Sehklinik

Cornea

Keratoconus — when your glasses are new every year and still do not fit

You have a new prescription yet again, and still you do not see any sharper. Letters trail shadows, headlights radiate in all directions at night, one eye is markedly worse than the other. Behind that pattern there is sometimes a keratoconus: the cornea slowly bulges forward into a cone. If it is recognised early, the first thing is to halt the progression — cross-linking is there for that. It does not bring back sharpness that has been lost, though, and that is exactly why the timing counts.

What a keratoconus is

The cornea is the clear window right at the front of the eye: about the size of a fingertip, roughly half a millimetre thin — and responsible for the larger part of the eye's refractive power. For an image to arrive sharply on the retina, this surface has to be evenly curved, like a cleanly ground watch glass. With Keratoconus that very evenness is lost: at a circumscribed spot — usually a little below the centre — the cornea becomes thinner and bulges forward in a cone under the normal intraocular pressure. The name says nothing more than that: 'kerato' for cornea, 'conus' for cone.

A keratoconus is not an inflammation and not an infection. You do not catch it, you have not 'picked it up', and it is not the consequence of too much screen work or too few vitamins. What has changed is the structure itself: the fibre scaffold of the cornea withstands the tension less well at this spot than elsewhere. What follows from that is not a clouding but a distortion. Light is no longer brought to a single point but spread over several — which is why most of those affected describe their vision not as 'foggy' but as double, warped, with shadows behind the letters.

It typically begins in puberty or in early adulthood. Both eyes are almost always affected, but seldom to the same degree — often one eye is years ahead of the other, and sometimes the finding in the second eye is only noticed once the first has long been noticeable. In many people the course largely comes to a standstill from the fourth decade of life. That is a pattern, not a promise: there are courses that settle earlier, and others that start moving again later.

Why you of all people — there is no satisfying answer to that. What is known are associations, not a single trigger: a familial clustering; allergic conditions such as hay fever, atopic eczema and asthma, together with the vigorous eye rubbing that goes with them; individual genetic syndromes. The link with rubbing is the only one on this list that you can change yourself — which is why there is a section of its own on it further down.

First signs — and why a keratoconus is often recognised late

Almost everyone affected describes the same pattern, long before anyone says the name of the condition:

  • Glasses stop being right after a short time — two or three new prescriptions within a few years, each time with the feeling that it is not really getting better
  • The astigmatism increases, and its axis shifts from measurement to measurement — an astigmatic value that will not hold still
  • Ghost images and double contours, which persist when you cover the other eye — unlike a squint, where the double images disappear with one eye
  • Starbursts and halos around lights, pronounced glare when driving at night, light sensitivity during the day
  • One eye sees markedly worse than the other, often without any recognisable reason for it
  • Itchy, frequently rubbed eyes in your history, usually in connection with an allergy

There is a simple reason why it nonetheless often goes unrecognised for years. The refraction done by an optician answers the question 'which lens makes the image sharpest' — and there is almost always an answer to that, even with an early keratoconus. What it does not answer is the question behind it: why the value is changing at all. A spectacle prescription is a number; the shape of the cornea is a map. The one cannot be read off from the other.

That is explicitly no reproach to opticians — on the contrary, a large proportion of keratoconus cases are first suspected there, because that is where it is noticed that the readings will not settle. Anyone who would like to pass such an observation on to us will find the way under Referring physicians. And if you would first like a general orientation on short-sightedness, long-sightedness and astigmatism: you will find them under Refractive errors — keratoconus is something else, even when it disguises itself at first as 'increasing astigmatism'.

Diagnosis: corneal topography is the whole story here

The diagnosis is not made by the eye test but by the picture of the corneal surface. The Corneal topography measures the curvature point by point and displays it as a colour map: cool colours for flat areas, warm colours for steep ones. On it a keratoconus shows a circumscribed bulge, usually displaced downwards and off centre — a pattern you see at once on a map and never in a spectacle prescription. Modern devices measure not only the front surface but also the back surface of the cornea and the distribution of thickness across the whole area — an early form shows there first, often before the front surface becomes noticeable. The measurement takes seconds, does not touch the eye and as a rule needs no drops.

In addition there is pachymetry, the measurement of corneal thickness: where is the thinnest point, and how thin is it? That number has two jobs. It supports the diagnosis, and it helps decide whether cross-linking is an option at all — the procedure requires sufficient corneal thickness. At the slit lamp we also look for the signs that a more pronounced form leaves behind, such as fine vertical lines in the deep layers or a brownish ring around the base of the cone.

