Does Pregnancy Make Keratoconus Worse? A Patient's Guide

If you’ve got keratoconus and you’re pregnant, or planning to be, or partway through fertility treatment, you’ve probably wondered what it means for your eyes. The honest answer is that it can matter. Pregnancy hormones can make keratoconus progress, the change is often temporary (though not always), and it can happen even in eyes that have already been cross-linked.

That sounds alarming, and I don’t want it to. With a scan before you conceive, and knowing that anything you lose can be treated after the birth, it becomes a manageable part of the disease. Let me go through what the evidence says and how I plan around it with my patients.

Why pregnancy affects the cornea

The underlying problem in keratoconus is that the cornea isn’t strong enough. It’s held in shape by a lattice of collagen, and in keratoconus that lattice is weaker than it should be, which is why the cornea gradually bulges forward into a cone. So anything that weakens collagen further can push the disease along, and pregnancy hormones seem to do that.

The cornea has receptors for sex hormones, and laboratory work has shown that oestrogen reduces the stiffness of corneal tissue. That finding was first published to explain why ectasia after laser surgery is more common in women. A systematic review published in 2026 pulled the observational evidence together and found consistent associations between fluctuations in oestrogens, gonadotropins and related hormones and both the development and the progression of keratoconus. The proposed mechanism is that these hormones switch on enzymes in the cornea that break down and remodel the collagen matrix.

Pregnancy also changes every cornea a little, keratoconus or not. In women without the disease the cornea becomes slightly thicker and steeper, less sensitive and drier, and those changes reverse after delivery. If the cornea is already weak, the same hormonal push can be enough to tip it from stable into progressing.

What the studies actually show

What we’ve got is a handful of case reports and one prospective cohort study, and they all point the same way.

• A 2011 series in the journal Cornea documented progression in seven eyes of four women during pregnancy. The change showed up on topography, in their glasses prescription and in the way their rigid contact lenses fitted.
• A 2013 report described two women whose corneas steepened significantly during pregnancy and then reversed several months after delivery, the first time anyone clearly showed that some of the change is temporary.
• Two women were diagnosed with keratoconus for the first time after pregnancy. The hormonal shift seems to have unmasked disease that had been sitting quietly.
• The strongest evidence is a prospective cohort study. It took women with keratoconus that had been stable for at least two years and scanned them before pregnancy, at 34 weeks, and six months after delivery, alongside matched non-pregnant women with keratoconus. The pregnant group progressed, and the changes were still there six months after the birth. The authors’ conclusion was that women with keratoconus who intend to become pregnant should consider cross-linking first.
• A 2023 case report with a review of the literature followed a woman whose Kmax (the steepest point of the cornea) rose from 47.6 to 48.2 dioptres in one eye and from 53.7 to 55.2 in the other across pregnancy and breastfeeding, then came back to baseline about six months after she stopped breastfeeding. Even so, the disease stage in one eye stayed higher than it had been. The review’s advice was to wait for the cornea to settle before deciding on treatment.

The way I read all that: progression during pregnancy is real, it often reverses at least partly but not always, and the hormonal window runs on through breastfeeding rather than ending at delivery, which surprises a lot of people.

What if you’ve already had cross-linking?

Corneal cross-linking stiffens the cornea and it’s the only treatment we have that’s proven to stop keratoconus progressing. Having had it makes pregnancy-related progression much less likely, but I can’t tell you it’s a guarantee.

The first warning came from a 2008 case report of a woman whose ectasia after LASIK had been stabilised with cross-linking, and then worsened again during her second pregnancy. A 2021 study of 24 previously cross-linked eyes in 19 women is more reassuring: about 42% of the eyes steepened during pregnancy, but the corneas then flattened by nearly the same amount after delivery, so most of that progression was temporary.

If you’ve been cross-linked, then, I’d say the risk in pregnancy is low, though I wouldn’t call it nil. Usually the change is temporary, and if something does persist it can be treated after the birth. One caveat from my own practice: cross-linking itself changes the corneal shape for the first year as the cornea remodels, and I don’t count anything in that window as progression, so scans taken in the year after cross-linking need to be read with that in mind. I’ve written more about this in what if cross-linking doesn’t work.

