Keratoconus Management: Navigating Patient Options


  • Amir R. Vosoughi, MD
  • Guillermo Rocha, MD, FRCSC, FACS



Keratoconus (KC) is a condition which results in progressive corneal thinning. It was first discovered by Dr. John Nottingham in 1854 who described it as “conical cornea” due to the outward bowing appearance caused by the condition. The prevalence of KC is between 0.2 and 4,790 per 100,000 people. KC does not have a gender predilection. It is believed to appear more commonly in South Asian and Middle Eastern populations.

Keratoconus typically begins in the second and third decades of life although it can develop at any time. The clinical symptoms of the condition include blurred and distorted vision. Patients may present with higher-order aberrations (HOA) ̶ the most characteristic of which is coma ̶ resulting in blurred and double vision. The common signs of KC include corneal protrusion and thinning, prominent corneal nerves, Fleischer ring, Vogt’s striae, and scissors reflex on retinoscopy. The most frequently encountered phenotype is oval cones in the central cornea. The primary diagnostic tool for KC is corneal topography, although pachymetry, including epithelial mapping and corneal tomography, are often performed in conjunction with each other as they aid with early detection and the monitoring of KC progression. 

Advancements in clinicians’ knowledge of KC and expertise in its treatment, have led to novel therapies. Stopping disease progression is now possible and improving patients’ quality of vision is feasible in many cases.

Preventive measures halting progression and management of mild and moderate forms of KC are reviewed. Treatment of severe KC will also be briefly reviewed.

Author Biographies

Amir R. Vosoughi, MD

Dr. Amir R. Vosoughi received his Bachelor of Science and Doctor of Medicine from the University of Manitoba. He is currently undertaking a Master of Science in Epidemiology from the London School of Hygiene and Tropical Medicine. He is interested in both basic and clinical research, with particular interest in neuro-ophthalmology and addressing sex and race disparities across clinical trials.

Guillermo Rocha, MD, FRCSC, FACS

Dr. Guillermo Rocha is originally from Mexico City, Mexico. He trained in ophthalmology at McGill University in Montreal and has completed subspecialty training in ocular immunology and inflammation, and cornea and external diseases. He completed the Physician CEO Executive Program at the Kellogg School of Management (2016) and the Foundations of Clinical Research Certificate Program, Harvard Medical School (2022). He is Professor of Ophthalmology at the University of Manitoba, President of the COS Foundation, Past President of the Canadian Ophthalmological Society (2016-2018), and past President of the Canadian Cornea, External Diseases and Refractive Surgery Society. In 1995, he was awarded the Canadian Society for Clinical Investigation & Medical Research Council of Canada Resident Research Award for his work on the causative factors of ocular inflammation. Dr. Rocha was the recipient of the Lieutenant Governor of Manitoba iCare Award for 2014. In 2015, he was recognized as one of the 10 Most Successful Mexicans in Canada, followed by an award as one of the 10 Most Influential Hispanic Canadians in 2016. Dr. Rocha performs anterior segment, refractive, and corneal surgeries.


Gokul A, Patel DV, McGhee CNJ. Dr. John Nottingham’s 1854 landmark treatise on conical cornea considered in the context of the current knowledge of keratoconus. Cornea. 2016;35(5):673-678. DOI:

Santodomingo-Rubido J, Carracedo G, Suzaki A, Villa-Collar C, Vincent SJ, Wolffsohn JS. Keratoconus: An updated review. Cont Lens Anterior Eye. 2022;45(3):101559. DOI:

Wajnsztajn D, Hopkinson CL, Larkin DFP. National Health Service Blood and Transplant Ocular Tissue Advisory Group and contributing ophthalmologists (OTAG Study 29). Keratoplasty for keratoconus in young patients: demographics, clinical features, and post-transplant outcomes. Am J Ophthalmol. 2021;226:68-75. DOI:

Hashemi H, Beiranvand A, Yekta A, Maleki A, Yazdani N, Khabazkhoob M. Pentacam top indices for diagnosing subclinical and definite keratoconus. J Curr Ophthalmol. 2016;28(1):21-26. DOI:

