Eyedolatry

Women in Focus: United Optometrists Association

When Rachel Simpson and Kate Hamm entered the Wal-Mart and Sam’s Club Project Foresight Scholarship competition, they weren’t sure that their idea was exactly what the company had in mind. The topic? “What does the future of Wal-Mart/Sam’s Club optometry look like?” The company was asking for submissions on how they can become a better workplace to attract millennials and grow for the future as both an employer of optometrists, and as a preferred practice location for patient care.

Simpson and Hamm, then third year students at University of Missouri St. Louis, entered the $15,000 scholarship competition with a focus on what they saw as one of the biggest issues young graduates face when entering the marketplace: discrimination in pay and workplace equality between genders and ethnicities.

“I read Women In Optometry's article "The Income Gap: Why are Women Earning Less?" and I couldn't get it out of my head,” Simpson said. “That article said the gender wage gap in optometry is more than 18%, which is pretty shocking since most optometry students are female. I told my friends that the wage gap in optometry is about to be our problem; no one is going to care about this more than we do, and no one is going to fix it unless we make them.”

“Looking at race and gender specifically, it showed that some female optometrists are being shorted as much as $40,000 a year compared to their male counterparts. When I heard that and thought about it and looked around and realized how even my classmates were going to be affected, I just thought, ‘No. That’s not okay with me.’”

They were already working hard on raising awareness of the wage gap in optometry, founding the United Optometrists Association at UMSL with a group of 8 students in January 2016. The numbers quickly grew to 55 student members at UMSL alone, with steps in place to collaborate with existing clubs or found new chapters at optometry schools across the country.

How are they tackling their goal of not just closing the wage gap, but achieving workplace equality in optometry? “Each semester, we start with a brainstorming meeting where all our members come up with ideas for how to forward the mission of the UOA. Right now, that's the UOA's greatest impact: getting future optometrists thinking of ways to close the wage gap and be better future employers. We need to always be looking for opportunities to take action to close the wage gap.”

Kate Hamm and Rachel Simpson, UMSL College of Optometry '18

Their first year as a club was focused on how to approach the wage gap from the initial job offer process. “We read that a person can fall into the wage gap starting with their very first salary at their very first job. We can learn to negotiate, if that would help close the wage gap. So that's the action we took. We asked ODs to share with us copies of job offers they'd received (with all the personal information removed) so that we could get used to seeing contracts and offers. We need to see these documents as students so that we know what is standard and what to ask for. We held a contract negotiation seminar with Dr. Mark Phebus, where we learned what parts of a job offer are open to negotiation.”

“When Kate and I entered the Walmart Project Foresight scholarship competition, the prompt was "how can Walmart attract millennial optometrists?" Which doesn't on its face seem like an opportunity to argue for equality. But that's what Kate and I did. We argued that millennials care about the wage gap in optometry, so if you close the wage gap you attract millennials. We made specific recommendations that have been shown to close the wage gap in other professions- like not allowing negotiations for starting salary so that everyone starts on equal footing; encouraging all ODs (male, female, and non binary) to take full advantage of their paid time off; and setting up a system to allow ODs to seamlessly substitute for one another, so that a business doesn't falter when the doctor takes time off for medical or maternity leave. With Walmart, we saw an opportunity to tell a major employer of optometrists what we want them to do to close the wage gap. They listened to us and said that the actions we recommended were do-able for them, and we won the scholarship. Winning is nice, but what's nicer is that it brings attention to the wage gap. We want everyone in the UOA to be looking for opportunities to shape the conversation. Make your own opportunities and make the most of them. I hope that the UOA will motivate optometry students and optometrists to take action in the interest of equality.”

When we graduate and become ODs, we'll keep working to make optometry more equal. We have some ideas for what that will look like, but it's hard to be sure until we really get there. Since the founding member so the UOA don't graduate until 2019, it's time for us to start thinking of how to better utilize OD members in addition to student members. We'd like to work with current ODs to come up with a set of recommendations for promoting equality within one's own workplace, as well as how to advocate for workplace equality within our profession."

