Keratoconus: Cross-Linking, Lenses, Other Treatments, and Where Integrative Care Fits

In short. Keratoconus is a thinning of the cornea, the clear window at the front of the eye, which bulges forward into a cone. It usually starts in the teens or twenties and blurs and distorts vision. Glasses or specialist contact lenses give clear vision for most people, without surgery. Corneal cross-linking, which uses vitamin B2 drops and ultraviolet light, is the only treatment shown to slow or stop it getting worse [1]. Stop rubbing your eyes, get any allergy treated, and go the same day for sudden painful clouding. No drop, supplement or herb has been shown to stop or reverse keratoconus, and integrative care does not treat it.

What keratoconus is. A Dutch study of 4.4 million insured people estimated that 1 in 375 people have keratoconus [2]. The average age at diagnosis was 28, and 61% of patients were male [2]. Older studies had found rates 5 to 10 times lower, probably because modern scans pick up milder cases [2].

Typical symptoms are blurred or distorted vision, doubled or "ghost" images, and glare or halos around lights at night. Glasses prescriptions often change quickly, with rising astigmatism. Both eyes are usually affected, often one more than the other.

A corneal tomography scan maps the shape and thickness of the cornea. Repeat scans show whether it is getting steeper, which is the main question in deciding on cross-linking.

What raises the risk. In one study, eye rubbing was the only factor still linked to keratoconus after allowing for others (odds ratio 6.3) [3]. A review of 29 studies found links with eye rubbing (odds ratio 3.1), family history (6.4), allergy, asthma and eczema [4]. In one family study, 3.3% of parents, brothers, sisters and children of patients had keratoconus, 15 to 67 times the general rate [5].

Acute hydrops is that sudden clouding: a tear in the back layer of a very thin cornea lets fluid flood in. A UK national study counted about 1.4 cases per 1,000 people with keratoconus each year [6]. By six months, a transplant was planned for 20% [6].

In a Japanese series, the swelling cleared within three months in 55 of 77 eyes with full follow-up (71%) [7].

Treatments with good evidence

Corneal cross-linking (CXL). Riboflavin (vitamin B2) drops soak into the cornea, then ultraviolet A light makes its collagen fibres bond and stiffen. In the standard "epi-off" method, the thin surface layer is removed first. The FDA approved this system (Photrexa Viscous, Photrexa and the KXL System, from Avedro) for progressive keratoconus on 18 April 2016 [8].

In the US multicentre trial of 205 people with progressive keratoconus, the steepest corneal reading flattened by 1.6 dioptres one year after CXL [9]. In the sham-treated comparison group, keratoconus continued to progress [9]. In an Australian trial of 100 eyes, untreated corneas steepened by 1.75 dioptres over three years, while treated corneas flattened by 1.03 [10].

The KERALINK trial treated 60 young people aged 10 to 16 [11]. At 18 months, keratoconus progressed in 7% after CXL, against 43% with glasses or contact lenses alone [11]. A 2015 Cochrane review called the evidence then available "very low quality" [12], and larger trials such as these have been published since.

In the Netherlands, about 25% fewer corneal transplants were needed for keratoconus after CXL came into use [13].

The first few days after epi-off CXL are usually sore while the surface layer grows back. Haze in the cornea was the most common side effect in the US trial [9]. CXL does not usually remove the need for glasses or lenses; its job is to protect the vision you have.

Epithelium-on cross-linking. On 20 October 2025 the FDA approved Epioxa (Glaukos), a cross-linking treatment that does not remove the surface layer [14]. It is approved for people aged 13 and over, and is based on two phase 3 trials with more than 400 patients [14]. The most common side effect was red eye, in 31% [14].

Earlier epi-on methods, in a 2021 Cochrane review of 13 trials, showed no clear difference from epi-off, but the evidence was very uncertain [1]. Ask your surgeon which method suits your eye.

Glasses and contact lenses. Experts agree on a stepwise approach to clear vision [15]. Glasses or soft toric lenses work in early keratoconus. Rigid gas permeable lenses create a smooth new front surface and often give much sharper vision.

