Second Global Consensus on Keratoconus

In 2013, the recognition of revolutionary advances in keratoconus diagnosis and management led experts to organise a Delphi panel and create a Global Consensus on Keratoconus and Ectatic Diseases. This work, which addressed controversies and open questions and introduced a new definition of the disease, was published as a position paper in the journal Cornea in April 2015.¹

“The fact that, to date, this paper has been cited by authors of more than 1,000 published articles speaks to its importance,” said Farhad Hafezi MD, PhD.

In the decade after work on the Global Consensus began, new knowledge accumulated at a rapid rate, and with the acknowledgement that the first consensus received criticism because it involved representatives from cornea societies but not refractive groups, work on a Second Global Consensus on Keratoconus began in 2023.

“Led by Dr José Alvaro Gomes, myself, and Dr Renato Ambrósio, more than two-thirds of the work on this new project is complete, as of September 2024,” he said. “Hopefully, a manuscript will be ready to be submitted for publication in a high-impact journal in the spring of 2025 and will be available to all in the summer.”

Providing an update on the process and progress of the Second Global Consensus group, Dr Hafezi began with its predecessor. He explained that it was a direct collaboration of four supranational cornea societies (PanCornea, Asia Cornea Society, EuCornea, and Cornea Society), whose participants divided among three subcommittees to address three major topics: definition/diagnosis, medical/clinical treatment, and surgical management. Each subcommittee was comprised of 3 coordinators and 12 experts, all selected because of their knowledge and experience and an aim of global representation. The project was led by Brazilian ophthalmologist José AP Gomes MD, who also served as a coordinator in the clinical treatment subcommittee.

Content was derived using the Delphi method to reach a consensus where more than two-thirds of the experts arrived at the same opinion.

“Our mission was not to create a guideline, but rather a momentary view of the prevailing opinion of leading experts in the field,” Dr Hafezi explained. “We realised it would never be possible to achieve 100% consensus of opinions among leading experts.”

A more inclusive worldview

An aim in organising the Second Global Consensus on Keratoconus group was to be more inclusive. To that end, participants were not only drawn from the same four supranational cornea societies but other international refractive surgery/ophthalmology/keratoconus societies (Middle East Council of Ophthalmology, Australia and New Zealand Cornea Society, Brazilian Association of Cataract and Refractive Surgery, International Society of Refractive Surgery, and the Keratoconus and Crosslinking Experts). The effort receives financial support from the Light for Sight and Violet June foundations and industry stakeholders.

“We asked every major player in industry to support us with the same amount of funding,” Dr Hafezi noted. “The industry sponsors have no influence on the outcome, but they all recognise how important it is for medical professionals to have a common view.”

The Second Global Consensus group is much larger than the first, consisting of 21 coordinators and 125 panellists. Participants split into subcommittees addressing seven topics: definition/diagnosis/staging, clinical treatment and non-invasive visual rehabilitation, cross-linking for progression, invasive visual rehabilitation, keratoplasty approaches, elective refractive surgery, and cataract surgery in keratoconus.

Invasive visual rehabilitation and elective refractive surgery

Dr Hafezi observed that the distinction between invasive visual rehabilitation and elective refractive surgery is an interesting one.

“Both types of procedures can involve excimer laser surgery,” he said. “However, elective refractive surgery refers to procedures done to improve uncorrected vision in patients who are borderline cases but do not meet the criteria for diagnosing keratoconus. Surgeons may question what to do in these situations, which are an important part of our daily practice life. Invasive visual rehabilitation, on the other hand, describes therapeutic procedures done to improve corrected visual acuity in eyes with keratoconus.”

Steps used to develop a consensus include the literature search and article filtering, led by a contract research organisation chosen for its extensive experience working with Delphi panels, including in ophthalmology.

So far, all subcommittee and total consensus group meetings have been conducted virtually. However, the coordinators of the Second Global Consensus on Keratoconus participants will gather face-to-face in October 2024 during the American Academy of Ophthalmology annual meeting in Chicago, Illinois. Prior to formal publication of the final document, the consensus group intends to report on its contents at World Cornea Congress IX, which takes place in March 2025 in Washington, DC.

Dr Hafezi spoke on this topic at Cornea Day during the 2024 ESCRS Congress in Barcelona.

Farhad Hafezi MD, PhD, FARVO is the Chief Medical Officer of the ELZA Institute in Zurich, Switzerland, and Professor of Ophthalmology at Geneva University (Switzerland), NYU Langone (US), the USC Roski Eye Institute (US), and Wenzhou Medical University (China). fhafezi@elza-institute.com

1. Gomes JA, Tan D, Rapuano CJ, et al; Group of Panelists for the Global Delphi Panel of Keratoconus and Ectatic Diseases. “Global consensus on keratoconus and ectatic diseases,” Cornea, 2015; 34(4): 359–369.