How Can You Get Involved?
All ODs (not just students!) can visit unitedopt.org and read up about the wage gap. “You don't have to be a woman to be affected by the wage gap, so you don't have to be a woman to join the UOA,” explains Simpson. They especially would appreciate If optometrists would be willing to share job offers or contracts with personal and identifying information removed so that students can get more comfortable looking at optometric contracts before they sign their own. “Students need to know what ODs are being offered so that we know what to ask for and don't undervalue ourselves and contribute to the wage gap. We need to better understand the realities you're facing in the workplace. What are you seeing? What changes would you like to see? What can we do to make your workplace more equal? We would love to talk with you!”

Want more about the mission of United Optometrists Association? I got a chance to interview Rachel and Kate for Defocus Media!

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Got Social Media? Building Your Private Practice Optometry Brand

Defocus Media 9:43 AM

In optometry school, you learn a lot about how to be a great doctor. Ocular disease, surgical procedures, prescribing medications. And the curriculum typically includes business management courses too - basics of understanding net versus gross profit, balancing the books, budgeting for staff and paying yourself (hopefully). Building your own practice from scratch though reveals a lot of the things we didn't learn: we know how to be a great doctor, but how do we figure out how to be a great brand?

via

Luckily there are a number of optometry entrepreneurs that are excelling at just that. Look around at the brands that are so ubiquitous in our daily lives: Starbucks, Apple, Amazon - their names conjure up a clear visual and emotional idea. We understand who, what, and why they are. Locally I'm sure you can think of stores, restaurants, and bars that are doing a great job branding themselves too - places that have created a clear identity and are go-to venues for their offerings in your community. Optometry, and healthcare for that matter, are no different in how we operate. We have the luxury of having one of the few medical careers where private, independently own businesses still flourish. But a key to small business ownership in 2017 is creating a brand that is the big idea. A brand that speaks to your local community and brings them in - that connects with them visually and emotionally to make you the go to source in eyecare and optical. Shopping small is an American movement; 90% of American consumers report shopping at a small business (under 500 employees) at least once a week. How can you become part of your local shop small movement?

When you think of the biggest independent, privately owned brands in optometry a few names come immediately to mind. Dr. Tanya Gill's practice, Oakland Vision Center is sure to top your list. Honored as America's Finest Optical Retailer in 2015, her practice has a booming social media following (nearly 10,000 followers on Instagram), and has rewritten the book on what a trunk show should look like. Earlier this year she teamed up with OD social media phenom Dr. Arian Fartash (aka GlamOptometrist) whose 15k and growing Instagram movement has been championing eyecare and optometry as both a career and a go-to profession for fashion as well as healthcare. Together this dynamic duo has teamed up on a new project to bring social media prowess to optometrists so they too can better connect and inspire their communities to have a passion for independent eyecare and eyewear.

Creating a visual brand is the key to social media success but it takes a lot of finesse and skill to hit your stride. Within 5 posts your patient should have a clear sense of who your office is as a brand, all through the aesthetic, word choice, color scheme, subject and framing of your posts! via

The Eye Doctors was formed by Drs. Gill and Fartash as a platform and workshop to help ODs better find their brand identity and learn the basics to successful social media management. "We decided it was important to help other ECPs to take control of their social media accounts to help grow their business, because with the right tools and guidance, it really isn’t that hard," says Fartash.

As a lecturer and columnist about social media management in optometry myself, and cofounder of Defocus Media which offers social media services for private practice ODs that are seeking professional help, I see many of the same pitfalls Dr. Fartash cites when helping other ODs get started on Facebook and Instagram. Red eyes, stock photos, and generic bulk posting service offerings have a very difficult time attracting the average patient to want to stop scrolling and click over to your page. Just having content isn't nearly enough - you have to have content that makes people want to stop and look.

Dr. Fartash also suggests skipping the overused equipment shots. "I think the most common mistake is to post pictures of what the office has to offer in terms of equipment. You see a lot of optometry pages post pictures of phoropters, slit lamps, etc…. Instead, ECPs should post happy patients and awesome glasses!" Personal photos with recognizable faces: your patients (with permission), your staff and yourself always connect best!

Creating a successful brand story, designing and editing visuals to improve patient engagement - these are all essentials to private practice ownership. And the returns are impressive: Drs. Gill and Fartash site that the patients brought to their practice from social media tend to be more private pay instead of insurance, and the average sale is $750 per patient encounter, compared to an average of around $300 per exam for an average patient seen by most practices.