What matters most comes afterwards: the monitoring with comparison images. A single image says what your cornea looks like today. Whether the keratoconus is progressing is told only by the comparison with the image from six or twelve months ago — on the same device if possible, because measurements from different systems are not readily comparable. This documentation is not bureaucracy: it is the basis of every treatment decision, and at the same time what the health insurer wants to see before covering the cost of cross-linking.

Everything else belongs to the normal ophthalmic examination: visual acuity with the best possible correction, refraction, assessment of the anterior segment of the eye, and where needed intraocular pressure and retina. What is measured in each case is set out under Eye examinations; you will find an overview of the other conditions affecting this layer under Cornea.

Stages and progression — how fast does it go?

There are numbered classifications of keratoconus, and they are useful for reports and for documenting the course. For you as the person affected they say little about what happens next. What is practically useful is the description in stages:

  • Early form — detectable only on the topography, vision with glasses is still good. Here it is solely a matter of monitoring.
  • Developing keratoconus — glasses no longer quite do the job, the values change, rigid lenses bring a marked gain.
  • Advanced keratoconus — without a specialist lens no usable vision is possible, and how well the lens is tolerated becomes the main issue.
  • Late stage — scarring in the cornea, no lens sits reliably any more. Only here does a corneal transplant become a question.

The pace is decided above all by age. The younger someone is at diagnosis, the faster it runs as a rule — in adolescents and young adults the values can change within a few months. That is why in this age group we monitor closely at first and not 'once a year'. Over the years the course becomes quieter in many of those affected.

Two situations are known from experience to speed it up. One of them is eye rubbing — more on that below. The other is pregnancy: under the hormonal changes of that time and while breastfeeding, a course that was previously stable can start moving again. Anyone with a known keratoconus who is pregnant should mention it when the appointment is arranged. Cross-linking is as a rule not carried out during pregnancy and breastfeeding, but postponed.

How your findings develop therefore hangs on several factors at once: your age at diagnosis, the change measured in the comparison images, the baseline findings and the corneal thickness, a treated or untreated allergy — and on whether the rubbing stops. There is no number that gives you your personal risk — it cannot honestly be derived from a single image.

Treatment: what makes sense at which stage

With keratoconus two questions are often mixed together that ought to be answered separately. The first is: How do you see better today? Glasses and contact lenses answer that. The second is: How do you stop it getting worse? Cross-linking answers that. The answer to the one question does not replace the other — a perfectly fitting specialist lens does not halt the progression, and cross-linking does not make a visual aid unnecessary.

Glasses and rigid specialist lenses

In the early form a pair of glasses is enough, and there is nothing against wearing them as long as you get on well with them. As the deformation increases they reach a limit that has nothing to do with the strength: a spectacle lens can compensate for a regular curvature, but not an irregular one. An irregular one is exactly what the cone produces.

Soft contact lenses help little for the same reason. They lie over the cornea like a thin film and take on its shape — so the irregularity remains, it merely sits under a new layer. Rigid lenses do something else: they keep their own shape, and the tear film fills the space between lens and cornea. The eye then looks through a new, regular front surface. That is why vision with a properly fitted rigid lens is often markedly better than with any pair of glasses — for many of those affected it is the most striking moment of the whole treatment.

Which design fits is decided by the findings: smaller rigid lenses, hybrid lenses with a soft rim, wearing a rigid lens on a soft carrier lens, or — with sensitive, steep or irregular corneas — larger scleral and mini-scleral lenses, which rest on the sclera and bridge the cornea. The fitting is specialist work, takes several appointments with trial lenses and readjustment, and there is no lens 'off the peg' here. Plan time for it.

Two things decide comfort in wear more than most people expect: treated or untreated dry eyes and the condition of the eyelid margins. Anyone who addresses both tolerates their lenses for longer each day. And a sentence about hygiene that is as unspectacular as it remains important: a red, painful eye with a lens in it needs to be looked at the same day — the most dangerous thing to mistake it for is an early corneal inflammation.

Cross-linking (CXL)

Cross-linking is today the procedure used to try to halt a progression. The principle is easy to explain: riboflavin (vitamin B2) is dropped onto the cornea, which is then irradiated with UV-A light under controlled conditions. In that combination additional cross-connections form between the collagen fibres — the tissue becomes mechanically more resilient. 'Cross-linking' therefore describes literally what happens: the fibres are linked across.

The procedure is carried out as an outpatient, under local anaesthetic with drops. In the longest-established variant the uppermost cell layer of the cornea is removed first so that the riboflavin can penetrate; the soaking time and the irradiation follow. At the end a bandage lens is placed on the eye. Expect afterwards a few days of pain, a foreign-body sensation, watering and light sensitivity until the surface has closed again — and with vision being worse at first and needing weeks to months to settle. Your own rigid lens stays out during that time — we tell you at the follow-up when you may wear it again, and usually refit it afterwards. Anyone who has planned a few days off work is glad of it.