Belin MW, Duncan JK. Keratoconus: the ABCD grading system. Klin Monbl Augenheilkd. 2016;233(06):701-707. DOI:

Martinez-Abad A, Piñero D. New perspectives on the detection and progression of keratoconus. J Catarac Refract Surg. 2017;43(9):1213-1227. DOI:

Pellegrini M, Bernabei F, Friehmann A, Giannaccare G. Obstructive sleep apnea and keratoconus: a systematic review and meta-analysis. Optom Vis Sci. 2020 Jan;97(1):9-14. doi:10.1097/OPX.0000000000001467 DOI:

Hashemi H, Heydarian S, Hooshmand E, Saatchi M, Yekta A, Aghamirsalim A, et al. The prevalence and risk factors for keratoconus: a systematic review and meta-analysis. Cornea. 2020;39(2):263-270. DOI:

Sorkin N, Varssano D. Corneal collagen crosslinking: a systematic review. Ophthalmologica. 2014;232(1):10-27. doi:10.1159/000357979 DOI:

Hersh PS, Stulting RD, Muller D, Durrie DS, Rajpal RK, U.S. Crosslinking Study Group. U.S. multicenter clinical trial of corneal collagen crosslinking for treatment of corneal ectasia after refractive surgery. Ophthalmology. 2017;124(10):1475-1484. DOI:

Greenstein SA, Fry KL, Hersh MJ, Hersh PS. Higher-order aberrations after corneal collagen crosslinking for keratoconus and corneal ectasia. J Cataract Refract Surg. 2012;38(2):292-302. DOI:

Muzychuk A, Penner V, Rocha G. High order aberration outcomes of corneal collagen crosslinking in eyes with keratoconus and post-LASIK ectasia. Int J Keratoconus Ectatic Corneal Dis. 2014;3(3):107-112. DOI:

Muzychuk A, Penner V, Rocha G, Al-Ghoul A. The effects of epithelium-off corneal collagen cross-linking on peripheral corneal keratometry, pachymetry as well as Scheimpflug imaging calculated corneal indices in keratoconus. Int J Keratoconus Ectatic Corneal Dis. 2014;3(3):113-117. DOI:

Zhu AY, Jun AS, Soiberman US. Combined protocols for corneal collagen cross-linking with photorefractive surgery for refractive management of keratoconus: update on techniques and review of literature. Ophthalmol Ther. 2019;8(1):15-31. DOI:

Hafezi F, Kling S, Gilardoni F, et al. Individualized corneal cross-linking with riboflavin and UV-A in ultrathin corneas: the Sub400 Protocol. Am J Ophthalmol. 2021;224:133-142. DOI:

Rocha G, Ibrahim T, Gulliver E, Lewis K. Combined phototherapeutic keratectomy, intracorneal ring segment implantation, and corneal collagen cross-linking in keratoconus management. Cornea. 2019;38(10):1233-1238. DOI:

Ang M, Mehta JS. Deep anterior lamellar keratoplasty as an alternative to penetrating keratoplasty. Ophthalmology. 2011;118(11):2306-2307. DOI:

Dragnea DC, Birbal RS, Ham L, Dapena I, Oellerish S, van Dijk K. Bowman layer transplantation in the treatment of keratoconus. Eye Vis (Lond). 2018 Sep 12;5:24. doi:10.1186/s40662-018-0117-y DOI:

El Zarif M, Alió del Barrio J L, Arnalich-Montiel F, De Miguel MP, Makdissy N, Alió JL. Corneal stroma regeneration: new approach for the treatment of cornea disease. Asia-Pac J Ophthal. 2020;9(6):571-579. DOI:

Jacob S, Patel SR, Agarwal A, Ramalingam A, Saijimol AI, Raj JM. Corneal allogenic intrastromal ring segments (CAIRS) combined with corneal cross-linking for keratoconus. J Refract Surg. 2018;34(5):296-303. DOI:



How to Cite

Vosoughi AR, Rocha G. Keratoconus Management: Navigating Patient Options. Can Eye Care Today [Internet]. 2023 Feb. 1 [cited 2024 May 19];2(1):25–29. Available from:




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