Inna Ozerov, M.D., a cornea and external disease specialist and surgical director of Miami Eye Institute, talks about a simple procedure that is saving people’s sight.
Interview conducted by Ivanhoe Broadcast News in February 2017.
First of all tell us the name of this eye condition and is it prevalent, do a lot of people suffer from it?
Dr. Ozerov: It’s called Keratoconus. As I described it to my patients Kerato means cornea and conus means cone. What that means is that the cornea ,which is a clear part of the eye, and it starts to become deformed and it changes into the shape of a cone or a mountain; hence the name Keratoconus. As far as prevalence it depends on what study you look at. In the US it’s estimated that approximately one in two thousand people may have this condition. However, other studies put the prevalence as high as one in four hundred. Also if you look at other parts of the world it’s actually more prevalent in other parts of the world. In the Middle East, in Asian countries we encounter it more frequently.
Now do we know what causes it?
Dr. Ozerov: We know that there is a defect in the collagen. Collagen is the molecule that makes up the cornea.
Do you see it in younger people too?
Dr. Ozerov: Yes and no, it is a dystrophy. Dystrophy means that a person has been born with it. However, it doesn’t become apparent until a person may be in their late teens, actually I should just say early teens. We have seen it in children as young as eight, nine, ten years of age. For most patients, the condition will be picked up when they are in the early teens, early to mid-teens. Often times it happens in school when kids go for their routine eye checkups and if they start complaining to their parents that they can’t see the board. Many times when a child will go to an optometrist, an optometrist will examine the patient and then they will see that there’s something going on with that prescription. The prescription is changing all the time, their eyeglass prescription, their contact lens prescription. This is usually how the condition gets diagnosed. It is unusual to see a patient in their thirties or forties who is not aware that they have this condition. But I have encountered patients in their twenties, probably early to mid-twenties who were diagnosed by me.
It’s a deformity of the cornea.
Dr. Ozerov: Correct.
Tell us the symptoms that a patient might experience if they have Keratoconus?
Dr. Ozerov: The symptoms often times as I had mentioned earlier, the symptoms can be as simple as a patient’s prescription may be changing. Their eyeglass prescription and their contact prescription are changing, blurred vision, difficulty seeing the computer, difficulty reading, and fluctuating vision. In the morning, you may be seeing better than in the afternoon. Primarily it really just has to do with quality of vision and the fact that it’s fluctuating and it’s changing. It may change it doesn’t necessarily have to change from day to day, but if let’s say somebody gets their new glasses today and then six months from now there’s a dramatic change, so that really should alert the optometrists or the ophthalmologist, whomever they are seeing that there may be something going on. It’s not just a simple, oh the prescription had changed.
Is that a progressive disease?
Dr. Ozerov: That Is correct. It is progressive. Keratoconus in the majority of patients is a progressive disease. What does that mean? That the cornea will continue to lose its shape and will continue to become more deformed. In addition to that the cornea also becomes thinner. As the deformity continues to progress the vision, of course, will worsen as well. It can progress to the point where no glasses or contact lenses will make a difference. In the past before we had advancements in treatment patients ended up needing a corneal transplant surgery. Because that was the only option that was available to them to treat this, to cure this.
So that was it, if things had progressed to that.
Dr. Ozerov: Correct.
Tell us corneal transplant; it obviously sounds like a major surgery or undertaking?
Dr. Ozerov: It is a major surgery. I do corneal transplants and I always tell my patients, I am a corneal transplant surgeon but if I can stop you from needing one, my job is done. Corneal transplant surgery is a good surgery, but it’s still a surgery, the recovery is quite lengthy and just like with any type of surgery in ocular surgery there are complications that are associated with it. We always have to worry about rejection of the tissue. The recovery in terms of visual acuity recovery can take up to a year for the vision to really stabilize. There are other complications that can ensue. For those patients who need it this really is a sight saving procedure. For patients who can avoid this type of surgery I always tell my patients you are better off holding on to your own organs.
The procedure that you did with Jesus, this is a relatively new procedure in that it was just approved recently by the FDA here.
Dr. Ozerov: Correct. It was approved recently in the US; it was approved in April of last year. However the procedure has been in existence for close to twenty years. We’re talking about collagen cross-linking. The procedure is the only type of treatment that can actually stop the progression of Keratoconus. We have other modalities that have been used to treat Keratoconus or I should say treat symptoms of Keratoconus. Treat the blurred vision, special contact lenses, special devices that can be inserted into the cornea that can stabilize the shape of the cornea. Collagen cross-linking really is the only type of treatment that gets to the essence of Keratoconus which is this deformed collagen. The idea behind it is that when we expose the cornea to riboflavin, which is a form of vitamin B in a liquid form. We expose the cornea to specific wavelengths of ultraviolet light. There’s a molecular reaction that occurs, a chemical reaction that occurs that allows the cornea to stiffen. There are chemical or molecular bonds that form that allow the collagen molecule to stiffen and therefore it doesn’t allow the cornea to deform further. Depending on what we start out with, how advanced the disease is if somebody presents with relatively mild Keratoconus then it will arrest the progression of the disease. In some patients it can even improve their vision. Of course when we’re dealing with patients with more advance disease like Jesus has, the goal really is to fix what he has so that it will not progress any further and then we can avoid corneal transplant in the future.
