Preferred practice patterns for keratoconus: An e-survey among Indian cornea specialists

**Background:** The management of keratoconus has evolved significantly with the introduction of advanced diagnostic tools (e.g., Scheimpflug imaging) and treatments such as corneal cross-linking (CXL) and deep anterior lamellar keratoplasty (DALK). However, the availability of these sophisticated and expensive procedures outside selected centers in India remains unknown. This study aimed to assess current diagnostic and treatment practices for keratoconus among Indian cornea specialists to identify gaps and guide clinical decision-making.

**Methods:** An e-survey was conducted among members of the Cornea Society of India (CSI) between September 21, 2022, and October 10, 2022. A 26-item questionnaire was developed by three cornea specialists, piloted, and revised. The closed survey was distributed via email to all 912 CSI members, with two reminders sent to nonrespondents. Data were collected on participant demographics, availability of diagnostic equipment, contact lens dispensing, treatment procedures (CXL, keratoplasty), and diagnostic criteria. Statistical analysis used Mann–Whitney U-test, independent-samples median test, and Pearson’s Chi-square test, with a two-tailed P < 0.05 considered significant.

**Key Results:** Of 912 members, 234 (25.7%) completed the survey. The mean age of respondents was 42.3 ± 8.5 years, 89.3% were cornea-trained, and the median practice duration was 10 years. Most worked in metro cities (56.4%) and private facilities (88.5%). Access to diagnostic equipment: 91.5% had a Scheimpflug-based device or Orbscan II; 70.5% had anterior segment OCT; 34.2% had Placido-based topography. Contact lens dispensing: 71.4% dispensed scleral contact lenses, 66.7% dispensed Rose K lenses, and 79.9% dispensed rigid gas-permeable lenses. Treatment procedures: 92.7% performed CXL, 81.2% had access to an excimer laser, and 73.1% performed DALK. Availability of Scheimpflug devices, Rose K/scleral lenses, CXL, and excimer lasers was significantly higher in private facilities (P < 0.05). The median number of keratoconus patients seen per month was 10 (mean 17.8 ± 27.1). Respondents with Scheimpflug/Orbscan devices saw a significantly higher median number of patients (10 vs. 4, P = 0.001). The most common diagnostic criteria for keratoconus were a combination of corneal curvature, elevation, and thickness (52.1%). For progression, 97.0% used an increase in K values >1D in 1 year or >0.5D in 6 months. For CXL, 97.2% used epithelium-off technique, 45.8% preferred 0.1% riboflavin in dextran, and 57.1% used an accelerated protocol (9 mW for 10 min) for corneas >400 µm. Notably, 77.2% of respondents routinely performed CXL in corneas <400 µm thick, with a mean minimum thickness of 370.7 ± 27.7 µm. For visual rehabilitation, spectacles (91.0%) and topography-guided PRK (37.6%) were preferred.

**Clinical Implications:** This study provides a comprehensive overview of keratoconus practice patterns in India, revealing that while advanced diagnostics and treatments are widely available among cornea specialists, there is a significant concentration in private urban centers. The lack of Scheimpflug-based devices in some settings may lead to underdiagnosis of early keratoconus. The widespread adoption of CXL, even in thin corneas (<400 µm), and the preference for DALK over PK reflect current global trends. The findings highlight a resource gap in government hospitals and smaller towns, which may contribute to delayed diagnosis and advanced disease presentation. These data can inform policy efforts to improve equitable distribution of keratoconus care across India.