The Eye Doctors Dr. Gill and Dr. Fartash via

Feeling motivated? Dr. Gill and Dr. Fartash will be hosting the inaugural TheEyeDoctors social media workshop on August 19th and 20th at Oakland Vision Center in Oakland, CA. Head to their website for all the details!

If you are wanting to read up on social media basics and advice for ODs in your free time, you can check out my articles with Dr. Darryl Glover in INVISION Magazine every month (subscription is free!). And I'll be presenting an Introduction to Social Media for Optometrists in Memphis, TN on Saturday, September 16th during the Southern College of Optometry's 2017 Homecoming CE event for COPE approved credit!

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Omegas and Dry Eye: The Science Behind the Supplements

Dry Eye 11:44 AM

We are what we eat, as the old saying goes, and as researchers delve deeper into chronic inflammatory conditions, the impact of our diet is hard to ignore. Dry Eye Syndrome is the most common chronic inflammatory condition of the eye, affecting an estimated 20-30 million Americans. The name “dry eye” is a bit of medical misnomer – we know now that the underlying mechanism is an inflammatory disruption of the ocular surface and tear film, causing symptoms ranging from dryness, watering, redness, fluctuating vision, burning, foreign body sensation, and chronic pain and discomfort. There are over 80 inflammatory molecules that have been identified in the human tear film, including cytokines, growth factors, interleukin, and macrophages. These inflammatory mediators are there naturally to protect and heal the eye from infection and injury, but external factors that increase or promote those normal inflammatory molecules can tip the scale for the body to begin chronically attacking itself. For many, simply using over the counter artificial tear drops provides no more than temporary relief of their symptoms; treating the underlying inflammation that’s causing discomfort is the true path to relief.

Dry eyes are often watery - the corneal nerves feel dryness, and create a watering response to try to help heal the corneal tissue. via

And that’s where we circle back to diet. Research has shown Americans have an exceedingly pro-inflammatory diet, increasing our risk for chronic conditions like dry eye as well as cardiovascular disease, diabetes, and chronic inflammatory conditions. If you’re a dry eye sufferer, what dietary choices can help you find relief?

Omegas and Inflammation

The most compelling dry eye research on nutrition focuses on omega fatty acids. They are essential dietary nutrients, but as humans we have to get all of our omega fatty acids from our diet – we are unable to synthesize our own. Omega fatty acids have a primary function in lipid (fat) metabolism, but also have anti-inflammatory actions such as lowering the blood stream concentration of inflammatory mediators like C-Reactive protein, interleukin, and tumor necrosis factor. Predominantly it’s the omega 3 fatty acids that we associate with having this anti-inflammatory action; these nutrients are found in fish, eggs, and flaxseed oil. But there is also an important omega-6 fatty acids that also works to combat inflammation, This omega-6, GLA (gamma linolenic acid), is largely absent from our diet, and not found in oils from fish or flaxseed. GLA is obtainable only from a few sources such as borage seed oil, evening primrose oil,and black currant seed oil.

Unfortunately the American diet is loaded up with another omega-6 called arachidonic acid (AA) – a potent pro-inflammatory that’s abundant in meat and dairy. Arachidonic acid is so central to inflammation, that its metabolism is the target of nearly all NSAIDS, from aspirin and ibuprofen to Celebrex (celecoxib).

It’s commonly assumed that all omega-6s are unhealthy– and many have heard that a better ratio of omega-3 to -6, can help reduce inflammation. However, it’s important to remember that this only applies to the inflammatory dietary omega-6 that's so common in our diet in meat and dairy products. Anti-inflammatory omega-6 like GLA is mostly lacking in our diet.

Why not just take Omega 3 fatty acids alone?

Most supplements on the market for dry eye focus on fish-oil derived Omega 3 fatty acids like ‎Eicosapentaenoic acid (EHA) and ‎Docosahexaenoic acid (DHA). There’s abundant research supporting the anti-inflammatory effects of omega 3 fatty acids, so why is the addition of GLA beneficial for dry eye? Gamma-linoleic acid (GLA) specifically gives rise to prostaglandin E1 a potent anti-inflammatory which also stimulates tear production (Pholpramool, 1979, 1983). Prostaglandin E1 inhibits several types of tumor necrosis factor, interleukins, and leukotrienes in the tear film.

