoconus: Thinking outside the cone

    Cases highlight various scenarios ranging from highly complex to simple

    Gloves Off with Gulani By Arun C. Gulani, MD, MS

    Dr. GulaniIn the previous “Gloves Off with Gulani” column, (OphthalmologyTimes.com/ThinkOutsideTheCone), I discussed the philosophy of viewing keratoconus as a refractive anomaly that can be brought to emmetropia rather than one in which the cornea is worked upon, or worse still, the topography is corrected while the patient is left with less- than-perfect vision.

    I want all surgeons to believe in the patients’ potential, have confidence in their own surgical skills, and then commit to emmetropia as a possible outcome in these cases. Yes, in some cases you might not succeed, but in most cases you will. It’s the mindset and expectation that will drive the thought process as a single or staged process toward a logical pathway to emmetropic endpoints.

    I also want to blur the diagnostic language by approaching all corneal ectasia (natural and surgery induced) based on my 5S system rather than on terminology that prevents “thinking outside the ‘cone’.”

    In this column, I will describe various keratoconus case scenarios from my referral-based practice—ranging from the highly complex to simple—that can be improved with single or staged techniques that move patients toward emmetropia. 

    In sharing my outcomes and philosophies over the past two decades with patients referred from around the world, I want to reinstate surgeons’ confidence in laser advanced surface ablation (ASA)/PRK as a valuable keratorefractive technique, corneal implants (Intacs, Addition Technology) as a directional and reversible technology; phakic and pseudophakic implants as optically manipulative ingredients; and the entire range of lamellar corneal techniques followed by corneal collagen crosslinking (CXL), which, I believe, should be a permanizing surgery to “trap” the visual endpoint gained by such an innovative trajectory of visual endpoints.

    Usually, I start my teaching sequence from simple surface surgeries to deeper into the cornea and then lens-laser combinations and complications reversals. However, this time, I juggle different case scenarios to keep surgeons engaged and actively thinking, with my end goal being to help surgeons realize through this plethora of keratoconus presentations that every case of keratoconus deserves the utmost commitment to emmetropia.

    Case scenarios

    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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