Keratoconus, a progressive disorder characterized by thinning and distortion of the cornea, presents complex diagnostic and management challenges that are drawing increased attention within the vision care community. At the forefront of this discourse are the insights presented at the Collaborative Care Symposium (CCS) 2025 by Dr. Peter Hersh, a renowned corneal specialist, who underscored the imperative of early and collaborative intervention to mitigate the disease's lifelong effects. For both primary and specialty eye care providers, the evolving landscape of keratoconus management demands a nuanced appreciation of diagnostic advances, patient comanagement strategies, and emerging therapeutic frontiers.
Keratoconus most frequently emerges in adolescence and young adulthood, with numerous studies now verifying that its onset often predates the appearance of serious visual symptoms. Unlike glaucoma or retinal diseases—ailments more common among older adults—keratoconus is disproportionately prevalent in younger populations. This demographic specificity raises the stakes for timely recognition; according to Hersh, cases identified in early teens demonstrate a heightened propensity for rapid disease progression, frequently culminating in severe vision loss if undetected.
A pivotal aspect of early detection hinges on primary eye care providers’ diligence during routine exams. Hersh emphasized the necessity for vigilance when standard vision correction fails to yield 20/20 acuity, especially in the presence of atypical astigmatism or irregular corneal curvatures. Both clinical judgment and advanced instrumentation play critical roles at this diagnostic juncture.
Corneal topography maps the corneal surface, illuminating deviations indicative of early keratoconus, such as inferotemporal steepening or asymmetric bow-tie patterns. Tomography, on the other hand, leverages cross-sectional imaging to construct a three-dimensional model of corneal structure, enhancing detection of posterior surface changes and stromal thinning—the earliest signs of ectasia. Meta-analyses from peer-reviewed journals, such as Investigative Ophthalmology & Visual Science (IOVS), confirm the superior diagnostic accuracy of these methods, especially when used in tandem.
Multicenter studies, including the Collaborative Longitudinal Evaluation of Keratoconus (CLEK), have verified that such early identification correlates with significantly improved clinical trajectories. Nevertheless, access to advanced imaging remains variable across geographies and practice settings, flagging a potential equity concern that warrants systemic attention.
Collaborative protocols have practical benefits. For example, optometrists often serve as the first point of contact, recognizing suspicious cases through irregular refraction or visual complaints. Ophthalmologists can confirm the diagnosis with in-depth imaging, while both professions coordinate longitudinal care, such as customizing contact lenses or timing surgical intervention. In advanced cases, corneal specialists may be called upon to perform procedures like cross-linking (CXL), with referring doctors resuming a central role in postoperative care and long-term follow-up.
Emerging literature increasingly supports this team-based approach. The American Academy of Ophthalmology (AAO) and the American Optometric Association (AOA) have published joint position statements in recent years, asserting that shared care pathways optimize patient safety, improve resource utilization, and reduce the burden of fragmented follow-up.
A large body of evidence, including randomized controlled trials published in the Journal of Cataract & Refractive Surgery and Ophthalmology, demonstrates that a majority of CXL-treated eyes either stabilize or show slight improvements in corneal shape within 12 to 24 months of treatment. Complications are rare but can include microbial keratitis, corneal haze, or epithelial healing problems—risks that highlight the value of robust preoperative patient education and careful post-procedure monitoring.
Notably, as patients age, difficulties may escalate: lens tolerance often declines due to ocular surface changes, and earlier surgical intervention (such as cataract extraction) can complicate lens fit or necessitate new prescriptions. According to Hersh, these scenarios make periodic comprehensive evaluations—ideally at least annually—indispensable.
Evidence from surgical registries indicates that outcomes are generally favorable when individualized approaches are adopted, though risks—such as unpredictable refractive outcomes or endothelial decompensation—remain higher than in non-keratoconic populations. This underscores the perennial need for specialized, multidisciplinary care throughout each life stage.
Hersh’s advocacy, echoed by voices across the CCS 2025 symposium and the broader research community, calls for multi-pronged solutions. Increased investment in provider education, proactive screening initiatives—especially in high-risk populations—and innovative telemedicine platforms are all poised to improve early detection and equitable access.
