Keratoconus: Diagnosis and Treatment

Foreword
Foreword
Preface
Contents
About the Editor
1: Epidemiology of Keratoconus
	1.1	 Introduction
	1.2	 Epidemiology
		1.2.1	 Incidence and Prevalence
		1.2.2	 Age of Onset
		1.2.3	 Gender
		1.2.4	 Laterality
	1.3	 Risk Factors
		1.3.1	 Genetic
		1.3.2	 Ethnic Groups
		1.3.3	 Eye Rubbing
		1.3.4	 Atopy
		1.3.5	 Ultraviolet and Sun Exposure
		1.3.6	 Hormonal
		1.3.7	 Associated Systemic and Ocular Disorders
	1.4	 Conclusion
	References
2: Etiology and Risk Factors of Keratoconus
	2.1	 Introduction
	2.2	 The Genetics of Keratoconus
		2.2.1	 Genome-Wide Association Studies (GWAS)
		2.2.2	 GWAS of Central Corneal Thickness (CCT) and Corneal Biomechanical Properties
	2.3	 KC and Family History
	2.4	 Functional Studies of Candidate Genes
		2.4.1	 DOCK9 and PPIP5K2
	2.5	 Genetic Determinants of Syndromic and Non-syndromic KC
	2.6	 Transcriptomic and Expression Studies
		2.6.1	 Noncoding RNA (lncRNAs and miRNAs) Involved in KC
	2.7	 Environmental Risk Factors
		2.7.1	 Eye Rubbing
		2.7.2	 Comorbidities
		2.7.3	 Contact Lens Wear
		2.7.4	 Asthma
		2.7.5	 Allergy
		2.7.6	 Atopy
		2.7.7	 UV Exposure
	2.8	 Conclusion
	References
3: Biomechanics of Keratoconus
	3.1	 Introduction
	3.2	 Background
	3.3	 Biomechanical Changes
		3.3.1	 Biomechanical Changes in KCN
		3.3.2	 Biomechanical Changes in ffKCN
		3.3.3	 Biomechanical Changes After Intrastromal Corneal Ring Segments
		3.3.4	 Biomechanical Changes in CXL
		3.3.5	 Biomechanics in Refractive Surgery
	3.4	 Conclusions
	References
4: Pathophysiology and Histopathology of Keratoconus
	4.1	 Introduction
	4.2	 Pathophysiology of Keratoconus
		4.2.1	 Composition of the Corneal Stroma in Keratoconus
		4.2.2	 Alterations in Volume/Stromal Thinning
		4.2.3	 Alterations in Characteristics
		4.2.4	 Role of Inflammatory Mediators Including TGF Beta Pathway and Cytokine Dysregulation
		4.2.5	 Imbalance of Proteolytic Enzymes
		4.2.6	 Oxidative Stresses
		4.2.7	 Cellular Hypersensitivity to Apoptosis
	4.3	 Histopathology
		4.3.1	 Penetrating Keratoplasty Specimens
		4.3.2	 Epithelial Changes
		4.3.3	 Bowman’s Layer
		4.3.4	 Stroma
		4.3.5	 Dua’s Layer
		4.3.6	 Descemet’s Membrane
		4.3.7	 Endothelial Cells
		4.3.8	 DALK and Attempted DALK Specimens
		4.3.9	 Acute Hydrops and Healed Hydrops
		4.3.10	 Histopathological Changes After Collagen Cross-linking
	4.4	 Conclusion
	References
5: Clinical Diagnosis of Keratoconus
	5.1	 Introduction
	5.2	 Symptoms
	5.3	 History
		5.3.1	 Past Ocular History
		5.3.2	 Family History
		5.3.3	 Medical History and Associated Diseases
	5.4	 Clinical Examination
	References
6: Classifications and Patterns of Keratoconus
	6.1	 Introduction
	6.2	 Classification Systems in Keratoconus
		6.2.1	 KISA Index
		6.2.2	 McMahon and Colleagues’ Keratoconus Severity Score (KSS)
	6.3	 Classification of Keratoconus Based on Clinical Characteristics
		6.3.1	 Based on Severity of the Corneal Curvature
		6.3.2	 Classification of Keratoconus Based on Morphological Appearance of the Cone
	6.4	 Amsler–Krumeich Classification
		6.4.1	 Belin ABCD Classification
	6.5	 Fourier-Domain OCT Classification