IVF and fertility treatment

It seems to be the hormones doing the damage rather than the pregnancy itself, and the clearest evidence for that comes from IVF. A 2016 report in the Journal of Refractive Surgery described three women with keratoconus, average age 32, whose disease progressed in all six eyes during IVF treatment, and none of them became pregnant, so the hormonal stimulation on its own was enough.

If you have keratoconus and you’re planning fertility treatment, have your cornea scanned before you start, and if it’s changing, get it stabilised first.

Can you have cross-linking while pregnant?

The standard advice is to avoid it, and I follow that advice. Nobody has shown cross-linking to be harmful in pregnancy. Riboflavin is just vitamin B2, and the ultraviolet light only goes onto the cornea. The problem is that the procedure has never been studied in pregnant women, and it does come with anaesthetic and antibiotic drops, usually some sedation, and pain relief afterwards. Patient organisations such as the National Keratoconus Foundation and the clinical reviews give the same advice I do: if the cornea is progressing, cross-link before conception, and anything that changes during pregnancy can be dealt with once the baby has arrived.

Very occasionally, with rapid progression or acute hydrops, say, treating during pregnancy becomes a conversation between you, me and your obstetrician. In my experience that’s rare, and most of the time the better route is to plan ahead so it never comes up.

Planning a pregnancy with keratoconus

This is the sequence I’d suggest, and it isn’t complicated.

Before you start trying. Have your cornea scanned with tomography, which is the three-dimensional corneal map that shows shape and thickness. If it shows progression, or if your keratoconus has never been cross-linked and you’re young enough that it’s probably still active, I’d have cross-linking done first. With epi-on treatment the recovery is measured in days, and that gives the cornea time to settle before you conceive.

During pregnancy. I don’t recommend routine scans, because I wouldn’t act on them, and I say that to every patient who asks. Cross-linking and CAIRS both wait until after the birth, so a scan that shows change halfway through a pregnancy does nothing except add worry, at a time when the health of your baby, and your own mental health, matter far more than a corneal map. If your vision changes, or your contact lenses stop fitting the way they did, note it and let us know, but please don’t lose sleep over it. Whatever ground is lost can almost always be recovered afterwards. The one thing I do want to see the same day is sudden pain with a cloudy white cornea, because that can be hydrops, where the inner layer of the cornea splits and fluid rushes in.

After the birth. A scan around six months after delivery, and if you’re breastfeeding, another one after you stop. If the progression has persisted rather than reversed, that’s the point to treat it, with cross-linking to stop it and, where a steeper cornea has cost you vision, CAIRS to rebuild the corneal shape. Between the two I can almost always recover what’s been lost.

Contact lenses, dry eyes and rubbing

There are a few practical things that make pregnancy easier on a keratoconic eye.

Lenses. The cornea thickens and steepens a little and the eye gets drier, so rigid and scleral lenses often feel different. Don’t push through a lens that’s uncomfortable, and keep a pair of glasses as backup. A change in fit usually means the cornea has steepened slightly. Your lens fitter can adjust it, and it may need adjusting back after the birth.

Dry eye. Preservative-free lubricating drops are safe and they help with the grittiness. Any other drop, check with your obstetrician or pharmacist first.

Rubbing. Eye rubbing is the single most important thing you can control in keratoconus, pregnant or not, and I say this to every patient. Pregnancy rhinitis and allergy flares are common, they make the eyes itch, and itching leads to rubbing. Cold compresses and lubricants will take the itch away without rubbing, and I’ve set out a full allergy management plan that applies just as well in pregnancy.

Labour and delivery

Keratoconus doesn’t change how you give birth. I’m not aware of any evidence that pushing, or the method of delivery, has any effect on the cornea, and keratoconus on its own isn’t a reason for a caesarean. If someone tells you otherwise, I’d ask them what evidence they’re basing that on.

The bottom line

Pregnancy can make keratoconus progress, and the change often reverses but not always. IVF hormones can do the same thing, and cross-linking lowers the risk without taking it away completely. None of that should stop anyone with keratoconus from having a family. What it means in practice is a scan before you conceive, cross-linking first if the cornea is changing, and a check after the birth. Nothing needs doing in between, and whatever pregnancy takes from the cornea can almost always be recovered afterwards with cross-linking or CAIRS. If you’re planning a pregnancy and your keratoconus hasn’t been checked in the last year, I’d make that appointment first.