Does Pregnancy Make Keratoconus Worse? A Patient's Guide

If you have keratoconus and you’re pregnant, planning to be, or going through fertility treatment, you’ve probably wondered whether it affects your eyes. The short answer is that it can. Pregnancy hormones can make keratoconus progress, the change is often temporary but 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 be. With a scan before you conceive, and the knowledge that anything lost can be treated after the birth, this is a manageable part of the disease rather than a crisis. Here’s what the evidence says and how I plan around it with my patients.

Why pregnancy affects the cornea

Keratoconus is a disease of corneal strength. The cornea is 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 into a cone. Anything that weakens collagen further can push the disease along, and pregnancy hormones appear to do exactly that.

The cornea has receptors for sex hormones, and laboratory work has shown that oestrogen reduces the stiffness of corneal tissue, a finding first published to explain why ectasia after laser surgery is more common in women. A systematic review published in 2026 pulled together the observational evidence and found consistent associations between fluctuations in oestrogens, gonadotropins and related hormones and both the development and 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 changes every cornea a little. Even in women without keratoconus, the cornea becomes slightly thicker and steeper, less sensitive and drier, and those changes reverse after delivery. In a cornea that’s already weak, the same hormonal push can tip it from stable into progressing.

What the studies actually show

The evidence is a mix of case reports and one prospective cohort, and it points the same way.

• A 2011 series in the journal Cornea documented progression in seven eyes of four women during pregnancy, with the change showing 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 clear demonstration that some of the change is temporary.
• Two women were diagnosed with keratoconus for the first time after pregnancy, the hormonal shift apparently unmasking disease that had been quiet.
• The strongest evidence is a prospective cohort study that scanned women with keratoconus that had been stable for at least two years, before pregnancy, at 34 weeks and six months after delivery, against matched non-pregnant women with keratoconus. The pregnant group progressed, and the changes were still present 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 returned to baseline about six months after she stopped breastfeeding. Even so, the disease stage in one eye stayed higher than before. The review’s advice was to wait for the cornea to settle before deciding on treatment.

Put together: progression during pregnancy is real, it often reverses at least partly, it doesn’t always, and the hormonal window runs through breastfeeding rather than ending at delivery.

What if you’ve already had cross-linking?

Corneal cross-linking stiffens the cornea and is the only treatment proven to stop keratoconus progressing. It makes pregnancy-related progression much less likely, but it isn’t a guarantee.

The first warning came from a 2008 case report of a woman whose ectasia after LASIK had been stabilised by cross-linking, only to worsen again during her second pregnancy. More reassuringly, a 2021 study of 24 previously cross-linked eyes in 19 women found that about 42% steepened during pregnancy, but the corneas then flattened by nearly the same amount after delivery. The progression was mostly temporary.

So if you’ve been cross-linked, pregnancy is lower risk, but it is not zero risk. The reassuring part is that the change is usually temporary, and anything that persists 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. 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

The hormones matter more than the pregnancy itself, and IVF is the proof. 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. None of them became pregnant. The hormonal stimulation alone 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. It isn’t that cross-linking is known to be harmful in pregnancy. Riboflavin is vitamin B2, and the ultraviolet light is applied only to the cornea. It’s that the procedure has never been studied in pregnant women, and it comes with anaesthetic and antibiotic drops, usually sedation, and pain relief afterwards. Patient organisations such as the National Keratoconus Foundation and clinical reviews give the same advice: if the cornea is progressing, cross-link before conception. Anything that changes during pregnancy can be dealt with after the birth.

In an exceptional situation, such as rapid progression or acute hydrops, treatment during pregnancy becomes a conversation between you, me and your obstetrician. That’s rare. The far better route is planning.

Planning a pregnancy with keratoconus

This is the sequence I’d suggest, and it’s simple.

Before you start trying. Have your cornea scanned with tomography, 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 likely to be active, have cross-linking done first. With epi-on treatment the recovery is measured in days, and the cornea then has time to settle before you conceive.

During pregnancy. I don’t recommend routine scans, because I wouldn’t act on them. Cross-linking and CAIRS both wait until after the birth, and a scan that shows change in the middle of a pregnancy only adds 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 don’t lose sleep over it. Whatever ground is lost can almost always be recovered afterwards. The one thing that does need to be seen the same day is sudden pain with a cloudy white cornea, because it can be hydrops, a split in the inner layer of the cornea that lets fluid rush in.

After the birth. A scan around six months after delivery, and if you’re breastfeeding, again after you stop. If progression has persisted rather than reversed, that is the point to treat it: cross-linking to stop it, and where a steeper cornea has cost you vision, CAIRS to rebuild the corneal shape. Between them they can almost always recover what pregnancy took.

Contact lenses, dry eyes and rubbing

Three practical things make pregnancy easier on a keratoconic eye.

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

Dry eye. Preservative-free lubricating drops are safe and help with the grittiness. Check any other drop with your obstetrician or pharmacist.

Rubbing. Eye rubbing is the single most important thing you can control in keratoconus, at any time. Pregnancy rhinitis and allergy flares are common and make eyes itch, and itching leads to rubbing. Cold compresses and lubricants 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 does not change how you give birth. I’m not aware of any evidence that pushing or the method of delivery affects the cornea, and keratoconus on its own is not a reason for a caesarean. If anyone tells you otherwise, ask them for the evidence.

The bottom line

Pregnancy can make keratoconus progress, the change often reverses but not always, IVF hormones can do the same, and cross-linking lowers the risk without removing it. None of that should stop anyone with keratoconus having a family. It just means 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 what pregnancy takes from the cornea can almost always be given back afterwards with cross-linking or CAIRS. If you’re planning a pregnancy and your keratoconus hasn’t been checked in the last year, that’s the appointment to make first.