What is required is a documented progression, sufficient corneal thickness, no pronounced central scars and no acute inflammation; pregnancy and breastfeeding are reasons to postpone the appointment. There are risks, as with any procedure: a temporary or lasting clouding of the cornea, delayed healing of the surface, rarely an infection, and rarely a loss of best-corrected visual acuity. We go through this in detail beforehand, and you decide afterwards.

Intrastromal ring segments

In selected cases small, arc-shaped plastic segments can be inserted into the middle layer of the cornea. They flatten the cone and make the surface more regular. The aim is rarely freedom from glasses, but something more modest and more useful: that a pair of glasses or a contact lens gives a usable image again at all, and is better tolerated.

Two limitations belong with that. First, the segments change the shape, not the stability — they do not replace cross-linking, and where progression is demonstrated the two procedures are often combined. Second, they are not suitable for everyone: the position of the cone, the corneal thickness and the absence of scarring decide. The result can be predicted less precisely than with cataract surgery, and in honesty that sentence belongs here before anyone agrees to it.

Corneal transplant (keratoplasty)

Transferring donor tissue is the last step and is needed less often today than it used to be — because keratoconus is more often recognised early and stabilised. It comes into question when central scars disturb vision irretrievably, or when the cornea has become so steep and irregular that no lens will sit any more.

Depending on the findings, only the front part of the cornea is replaced and your own innermost cell layer left in place, or the entire thickness. What holds in both cases: the road is long. The sutures stay in for months, visual acuity develops over a year and longer, a rejection reaction is possible at any time and makes lifelong monitoring necessary. And even after a transplant many of those affected wear a contact lens again. The procedure itself is carried out at centres specialising in it; we prepare the referral and take the follow-up back on again close to where you live.

What cross-linking achieves — and what it does not

The most important sentence on this page is a simple one, and in consultation it is regularly not heard, because it is not the answer people want: Cross-linking as a rule halts keratoconus. It does not reverse it. The aim of treatment is the stability of the cornea — not visual acuity.

What it is meant to achieve: mechanically more resilient tissue, so that the values stay where they are today, and a course that does not deteriorate further. For people in whom the progression has been measured that is a large gain — as a rule they keep what they have.

What it does not achieve: It does not bring back visual acuity that is already lost. It does not make glasses or contact lenses unnecessary — after the procedure you wear, as a rule, the same kind of visual aid as before, and the lens is often refitted afterwards. It removes no scar. And it does not correct the deformation: the cone stays, it is only meant not to grow larger. That some eyes flatten a little over time and see somewhat better as a result does happen — that is a possible side effect and not a treatment aim. To base a decision on it would be wrong.

Everything else follows from that. The timing is decisive: the earlier stabilisation happens, the better the visual acuity that is preserved. Cross-linking on a heavily scarred eye freezes a state nobody is content with. Conversely, a procedure without documented progression is not sensible 'to be on the safe side'; it is only a procedure with risks and without demonstrated grounds. In a young person with a markedly progressing finding, on the other hand, waiting is the riskier decision.

And because the question comes up regularly: cross-linking can in rare cases be repeated if progression is measured again after some years. So it is not a decision that closes every further door — but nor is it one that makes the follow-up appointments unnecessary. After the procedure you stay in monitoring, with the same comparison images as before.

No eye rubbing: the most important thing you can do yourself

It sounds too simple to be important, and is nonetheless the most effective piece of advice on this page. Vigorous rubbing exerts considerable mechanical pressure on the cornea — repeatedly, often daily, over years, and on precisely the structure that in keratoconus offers too little support. The connection between habitual, vigorous rubbing and keratoconus is well described in ophthalmology. It becomes particularly noticeable in people whose eyes are affected to different degrees: often the worse eye is the one that is rubbed more — or the side someone sleeps on.

Almost nobody rubs without a reason. The commonest reason is itching, and that usually comes from an allergy: pollen, house dust mites, animal hair, along with atopic eczema and asthma. Treating the itch takes away the occasion for rubbing — that is the real lever, not good intentions alone. Also underestimated as a reason to rub: dry eyes and inflamed eyelid margins, which produce a constant foreign-body sensation.

What helps instead:

  1. Cool it rather than rub it. A cold, damp flannel or a cool compress on the closed lids for one to two minutes takes the itch away more reliably than any amount of rubbing — and does no harm.
  2. Keep lubricating eye drops to hand, preservative-free if used often: in the car, at work, on the bedside table. Being within reach is half the battle.
  3. Have the allergy treated, rather than putting up with it every spring. Anti-allergic eye drops work well; which ones are suitable we discuss with you or with your GP.
  4. Treat dry eyes and blepharitis alongside — lid hygiene, warmth, artificial tears. That takes away the irritation that brings the hand to the eye.
  5. Pay attention to your sleeping position. Anyone who sleeps face down in the pillow or with a fist against the eye exerts pressure for hours without noticing it. A different position is a serious measure, not a quirk.
  6. Explain the reason to children and adolescents. A ban does not hold; understanding why their eyes in particular cannot take it holds considerably better — especially where there is atopic eczema in the family.