	6.6	 Topographic Patterns in Keratoconus
	6.7	 Conclusion
	References
7: Differential Diagnosis of Keratoconus
	7.1	 Introduction
	7.2	 True Corneal Ectasias
		7.2.1	 Pellucid Marginal Degeneration (PMD): Keratotorus
		7.2.2	 Keratoglobus
		7.2.3	 Isolated Keratoconus Posticus
		7.2.4	 Regular Astigmatism
		7.2.5	 Post-LASIK Ectasia
		7.2.6	 Superior Keratoconus and Superior Pellucid Marginal Degeneration (PMD)
	7.3	 Corneal Diseases with Pseudokeratoconic Tomography
		7.3.1	 Epithelial Basement Membrane Dystrophy (EBMD)
		7.3.2	 Scar-Associated Irregular Astigmatism
		7.3.3	 Central Fuchs Endothelial Corneal Dystrophy
	7.4	 Differential Diagnosis of Corneal Hydrops
		7.4.1	 Salzmann’s Nodular and Peripheral Hypertrophic Subepithelial Corneal Degeneration (PHSCD)
	References
8: Keratoconus in Children
	8.1	 Introduction
	8.2	 Epidemiology
	8.3	 Genetics
	8.4	 Ocular Allergy
	8.5	 Syndromes
	8.6	 Risk Factors
	8.7	 Clinical Features and Diagnosis
	8.8	 Adult vs. Pediatric Keratoconus
	8.9	 Treatment
	8.10	 Contact Lens
	8.11	 Surgical Procedures
		8.11.1	 Collagen Cross-linking
			8.11.1.1	 Indications and Timing of the Procedure in Children vs. Adolescent
		8.11.2	 CXL Standard Dresden Protocol
		8.11.3	 Transepithelial CXL (TE CXL)
		8.11.4	 Accelerated Cross-linking Protocol
		8.11.5	 Other Methods
		8.11.6	 Safety
			8.11.6.1	 Epithelial Defect
			8.11.6.2	 Endothelial Cell Loss
			8.11.6.3	 Limbal Cell Loss
			8.11.6.4	 Efficacy of Standard Protocol
			8.11.6.5	 Efficacy of Transepithelial CXL (EPI-ON) and Accelerated Protocol
		8.11.7	 Intracorneal Ring Segments
		8.11.8	 Keratoplasty
	References
9: Allergic Eye Disease and Keratoconus
	9.1	 Introduction
	9.2	 Association between Allergic Eye Diseases and Keratoconus
	9.3	 Etiopathogenesis
		9.3.1	 Causative Factors
		9.3.2	 Genetic Factors
		9.3.3	 Environmental Factors
		9.3.4	 Role of Inflammation
		9.3.5	 Role of Enzymes
		9.3.6	 Role of Oxidative Stress
		9.3.7	 Role of Hormones
	9.4	 Role of Early Topography in Allergic Eye Diseases
	9.5	 Role of Allergic Eye Diseases in KC Progression
	9.6	 Role of Allergic Eye Diseases in Acute Corneal Hydrops and Perforation
	9.7	 Management of Allergic Eye Disorders
		9.7.1	 Treatment Options for Ocular Allergy
			9.7.1.1	 Avoidance of Allergen
			9.7.1.2	 Cold Compresses
			9.7.1.3	 Artificial Tear Substitutes
			9.7.1.4	 Topical Antihistamine
			9.7.1.5	 Topical Vasoconstrictors
			9.7.1.6	 Topical Mast Cell Stabilizers
			9.7.1.7	 Multimodal Anti-Allergic Agents
			9.7.1.8	 Topical Corticosteroids
			9.7.1.9	 Topical Immunomodulatory Agents
			9.7.1.10	 Systemic Agents
	9.8	 Prevention of Eye Rubbing
	9.9	 Surgical Treatment
		9.9.1	 Surgical Outcome in Cases with Allergic Eye Diseases and KC
	9.10	 Conclusion
	References
10: Topography and Tomography of Keratoconus
	10.1	 Introduction
	10.2	 Topography Vs. Tomography
		10.2.1	 Historical Background
	10.3	 Placido-Based Corneal Topographer
		10.3.1	 Principle
		10.3.2	 Features
		10.3.3	 Application Tools for Keratoconus Management
	10.4	 Scheimpflug-Based Tomography
		10.4.1	 Principle
		10.4.2	 Features
		10.4.3	 Application Tools for Keratoconus Management