Mobile-based diagnostic modalities, such as smartphone-enabled topographers, are already showing promise in community outreach programs, especially in underserved regions. Pilot studies published in the American Journal of Ophthalmology have demonstrated diagnostic accuracies approaching those of traditional devices, offering a scalable solution that could transform screening paradigms worldwide.
Public awareness campaigns—leveraging both traditional and digital media—will further amplify early detection efforts, empowering individuals to seek timely evaluation and reducing the latent burden of undiagnosed or late-presenting keratoconus.
Yet, gaps remain—both in public and provider education, and in ensuring equitable access to life-changing care. Advancing toward a future where no child, adolescent, or adult is deprived of their sight by this silent disease will demand persistence, innovation, and unity across the optometric and ophthalmologic communities. For all stakeholders, from frontline clinicians to industry innovators and policymakers, the time for action has never been more urgent—or more promising.
Source: Optometry Times CCS 2025: Identifying keratoconus in patients through successful comanagement
Understanding Keratoconus: Early Detection is Paramount
Keratoconus most frequently emerges in adolescence and young adulthood, with numerous studies now verifying that its onset often predates the appearance of serious visual symptoms. Unlike glaucoma or retinal diseases—ailments more common among older adults—keratoconus is disproportionately prevalent in younger populations. This demographic specificity raises the stakes for timely recognition; according to Hersh, cases identified in early teens demonstrate a heightened propensity for rapid disease progression, frequently culminating in severe vision loss if undetected.A pivotal aspect of early detection hinges on primary eye care providers’ diligence during routine exams. Hersh emphasized the necessity for vigilance when standard vision correction fails to yield 20/20 acuity, especially in the presence of atypical astigmatism or irregular corneal curvatures. Both clinical judgment and advanced instrumentation play critical roles at this diagnostic juncture.
Evidence-Based Diagnostic Approaches
Traditional diagnostic methods, such as retinoscopy and manual keratometry, remain relevant for basic screening, yet have inherent limitations in sensitivity to early or subtle corneal changes. Today, gold-standard technologies—particularly corneal topography and tomography—enable practitioners to objectively assess anterior and posterior corneal surfaces, quantifying curvature and detecting irregularities that may escape detection with conventional tools.Corneal topography maps the corneal surface, illuminating deviations indicative of early keratoconus, such as inferotemporal steepening or asymmetric bow-tie patterns. Tomography, on the other hand, leverages cross-sectional imaging to construct a three-dimensional model of corneal structure, enhancing detection of posterior surface changes and stromal thinning—the earliest signs of ectasia. Meta-analyses from peer-reviewed journals, such as Investigative Ophthalmology & Visual Science (IOVS), confirm the superior diagnostic accuracy of these methods, especially when used in tandem.
Multicenter studies, including the Collaborative Longitudinal Evaluation of Keratoconus (CLEK), have verified that such early identification correlates with significantly improved clinical trajectories. Nevertheless, access to advanced imaging remains variable across geographies and practice settings, flagging a potential equity concern that warrants systemic attention.
The Role of Collaborative Care in Keratoconus Management
Keratoconus is rarely a static diagnosis; rather, it is a dynamic, lifelong condition that often requires evolving care strategies. Hersh, alongside colleagues Dr. John Gelles and Dr. Steven Greenstein, used CCS 2025 as a platform to champion interdisciplinary comanagement—integrating the expertise of optometrists, ophthalmologists, and surgical specialists at every clinical stage.Interprofessional Communication: Moving Beyond Referral
Traditional referral models, where primary providers pass patients to tertiary care and disengage from the process, are increasingly viewed as obsolete in the context of keratoconus. Hersh advocates for a “hands-on” comanagement framework, where initial diagnosis, ongoing monitoring, therapeutic decision-making, and patient education are shared responsibilities. This model not only streamlines care but also fosters trust, improves adherence, and enhances outcomes.Collaborative protocols have practical benefits. For example, optometrists often serve as the first point of contact, recognizing suspicious cases through irregular refraction or visual complaints. Ophthalmologists can confirm the diagnosis with in-depth imaging, while both professions coordinate longitudinal care, such as customizing contact lenses or timing surgical intervention. In advanced cases, corneal specialists may be called upon to perform procedures like cross-linking (CXL), with referring doctors resuming a central role in postoperative care and long-term follow-up.