When GLA and EPA are combined in the proper balance, they work in conjunction to promote anti-inflammatory prostaglandins E1 and E3 and inhibit pro-inflammatory prostaglandin E2. The result is an increase in tear production, and a reduction in surface inflammation.

The Research and Results

Let’s be honest, when is the last time you topped off your lunch of Siberian pine nuts and salmon with a black currant seed oil dressing? So changing to a perfect diet is ideal yes, but perhaps not easy enough to be feasible for the average American. Reducing your dietary pro-inflammatory intake is an excellent starting place, but you’ll also likely need to supplement with anti-inflammatory sources of omega 3 and 6 fatty acids. The HydroEye Study was published in 2013 by Dr. John Sheppard and Dr. Stephen Pflugfelder. Thirty eight post-menopausal patients with moderate to severe keratoconjuncitivis sicca (dry eye) were started on a supplement of omega 6 gamma-linolenic acid and omega 3 polyunsaturated fatty acids or placebo for 6 months. They were evaluated for dry eye improvement with standard diagnostic tests including Ocular Surface Disease Index (OSDI), Schirmer test, tear breakup time, conjunctival fluorescein and lissamine green staining, as well as the expression of inflammatory cellular indicators dendritic cell CD11c integrin and HLA-DR (a key dry eye indicator) in conjunctival compression cytology. At 12-24 weeks, the supplement group had clinically significant improvement in symptoms (as measured by OSDI scores) versus placebo, significantly lower HLA-DR intensity and CD11c expression , and smoother corneas, as measured with topography (SAI Index).

There’s abundant research supporting the combination of omega 6 gamma-linoleic acid (GLA) and omega 3 fatty acids in the improvement of both the signs and symptoms of dry eye. A 2003 study followed patients for 45 days taking supplements versus placebo, and the supplement group had improved symptoms, corneal and conjunctival staining, and ocular surface inflammation mediator expression. A 2008 study of contact lens wearers with dry eye given evening primrose oil (an omega 6 fatty acid) for 6 months versus placebo (olive oil in this case) showed improved symptoms of dry eye, tear meniscus height, and improved contact lens comfort.

But what about Meibomian Gland Dysfunction?

Meibomian gland dysfunction is the most common underlying component of dry eye, with an estimated 86% of dry eye sufferers having Meibomian gland dysfunction. Studies show omega supplementation improves this underlying cause of dry eye as well. A 2007 study showed improvement in meibomian gland function with oral omega-6 supplementation of linoleic acid and gamma-linoleic acid over 180 days. A group of 57 men and women with previously diagnosed Meibomian gland dysfunction were separated randomly into 3 groups: Group A received tablets containing linoleic acid (28.5 mg) and gamma-linolenic acid (15 mg) once daily, Group B performed eyelid hygiene once daily, and Group C received both treatments. All groups had improvement in signs and symptoms of Meibomian gland dysfunction, but Group C that combined lid hygiene and supplements had the biggest statistically significant improvement in lid inflammation, including lid margin edema, Meibomian gland turbidity, and corneal staining.

Take Home

Managing dry eye is complicated, and turning the lens on managing your diet is a logical source contributor, but doesn’t make change any easier. Nutritional supplements have shown to make significant impact on the signs and the symptoms of dry eye as early as within 60 days of routine use. At my practice, we recommend HydroEye supplements because its’ formula combines both GLA with Omega-3s from fish oil for a maximized anti-inflammatory effect. If you are suffering from dry eye, there’s really no risk in trying this supplement – ScienceBased Health offers a 60 day money back guarantee. The supplement also combines vitamins Cs and B6, plus magnesium to promote fatty acid metabolism (and help convert GLA to important prostaglandin E1), and vitamin A to for tear film mucin support. What you can’t do if you suffer from dry eye is ignore your symptoms in hopes that they will improve on their own. Dry eye, like all chronic inflammatory diseases, only worsens and becomes harder to treat as inflammation lingers unchecked for longer periods of time. Unlike over the counter eye drops that can’t change the inflammatory chemistry of the ocular surface and tear film at the root of your discomfort and visual symptoms, dietary supplements and changes to your daily food choices can help reduce your inflammation from the inside out. The eyes are a part of the body, and dry eye is just an expression on inflammation going on elsewhere. Approach it from the source for the best chance of relief!