How does it work? In the simplest of terms like the way that he described it, is like shaving off of the top of the cornea. What are you doing during the procedure?
Dr. Ozerov: It sounds very scary, but I have a full discussion with my patients. There is a number of ways how the treatment can be done. The way I do it is something that’s called epithelium off. Epithelium refers to the top layer of the cornea. Kind of like the surface of your skin. If you scratch it hurts. The reason I do the treatment this particular way is because when the original protocol from Europe, called the Dresden protocol came out this is how the treatment has been performed. It allows the riboflavin, which is a pretty large molecule; it allows the riboflavin to penetrate in to deeper tissues of the cornea because it’s that combination of riboflavin and UV light that allows the reaction to occur. If you allow the riboflavin to just sit on top of the cornea it doesn’t penetrate as well. Therefore, my method as scary as it sounds we do numb the cornea so a patient does not feel any pain during the treatment. We prepare the corneal surface and then I essentially remove the top layer of the cornea. I tell the patients I create a scratch on their cornea. Allow the riboflavin to sit on the cornea surface for up to thirty minutes. After that we expose the corneal surface to ultraviolet light. That is about a five minute procedure. After that we clean the eye, we irrigate the eye and we will put a bandage contact lens which is a soft contact lens. What it allows is it protects the eye while the eye is healing, it’s not for visual rehab, it’s not to allow patients to see better but it protects their corneal surface while their healing. Then we initiate a protocol of antibiotic eye drops and some other drops to expedite the healing of the corneal surface. Then usually the patient will come back to me within four to six days and I will remove the soft contact lens and then we go from there.
When you say, you go from there do you use, there’s a contact lens for this specific condition and they can use that for better vision?
Dr. Ozerov: It depends on what we start out with. As I mentioned earlier, some of my patients they do get spontaneous improvement in their visual acuity and it’s always exciting. For somebody like Jesus because again his condition is quite advanced he does use a contact lens. It’s a special type it’s called a scleral contact lens. It’s a rigid type of lens. It’s not what people think of when they think about hard lenses. It’s a different type of lens that actually spans from white to white of the eye. My Keratoconus patients tend to do really well with these types of lenses. Because of how it fits it floats over their corneal surface so it can give them pretty spectacular vision.
Other patients with this can they go back after this procedure, after the corneal cross-linking procedure, can they go back to pretty much a normal life? Can they go back to driving, working on a computer and doing things they have to do during the day?
Dr. Ozerov: Absolutely. That’s kind of the whole point, is that we want our patients to get back to their normal activities. We want them to enjoy whatever things they were enjoying before. The point of treatment is to maintain the health of their eyes. We want our patients and that’s the beauty of being able to do this kind of procedure versus somebody undergoing a corneal transplant. Because they can be taken out of their environment for quite a while, while they are recovering from corneal transplant surgery. Somebody who undergoes collagen cross-linking treatment the recovery is much faster. We’re talking about weeks versus months, maybe even years since somebody undergoes a transplant. We want them to get back to their normal activities as quickly as possible. But more importantly we want them to be able to preserve their vision so that they can enjoy those activities.
It’s not necessarily a cure for this condition, but it can stop the progression of it. And for some people it does improve their vision.
Dr. Ozerov: Absolutely.
Okay perfect. Is there a way to prevent something like this from happening or is it in your estimation a genetic condition?
Dr. Ozerov: We believe it is a genetic condition. Even though Keratoconus has been studied for a long time we still have not isolated a particular gene that’s responsible. Now there are patients who have other collagen sort of genetic defects. Patients for example, with Marfan syndrome or patients with Down syndrome because they do these patients tend have other collagen related issues. These patients have high prevalence of developing Keratoconus. Unfortunately, there’s no way to prevent it. I think screening is crucial, and this is something that I always talk to my patients about, especially patients with kids. I always ask them about their siblings. If I have a patient and they are in their twenties or thirties and they do have children I always offer to test their children because you want to catch it as early as possible. Because nowadays we do have the treatment and the treatment is extremely effective. It’s just something I think you just have to be aware of it. Also optometric colleagues a lot of them are wonderful at picking up this condition. Or even if they don’t know that this is specifically Keratoconus I think their radar is definitely higher, so this way they can refer to a cornea specialist, somebody like me so that I can address it further. Basically it’s screening and just being aware. If you have somebody in your family who has this condition then it’s educational and, just allowing the information to be out there. Also the fact that it’s been FDA approved, I think it also raised their awareness for patients. It also made them feel more comfortable but again, the procedure has been around for twenty years. It’s been incredibly successful.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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Miami Eye Institute
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