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Pediatric keratoconus demonstrates several distinctive management issues in comparison with adult keratoconus with respect to under-diagnosis, poor compliance and modifications in treatment patterns. The major concerns comprise of the accelerated progression of the disease in the pediatric age group and management of co-morbidities such as vernal keratoconjuntivitis. Visual impairment in pediatric patients may affect social and educational development and overall negatively impact their quality of life. The treatment algorithm between adults and pediatric keratoconus has been similar; comprising mainly of visual rehabilitation with spectacles, contacts lenses (soft or rigid) and keratoplasty (lamellar or penetrating) depending on the stage of the disease. There is a paradigm shift in the management of keratoconus, a new treatment modality, corneal collagen crosslinking (CXL), has been utilized in adult keratoconic patients halting the progression of the disease. CXL has been utilized for over a 10 year period and based on the evidence of efficacy and safety in the adult population; this treatment has been recently utilized in management of pediatric keratoconus. This article will present an update about current management of pediatric keratoconus with special focus on CXL in this age group.

Acute corneal hydrops is a condition characterized by stromal edema due to leakage of aqueous through a tear in descemet membrane. The patient presents with sudden onset decrease in vision, photophobia, and pain. Corneal thinning and ectasias combined with trivial trauma to the eye mostly by eye rubbing is considered as the underlying cause. With conservative approach self-resolution takes around 2 to 3 months. Surgical intervention is required in cases of non-resolution of corneal edema to avoid complications and for early visual rehabilitation. Intracameral injection of air or gas such as perflouropropane is the most common surgical procedure done. Recent investigative modality such as anterior segment optical coherence tomography is an extremely useful tool for diagnosis, surgical planning, and postoperative follow up. Resolution of hydrops may improve the contact lens tolerance and visual acuity but most cases require keratoplasty for visual rehabilitation.

In this brief review we will discuss the reasoning and evolution of our current use of combined very high-fluence collagen crosslinking and laser in situ keratomileusis. Several presentations and pertinent publications are reviewed, along with the key steps of the enhanced LASIK procedure. Long term outcome data support the safety and efficacy of LASIK Xtra in stabilizing myopic but also hyperopic LASIK results.In conclusion, we have compelling evidence that LASIK Xtra is a safe and effective adjunct.

Keratoconus is a progressive corneal ectasia, which can be managed both by conservative measures like glasses or contact lenses in non-progressive cases or surgical procedures like collagen crosslinking (CXL) with or without adjuvant measures like intrastromal corneal rings segments (ICRS) or topography guided ablation. Various kinds of ICRS are available to the surgeon, but it is most essential to be able to plan the implantation of the ring to optimize outcomes. Aims: The aim of this study is to evaluate the visual outcome and progression in patients of keratoconus implanted with ICRS. Materials and Methods: Two different types of ICRS-Intacs (Addition Technology) and Kerarings (Mediphacos Inc.) were implanted in 2 different cohorts of patients and were followed-up to evaluate the outcome of the procedure. All patients underwent a complete ocular examination including best spectacle corrected visual acuity, slit lamp examination fundus examination, corneal topography and pachymetry. The ICRS implantation is done with CXL to stop the progression of the disease. Improvement in uncorrected visual acuity (UCVA), best spectacle corrected visual acuity and topographic changes were analyzed. Results: A significant improvement in keratometry and vision was seen in both groups. Conclusion: ICRS have been found to reduce corneal irregularity and flatten keratometry with improvement in UCVA and best corrected visual acuity.

Advanced cases of keratoconus often require surgical intervention to restore corneal anatomy and improve eyesight. Penetrating keratoplasty (PK) although commonly performed has potential risk of immunological rejection and is now no longer automatically the first choice of surgery. DALK procedures have evolved, which allows surgical replacement of recipient′s corneal stroma, leaving behind healthy descemet membrane (DM) and endothelium. This reduces the risk of allograft endothelial rejection and late graft failure. In recent times, DALK techniques have led to significant improvements in visual outcome and current results are comparable to PK. Big bubble technique of DALK has become the most popular among the various surgical techniques described. Manual near DM DALK also gives good outcome although the visual recovery is often delayed. Future integration of femtosecond laser technology along with diagnostic imaging technology is likely to further improve outcomes of DALK in keratoconus.

Keratoconus is a progressive ectatic disorder of the cornea which often presents with fluctuating refraction and high irregular astigmatism. Correcting the vision of these patients is often a challenge because glasses are unable to correct the irregular astigmatism and regular contact lenses may not fit them very well. Topography-guided custom ablation treatment (T-CAT) is a procedure of limited ablation of the cornea using excimer laser with the aim of regularizing the cornea, improving the quality of vision and possibly contact lens fit. The aim of the procedure is not to give a complete refractive correction. It has been tried with a lot of success by various groups of refractive surgeons around the world but a meticulous and methodical planning of the procedure is essential to ensure optimum results. In this paper, we attempt to elucidate the planning for a T-CAT procedure for various types of cones and asphericities.

The success of collagen cross-linking as a clinical modality to modify the clinical course in keratoconus seems to have fueled the search for alternative applications for this treatment. Current clinical data on its efficacy is limited and laboratory data seems to indicate that it performs poorly against resistant strains of bacteria and against slow growing organisms. However, the biological plausibility of crosslinking and the lack of effective strategies in managing infections with these organisms continue to focus attention on this potential treatment. Well-conducted experimental and clinical studies with controls are required to answer the questions of its efficacy in future.

Corneal collagen cross-linking with riboflavin and UVA light (CXL) is the only method designed to arrest the progression of keratoconus. Visual improvement generally starts 3 months after treatment. Reduction is coma seen on aberrometry in early postoperative phase is also responsible for the improvement in visual acuity. In the light of currently available data we can thus say that CXL is a safe procedure that is successful in arresting keratoconus.

Purpose : To assess the efficacy and advantages of femtosecond laser enabled keratoplasty (FLEK) over conventional penetrating keratoplasty (PKP) in advanced keratoconus. Materials and Methods: Detailed review of literature of published randomized controlled trials of operative techniques in PKP and FLEK. Results: Fifteen studies were identified, analyzed, and compared with our outcome. FLEK was found to have better outcome in view of better and earlier stabilization uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), and better refractive outcomes with low astigmatism as compared with conventional PKP. Wound healing also was noticed to be earlier, enabling early suture removal in FLEK. Conclusions: Studies relating to FLEK have shown better results than conventional PKP, however further studies are needed to assess the safety and intraoperative complications of the procedure.

Keratoconus is a progressive non-inflammatory thinning of the cornea that induces myopia and irregular astigmatism and decreases the quality of vision due to monocular diplopia, halos, or ghost images. Keratoconus patients unfit for corneal procedures and intolerant to refractive correction by spectacles or contact lenses have been implanted toric posterior chamber phakic intraocular lenses (PC pIOLs) alone or combined with other surgical procedures to correct the refractive errors associated with keratoconus as an off label procedure with special informed consent from the patients. Several reports attest to the safety and efficacy of the procedure, though the associated corneal higher order aberrations would have an impact on the final visual quality.