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Clinical relevance The Keratoconus International Consortium (KIC) will allow better understanding of keratoconus. Background Keratoconus is a disorder characterised by corneal elevation and thinning, leading to reduced vision. The current gaps in understanding of this disease will be discussed and the need for a multi-pronged and multi-centre engagement to enhance our understanding of keratoconus will be highlighted. Design KIC has been established to address the gaps in our understanding of keratoconus with the aim of collecting baseline as well as longitudinal data on several fields. Participants Keratoconus and control (no corneal condition) subjects from different sites globally will be recruited in the study. Methods KIC collects data using an online, secure database, which enables standardised data collection at member sites. Data fields collected include medical history, clinical features, quality of life and economic burden questionnaires and possible genetic sample collection from patients of different ethnicities across different geographical locations. Results There are currently 40 Australian and international clinics or hospital departments who have joined the KIC. Baseline data has so far been collected on 1130 keratoconus patients and indicates a median age of 29.70 years with 61% being male. A total of 15.3% report a positive family history of keratoconus and 57.7% self-report a history of frequent eye rubbing. Conclusion The strength of this consortium is its international, collaborative design and use of a common data collection tool. Inclusion and analyses of cross-sectional and longitudinal data will help answer many questions that remain in keratoconus, including factors affecting progression and treatment outcomes.

Purpose To evaluate the efficacy and safety of accelerated corneal cross-linking (A-CXL) while preserving the epithelium over the central 3 mm of the cornea compared to epithelium removal CXL in cases of paracentral keratoconus. Methods In this prospective comparative study, 140 eyes of 77 patients were randomized to receive either A-CXL with preservation of the central 3 mm of corneal epithelium or A-CXL with removal of whole corneal epithelium over a central disk area with a diameter of 9 mm. Patients were observed regularly for 1 year after the procedure. The primary outcome measures were to compare early uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA), corneal haze, pain, and discomfort in the first week between the two groups. The secondary outcome measure was keratoconus progression after 12 months of follow-up, measured by the maximum keratometry (Kmax) value. Results A significant difference was found between the two groups regarding early postoperative CDVA, corneal haze, pain, and discomfort, with more favorable results in the ACXL with preservation of the central 3 mm of corneal epithelium group. At 12 months of follow-up, a significant improvement in UDVA, CDVA, and Kmax was noticed among patients of the same group, with better final vision and a reduction in Kmax as compared to the preoperative values. Conclusions Preserving the epithelium over the central 3 mm of the cornea during A-CXL in cases with paracentral keratoconus can provide the benefits of immediate early postoperative visual rehabilitation, less corneal haze, less pain, good efficacy, and prevention of keratoconus progression. [J Refract Surg. 2025;41(5):e492–e500.]

To report the safety and long-term efficacy of topography-guided partial-refraction PRK combined with corneal cross-linking (CXL) (the Athens Protocol), refractive, topographic, and pachymetric changes of keratoconic eyes treated were studied. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), refraction, keratometry, qualitative and quantitative assessment of corneal keratometric, and pachymetric properties recorded by topography and tomography were evaluated for 10 years postoperatively. A total of 144 eyes were followed up for a mean 128 ± 4 months (range: 120 to 146 months). Mean UDVA markedly improved at 1 year (0.19 ± 0.17 to 0.53 ± 0.21 decimal) with further improvement to 0.55 ± 0.19 decimal at 10 years. CDVA increased from 0.59 ± 0.21 to 0.80 ± 0.17 decimal at 1 year and further to 0.81 ± 0.19 decimal at 10 years. Corneal thickness decreased from 468.74 ± 35.05 to 391.14 ± 40.07 μm at 1 year (P < .01) and up to 395.42 ± 32.21 μm at 10 years. Steep keratometry decreased from 50.57 ± 2.80 to 45.87 ± 2.70 diopters (D) (P < .01) at 1 year and to 44.00 ± 3.22 D at 10 years. Maximum keratometry decreased from 53.43 ± 2.97 to 46.17 ± 1.18 D at 1 year and 44.75 ± 2.14 D at 10 years (P < .01). A total of 94.4% demonstrated ectasia stabilization and 3.5% showed progressive \"overcorrection\" or \"hyperopic\" shift. The Athens Protocol confirms long-term safety and efficacy for corneal ectasia and visual function. Most parameters had little change after 1 year, through year 10. [J Refract Surg. 2019;35(8):478-483.].