Hybrid lenses have a rigid centre and a soft skirt for comfort. Scleral lenses are larger rigid lenses that vault over the cornea on a pool of saline, and they often help when other lenses fail. Lenses correct vision but do not stop progression: in KERALINK, 43% of eyes on glasses or lenses alone got worse in 18 months [11].

Corneal transplant, for advanced disease. A transplant is used for scarring, or when lenses no longer give useful vision. About 10% to 15% of people with keratoconus eventually need one [16].

Deep anterior lamellar keratoplasty (DALK) replaces the front layers and keeps your own inner layer. Penetrating keratoplasty (PK) replaces the full thickness. A Cochrane review of two trials (111 people) found similar vision with either method [16].

Treatments with some evidence

Stopping eye rubbing and treating allergy. The link between rubbing and keratoconus is strong [3,4], although no trial has tested stopping. Ask your doctor about allergy drops, and use cold compresses instead of rubbing.

Intracorneal ring segments. Small curved plastic inserts are placed inside the cornea to flatten the cone. In selected eyes they can improve vision or lens fit, and they are often combined with CXL.

What is not proven

• Acupuncture and herbal medicine. We have not found any clinical trial of acupuncture, Chinese herbs or Ayurvedic herbs in keratoconus. There is no reason to expect needling or herbs to change the cornea's shape.
• Supplements and vitamins. In the only randomised trial we found, 34 patients took DHA (an omega-3 fat) or nothing for three months [17]. Blood markers changed, but the trial did not show that keratoconus was slowed or stopped [17]. Vitamin B2 tablets do not cross-link the cornea; CXL needs the drops plus ultraviolet light.
• Eye drops, eye exercises and "restorative corneal care" sold online. None has been shown to reverse or stop keratoconus.
• Anything that asks you to delay cross-linking while your cornea is getting steeper. Lost corneal shape does not come back.

Where Netra fits

Netra Eye Institute is an acupuncture and Oriental medicine practice. We do not diagnose or treat keratoconus, and we do not replace your cornea specialist or contact lens fitter. Our role is adjunctive:

• We check that the basics are in place: regular corneal scans, a plan for cross-linking if scans show progression, and allergy treatment.
• We offer acupuncture and, where appropriate, Chinese herbal medicine within Netra Restoration Therapy (NRT), with the evidence explained before you start. For keratoconus that evidence is absent. Herbs are reviewed against your medicines.
• We help with the itch-and-rub habit, and we never put herbal washes or drops in the eye. After CXL or a transplant, we wait for your surgeon's approval before any treatment near the eyes.
• We share what we see with your eye doctor. We refer back quickly if your vision changes, or your eye becomes red or painful.

NRT is not a treatment for keratoconus and does not replace cross-linking, specialist lenses or corneal surgery. For Ayurvedic approaches, see Ayurvedic treatment for keratoconus. If you want to talk through whether integrative care makes sense alongside your treatment, request a consultation.

Questions people ask

Is there a cure for keratoconus?

No treatment returns the cornea to normal. Cross-linking stops progression in most eyes [11], lenses give clear vision for most people, and a transplant replaces badly scarred tissue [16]. Together these mean most people keep useful vision.

Is there a non-surgical keratoconus treatment, or one without surgery?

Yes. Glasses and contact lenses, including scleral lenses, are non-surgical. Cross-linking is a clinic procedure with drops and light, with no cut, and the newer epi-on method leaves the surface layer in place [14].

Can keratoconus be managed naturally?

The natural steps that matter are to stop rubbing your eyes, keep allergies under control and keep your scan appointments [3,4]. Good contact lens hygiene protects against infection. Nothing natural has been shown to stop or reverse the cone.

Can supplements or vitamins treat keratoconus?

No supplement or vitamin has been shown to slow or reverse it [17]. The vitamin B2 in cross-linking works only as drops activated by ultraviolet light in the clinic.

