Real-World Clinical Management of Keratoconus in Europe and the Middle East: A Multicountry Survey on Diagnostic and Surgical Practices (Keratoconus in Mind - KIM Project)

Purpose: This study aimed to describe the current management of patients with keratoconus in European and Middle Eastern countries through the collection of real-world data from clinicians actively managing keratoconus. Methods: Computer-assisted web interviewing survey targeting ophthalmologists actively involved in collagen cross-linking (CXL) management. The questionnaire covered clinician demographics and professional experience, patient profiles, diagnostic criteria and tools, treatment pathways, and surgical practices, with a focus on corneal CXL. Descriptive statistics were used to analyze responses. Results: In total, 161 ophthalmologists completed the survey, comprising 126 from Europe (45 from Italy, 35 from Poland, and 46 for the remaining countries), and 35 from Middle Eastern countries. Italian clinicians reported the highest average number of patients with keratoconus (205 ± 198/year) and CXL procedures (112 ± 115/year) compared with 24 ± 21 to 37 ± 42/year in other regions. Corneal topography was the most frequently used diagnostic tool (up to 69%), and CXL was performed mainly on patients aged 20 to 30 years, predominantly students and employed individuals. However, a high variability was observed in the choice of CXL protocols. Public health care systems were the primary source of funding for CXL (up to 58% in Italy). Conclusions: This survey highlights substantial heterogeneity in the management of keratoconus across regions. At the same time, surgical indications align with recommendations from the 2015 global consensus on the definition and treatment of ectatic corneal diseases. However, discrepancies in diagnostic criteria and tool usage suggest the need to support harmonization of diagnostic and management approaches.