	10.5	 Anterior Segment OCT
		10.5.1	 Principle
		10.5.2	 Feature
		10.5.3	 Application Tools for Keratoconus Management
	10.6	 Combined Systems with a Wavefront Aberrometer
	10.7	 Tips for the Measurements
	10.8	 Tips at Reading the Maps
	10.9	 Final Practical Comment from Specialists
	References
11: Newer Diagnostic Technology for Diagnosis of Keratoconus
	11.1	 Introduction
	11.2	 Corneal Topography
		11.2.1	 Types of Topographic Indices
	11.3	 Epithelial Mapping in Keratoconus
		11.3.1	 Classification of OCT-Based Devices
			11.3.1.1	 RTVUE®
			11.3.1.2	 CASIA 2
			11.3.1.3	 MS-39: A Hybrid Tomographer
		11.3.2	 Importance of Epithelial Mapping in Diagnosis of Subclinical Keratoconus
		11.3.3	 Imaging the Bowman’s Layer in Subclinical and Clinical Keratoconus
		11.3.4	 Epithelial Changes in Keratoconus
		11.3.5	 True Progression in Keratoconus
		11.3.6	 Pseudoprogression in Keratoconus
		11.3.7	 Epithelial Remodeling Post-Cross-Linking
		11.3.8	 Importance of Epithelial Imaging in Identifying Keratoconus Masquerades
		11.3.9	 Clinical Applications
	11.4	 Corneal Biomechanics
		11.4.1	 Introduction
		11.4.2	 Ocular Response Analyzer
			11.4.2.1	 Application in Keratoconus
		11.4.3	 Corvis ST
			11.4.3.1	 Vinciguerra Screening Report
			11.4.3.2	 TBI (Tomographic/Biomechanical Index)
			11.4.3.3	 Biomechanics Comparative Display
		11.4.4	 Clinical Applications
	11.5	 Confocal Microscopy
		11.5.1	 Introduction
		11.5.2	 Principle
			11.5.2.1	 Tandem Scanning Confocal Microscope (TSCM)
			11.5.2.2	 Scanning Slit Confocal Microscope (SSCM)
			11.5.2.3	 Confocal Laser Scanning Microscope (CLSM)
		11.5.3	 Confocal Microscopy in Normal
			11.5.3.1	 Corneal Epithelium
				Superficial Cells
				Wing Cells
				Basal Cells
			11.5.3.2	 Bowman’s Membrane
			11.5.3.3	 Corneal Stroma
			11.5.3.4	 Descemet’s Membrane
		11.5.4	 Confocal Microscopy in Keratoconus
			11.5.4.1	 Corneal Epithelium
				Superficial Cells
				Basal Cells
			11.5.4.2	 Bowman’s Membrane
			11.5.4.3	 Corneal Stroma
			11.5.4.4	 Corneal Nerves in Keratoconus
			11.5.4.5	 Descemet’s Membrane
		11.5.5	 Clinical Applications
	11.6	 Polarization-Sensitive Optical Coherence Tomography (PS-OCT)
		11.6.1	 Introduction
		11.6.2	 Principle of PS-OCT
		11.6.3	 Corneal Imaging Using PS-OCT
		11.6.4	 Clinical Applications
			11.6.4.1	 Normal Patients
			11.6.4.2	 Keratoconus
			11.6.4.3	 Post-Corneal Collagen Cross-Linking
	11.7	 Brillouin Microscopy
		11.7.1	 Introduction
		11.7.2	 Principle of Brillouin Microscopy
		11.7.3	 Clinical Applications [73]
			11.7.3.1	 Screening/Diagnosis of Corneal Disease
			11.7.3.2	 Monitoring Response to Corneal Cross-Linking
			11.7.3.3	 Advantages
	11.8	 MMP-9 Kit Useful in the Diagnosis of Molecular Markers for Keratoconus
	References
12: Acute Corneal Hydrops: Etiology, Risk Factors, and Management
	12.1	 Introduction
	12.2	 Etiology
		12.2.1	 Primary Corneal Ectasia
		12.2.2	 Secondary Corneal Ectasia
			12.2.2.1	 Post-Laser in Situ Keratomileusis (LASIK)
			12.2.2.2	 Post-Radial Keratotomy (RK)
			12.2.2.3	 Post-Penetrating Keratoplasty
			12.2.2.4	 Post-Anterior Lamellar Keratoplasty
