Systematic Navigation through Keratoconus Landscape: The Crucial Role of Ocular Surface.

Abstract

Topic: This comprehensive systematic review addresses how concurrent ocular surface diseases (OSDs) in keratoconus (KC) patients affect KC's development, progression, diagnostic evaluation, and management, as well as KC's effect on ocular surface disturbance. This review integrates findings to bridge the gap between basic KC pathophysiology and its practical clinical management to provide a structured framework for optimizing KC treatment.

Clinical relevance: This study represents the first systematic effort to operationally synthesize existing knowledge on the interplay between OSDs and KC, offering actionable insights for clinicians. OSDs are not only recognized contributors to KC onset but are also major factors in treatment failure, making their evaluation critical in KC management.

Methods: A systematic search was conducted in Scopus, PubMed, Cochrane, Embase, and Web of Science for studies published up to February 2025. Studies were included regardless of language, provided they met predefined relevance and quality criteria. Exclusion criteria included replies, commentaries, case studies, retracted studies, ex vivo investigations, and studies scoring low on the AMSTAR checklist.

Results: Initially, 9,572 records were identified; 5,337 duplicates were removed, leaving 4,235 for screening. After title and abstract review, 576 full texts were assessed, with 372 excluded based on AMSTAR scores or study type, leaving 204 studies. Findings highlight that OSDs significantly impact KC pathogenesis and clinical management. Non-ectatic conditions such as dry eye and tear film instability are increasingly included in the differential diagnosis of KC, emphasizing the need for a multidisciplinary approach. OSDs not only contribute to KC progression but also complicate diagnostic interpretations and influence treatment efficacy.

Conclusion: The ocular surface plays a pivotal role not only in KC pathogenesis but also in treatment success or failure. Thus, it is important to address concurrent OSDs in patients with KC as they can complicate its course. This is a vital consideration for treatment strategies. However, more studies on the causal link between KC and OSD are needed to help clinicians diagnose and manage these conditions better.