If you are an optometrist interested in trying out HydroEye for yourself and your patients, head here to get your free 60 day sample!

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Diagnosing Meibomian Gland Disease

diagnosing meibomian gland dysfunction dry eye 7:09 AM

For the estimated 30 million Americans suffering from dry eye, the initial diagnosis is often the biggest barrier to experiencing relief. In a world where spending 9+ hours a day on screens and devices is considered normal (1/3 of Americans do!), we can often normalize our ocular discomfort as just “being tired.” But redness, watering, fluctuating vision, and eye fatigue are signals of a much more serious underlying medical condition. Dry eye isn’t just uncomfortable eyes – it’s a progressive inflammatory condition that can result in permanent structural damage and even vision loss. The initial diagnosis is key to getting treatment to prevent severe damage to the ocular tissue.

Dr. Lyerly spends a lot of time talking about meibomian gland disease in her practice.

Where to look first?

Since the 1980s, there has been an abundance of research and evidence showing that dry eye often begins at the level of the meibomian gland. In fact an estimated 86% of people diagnosed with dry eye have underlying Meibomian Gland Dysfunction. Every human has around 20 glands in their inferior eyelid and 30 in their upper eyelid that secrete tear film oil (called meibum) onto the surface of the eye with each blink. These glands produce the top layer of the tear film, the important oil layer that holds the tear film onto the surface of the eye to prevent watering and evaporation. If the meibomian gland secretion becomes blocked or irregular, tear film evaporates at a much faster rate, causing eyes to burn, water, and vision to fluctuate. But more importantly (and detrimentally), the body’s own protective feedback loop to prevent dry eye is initiated. If the corneal nerves sense that the eye is too dry, they send feedback to the lacrimal and meibomian glands to produce more tear film. But if the glands are blocked or obstructed, no matter how much tear film gets produced, nothing can be secreted when the person blinks. The result is inflammation: the glands are hyperactive to try to overproduce missing tear film, but no relief occurs, so more hyperactivity is turned on. It’s a devastating feedback circle that can result in a persistent cycle of worsening pain, redness, and blurry vision.

The yellowish circles here are the meibomian glands of the superior eyelid. Inflammation is clearly evident in my patient; the lid margin is very injected (red) - a hallmark of chronic dry eye.

Detecting Meibomian Gland Dysfunction

How does your doctor discover underlying problems with your Meibomian glands? We have a variety of techniques and diagnostic devices to help us find early signs before the patient may even experience any symptoms, which is of course the best time to intervene!

“Not every patient who presents with dry eye or meibomian gland dysfunction is symptomatic. Typically, however, patients will notice some occasional foreign body sensation, irritation, redness, blurred, or fluctuating vision,” says Dr. Christine Wisecarver of See Clearly Vision. In addition to just asking about symptoms, doctors may also use questionnaires like the Ocular Surface Disease Index (OSDI) or Standard Patient Evaluation of Eye Dryness(SPEED). These surveys are designed to unlock dry eye complaints that may be passed off by the patient as “normal” and thus underreported when the doctor directly asks.

Dr. Leslie O’Dell of Mechanicsburg Eye also recommends asking patients about specific activities and times of their day to unlock possible meibomian gland dysfunction-related symptoms. She asks patients how their eyes feel in the morning when they wake up – AM watering or burning could be associated with inflammatory eyelid conditions like blepharitis or demodex mites, or not fully closing the eyes when we sleep (called lagophthalmos). Another useful question is asking about how eyes feel after being on the computer for several hours. The average person blinks 50% less often when looking at screens, which results in less meibomian gland expression (the glands only secrete when we blink). Blinking less can have a devastating toll on the glands as it can also result in higher incidence of clogged glands. If oil stays in the gland too long it can begin to harder and obstruct, eventually choking the gland off from nutrients and causing gland atrophy and death.