Emerging literature increasingly supports this team-based approach. The American Academy of Ophthalmology (AAO) and the American Optometric Association (AOA) have published joint position statements in recent years, asserting that shared care pathways optimize patient safety, improve resource utilization, and reduce the burden of fragmented follow-up.
Key Clinical Interventions: Corneal Cross-Linking and Beyond
The last decade has seen a paradigm shift in keratoconus management, particularly since the U.S. FDA approved corneal collagen cross-linking (CXL) in 2016. CXL remains the only intervention demonstrated to halt or slow progression by permanently stabilizing corneal biomechanics through photochemical induction of collagen bonds.Corneal Cross-Linking: Mechanism, Indications, and Outcomes
Cross-linking entails saturating the cornea with riboflavin (vitamin B2) and then irradiating it with ultraviolet-A light. This process triggers molecular cross-links within the stromal collagen lattice, thereby increasing corneal rigidity and arresting further ectasia. Hersh and colleagues stress that timing is critical: CXL is most effective when deployed before advanced thinning or scarring have developed, reinforcing the message that early diagnosis is not just valuable—it is actionable.A large body of evidence, including randomized controlled trials published in the Journal of Cataract & Refractive Surgery and Ophthalmology, demonstrates that a majority of CXL-treated eyes either stabilize or show slight improvements in corneal shape within 12 to 24 months of treatment. Complications are rare but can include microbial keratitis, corneal haze, or epithelial healing problems—risks that highlight the value of robust preoperative patient education and careful post-procedure monitoring.
Innovative Refractive Techniques: CTAK and Topography-Guided PRK
As patients’ needs evolve—particularly when functional rehabilitation with glasses or standard contacts becomes untenable—specialized refractive techniques are attracting growing interest. Hersh’s CCS 2025 presentation spotlighted two promising innovations: corneal tissue addition keratoplasty (CTAK) and topography-guided photorefractive keratectomy (PRK).- CTAK involves grafting donor tissue onto the diseased cornea to regularize its shape, a method that can restore both optical clarity and biomechanical stability. Although CTAK remains largely investigational in the U.S., early case series from Europe and Asia suggest substantial improvements in visual acuity and quality of life.
- Topography-guided PRK customizes laser ablation patterns based on the individual’s corneal map, smoothing localized steepening and enhancing best-corrected vision. Multiple peer-reviewed studies, including those in the British Journal of Ophthalmology, affirm that this technology can yield significant gains in corneal symmetry and functional vision, though long-term data are still accruing.
Lifetime Management: Adapting Care Across the Disease Spectrum
A diagnosis of keratoconus ushers in a lifelong journey, marked by periods of stability interspersed with clinical and optical challenges. One of the thorniest ongoing issues is contact lens wear—specifically, the unique obstacles faced by keratoconus patients as their corneal shape alters over time.Contact Lens Fitting: The Frontline of Functional Vision Rehabilitation
For most patients, specially designed rigid gas-permeable (RGP) lenses, hybrid lenses, or scleral lenses form the therapeutic cornerstone, providing both structural protection and the high visual acuity unattainable with spectacles. Lens fitting, however, is inherently more complex in keratoconus, demanding both clinical expertise and patience.Notably, as patients age, difficulties may escalate: lens tolerance often declines due to ocular surface changes, and earlier surgical intervention (such as cataract extraction) can complicate lens fit or necessitate new prescriptions. According to Hersh, these scenarios make periodic comprehensive evaluations—ideally at least annually—indispensable.
