Keratoconus,Innovation, and Access to Care

Keratoconus is a progressive condition in which the cornea—the clear front surface of the eye—gradually thins and bulges forward into a cone-like shape. As the cornea changes shape, vision becomes increasingly distorted and difficult to correct with glasses alone. The condition often begins in adolescence or early adulthood and can progress over many years.

Historically, treatment options for keratoconus have ranged from specialty contact lenses to corneal collagen cross-linking and, in advanced cases, corneal transplantation. Cross-linking has been a major advancement because it can stabilize the cornea and reduce progression of the disease. In British Columbia, cross-linking is covered by MSP, reflecting its recognized value in preserving vision and preventing more advanced disease.

In recent years, however, several new minimally invasive corneal procedures have emerged that offer additional options for patients with keratoconus. These procedures aim to improve corneal shape, strengthen the cornea, and enhance visual function while avoiding or delaying more invasive surgical interventions.

One such procedure is Corneal Allogenic Intrastromal Ring Implantation (CAIRS). Rather than using synthetic ring segments, CAIRS utilizes donor corneal tissue that is implanted within the cornea to flatten the cone and improve visual function. The procedure is minimally invasive and uses either femtosecond laser technology or specialized surgical instruments to create channels within the cornea for placement of the donor tissue.

Another promising option is Corneal Tissue Addition for Keratoplasty (CTAK). This procedure uses a femtosecond laser to create a precise channel within the cornea, allowing the placement of a custom-shaped donor corneal tissue segment. By adding thickness and structural support to areas of thinning, CTAK aims to improve corneal stability and reduce irregularity while preserving the patient’s own cornea.

Although not specifically intended for keratoconus, advances in biologic corneal implants such as the Allotex Inlay also demonstrate the growing role of donor corneal tissue in refractive and corneal surgery. These technologies highlight a broader movement toward tissue-based solutions that work with the eye’s natural anatomy rather than replacing it.

What makes these innovations particularly exciting is that they are often considerably less invasive than corneal transplantation. While corneal transplantation remains an excellent option for advanced disease, it is still major surgery requiring donor tissue, operating room resources, lengthy recovery, and long-term follow-up. Procedures such as CAIRS and CTAK seek to intervene earlier in the disease process, potentially improving vision while preserving native corneal tissue.

As these technologies become available in British Columbia, an important challenge remains: access. At present, these procedures are generally not covered through MSP, meaning many patients face significant out-of-pocket costs if they wish to pursue treatment.

This creates an unfortunate situation. We have emerging technologies that may help patients avoid more invasive procedures, preserve vision, and improve quality of life, yet access may depend on an individual’s ability to pay. Ideally, fee codes for these procedures would be incorporated into MSP coverage so that treatment decisions could be guided by clinical need rather than financial circumstances.

The history of medicine is filled with examples of innovation eventually becoming standard of care. Cross-linking itself was once considered a novel technology before becoming widely accepted and publicly funded. As evidence continues to accumulate for procedures such as CAIRS and CTAK, there is a strong argument that patients across British Columbia should have equitable access to these advancements.

Takeaway

Keratoconus is a progressive disease that can significantly impact vision, but treatment options continue to evolve. New minimally invasive procedures such as CAIRS and CTAK offer exciting opportunities to improve corneal structure and visual function while potentially delaying or reducing the need for more invasive interventions such as corneal transplantation. As these technologies become available in BC, expanding MSP coverage would help ensure that all patients—not just those who can afford private care—have access to the full spectrum of modern keratoconus treatment.