Symptoms of watering are extremely common indicators of dry eye. “When our technicians meet with patients who present with dry eye, and their main complaint is excessive tearing, the patient is extremely confused to hear they have dry eye,” states Dr. Wisecarver. “WE must explain that the tear film is made up of three different parts. If the eye isn't producing all three parts in the correct proportions, your eye will over produce others, thus causing excessive tearing.”

Blurry vision is another indicative complaint Dr. Wisecarver sees in her dry eye practice. “Some patients also have the misconception that their blurred vision means they simply need to change their glasses prescription. We often explain that blurred vision may not be a prescription change but rather a consequence of an unstable tear film or other ocular disorder.”

In the Microscope

Physically assessing the glands at the microscope is an essential way for doctors to detect early signs of dry eye disease. “Clinically, we look for blocked, or capped, glands, thickened and red lid margins, and dilated blood vessels at the lid margin. The doctor will often gently press on the lids to see the consistency of the oil secretion,” states Dr. Wisecarver.

Evaluating the meibomian glands with the Korb Meibomian Gland Evaluator via

The key to evaluating meibomian gland expression is gentle pressure. Our blink offers only a minimal amount of force on the glands, but a doctor using their finger to manually push on the gland to determine expression can falsely indicate the glands are working better than they really are. Meibomian gland guru Dr. Donald Korb invented the Korb Meibomian Gland Evaluator to prevent this issue. The device uses the exact amount of pressure a blink would naturally put on the gland to prevent overestimating expression. There is much debate within eyecare about the potential dangers of manually and forcefully expressing the glands (could it damage the glands or cause increased gland inflammation?), so using this gentle gland evaluation method is preferred.

There are also great tools to visibly evaluate the length of the meibomian gland. Gland dilation and shortening (or atrophy) is evidence of advanced disease, so observing damaged and dying glands requires immediate intervention. Doctors can use a transilluminator held to the eyelid skin to visibly see the glands to evaluate length and regularity, or higher tech imaging systems that can show the glands in all of their subtle detail.

A doctor uses a transilluminator to see the meibomian glands. To do this, turn the slit lamp and room lights off, place the transillumintor on the bottom eyelid and gently evert the lower lid. via

Imaging systems offer a great tool for both the doctor and the patient to be able to see damaged meibomian glands. The LipiView imaging system uses infrared light to highlight the glands (below). Also available is the Oculus Keratograph with its Meibo-Scan software.

The LipiView system by TearScience is the method used where Dr. Lyerly practices, Triangle Visions Optometry. The patient pictured here is in her 20s and unable to wear contact lenses anymore due to dry eye and fluctuating vision with lenses.

Take Home

Once the doctor diagnoses Meibomian gland disease, the most important thing for the patient is to understand is that dead and damaged glands is not normal – it’s a sign of advanced disease that can result in permanent discomfort and visual distortion. Waiting to intervene will only worsen the severity of the disease, so there is no better time to start treating the eyes than when minimal or even no symptoms yet exist.

“MGD is a chronic condition,” states Dr. Wisecarver. “We are able to improve the function of the meibomian glands, but not necessarily reverse damage that has already been done through years of gland blockage. Treatment will reduce symptoms but consistency is key to managing the problem and preventing the long term damage.”

“Ultimately, educating patients as to WHY we recommend following a certain protocol for treatment will encourage the patient to continue with the regimen. Just like dentistry, you get cavities if you don't brush your teeth well. However, if you brush your teeth, your risk of decay is greatly reduced. Similarly, treating MGD daily reduces a patient's risk of styes, dry eye and damage to the oil glands themselves.”

Whether treatment includes heating the glands to remove obstruction with Lipiflow, daily heated Bruder masks, eyelid hygiene, nutritional supplements, or medication, daily maintenance is key to preventing worsening ocular health, comfort, and vision.

A big thanks to Irina Price and Dr. Christine Wisecarver for contributing on this post!

