AOA 2025: Is it keratoconus or a bonus diagnosis?

At the 2025 AOA Optometry’s Meeting, Janna Pham, OD, delivered an insightful and engaging lecture titled, "To be or not to be: keratoconus or a bonus diagnosis," presented alongside Travis Pfeifer, OD; and Matthew McGee, OD. The session addressed a topic that continues to challenge and intrigue optometrists: how to confidently diagnose keratoconus and differentiate it from similar corneal irregularities.

Understanding keratoconus

Pham began by reviewing the fundamentals of keratoconus—a progressive, degenerative corneal disease characterized by thinning and conical protrusion of the cornea. Patients often present with distorted vision, frequent prescription changes, and, in advanced cases, significant visual impairment.

During the lecture, Pham emphasized the importance of recognizing early signs and subtle presentations. She noted that a thorough understanding of the condition’s clinical features—such as irregular astigmatism, inferior corneal steepening, and characteristic topographic changes—is essential for early detection and timely intervention.

The role of tomography and advanced diagnostics

A significant portion of the presentation focused on corneal tomography, which can reveal subtle signs of ectasia even before significant visual changes occur. Pham and her colleagues shared real-world case studies where initial tomography scans suggested keratoconus due to borderline inferior steepening. However, after additional assessments—including refraction, slit lamp examination, OCT, and the Belin/Ambrosio Enhanced Ectasia Display—these cases were ultimately determined not to be keratoconus.

Pham highlighted the importance of combining multiple diagnostic tools rather than relying on a single scan. She encouraged optometrists to consider the entire clinical picture and avoid premature conclusions based solely on tomography.

The importance of monitoring and referrals

A major takeaway from Pham’s presentation was the critical need for repeat scanning and monitoring for progression. Even if keratoconus is ruled out at the initial visit, optometrists should continue to monitor for subtle changes over time. Progression might manifest later, making periodic tomography essential to protect long-term visual outcomes.

She also stressed the value of timely referrals for corneal cross-linking—a treatment that can halt progression and preserve vision if performed early enough. Recognizing progression and referring patients to the appropriate specialist can make a profound difference in their quality of life.

Key Takeaways for Optometrists

• Don’t rely solely on 1 scan: Use a combination of tomography, refraction, slit lamp, and OCT to make an accurate diagnosis.
• Repeat scans when necessary: Disease progression can be slow and subtle; ongoing monitoring is vital.
• Refer early for cross-linking: Timely treatment can help preserve vision and prevent severe keratoconus complications.

Pham’s lecture served as both a practical guide and a reminder of the importance of vigilance in corneal disease management. By thoughtfully combining advanced diagnostics and careful monitoring, optometrists can make a significant impact on patient outcomes—ensuring they not only "see" keratoconus but see it at the right time.