Surgical Considerations in the Aging Keratoconic Patient
Later in life, keratoconus patients may encounter additional challenges, such as the development of cataracts. Standard cataract surgery protocols are often inadequate, as irregular corneas can confound both biometry and intraocular lens (IOL) selection. Clinicians must therefore harness advanced preoperative planning tools and, where appropriate, collaborate with anterior segment surgeons skilled in the nuances of keratoconic eyes.Evidence from surgical registries indicates that outcomes are generally favorable when individualized approaches are adopted, though risks—such as unpredictable refractive outcomes or endothelial decompensation—remain higher than in non-keratoconic populations. This underscores the perennial need for specialized, multidisciplinary care throughout each life stage.
Challenges and Opportunities: Bridging Gaps in Awareness and Access
Despite technological and therapeutic advances, keratoconus remains significantly underdiagnosed on a global scale. Several headwinds persist, including disparities in access to topography, variable insurance coverage for CXL and specialty lenses, and a general lack of public and primary care awareness about the disease’s early manifestations.Hersh’s advocacy, echoed by voices across the CCS 2025 symposium and the broader research community, calls for multi-pronged solutions. Increased investment in provider education, proactive screening initiatives—especially in high-risk populations—and innovative telemedicine platforms are all poised to improve early detection and equitable access.
Mobile-based diagnostic modalities, such as smartphone-enabled topographers, are already showing promise in community outreach programs, especially in underserved regions. Pilot studies published in the American Journal of Ophthalmology have demonstrated diagnostic accuracies approaching those of traditional devices, offering a scalable solution that could transform screening paradigms worldwide.
Critical Analysis: Strengths, Caveats, and the Road Ahead
Notable Strengths
- Technological Innovation: The integration of topography, tomography, and emerging AI-driven analytics has exponentially increased sensitivity and specificity in keratoconus detection, positioning practitioners to intervene early and effectively.
- Interdisciplinary Collaboration: The normalization of comanagement across optometric and surgical specialties ensures a patient-centered continuum of care, minimizing fallout from fragmented treatment.
- Therapeutic Progress: Widespread adoption of CXL—supplemented by promising interventions like CTAK and topography-guided PRK—has shifted the focus from mere visual rehabilitation to disease stabilization and, increasingly, restoration of quality vision.
Ongoing Risks and Unresolved Challenges
- Access and Equity: Significant geographic and financial barriers persist, particularly regarding advanced diagnostics and FDA-approved cross-linking procedures. Healthcare systems and policymakers must proactively address these discrepancies to prevent avoidable vision loss.
- Patient Adherence: Lifelong follow-up is essential but difficult to enforce, especially among young adults facing socioeconomic or logistical obstacles. Tailored counseling and digital reminder systems may offer partial solutions.
- Procedural Uncertainties: While innovative interventions appear promising, the paucity of long-term data—especially for techniques like CTAK—necessitates caution in widespread adoption. Practitioners and patients alike should temper enthusiasm with realism and participate in structured clinical trials when possible.
The Importance of Continuous Education
The rapidly evolving keratoconus landscape necessitates continuous provider education. National and international societies are responding with updated guidelines, CME modules, and practical workshops to ensure the broader eye care workforce maintains fluency in current best practices.Public awareness campaigns—leveraging both traditional and digital media—will further amplify early detection efforts, empowering individuals to seek timely evaluation and reducing the latent burden of undiagnosed or late-presenting keratoconus.
Conclusion: A Blueprint for Lifelong Vision Health
Keratoconus, once a neglected and irreversible threat to sight, now stands at the threshold of a new era in diagnosis and management. The insights and collaborative ethos championed at CCS 2025—anchored by the leadership of Dr. Peter Hersh and his peers—have laid a durable foundation for ongoing progress. Early, technology-enabled detection; seamless interdisciplinary comanagement; and judicious application of both established and experimental therapies together form a blueprint capable of dramatically improving outcomes for countless patients.Yet, gaps remain—both in public and provider education, and in ensuring equitable access to life-changing care. Advancing toward a future where no child, adolescent, or adult is deprived of their sight by this silent disease will demand persistence, innovation, and unity across the optometric and ophthalmologic communities. For all stakeholders, from frontline clinicians to industry innovators and policymakers, the time for action has never been more urgent—or more promising.
Source: Optometry Times CCS 2025: Identifying keratoconus in patients through successful comanagement