Purpose: To evaluate the long-term efficacy of accelerated corneal cross-linking (A-CXL) in halting the progression of recurrence of keratoconus in the graft. Methods: This was a retrospective chart review of patients who underwent A-CXL for recurrence of keratoconus between January 2017 and December 2018. Results of eye evaluations performed up to 4 years after A-CXL included slit-lamp examination, corneal tomography and biomechanics, binocular corrected distance visual acuity (CDVA), and the manifest refraction equivalent sphere. The efficacy of A-CXL was assessed with reference to thinnest corneal thickness (TCT), mean anterior axial radius curvature in corneal periphery (ARC), and posterior axial radius curvature (PRC) tomography data indicating the stability of the ectasia. Results: Data from 25 eyes were collected. Significant worsening in TCT, ARC, PCR, maximum keratometry, posterior eccentricity, and CDVA (P = .01) were found before A-CXL. At 4 years of follow-up, no changes in all tomographic parameters and significant improvement in CDVA (P = .02) and in corneal biomechanics (stiffness parameter A1, deformation amplitude ratio highest, inverse concave radius, and appla-nation 2 velocity; P = .01) were found. None of the included eyes developed postoperative complications or required re-grafting or refractive procedures. Conclusions: A-CXL is a safe procedure that could play a role in preventing graft ectatic changes in patients with recurrence of keratoconus after keratoplasty, strengthening the graft and halting the natural progression of the ectasia, with positive effects in improving CDVA.

AimsA blind, randomised, prospective, bilateral study to investigate the efficacy of riboflavin/ultraviolet A corneal collagen cross-linkage to halt the progression of keratoconus.Methods24 patients with early/moderate bilateral keratoconus with recent progression were recruited. One eye was randomly assigned to undergo collagen cross-linkage following epithelial removal with riboflavin 0.1% and ultraviolet A (370 nm at 3 mW/cm2). The other remained untreated as a control. The follow-up was 18 months in 22 patients.ResultsAt 18 months, Orbscan II 3 mm, 5 mm keratometry and simulated astigmatism and cone apex power and wave-front measurements (Keraton Scout), including root mean square, coma and pentafoil showed significant reductions from baseline in treated compared with untreated eyes (p=0.04). In treated eyes at 18 months, the best spectacle-corrected acuity improved (p=0.01), and Orbscan II-simulated keratometry (p<0.001), 3 mm keratometry (p=0.008), simulated astigmatism (p=0.007), cone apex power (p=0.002), root mean square, coma, spherical aberration, secondary astigmatism and pentafoil (p=0.05) decreased from baseline. One treated eye experienced transient recurrent corneal erosions; otherwise there were no complications attributable to the treatment.ConclusionsCorneal collagen cross-linkage appears to be an effective and safe modality to halt the progression of keratoconus. Improvements in visual and topographic parameters are seen in some eyes.

Background This retrospective comparative cohort study aimed to compare the one-year outcomes of two modified surgical protocols, the Athens protocol followed by accelerated corneal cross-linking (ACXL) (topography-guided transepithelial photorefractive keratectomy [TG-TPRK] combined with ACXL) and the Cretan protocol followed by ACXL (transepithelial phototherapeutic keratectomy [TPTK] combined with ACXL), in patients with progressive keratoconus. Methods The study included 92 eyes of 67 patients (49 eyes/34 patients in the TG-TPRK-ACXL group; 43 eyes/33 patients in the TPTK-ACXL group). According to the TG-TPRK-ACXL ablation plan, TPTK was conducted on patients with a projected postoperative thinnest corneal thickness (TCT) of less than 400 μm. Visual acuity, refractive status, keratometry readings, corneal thickness, and keratoconus parameters were assessed preoperatively and 1-year postoperatively. Intraoperative ablation depth was also recorded. Generalized estimating equations (GEE) were applied to adjust for baseline characteristics and to compare the differences in ocular characteristic changes between the two groups after 1 year. Results Both groups showed significant improvement in uncorrected and best spectacle-corrected distance visual acuity (UDVA and BCVA) as well as a reduction in postoperative corneal curvature and irregularity index. After GEE correction, the TPTK-ACXL group showed a greater increase in BCVA (β = -0.117, P  = 0.002). There were no significant variances between the two groups regarding changes in refractive error, corneal curvature, corneal astigmatism, and keratoconus parameters. Central and maximum ablation depths were thinner in the TPTK-ACXL group than in the TG-TPRK-ACXL group ( P  < 0.001). No serious intraoperative or postoperative complications were reported. Conclusions Both TPTK-ACXL and TG-TPRK-ACXL treatments have demonstrated efficacy in improving visual acuity and corneal regularity among keratoconus patients at the 1-year follow-up. TPTK-ACXL may be particularly beneficial for patients with poorer corneal conditions, potentially minimizing corneal thickness loss and serving as a substitute for TG-TPRK-ACXL.