			12.2.2.5	 Post-Corneal Trauma or Degeneration
		12.2.3	 Primary Infantile Glaucoma
	12.3	 Natural History of Disease
	12.4	 Histopathology of Corneal Hydrops
	12.5	 Clinical Presentation
	12.6	 Investigative Modalities
		12.6.1	 Ultrasound Biomicroscopy (UBM)
		12.6.2	 Anterior Segment Optical Coherence Tomography (AS-OCT)
		12.6.3	 In Vivo Confocal Microscopy
	12.7	 Management
		12.7.1	 Conservative Management
		12.7.2	 Surgical Management
			12.7.2.1	 Thermokeratoplasty (TKP)
			12.7.2.2	 Intracameral Air or Gas Injection
			12.7.2.3	 Compression Sutures with Intracameral Gas Injection
			12.7.2.4	 Amniotic Membrane Transplantation with Cauterization
			12.7.2.5	 Penetrating Keratoplasty (PK)
			12.7.2.6	 Deep Anterior Lamellar Keratoplasty (DALK)
			12.7.2.7	 Endothelial Keratoplasty (EK)
	12.8	 Visual Rehabilitation Post-Corneal Hydrops
	12.9	 Summary and Conclusion
	References
13: Contact Lenses for Keratoconus
	13.1	 Introduction
	13.2	 Prerequisite for Fitting
		13.2.1	 Clinical Examination
	13.3	 Investigations
		13.3.1	 Corneal Topography
	13.4	 Selection of a Lens
		13.4.1	 Soft Lenses
		13.4.2	 Rigid Gas Permeable Lenses
	13.5	 Fitting Philosophies
		13.5.1	 Apical Clearance
		13.5.2	 Apical Bearing
		13.5.3	 Three-Point Touch or Divided Support
		13.5.4	 Fitting RGP Lenses
	13.6	 Lens Designs
		13.6.1	 Rose K Lenses
		13.6.2	 Assessment of Fitting
		13.6.3	 Intralimbal Lenses
		13.6.4	 Piggybacking Lenses
		13.6.5	 Hybrid Lenses
		13.6.6	 Scleral Lenses
	13.7	 Assessment of Fitting
	13.8	 Contact Lenses in Special Scenarios
		13.8.1	 Keratoconus with Vernal Keratoconjunctivitis or Allergic Conjunctivitis
		13.8.2	 After Collagen Cross-Linking
		13.8.3	 After Intracorneal Ring Segment Surgeries
		13.8.4	 Keratoconus with Stevens-Johnson Syndrome
		13.8.5	 Warpage or Progression after RGP Fitting
	13.9	 Conclusion
	References
14: Corneal Cross-Linking in Keratoconus
	14.1	 Introduction
	14.2	 CXL to Arresting Keratoconus Progression
	14.3	 Epi-on Versus Epi-off CXL
	14.4	 Accelerated CXL Protocols
	14.5	 Attempts to Overcome the Rate-Limiting Effects of Oxygen
	14.6	 CXL in Thin Corneas
		14.6.1	 Artificial Thickening Approaches
		14.6.2	 Choosing a Protocol that Delivers the Desired Cross-Linking Depth
		14.6.3	 Individualizing Fluence to each Patient’s Corneal Thickness
		14.6.4	 Cross-Linking Corneal Infections
		14.6.5	 The Future of CXL
	References
15: Penetrating Keratoplasty in Keratoconus
	15.1	 History of Keratoplasty in Keratoconus
	15.2	 Long-Term Results of Penetrating Keratoplasty in Keratoconus
	15.3	 Indications for PK in the Era of DALK
	15.4	 Surgical Steps of PK
	15.5	 Femto-Assisted PK
	15.6	 Deep Anterior Lamellar Keratoplasty (DALK) Versus PK
		15.6.1	 Learning Curve
		15.6.2	 Visual Acuity
		15.6.3	 Refractive Astigmatism
		15.6.4	 Topographic or Keratometric Astigmatism
		15.6.5	 Spherical Equivalent
		15.6.6	 Q Value
		15.6.7	 Corneal Densitometry
		15.6.8	 Contrast Sensitivity
		15.6.9	 Endothelial Cell Loss
		15.6.10 Graft Survival
		15.6.11 Graft Rejections
		15.6.12 Corneal Biomechanics
		15.6.13 Miscellaneous
		15.6.14 Complications