How can I relieve keratoconus eye pain?

Keratoconus itself is not usually painful. Pain more often comes from a poorly fitting lens, dry eye, a scratch, infection or hydrops. Remove your lenses, use preservative-free lubricating drops, and see your eye doctor, the same day if pain is severe or the eye is red.

Should my family be checked?

Yes, especially brothers, sisters and children in their teens. Close relatives are many times more likely to have keratoconus [5], and early scans allow cross-linking before vision is lost.

References

1. Ng SM, Ren M, Lindsley KB, et al. Transepithelial versus epithelium-off corneal crosslinking for progressive keratoconus. Cochrane Database Syst Rev. 2021;3:CD013512.
2. Godefrooij DA, de Wit GA, Uiterwaal CS, et al. Age-specific incidence and prevalence of keratoconus: a nationwide registration study. Am J Ophthalmol. 2017;175:169-172.
3. Bawazeer AM, Hodge WG, Lorimer B. Atopy and keratoconus: a multivariate analysis. Br J Ophthalmol. 2000;84(8):834-836.
4. Hashemi H, Heydarian S, Hooshmand E, et al. The prevalence and risk factors for keratoconus: a systematic review and meta-analysis. Cornea. 2020;39(2):263-270.
5. Wang Y, Rabinowitz YS, Rotter JI, et al. Genetic epidemiological study of keratoconus: evidence for major gene determination. Am J Med Genet. 2000;93(5):403-409.
6. Barsam A, Petrushkin H, Brennan N, et al. Acute corneal hydrops in keratoconus: a national prospective study of incidence and management. Eye (Lond). 2015;29(4):469-474.
7. Aichi T, Kitazawa K, Kozaki R, et al. Identification of risk factors for persistent corneal edema associated with acute corneal hydrops in keratoconus. Jpn J Ophthalmol. 2025;69(3):365-370.
8. Avedro. Avedro receives FDA approval for Photrexa Viscous, Photrexa and the KXL System for corneal cross-linking. Press release, 18 April 2016. Flagship Pioneering (repost).
9. Hersh PS, Stulting RD, Muller D, et al. United States multicenter clinical trial of corneal collagen crosslinking for keratoconus treatment. Ophthalmology. 2017;124(9):1259-1270.
10. Wittig-Silva C, Chan E, Islam FM, et al. A randomized, controlled trial of corneal collagen cross-linking in progressive keratoconus: three-year results. Ophthalmology. 2014;121(4):812-821.
11. Larkin DFP, Chowdhury K, Burr JM, et al. Effect of corneal cross-linking versus standard care on keratoconus progression in young patients: the KERALINK randomized controlled trial. Ophthalmology. 2021;128(11):1516-1526.
12. Sykakis E, Karim R, Evans JR, et al. Corneal collagen cross-linking for treating keratoconus. Cochrane Database Syst Rev. 2015;(3):CD010621.
13. Godefrooij DA, Gans R, Imhof SM, et al. Nationwide reduction in the number of corneal transplantations for keratoconus following the implementation of cross-linking. Acta Ophthalmol. 2016;94(7):675-678.
14. Glaukos Corporation. Glaukos announces FDA approval of Epioxa. Press release, Aliso Viejo, CA, 20 October 2025. Glaukos (PDF); Business Wire.
15. Gomes JAP, Tan D, Rapuano CJ, et al. Global consensus on keratoconus and ectatic diseases. Cornea. 2015;34(4):359-369.
16. Keane M, Coster D, Ziaei M, et al. Deep anterior lamellar keratoplasty versus penetrating keratoplasty for treating keratoconus. Cochrane Database Syst Rev. 2014;(7):CD009700.
17. Peris-Martínez C, Piá-Ludeña JV, Rog-Revert MJ, et al. Antioxidant and anti-inflammatory effects of oral supplementation with a highly-concentrated docosahexaenoic acid (DHA) triglyceride in patients with keratoconus: a randomized controlled preliminary study. Nutrients. 2023;15(5):1300.