Purpose: To study the demographics and clinical profile of keratoconus (KC) presenting in pre-teen children in India. Methods: This was a retrospective case series conducted as a single-institutional study at a tertiary eye center in India. A total of 586 eyes from 294 KC patients (aged 12 years or less) without any active comorbid conditions of the eye were included in the study. Slit-lamp biomicroscopy was used to document the clinical signs of KC. Information on age; gender; reason for consultation; family history; history of allergy, atopy, and eye rubbing; manifest refraction; uncorrected and best-corrected distance visual acuity (UCVA and BCVA, respectively); clinical presentation; and contact lens usage were also analyzed, along with data on types of medical and surgical treatments for KC and their outcomes. Results: The mean age of this pediatric KC patient cohort was 9.3 ± 1.8 years, and there was a male (70%) preponderance. Baseline mean UCVA, BCVA, steep keratometry, and flat keratometry were 0.86 ± 0.58 logMAR, 0.44 ± 0.38 logMAR, 54.82 ± 8.4 D, and 48.21 ± 9.5 D, respectively. Progression, necessitating collagen crosslinking (CXL), was noted in 12.7% eyes. Post-CXL, visual and topographic parameters remained stable without any complications till 6 months posttreatment. However, in eyes that did not undergo CXL, significant progression over time (P < 0.001) was observed. A keratoplasty was required in 2.3% eyes. Conclusion: KC was present at an advanced stage in 25% of the pre-teens in our series, and therefore, it is an important diagnostic entity when a refractive error is diagnosed, even in very young children.

Keratoconus (KC) is an ectatic disease of the cornea characterized by localized thinning and protrusion causing irregular astigmatism, which can lead to significant visual impairment. KC has often been associated with allergy and/or atopy, which are immune-mediated inflammatory reactions primarily driven by IgE. A higher proportion of KC patients were reported to have history or suffer from systemic and/or ocular allergy with elevated allergen-specific IgE and/or total serum IgE. Eye rubbing, one of the risk factors for worsening of the disease and developing related complications in KC, is associated with IgE driven conditions. The current review enumerates and contextualizes the evidence related to IgE in mediating KC pathogenesis, including aberrant extra-cellular matrix remodeling. This review also discusses clinical strategies directed at modulating IgE-mediated responses in the management of KC, and the emerging academic and plausible clinical relevance of assessing serum and tear IgE (allergen-specific and total) status in improving the understanding of disease pathobiology, treatment planning, and prognosis.

Purpose: To determine the repeatability of the Pentacam HR (Oculus Optikgeräte GmbH) and IOLMaster 700 (Carl Zeiss Meditec AG) in patients with keratoconus and intracorneal ring segments (ICRS) implantation. Methods: The setting of this cross-sectional and observational study was the Fundación de Oftalmología Médica de la Comunitat Valenciana, Valencia, Spain. Eyes were scanned three consecutive times on each device. Repeatability was assessed using within-subject standard deviation (Sw), within-subject coefficient of variation (CVw), repeatability index (R), and intraclass correlation coefficient (ICC). Agreement between devices was evaluated with Bland-Altman plots and 95% limits of agreement (LoA). The sample was divided into two (lower and higher keratometry groups) to evaluate differences according to the severity of keratoconus. Results: The study comprised 131 eyes of 100 patients. The repeatability of all parameters for both devices was excellent (ICC > 0.9 and low Sw), Bland-Altman analysis revealed wide 95% LoA, indicating clinically relevant differences between devices. A slight decrease in repeatability was observed in the higher keratometry group for flat keratometry in the IOLMaster 700 (ICC = 0.894) and ACD in the Pentacam HR (ICC = 0.895). Keratometry Sw and R values in both devices were slightly higher in the higher keratometry group. Conclusions: The Pentacam HR and IOLMaster 700 showed high repeatability in patients with ICRS. However, the wide 95% LoA indicate poor agreement between devices and hence they cannot be used interchangeably in clinical practice. A slight decrease in repeatability could be expected in eyes with higher keratometry.

This prospective, randomized, controlled trial aims to provide evidence in relation to the efficacy and safety of corneal collagen cross-linking (CXL) in the management of progressive keratoconus. Eligible eyes were separately randomized into either treatment or control groups. Collagen crosslinking was performed using 0.1% riboflavin (in 20% dextran T500) and ultraviolet A (UVA) irradiation (370 nm, 3 mW/cm2, 30 min) in accordance with a previously published protocol. At each review, a full clinical ophthalmic examination was performed including endothelial cell count and confocal microscopy. To date, 66 eyes of 49 patients with documented progression of keratoconus have been enrolled and randomized. Interim analysis of treated eyes showed a flattening of the steepest simulated keratometry value (K-max) by an average of 0.74 diopters (D) (P = .004) at 3 months, 0.92 D (P = .002) at 6 months, and 1.45 D (P = .002) at 12 months. A trend toward improvement in best spectacle-corrected visual acuity was also observed. In the control eyes, mean K-max steepened by 0.60 D (P = .041) after 3 months, by 0.60 D (P = .013) after 6 months, and by 1.28 D (P < or = .0001) after 12 months. Best spectacle-corrected visual acuity decreased by logMAR 0.003 (P = .883) over 3 months, 0.056 (P = .092) over 6 months, and 0.12 (P = .036) over 12 months. No statistically significant changes were found for spherical equivalent or endothelial cell density. Preliminary results of this randomized controlled trial suggest a temporary stabilization of all treated eyes after CXL.