		15.6.15 Conclusion
	15.7	 Complications of PK in Keratoconus (KC)
	15.8	 Graft-Host Misalignment
	15.9	 Wound Healing in Keratoconus
	15.10	 Post-PK Refractive Errors
	15.11	 Post-PK Astigmatism
		15.11.1 Spectacles and Contact Lenses
		15.11.2 Suture Removal or Adjustments
		15.11.3 Relaxing Incisions
		15.11.4 Astigmatic Keratotomy
		15.11.5 Wedge Resection
		15.11.6 Intraocular Lens
		15.11.7 Intrastromal Ring Segments
	15.12	 Recurrence/Progression of Keratoconus Following PK
	15.13	 Rejection
	References
16: Lamellar Keratoplasty in Keratoconus
	16.1	 Introduction
	16.2	 Anterior Lamellar Keratoplasty
		16.2.1	 Manual ALKP
		16.2.2	 Automated ALKP/Microkeratome-Assisted ALKP (MALKP)/Automated Lamellar Therapeutic Keratoplasty (ALTK)
		16.2.3	 Procedure
			16.2.3.1	 Recipient Preparation
			16.2.3.2	 Donor Preparation
		16.2.4	 Excimer Laser-Assisted LKP (ELLKP)
		16.2.5	 Femtosecond Laser-Assisted ALK (FALK)
	16.3	 DALK Surgical Techniques
		16.3.1	 Layer-by-Layer Manual Dissection
		16.3.2	 Visco-Delamination
		16.3.3	 Hydro-Delamination
		16.3.4	 Pneumo-Delamination
		16.3.5	 Modifications of Big Bubble Technique
			16.3.5.1	 Small Bubble-Guided Big Bubble Technique
			16.3.5.2	 Microbubble-Assisted Baring of DM
			16.3.5.3	 Femtosecond Laser-Assisted DALK (FS-DALK)
			16.3.5.4	 DALK after ICRS
			16.3.5.5	 DALK after Resolved Hydrops
		16.3.6	 Outcomes
			16.3.6.1	 Visual Refractive and Graft Success
			16.3.6.2	 CDVA
			16.3.6.3	 Spherical Equivalent (SE)
			16.3.6.4	 Astigmatism
			16.3.6.5	 Endothelial Cell Density (ECD)
			16.3.6.6	 Graft Rejection Episodes
			16.3.6.7	 Graft Survival
			16.3.6.8	 Complications
	16.4	 Perforation of DM
		16.4.1	 Double Anterior Chamber (AC)/Pseudo AC
		16.4.2	 Pupillary Block and Fixed Dilated Pupil (Urrets-Zavalia Syndrome)
		16.4.3	 Graft Rejection
		16.4.4	 Interface Complications
	16.5	 Conclusion
	References
17: Intracorneal Ring Segments in Keratoconus
	17.1	 Introduction
	17.2	 Mechanism of Action of the Intracorneal Ring Segments and Effects on the Cornea
		17.2.1	 Types of Intracorneal Ring Segments
	17.3	 Nomograms for Intracorneal Ring Segments Implantation
	17.4	 Surgical Techniques for Intracorneal Ring Segments Implantation
	17.5	 Efficacy and Complications of Intracorneal Ring Segments Implantation
	References
18: Intraocular Lens (IOL) Implantation in Kertaoconus
	18.1	 Introduction
	18.2	 Phakic Intraocular Lens Implantation (pIOLs)
		18.2.1	 Anterior Chamber pIOLs
			18.2.1.1	 Acrysof Cachet
			18.2.1.2	 Artisan/Verisyse
			18.2.1.3	 Artiflex/Veriflex
		18.2.2	 Posterior Chamber pIOLs
			18.2.2.1	 Visian ICL
		18.2.3	 Phakic Intraocular Lens Implantation (pIOLs) in Keratoconus
	18.3	 Patient Selection
		18.3.1	 Preoperative Evaluations and Considerations
	18.4	 pIOL Sizing and Power Calculations
		18.4.1	 WTW Distance and the Anterior Chamber Depth (ACD)-Based Sizing Formula
		18.4.2	 NK-Formula Version 2 (NK-Formula V2)
		18.4.3	 Safe Ranges of Vault
	18.5	 The Key Points for Successful pIOL Surgery in Keratoconus
		18.5.1	 Stable Keratoconus (KC) with Low Irregularity
		18.5.2	 Unstable Keratoconus with Low Irregularity