And with it the honest qualification: nobody stops completely overnight. It is not about perfection but about turning vigorous, habitual rubbing into rare, gentle dabbing. If you catch yourself at it, that is not a relapse but the moment the cool compress has its job to do.

When you should not wait

Day to day, a keratoconus is a matter of follow-up appointments, not of emergencies. There are, however, situations in which a few days make a difference. Call us the same day if one of these applies:

  • Sudden, marked worsening of vision in one eye within hours to a few days — particularly together with pain, heavy watering, light sensitivity and a cornea that appears milky and cloudy. Behind it can be a tear in the innermost layer of the cornea, through which fluid enters the tissue. It looks dramatic and is treatable, but it needs to be assessed promptly and not next week.
  • A red, painful eye while wearing a contact lens — take the lens out immediately, do not keep wearing it, call us. A corneal inflammation looks harmless at first and does not forgive delay.
  • After cross-linking: increasing rather than decreasing pain from the third day, increasing redness, yellowish discharge or a rapid drop in visual acuity.
  • After a corneal transplant: newly developed redness, light sensitivity and worsening vision — possible signs of a rejection reaction. That combination is always a case for the same day.
  • With a known keratoconus during pregnancy, if your vision changes noticeably. Not an emergency, but a reason to bring the next follow-up appointment forward.

Our central number: +41 44 500 69 00, Mon–Fri 08:00–12:00 / 13:00–17:30. Describe on the phone what has changed — we will tell you whether it can wait until tomorrow. Outside consulting hours the ophthalmic emergency service applies.

For everything else the calmer route applies: Book an appointment, have the images taken, document the progression. You can see who looks after you here under Team; you will find an overview of our specialty under Ophthalmology.

Costs & health insurance

What does the insurer pay for — and what not?

With keratoconus, basic health insurance (OKP) draws a fairly clear line between what serves the treatment of the disease and what belongs to a visual aid. The first is covered, the second only in part. What applies in your case we tell you before the treatment — not on the invoice.

ServiceCoverageWhat this means for you

Assessment with corneal topography and pachymetry

Basic insurance (OKP)

Where there is well-founded suspicion or a known keratoconus, the examination is treatment of an illness — including the follow-up images that document the progression. Your deductible and co-payment apply as with any visit to a doctor.

Cross-linking where progression is demonstrated

Basic insurance (OKP)

The prerequisite is a documented deterioration on comparison of several images. Without that evidence the procedure is not covered — and from a medical point of view not recommended either. We settle the cost approval before the appointment.

Rigid specialist lenses, scleral and hybrid lenses

Contribution, limited

Where there is a medically justified indication — keratoconus is one — basic health insurance pays a limited annual contribution towards the lenses at the applicable rates. The actual cost is as a rule higher; the remainder stays with you or with a supplementary insurance.

Fitting the specialist lenses and follow-up checks

Depending on the service

The ophthalmic follow-up is covered by basic health insurance. The lens fitting itself, with trial lenses and several appointments, is billed separately depending on the provider — ask there in advance for the price of the whole fitting, not just for the lens.

Corneal transplant

Basic health insurance where indicated

A procedure to treat the disease, and covered where the indication is there. The process, with cost approval, referral and follow-up checks, is set down in writing beforehand so that nobody is surprised.

Intrastromal ring segments

Covered case by case

Unlike with a transplant, the obligation to pay is not established here in the same way: the insurer examines the individual case and does also refuse. We obtain the cost approval beforehand and tell you the decision before any appointment is arranged.

Refractive laser correction (LASIK and related procedures)

Not covered

We do not generally carry out refractive laser correction ourselves — with keratoconus it is out of the question in any case, because it weakens the cornea further. Cross-linking is something entirely different: it removes no tissue.

Unsure what to expect? Call us — +41 44 500 69 00. We tell you on the phone what steps to expect, and with that same information you can check with your health insurer if in doubt. For the contribution towards contact lenses that call is particularly worthwhile: the rates change, and your insurer knows where you stand.

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Medically reviewed by PD Dr. med. Dietlind Friedrich · Last reviewed

Frequently asked questions about keratoconus

Two images months apart say more than any feeling.

If your prescription keeps changing or one eye falls markedly behind, a corneal topography is worth it — once as a baseline finding and once as a comparison. Everything else is decided on that.