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A New Standard in Stability: Meet Ultra for Astigmatism

astigmatism contact lens rotation 4:13 PM

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Keratoconus Is Much More Prevalent Than We Thought

1 in 375 have keratoconus 4:42 PM

If you're a long time reader, you'll know I've dedicated a lot of articles to writing about specialty contact lenses for keratoconus because its the specialty I've chosen to pursue in my own eyecare practice. In the five years that I have been out of optometry school, I've fit hundreds of patients with specialty contact lenses for irregular corneas, and over and over I found myself wondering, how could I be seeing so many? A new study out of the Netherlands in 2016 has revolutionized how common we believe keratoconus to be, reporting a prevalence of 1 in 375 people. Compare that to the previous estimated prevalence of 1 in 2000 reported in a 1986 study out of Minnesota, and you can see why the news has rocked the eyecare world.

An eye with keratoconus and corneal scarring via

What is Keratoconus?
Eyecare specialists define keratoconus as "bilateral, asymmetrical, noninflammatory pathology characterized by progressive, localized thinning and protrusion of corneal tissue." In layman's terms, you'll often hear it described as a steepening of the cornea, causing the cornea to bulge forward and disrupt vision. One reason why we've struggled so much to both treat and properly define how prevalent keratoconus is in society is because we still have a poor understanding of what is happening in this disease. We know that the process of corneal thinning and protrusion usually starts around puberty, and progresses on average 10-20 years from there. Most people by age 40 have no further progression of the disease because of aging changes that stiffen and thus strengthen the cornea and prevent further prolapse. Keratoconus can be detected in its earliest stages with corneal topography, where the tell-tale surface steepening is visible creating a pattern of asymmetric and irregular astigmatism on the corneal surface.

Corneal topography showing normal (regular) astigmsim on the left and irregular astigmatism caused by keratoconus on the right. Note the lack of symmetry vertically in this map - a giveaway of corneal dystrophy. via

Access to corneal topography is the big reason researchers think keratoconus was so greatly under reported in earlier population studies. In the 1986 study that reported a prevalence of 1 in 2000, doctors had to detect keratoconus based on irregularities seen on keratometry and during retinoscopy. These days, you'll be hard pressed to find an office with old-school manual keratometers, replaced with high tech corneal topography that can detect even subtle changes. With this newer technology, earlier and much milder forms of corneal irregularity can be detected.

What We Know and What We Don't
For years doctors have theorized that keratoconus had a genetic component, but there has never been a gene found that definitively proved this. And population studies looking at genetic prevalence show mixed results. Environmental factors like allergies and chronic eye rubbing also appear to contribute. So if you are looking for a definitive answer to why you have keratoconus, the answer is not so simple. It's probably a mixture of environmental and genetic risk factors.

Here's what we do know:

Keratoconus is more common in India, the Middle East, and China than other countries around the world. It is unknown if this is due to environmental difference in temperature, oxidative UV damage from being closer to the equator, or diet and nutritional differences.
The genetic prevalence of keratoconus differs based on ethnicity.

In the US, the genetic prevalence of keratoconus is between 6 and 13.5% depending on the study you look at.
When prevalence in a 2015 study was separated by ethnicity, Caucasians were found to have a genetic prevalence of 5% and Asians had 25% prevalence.

Eye rubbing is an associated risk factor; chronic ocular allergies may be a risk factor (or is it just the rubbing?)

People with keratoconus tend to rub their eyes longer and "more vigorously" than those with normal corneas. An average cornea patient tends to rub their eyes on average for 5 seconds and no longer than 15 seconds even when bothered by allergies; surveyed keratoconus patient rubbed their eyes between 10 and 180 seconds. Additionally, keratoconus is associated with:

rotational knuckling motion with rubbing
more forceful rubbing
rubbing frequency greater than once a day
rubbing year round (not just seasonal with allergies)

Study results are mixed as to whether the risk of keratoconus is higher with a history of chronic allergies or atopic hypersensitivity like asthma and eczema. About 1/3 of patients with keratoconus self-report a history of allergies.

An eye with keratoconus via

There is still much to learn about why keratoconus develops and we are no closer to a cure unfortunately. Luckily new treatments like corneal cross linking are showing excellent results at slowing progression of the disease. Early detection is key to stabilizing vision before the condition has progressed too far, and with the knowledge that keratoconus is so much more common than once believed, the hope is that doctors will be more active than ever in trying to detect early cases and get them referred for intervention and treatment as soon as possible.

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