		18.5.3	 Stable Keratoconus with High Irregularity
		18.5.4	 Unstable Keratoconus with High Irregularity
	18.6	 Surgical Technique
		18.6.1	 Artiflex/Veriflex
		18.6.2	 Visian ICL
	18.7	 Results of pIOLs in KCN
		18.7.1	 Refractive Outcomes
			18.7.1.1	 Efficacy
			18.7.1.2	 Predictability
			18.7.1.3	 Safety
			18.7.1.4	 Stability
		18.7.2	 Visual Quality Outcomes
			18.7.2.1	 HOAs
			18.7.2.2	 Glare
		18.7.3	 Corneal Biomechanical Effects of pIOLs Implantation
		18.7.4	 Complications of pIOLs in KCN
	18.8	 ICL Replacement
		18.8.1	 Cataract
		18.8.2	 Pigment Dispersion Glaucoma
		18.8.3	 Endothelial Cell Loss
	18.9	 Conclusion
	References
19: Stromal Augmentation Techniques for Keratoconus
	19.1	 Introduction
	19.2	 Corneal Stroma-Applied Surgical Anatomical Considerations
	19.3	 Bowman’s Membrane Transplant (BLT)
	19.4	 Surgical Technique
		19.4.1	 Graft Preparation
		19.4.2	 Surgery in the Recipient
		19.4.3	 Clinical Outcomes
	19.5	 Stromal Lenticule Addition Keratoplasty (SLAK)
		19.5.1	 Surgical Technique
			19.5.1.1	 Clinical Outcomes
	19.6	 Cellular Therapy of the Corneal Stroma
	19.7	 Autologous Adipose-Derived Adult Stem Cells (ADASCs) Isolation and Intrastromal Implantation Techniques
		19.7.1	 Clinical Outcomes
	19.8	 Conclusion
	References
20: Cataract Surgery in Keratoconus
	20.1	 Introduction
	20.2	 Preoperative Evaluation
	20.3	 CXL and ICRS Prior to Cataract
	20.4	 Intraocular Lens Power Calculation Formulas
	20.5	 Intraocular Lens Choice
	20.6	 Surgical Technique
	20.7	 Vision Recovery Following Cataract Surgery
		20.7.1	 Lens-Based Surgeries
		20.7.2	 Corneal-Based Surgeries
		20.7.3	 Contact Lens
	20.8	 Conclusion
	References
21: Refractive Surgery in Management of Keratoconus
	21.1	 Introduction
	21.2	 Corneal Therapeutic Laser Refractive Surgery
		21.2.1	 Combined Protocols: Efficacy and Safety
		21.2.2	 PRK + CXL: Simultaneous or Sequential?
		21.2.3	 Transepithelial PTK + CXL with Better Results Compared to Manual Epithelial Debridement
		21.2.4	 Wavefront-Guided PRK
			21.2.4.1	 Surgical Technique
			21.2.4.2	 Outcomes
	21.3	 Therapeutic Refractive Surgery of Keratoconus with Phakic IOLs
		21.3.1	 Implantation Criteria
	References
22: Artificial Intelligence in the Diagnosis and Management of Keratoconus
	22.1	 Introduction
		22.1.1	 Machine Learning and Keratoconus
	22.2	 Introduction to Machine Learning and Artificial Intelligence
		22.2.1	 Machine Learning Terminology
	22.3	 Neural Networks in Deep Learning
		22.3.1	 Multiperceptron (MLP) Neural Network
		22.3.2	 Convolutional Neural Networks (CNNs)
		22.3.3	 Recurrent Neural Networks (RNNs)
		22.3.4	 Limitations of Artificial Intelligence Programs
		22.3.5	 Open-Source Vs Purpose-Built?
		22.3.6	 Keratoconus and Artificial Intelligence
	22.4	 AI for Keratoconus Detection
	22.5	 AI for Keratoconus Classification
	22.6	 AI for Keratoconus Progression
	22.7	 Surgery Optimization
	22.8	 Summary
	References
23: Changing Paradigm in the Diagnosis and Management of Keratoconus
	23.1	 Introduction
	23.2	 Epidemiology
	23.3	 Diagnosis
	23.4	 Evolution in Topography
	23.5	 Treatment
	23.6	 Summary
	References